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By Alex Fradera

New research on gender identity disorder (also known as gender dysphoria, in which a person does not identify with their biological sex) questions how best to handle the condition when it arises in children and adolescents. Should biological treatments be used as early as possible to help a young client transition, or is caution required, in case of complicating psychological issues?

Melanie Bechard of the University of Toronto and her colleagues examined the prevalence of "psychosocial and psychological vulnerabilities" in 50 child and teen cases of gender dysphoria, and writing in a recent issue of the Journal of Sex and Marital Therapy, they argue their findings show that physicians should be considering these factors more seriously when deciding on a treatment plan. Salting the situation, one of the paper's co-authors is Kenneth Zucker, an expert on gender dysphoria who was last year considered too controversial for Canadian state television.

As recently as 2013, Zucker headed the American Psychiatric Association's group deciding the diagnostic criteria for gender dysphoria, but he fell from grace in 2015 when he was fired from his clinic at the Toronto Centre for Addiction and Mental Health for failing to follow the now prominent "gender-affirmative" approach that places a clinical emphasis on smoothing the process of gender transition for children and adolescents who say they no longer identify with their biological sex.

Zucker's approach, in contrast, was more hesitant and he questioned the ease with which young people can draw conclusions about their gender identity during a universally tumultuous stage of life. He also placed more emphasis on the costs that transition may bear upon an individual. To say that he considered transition a last resort would be as much of a caricature as saying the gender affirmative approach considers it a first resort, but they clearly represent different points on this spectrum.

To Zucker's critics he was a transphobe, his approach analogous to gay conversion therapy (the now widely condemned use of psychological therapy to attempt to alter a client's sexual orientation) - for example, he reportedly advised some parents to discourage their younger children from behaving in ways that contradicted their assigned gender.

Last year, hostility toward Zucker's views was substantive enough to lead the Canadian broadcaster CBC to pull a BBC documentary that reported his perspective. For his part, Zucker continues to maintain that his priority has always been the wellbeing of his clinical charges. The recent article that he co-authored with Bechard and others puts into the scientific record one of the concerns of his clinic, that gender dysphoric youth are a psychologically vulnerable population.

The paper examines the case files of 17 people assigned a male gender and 33 people assigned a female gender, at birth, based on their biological sex. Following their experience of gender dysphoria, the clients had been referred to a specialist gender identity service for young people, at which time they were aged 13 to 20. Sixty-four per cent of the clients were homosexual with respect to the gender they were assigned at birth.

The researchers looked for evidence of 15 factors that can signify or contribute to psychological issues, from self-harm to a previous outpatient therapy visit, and found that over half their sample had six or more of these factors. The majority had two or more prior diagnoses of a psychological disorder, the most common being a mood disorder such as depression. More than half had reported thinking about suicide, a third had dropped out of high school, a quarter had self harmed. A history of sexual abuse was rarer, observed in "only" 10 per cent of cases.

All these measures are likely to be underestimates because they depended on the clients' own descriptions during their initial interview at the gender identity clinic. Without a control group, it's hard to say whether these rates of psychological distress are higher than for other client groups. Certainly though, the findings are consistent with the sense that these individuals were already in a state of psychological vulnerability when they were referred for gender dysphoria.

Bechard's team present in-depth examples of two clients, both assigned as female at birth, that bring these psychological complexities to life, demonstrating the kinds of situations these cases often involve.

The first individual was very intelligent but struggling socially, especially around girls. They were fixated on emphasising their femininity in selfies, leading the parents to suspect body dysmorphic disorder (a troubling belief that there is something wrong with one's body). This individual's boyfriend then came out as gay. Sometime following this, the client disclosed that they identified as a boy. This change in identity happened "overnight" with no developmental history of cross-gender identification.

The second client's history is more convoluted: at around age 14-15 this individual had disclosed that they were transgender (now identifying as male), and had felt this way for a while. This individual also had a history of anxiety, social problems interacting with girls, and extreme anxiety about sexuality. From the point of disclosing their gender dysphoria, they also reported that they were gay (oriented towards men) but had no interest in romantic/sexual relations.

In both these cases, after an initial assessment the individual was given testosterone treatment by a physician against the wishes of the parents - in the first case, the physician actually refused to meet the parents, and in the second, the physician recorded that the issues raised by the parents regarding anxiety, sexual and social problems weren't relevant for the course of action. Sadly, in the case of the second individual, a few months after the start of the hormone treatment, they made a suicide attempt that required hospitalisation; the reasons for this were not reported.

Are the indicators of psychological vulnerability identified in these case histories the consequence, cause or simply coincident to gender identity disorder? If they are all solely a fall-out from the gender dysphoria, then the decisive approach of the physicians described above has a certain sense to it. But if some of the psychological complications pre-dated the gender dysphoria, or were separate from it, then at the very least this would suggest that the consulted physicians should have considered a broader treatment plan, and considered the psychological complications when judging their clients' "readiness" to commence biomedical treatments.

The possibility that disclosure of gender dysphoria may in some cases be driven by earlier psychological vulnerabilities and social problems seems likely to be greater than zero. This is a controversial idea among many online trans activists, but actually it isn't among health practitioners, even those who espouse the gender affirmation philosophy, who recognise that some young gender identity referrals may be transiently mixed-up individuals.

The issue of pre-existing or concurrent psychological vulnerabilities also speaks to the fact that a substantial proportion, perhaps even the majority, of children who experience some form of gender identity challenge, later come to endorse the gender they were raised as ( further commentary and discussion); the new findings may also be relevant to the experience of detransitioning individuals, who reach similar conclusions, but often after a much greater investment in the process of transition - a phenomenon that is struggling to get scientific attention.

However, when a child with gender dysphoria is " insistent, persistent, and consistent " over an extended period, then (under the gender affirmative approach) this is typically treated as a good indicator that it is appropriate to begin facilitating the transition process. The trouble is, psychological vulnerabilities can also be persistent, and if a young person feels like they've found the solution, it's understandable that they might not want to let go.

Life can sometimes feel as complicated as the Gordian knot, the legendary challenge that was seemingly impossible to disentangle. It's understandable to weigh up a radical solution, like Alexander the Great cleaving the knot with a single sword-stroke: to abandon your external environment for a new home, to step outside of the confines of an identity that may be the source of the myriad issues plaguing you.

This research from Bechard, Zucker and company provides preliminary evidence about the psychological vulnerabilities of children and teens with gender dysphoria, extending previous work that's shown high rates of self-harm and suicidal ideation in this group, but more research is required to give us the full clinical picture. As such, this new paper represents just the latest sally in a difficult, complicated conversation that's far from over: a conversation about how we can most compassionately treat those who feel out of step with where they find themselves in the social world.

- Psychosocial and Psychological Vulnerability in Adolescents with Gender Dysphoria: A "Proof of Principle" Study
Alex Fradera (@alexfradera) is Staff Writer at BPS Research Digest

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Most children and teens with gender dysphoria also have multiple other psychological issues

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By Alex Fradera New research on gender identity disorder (also known as gender dysphoria, in which a person does not identify with their biological sex) questions how best to handle the condition when it arises in children and adolescents.

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How did you learn that Kyle was transgender?

It was summer vacation after seventh grade. And I got a text from his friend's mother, who said, "I just want you to know, your daughter is telling my daughter that he thinks he's male. That he thinks he's transgender."

What was your reaction?

I was like, "Wait, what?" And I went to go talk to him, and he was very upset that I had been told that. And felt very, kind of attacked. My reaction wasn't angry, but he definitely felt the energy coming off of me, which was like, "I'm not comfortable with this." I wasn't embracing where he was at all. I was really, really struggling, and I did that for a year. Just, "I'm not going to ask him about it, because I just want to see if it'll go away on its own."

How did he go public as a trans male?

The summer after eighth grade, he went to sleepaway camp, and the second day that he was at camp, in a girl's cabin, he announced to his cabin that he's transgender, and he wants them all to call him Kyle. And that he's a he.

How did you handle that?

I figured, okay, he decided to stop waiting for me. He decided, "I'm just gonna do what I want to do." And I'm really, really proud of him for that. I thought, this will be a test run. It's a way to try this out, without being in school, and among all his friends and family and everything.

What helped you when you were struggling with this?

Before Kyle was starting freshman year of high school, in a new school, I asked him, "Do you want to go to school as a guy?" And he said yes. And that was really scary. And I went to a support group, for parents of LGBT kids, and I remember saying to them, "I'm really terrified, 'cause once I call the school and tell them, I feel like it's a train that I cannot get off of."

And they said to me, "You're already on the train." And that gave me a lot of clarity. I think acknowledging that made things a lot easier.

What has been the most challenging thing for you?

At first, just dealing with it altogether was challenging. But now the thing I worry about is his relationships. It's harder for him to find friends, because he's like an oddity to most kids. He doesn't completely fit in with girls, he doesn't completely fit in with guys. And I also worry about, long term, his having a loving relationship, someone who is really special and wonderful and good to him. That said, he's in a relationship with a lovely girlfriend. He is an incredibly thoughtful and caring boyfriend, and I am so proud of him for that.

And what was the most surprising thing?

I think the most surprising thing for me is how much better we're all doing after we stopped fighting it. It's so much easier than it was. And I think, if I had known that, it would have been a little easier. You know, to kind of go with the flow.

How did you stop fighting it?

It was a moment by moment thing for me. I would think, "What does my child need right now at this particular moment?" And I'd do that thing. And then the next moment, my child may need something else, and it may be hard for me, but it's what my child needs. It's just getting through those moments, you know? And just trying to be there for your kid. And as much as I could, not bringing my own grief, and my own pain, into his world.

Was Kyle impatient with your progress?

My husband took him to Radio Shack, and they got materials to make this little box, so Kyle could build a buzzer. When you pushed a button, it would go, "Riiing." Every time anyone in the family misgendered him he would hit the button. He was like, "People, get in line."

What advice would you give to other parents?

I would say a couple of things. One, it's okay to grieve. It's okay to be really, really sad, and still love and support your kid. And another thing I would say is be informed about the medical treatment, the hormones and all those things, because you may want to start certain things at certain times in their lives, to minimize the physical stress and the emotional pain that they have just being in a body that's matured in a certain way.

What do you say if someone tells you being transgender is wrong?

It depends on how invested a person is in this viewpoint. Sometimes that means just not engaging with that person. More often I find people who err on the side of thinking it is "weird" or a "phase." They lack understanding, and have never known a transgender person. A few times, relative strangers have brought up transgender people in the military, or in church. So far, I have always taken the opportunity to let them know that my beloved son is transgender. My intentions are always to educate, and to remove obstacles for my son's future. So, I communicate with kindness in my voice, not anger.

How's Kyle doing now?

Overall, compared to where he used to be, before any of us knew he was transgender, he's light years better. Before, he had no way of knowing what it was. He had no words for it. And then he learned about it, and said, "Oh my god, that's me."

Now, he's much more at peace. He's an awesome kid. And I couldn't be more proud of him.

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Transgender Children: A Mother's Story | Child Mind Institute

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Melanie's son Kyle, now 16, is a transgender male who made the change public when he was 13. How did you learn that Kyle was transgender? It was summer vacation after seventh grade. And I got a text from his friend's mother, who said, "I just want you to know, your daughter is telling my [...]

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GENDER DYSPHORIAUsed to describe when a person experiences discomfort or distress because there is a mismatch between their sex assigned at birth and their gender identity.This is also the clinical diagnosis for someone who doesn’t feel comfortable with the sex they were assigned at birth.

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GENDER DYSPHORIAUsed to describe when a person experiences discomfort or distress because there is a mismatch between their sex assigned at birth and their gender identity.This is also the clinical diagnosis for someone who doesn’t feel comfortable with the sex they were assigned at birth.

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Louis Theroux documentary

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Louis meets pioneering medical professionals who help children with gender dysphoria.

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A literature review- The developmental perspective

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A literature review- The developmental perspective

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Documentary series visiting the NHS's Tavistock trust to explore children's mental health

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Gender dysphoria in adolescence...

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Riittakerttu Kaltiala-Heino, ¹⁻³ Hannah Bergman, ⁴ Marja Työläjärvi, ² Louise Frisén ⁴

1Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland; ²Department of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland; ³Vanha Vaasa Hospital, Vaasa, Finland; ⁴Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

Abstract: Increasing numbers of adolescents are seeking treatment at gender identity services in Western countries. An increasingly accepted treatment model that includes puberty suppression with gonadotropin-releasing hormone analogs starting during the early stages of puberty, cross-sex hormonal treatment starting at ~16 years of age and possibly surgical treatments in legal adulthood, is often indicated for adolescents with childhood gender dysphoria (GD) that intensifies during puberty. However, virtually nothing is known regarding adolescent-onset GD, its progression and factors that influence the completion of the developmental tasks of adolescence among young people with GD and/or transgender identity. Consolidation of identity development is a central developmental goal of adolescence, but we still do not know enough about how gender identity and gender variance actually evolve. Treatment-seeking adolescents with GD present with considerable psychiatric comorbidity. There is little research on how GD and/or transgender identity are associated with completion of developmental tasks of adolescence.

Keywords: gender dysphoria, gender identity, adolescence, developmental tasks

Gender dysphoria and related concepts

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines gender dysphoria (GD) as a condition in which a person has marked incongruence between the expressed or experienced gender and the biological sex at birth. This causes clinically significant distress or impairment in social, occupational or other important areas of functioning. Individuals with GD experience a strong desire to be treated as the other gender (or some alternative gender different from their assigned gender) and/or to be rid of their sex characteristics, and/or the strong conviction of having feelings and reactions typical of the other gender (or some alternative gender). The previous diagnostic term, gender identity disorder, was rejected in the DSM-5 to avoid pathologizing identity.

According to the International Classification of Diseases (ICD)-10, transsexualism is defined as a desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with or the inappropriateness of one's anatomical sex and a wish to undergo surgery and hormonal treatment to make the body as congruent as possible with the individual's preferred sex. The forthcoming ICD-11 will reconceptualize gender identity-related diagnoses using gender incongruence as the main term.

In addition to the DSM-5 diagnostic term, gender dysphoria can also refer to anxiety and distress about gender features at large. Gender nonconformity refers to behaviors and an appearance that are considered atypical of an individual's assigned gender. Gender variance refers to a spectrum of gender experience, in contrast to the dichotomized conception of gender. The term "transgender" is used as an umbrella term to refer to wider variation of gender identities. Not all who identify as transgender or display gender nonconformity or gender variance suffer from dysphoria.

In this article, we use the DSM-5 and ICD-10 terms "gender dysphoria (GD)" and "transsexualism/transsexual", respectively, when referring to diagnosed clinical samples, and also when referring to the literature published when earlier versions of the DSM classification were in use. We use "transgender" to refer to self-identified population samples and "gender dysphoria" to refer to those who present clinical symptoms.

How common are GD and transgender identity among adults and adolescents?

The number of people who seek treatment suggest that male-to-female transsexualism has a prevalence of 6.8/100,000 and female-to-male transsexualism has a prevalence of 2.6/100,000 among adults. In the Netherlands, 0.6% of men and 0.2% of women (aged 15-70 years) reported incongruent gender identity and a desire to undergo sex reassignment (SR).Population surveys have suggested that about 0.5% of adults in the general population identify as transgender.

The number of adolescents contacting specialized gender identity services has risen considerably over the past decade across Europe and North America. No conclusions regarding the prevalence of GD in general or of GD/transsexualism specifically can be drawn based on these increases. Studies using short (one to three item) self-reports of gender identity and its variance suggest that 0.17%-1.3% of adolescents and young adults identify as transgender. A school-based survey eliciting gender experiences with scales commonly used at gender identity services suggested that 1.3% of 16-19 year olds had potentially clinically significant gender dysphoria.

Gender identity

Identity is the way one understands, describes and expresses oneself and the reflection of those entities to others. Identity consists of many integrated aspects such as gender, nationality, language, academic and occupational endeavors, and religious and political convictions. It is affected by interpersonal relationships, society and different events throughout the life course. Adolescence is an important period of identity formation and integration. Adolescents and young adults establish their identity by actively exploring identity-related choices and making identity commitments in their chosen directions.

Gender identity concerns the individual's core sense of being "female", "male" or another gender. The development of gender identity is a complex process affected by multiple factors. In the research tradition of gender identity, the broad focus has been on the theme "sex differences", and two major topics have received the most attention: the description and measurement of sex differences and the etiology of these differences. Several theories have been proposed. According to early psychodynamic theories, gender variant behavior was hypothesized to derive from parent-infant interpersonal issues or trauma (see Gray et al). However, these theories have not undergone adequate scientific testing. Gender identity development has mostly been described from the viewpoint of cognitive and social learning theories, which argue that human beings are active constructors of cognitive schemas, including gender, in continuous interaction with the environment. Other theories on processes of gender typing have focused on proximal and distal biological influences, genetic and epigenetic or hormonal and neural mechanisms as well as brain anatomy differences in the etiology of gendered behavior and gender variance. There are structural and functional sex differences in the brain, some of them observable across the life span and others only during specific developmental phases. Sex differences in the brain are largely determined by steroid hormone exposure during a perinatal sensitive period that alters subsequent hormonal and non-hormonal responses throughout the lifespan, but they also depend on genes on sex chromosomes. Moreover, there is continuous interaction between genes and experiences, "epigenetics", which changes the expression of genes without any change in the underlying DNA sequence. Research suggests that, for example, early social experiences may act as such epigenetic influence that they ultimately shape lasting sex differences in brain and behavior, but a lot more research is needed in this field to obtain solid knowledge relevant for understanding GD.

While the theories proposed in the past have generally been either essentialist or social cognitive/constructivist in nature, researchers today are expanding the focus to include the bio-psycho-social processes that probably occur across development.

Childhood GD and puberty development

GD in childhood (GDC) describes a feeling of incongruence between the experienced (psychological) gender and the sex assigned at birth. A corresponding diagnosis is included in the ICD-10. Healthy children vary considerably in their gendered behaviors. The diagnosis of GD in prepubescent children has been widely discussed throughout the history of gender identity research, mainly in terms of weighing the risk of stigmatization against diagnosis as a means of access to publicly funded or insurance-covered health care. The prevalence of GDC is not known.

Adolescence is a crucial time for identity and psychosexual development in young people with gender identity concerns. The outcomes of GDC have been discussed in terms of its persistence and desistence. For most children with GDC, whether GD will persist or desist will probably be determined between the ages of 10 and 13 years, although some may need more time. Evidence from the 10 available prospective follow-up studies from childhood to adolescence (reviewed in the study by Ristori and Steensma) indicates that for ~80% of children who meet the criteria for GDC, the GD recedes with puberty. Instead, many of these adolescents will identify as non-heterosexual. Steensma et al interviewed adolescents with different outcomes of GDC (persistence or desistance). The adolescents mentioned social environment, the anticipated results of bodily changes and first romantic and/or sexual experiences as central factors in the desistance or persistence of GD.

Treatment of GD intensifying in puberty: the Dutch model

The Dutch protocol recommends medical treatment if GD intensifies in puberty, while the care for children with GD and their families consists of providing information, psychological support, parental or/and family counseling. In adolescents, medical treatment is recommended at age 12 years and older for those who are in or beyond the early stages (Tanner II-III) of puberty and are still experiencing persistent GD. Puberty suppression with gonadotropin-releasing hormone analogs is part of the protocol for these patients. The purpose of puberty suppression is to relieve the psychological suffering caused by the development of secondary sex characteristics, to give the adolescent time to make a balanced decision regarding whether to undergo actual medical gender-confirming treatment (with cross-sex hormones and surgery) and to make social "passing" in the experienced gender easier. Cross-sex hormones are used for adolescents aged 16 years and older who continue to experience persistent GD. People aged 18 years and older with a diagnosis of GD may undergo SR surgery.

Outcome of and ethical debates around medical interventions for GD in adolescence

The Dutch protocol is largely used, but it has its critics. Controversy regarding the use of drugs for puberty touches on fundamental ethical concepts in pediatrics: the best interests of the minor, autonomy and the role of social context. Professionals recognize the distress of young people with GD and feel an urge to treat them. At the same time, most of these professionals have doubts because of the lack of data regarding long-term physical and psychological outcomes.

Reports of the outcomes of puberty suppression treatment in adolescents have shown reasonable safety and good outcomes regarding patient satisfaction and psychosocial functioning, but research is still scarce. Nevertheless, puberty suppression is not indicated in a considerable proportion of gender dysphoric minors because of several reasons, for example, severe psychiatric comorbidity, considerable instability of psychosocial support or onset of GD later during puberty and diagnostic uncertainty; nevertheless, more follow-up data even from patients who are fulfilling the criteria for "the Dutch model" are still needed.

Psychiatric disorders among adolescents with GD

Descriptive studies of adolescents referred to specialized gender identity services at different centers in Europe and North America have mainly suggested that ~40%-45% of these young people present with clinically significant psychopathology. The lowest figures for psychiatric comorbidity (one-third of the presenting population) were reported in the Netherlands, and the highest (up to three quarters) was reported in Finland and Canada.Gender-referred adolescents actually appear to display clinically significant psychopathology to the same extent as adolescents referred to mental health services due to other reasons. The most commonly reported disorders are depression and anxiety disorders. Self-harm and suicidal ideation/behavior are also common, whereas conduct disorder and antisocial development do not appear central in this population.

Likewise, community-level information suggests that transgender-identifying youth present four to six times more often with depression and three to four times more often with self-harm and/or suicidal behavior compared with cisgender adolescents. Clinical and population data, though scarce, also suggest an overrepresentation of eating pathology among adolescents with GD or transgender identity.

An increased prevalence of autism spectrum disorders (ASDs), varying from ~6% to over 20%, has been reported among samples of adolescents referred to gender identity services. This vastly exceeds the estimated prevalence of 0.6%-0.7% in the general population. In comparison, among children and early adolescents with ASDs, gender variance is >7-fold more common than among non-referred controls.

Hypotheses to explain this are manifold. The theory of the extreme male brain suggests that individuals with ASD demonstrate an extreme of the typical male pattern of behaviors and cognitions originating from high levels of fetal testosterone. High fetal levels could likewise contribute to GD in natal girls, explaining their male identity and behavior. However, this theory cannot explain the association between ASD and GD in natal boys. Social factors-related hypotheses propose that the social perception and communication difficulties typical of autism could make a child more likely to miss social cues regarding how to conform to gender norms or to identify with the opposite sex when he/she faces difficulties joining the peer group of her/his own sex. Hypotheses focusing on individual psychological characteristics suggest, firstly, that gender could be among the preoccupations or obsessions often seen in ASDs. On the other hand, the development of atypical gender identity in autism could relate to the developmental rigidity typical of autism. Individuals with ASD might not reach normative flexibility in gender development necessary to deal with gender variant feelings, which might lead to the overrepresentation of ASD in GD. The suggested causes, however, remain speculative. In a recent study, both boys and girls with GD displayed elevated levels of autistic symptomatology in all subdomains of autism, which did not exclusively support any of the suggested hypotheses. Nevertheless, ASDs pose particular challenges for the diagnosis and treatment of GD in adolescents.

GD and the developmental tasks of adolescence

"Developmental tasks" refer to the normative developmental milestones that should be reached during a given developmental stage. They arise from interactions among physical development, personal attributes and societal expectations. Favorable completion of the developmental tasks of a given stage is a prerequisite for success in the subsequent stages. The developmental tasks of adolescence were first formulated by Havighurst and comprise accepting one's body, adopting a masculine or feminine social role, achieving emotional independence from parents, developing close relationships with peers of the same and opposite genders, preparing for an occupation, preparing for marriage and family life, establishing a personal value or an ethical system and achieving socially responsible behavior. Although puberty now occurs earlier and the transition to adulthood occurs later than they did when these developmental tasks were initially proposed, they remain relevant. The relationship with one's own body and the acquisition of a gendered social role - not necessarily binary - are by definition challenging for adolescents with GD. In the following sections, we discuss the available information on GD/transgender identity and the other developmental tasks of adolescence.

GD in adolescence and relationships with parents

Parents of adolescents with GD and/or transgender identity may face special challenges that are shaped by a variety of factors, such as ethnicity, religious background, social class and the prevailing attitudes in their community and society. These challenges likely shape the support that a nonconforming adolescent can receive. Adverse parental reactions toward an adolescent's gender nonconformity have been noted as a special risk, but parents of sexual- and gender-minority offspring have also reported particular positive aspects of being a parent in this situation, such as personal growth, unconditional love, activism, social connection and closer relationships. However, few studies have empirically explored the parental reactions and support among youth with GD and/or transgender identity.

In a Canadian community study of transgender-identifying youth, of those who had disclosed their gender identity to their parents, 34% considered their parents "very" supportive and 25% considered their parents "somewhat" supportive. Forty-two percent reported that their parents were "not very" or "not at all" supportive. However, the study was based on a nonrandom sample and solely adolescent self-reports, so findings need to be interpreted with caution and causalities cannot be concluded. Strong perceived parental support was, nevertheless, associated with many positive mental health outcomes. Lack of parental support was associated with inadequate housing and homelessness in addition to negative psychological outcomes. Better parental support has also been associated with fewer risk-taking sexual behaviors among transgender youth.

In a community study of trans female adolescents and young adults, more than half of the participants reported that their parents supported their gender identity, showed their support in many ways and believed the respondent could have a happy future as a trans adult. However, approximately two in five respondents had not experienced parental acceptance. Parental acceptance was associated with perceiving parents as the primary source of social support.

In a school-based survey transgender-identifying adolescents felt less often (odds Ratio 0.3) than their cis-gender peers that at least one parent cared for them.

Studies of clinically referred gender dysphoric youth have rarely addressed parent-related issues. Simons et al reported that in a clinical sample of adolescents with GD, parental support was significantly associated with higher life satisfaction, lower perceived burden of being transgender and fewer depressive symptoms. In a Finnish study comparing childhood gender identity in community and clinical samples, a smaller proportion of adolescents with GD than of non-referred adolescents in the population agreed with the statement "I always felt that my parents cared fore me." It was also noticed that the clinically referred adolescents with GD less commonly lived with both their parents than the adolescents in the normal population (48% vs. 78%). In British and Spanish samples of gender-referred adolescents, parental divorce was observed in the background of approximately three in five participants, but the authors did not compare this finding with a corresponding rate in the general population.

Gender nonconformance and peer relationships in adolescence

During adolescence, peer relationships are critical for psychological well-being. Peer relationships also shape development, including aspects of gender identity consolidation. Loneliness and social isolation from peer relationships is associated with developmental difficulties and impaired mental health. An important peer network-related risk factor is bullying.

Observations in referred samples of adolescents with GD suggest considerable peer relationship difficulties. In both the UK and in Finland, approximately half of adolescents who presented at a specialized gender identity service reported significant experiences of being bullied. In the Finland study, 45% of the referred adolescents also had a history of marked periods of social isolation in childhood and/or adolescence. In the Netherlands and in Canada, self-, parent and teacher ratings indicated poorer peer relationships among adolescents referred for GD than in the same-aged population and poor peer relationships were an important correlate of mental health problems in this group. Similarly, in another Canadian comparison among gender-referred, mental health-referred and general population adolescents bullying was reported by the GD group more commonly than by population controls, and to the same extent as by those referred due to mental health issues. Gender-related bullying was most common among the GD group.

On the population level, Clark et al found that transgender-identifying adolescents had 4.5-fold increased odds of being bullied and were approximately twice as likely to report being afraid for their personal safety, having been in a serious physical fight and having been hit or otherwise harmed by others, compared with their cisgender-identifying peers. They also less commonly felt that their friends cared about them and that school was okay.

Gender-nonconforming behavior is characteristic of both sexual- and gender-minority youth and has been associated with an increased likelihood of experiencing bullying and harassment in peer groups.Adolescents with GD likely represent the extreme end of gender nonconformity, and this may strongly contribute to their experiences of being bullied. Bullying and stigmatization have also been suggested to (partially) mediate the association between gender nonconformity and lower mental well-being across adolescence.

However, not all the difficulties the gender dysphoric adolescents face in peer relationships can be explained by gender expression-related victimization or discrimination. In the Finnish clinical sample, of the gender identity-referred adolescents who had experienced severe bullying at school, three quarters had been bullied before they ever questioned their gender. Likewise, three-quarters of them reported that the bullying had not been related to gender expression or sexual identity, but to other factors such as not being slim, being successful at school or having unfashionable hobbies and interests. Bullying is a severe problem regardless of the reported reasons for it, but it is important to acknowledge that adolescents who develop GD also have unrelated difficulties that may need attention.

GD, transgender identity and sexuality in adolescence

Sexual orientation and gender identity are different entities, and transgender people present with a variety of sexual orientations. Nevertheless, sexual orientation has long been used to subtype GD/transsexualism. During adolescence, the different facets of sexual orientation - attraction, behavior and identity - may still be developing. It may be more important to determine whether adolescents with GD or transgender identity display developmentally appropriate and favorable involvement in romantic and erotic relationships.

In adolescence, sexual development accelerates. Young people's experiences of a maturing and changing body, sexuality and their developing gender identity affect intrapersonal, interpersonal and societal interactions. In Western countries, between one-tenth and one-third of adolescents first experience sexual intercourse by the age of 15, and the vast majority experience it by age 20. Various practices of kissing and petting typically precede first sexual intercourse by several years. Early sexual activity has been viewed as a problem behavior associated with risky sexual behaviors, psychosocial difficulties and emotional and behavioral disorders. In contrast, in the late stages of adolescent development, a lack of experiences might suggest developmental difficulties.

GD and/or transgender identification could be expected to be associated with delayed sexual development, given that it is the sexual body, in particular, that is the source of distress in GD and that differing from the mainstream may increase the adolescent's risk of problems in social relationships, including dating, and sexual encounters. Sexual- and gender-minority adolescents may also have a reduced availability of potential partners and increased challenges in finding potential partners than their heterosexual peers. However, developmental challenges have also been associated with premature and risky sexual behavior. Adolescents with GD and/or transgender identification could engage in risky sexual behaviors due to identity experiments or because associated mental health problems could increase their search for comfort in intimacy or decrease their self-protection skills.

To the best of our knowledge, the only study focusing on the sexual experiences of treatment-seeking adolescents with GD is that of Bungener et al from the Netherlands. They compared the sexual experiences of 137 transsexual adolescents (mean [SD] age 14.69 [2.2] years) with those of a same-aged adolescent population. Transsexual adolescents had fewer sexual experiences than the same-aged population in all areas measured (falling in love, romantic relationships, kissing, petting, intercourse). However, a majority of the transsexual adolescents had fallen in love and approximately half had been involved in romantic relationships. One quarter had experienced petting while undressed, and 5% had experienced sexual intercourse. Fewer transsexual adolescents than the adolescents in the same-aged population (24% vs. 48%) valued sex as important. In a descriptive study of clinically presenting adolescents with GD in the USA, nearly half of the respondents (mean [SD] age 19.2 [2.9] years) reported being sexually active.

Transgender adolescents and young adults, particularly trans females, are at a disproportionately high risk of contracting human immunodeficiency virus and other sexually transmitted diseases. The risk of unprotected sex in this population has been associated with sex work and drug use, which are further associated with rejection, stigma and discrimination. Of the studies of referred samples, only one addressed sex work. In that sample, 6% of the referred adolescents reported engaging in the trading of sex.

Sexual education is an important way to promote positive and responsible sexual behaviors in youth. The planned curricula and practical applications likely vary widely across countries and schools. Sexual- and gender-minority youth were found to desire minority-inclusive sexual education in a study by Gowen and Wingez-Yanez. The sexual- and gender-minority youth felt that the sexual education that was offered isolated them by silencing them, adopting a heterocentric perspective and pathologizing minorities. Reflecting on the available sexual education in light of these findings is appropriate for all educators.

Preparing for occupation: academic performance and socioeconomic status

To the best of our knowledge, research has not specifically focused on academic performance and the progression to work life among adolescents with GD, but given the burden of psychiatric comorbidities among gender-referred youth, special needs regarding education are likely to exist.

Aspects of social relationships are relevant to well-being in school, school performance and pathways to occupation. Transgender youth have been reported to experience bullying and discrimination in schools, not only by peers but even by teachers; consequently, they perceive schools as unsafe places, which again increases the risk of non-attendance and poorer results. Gender- and sexuality-related victimization may impair academic performance through, for example, decreased motivation, concentration and self-efficacy and the resulting school avoidance and harmful coping strategies. Nevertheless, being "out" at school improves self-esteem among gender- and sexual-minority youth and increases their well-being, which can have a positive impact on academic performance.

School dropout is strongly linked to social exclusion. School dropout was associated with high masculinity in girls and low masculinity combined with high femininity in boys in a study of late-adolescent school dropouts and attenders in the Netherlands. The authors suggested that such deviation from gender norms increases the risk of unpopularity among peers, which again predisposes individuals toward school dropout. However, school dropout was also associated with very masculine attitudes and self-evaluations among boys. The role of gendered behaviors, attitudes and experiences in school adjustment and academic performance deserves further research.

Why the increase in referrals?

Zucker et al observed an increase in the number of adolescents presenting at gender identity services in the early 2000s. Since then, several gender identity services for minors from across Western countries have reported increases. Simultaneously, the earlier overrepresentation of natal boys has equaled or turned to overrepresentation of natal girls. Natal girls now comprise from half to ~90% of clinical adolescent samples. The reasons for these changes are not known. The increase in referrals could be attributable to enhanced provision of services, or the threshold for seeking help may now be lower due to increased knowledge and improved societal acceptance. Aitken et al, however, did not find evidence supporting a lowered threshold to gender identity services. Sociocultural features related to what kind of identities are available for whom, and sex-related differences of pressure to conform may play a role.

Comments

Research regarding the clinical treatment of adolescents with GD has mainly focused on childhood-onset GD that intensifies during puberty, and the Dutch treatment protocol is also tailored for this group. There is little empirical knowledge regarding young people who experience their first signs of GD in adolescence, well after the onset of puberty, especially regarding biological girls. Among a treatment-seeking sample in the UK, 18% experienced their first feelings of GD in adolescence compared with approximately two-thirds of the Finnish sample, and for the majority of adolescent-onset cases, GD presented in the context of severe mental disorders and general identity confusion. In such situations, appropriate treatment for psychiatric comorbidities may be warranted before conclusions regarding gender identity can be drawn. Gender-referred adolescents actually display psychopathology to the same extent as mental health-referred youth. In a nationwide long-term follow-up study of adult cases, psychiatric morbidity, suicide attempts and suicide mortality persisted as elevated after juridical and medical SR.

Emerging discussions raise concern for post-pubertally abruptly emerging cross-gender identification ("rapid onset"), particularly among biological girls, suggesting a role for intensive media influences and generous group validation as shaping the understanding of, and giving new meanings to, the body discomfort common among female adolescents at large. The persistence of increasing adolescent-onset transgender identification is not known.

More empirical research is needed regarding virtually all aspects of GD in adolescence to create treatment approaches that optimize these young people's future psychosocial health and well-being. It seems unlikely that all the psychopathology observed in the referred samples is secondary to gender identity issues and would resolve with hormonal and later surgical treatments. There is still no clear consensus regarding hormonal treatment for adolescents because long-term data are unavailable; actually, only one long-term follow up has been carried out, with a highly selected intervention group and an at baseline non-comparable comparison group.

An affirmative approach is increasingly implemented in the health care of gender nonconforming children. This includes, based on a comprehensive psychological and psychosocial assessment, work with the children and their families and schools to support the gender-nonconforming minors to express themselves in a way that feels most comfortable for them. With the starting point that gender presentations are fluid and changing over time, gender variant children need to be allowed to freely explore a range of gender identities and expressions. A debate concerns whether or not a prepubertal child should be allowed to completely transition to live in other than birth gender. Concerns include that childhood transition may be forcing adolescents to proceed to biomedical interventions, as stepping back may be psychologically troublesome, even though identity development has taken a new direction.

The etiology of gender incongruence remains unknown. Gender identity differentiation does not occur in a psychosocial vacuum; instead, research in the field suggests that the developmental course is influenced by numerous psychosocial factors, likely in continuous interaction with biological factors. Gray et al noted that the general narrative in the research literature concerning gender variation among children focuses on gender "atypical" behavior and deviation from "normative patterns", thus viewing gender in a binary way instead of as a wider spectrum of (healthy) identities, personalities and behaviors among children. This is surely relevant for adolescents as well. These authors also requested a shift in research paradigms away from the study of outcomes of sexuality and gender identity and the child/adolescent in isolation toward outcomes of adjustment and the child/adolescent in contexts that affect adjustment. Along with further discussions of the best treatment interventions, it is relevant to attempt to contribute to societal attitudes that enable children and adolescents with gender variance to express themselves and successfully complete the developmental tasks common to all, independent of gender.

Disclosure

The authors report no conflicts of interest in this work.

References

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[Full text] Gender dysphoria in adolescence: current perspectives | AHMT

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Gender dysphoria in adolescence: current perspectives Riittakerttu Kaltiala-Heino,1-3 Hannah Bergman,4 Marja Työläjärvi,2 Louise Frisén4 1Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland; 2Department of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland; 3Vanha Vaasa Hospital, Vaasa, Finland; 4Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Abstract: Increasing numbers of adolescents are seeking treatment at gender identity services in Western countries.

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History and a bit of Maslow!...

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Gender Transformation Motivation - U3160551

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Verified by Psychology Today

Gender dysphoria (formerly known as gender identity disorder in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders, or DSM) is defined by strong, persistent feelings of identification with another gender and discomfort with one's own assigned gender and sex; in order to qualify for a diagnosis of gender dysphoria, these feelings must cause significant distress or impairment. People with gender dysphoria often desire to live in accordance with their gender identity and may dress and use mannerisms associated with the gender with which they identify in order to achieve this goal.

Both gender identity issues and feelings of dysphoria may manifest in a variety of different ways. A person with female sex characteristics, for example, may privately identify as a man, but continue to publicly present themselves as a woman. Another may choose to dress in clothes associated with the gender with which they identify, while yet another may seek hormone treatment or surgery as part of a transition to living full-time as the gender with which they identify. Each of these individuals may-or may not-experience significant feelings of distress or impairment as a result of their gender identity concerns. Adults with gender dysphoria typically feel uncomfortable being regarded by others as their assigned gender and often desire to be rid of the physical sex characteristics associated with it

Gender identity incongruence and the feelings of distress that indicate gender dysphoria can be present in children, adolescents, or adults, and can manifest differently across age groups. A child who is assigned one gender may express the wish to be a different gender, state that they are, or assert that they will grow up to be. They may also prefer the clothing, hairstyles, or toys typically associated with the other gender and may demonstrate intense negative reactions when adults in their life attempt to have them wear clothing associated with their assigned gender. Additionally, some children will show discomfort with their physical sex characteristics.

Gender dysphoria in adults and children is considered a disorder if the person also experiences significant distress or impairment in major areas of life as a result of the incongruence. Identifying with a gender different from the one that was assigned is no longer considered a mental disorder in itself.
Associated Features and Disorders of Gender Dysphoria
Due to feelings of distress and stigma, many individuals with gender dysphoria become socially isolated-whether by choice or through ostracism-which can contribute to low self-esteem and may lead to school aversion or even dropping out.

In some cases of gender dysphoria, the disturbance can be so pervasive that an individual's mental life revolves around activities that lessen gender-related distress. These individuals may be preoccupied with their appearance, especially prior to or early in a formal gender transition. Relationships with family members may also be seriously impaired, particularly in cases where family members hold negative or stigmatizing views about transgender or gender non-conforming individuals.

Suicidal ideation, suicide attempts, and substance-related disorders are relatively common among those experiencing gender dysphoria. After gender transition occurs, suicide risk may dissipate or persist, depending on the adjustment of the individual. Children with gender dysphoria may manifest coexisting separation anxiety disorder, generalized anxiety disorder, or symptoms of depression. Adults may display anxiety and depressive symptoms as well.

Gender dysphoria has been reported across many countries and cultures, and incongruences between sex and gender have existed in human society for thousands of years. According to the DSM-5, among individuals who are assigned male at birth, approximately 0.005 percent to 0.014 percent are later diagnosed with gender dysphoria. Among individuals who are assigned female at birth, approximately 0.002 percent to 0.003 percent are later diagnosed with gender dysphoria. Because these estimates are based on the number of people who seek formal treatment-including hormone therapy and/or surgical reassignment-these rates are likely an underestimate of actual prevalence.

The level of distress experienced by someone with gender dysphoria is significant, and individuals do much better if they are in supportive environments, allowed to express their gender in the way that's most comfortable to them, and are given knowledge that, if necessary, treatments exist to reduce the sense of incongruence they feel.

Symptoms

Gender dysphoria looks different in different age groups. According to the DSM-5, health professionals deciding whether to diagnose gender dysphoria in children, adolescents, and adults should look for the presence of the following symptoms:
Children

An incongruence, present for six months or longer, between the child's experienced/expressed gender and the gender they were assigned at birth

A strong desire to be of the other gender (or another gender identity, such as non-binary) or an insistence that one is another gender

In boys (assigned gender), a strong preference for wearing or simulating female attire, and/or a resistance to wearing traditional masculine clothing

In girls (assigned gender), a strong preference for wearing typical masculine clothing, and/or a resistance to wearing traditional feminine clothing

A strong preference for cross-gender roles in make-believe or fantasy play

A strong preference for the toys, games, or activities stereotypically used by the other gender

A strong dislike of one's sexual anatomy

If at least six of the above symptoms are present, a diagnosis of gender dysphoria may be given if it includes:

Clinically significant distress or impairment in major areas of functioning, such as social relationships, school, or home life
Adolescents and Adults

An incongruence between the individual's experienced/expressed gender and primary sex characteristics (sexual organs) and/or secondary sex characteristics (breasts, underarm hair), lasting for at least six months

A strong desire to be rid of one's primary and/or secondary sex characteristics

A strong desire for the primary and/or secondary sex characteristics of the other gender

A strong desire to be of the other gender or an alternative gender

A strong desire to be treated as the other gender or an alternative gender

A strong conviction that one has the typical feelings and reactions of the other gender or an alternative gender

If at least two of the above symptoms are present, a diagnosis of gender dysphoria may be given if it includes:

Clinically significant distress or impairment in major areas of functioning, such as social relationships, school, or home life

Cross-gender behaviors can begin as early as 2 years old, which is the start of the developmental period in which children begin expressing gendered behaviors and interests. Early-onset gender dysphoria typically starts in childhood and continues into adolescence and adulthood; late-onset gender dysphoria, on the other hand, occurs around puberty or much later in life.

Causes

The causes of gender dysphoria are currently unknown, but genes, hormonal influences in the womb, and environmental factors are all suspected to be involved.

The onset of cross-gender interests and activities is usually between ages 2 and 4 years, and many parents later report that their child has always had cross-gender interests. Only a small number of children with gender dysphoria will continue to have symptoms in later adolescence or adulthood. Typically, children with gender dysphoria are referred around the time of school entry, particularly if peer relationships become challenging or parents suspect that their child's gender identity issues are not a phase.

Adult onset is typically in early to mid-adulthood. There are two common courses for the development of gender dysphoria:

The first, typically observed in late adolescence or adulthood, is a continuation of gender dysphoria that had an onset in childhood or early adolescence.

In the other course, the more overt signs of cross-gender identification appear later and more gradually, with a clinical presentation in early to mid-adulthood.

Treatment

Individual and family counseling is recommended for children with gender dysphoria, while individual and/or couples therapy is recommended for adults. Surgery and hormone therapy are options, but they are not desired by every individual, and feelings of distress may continue after this treatment. These possibilities should be discussed in psychotherapy.

While some individuals manage to overcome symptoms of distress on their own, psychotherapy is often very helpful in bringing about the personal discovery that facilitates self-comfort and in dealing with strong emotions that may have resulted from peer-related challenges or social stigma. The best outcomes for those with gender dysphoria are associated with early diagnosis, a supportive environment, and comprehensive treatment that respects the wishes and desires of the individual.

References

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

National Institutes of Health-National Library of Medicine

Last reviewed 02/23/2019

# data[].attributes.attachment_link.description
Gender dysphoria (formerly known as gender identity disorder in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders, or DSM) is defined by strong, persistent feelings of identification with another gender and discomfort with one's own assigned gender and sex; in order to qualify for a diagnosis of gender dysphoria,

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Understanding Gender Dysphoria in Children and Teens with Dr. Daniels | CHOC

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🤔 Lots of interesting bits in here!...

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Gender Identity Disorder and Attachment Theory...

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Gender Identity Disorder and Attachment Theory: The Influence of the Patient's Internal Working Models on Psychotherapeutic Engagement and Objective. A Study Undertaken Using the Adult Attachment Interview

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Until now, studies related to gender identity disorder (GID) in adult patients carried out within the framework of attachment theory have been scarce. The current research project aimed to explore the theme related to the specific nature of the current states of mind with respect to attachment in adult male patients suffering from GID, and to evaluate simultaneously the level of psychopathology associated with conditions of GID.

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Gender Identity in Accordance with Erikson's Theory...

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Erikson theorized that people go through 8 stages of developement in life, overcoming certain crises to gain virtues. During Adolescence, discovering one's gender identity is highly crucial to development, and usually occurs during Erikson's Identity vs. Role Confusion stage. Knowing whether to identify as male or female determines the type of roles and activities that one participates in as well as future places in society. Parents can sometimes lack understanding when their ideal version of gender is not met by their teen. This can lead to problems with communication and openness. Society states the norms for what roles males and females have, but it is perfectly normal if a teen does not fit into these norms.

Parents should understand the topic in order to understand their teen. Below is a site that will provide helpful information. Adolescence is a time of finding out about oneself, about attraction, and about life choices. Gender is highly important to develop social roles and relationship roles. If one becomes confused, problems may arise, such as failing the next stage of Erikson's theory, intimacy vs. isolation. Parents need to discuss gender identity with their teen, determine if they are struggling with it or are deviated from the norm, and provide support and love to show them that it is normal to not follow the norms. When parents become accepting, teens can have a safe haven, since the rest of society may not be as supportive.

Look below for additional help in gender identity!

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Gender Identity In Accordance with Erikson's Theory - Parenting 101

# data[].attributes.attachment_link.description
Erikson theorized that people go through 8 stages of developement in life, overcoming certain crises to gain virtues. During Adolescence, discovering one's gender identity is highly crucial to development, and usually occurs during Erikson's Identity vs. Role Confusion stage.

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Biological Theories...

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Biological Theories of Gender | Simply Psychology By Saul McLeod, published 2014 People often get confused between the terms sex and gender. Sex refers to biological differences between males and females. For example, chromosomes (female XX, male XY), reproductive organs (ovaries, testes), hormones (oestrogen, testosterone).

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Biological explanation...

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Gender identity disorder biological explanation

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Verified by Psychology Today

Gender dysphoria (formerly known as gender identity disorder in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders, or DSM) is defined by strong, persistent feelings of identification with another gender and discomfort with one's own assigned gender and sex; in order to qualify for a diagnosis of gender dysphoria, these feelings must cause significant distress or impairment. People with gender dysphoria often desire to live in accordance with their gender identity and may dress and use mannerisms associated with the gender with which they identify in order to achieve this goal.

Both gender identity issues and feelings of dysphoria may manifest in a variety of different ways. A person with female sex characteristics, for example, may privately identify as a man, but continue to publicly present themselves as a woman. Another may choose to dress in clothes associated with the gender with which they identify, while yet another may seek hormone treatment or surgery as part of a transition to living full-time as the gender with which they identify. Each of these individuals may-or may not-experience significant feelings of distress or impairment as a result of their gender identity concerns. Adults with gender dysphoria typically feel uncomfortable being regarded by others as their assigned gender and often desire to be rid of the physical sex characteristics associated with it

Gender identity incongruence and the feelings of distress that indicate gender dysphoria can be present in children, adolescents, or adults, and can manifest differently across age groups. A child who is assigned one gender may express the wish to be a different gender, state that they are, or assert that they will grow up to be. They may also prefer the clothing, hairstyles, or toys typically associated with the other gender and may demonstrate intense negative reactions when adults in their life attempt to have them wear clothing associated with their assigned gender. Additionally, some children will show discomfort with their physical sex characteristics.

Gender dysphoria in adults and children is considered a disorder if the person also experiences significant distress or impairment in major areas of life as a result of the incongruence. Identifying with a gender different from the one that was assigned is no longer considered a mental disorder in itself.
Associated Features and Disorders of Gender Dysphoria
Due to feelings of distress and stigma, many individuals with gender dysphoria become socially isolated-whether by choice or through ostracism-which can contribute to low self-esteem and may lead to school aversion or even dropping out.

In some cases of gender dysphoria, the disturbance can be so pervasive that an individual's mental life revolves around activities that lessen gender-related distress. These individuals may be preoccupied with their appearance, especially prior to or early in a formal gender transition. Relationships with family members may also be seriously impaired, particularly in cases where family members hold negative or stigmatizing views about transgender or gender non-conforming individuals.

Suicidal ideation, suicide attempts, and substance-related disorders are relatively common among those experiencing gender dysphoria. After gender transition occurs, suicide risk may dissipate or persist, depending on the adjustment of the individual. Children with gender dysphoria may manifest coexisting separation anxiety disorder, generalized anxiety disorder, or symptoms of depression. Adults may display anxiety and depressive symptoms as well.

Gender dysphoria has been reported across many countries and cultures, and incongruences between sex and gender have existed in human society for thousands of years. According to the DSM-5, among individuals who are assigned male at birth, approximately 0.005 percent to 0.014 percent are later diagnosed with gender dysphoria. Among individuals who are assigned female at birth, approximately 0.002 percent to 0.003 percent are later diagnosed with gender dysphoria. Because these estimates are based on the number of people who seek formal treatment-including hormone therapy and/or surgical reassignment-these rates are likely an underestimate of actual prevalence.

The level of distress experienced by someone with gender dysphoria is significant, and individuals do much better if they are in supportive environments, allowed to express their gender in the way that's most comfortable to them, and are given knowledge that, if necessary, treatments exist to reduce the sense of incongruence they feel.

Symptoms

Gender dysphoria looks different in different age groups. According to the DSM-5, health professionals deciding whether to diagnose gender dysphoria in children, adolescents, and adults should look for the presence of the following symptoms:
Children

An incongruence, present for six months or longer, between the child's experienced/expressed gender and the gender they were assigned at birth

A strong desire to be of the other gender (or another gender identity, such as non-binary) or an insistence that one is another gender

In boys (assigned gender), a strong preference for wearing or simulating female attire, and/or a resistance to wearing traditional masculine clothing

In girls (assigned gender), a strong preference for wearing typical masculine clothing, and/or a resistance to wearing traditional feminine clothing

A strong preference for cross-gender roles in make-believe or fantasy play

A strong preference for the toys, games, or activities stereotypically used by the other gender

A strong dislike of one's sexual anatomy

If at least six of the above symptoms are present, a diagnosis of gender dysphoria may be given if it includes:

Clinically significant distress or impairment in major areas of functioning, such as social relationships, school, or home life
Adolescents and Adults

An incongruence between the individual's experienced/expressed gender and primary sex characteristics (sexual organs) and/or secondary sex characteristics (breasts, underarm hair), lasting for at least six months

A strong desire to be rid of one's primary and/or secondary sex characteristics

A strong desire for the primary and/or secondary sex characteristics of the other gender

A strong desire to be of the other gender or an alternative gender

A strong desire to be treated as the other gender or an alternative gender

A strong conviction that one has the typical feelings and reactions of the other gender or an alternative gender

If at least two of the above symptoms are present, a diagnosis of gender dysphoria may be given if it includes:

Clinically significant distress or impairment in major areas of functioning, such as social relationships, school, or home life

Cross-gender behaviors can begin as early as 2 years old, which is the start of the developmental period in which children begin expressing gendered behaviors and interests. Early-onset gender dysphoria typically starts in childhood and continues into adolescence and adulthood; late-onset gender dysphoria, on the other hand, occurs around puberty or much later in life.

Causes

The causes of gender dysphoria are currently unknown, but genes, hormonal influences in the womb, and environmental factors are all suspected to be involved.

The onset of cross-gender interests and activities is usually between ages 2 and 4 years, and many parents later report that their child has always had cross-gender interests. Only a small number of children with gender dysphoria will continue to have symptoms in later adolescence or adulthood. Typically, children with gender dysphoria are referred around the time of school entry, particularly if peer relationships become challenging or parents suspect that their child's gender identity issues are not a phase.

Adult onset is typically in early to mid-adulthood. There are two common courses for the development of gender dysphoria:

The first, typically observed in late adolescence or adulthood, is a continuation of gender dysphoria that had an onset in childhood or early adolescence.

In the other course, the more overt signs of cross-gender identification appear later and more gradually, with a clinical presentation in early to mid-adulthood.

Treatment

Individual and family counseling is recommended for children with gender dysphoria, while individual and/or couples therapy is recommended for adults. Surgery and hormone therapy are options, but they are not desired by every individual, and feelings of distress may continue after this treatment. These possibilities should be discussed in psychotherapy.

While some individuals manage to overcome symptoms of distress on their own, psychotherapy is often very helpful in bringing about the personal discovery that facilitates self-comfort and in dealing with strong emotions that may have resulted from peer-related challenges or social stigma. The best outcomes for those with gender dysphoria are associated with early diagnosis, a supportive environment, and comprehensive treatment that respects the wishes and desires of the individual.

References

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

National Institutes of Health-National Library of Medicine

Last reviewed 02/23/2019

# data[].attributes.attachment_link.description
Gender dysphoria (formerly known as gender identity disorder in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders, or DSM) is defined by strong, persistent feelings of identification with another gender and discomfort with one's own assigned gender and sex; in order to qualify for a diagnosis of gender dysphoria,

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A New Theory of Gender Dysphoria...

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A New Theory of Gender Dysphoria Incorporating the Distress, Social Behavioral, and Body-Ownership Networks

# data[].attributes.attachment_link.description
When postmortem studies related to transgender individuals were first published, little was known about the function of the various identified nuclei. Now, over 2 decades later, significant progress has been made associating function with specific brain regions, as well as in identifying networks associated with groups of behaviors.