There is broad scientific consensus that the body of evidence regarding the benefits and risks of various treatment approaches for gender dysphoria - from highly invasive, such medical "gender affirmation" through hormones and surgeries, to least invasive such as psychotherapy - is of very low quality. SEGM recognizes the right of mature adults to undergo gender-affirming interventions despite the low quality of evidence on which the interventions are based. However SEGM is very concerned about applying experimental procedures to vulnerable youth whose pre-frontal cerebral cortices are still developing, whose identities are evolving, and whose ability to meaningfully consent to interventions with unknown long-term outcomes is highly uncertain.

SEGM's concern for gender-dysphoric youth is reinforced by a recent surge of youth with a new, poorly understood variant of gender dysphoria, complicated by multiple mental health issues. This further amplifies the risks of applying irreversible interventions not based on quality, reliable scientific evidence. SEGM has begun to compile a compendium of literature highlighting key studies that support our position of concern. This is an ongoing project, and we welcome any feedback from the research community. As a key part of the project, we will be providing critical evaluation and summaries of the key studies.

Please check this site frequently for updates.

A. Novel epidemiological trend: adolescent-onset gender dysphoria with mental health comorbidities
de Vries, A. L. C. (2020). Challenges in Timing Puberty Suppression for Gender-Nonconforming Adolescents. Pediatrics, 146(4), e2020010611. https://doi.org/10.1542/peds.2020-010611
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Hutchinson, A., Midgen, M., & Spiliadis, A. (2020). In Support of Research Into Rapid-Onset Gender Dysphoria. Archives of Sexual Behavior, 49(1), 79–80. https://doi.org/10.1007/s10508-019-01517-9
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Zucker, K. J. (2019). Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues. Archives of Sexual Behavior, 48(7), 1983–1992. https://doi.org/10.1007/s10508-019-01518-8
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Journal AbstractThis article provides an overview of five contemporary clinical and research issues pertaining to adolescents with a diagnosis of gender dysphoria: (1) increased referrals to specialized gender identity clinics; (2) alteration in the sex ratio; (3) suicidality; (4) “rapid-onset gender dysphoria” (ROGD) as a new developmental pathway; (5) and best practice clinical care for adolescents who may have ROGD.
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de Graaf, N. M., & Carmichael, P. (2019). Reflections on emerging trends in clinical work with gender diverse children and adolescents. Clinical Child Psychology and Psychiatry, 24(2), 353–364. https://doi.org/10.1177/1359104518812924
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Journal AbstractGender is a fast-evolving and topical field which is often the centre of attention in the media and in public policy debates. The current cultural and social climate provides possibilities for young people to express themselves. Gender diverse young people are not only developing new
ways of describing gender, but they are also shaping what is required of clinical interventions.

Emerging cultural, social and clinical trends, such as increases in referrals, shifts in sex ratio and diversification in gender identification, illustrate that gender diverse individuals are not a homogeneous group. How do evolving concepts of gender impact the clinical care of gender diverse young people presenting to specialist gender clinics today?
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Littman, L. (2018). Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLOS ONE, 13(8), e0202330. https://doi.org/10.1371/journal.pone.0202330
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Journal AbstractPURPOSE: In on-line forums, parents have reported that their children seemed to experience a sudden or rapid onset of gender dysphoria, appearing for the first time during puberty or even after its completion. Parents describe that the onset of gender dysphoria seemed to occur in the context of belonging to a peer group where one, multiple, or even all of the friends have become gender dysphoric and transgender-identified during the same timeframe. Parents also report that their children exhibited an increase in social media/internet use prior to disclosure of a transgender identity. Recently, clinicians have reported that post-puberty presentations of gender dysphoria in natal females that appear to be rapid in onset is a phenomenon that they are seeing more and more in their clinic. Academics have raised questions about the role of social media in the development of gender dysphoria. The purpose of this study was to collect data about parents’ observations, experiences, and perspectives about their adolescent and young adult (AYA) children showing signs of an apparent sudden or rapid onset of gender dysphoria that began during or after puberty, and develop hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among this demographic group.
METHODS: For this descriptive, exploratory study, recruitment information with a link to a 90-question survey, consisting of multiple-choice, Likert-type and open-ended questions was placed on three websites where parents had reported sudden or rapid onsets of gender dysphoria occurring in their teen or young adult children. The study’s eligibility criteria included parental response that their child had a sudden or rapid onset of gender dysphoria and parental indication that their child’s gender dysphoria began during or after puberty. To maximize the chances of finding cases meeting eligibility criteria, the three websites (4thwavenow, transgender trend, and youthtranscriticalprofessionals) were selected for targeted recruitment. Website moderators and potential participants were encouraged to share the recruitment information and link to the survey with any individuals or communities that they thought might include eligible participants to expand the reach of the project through snowball sampling techniques. Data were collected anonymously via SurveyMonkey. Quantitative findings are presented as frequencies, percentages, ranges, means and/or medians. Open-ended responses from two questions were targeted for qualitative analysis of themes.
RESULTS: There were 256 parent-completed surveys that met study criteria. The AYA children described were predominantly natal female (82.8%) with a mean age of 16.4 years at the time of survey completion and a mean age of 15.2 when they announced a transgender-identification. Per parent report, 41% of the AYAs had expressed a non-heterosexual sexual orientation before identifying as transgender. Many (62.5%) of the AYAs had reportedly been diagnosed with at least one mental health disorder or neurodevelopmental disability prior to the onset of their gender dysphoria (range of the number of pre-existing diagnoses 0–7). In 36.8% of the friendship groups described, parent participants indicated that the majority of the members became transgender-identified. Parents reported subjective declines in their AYAs’ mental health (47.2%) and in parent-child relationships (57.3%) since the AYA “came out” and that AYAs expressed a range of behaviors that included: expressing distrust of non-transgender people (22.7%); stopping spending time with non-transgender friends (25.0%); trying to isolate themselves from their families (49.4%), and only trusting information about gender dysphoria from transgender sources (46.6%). Most (86.7%) of the parents reported that, along with the sudden or rapid onset of gender dysphoria, their child either had an increase in their social media/internet use, belonged to a friend group in which one or multiple friends became transgender-identified during a similar timeframe, or both.
CONCLUSION: 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.
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Bonfatto, M., & Crasnow, E. (2018). Gender/ed identities: an overview of our current work as child psychotherapists in the Gender Identity Development Service. Journal of Child Psychotherapy, 44(1), 29–46. https://doi.org/10.1080/0075417X.2018.1443150
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Journal AbstractThis paper is adapted from a presentation first given at the 2017 Association of Child Psychotherapists (ACP) Conference. We hope to give a feel of our work as psychoanalytic child psychotherapists working in a Tier 4 national assessment service for gender variant children and connect with our colleagues working therapeutically with these families in Child and Adolescent Mental Health Services (CAMHS) and other settings.

Gender variance does not have a single cause, or straightforward developmental pathway; rather it is a complex interplay of multiple factors, akin to sexuality in the diverse manifestations and ‘tributaries’ taken. This paper is given as a plea for complexity, to counter the current intense focus on gender identity and the consequent reductionism this can lead to.

To this end, three case studies from the clinic, taken from Under Five, Latency and Adolescent phases of development, are explored. The complexity of the cases is then discussed, followed by parallel issues of development, divergence and difference. These three ‘average’ cases from the Gender Identity Development Services (GIDS) serve to demonstrate the need for child psychotherapy as part of multi-disciplinary thinking about gender variance and how attention must be maintained to each unique story and process of identity development; as well as our clinical task to establish and encourage depressive functioning and secondary processes where possible.
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de Graaf, N. M., Giovanardi, G., Zitz, C., & Carmichael, P. (2018). Sex Ratio in Children and Adolescents Referred to the Gender Identity Development Service in the UK (2009–2016). Archives of Sexual Behavior, 47(5), 1301–1304. https://doi.org/10.1007/s10508-018-1204-9
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Kaltiala-Heino, R., Bergman, H., Työläjärvi, M., & Frisen, L. (2018). Gender dysphoria in adolescence: current perspectives. Adolescent Health, Medicine and Therapeutics, Volume 9, 31–41. https://doi.org/10.2147/AHMT.S135432
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Journal AbstractIncreasing 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.
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Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015). Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health, 9(1), 9. https://doi.org/10.1186/s13034-015-0042-y
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Journal AbstractBACKGROUND: Increasing numbers of adolescents present in adolescent gender identity services, desiring sex reassignment (SR). The aim of this study is to describe the adolescent applicants for legal and medical sex reassignment during the first two years of adolescent gender identity team in Finland, in terms of sociodemographic, psychiatric and gender identity related factors and adolescent development.
METHODS: Structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of 2013.
RESULTS: The number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common.
CONCLUSION: The findings do not fit the commonly accepted image of a gender dysphoric minor. Treatment guidelines need to consider gender dysphoria in minors in the context of severe psychopathology and developmental difficulties.
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Aitken, M., Steensma, T. D., Blanchard, R., VanderLaan, D. P., Wood, H., Fuentes, A., Spegg, C., Wasserman, L., Ames, M., Fitzsimmons, C. L., Leef, J. H., Lishak, V., Reim, E., Takagi, A., Vinik, J., Wreford, J., Cohen‐Kettenis, P. T., de Vries, A. L. C., Kreukels, B. P. C., & Zucker, K. J. (2015). Evidence for an Altered Sex Ratio in Clinic‐Referred Adolescents with Gender Dysphoria. The Journal of Sexual Medicine, 12(3), 756–763. https://doi.org/10.1111/jsm.12817
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Journal AbstractITNRODUCTION. The number of adolescents referred to specialized gender identity clinics for gender dysphoria appears to be increasing and there also appears to be a corresponding shift in the sex ratio, from one favoring natal males to one favoring natal females.

AIM. We conducted two quantitative studies to ascertain whether there has been a recent inversion of the sex ratio of adolescents referred for gender dysphoria.

METHODS. The sex ratio of adolescents from two specialized gender identity clinics was examined as a function of two cohort periods (2006–2013 vs. prior years). Study 1 was conducted on patients from a clinic in Toronto, and Study 2 was conducted on patients from a clinic in Amsterdam.

RESULTS. Across both clinics, the total sample size was 748. In both clinics, there was a significant change in the sex ratio of referred adolescents between the two cohort periods: between 2006 and 2013, the sex ratio favored natal females, but in the prior years, the sex ratio favored natal males. In Study 1 from Toronto, there was no corresponding change in the sex ratio of 6,592 adolescents referred for other clinical problems.

CONCLUSIONS. Sociological and sociocultural explanations are offered to account for this recent inversion in the sex ratio of adolescents with gender dysphoria.

Aitken M, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A, Spegg C, Wasserman L, Ames M, Fitzsimmons CL, Leef JH, Lishak V, Reim E, Takagi A, Vinik J, Wreford J, Cohen-Kettenis PT, de Vries ALC, Kreukels BPC, and Zucker KJ.

Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. J Sex Med 2015;12:756–763.

SEGM Summary

Short Summary: 

This research empirically documents a change in the demographics of gender dysphoric adolescents referred to gender clinics, notable for: 1) an increased rate of referrals for gender dysphoric adolescents; and 2) a reversal of the sex ratio of referred gender dysphoric adolescents from a population that favored natal males to a population that favors natal females. These changes occurred in two independent specialty gender clinics (Toronto and Amsterdam) around 2006. The etiology of these changes is unknown. None of the hypotheses offered fully explain the demographic changes observed for gender dysphoric adolescents and the absence of similar changes in adults.

Detail:

This is one of the earlier research studies to empirically document a change in the sex ratio of gender dysphoric adolescent patients referred to gender clinics, from a patient population that favored natal males (prior to 2006) to a patient population favoring natal females (2006-2013).

The current research consists of two studies that analyzed the sex ratio of gender dysphoric adolescent patients referred to the Gender Identity Service at the Center for Addiction and Mental Health (CAMH) in Toronto, Canada (the Toronto Clinic) and to the Center of Expertise on Gender Dysphoria at the VU University Medical Center in Amsterdam, the Netherlands (the Amsterdam clinic), respectively.

Study 1 evaluated data from 328 adolescents (13-19 years of age) referred to the Toronto clinic between 1976 and 2013. Over time, there was a significant increase in referred adolescents. Two time periods (1999-2005 and 2006-2013) were selected to analyze the patient natal sex data. Prior to 2006 (1999-2005), the percentage of natal males (67.9%) was greater than natal females (32.1%) but from 2006-2013, the percentage of natal females (63.9%) was greater than natal males (36.1%). In other words, the male to female sex ratio shifted from 2.11:1 to 1:1.76. The population of adolescents referred for gender dysphoria was compared to a control group which consisted of 6,592 adolescents who were referred for other reasons (not gender dysphoria) to the Children Youth and Family Services. The change in the sex ratio of referred patients was specific to the gender dysphoric youth and was not observed in the population of adolescents referred for other diagnoses.

Study 2 evaluated data from 420 adolescents (13 years of age and older) who were referred to the Amsterdam clinic between 1989 and 2013. Similar to the findings from the Toronto clinic, the Amsterdam clinic also documented a reversal in the sex ratio in adolescents referred for gender dysphoria. Prior to 2006 (1989-2005), the percentage of natal males (58.6%) was greater than natal females (41.4%) but from 2006-2013, the percentage of natal females (63.3%) was greater than natal males (36.7%). In other words, the male to female sex ratio shifted from 1.41: 1 to 1:1.72.

The authors of this research stated that “This inversion in the sex ratio of gender dysphoric youth is a new development, which requires an explanation or set of explanations” and offered several hypotheses about possible factors that may have contributed to the identified demographic changes.

They considered that the increase in visibility of transgender people in the media; wider availability of online information; reduction of stigma; and the growing awareness about the availability of medical treatments for gender dysphoria could contribute to the increased number of referrals. However, those factors would not explain the change in the sex ratio of referred adolescents. The authors offered that sex-based differences in stigma could plausibly contribute to greater numbers of natal females seeking care. However, SEGM points out that sex-based differences in stigma would not explain why the sex ratio has changed for adolescents but not for older adults.

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Giovanardi, G., Fortunato, A., Mirabella, M., Speranza, A. M., & Lingiardi, V. (2020). Gender Diverse Children and Adolescents in Italy: A Qualitative Study on Specialized Centers’ Model of Care and Network. International Journal of Environmental Research and Public Health, 17(24), 9536. https://doi.org/10.3390/ijerph17249536
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Journal AbstractIn recent years, Italy, similar to many other countries, has witnessed an increase in children and adolescents presenting gender incongruence. This trend has led to the development and implementation of specialized centers providing care and support for these youths and their families. The present study aimed at investigating the functioning of agencies specialized in working with transgender and gender non-conforming youths in the Italian territory. Professionals in these agencies were interviewed about their perspectives on their agency’s functioning, networks with other services, and work with trans* youths and their families. A semi-structured interview was developed and administered to professionals in specialized centers and associations dedicated to trans * youths, and deductive thematic analysis was applied to the transcripts. Eight professionals were interviewed: six working in specialized centers and two working in associations. The qualitative analyses of transcripts revealed four main themes, pertaining to service referrals, assessment protocols and intervention models, psychological support for youths and families, and agency shortcomings. The study explored the functioning of Italian agencies specialized in caring for transgender and gender non-conforming youths, from the perspective of professionals working in these agencies. While several positive aspects of the work emerged, the study highlighted a lack of uniformity across the Italian territory and the need for better networks between agencies and other medical professionals.
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Littman, L. (2020). The Use of Methodologies in Littman (2018) Is Consistent with the Use of Methodologies in Other Studies Contributing to the Field of Gender Dysphoria Research: Response to Restar (2019). Archives of Sexual Behavior, 49(1), 67–77. https://doi.org/10.1007/s10508-020-01631-z
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de Graaf, N. M., Carmichael, P., Steensma, T. D., & Zucker, K. J. (2018). Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London (2000–2017). The Journal of Sexual Medicine, 15(10), 1381–1383. https://doi.org/10.1016/j.jsxm.2018.08.002
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Journal AbstractINTRODUCTION: The prevalence of gender dysphoria in children is not known; however, there are some data on the sex ratio of children referred to specialized gender identity clinics.

AIM: We sought to examine the sex ratio of children, and some associated factors (age at referral and year of referral), referred to the Gender Identity Development Service in the United Kingdom, the largest such clinic in the world.

METHODS: The sex ratio of children (N ¼ 1,215) referred to the Gender Identity Development Service between 2000-2017 was examined, along with year of referral, age-related patterns, and age at referral.

MAIN OUTCOME MEASURE: Sex ratio of birth-assigned boys vs birth-assigned girls.

RESULTS: The sex ratio significantly favored birth-assigned boys over birth-assigned girls (1.27:1), but there were also age and year of referral effects. The sex ratio favored birth-assigned boys at younger ages (3-9 years), but favored birth-assigned girls at older ages (10-12 years). The percentage of referred birth-assigned boys significantly decreased when 2 cohorts were compared (2000-2006 vs 2007-2017). On average, birth-assigned boys were referred at a younger age than birth-assigned girls.

CLINICAL IMPLICATIONS: The evidence for a change in the sex ratio of children referred for gender dysphoria, particularly in recent years, matches a similar change in the sex ratio of adolescents referred for gender dysphoria. The reasons for this remain understudied.

STRENGTH & LIMITATIONS: The United Kingdom data showed both similarities and differences when compared to data from 2 other gender identity clinics for children (Toronto, Ontario, Canada, and Amsterdam, The Netherlands). Such data need to be studied in more gender identity clinics for children, perhaps with the establishment of an international registry.

CONCLUSION: Further study of the correlates of the sex ratio for children referred for gender dysphoria will be useful in clinical care and management.

de Graaf NM, Carmichael P, Steensma TD, et al.

Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London (2000-2017). J Sex Med 2018;15:1381e1383.
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Fewer Studies
B. Scientists debate medical affirmation of minors
Vandenbussche, E. (2021). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, 20. https://doi.org/10.1080/00918369.2021.1919479
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Journal AbstractThe aim of this study is to analyze the specific needs of detransi­ tioners 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 rever­ sal 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 respon­ dents overall, with a lot of negative experiences coming from medical and mental health systems and from the LGBT+ com­ munity. The study highlights the importance of increasing awareness and support given to detransitioners.
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Malone, W., D’Angelo, R., Beck, S., Mason, J., & Evans, M. (2021). Puberty blockers for gender dysphoria: the science is far from settled. The Lancet Child & Adolescent Health, 5(9), e33–e34. https://doi.org/10.1016/S2352-4642(21)00235-2
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Entwistle, K. (2020). Debate: Reality check – Detransitioner’s testimonies require us to rethink gender dysphoria. Child and Adolescent Mental Health, camh.12380. https://doi.org/10.1111/camh.12380
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Kaltiala, R., Heino, E., Työläjärvi, M., & Suomalainen, L. (2020). Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria. Nordic Journal of Psychiatry, 74(3), 213–219. https://doi.org/10.1080/08039488.2019.1691260
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de Vries, A. L. C. (2020). Challenges in Timing Puberty Suppression for Gender-Nonconforming Adolescents. Pediatrics, 146(4), e2020010611. https://doi.org/10.1542/peds.2020-010611
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Hruz, P. W. (2020). Deficiencies in Scientific Evidence for Medical Management of Gender Dysphoria. The Linacre Quarterly, 87(1), 34–42. https://doi.org/10.1177/0024363919873762
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Journal AbstractIndividuals who experience a gender identity that is discordant with biological sex are increasingly presenting to physicians for assistance in alleviating associated psychological distress. In contrast to prior efforts to identify and primarily address underlying psychiatric contributors to gender dysphoria, interventions that include uncritical social affirmation, use of gonadotropin-releasing hormone agonists to suppress normally timed puberty, and administration of cross-sex steroid hormones to induce desired secondary sex characteristics are now advocated by an emerging cohort of transgender medicine specialists. For patients with persistent gender dysphoria, surgery is offered to alter the appearance of breasts and genital organs. Efforts to address ethical concerns regarding this contentious treatment paradigm are dependent upon reliable evidence on immediate and long-term risks and benefits. Although strong recommendations have been made for invasive and potentially irreversible interventions, high-quality scientific data on the effects of this approach are generally lacking. Limitations of the existing transgender literature include general lack of randomized prospective trial design, small sample size, recruitment bias, short study duration, high subject dropout rates, and reliance on “expert” opinion. Existing data reveal significant intervention-associated morbidity and raise serious concern that the primary goal of suicide prevention is not achieved. In addition to substantial moral questions, adherence to established principles of evidence-based medicine necessitates a high degree of caution in accepting gender-affirming medical interventions as a preferred treatment approach. Continued consideration and rigorous investigation of alternate approaches to alleviating suffering in people with gender dysphoria are warranted.


Summary:
This paper provides an overview of what is currently known about people who experience a gender identity that differs from their biological sex and the associated desire to engage the medical profession in alleviating associated discomfort and distress. The scientific evidence used to support current recommendations for affirming one’s preferred gender, halting normally timed puberty, administering cross-sex hormones, and surgically altering primary and secondary sexual traits are summarized and critically evaluated. Serious deficits in understanding the cause of this condition, the reasons for the marked increase in people presenting for medical care, together with immediate and long-term risks relative to benefit of medical intervention are exposed.
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Hutchinson, A., Midgen, M., & Spiliadis, A. (2020). In Support of Research Into Rapid-Onset Gender Dysphoria. Archives of Sexual Behavior, 49(1), 79–80. https://doi.org/10.1007/s10508-019-01517-9
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Zucker, K. J. (2019). Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues. Archives of Sexual Behavior, 48(7), 1983–1992. https://doi.org/10.1007/s10508-019-01518-8
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Journal AbstractThis article provides an overview of five contemporary clinical and research issues pertaining to adolescents with a diagnosis of gender dysphoria: (1) increased referrals to specialized gender identity clinics; (2) alteration in the sex ratio; (3) suicidality; (4) “rapid-onset gender dysphoria” (ROGD) as a new developmental pathway; (5) and best practice clinical care for adolescents who may have ROGD.
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Churcher Clarke, A., & Spiliadis, A. (2019). ‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties. Clinical Child Psychology and Psychiatry, 24(2), 338–352. https://doi.org/10.1177/1359104518825288
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Journal AbstractAs 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.
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Zucker, K. J. (2018). The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender non-conforming children” by Temple Newhook et al. (2018). International Journal of Transgenderism, 19(2), 231–245. https://doi.org/10.1080/15532739.2018.1468293
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Journal AbstractTemple Newhook et al. (2018) provide a critique of recent follow-up studies of children referred to specialized gender identity clinics, organized around rates of persistence and desistance. The critical gaze of Temple Newhook et al. examined three primary issues: (1) the terms persistence and desistance in their own right; (2) methodology of the follow-up studies and interpretation of the data; and (3) ethical matters. In this response, I interrogate the critique of Temple Newhook et al. (2018).
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More Studies
Kozlowska, K., McClure, G., Chudleigh, C., Maguire, A. M., Gessler, D., Scher, S., & Ambler, G. R. (2021). Australian children and adolescents with gender dysphoria: Clinical presentations and challenges experienced by a multidisciplinary team and gender service. Human Systems, 26344041211010776. https://doi.org/10.1177/26344041211010777
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Journal AbstractThis prospective study examines the clinical characteristics of children (n = 79; 8.42–15.92 years old; 33 biological males and 46 biological females) presenting to a newly established, multidisciplinary Gender Service in New South Wales, Australia, and the challenges faced by the clinicians providing clinical services to these patients and their families. The clinical characteristics of the children were comparable to those described by other paediatric clinics providing gender services: a slight preponderance of biological females to males (1.4: 1); high levels of distress (including dysphoria about gender), suicidal ideation (41.8%), self-harm (16.3%), and suicide attempts (10.1%); and high rates of comorbid mental health disorders: anxiety (63.3%), depression (62.0%), behavioural disorders (35.4%), and autism (13.9%). The developmental stories told by the children and their families highlighted high rates of adverse childhood experiences, with family conflict (65.8%), parental mental illness (63.3%), loss of important figures via separation (59.5%), and bullying (54.4%) being most common. A history of maltreatment was also common (39.2%). Key challenges faced by the clinicians included the following: the effects of increasingly dominant, polarized discourses on daily clinical practice; issues pertaining to patient and clinician safety (including pressures to abandon the holistic [biopsychosocial] model); the difficulties of untangling gender dysphoria from comorbid factors such as anxiety, depression, and sexual abuse; and the factual uncertainties present in the currently available literature on longitudinal outcomes. Our results suggest the need to bring into play a biopsychosocial, trauma-informed model of mental health care for children presenting with gender dysphoria. Ongoing therapeutic work needs to address unresolved trauma and loss, the maintenance of subjective well-being, and the development of the self.
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Malone, W. J., Hruz, P. W., Mason, J. W., & Beck, S. (2021). Letter to the Editor from William J. Malone et al: “Proper Care of Transgender and Gender-diverse Persons in the Setting of Proposed Discrimination: A Policy Perspective.” The Journal of Clinical Endocrinology & Metabolism, dgab205. https://doi.org/10.1210/clinem/dgab205
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Bewley, S., McCartney, M., Meads, C., & Rogers, A. (2021). Sex, gender, and medical data. BMJ, n735. https://doi.org/10.1136/bmj.n735
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Biggs, M. (2021, February 3). More questions than answers about the outcomes of puberty suppression. https://journals.plos.org/plosone/article/comment?id=10.1371%2Fannotation%2F71faadb8-de18-4c65-9482-93ded40984b6&s=08
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Walch, A., Davidge-Pitts, C., Safer, J. D., Lopez, X., Tangpricha, V., & Iwamoto, S. J. (2021). Proper Care of Transgender and Gender Diverse Persons in the Setting of Proposed Discrimination: A Policy Perspective*. The Journal of Clinical Endocrinology & Metabolism, 106(2), 305–308. https://doi.org/10.1210/clinem/dgaa816
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Journal AbstractAbstract
Transgender and gender diverse (TGD) individuals face significant barriers to accessing health care. Recent introductions of regulatory policies at state and federal levels raise concerns over the politicization of gender-affirming health care, the risks of further restricting access to quality care, and the potential criminalization of healthcare professionals who care for TGD patients. The Endocrine Society and the Pediatric Endocrine Society have published several news articles and comments in the last couple of years supporting safe and effective gender-affirming interventions as outlined in the 2017 Endocrine Society’s Clinical Practice Guidelines. The Endocrine Society Position Statement on Transgender Health also acknowledges the rapid expansion in understanding the biological underpinning of gender identity and the need for increased funding to help close gaps in knowledge about the optimal care of TGD individuals. This Policy Perspective affirms these principles in the context of pending and future legislation attempting to discriminate against TGD patients while also stressing the need for science and health care experts to inform health policies.
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Expósito-Campos, P. (2021). A Typology of Gender Detransition and Its Implications for Healthcare Providers. Journal of Sex & Marital Therapy. https://www.tandfonline.com/doi/abs/10.1080/0092623X.2020.1869126
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Journal Abstract(2021). A Typology of Gender Detransition and Its Implications for Healthcare Providers. Journal of Sex & Marital Therapy. Ahead of Print.
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Armitage, R. (2021). The communication of evidence to inform trans youth health care. The Lancet Child & Adolescent Health, S2352464221001929. https://doi.org/10.1016/S2352-4642(21)00192-9
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O’Malley, S., Garner, M., Withers, R., Caspian, J., & Jenkins, P. (2021). The communication of evidence to inform trans youth health care. The Lancet Child & Adolescent Health, S2352464221001978. https://doi.org/10.1016/S2352-4642(21)00197-8
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Dahlen, S., Connolly, D., Arif, I., Junejo, M. H., Bewley, S., & Meads, C. (2021). International clinical practice guidelines for gender minority/trans people: systematic review and quality assessment. BMJ Open, 11(4), e048943. https://doi.org/10.1136/bmjopen-2021-048943
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Journal AbstractObjectives
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.


PROSPERO registration number
CRD42019154361.
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Kozlowska, K., Chudleigh, C., McClure, G., Maguire, A. M., & Ambler, G. R. (2021). Attachment Patterns in Children and Adolescents With Gender Dysphoria. Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.582688
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Journal AbstractThe 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) (χ2=52.66; p<.001) and had a high rate of unresolved loss/trauma (χ2=18.64; p<.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 (χ2=2.43; p=.30) and rates of unresolved loss and trauma (χ2=0.70; p=.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.
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D’Angelo, R., Syrulnik, E., Ayad, S., Marchiano, L., Kenny, D. T., & Clarke, P. (2020). One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-020-01844-2
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Bailey, J. (2020). The Minority Stress Model Deserves Reconsideration, Not Just Extension. Archives of Sexual Behavior, 49. https://doi.org/10.1007/s10508-019-01606-9
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D’Angelo, Roberto. (2020). The man I am trying to be is not me. The International Journal of Psychoanalysis. https://doi.org/10.1080/00207578.2020.1810049
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Anckarsäter, H., & Gillberg, C. (2020). Methodological Shortcomings Undercut Statement in Support of Gender-Affirming Surgery. American Journal of Psychiatry, 177(8), 764–765. https://doi.org/10.1176/appi.ajp.2020.19111117
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Ring, A., & Malone, W. J. (2020). Confounding Effects on Mental Health Observations After Sex Reassignment Surgery. American Journal of Psychiatry, 177(8), 768–769. https://doi.org/10.1176/appi.ajp.2020.19111169
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Van Mol, A., Laidlaw, M. K., Grossman, M., & McHugh, P. R. (2020). Gender-Affirmation Surgery Conclusion Lacks Evidence. American Journal of Psychiatry, 177(8), 765–766. https://doi.org/10.1176/appi.ajp.2020.19111130
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Evans, M. (2020). Freedom to think: the need for thorough assessment and treatment of gender dysphoric children. BJPsych Bulletin, 1–5. https://doi.org/10.1192/bjb.2020.72
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Journal AbstractSUMMARY: Referrals (particularly natal female) to gender identity clinics have increased significantly in recent years. Understanding the reasons for this increase, and how to respond, is hampered by a politically charged debate regarding gender identity. This article starts with a discussion of the so-called 'affirmative approach' to gender dysphoria and considers the implications of the Memorandum of Understanding on conversion therapy. I then say something about the relationship between gender dysphoria and the developmental problems that are characteristic of adolescence. Finally, I outline what changes to the current approach are needed to do our best to ensure these patients receive the appropriate treatment.
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Griffin, L., Clyde, K., Byng, R., & Bewley, S. (2020). Sex, gender and gender identity: a re-evaluation of the evidence. BJPsych Bulletin, 1–9. https://doi.org/10.1192/bjb.2020.73
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Journal AbstractSummary
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.
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Cantor, J. M. (2020). Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy. Journal of Sex & Marital Therapy, 46(4), 307–313. https://doi.org/10.1080/0092623X.2019.1698481
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Journal AbstractThe American Academy of Pediatrics (AAP) recently published a policy statement: Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Although almost all clinics and professional associations in the world use what's called the watchful waiting approach to helping gender diverse (GD) children, the AAP statement instead rejected that consensus, endorsing gender affirmation as the only acceptable approach. Remarkably, not only did the AAP statement fail to include any of the actual outcomes literature on such cases, but it also misrepresented the contents of its citations, which repeatedly said the very opposite of what AAP attributed to them.
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D’Angelo, R. (2020). Who is Phoenix? Journal of Medical Ethics, 46(11), 753–754. https://doi.org/10.1136/medethics-2020-106822
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D’Angelo, R. (2020). The complexity of childhood gender dysphoria. Australasian Psychiatry, 28(5), 530–532. https://doi.org/10.1177/1039856220917076
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Journal AbstractObjective:
To explore a developmental understanding of childhood gender dysphoria and to compare it to the prevailing paradigm, gender-affirming care.


Conclusion:
Viewing gender dysphoria through a contemporary developmental frame generates a different understanding of the nature of the phenomenon and its treatment and raises ethical questions about our current gender-affirming approach.
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Biggs, M. (2020). Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria. Archives of Sexual Behavior, 49(7), 2227–2229. https://doi.org/10.1007/s10508-020-01743-6
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Biggs, M. (2020). Gender Dysphoria and Psychological Functioning in Adolescents Treated with GnRHa: Comparing Dutch and English Prospective Studies. Archives of Sexual Behavior, 49(7), 2231–2236. https://doi.org/10.1007/s10508-020-01764-1
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Zucker, K. J. (2020). Debate: Different strokes for different folks. Child and Adolescent Mental Health, 25(1), 36–37. https://doi.org/10.1111/camh.12330
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Withers, Robert. (2020). Transgender medicalization and the attempt to evade psychological distress. Journal of Analytical Psychology, 65(5), 865–889.
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Byng, R., & Bewley, S. (2019). Gender dysphoria: scientific oversight falling between responsible institutions should worry us all. BMJ, l6439. https://doi.org/10.1136/bmj.l6439
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Levine, S. B. (2019). Informed Consent for Transgendered Patients. Journal of Sex & Marital Therapy, 45(3), 218–229. https://doi.org/10.1080/0092623X.2018.1518885
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Journal AbstractThe request of a transgendered-identified patient for psychiatric, medical, or surgical services creates ethical tensions in mental health professionals, primary care physicians, endocrinologists, and surgeons. These may be summarized as follows: Does the patient have a clear idea of the risks of the services that are being requested? Is the consent truly informed? While this question is starkly evident among cross-gender identified children contemplating puberty suppression and social gender transition and young adolescents with rapid-onset gender dysphoria, it is also relevant to young, middle-aged, and older adults requesting assistance. Many patients cannot tolerate detailed discussion of the risks. This article reviews the history of informed consent, presents the conflicts of ethical principles, and presents three categories of risk that must be appreciated before informed consent is accomplished. The risks involve biological, social, and psychological consequences. Four specific risks exist in each category. The World Professional Association for Transgender Health's Standards of Care recommend an informed consent process, which is at odds with its recommendation of providing hormones on demand. With the knowledge of these 12 risks and benefits of treatment, it is possible to organize the informed consent process by specialty, and for the specific services requested. As it now stands, in many settings informed consent is a perfunctory process creating the risk of uninformed consent.
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Laidlaw, M. K., Van Meter, Q. L., Hruz, P. W., Van Mol, A., & Malone, W. J. (2019). Letter to the Editor: “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, 104(3), 686–687. https://doi.org/10.1210/jc.2018-01925
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Heneghan, Carl, & Jefferson, Tom. (2019, February 25). Gender-affirming hormone in children and adolescents. BMJ EBM Spotlight. https://blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormone-in-children-and-adolescents-evidence-review/
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Journal AbstractGender dysphoria occurs when a person experiences discomfort or distress because of a mismatch between their biological sex and gender identity.  Gender dysphoria can arise in childhood and adolescent which raises many questions about how best to handle the condition. This post sets out some of  the current evidence for gender-affirming hormones in adolescents [...]Read More...
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Biggs, M. (2019). A Letter to the Editor Regarding the Original Article by Costa et al: Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria. The Journal of Sexual Medicine, 16(12), 2043. https://doi.org/10.1016/j.jsxm.2019.09.002
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Bewley, S., Clifford, D., McCartney, M., & Byng, R. (2019). Gender incongruence in children, adolescents, and adults. British Journal of General Practice, 69(681), 170–171. https://doi.org/10.3399/bjgp19X701909
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Laidlaw, M., Cretella, M., & Donovan, K. (2019). The Right to Best Care for Children Does Not Include the Right to Medical Transition. The American Journal of Bioethics, 19(2), 75–77. https://doi.org/10.1080/15265161.2018.1557288
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Spiliadis, A. (2019). Towards a gender exploratory model: Slowing things down, opening things up and exploring identity development. Metalogos Systemic Therapy Journal, 35, 1–9. https://www.ohchr.org/Documents/Issues/SexualOrientation/IESOGI/Other/Rebekah_Murphy_TowardsaGenderExploratoryModelslowingthingsdownopeningthingsupandexploringidentitydevelopment.pdf
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Journal AbstractThroughout the western world, the care of children and adolescents whose
sexed corporeality is at odds with their gender-related feelings raises medical,
psychological, and ethical dilemmas. There are currently differing views
around what constitutes responsive and timely support for these young people
and how professionals can operate within a rapidly shifting and contested field,
in which evidence-base is scarce. In this article I aim to reposition the
theoretical framework away from ‘affirmative’ or ‘reparative’ polarities, arguing
that both can be problematic, and to invite the reader into a Gender
Exploratory Model (GEM) grounded in a systemic-developmental framework;
such a model acknowledges and often embraces the notion of uncertainty with
regards to young people’s developmental trajectories and clinician’s ‘unknown
unknowns’ and exploratory responsibilities. A short introduction to the service
(GIDS), as well as a presentation of the current theoretical and clinical
debates, will offer a contextual base for clinicians supporting young people
experiencing gender dysphoria. This is not an attempt to explore the
multifactorial aetiology of gender dysphoria but rather one to add on the
theoretical underpinning of therapeutic approaches in supporting these young
people.
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Byng, R., Bewley, S., Clifford, D., & McCartney, M. (2018). Redesigning gender identity services: an opportunity to generate evidence. BMJ, k4490. https://doi.org/10.1136/bmj.k4490
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Levine, S. B. (2018). Ethical Concerns About Emerging Treatment Paradigms for Gender Dysphoria. Journal of Sex & Marital Therapy, 44(1), 29–44. https://doi.org/10.1080/0092623X.2017.1309482
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Journal AbstractThe increasing incidence of requests for medical services to support gender transition for children, adolescents, and adults has consequences for society, governmental institutions, schools, families, health-care professionals, and, of course, patients. The sociological momentum to recognize and accommodate to trans phenomena has posed ethical dilemmas for endocrinologists, mental health professionals, and sexual specialists as they experience within themselves the clash between respect for patient autonomy, beneficence, nonmaleficence, and informed consent. The larger ethical clashes are cultural and therefore political. There is a distinct difference between pronouncements that represent human rights ideals and the reality of clinical observations. Some interpret this clash as a moral issue. This article delves into these tensions and reminds apologists from both passionate camps that clinical science has a rich tradition of resolving controversy through careful follow-up, which is not yet well developed in this arena.
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de Graaf, N. M., Carmichael, P., Steensma, T. D., & Zucker, K. J. (2018). Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London (2000–2017). The Journal of Sexual Medicine, 15(10), 1381–1383. https://doi.org/10.1016/j.jsxm.2018.08.002
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Journal AbstractINTRODUCTION: The prevalence of gender dysphoria in children is not known; however, there are some data on the sex ratio of children referred to specialized gender identity clinics.

AIM: We sought to examine the sex ratio of children, and some associated factors (age at referral and year of referral), referred to the Gender Identity Development Service in the United Kingdom, the largest such clinic in the world.

METHODS: The sex ratio of children (N ¼ 1,215) referred to the Gender Identity Development Service between 2000-2017 was examined, along with year of referral, age-related patterns, and age at referral.

MAIN OUTCOME MEASURE: Sex ratio of birth-assigned boys vs birth-assigned girls.

RESULTS: The sex ratio significantly favored birth-assigned boys over birth-assigned girls (1.27:1), but there were also age and year of referral effects. The sex ratio favored birth-assigned boys at younger ages (3-9 years), but favored birth-assigned girls at older ages (10-12 years). The percentage of referred birth-assigned boys significantly decreased when 2 cohorts were compared (2000-2006 vs 2007-2017). On average, birth-assigned boys were referred at a younger age than birth-assigned girls.

CLINICAL IMPLICATIONS: The evidence for a change in the sex ratio of children referred for gender dysphoria, particularly in recent years, matches a similar change in the sex ratio of adolescents referred for gender dysphoria. The reasons for this remain understudied.

STRENGTH & LIMITATIONS: The United Kingdom data showed both similarities and differences when compared to data from 2 other gender identity clinics for children (Toronto, Ontario, Canada, and Amsterdam, The Netherlands). Such data need to be studied in more gender identity clinics for children, perhaps with the establishment of an international registry.

CONCLUSION: Further study of the correlates of the sex ratio for children referred for gender dysphoria will be useful in clinical care and management.

de Graaf NM, Carmichael P, Steensma TD, et al.

Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London (2000-2017). J Sex Med 2018;15:1381e1383.
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Marchiano, L. (2017). Outbreak: On Transgender Teens and Psychic Epidemics. Psychological Perspectives, 60(3), 345–366. https://doi.org/10.1080/00332925.2017.1350804
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Journal AbstractHaving 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.
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Hakeem, A. (2012). Psychotherapy for gender identity disorders. Advances in Psychiatric Treatment, 18(1), 17–24. https://doi.org/10.1192/apt.bp.111.009431
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Journal AbstractThis article describes a special adaptation of group psychotherapy as a psychological treat­ ment 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.
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Fewer Studies
C. Health risks of medical and surgical affirmation
Bone health complications
Biggs, M. (2021). Revisiting the effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria. Journal of Pediatric Endocrinology & Metabolism: JPEM, 34(7), 937–939. https://doi.org/10.1515/jpem-2021-0180
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SEGM Summary

Suppressing puberty in children suffering from gender dysphoria by administering Gonadotropin-Releasing Hormone Agonist (GnRHa) entails several known risks. One is that patients could “end with a decreased bone density, which is associated with a high risk of osteoporosis" (Delemarre-van de Waal & Cohen-Kettenis 2006).

This study analyzed data from UK's Tavistock clinic regarding bone density of young gender dysphoric people undergoing puberty blockade. The analysis found that after two years on GnRHa, the Z-scores for a significant minority of the children had declined to clinically-concerning levels. For the hip, one third of Z-scores were below -2. For the spine, over a quarter of Z-scores were below the threshold of -2. Some scores fell below ‑3; such low bone density is found in only 0.13% of the population.

The clinical consequences of the failure to accrue normal bone mass are unknown, as no data on fractures experienced by children undergoing puberty suppression have been tracked. Biggs cites an example of one patient at the Tavistock clinic who started GnRHa at age 12 and then experienced four broken bones by the age of 16, however it is possible that this case is exceptional.

Researchers in the Netherlands have published similar results on bone density, suggesting that future studies should “investigate clinically important outcomes such as fracture risk” (Schagen et al. 2020).

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Schagen, S. E. E., Wouters, F. M., Cohen-Kettenis, P. T., Gooren, L. J., & Hannema, S. E. (2020). Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones. The Journal of Clinical Endocrinology & Metabolism, 105(12), dgaa604. https://doi.org/10.1210/clinem/dgaa604
JOURNAL ABSTRACT
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Journal AbstractAbstract

CONTEXT

Hormonal interventions in adolescents with gender dysphoria may have adverse effects, such as reduced bone mineral accrual.

OBJECTIVE

To describe bone mass development in adolescents with gender dysphoria treated with gonadotropin-releasing hormone analogues (GnRHa), subsequently combined with gender-affirming hormones.


DESIGN

Observational prospective study.

SUBJECTS

51 transgirls and 70 transboys receiving GnRHa and 36 transgirls and 42 transboys receiving GnRHa and gender-affirming hormones, subdivided into early- and late-pubertal groups.


MAIN OUTCOME MEASURES

Bone mineral apparent density (BMAD), age- and sex-specific BMAD z-scores, and serum bone markers.

RESULTS

At the start of GnRHa treatment, mean areal bone mineral density (aBMD) and BMAD values were within the normal range in all groups. In transgirls, the mean z-scores were well below the population mean. During 2 years of GnRHa treatment, BMAD stabilized or showed a small decrease, whereas z-scores decreased in all groups. During 3 years of combined administration of GnRHa and gender-affirming hormones, a significant increase of BMAD was found. Z-scores normalized in transboys but remained below zero in transgirls. In transgirls and early pubertal transboys, all bone markers decreased during GnRHa treatment.


CONCLUSIONS

BMAD z-scores decreased during GnRHa treatment and increased during gender-affirming hormone treatment. Transboys had normal z-scores at baseline and at the end of the study. However, transgirls had relatively low z-scores, both at baseline and after 3 years of estrogen treatment. It is currently unclear whether this results in adverse outcomes, such as increased fracture risk, in transgirls as they grow older.

SEGM Summary

This prospective but uncontrolled observational study investigated the effect of GnRH agonist therapy alone or with subsequent cross-sex hormone administration on markers of bone turnover, apparent bone density (BMAD) and bone density z-scores, with analysis of subjects started early (Tanner state 1-2) and late (Tanner 3-4) in pubertal development.  The study included 51 MTF and 70 FTM subjects receiving GnRH agonsits for 2 years, with 36 MTF and 42 FTM receiving cross-sex hormones for 3 years.

This study confirmed reduction in bone turnover and failure to increase BMAD during exposure to GnRH agonists.  Administration of estrogen to biological males led to increased bone density accrual but did not normalize BMAD z-scores after 3 years.  Biological females receiving testosterone showed improvement in BMAD z-scores to those of biological female peers. 

 

SEGM Plain Language Conclusion:

This study confirmed that use of puberty blockers during normally timed puberty reduces bone turnover and prevents normal accrual of bone density. The addition of cross-sex hormones for three years after pubertal blockade did not result in normalization of bone density in males treated with estrogen. Females receiving testosterone showed near normalization of bone density. Effects on bone structure and fracture risk remain unknown. 

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Stoffers, I. E., de Vries, M. C., & Hannema, S. E. (2019). Physical changes, laboratory parameters, and bone mineral density during testosterone treatment in adolescents with gender dysphoria. The Journal of Sexual Medicine, 16(9), 1459–1468. https://doi.org/10.1016/j.jsxm.2019.06.014
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Journal AbstractINTRODUCTION: Current treatment guidelines for adolescents with gender dysphoria recommend therapy with gonadotropin-releasing hormone agonists (GnRHa) and testosterone in transgender males. However, most evidence on the safety and efficacy of testosterone is based on studies in adults.
AIM: This study aimed to investigate the efficacy and safety of testosterone treatment in transgender adolescents.
METHODS: The study included 62 adolescents diagnosed with gender dysphoria who had started GnRHa treatment and had subsequently received testosterone treatment for more than 6 months.
MAIN OUTCOME MEASURE: Virilization, anthropometry, laboratory parameters, and bone mineral density (BMD) were analyzed.
RESULTS: Adolescents were treated with testosterone for a median duration of 12 months. Voice deepening began within 3 months in 85% of adolescents. Increased hair growth was first reported on the extremities, followed by an increase of facial hair. Acne was most prevalent between 6 and 12 months of testosterone therapy. Most adolescents had already completed linear growth; body mass index and systolic blood pressure increased but diastolic blood pressure did not change. High-density lipoprotein (HDL) cholesterol and sex hormone binding globulin significantly decreased, but hematocrit, hemoglobin, prolactin, androstenedione, and dehydroepiandrosterone sulfate significantly increased, although not all changes were clinically significant. Other lipids and HbA1c did not change. Vitamin D deficiency was seen in 32-54% throughout treatment. BMD z-scores after 12 to 24 months of testosterone treatment remained below z-scores before the start of GnRHa treatment.
CLINICAL IMPLICATIONS: Adolescents need to be counseled about side effects with potential longer term implications such as increased hematocrit and decreased HDL cholesterol and decreased BMD z-scores. They should be advised on diet, including adequate calcium and vitamin D intake; physical exercise; and the use of tobacco and alcohol to avoid additional risk factors for cardiovascular disease and osteoporosis.
STRENGTHS & LIMITATIONS: Strengths are the standardized treatment regimen and extensive set of safety parameters investigated. Limitations are the limited duration of follow-up and lack of a control group so some of the observed changes may be due to normal maturation rather than to treatment.
CONCLUSION: Testosterone effectively induced virilization beginning within 3 months in the majority of adolescents. Acne was a common side effect, but no short-term safety issues were observed. The increased hematocrit, decreased HDL cholesterol, and decreased BMD z-scores are in line with previous studies. Further follow-up studies will need to establish if the observed changes result in adverse outcomes in the long term. Stoffers IE, de Vries MC, Hannema SE. Physical Changes, Laboratory Parameters, and Bone Mineral Density During Testosterone Treatment in Adolescents with Gender Dysphoria. J Sex Med 2019;16:1459-1468.

SEGM Summary

This retrospective uncontrolled study investigated the metabolic and bone effects of testosterone administration on 62 gender dysphoric female subjects after GnRH agonist mediated pubertal blockade.  Following 6 and 12 months of  testosterone administration, BMAD z-scores remained below those observed prior to the start of GnRH agonists. In addition, HDL cholesterol was significantly lower and Hct higher with testosterone administration.  Most subjects had completed linear growth prior to starting testosterone.  Vitamin D deficiency was seen in 32-54% of study subjects throughout the study period.

In gender dysphoric females who had received GnRH agonists for at least 6 months, bone density losses were not corrected 12 months after starting testosterone. 

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Stevenson, M. O., & Tangpricha, V. (2019). Osteoporosis and Bone Health in Transgender Persons. Endocrinology and Metabolism Clinics of North America, 48(2), 421–427. https://doi.org/10.1016/j.ecl.2019.02.006
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Journal AbstractThis review summarizes current studies, systematic reviews, and clinical practice guidelines regarding the screening, diagnosis, and treatment of osteoporosis in transgender persons. Gender-affirming hormone therapy has been shown to maintain or promote acquisition of bone density as measured by dual-energy x-ray absorptiometry. No differences in fracture rates have been seen in trans women or men in short, prospective trials. Trans children and adolescents on gonadotropin-releasing hormone may be at risk for decreasing bone density while not on sex steroid hormone replacement. Screening for osteoporosis should be based on clinical factors. Treatment for osteoporosis follows the same guidelines as cisgender populations.
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Vlot, M. C., Klink, D. T., den Heijer, M., Blankenstein, M. A., Rotteveel, J., & Heijboer, A. C. (2017). Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents. Bone, 95, 11–19. https://doi.org/10.1016/j.bone.2016.11.008
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Journal AbstractPuberty is highly important for the accumulation of bone mass. Bone turnover and bone mineral density (BMD) can be affected in transgender adolescents when puberty is suppressed by gonadotropin-releasing hormone analogues (GnRHa), followed by treatment with cross-sex hormone therapy (CSHT). We aimed to investigate the effect of GnRHa and CSHT on bone turnover markers (BTMs) and bone mineral apparent density (BMAD) in transgender adolescents. Gender dysphoria was diagnosed based on diagnostic criteria according to the DSM-IV (TR). Thirty four female-to-male persons (transmen) and 22 male-to-female persons (transwomen)were included. Patients were allocated to a young (bone age of <15years in transwomen or <14 in transmen) or old group (bone age of ≥15years in transwomen or ≥14years in transmen). All were treated with GnRHa triptorelin and CSHT was added in incremental doses from the age of 16years. Transmen received testosterone esters (Sustanon, MSD) and transwomen received 17-β estradiol. P1NP, osteocalcin, ICTP and BMD of lumbar spine (LS) and femoral neck (FN) were measured at three time points. In addition, BMAD and Z-scores were calculated. We found a decrease of P1NP and 1CTP during GnRHa treatment, indicating decreased bone turnover (young transmen 95% CI -74 to -50%, p=0.02, young transwomen 95% CI -73 to -43, p=0.008). The decrease in bone turnover upon GnRHa treatment was accompanied by an unchanged BMAD of FN and LS, whereas BMAD Z-scores of predominantly the LS decreased especially in the young transwomen. Twenty-four months after CSHT the BTMs P1NP and ICTP were even more decreased in all groups except for the old transmen. During CSHT BMAD increased and Z-scores returned towards normal, especially of the LS (young transwomen CI 95% 0.1 to 0.6, p=0.01, old transwomen 95% CI 0.3 to 0.8, p=0.04). To conclude, suppressing puberty by GnRHa leads to a decrease of BTMs in both transwomen and transmen transgender adolescents. The increase of BMAD and BMAD Z-scores predominantly in the LS as a result of treatment with CSHT is accompanied by decreasing BTM concentrations after 24months of CSHT. Therefore, the added value of evaluating BTMs seems to be limited and DXA-scans remain important in follow-up of bone health of transgender adolescents.

SEGM Summary

In healthy adolescents, bone mass accumulates during puberty. The first retrospective study of the effects of suppressing puberty and cross-sex hormones on bone turnover markers in 56 adolescents with gender dysphoria examined the effects of pubertal suppression by gonadotropin-releasing hormone analogues (GnRHa) and subsequent cross-sex hormone administration on bone turnover markers (BTM), bone mineral apparent density (BMAD), and the associated Z-scores. 

In this in study, administration GnRHa treatment led to a decrease in BTM, a reduction in BMAD Z-scores, and a stable, rather than increased  BMAD, suggesting a loss of bone density in the GnRHa-treated adolescents compared to their peers. After the initiation of CSH, BTM continued to decrease, while BMAD increased. Although BMAD Z-scores increased, the pre-treatment BMAD Z-scores were not reached in most adolescents treated with CSH after 24 months.

SEGM Plain Language Conclusion: In this study, puberty-blocker treatment led to a delay in bone mass accumulation. Although  the subsequent cross-sex hormone administration stimulated bone growth, it was not sufficient to catch up to the bone density of the untreated peers. Thus, the treatment pathway of puberty blockade followed by cross-sex hormones for at least two years lead to a failure to achieve peak bone density for both biologically male and female adolescents.

 

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Klink, D., Caris, M., Heijboer, A., van Trotsenburg, M., & Rotteveel, J. (2015). Bone Mass in Young Adulthood Following Gonadotropin-Releasing Hormone Analog Treatment and Cross-Sex Hormone Treatment in Adolescents With Gender Dysphoria. The Journal of Clinical Endocrinology & Metabolism, 100(2), E270–E275. https://doi.org/10.1210/jc.2014-2439
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Journal AbstractCONTEXT: Sex steroids are important for bone mass accrual. Adolescents with gender dysphoria (GD) treated with gonadotropin-releasing hormone analog (GnRHa) therapy are temporarily sex-steroid deprived until the addition of cross-sex hormones (CSH). The effect of this treatment on bone mineral density (BMD) in later life is not known.
OBJECTIVE: This study aimed to assess BMD development during GnRHa therapy and at age 22 years in young adults with GD who started sex reassignment (SR) during adolescence.
DESIGN AND SETTING: This was a longitudinal observational study at a tertiary referral center.
PATIENTS: Young adults diagnosed with gender identity disorder of adolescence (DSM IV-TR) who started SR in puberty and had undergone gonadectomy between June 1998 and August 2012 were included. In 34 subjects BMD development until the age of 22 years was analyzed.
INTERVENTION: GnRHa monotherapy (median duration in natal boys with GD [transwomen] and natal girls with GD [transmen] 1.3 and 1.5 y, respectively) followed by CSH (median duration in transwomen and transmen, 5.8 and 5.4 y, respectively) with discontinuation of GnRHa after gonadectomy.
MAJOR OUTCOME MEASURES: How BMD develops during SR until the age of 22 years.
RESULTS AND CONCLUSION: Between the start of GnRHa and age 22 years the lumbar areal BMD z score (for natal sex) in transwomen decreased significantly from -0.8 to -1.4 and in transmen there was a trend for decrease from 0.2 to -0.3. This suggests that the BMD was below their pretreatment potential and either attainment of peak bone mass has been delayed or peak bone mass itself is attenuated.

SEGM Summary

This retrospective study looked at bone mineral density (BMD) in 34 young gender dysphoric adults at the average age of 22, who had been given gonadotropin releasing hormone analog (GnRHa) to suppress or delay puberty for 1.3  - 1.5 years, followed by cross-sex hormones for about 3 years.

The main finding of this study is that young adults treated with GnRHa during adolescence have decreased BMD and loss of bone mass despite the subsequent administration of cross-sex hormones. Importantly, most of the study subjects were relatively late in their puberty when GnRHAs were initiated (average age 15), so much of their bone mass development had already occurred. It is not yet known how much BMD in children and younger adolescents treated with GnRHAs at a younger age will be affected, nor is it known whether these losses will lead to increased risk of fractures in later life.

SEGM Plain-Language Conclusion: In this study, young adults treated with puberty blockers during mid-adolescence had decreased bone mineral density and a loss of bone mass, despite a relatively late initiation of puberty blockers,  and despite a subsequent administration of cross-sex hormones.

 

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Lee, J. Y., Finlayson, C., Olson-Kennedy, J., Garofalo, R., Chan, Y.-M., Glidden, D. V., & Rosenthal, S. M. (2020). Low Bone Mineral Density in Early Pubertal Transgender/Gender Diverse Youth: Findings From the Trans Youth Care Study. Journal of the Endocrine Society, 4(9), bvaa065. https://doi.org/10.1210/jendso/bvaa065
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Journal AbstractAbstract

Context
Transgender youth may initiate GnRH agonists (GnRHa) to suppress puberty, a critical period for bone-mass accrual. Low bone mineral density (BMD) has been reported in late-pubertal transgender girls before gender-affirming therapy, but little is known about BMD in early-pubertal transgender youth.


Objective
To describe BMD in early-pubertal transgender youth.


Design
Cross-sectional analysis of the prospective, observational, longitudinal Trans Youth Care Study cohort.


Setting
Four multidisciplinary academic pediatric gender centers in the United States.


Participants
Early-pubertal transgender youth initiating GnRHa.


Main Outcome Measures
Areal and volumetric BMD Z-scores.


Results
Designated males at birth (DMAB) had below-average BMD Z-scores when compared with male reference standards, and designated females at birth (DFAB) had below-average BMD Z-scores when compared with female reference standards except at hip sites. At least 1 BMD Z-score was < -2 in 30% of DMAB and 13% of DFAB. Youth with low BMD scored lower on the Physical Activity Questionnaire for Older Children than youth with normal BMD, 2.32 ± 0.71 vs. 2.76 ± 0.61 (P = 0.01). There were no significant deficiencies in vitamin D, but dietary calcium intake was suboptimal in all youth.


Conclusions
In early-pubertal transgender youth, BMD was lower than reference standards for sex designated at birth. This lower BMD may be explained, in part, by suboptimal calcium intake and decreased physical activity–potential targets for intervention. Our results suggest a potential need for assessment of BMD in prepubertal gender-diverse youth and continued monitoring of BMD throughout the pubertal period of gender-affirming therapy.

SEGM Summary

This is a multi-center cross-sectional analysis of bone density in 63 early pubertal transgender youth prior to or just after initiation of GnRH agonist administration. 

Average BMAD z-scores were found to be lower in study subjects compared to sex in the general population.  Z-scores < -2 were found in 30% of males and 15% of females. 

Correlation was found between decreased physical activity (PAQ-C) and lower bone density.  Calcium intake was lower among the cohort but this did not correlate with differences in bone density.  No difference in 25OH vitamin D was observed.

The authors conclude that poor bone health prior to hormonal therapy is at least partially responsible for adverse bone density in this population. Direct comparison to a control population in all comparisons is needed to fully interpret the significance of their findings. 

Weaknesses:  A third of the subjects in the observational GnRH agonist study cohort were excluded from this analysis. No control group was included. 

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Joseph, T., Ting, J., & Butler, G. (2019). The effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria: findings from a large national cohort. Journal of Pediatric Endocrinology and Metabolism, 32(10), 1077–1081. https://doi.org/10.1515/jpem-2019-0046
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Journal AbstractBackground: More young people with gender dysphoria (GD) are undergoing hormonal intervention starting with gonadotropin-releasing hormone analogue (GnRHa) treatment. The impact on bone density is not known, with guidelines mentioning that bone mineral density (BMD) should be monitored without suggesting when. This study aimed to examine a cohort of adolescents from a single centre to investigate whether there were any clinically significant changes in BMD and bone mineral apparent density (BMAD) whilst on GnRHa therapy.
Methods: A retrospective review of 70 subjects aged 12–14 years, referred to a national centre for the management of GD (2011–2016) who had yearly dual energy X-ray absorptiometry (DXA) scans. BMAD scores were calculated from available data. Two analyses were performed, a complete longitudinal analysis (n = 31) where patients had scans over a 2-year treatment period, and a larger cohort over the first treatment year (n = 70) to extend the observation of rapid changes in lumbar spine BMD when puberty is blocked.
Results: At baseline transboys had lower BMD measures than transgirls. Although there was a significant fall in hip and lumbar spine BMD and lumbar spine BMAD Z-scores, there was no significant change in the absolute values of hip or spine BMD or lumbar spine BMAD after 1 year on GnRHa and a lower fall in BMD/BMAD Z-scores in the longitudinal group in the second year.
Conclusions: We suggest that reference ranges may need to be re-defined for this select patient cohort. Long-term

SEGM Summary

This is a retrospective single center study investigating longitudinal change in bone density in transgender 12-14 year old adolescents exposed to GnRH agonists. 70 subjects had DEXA scans at baseline and 12 months. 31 subjects had data at 24 months.  BMD and BMAD were unchanged but Z-scores significantly decreased. 

This study shows that pubertal blockade in gender dysphoric teens is associated with arrest of normal bone density accrual with resulting fall in bone density z-scores.

Strength:  Relatively large number of subjects.

Limitations: Limited follow up. Analysis limited to DEXA scans. Does not assess effects of subsequent cross-sex hormones. Does not assess bone turnover.

 

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Delgado-Ruiz, R., Swanson, P., & Romanos, G. (2019). Systematic Review of the Long-Term Effects of Transgender Hormone Therapy on Bone Markers and Bone Mineral Density and Their Potential Effects in Implant Therapy. Journal of Clinical Medicine, 8(6), 784. https://doi.org/10.3390/jcm8060784
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Journal AbstractThis study seeks to evaluate the long-term effects of pharmacologic therapy on the bone markers and bone mineral density of transgender patients and to provide a basis for understanding its potential implications on therapies involving implant procedures. Following the referred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and well-defined PICOT (Problem/Patient/Population, Intervention, Comparison, Outcome, Time) questionnaires, a literature search was completed for articles in English language, with more than a 3 year follow-up reporting the long-term effects of the cross-sex pharmacotherapy on the bones of adult transgender patients. Transgender demographics, time under treatment, and treatment received were recorded. In addition, bone marker levels (calcium, phosphate, alkaline phosphatase, and osteocalcin), bone mineral density (BMD), and bone turnover markers (Serum Procollagen type I N-Terminal pro-peptide (PINP), and Serum Collagen type I crosslinked C-telopeptide (CTX)) before and after the treatment were also recorded. The considerable variability between studies did not allow a meta-analysis. All the studies were completed in European countries. Transwomen (921 men to female) were more frequent than transmen (719 female to male). Transwomen’s treatments were based in antiandrogens, estrogens, new drugs, and sex reassignment surgery, meanwhile transmen’s surgeries were based in the administration of several forms of testosterone and sex reassignment. Calcium, phosphate, alkaline phosphatase, and osteocalcin levels remained stable. PINP increased in transwomen and transmen meanwhile, CTX showed contradictory values in transwomen and transmen. Finally, reduced BMD was observed in transwomen patients receiving long-term cross-sex pharmacotherapy. Considering the limitations of this systematic review, it was concluded that long-term cross-sex pharmacotherapy for transwomen and transmen transgender patients does not alter the calcium, phosphate, alkaline phosphatase, and osteocalcin levels, and will slightly increase the bone formation in both transwomen and transmen patients. Furthermore, long-term pharmacotherapy reduces the BMD in transwomen patients.

SEGM Summary

This systematic literature review aimed to determine the effects of long-term (follow-up >3 years) cross-sex hormone administration and non-hormonal pharmacological treatments on bone markers and bone mineral density (BMD) of adults with gender dysphoria. The review also sought to determine how these long-term treatments might affect the success of orthopedic or dental implants.

This review of nine European studies found that BMD in natal males was somewhat reduced by these treatments. Because of this finding and the lack of information about bone healing in persons undergoing hormone treatment, the authors recommend using precautions intended for osteoporotic patients and monitoring of bone parameters prior to dental implant therapy.

SEGM Plain-Language Conclusion: A systematic review of 9 studies concluded that cross-sex hormones treatments reduced bone mineral in male to female adult patients. Adolescent and young patients were excluded from the analysis. The authors noted the substantial group variability in age, drug and dosage, time under treatment, and biomarkers analyzed, which contributed to contradictory findings and precluded a statistical analysis.

 

 

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Dobrolińska, M., van der Tuuk, K., Vink, P., van den Berg, M., Schuringa, A., Monroy-Gonzalez, A. G., García, D. V., Schultz, W. C. M. W., & Slart, R. H. J. A. (2019). Bone Mineral Density in Transgender Individuals After Gonadectomy and Long-Term Gender-Affirming Hormonal Treatment. The Journal of Sexual Medicine, 16(9), 1469–1477. https://doi.org/10.1016/j.jsxm.2019.06.006
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Journal AbstractINTRODUCTION: Establishing the influence of long-term, gender-affirming hormonal treatment (HT) on bone mineral density (BMD) in transgender individuals is important to improve the therapeutic guidelines for these individuals.
AIM: To examine the effect of long-term HT and gonadectomy on BMD in transgender individuals.
METHODS: 68 transwomen and 43 transmen treated with HT who had undergone gonadectomy participated in this study. Dual-energy x-ray absorptiometry (DXA) scans were performed to measure BMD at the lumbar spine and total hip. Laboratory values related to sex hormones were collected within 3 months of performing the DXA scan and analyzed.
MAIN OUTCOME MEASURE: BMD and levels of sex hormones in transwomen and transmen.
RESULTS: In transwomen, the mean BMD values at the lumbar spine and total hip at the first DXA scan were, respectively, 0.99 ± 0.15 g/cm2 (n = 68) and 0.94 ± 0.28 g/cm2 (n = 65). In transmen, the mean BMD values at the lumbar spine and total hip at the first DXA scan were, respectively, 1.08 ± 0.16 g/cm2 (n = 43) and 1.01 ± 0.18 g/cm2 (n = 43). A significant decrease in total hip BMD was found in both transwomen and transmen after 15 years of HT compared with 10 years of HT (P = .02).
CONCLUSION: In both transwomen and transmen, a decrease was observed in total hip bone mineral density after 15 years of HT compared to the first 10 years of HT. Dobrolińska M, van der Tuuk K, Vink P, et al. Bone Mineral Density in Transgender Individuals After Gonadectomy and Long-Term Gender-Affirming Hormonal Treatment. J Sex Med 2019; 16:1469-1477.

SEGM Summary

This retrospective study of 111 gender-dysphoric individuals was conducted to determine the long-term effects of gonadectomy and long-term hormonal treatment (HT) on bone mineral density (BMD).  The individuals were on average 36 (MTF) and 30 (FMT) years old at the time of the initiation of HT.  Dual-energy x-ray absorptiometry (DXA) scans measured BMD at the lumbar spine and hip after 10 and 15 years of HT.

At 15 years, males and females on HT had reduced BMD, compared to measurements taken after 10 years. The duration of treatment with HT and the time since gonadectomy correlated with an observed decrease in total hip BMD in males and females. A high prevalence of osteoporosis in the treated population was observed.

SEGM Plain-Language Conclusion: Given the relatively old age of the initiation of HT (36 and 30 years old for trans women and trans men respectively), and a presumed lack of pubertal suppression, this finding suggests that even after peak bone mass density has been achieved, gonadectomy and long-term HT are associated with an adverse impact on BMD.

 

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Cardiovascular complications
Nota, N. M., Wiepjes, C. M., de Blok, C. J. M., Gooren, L. J. G., Kreukels, B. P. C., & den Heijer, M. (2019). Occurrence of Acute Cardiovascular Events in Transgender Individuals Receiving Hormone Therapy: Results From a Large Cohort Study. Circulation, 139(11), 1461–1462. https://doi.org/10.1161/CIRCULATIONAHA.118.038584
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Alzahrani, T., Nguyen, T., Ryan, A., Dwairy, A., McCaffrey, J., Yunus, R., Forgione, J., Krepp, J., Nagy, C., Mazhari, R., & Reiner, J. (2019). Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population. Circulation: Cardiovascular Quality and Outcomes, 12(4). https://doi.org/10.1161/CIRCOUTCOMES.119.005597
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Getahun, D., Nash, R., Flanders, W. D., Baird, T. C., Becerra-Culqui, T. A., Cromwell, L., Hunkeler, E., Lash, T. L., Millman, A., Quinn, V. P., Robinson, B., Roblin, D., Silverberg, M. J., Safer, J., Slovis, J., Tangpricha, V., & Goodman, M. (2018). Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons. Annals of Internal Medicine, 169(4), 205–213. https://doi.org/10.7326/M17-2785
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Journal AbstractBackground:
Venous thromboembolism (VTE), ischemic stroke, and myocardial infarction in transgender persons may be related to hormone use.

Objective:
To examine the incidence of these events in a cohort of transgender persons.

Design:
Electronic medical record-based cohort study of transgender members of integrated health care systems who had an index date (first evidence of transgender status) from 2006 through 2014. Ten male and 10 female cisgender enrollees were matched to each transgender participant by year of birth, race/ethnicity, study site, and index date enrollment.

Setting:
Kaiser Permanente in Georgia and northern and southern California.

Patients:
2842 transfeminine and 2118 transmasculine members with a mean follow-up of 4.0 and 3.6 years, respectively, matched to 48 686 cisgender men and 48 775 cisgender women.

Measurements:
VTE, ischemic stroke, and myocardial infarction events ascertained from diagnostic codes through the end of 2016 in transgender and reference cohorts.

Results:
Transfeminine participants had a higher incidence of VTE, with 2-and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women. The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for VTE and ischemic stroke were observed among transfeminine participants who initiated hormone therapy during follow-up. The evidence was insufficient to allow conclusions regarding risk among transmasculine participants.

Limitation:
Inability to determine which transgender members received hormones elsewhere.

Conclusion:
The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen.
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Fewer Studies
Fertility complications
Baram, S., Myers, S. A., Yee, S., & Librach, C. L. (2019). Fertility preservation for transgender adolescents and young adults: a systematic review. Human Reproduction Update, 25(6), 694–716. https://doi.org/10.1093/humupd/dmz026
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Journal AbstractAbstract

BACKGROUND
Many transgender individuals choose to undergo gender-affirming hormone treatment (GAHT) and/or sex reassignment surgery (SRS) to alleviate the distress that is associated with gender dysphoria. Although these treatment options often succeed in alleviating such symptoms, they can also negatively impact future reproductive potential.


OBJECTIVE AND RATIONALE
The purpose of this systematic review was to synthesize the available psychosocial and medical literature on fertility preservation (FP) for transgender adolescents and young adults (TAYAs), to identify gaps in the current research and provide suggestions for future research directions.


SEARCH METHODS
A systematic review of English peer-reviewed papers published from 2001 onwards, using the preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA-P) guidelines, was conducted. Four journal databases (Ovid MEDLINE, PubMed Medline, Ovid Embase and Ovid PsychINFO) were used to identify all relevant studies exploring psychosocial or medical aspects of FP in TAYAs. The search strategy used a combination of subject headings and generic terms related to the study topic and population. Bibliographies of the selected articles were also hand searched and cross-checked to ensure comprehensive coverage. All selected papers were independently reviewed by the co-authors. Characteristics of the studies, objectives and key findings were extracted, and a systematic review was conducted.


OUTCOMES
Included in the study were 19 psychosocial-based research papers and 21 medical-based research papers that explore fertility-related aspects specific for this population. Key psychosocial themes included the desire to have children for TAYAs; FP discussions, counselling and referrals provided by healthcare providers (HCPs); FP utilization; the attitudes, knowledge and beliefs of TAYAs, HCPs and the parents/guardians of TAYAs; and barriers to accessing FP. Key medical themes included fertility-related effects of GAHT, FP options and outcomes. From a synthesis of the literature, we conclude that there are many barriers preventing TAYAs from pursuing FP, including a lack of awareness of FP options, high costs, invasiveness of the available procedures and the potential psychological impact of the FP process. The available medical data on the reproductive effects of GAHT are diverse, and while detrimental effects are anticipated, the extent to which these effects are reversible is unknown.


WIDER IMPLICATIONS
FP counselling should begin as early as possible as a standard of care before GAHT to allow time for informed decisions. The current lack of high-quality medical data specific to FP counselling practice for this population means there is a reliance on expert opinion and extrapolation from studies in the cisgender population. Future research should include large-scale cohort studies (preferably multi-centered), longitudinal studies of TAYAs across the FP process, qualitative studies of the parents/guardians of TAYAs and studies evaluating the effectiveness of different strategies to improve the attitudes, knowledge and beliefs of HCPs.
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Nahata, L., Tishelman, A. C., Caltabellotta, N. M., & Quinn, G. P. (2017). Low Fertility Preservation Utilization Among Transgender Youth. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 61(1), 40–44. https://doi.org/10.1016/j.jadohealth.2016.12.012
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Journal AbstractPURPOSE: Research demonstrates a negative psychosocial impact of infertility among otherwise healthy adults, and distress among adolescents facing the prospect of future infertility due to various medical conditions and treatments that impair reproductive health. Guidelines state that providers should counsel transgender youth about potential infertility and fertility preservation (FP) options prior to initiation of hormone therapy. The purpose of this study was to examine the rates of fertility counseling and utilization of FP among a cohort of adolescents with gender dysphoria seen at a large gender clinic.
METHODS: An Institutional Review Board-approved retrospective review of electronic medical records was conducted of all patients with ICD-9/10 codes for gender dysphoria referred to Pediatric Endocrinology for hormone therapy (puberty suppression and/or cross-sex hormones) from January 2014 to August 2016.
RESULTS: Seventy-eight patients met inclusion criteria. Five children were prepubertal, no hormone therapy was considered, and they were therefore excluded. Of the remaining 73 patients, 72 had documented fertility counseling prior to initiation of hormone therapy and 2 subjects attempted FP; 45% of subjects mentioned a desire or plan to adopt, and 21% said they had never wanted to have children.
CONCLUSIONS: Utilization rates of FP are low among transgender adolescents. More research is needed to understand parenthood goals among transgender youth at different ages and developmental stages and to explore the impact of gender dysphoria on decision-making about FP and parenthood. Discussions about infertility risk, FP, and other family building options should be prioritized in this vulnerable adolescent population.
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Mayhew, A. C., & Gomez-Lobo, V. (2020). Fertility Options for the Transgender and Gender Nonbinary Patient. The Journal of Clinical Endocrinology and Metabolism, 105(10). https://doi.org/10.1210/clinem/dgaa529
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Journal AbstractComprehensive care for transgender and gender nonbinary patients has been a priority established by the World Professional Association for Transgender Health. Because pubertal suppression, gender-affirming hormone therapy, and antiandrogen therapy used alone or in combination during medical transition can affect gonadal function, understanding the effects these treatments have on fertility potential is important for practitioners caring for transgender and gender nonbinary patients. In this review, we outline the impacts of gender-affirming treatments on fertility potential and discuss the counseling and the treatment approach for fertility preservation and/or family building in transgender and gender nonbinary individuals.
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Pang, K. C., Peri, A. J. S., Chung, H. E., Telfer, M., Elder, C. V., Grover, S., & Jayasinghe, Y. (2020). Rates of Fertility Preservation Use Among Transgender Adolescents. JAMA Pediatrics, 174(9), 890. https://doi.org/10.1001/jamapediatrics.2020.0264
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Dulohery, K., Trottmann, M., Bour, S., Liedl, B., Alba‐Alejandre, I., Reese, S., Hughes, B., Stief, C. G., & Kölle, S. (2020). How do elevated levels of testosterone affect the function of the human fallopian tube and fertility?—New insights. Molecular Reproduction and Development, 87(1), 30–44. https://doi.org/10.1002/mrd.23291
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Journal AbstractExcess testosterone levels affect up to 20% of the female population worldwide and are a key component in the pathogenesis of polycystic ovary syndrome. However, little is known about how excess testosterone affects the function of the human fallopian tube—the site of gamete transport, fertilization, and early embryogenesis. Therefore, this study aimed to characterize alterations caused by long‐term exposure to male testosterone levels. For this purpose, the Fallopian tubes of nine female‐to‐male transsexuals, who had been undergoing testosterone treatment for 1–3 years, were compared with the tubes of 19 cycling patients. In the ampulla, testosterone treatment resulted in extensive luminal accumulations of secretions and cell debris which caused ciliary clumping and luminal blockage. Additionally, the percentage of ciliated cells in the ampulla was significantly increased. Transsexual patients, who had had sexual intercourse before surgery, showed spermatozoa trapped in mucus. Finally, in the isthmus complete luminal collapse occurred. Our results imply that fertility in women with elevated levels of testosterone is altered by tubal luminal obstruction resulting in impaired gamete transport and survival.
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Leung, A., Sakkas, D., Pang, S., Thornton, K., & Resetkova, N. (2019). Assisted reproductive technology outcomes in female-to-male transgender patients compared with cisgender patients: a new frontier in reproductive medicine. Fertility and Sterility, 112(5), 858–865. https://doi.org/10.1016/j.fertnstert.2019.07.014
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Journal AbstractOBJECTIVE: To investigate assisted reproductive technology (ART) outcomes in a female-to-male transgender cohort and compare the results with those of a matched cisgender cohort.
DESIGN: Matched retrospective cohort study.
SETTING: In vitro fertilization clinic.
PATIENT(S): Female-to-male transgender patients (n = 26) who sought care from 2010 to 2018. A cisgender cohort (n = 130) was matched during the same time period by age, body mass index, and antimüllerian hormone levels.
INTERVENTION(S): Not applicable.
MAIN OUTCOME MEASURE(S): Cycle outcomes, including oocyte yield, number of mature oocytes, total gonadotropin dose, and peak E2 levels.
RESULT(S): The mean number of oocytes retrieved in the transgender group was 19.9 ± 8.7 compared with 15.9 ± 9.6 in the cisgender group. Peak E2 levels were the same between the two groups. The total dose of gonadotropins used was higher in the transgender group compared with the cisgender group (3,892 IU vs. 2,599 IU). Of the 26 patients, 16 performed oocyte banking only. Seven couples had fresh or frozen transfers, with all achieving live births.
CONCLUSION(S): This is the first study of this size investigating ART outcomes in female-to-male transgender patients. The findings may serve to reassure transgender patients and their care providers that outcomes can be excellent even if testosterone therapy has already been initiated. Further investigation needs to be performed on the generalizability of these findings, and whether similar results can be achieved without stopping testosterone therapy.
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Cheng, P. J., Pastuszak, A. W., Myers, J. B., Goodwin, I. A., & Hotaling, J. M. (2019). Fertility concerns of the transgender patient. Translational Andrology and Urology, 8(3), 209–218. https://doi.org/10.21037/tau.2019.05.09
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Journal AbstractTransgender individuals who undergo gender-affirming medical or surgical therapies are at risk for infertility. Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery (GAS) that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility. It is recommended that clinicians counsel transgender patients on fertility preservation (FP) options prior to initiation of gender-affirming therapy. Transmen can choose to undergo cryopreservation of oocytes or embryos, which requires hormonal stimulation for egg retrieval. Uterus preservation allows transmen to gestate if desired. For transwomen, the option for FP is cryopreservation of sperm either through masturbation or testicular sperm extraction. Experimental and future options may include cryopreservation and in vitro maturation of ovarian or testicular tissue, which could provide prepubertal transgender youth an option for FP since they lack mature gametes. Successful uterus transplantation with subsequent live birth is a new medical breakthrough for cisgender women with uterus factor infertility. Although it has not yet been performed in transgender women, uterus transplantation is a potential solution for those who wish to get pregnant. The transgender population faces many barriers to care, such as provider discrimination, lack of information, legal barriers, scarcity of fertility centers, financial burden, and emotional cost. Further research is necessary to investigate the feasibility of experimental FP options, provide better evidence-based information to clinicians and transgender patients alike, and to improve access to and quality of reproductive services for the transgender population.
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Bizic, M. R., Jeftovic, M., Pusica, S., Stojanovic, B., Duisin, D., Vujovic, S., Rakic, V., & Djordjevic, M. L. (2018). Gender Dysphoria: Bioethical Aspects of Medical Treatment. BioMed Research International, 2018, 1–6. https://doi.org/10.1155/2018/9652305
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Journal AbstractGender affirmation surgery remains one of the greatest challenges in transgender medicine. In recent years, there have been continuous discussions on bioethical aspects in the treatment of persons with gender dysphoria. Gender reassignment is a difficult process, including not only hormonal treatment with possible surgery but also social discrimination and stigma. There is a great variety between countries in specified tasks involved in gender reassignment, and a complex combination of medical treatment and legal paperwork is required in most cases. The most frequent bioethical questions in transgender medicine pertain to the optimal treatment of adolescents, sterilization as a requirement for legal recognition, role of fertility and parenthood, and regret after gender reassignment. We review the recent literature with respect to any new information on bioethical aspects related to medical treatment of people with gender dysphoria.
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Delemarre-van de Waal, H. A., & Cohen-Kettenis, P. T. (2006). Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. European Journal of Endocrinology, 155(suppl_1), S131–S137. https://doi.org/10.1530/eje.1.02231
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Journal AbstractTreatment outcome in transsexuals is expected to be more favourable when puberty is suppressed than when treatment is started after Tanner stage 4 or 5. In the Dutch protocol for the treatment of transsexual adolescents, candidates are considered eligible for the suppression of endogenous puberty when they fulfil the Diagnostic and Statistic Manual of Mental Disorders-IV-RT criteria for gender disorder, have suffered from lifelong extreme gender dysphoria, are psychologically stable and live in a supportive environment. Suppression of puberty should be considered as supporting the diagnostic procedure, but not as the ultimate treatment. If the patient, after extensive exploring of his/her sex reassignment (SR) wish, no longer pursues SR, pubertal suppression can be discontinued. Otherwise, cross-sex hormone treatment can be given at 16 years, if there are no contraindications. Treatment consists of a GnRH analogue (GnRHa) to suppress endogenous gonadal stimulation from B2-3 and G34, and prevents development of irreversible sex characteristics of the unwanted sex. From the age of 16 years, cross-sex steroid hormones are added to the GnRHa medication.
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Other biomedical risks and uncertanties
Hruz, P. W. (2020). Deficiencies in Scientific Evidence for Medical Management of Gender Dysphoria. The Linacre Quarterly, 87(1), 34–42. https://doi.org/10.1177/0024363919873762
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Journal AbstractIndividuals who experience a gender identity that is discordant with biological sex are increasingly presenting to physicians for assistance in alleviating associated psychological distress. In contrast to prior efforts to identify and primarily address underlying psychiatric contributors to gender dysphoria, interventions that include uncritical social affirmation, use of gonadotropin-releasing hormone agonists to suppress normally timed puberty, and administration of cross-sex steroid hormones to induce desired secondary sex characteristics are now advocated by an emerging cohort of transgender medicine specialists. For patients with persistent gender dysphoria, surgery is offered to alter the appearance of breasts and genital organs. Efforts to address ethical concerns regarding this contentious treatment paradigm are dependent upon reliable evidence on immediate and long-term risks and benefits. Although strong recommendations have been made for invasive and potentially irreversible interventions, high-quality scientific data on the effects of this approach are generally lacking. Limitations of the existing transgender literature include general lack of randomized prospective trial design, small sample size, recruitment bias, short study duration, high subject dropout rates, and reliance on “expert” opinion. Existing data reveal significant intervention-associated morbidity and raise serious concern that the primary goal of suicide prevention is not achieved. In addition to substantial moral questions, adherence to established principles of evidence-based medicine necessitates a high degree of caution in accepting gender-affirming medical interventions as a preferred treatment approach. Continued consideration and rigorous investigation of alternate approaches to alleviating suffering in people with gender dysphoria are warranted.


Summary:
This paper provides an overview of what is currently known about people who experience a gender identity that differs from their biological sex and the associated desire to engage the medical profession in alleviating associated discomfort and distress. The scientific evidence used to support current recommendations for affirming one’s preferred gender, halting normally timed puberty, administering cross-sex hormones, and surgically altering primary and secondary sexual traits are summarized and critically evaluated. Serious deficits in understanding the cause of this condition, the reasons for the marked increase in people presenting for medical care, together with immediate and long-term risks relative to benefit of medical intervention are exposed.
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Shirazi, T. N., Self, H., Dawood, K., Cárdenas, R., Welling, L. L. M., Rosenfield, K. A., Ortiz, T. L., Carré, J. M., Balasubramanian, R., Delaney, A., Crowley, W., Breedlove, S. M., & Puts, D. A. (2020). Pubertal timing predicts adult psychosexuality: Evidence from typically developing adults and adults with isolated GnRH deficiency. Psychoneuroendocrinology, 119, 104733. https://doi.org/10.1016/j.psyneuen.2020.104733
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Journal AbstractEvidence suggests that psychosexuality in humans is modulated by both organizational effects of prenatal and
peripubertal sex steroid hormones, and by activational effects of circulating hormones in adulthood.
Experimental work in male rodents indicates that sensitivity to androgen-driven organization of sexual motivation
decreases across the pubertal window, such that earlier puberty leads to greater sex-typicality. We test
this hypothesis in typically developing men (n = 231) and women (n = 648), and in men (n = 72) and women
(n = 32) with isolated GnRH deficiency (IGD), in whom the precise timing of peripubertal hormone exposure
can be ascertained via the age at which hormone replacement therapy (HRT) was initiated. Psychosexuality was
measured with the Sexual Desire Inventory-2 (SDI-2) and Sociosexual Orientation Inventory-Revised (SOI-R). In
both sexes, earlier recalled absolute pubertal timing predicted higher psychosexuality in adulthood, although the
magnitude of these associations varied with psychosexuality type and group (i.e., typically developing and IGD).
Results were robust when controlling for circulating steroid hormones in typically developing participants. Age
of initiation of HRT in men with IGD negatively predicted SOI-R. We discuss the clinical implications of our
findings for conditions in which pubertal timing is medically altered.
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Stoffers, I. E., de Vries, M. C., & Hannema, S. E. (2019). Physical changes, laboratory parameters, and bone mineral density during testosterone treatment in adolescents with gender dysphoria. The Journal of Sexual Medicine, 16(9), 1459–1468. https://doi.org/10.1016/j.jsxm.2019.06.014
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Journal AbstractINTRODUCTION: Current treatment guidelines for adolescents with gender dysphoria recommend therapy with gonadotropin-releasing hormone agonists (GnRHa) and testosterone in transgender males. However, most evidence on the safety and efficacy of testosterone is based on studies in adults.
AIM: This study aimed to investigate the efficacy and safety of testosterone treatment in transgender adolescents.
METHODS: The study included 62 adolescents diagnosed with gender dysphoria who had started GnRHa treatment and had subsequently received testosterone treatment for more than 6 months.
MAIN OUTCOME MEASURE: Virilization, anthropometry, laboratory parameters, and bone mineral density (BMD) were analyzed.
RESULTS: Adolescents were treated with testosterone for a median duration of 12 months. Voice deepening began within 3 months in 85% of adolescents. Increased hair growth was first reported on the extremities, followed by an increase of facial hair. Acne was most prevalent between 6 and 12 months of testosterone therapy. Most adolescents had already completed linear growth; body mass index and systolic blood pressure increased but diastolic blood pressure did not change. High-density lipoprotein (HDL) cholesterol and sex hormone binding globulin significantly decreased, but hematocrit, hemoglobin, prolactin, androstenedione, and dehydroepiandrosterone sulfate significantly increased, although not all changes were clinically significant. Other lipids and HbA1c did not change. Vitamin D deficiency was seen in 32-54% throughout treatment. BMD z-scores after 12 to 24 months of testosterone treatment remained below z-scores before the start of GnRHa treatment.
CLINICAL IMPLICATIONS: Adolescents need to be counseled about side effects with potential longer term implications such as increased hematocrit and decreased HDL cholesterol and decreased BMD z-scores. They should be advised on diet, including adequate calcium and vitamin D intake; physical exercise; and the use of tobacco and alcohol to avoid additional risk factors for cardiovascular disease and osteoporosis.
STRENGTHS & LIMITATIONS: Strengths are the standardized treatment regimen and extensive set of safety parameters investigated. Limitations are the limited duration of follow-up and lack of a control group so some of the observed changes may be due to normal maturation rather than to treatment.
CONCLUSION: Testosterone effectively induced virilization beginning within 3 months in the majority of adolescents. Acne was a common side effect, but no short-term safety issues were observed. The increased hematocrit, decreased HDL cholesterol, and decreased BMD z-scores are in line with previous studies. Further follow-up studies will need to establish if the observed changes result in adverse outcomes in the long term. Stoffers IE, de Vries MC, Hannema SE. Physical Changes, Laboratory Parameters, and Bone Mineral Density During Testosterone Treatment in Adolescents with Gender Dysphoria. J Sex Med 2019;16:1459-1468.

SEGM Summary

This retrospective uncontrolled study investigated the metabolic and bone effects of testosterone administration on 62 gender dysphoric female subjects after GnRH agonist mediated pubertal blockade.  Following 6 and 12 months of  testosterone administration, BMAD z-scores remained below those observed prior to the start of GnRH agonists. In addition, HDL cholesterol was significantly lower and Hct higher with testosterone administration.  Most subjects had completed linear growth prior to starting testosterone.  Vitamin D deficiency was seen in 32-54% of study subjects throughout the study period.

In gender dysphoric females who had received GnRH agonists for at least 6 months, bone density losses were not corrected 12 months after starting testosterone. 

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Hough, D., Bellingham, M., Haraldsen, I. R. H., McLaughlin, M., Rennie, M., Robinson, J. E., Solbakk, A. K., & Evans, N. P. (2017). Spatial memory is impaired by peripubertal GnRH agonist treatment and testosterone replacement in sheep. Psychoneuroendocrinology, 75, 173–182. https://doi.org/10.1016/j.psyneuen.2016.10.016
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Journal Abstract
Peripubertal GnRHa impaired long-term spatial reference memory.



This GnRHa-effect was not counteracted with testosterone replacement in rams.



Traverse times of spatial orientation and learning tasks were unaffected by GnRHa.



GnRHa exaggerated emotional reactivity during these spatial tasks.



Testosterone replacement decreased emotional reactivity and motivation in tasks.


, Chronic gonadotropin-releasing hormone agonist (GnRHa) is used therapeutically to block activity within the reproductive axis through down-regulation of GnRH receptors within the pituitary gland. GnRH receptors are also expressed in non-reproductive tissues, including areas of the brain such as the hippocampus and amygdala. The impact of long-term GnRHa-treatment on hippocampus-dependent cognitive functions, such as spatial orientation, learning and memory, is not well studied, particularly when treatment encompasses a critical window of development such as puberty. The current study used an ovine model to assess spatial maze performance and memory of rams that were untreated (Controls), had both GnRH and testosterone signaling blocked (GnRHa-treated), or specifically had GnRH signaling blocked (GnRHa-treated with testosterone replacement) during the peripubertal period (8, 27 and 41 weeks of age). The results demonstrate that emotional reactivity during spatial tasks was compromised by the blockade of gonadal steroid signaling, as seen by the restorative effects of testosterone replacement, while traverse times remained unchanged during assessment of spatial orientation and learning. The blockade of GnRH signaling alone was associated with impaired retention of long-term spatial memory and this effect was not restored with the replacement of testosterone signaling. These results indicate that GnRH signaling is involved in the retention and recollection of spatial information, potentially via alterations to spatial reference memory, and that therapeutic medical treatments using chronic GnRHa may have effects on this aspect of cognitive function.
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Schagen, S. E. E., Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., & Hannema, S. E. (2016). Efficacy and Safety of Gonadotropin-Releasing Hormone Agonist Treatment to Suppress Puberty in Gender Dysphoric Adolescents. The Journal of Sexual Medicine, 13(7), 1125–1132. https://doi.org/10.1016/j.jsxm.2016.05.004
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Journal AbstractIntroduction: Puberty suppression using gonadotropin-releasing hormone agonists (GnRHas) is recommended by current guidelines as the treatment of choice for gender dysphoric adolescents. Although GnRHas have long been used to treat precocious puberty, there are few data on the efficacy and safety in gender dysphoric adolescents. Therefore, the Endocrine Society guideline recommends frequent monitoring of gonadotropins, sex steroids, and renal and liver function. Aim: To evaluate the efficacy and safety of GnRHa treatment to suppress puberty in gender dysphoric adolescents.
Methods: Forty-nine male-to-female and 67 female-to-male gender dysphoric adolescents treated with triptorelin were included in the analysis. Main Outcome Measures: Physical examination, including assessment of Tanner stage, took place every 3 months and blood samples were drawn at 0, 3, and 6 months and then every 6 months. Body composition was evaluated using dual energy x-ray absorptiometry.
Results: GnRHa treatment caused a decrease in testicular volume in 43 of 49 male-to-female subjects. In one of four female-to-male subjects who presented at Tanner breast stage 2, breast development completely regressed. Gonadotropins and sex steroid levels were suppressed within 3 months. Treatment did not have to be adjusted because of insufficient suppression in any subject. No sustained abnormalities of liver enzymes or creatinine were encountered. Alkaline phosphatase decreased, probably related to a slower growth velocity, because height SD score decreased in boys and girls. Lean body mass percentage significantly decreased during the first year of treatment in girls and boys, whereas fat percentage significantly increased.
Conclusion: Triptorelin effectively suppresses puberty in gender dysphoric adolescents. These data suggest routine monitoring of gonadotropins, sex steroids, creatinine, and liver function is not necessary during treatment with triptorelin. Further studies should evaluate the extent to which changes in height SD score and body composition that occur during GnRHa treatment can be reversed during subsequent cross-sex hormone treatment.
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Mul, D., Versluis-den Bieman, H. J., Slijper, F. M., Oostdijk, W., Waelkens, J. J., & Drop, S. L. (2001). Psychological assessments before and after treatment of early puberty in adopted children. Acta Paediatrica (Oslo, Norway: 1992), 90(9), 965–971. https://doi.org/10.1080/080352501316978011
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Journal AbstractEarly puberty is frequently observed in adopted children. This randomized trial treated 30 adopted children with early puberty and short stature with either gonadotropin-releasing hormone agonist (GnRHa) alone or in combination with growth hormone (GH) for 3 y. Before the start of treatment (T1) in the trial and at discontinuation (T2) the children and their parents underwent a psychological evaluation. At the start of treatment the children did not have increased levels of behavioural or emotional problems as assessed by the Child Behaviour Checklist (CBCL). During treatment the CBCL scores did not increase. Self-perception of the children appeared to be normal, and after 3 y a significantly higher score for acceptance by peers was observed. At T1, an overestimation of future height was present in 80% of the children and 17% of the parents. Lower family stress was observed at T1 and T2 compared with reference values. Intelligence quotient levels decreased significantly during treatment. The findings are discussed with reference to the reported levels of behavioural and emotional problems in adopted children and the psychosocial effects of precocious puberty.
CONCLUSION: This psychological evaluation did not reveal any consistent abnormalities in adopted children with early puberty. Treatment with GnRHa with or without GH did not increase emotional and behavioural problems in adopted children, nor was their self-perception decreased.
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D. Desistence, detransition and regret
Adolescent-onset gender dysphoria
Vandenbussche, E. (2021). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, 20. https://doi.org/10.1080/00918369.2021.1919479
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Journal AbstractThe aim of this study is to analyze the specific needs of detransi­ tioners 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 rever­ sal 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 respon­ dents overall, with a lot of negative experiences coming from medical and mental health systems and from the LGBT+ com­ munity. The study highlights the importance of increasing awareness and support given to detransitioners.
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Entwistle, K. (2020). Debate: Reality check – Detransitioner’s testimonies require us to rethink gender dysphoria. Child and Adolescent Mental Health, camh.12380. https://doi.org/10.1111/camh.12380
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Hutchinson, A., Midgen, M., & Spiliadis, A. (2020). In Support of Research Into Rapid-Onset Gender Dysphoria. Archives of Sexual Behavior, 49(1), 79–80. https://doi.org/10.1007/s10508-019-01517-9
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Expósito-Campos, P. (2021). A Typology of Gender Detransition and Its Implications for Healthcare Providers. Journal of Sex & Marital Therapy. https://www.tandfonline.com/doi/abs/10.1080/0092623X.2020.1869126
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Journal Abstract(2021). A Typology of Gender Detransition and Its Implications for Healthcare Providers. Journal of Sex & Marital Therapy. Ahead of Print.
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Hall, R., Mitchell, L., & Sachdeva, J. (2021). Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review. BJPsych Open, 7(6), e184. https://doi.org/10.1192/bjo.2021.1022
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Journal AbstractBackground
UK adult gender identity clinics (GICs) are implementing a new streamlined service model. However, there is minimal evidence from these services underpinning this. It is also unknown how many service users subsequently ‘detransition’.


Aims
To describe service users’ access to care and patterns of service use, specifically, interventions accessed, reasons for discharge and re-referrals; to identify factors associated with access; and to quantify ‘detransitioning’.


Method
A retrospective case-note review was performed as a service evaluation for 175 service users consecutively discharged by a tertiary National Health Service adult GIC between 1 September 2017 and 31 August 2018. Descriptive statistics were used for rates of accessing interventions sought, reasons for discharge, re-referral and frequency of detransitioning. Using multivariate analysis, we sought associations between several variables and ‘accessing care’ or ‘other outcome’.


Results
The treatment pathway was completed by 56.1%. All interventions initially sought were accessed by 58%; 94% accessed hormones but only 47.7% accessed gender reassignment surgery; 21.7% disengaged; and 19.4% were re-referred. Multivariate analysis identified coexisting neurodevelopmental disorders (odds ratio [OR] = 5.7, 95% CI = 1.7–19), previous adverse childhood experiences (ACEs) per reported ACE (OR = 1.5, 95% CI = 1.1–1.9), substance misuse during treatment (OR = 4.3, 95% CI = 1.1–17.6) and mental health concerns during treatment (OR = 2.2, 95% CI 1.1–4.4) as independently associated with accessing care. Twelve people (6.9%) met our case definition of detransitioning.


Conclusions
Service users may have unmet needs. Neurodevelopmental disorders or ACEs suggest complexity requiring consideration during the assessment process. Managing mental ill health and substance misuse during treatment needs optimising. Detransitioning might be more frequent than previously reported.
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Butler, C., & Hutchinson, A. (2020). Debate: The pressing need for research and services for gender desisters/detransitioners. Child and Adolescent Mental Health, 25(1), 45–47. https://doi.org/10.1111/camh.12361
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Journal AbstractThe number of people presenting at gender clinics is increasing worldwide. Many people undergo a gender
transition with subsequent improved psychological well-being (Paediatrics, 2014, 134, 696). However, some
people choose to stop this journey, ‘desisters’, or to reverse their transition, ‘detransitioners’. It has been suggested
that some professionals and activists are reluctant to acknowledge the existence of desisters and detransitioners, possibly fearing that they may delegitimize persisters’ experiences (International Journal of Transgenderism, 2018, 19, 231).

Certainly, despite their presence in all follow-up studies of young people who
have experienced gender dysphoria (GD), little thought has been given to how we might support this cohort. Levine (Archives of Sexual Behaviour, 2017, 47, 1295) reports that the 8th edition of the WPATH Standards of Care will include a section on detransitioning – confirming that this is an increasingly witnessed phenomenon
worldwide. It also highlights that compared to the extensive protocols for working with children, adolescents
and adults who wish to transition, nothing exists for those working with desisters or detransitioners. With very
little research and no clear guidance on how to work with this population, and with numbers of referrals to
gender services increasing, this is a timely juncture to consider factors that should be taken into account within
clinical settings and areas for future research.
[+notes+]
Hide
Fewer Studies
Childhood-onset gender dysphoria
Zucker, K. J. (2018). The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender non-conforming children” by Temple Newhook et al. (2018). International Journal of Transgenderism, 19(2), 231–245. https://doi.org/10.1080/15532739.2018.1468293
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractTemple Newhook et al. (2018) provide a critique of recent follow-up studies of children referred to specialized gender identity clinics, organized around rates of persistence and desistance. The critical gaze of Temple Newhook et al. examined three primary issues: (1) the terms persistence and desistance in their own right; (2) methodology of the follow-up studies and interpretation of the data; and (3) ethical matters. In this response, I interrogate the critique of Temple Newhook et al. (2018).
[+notes+]
Hide
Ristori, J., & Steensma, T. D. (2016). Gender dysphoria in childhood. International Review of Psychiatry, 28(1), 13–20. https://doi.org/10.3109/09540261.2015.1115754
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractGender dysphoria (GD) in childhood is a complex phenomenon characterized by clinically significant distress due to the incongruence between assigned gender at birth and experienced gender. The clinical presentation of children who present with gender identity issues can be highly variable; the psychosexual development and future psychosexual outcome can be unclear, and consensus about the best clinical practice is currently under debate. In this paper a clinical picture is provided of children who are referred to gender identity clinics. The clinical criteria are described including what is known about the prevalence of childhood GD. In addition, an overview is presented of the literature on the psychological functioning of children with GD, the current knowledge on the psychosexual development and factors associated with the persistence of GD, and explanatory models for psychopathology in children with GD together with other co-existing problems that are characteristic for children referred for their gender. In light of this, currently used treatment and counselling approaches are summarized and discussed, including the integration of the literature detailed above.
[+notes+]
Hide
Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry, 52(6), 582–590. https://doi.org/10.1016/j.jaac.2013.03.016
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractOBJECTIVE: To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence.
METHOD: The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence.
RESULTS: We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls.
CONCLUSION: Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.
[+notes+]
Hide
More Studies
Singh, D., Bradley, S. J., & Zucker, K. J. (2021). A Follow-Up Study of Boys With Gender Identity Disorder. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.632784
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThis 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 boys 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 boys, 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 boys: 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 boys: 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.
[+notes+]
Hide
Fewer Studies
Mature adult transitioners
D’Angelo, R. (2018). Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry, 26(5), 460–463. https://doi.org/10.1177/1039856218775216
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractOBJECTIVE: To reflect on the role of psychiatry in authorising physical treatments for Gender Dysphoria and to examine the quality of evidence for gender-reassignment.
METHOD: A Medline search was performed with the subject term "transsexualism" or "gender dysphoria" and "outcome" or "follow-up" in the title. Studies published from 2005 onwards reporting psychosocial outcomes were selected for review.
RESULTS: Most available evidence indicating positive outcomes for gender reassignment is of poor quality. The few studies with robust methodology suggest that some patients have poor outcomes and may be at risk of suicide.
CONCLUSION: The author raises questions about the implications for ethical treatment of transgender individuals.

SEGM Summary

The paper examines the unusually high patient drop-out rates in studies examining satisfaction with gender-affirming surgeries. This raises the possibility that patients who refuse to engage in follow-up research or lose contact with the gender clinics who treat them may have worse outcomes, and that failure to account for their outcomes may be masking a higher than claimed regret rates.

The paper highlights the following:

  • Smith et al. report that sex reassignment is effective, based on a study of 162 adults who had undergone [gender confirmation surgery]. They were able to obtain follow-up data from only 126 (78%) of subjects because a significant number were “untraceable” or had moved abroad.
  • De Cuypere et al. report that [gender confirmation surgery] is an effective treatment for transsexuals. Of 107 patients who had undergone [gender confirmation surgery] between 1986 and 2001, 30 (28%) could not be contacted and 15 (14%) refused to participate.
  • Johannson et al. reported good outcomes for [gender confirmation surgery]. Of 60 patients who had undergone [gender confirmation surgery], 42 (70%) agreed to participate in the follow up research. Of the non-participants, 1 had died of complications of [gender confirmation surgery], 8 could not be contacted and 9 refused to participate.
  • Salvador et al. reported that [gender confirmation surgery] has a positive effect on psychosocial functioning. Only 55 of the 69 patients (80%) could
    be contacted as 17 were lost to follow-up
  • Van de Grift et al. reported 94–96% of patients are satisfied with SRS and have good quality of life. A total of 546
    patients with Gender Dysphoria who had applied for [gender confirmation surgery] at clinics in Amsterdam, Hamburg and Ghent were contacted to
    complete an online survey. Only 201 (37%) responded and completed the survey.
Hide
Dhejne, C., Öberg, K., Arver, S., & Landén, M. (2014). An Analysis of All Applications for Sex Reassignment Surgery in Sweden, 1960–2010: Prevalence, Incidence, and Regrets. Archives of Sexual Behavior, 43(8), 1535–1545. https://doi.org/10.1007/s10508-014-0300-8
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractIncidence and prevalence of applications in Sweden for legal and surgical sex reassignment were examined over a
50-year period (1960–2010), including the legal and surgical reversal applications. A total of 767 people (289 natal females
and 478 natal males) applied for legal and surgical sex reassignment.
Out of these,89%(252female-to-males [FM] and429male-to-females [MF]) received a new legal gender and underwent sex reassignmentsurgery(SRS).Atotal of 25 individuals (7 natal females and 18 natal males), equaling 3.3 %, were denied a
new legal gender and SRS. The remaining withdrew their application, were on a waiting list for surgery, or were granted
partial treatment. The incidence of applications was calculated and stratified over four periods between 1972 and 2010. The incidence increased significantly from 0.16 to 0.42/100,000/year
(FM) and from 0.23 to 0.73/100,000/year (MF). The most pronounced
increase occurred after 2000. The proportion of FM individuals 30 years or older at the time of application remained
stable around 30 %.In contrast, the proportion of MF individuals 30 years or older increased from37%in the first decade to 60% in the latter three decades. The point prevalence at December
2010 for individualswho applied for a new legal genderwas for FM 1:13,120 and for MF 1:7,750. The FM:MF sex ratio fluctuated but was 1:1.66 for the whole study period. There were 15 (5
MF and 10 MF) regret applications corresponding to a 2.2%
regret rate for both sexes. There was a significant decline of regrets over the time period.
[+notes+]
Hide
More Studies
Wiepjes, C. M., Nota, N. M., de Blok, C. J. M., Klaver, M., de Vries, A. L. C., Wensing-Kruger, S. A., de Jongh, R. T., Bouman, M.-B., Steensma, T. D., Cohen-Kettenis, P., Gooren, L. J. G., Kreukels, B. P. C., & den Heijer, M. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972–2015): Trends in Prevalence, Treatment, and Regrets. The Journal of Sexual Medicine, 15(4), 582–590. https://doi.org/10.1016/j.jsxm.2018.01.016
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
[+notes+]
Hide
Fewer Studies
Vandenbussche, E. (2021). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, 20. https://doi.org/10.1080/00918369.2021.1919479
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThe aim of this study is to analyze the specific needs of detransi­ tioners 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 rever­ sal 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 respon­ dents overall, with a lot of negative experiences coming from medical and mental health systems and from the LGBT+ com­ munity. The study highlights the importance of increasing awareness and support given to detransitioners.
[+notes+]
Hide
Zucker, K. J. (2018). The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender non-conforming children” by Temple Newhook et al. (2018). International Journal of Transgenderism, 19(2), 231–245. https://doi.org/10.1080/15532739.2018.1468293
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractTemple Newhook et al. (2018) provide a critique of recent follow-up studies of children referred to specialized gender identity clinics, organized around rates of persistence and desistance. The critical gaze of Temple Newhook et al. examined three primary issues: (1) the terms persistence and desistance in their own right; (2) methodology of the follow-up studies and interpretation of the data; and (3) ethical matters. In this response, I interrogate the critique of Temple Newhook et al. (2018).
[+notes+]
Hide
Ristori, J., & Steensma, T. D. (2016). Gender dysphoria in childhood. International Review of Psychiatry, 28(1), 13–20. https://doi.org/10.3109/09540261.2015.1115754
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractGender dysphoria (GD) in childhood is a complex phenomenon characterized by clinically significant distress due to the incongruence between assigned gender at birth and experienced gender. The clinical presentation of children who present with gender identity issues can be highly variable; the psychosexual development and future psychosexual outcome can be unclear, and consensus about the best clinical practice is currently under debate. In this paper a clinical picture is provided of children who are referred to gender identity clinics. The clinical criteria are described including what is known about the prevalence of childhood GD. In addition, an overview is presented of the literature on the psychological functioning of children with GD, the current knowledge on the psychosexual development and factors associated with the persistence of GD, and explanatory models for psychopathology in children with GD together with other co-existing problems that are characteristic for children referred for their gender. In light of this, currently used treatment and counselling approaches are summarized and discussed, including the integration of the literature detailed above.
[+notes+]
Hide
Dhejne, C., Öberg, K., Arver, S., & Landén, M. (2014). An Analysis of All Applications for Sex Reassignment Surgery in Sweden, 1960–2010: Prevalence, Incidence, and Regrets. Archives of Sexual Behavior, 43(8), 1535–1545. https://doi.org/10.1007/s10508-014-0300-8
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractIncidence and prevalence of applications in Sweden for legal and surgical sex reassignment were examined over a
50-year period (1960–2010), including the legal and surgical reversal applications. A total of 767 people (289 natal females
and 478 natal males) applied for legal and surgical sex reassignment.
Out of these,89%(252female-to-males [FM] and429male-to-females [MF]) received a new legal gender and underwent sex reassignmentsurgery(SRS).Atotal of 25 individuals (7 natal females and 18 natal males), equaling 3.3 %, were denied a
new legal gender and SRS. The remaining withdrew their application, were on a waiting list for surgery, or were granted
partial treatment. The incidence of applications was calculated and stratified over four periods between 1972 and 2010. The incidence increased significantly from 0.16 to 0.42/100,000/year
(FM) and from 0.23 to 0.73/100,000/year (MF). The most pronounced
increase occurred after 2000. The proportion of FM individuals 30 years or older at the time of application remained
stable around 30 %.In contrast, the proportion of MF individuals 30 years or older increased from37%in the first decade to 60% in the latter three decades. The point prevalence at December
2010 for individualswho applied for a new legal genderwas for FM 1:13,120 and for MF 1:7,750. The FM:MF sex ratio fluctuated but was 1:1.66 for the whole study period. There were 15 (5
MF and 10 MF) regret applications corresponding to a 2.2%
regret rate for both sexes. There was a significant decline of regrets over the time period.
[+notes+]
Hide
Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry, 52(6), 582–590. https://doi.org/10.1016/j.jaac.2013.03.016
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractOBJECTIVE: To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence.
METHOD: The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence.
RESULTS: We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls.
CONCLUSION: Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.
[+notes+]
Hide
More Studies
Butler, C., & Hutchinson, A. (2020). Debate: The pressing need for research and services for gender desisters/detransitioners. Child and Adolescent Mental Health, 25(1), 45–47. https://doi.org/10.1111/camh.12361
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThe number of people presenting at gender clinics is increasing worldwide. Many people undergo a gender
transition with subsequent improved psychological well-being (Paediatrics, 2014, 134, 696). However, some
people choose to stop this journey, ‘desisters’, or to reverse their transition, ‘detransitioners’. It has been suggested
that some professionals and activists are reluctant to acknowledge the existence of desisters and detransitioners, possibly fearing that they may delegitimize persisters’ experiences (International Journal of Transgenderism, 2018, 19, 231).

Certainly, despite their presence in all follow-up studies of young people who
have experienced gender dysphoria (GD), little thought has been given to how we might support this cohort. Levine (Archives of Sexual Behaviour, 2017, 47, 1295) reports that the 8th edition of the WPATH Standards of Care will include a section on detransitioning – confirming that this is an increasingly witnessed phenomenon
worldwide. It also highlights that compared to the extensive protocols for working with children, adolescents
and adults who wish to transition, nothing exists for those working with desisters or detransitioners. With very
little research and no clear guidance on how to work with this population, and with numbers of referrals to
gender services increasing, this is a timely juncture to consider factors that should be taken into account within
clinical settings and areas for future research.
[+notes+]
Hide
Fewer Studies
E. Psychotherapy
Older studies
Hakeem, A. (2012). Psychotherapy for gender identity disorders. Advances in Psychiatric Treatment, 18(1), 17–24. https://doi.org/10.1192/apt.bp.111.009431
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThis article describes a special adaptation of group psychotherapy as a psychological treat­ ment 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.
[+notes+]
Hide
Levine, S. B., & Lothstein, L. (1981). Transsexualism or the Gender Dysphoria Syndromes. Journal of Sex & Marital Therapy, 7(2), 85–113. https://doi.org/10.1080/00926238108406096
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractProfessional, patient and media forces tend to oversimplify the complexity of the gender dysphoria syndromes. Because sex reassignment surgery may be helpful to some patients with the syndrome and harmful to others, mental health professionals need to competently perform differential diagnoses of both the gender disorder and the associated psychopathologies. This frequently involves distinctions between subtle forms of psychosis, character pathologies of varying severity, and major developmental problems.

Surgery should not be considered the only, or the best, treatment for the syndrome. Contrary to popular belief, psychotherapy can help many patients, especially those with secondary gender dysphoria.
[+notes+]
Hide
Davenport, C. W., & Harrison, S. I. (1977). Gender identity change in a female adolescent transsexual. Archives of Sexual Behavior, 6(4), 327–340. https://doi.org/10.1007/BF01541204
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractTwo years of individual and milieu therapy are described of a 14 1/2-year-old girl who had presented with the persistent request to have a sex-change operation since age 12. Her past history was obtained from her parents and the records of the child guidance clinic which evaluated her at 3 years of age. She gives a history of remarkable tomboyism during her latency years and increasing withdrawal from peers and family during early adolescence.

The patient's personal and family dynamics are explored, and these major therapeutic themes are discussed. The individual and milieu therapy are described and discussed with some speculation about the reasons for her positive response to psychotherapy. It would appear that this is a rare case of a postpubertal female transsexual reported to have made a gender identity change.
[+notes+]
Hide
More Studies
Meyer-Bahlburg, H. F. L. (2002). Gender Identity Disorder in Young Boys: A Parent- and Peer-Based Treatment Protocol. Clinical Child Psychology and Psychiatry, 7(3), 360–376. https://doi.org/10.1177/1359104502007003005
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractGender identity disorder (GID) as a psychiatric category is currently under debate. Because of the psychosocial consequences of childhood GID and the fact that childhood GID, in most cases, appears to have faded by the time of puberty, we think that a cost-effective treatment approach that speeds up the fading process would be beneficial.

Our treatment approach is informed by the known psychosocial factors and mechanisms that contribute to gender identity development in general, and focuses on the interaction of the child with the parents and with the same-gender peer group.

To minimize the child’s stigmatization, only the parents come to treatment sessions. A review of a consecutive series of 11 families of young boys with GID so treated shows a high rate of success with a relatively low number of sessions. We conclude that this treatment approach holds considerable promise as a cost-effective procedure for families in which both parents are present.
[+notes+]
Hide
Cohen-Kettenis, P., & Kuiper, B. (1984). Transexuality and psychotherapy. Tijdschrift Voor Psychotherapie. https://www.semanticscholar.org/paper/Transexuality-and-psychotherapy-Cohen-Kettenis-Kuiper/25337c85366442c712c4c11528f7ca2925890b7e?sort=relevance&pdf=true
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractIn this article, the effects of sex reassignment surgery and of psychotherapy are compared. As opposed to the contentions of some advocates of psychotherapy, no disqualifications of sex reassignment surgery have been encountered.

The authors argue that more attention should be paid to the possibilities of psychotherapy, and expect that its most important contributions are to be found in the treatment of those who have doubts concerning their gender identity or the sex reassignment procedure, and in extra support of those undergoing medical treatment.
[+notes+]
Hide
Lothstein, L. M., & Levine, S. B. (1981). Expressive Psychotherapy With Gender Dysphoric Patients. Archives of General Psychiatry, 38(8), 924. https://doi.org/10.1001/archpsyc.1981.01780330082009
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThe dictum that transsexualism is resistant to psychotherapy has led many investigators to view sex reassignment surgery (SRS) as the treatment of choice and dismiss psychotherapy as unfeasible. The Gender Identity Clinic at Case Western Reserve University, Cleveland, was organized to treat transsexuals with individual and group psychotherapy and SRS.

Of 50 gender dysphoric (GD) patients, 70% have adjusted to nonsurgical solutions, 20% are receiving treatment, and 10% have received SRS and psychotherapy. The crux of psychotherapy is establishing a therapeutic alliance; this is aided by the context of the Gender Identity Clinic.

Clinical evidence suggests that new therapeutic techniques may enable psychotherapy to become the treatment of choice with most GD patients and that psychotherapy and SRS are not mutually exclusive. Most patients request and benefit from psychotherapy after SRS.
[+notes+]
Hide
Morgan, A. J. (1978). Psychotherapy for transsexual candidates screened out of surgery. Archives of Sexual Behavior, 7(4), 273–283. https://doi.org/10.1007/BF01542035
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
[+notes+]
Hide
Kirkpatrick, M., & Friedmann, C. (1976). Treatment of requests for sex-change surgery with psychotherapy. American Journal of Psychiatry, 133(10), 1194–1196. https://doi.org/10.1176/ajp.133.10.1194
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThe authors describe two patients whose requests for sex-change surgery represented crises in sexual identity and anxiety-masking symptoms. Brief psychotherapy enabled these patients to relinquish their belief in a surgical "cure".

In evaluating such request, the psychiatrist should consider the patient's total personality rather than focusing on the genuineness of the perceived gender disorder. Whatever the final decision, the opportunity for continued psychotherapy should be provided.
[+notes+]
Hide
Fewer Studies
Recently-presenting cases
D’Angelo, R., Syrulnik, E., Ayad, S., Marchiano, L., Kenny, D. T., & Clarke, P. (2020). One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-020-01844-2
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
[+notes+]
Hide
Churcher Clarke, A., & Spiliadis, A. (2019). ‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties. Clinical Child Psychology and Psychiatry, 24(2), 338–352. https://doi.org/10.1177/1359104518825288
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractAs 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.
[+notes+]
Hide
Spiliadis, A. (2019). Towards a gender exploratory model: Slowing things down, opening things up and exploring identity development. Metalogos Systemic Therapy Journal, 35, 1–9. https://www.ohchr.org/Documents/Issues/SexualOrientation/IESOGI/Other/Rebekah_Murphy_TowardsaGenderExploratoryModelslowingthingsdownopeningthingsupandexploringidentitydevelopment.pdf
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThroughout the western world, the care of children and adolescents whose
sexed corporeality is at odds with their gender-related feelings raises medical,
psychological, and ethical dilemmas. There are currently differing views
around what constitutes responsive and timely support for these young people
and how professionals can operate within a rapidly shifting and contested field,
in which evidence-base is scarce. In this article I aim to reposition the
theoretical framework away from ‘affirmative’ or ‘reparative’ polarities, arguing
that both can be problematic, and to invite the reader into a Gender
Exploratory Model (GEM) grounded in a systemic-developmental framework;
such a model acknowledges and often embraces the notion of uncertainty with
regards to young people’s developmental trajectories and clinician’s ‘unknown
unknowns’ and exploratory responsibilities. A short introduction to the service
(GIDS), as well as a presentation of the current theoretical and clinical
debates, will offer a contextual base for clinicians supporting young people
experiencing gender dysphoria. This is not an attempt to explore the
multifactorial aetiology of gender dysphoria but rather one to add on the
theoretical underpinning of therapeutic approaches in supporting these young
people.
[+notes+]
Hide
Lemma, A. (2018). Trans-itory identities: some psychoanalytic reflections on transgender identities. The International Journal of Psychoanalysis, 99(5), 1089–1106. https://doi.org/10.1080/00207578.2018.1489710
JOURNAL ABSTRACT
SEGM ANALYSIS
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Journal AbstractThe capacity of transgender to incorporate all gender variance and sexual preferences has become a powerful tool of activism and personal identification. Rather than being an index of marginality “trans” has become a central cultural site. In this paper, I will argue that this identity label encompasses a complex range of internal psychic positions in relation to consciously stated sexual preferences and gender identifications. My aim is to explore what can appear to be in some cases a premature embracement of the empowering potential of the transgender identification through my work with under 18-year-olds who are seeking medical intervention for gender dysphoria. This can undermine the painful psychic work required to establish what transgender means for any given young person. In an external culture where to ask “why transgender” (as opposed to “how transgender”) is felt to be pathologising, working with these young people can prove difficult for the analyst. The challenge is to tread the fine line between a dialogue based on an equidistant curiosity about meaning and function that is core to an analytic approach, and a posture of implicit skepticism.
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Bonfatto, M., & Crasnow, E. (2018). Gender/ed identities: an overview of our current work as child psychotherapists in the Gender Identity Development Service. Journal of Child Psychotherapy, 44(1), 29–46. https://doi.org/10.1080/0075417X.2018.1443150
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Journal AbstractThis paper is adapted from a presentation first given at the 2017 Association of Child Psychotherapists (ACP) Conference. We hope to give a feel of our work as psychoanalytic child psychotherapists working in a Tier 4 national assessment service for gender variant children and connect with our colleagues working therapeutically with these families in Child and Adolescent Mental Health Services (CAMHS) and other settings.

Gender variance does not have a single cause, or straightforward developmental pathway; rather it is a complex interplay of multiple factors, akin to sexuality in the diverse manifestations and ‘tributaries’ taken. This paper is given as a plea for complexity, to counter the current intense focus on gender identity and the consequent reductionism this can lead to.

To this end, three case studies from the clinic, taken from Under Five, Latency and Adolescent phases of development, are explored. The complexity of the cases is then discussed, followed by parallel issues of development, divergence and difference. These three ‘average’ cases from the Gender Identity Development Services (GIDS) serve to demonstrate the need for child psychotherapy as part of multi-disciplinary thinking about gender variance and how attention must be maintained to each unique story and process of identity development; as well as our clinical task to establish and encourage depressive functioning and secondary processes where possible.
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D’Angelo, R. (2020). The man I am trying to be is not me. The International Journal of Psychoanalysis, 101(5), 951–970. https://doi.org/10.1080/00207578.2020.1810049
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Journal AbstractThis paper explores the therapeutic process between analyst and Josh, a trans man whose life had fallen apart after transition. Repetitive enactments involving hiding, deceiving and mystification constituted a prolonged therapeutic impasse. The analyst’s struggle with these binds and with countertransference confusion and anxiety, ultimately illuminated zones that had remained off-limits for a prolonged period of time. Where the couple had been snared in a bind structured by gender, they were now able to access a history of violation and to ask more profound questions about connection, aloneness, authenticity and loss.
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D’Angelo, R. (2020). The complexity of childhood gender dysphoria. Australasian Psychiatry, 28(5), 530–532. https://doi.org/10.1177/1039856220917076
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Journal AbstractObjective:
To explore a developmental understanding of childhood gender dysphoria and to compare it to the prevailing paradigm, gender-affirming care.


Conclusion:
Viewing gender dysphoria through a contemporary developmental frame generates a different understanding of the nature of the phenomenon and its treatment and raises ethical questions about our current gender-affirming approach.
[+notes+]
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Sevlever, M., & Meyer-Bahlburg, H. F. L. (2019). Late-Onset Transgender Identity Development of Adolescents in Psychotherapy for Mood and Anxiety Problems: Approach to Assessment and Treatment. Archives of Sexual Behavior, 48(7), 1993–2001. https://doi.org/10.1007/s10508-018-1362-9
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Journal AbstractThe rate of adolescents with gender-nonconforming behavior and/or gender dysphoria seeking mental health care has dramatically increased in the past decade. Many of these youths also present with co-occurring psychiatric problems, including depression, anxiety, suicidality, substance use, and others. This combination may generate a complex clinical picture that challenges the ability of clinicians to accurately diagnose gender distress and develop suitable treatment recommendations. This article illustrates those challenges with two adolescent patients who developed late-onset gender dysphoria in the course of long-term mental health care for diverse psychiatric problems preceding the emergence of gender dysphoria. One underwent full progression from gender dysphoria as a male through social and medical transition to female, the other a less definitive progression from gender dysphoria as female through social transition to male without deciding for any medical treatment. The report provides details on the assessment procedures and the resulting findings, the rationale for treatment recommendations, and short-term follow-up information.
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Le Roux, N. (n.d.). GENDER VARIANCE IN CHILDHOOD/ADOLESCENCE: GENDER IDENTITY JOURNEYS NOT INVOLVING PHYSICAL INTERVENTION [University of East London]. https://repository.uel.ac.uk/item/85vvw
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Journal AbstractMuch of the current literature on gender-variant children and young people focuses on aetiology and developmental outcomes in adolescence, whereas their developmental experiences have been neglected. Furthermore, there is little understanding about the experiences of gender-variant youth for whom gender reassignment does not offer a straightforward solution.
This qualitative study interviewed 10 gender-variant young people (Mean age = 20; range 17-27) who were not actively pursuing gender reassignment. The aim was to gain a better understanding of the developmental process of their gender identity development and how they made sense of their gender variance; the challenges that they faced; the resources that they drew upon; and what is important to them. A grounded theory methodology was adopted.
The period between the approximate ages of 9 and 14 years was identified as crucial in their gender identity development and as a significant developmental challenge. A widening social gap between male and female gender roles and an emergent homosexual identity influenced how they made sense of their gender-variant expression and their bodily development, which in turn was situated within a context of widespread social exclusion. This promoted a profound lack of social belonging, which for most translated into a sense of not belonging in their bodies. A transgender identity afforded social membership, but brought with it a variety of challenges. A range of gender identities and views on gender reassignment were identified, that do not neatly fit into current conceptions of desisting and persisting gender dysphoria. Education on gender variance within the public, educational and health domain was an important priority for the participants. The findings of this study contribute to our understanding of the developmental trajectories of gender variant youth. It also intimates a number of recommendations for future research and clinical practice.
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D’Angelo, R., Syrulnik, E., Ayad, S., Marchiano, L., Kenny, D. T., & Clarke, P. (2020). One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-020-01844-2
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Churcher Clarke, A., & Spiliadis, A. (2019). ‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties. Clinical Child Psychology and Psychiatry, 24(2), 338–352. https://doi.org/10.1177/1359104518825288
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Journal AbstractAs 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.
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Spiliadis, A. (2019). Towards a gender exploratory model: Slowing things down, opening things up and exploring identity development. Metalogos Systemic Therapy Journal, 35, 1–9. https://www.ohchr.org/Documents/Issues/SexualOrientation/IESOGI/Other/Rebekah_Murphy_TowardsaGenderExploratoryModelslowingthingsdownopeningthingsupandexploringidentitydevelopment.pdf
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Journal AbstractThroughout the western world, the care of children and adolescents whose
sexed corporeality is at odds with their gender-related feelings raises medical,
psychological, and ethical dilemmas. There are currently differing views
around what constitutes responsive and timely support for these young people
and how professionals can operate within a rapidly shifting and contested field,
in which evidence-base is scarce. In this article I aim to reposition the
theoretical framework away from ‘affirmative’ or ‘reparative’ polarities, arguing
that both can be problematic, and to invite the reader into a Gender
Exploratory Model (GEM) grounded in a systemic-developmental framework;
such a model acknowledges and often embraces the notion of uncertainty with
regards to young people’s developmental trajectories and clinician’s ‘unknown
unknowns’ and exploratory responsibilities. A short introduction to the service
(GIDS), as well as a presentation of the current theoretical and clinical
debates, will offer a contextual base for clinicians supporting young people
experiencing gender dysphoria. This is not an attempt to explore the
multifactorial aetiology of gender dysphoria but rather one to add on the
theoretical underpinning of therapeutic approaches in supporting these young
people.
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Hakeem, A. (2012). Psychotherapy for gender identity disorders. Advances in Psychiatric Treatment, 18(1), 17–24. https://doi.org/10.1192/apt.bp.111.009431
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Journal AbstractThis article describes a special adaptation of group psychotherapy as a psychological treat­ ment 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.
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Levine, S. B., & Lothstein, L. (1981). Transsexualism or the Gender Dysphoria Syndromes. Journal of Sex & Marital Therapy, 7(2), 85–113. https://doi.org/10.1080/00926238108406096
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Journal AbstractProfessional, patient and media forces tend to oversimplify the complexity of the gender dysphoria syndromes. Because sex reassignment surgery may be helpful to some patients with the syndrome and harmful to others, mental health professionals need to competently perform differential diagnoses of both the gender disorder and the associated psychopathologies. This frequently involves distinctions between subtle forms of psychosis, character pathologies of varying severity, and major developmental problems.

Surgery should not be considered the only, or the best, treatment for the syndrome. Contrary to popular belief, psychotherapy can help many patients, especially those with secondary gender dysphoria.
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Davenport, C. W., & Harrison, S. I. (1977). Gender identity change in a female adolescent transsexual. Archives of Sexual Behavior, 6(4), 327–340. https://doi.org/10.1007/BF01541204
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Journal AbstractTwo years of individual and milieu therapy are described of a 14 1/2-year-old girl who had presented with the persistent request to have a sex-change operation since age 12. Her past history was obtained from her parents and the records of the child guidance clinic which evaluated her at 3 years of age. She gives a history of remarkable tomboyism during her latency years and increasing withdrawal from peers and family during early adolescence.

The patient's personal and family dynamics are explored, and these major therapeutic themes are discussed. The individual and milieu therapy are described and discussed with some speculation about the reasons for her positive response to psychotherapy. It would appear that this is a rare case of a postpubertal female transsexual reported to have made a gender identity change.
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D’Angelo, R. (2020). The complexity of childhood gender dysphoria. Australasian Psychiatry, 28(5), 530–532. https://doi.org/10.1177/1039856220917076
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractObjective:
To explore a developmental understanding of childhood gender dysphoria and to compare it to the prevailing paradigm, gender-affirming care.


Conclusion:
Viewing gender dysphoria through a contemporary developmental frame generates a different understanding of the nature of the phenomenon and its treatment and raises ethical questions about our current gender-affirming approach.
[+notes+]
Hide
Sevlever, M., & Meyer-Bahlburg, H. F. L. (2019). Late-Onset Transgender Identity Development of Adolescents in Psychotherapy for Mood and Anxiety Problems: Approach to Assessment and Treatment. Archives of Sexual Behavior, 48(7), 1993–2001. https://doi.org/10.1007/s10508-018-1362-9
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThe rate of adolescents with gender-nonconforming behavior and/or gender dysphoria seeking mental health care has dramatically increased in the past decade. Many of these youths also present with co-occurring psychiatric problems, including depression, anxiety, suicidality, substance use, and others. This combination may generate a complex clinical picture that challenges the ability of clinicians to accurately diagnose gender distress and develop suitable treatment recommendations. This article illustrates those challenges with two adolescent patients who developed late-onset gender dysphoria in the course of long-term mental health care for diverse psychiatric problems preceding the emergence of gender dysphoria. One underwent full progression from gender dysphoria as a male through social and medical transition to female, the other a less definitive progression from gender dysphoria as female through social transition to male without deciding for any medical treatment. The report provides details on the assessment procedures and the resulting findings, the rationale for treatment recommendations, and short-term follow-up information.
[+notes+]
Hide
Lemma, A. (2018). Trans-itory identities: some psychoanalytic reflections on transgender identities. The International Journal of Psychoanalysis, 99(5), 1089–1106. https://doi.org/10.1080/00207578.2018.1489710
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Meyer-Bahlburg, H. F. L. (2002). Gender Identity Disorder in Young Boys: A Parent- and Peer-Based Treatment Protocol. Clinical Child Psychology and Psychiatry, 7(3), 360–376. https://doi.org/10.1177/1359104502007003005
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Journal AbstractGender identity disorder (GID) as a psychiatric category is currently under debate. Because of the psychosocial consequences of childhood GID and the fact that childhood GID, in most cases, appears to have faded by the time of puberty, we think that a cost-effective treatment approach that speeds up the fading process would be beneficial.

Our treatment approach is informed by the known psychosocial factors and mechanisms that contribute to gender identity development in general, and focuses on the interaction of the child with the parents and with the same-gender peer group.

To minimize the child’s stigmatization, only the parents come to treatment sessions. A review of a consecutive series of 11 families of young boys with GID so treated shows a high rate of success with a relatively low number of sessions. We conclude that this treatment approach holds considerable promise as a cost-effective procedure for families in which both parents are present.
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Lothstein, L. M., & Levine, S. B. (1981). Expressive Psychotherapy With Gender Dysphoric Patients. Archives of General Psychiatry, 38(8), 924. https://doi.org/10.1001/archpsyc.1981.01780330082009
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Journal AbstractThe dictum that transsexualism is resistant to psychotherapy has led many investigators to view sex reassignment surgery (SRS) as the treatment of choice and dismiss psychotherapy as unfeasible. The Gender Identity Clinic at Case Western Reserve University, Cleveland, was organized to treat transsexuals with individual and group psychotherapy and SRS.

Of 50 gender dysphoric (GD) patients, 70% have adjusted to nonsurgical solutions, 20% are receiving treatment, and 10% have received SRS and psychotherapy. The crux of psychotherapy is establishing a therapeutic alliance; this is aided by the context of the Gender Identity Clinic.

Clinical evidence suggests that new therapeutic techniques may enable psychotherapy to become the treatment of choice with most GD patients and that psychotherapy and SRS are not mutually exclusive. Most patients request and benefit from psychotherapy after SRS.
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Morgan, A. J. (1978). Psychotherapy for transsexual candidates screened out of surgery. Archives of Sexual Behavior, 7(4), 273–283. https://doi.org/10.1007/BF01542035
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Kirkpatrick, M., & Friedmann, C. (1976). Treatment of requests for sex-change surgery with psychotherapy. American Journal of Psychiatry, 133(10), 1194–1196. https://doi.org/10.1176/ajp.133.10.1194
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Journal AbstractThe authors describe two patients whose requests for sex-change surgery represented crises in sexual identity and anxiety-masking symptoms. Brief psychotherapy enabled these patients to relinquish their belief in a surgical "cure".

In evaluating such request, the psychiatrist should consider the patient's total personality rather than focusing on the genuineness of the perceived gender disorder. Whatever the final decision, the opportunity for continued psychotherapy should be provided.
[+notes+]
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Le Roux, N. (n.d.). GENDER VARIANCE IN CHILDHOOD/ADOLESCENCE: GENDER IDENTITY JOURNEYS NOT INVOLVING PHYSICAL INTERVENTION [University of East London]. https://repository.uel.ac.uk/item/85vvw
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractMuch of the current literature on gender-variant children and young people focuses on aetiology and developmental outcomes in adolescence, whereas their developmental experiences have been neglected. Furthermore, there is little understanding about the experiences of gender-variant youth for whom gender reassignment does not offer a straightforward solution.
This qualitative study interviewed 10 gender-variant young people (Mean age = 20; range 17-27) who were not actively pursuing gender reassignment. The aim was to gain a better understanding of the developmental process of their gender identity development and how they made sense of their gender variance; the challenges that they faced; the resources that they drew upon; and what is important to them. A grounded theory methodology was adopted.
The period between the approximate ages of 9 and 14 years was identified as crucial in their gender identity development and as a significant developmental challenge. A widening social gap between male and female gender roles and an emergent homosexual identity influenced how they made sense of their gender-variant expression and their bodily development, which in turn was situated within a context of widespread social exclusion. This promoted a profound lack of social belonging, which for most translated into a sense of not belonging in their bodies. A transgender identity afforded social membership, but brought with it a variety of challenges. A range of gender identities and views on gender reassignment were identified, that do not neatly fit into current conceptions of desisting and persisting gender dysphoria. Education on gender variance within the public, educational and health domain was an important priority for the participants. The findings of this study contribute to our understanding of the developmental trajectories of gender variant youth. It also intimates a number of recommendations for future research and clinical practice.
[+notes+]
Hide
Fewer Studies