Gender nonconforming (GN) children and adolescents, collectively referred to as GN youth, may seek care to understand their internal gender identities, socially transition to their affirmed genders, and/or physically transition to their affirmed genders. Because general pediatricians are often the first point of contact with the health care system for GN youth, familiarity with the psychological and medical approaches to providing care for this population is crucial. The objective of this review is to provide an overview of existing clinical practice guidelines for GN youth. Such guidelines emphasize a multidisciplinary approach with collaboration of medical, mental health, and social services/advocacy providers. Appropriate training needs to be provided to promote comprehensive, culturally competent care to GN youth, a population that has traditionally been underserved and at risk for negative psychosocial outcomes.
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December 2014
State-of-the-Art Review Article|
December 01 2014
Psychological and Medical Care of Gender Nonconforming Youth
Stanley R. Vance, Jr, MD;
Stanley R. Vance, Jr, MD
aDivision of Adolescent Medicine, and
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Diane Ehrensaft, PhD;
Diane Ehrensaft, PhD
bDivision of Endocrinology, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
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Stephen M. Rosenthal, MD
bDivision of Endocrinology, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
Address correspondence to Stephen M. Rosenthal, MD, Department of Pediatrics, Division of Endocrinology, University of California, San Francisco, 513 Parnassus Ave, Suite S-672-D, San Francisco, CA 94143-0434. E-mail: rosenthals@peds.ucsf.edu
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Address correspondence to Stephen M. Rosenthal, MD, Department of Pediatrics, Division of Endocrinology, University of California, San Francisco, 513 Parnassus Ave, Suite S-672-D, San Francisco, CA 94143-0434. E-mail: rosenthals@peds.ucsf.edu
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Pediatrics (2014) 134 (6): 1184–1192.
Article history
Accepted:
June 18 2014
Citation
Stanley R. Vance, Diane Ehrensaft, Stephen M. Rosenthal; Psychological and Medical Care of Gender Nonconforming Youth. Pediatrics December 2014; 134 (6): 1184–1192. 10.1542/peds.2014-0772
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We respectfully disagree with many assertions made by the authors responding to our article "Psychological and Medical Care of Gender Nonconforming Youth." Firstly, the respondents' use of the psychiatric diagnosis Gender Identity Disorder (GID) is in itself problematic. The American Psychiatric Association changed this diagnosis in the Diagnostic Statistical Manual of Mental Disorders 5 (DSM-5) to Gender Dysphoria. The psychiatric and pathological focus is not on the cross-gender identity but instead on the distress stemming from the mismatch between "assigned" and affirmed gender identity and from societal stigma and lack of acceptance. Our center and other major professional organizations do not view gender nonconformity as pathological, as our article discusses at length; this may be at odds with the stated perspective of the respondents. Furthermore, the respondents suggest that gender-nonconforming children suffer from delusions regarding their gender identity; symptoms of delusions are not included in any diagnostic criteria for Gender Dysphoria in the DSM-5.
The respondents misinterpret the goals of our gender-affirming approach by stating that "affected children and their parents may report being 'happier' when [professionals and community] affirm their false beliefs," and "'happiness' is not always consistent with good health." We not only want these youth to be happy; we want them to be less depressed, less suicidal, higher functioning, and most importantly, thriving. As explained in our article, exposure to an environment supportive and affirming of gender nonconformity can be protective against suicidality, depression, and poor self-esteem (1,2).
To promote their argument that gender-modulating therapies are deleterious, the responding authors cite a follow-up study of adults who had gender-affirming surgery. The study compared these individuals to gender conforming controls and compared mortality, mental illness, and criminality; it found that gender nonconforming adults had higher rates of the latter at follow-up. The responding authors inappropriately cite this paper to suggest gender-affirming surgery leads to these psychosocial risks when the study does not take in account the societal stigma, ostracism, unemployment, and victimization that transgender adults may face even after surgery. The authors of the paper explicitly state, "[this study] does not, however, address whether sex reassignment is an effective treatment or not." In fact, it is surprising that the respondents failed to acknowledge the one study, also recently published in Pediatrics, that is directly relevant to the gender-affirming model of care in adolescents and young adults. This study, using rigorous methodology, demonstrated that gender nonconforming youth seeking gender- modulating medications with pubertal blocking medications followed by cross-sex hormones, have improved psychological and social functioning and improved quality of life (3). In fact, "well-being" was found to be similar to or better than that in age-matched young adults from the general population (3).
It is also striking that the respondents claim that pubertal blockers can lead to stunted growth when the reference they cite actually notes that any slowdown in growth is remedied once puberty ensues, either through discontinuation of blockers or through addition of cross-sex hormones appropriate for the affirmed gender (4). Any compromise of fertility would also be reversed should pubertal blockers be stopped with resumption of endogenous puberty (4). The respondents also raise concern for malignancies with synthetic (cross-sex) hormones, yet the reference they cite shows no increased risk of cancer during an observation period of up to 30 years, and points to the need for long-term studies(4). Finally, the respondents reject the value of pubertal blockers in gender dysphoric adolescents since most will not persist as transgender adults. They have ignored the observation that gender dysphoria persists and worsens with onset of puberty in up to 20% of gender non-conforming youth, and it is for this defined subset of youth that pubertal blockers can be life-saving. The respondents claim that the use of pubertal blockers "violates the oath physicians take to 'do no harm'." The respondents should recognize that non-intervention is not a neutral option and is the more likely path to an adverse mental health outcome.
We agree more research is needed to identify optimal provision of care to gender-nonconforming youth, but citing research not applicable to the target clinical population of our review article results in gross inaccuracies while neglecting the current research supporting the provision of gender affirming care and gender modulating therapies to youth meeting medical criteria as potentially life-saving.
1. Children's Aid Society of Toronto and Delisle Youth Services. Impacts of strong parental support for trans youth. . 2012. 2. Ryan C, Russell ST, Huebner D, Diaz R, Sanchez J. Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs. 2010;23(4):205-213. 3. de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696-704. 4. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: An endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132-3154.
Conflict of Interest:
None declared
We vigorously object to the normalization of childhood Gender Identity Disorder (GID) promoted by the AAP in the article, "Psychological and Medical Care of Gender Nonconforming Youth," published in the December issue of Pediatrics. The recommendations of the authors to reinforce the delusions of gender identity confused children, and to prescribe puberty- blocking hormones as though puberty were a disorder, are outrageous. This approach violates the oath physicians take to "do no harm."
While some affected children and their parents may report being happier when health professionals, families, friends and schools affirm their false beliefs, "happiness" is not always consistent with good health. It can also be short-lived.
A recent thirty-year study of transgendered adults in Sweden, unquestionably a transgender affirming culture, should give the AAP and APA pause: it showed that individuals who underwent sex reassignment surgery suffered significantly greater morbidity and mortality when compared to matched controls. Shockingly, their suicide mortality rose almost 20-fold above the comparable non-transgender population. The authors concluded, "Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism... [emphasis added]." (1)
There is no adequate body of research on the long-term use of puberty blockers in early adolescence, followed by lifelong administration of exogenous testosterone to biological girls or of exogenous estrogen to biological boys. However, there is significant evidence indicating stunted growth and infertility from puberty blocking hormones, and possible malignancies from chronic use of synthetic hormones.(2) Yet, this is what the AAP and APA recommend.
We submit that children who dread the development of secondary sex characteristics are emotionally troubled; puberty is not a disease. In fact, puberty brings relief for the vast majority of children receiving therapy for GID, as hormone surges propel the development of their brains as well as their bodies, and they come to identify with their biological sex.(3,4) Science and ethics trump the current recommendations of the AAP and APA which amount to conducting an ideology-driven social experiment upon vulnerable children and their families. All physicians must work for reinstatement of the diagnosis and sound treatment of childhood GID.
Den Trumbull, MD, FCP President of the American College of Pediatricians
Michelle A. Cretella, MD, FCP Vice President of the American College of Pediatricians
Miriam Grossman, MD Psychiatric consultant to the American College of Pediatricians
REFERENCES:
1) Dhejne C, Lichtenstein P, Boman M, Johansson ALV, Langstrom N, et al. Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden, 2011; PLoS ONE 6(2): e16885. doi:10.1371/journal.pone.0016885
2) Hembree, WC, et al. Endocrine treatment of transsexual persons: an Endocrine Society's Clinical practice guideline. J Clin Endocrinol Metab., 2009;94:3132-3154.
3) Zucker, K. J. Measurement of psychosexual differentiation. Archives of Sexual Behavior, 2005;34(4): 375-388.
4) Vigil P, Orellana R, Cortes M, Molina C, et al. Endocrine Modulation of the Adolescent Brain: A Review. North American Society for Pediatric and Adolescent Gynecology, 2011;330-337.
Conflict of Interest:
None declared