The recognition and acknowledgment that gender identity and birth-assigned sex may be incongruent in children and adolescents have evolved in recent decades. Transgender care for children and adolescents has developed and is now more widely available. Controversies exist, however, around clinical management of gender dysphoria and gender incongruence in children and adolescents. Clinical guidelines are consensus based and research evidence is limited. Puberty suppression as part of clinical management has become a valuable element of adolescent transgender care, but long-term evidence of success is limited. These uncertainties should be weighed against the risk of harming a transgender adolescent when medical intervention is denied.
Key points
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Many children diagnosed with gender incongruence do not become transgender adolescents or adults.
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Delaying puberty as part of multidisciplinary care can help transgender adolescents develop into well-functioning young adults.
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During medical endocrine treatment few adverse events occur, but long-term outcomes are currently unknown.
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Research evidence is limited concerning what is best transgender care for children and adolescents who have gender dysphoria; existing guidelines are consensus based.
Introduction and terminology
For an ever more visible group of children and adolescents their sense of being male or female, named gender identity, is incongruent with their birth-assigned sex and sexual body characteristics. They may suffer from gender dysphoria, the distress resulting from this incongruence. These youth form a subgroup of the children and adolescents with gender variance or gender nonconformity, which refers to the entire spectrum of variation in gender role behavior or gender expression, with or without gender identity variance, behavior that is considered nonstereotypical for one’s birth-assigned sex. This group also includes many gay, lesbian, and bisexual youth without gender identity variance (See Stewart Adelson and colleagues article, “ Development and Mental Health of LGBT Youth in Pediatric Practice ,” in this issue, for fuller discussion of multiple LGBT developmental trajectories; and the American Academy of Child and Adolescent Psychiatry Practice Parameter ).
Gender is not a dichotomous concept but consists of more than the male-female binary. Such terms as nonbinary, gender queer, third gender, or a-gender reflect this. Social transitioning is used when someone starts to live in the experienced gender role and encompasses clothing, gender role behavior, and the use of a name and pronouns of that gender. Gender-affirming treatment is the clinical approach that supports the expression of one’s experienced gender of which puberty blockers, hormone treatment, and surgeries may be part. However, such treatments may not be desired or needed by all gender identity variant youth, some of whom do not experience distress. A transwoman is a birth-assigned male with a female gender identity, and a transman is a birth-assigned female who identifies as male. Male-to-female transgender and female-to-male transgender are also used terms.
Gender dysphoria is currently the official name of the diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). There is debate about whether gender incongruence is a psychiatric diagnosis and whether distress is inherent for the condition. Suffering caused by social stigma, such as family nonacceptance and peer bullying (See Mark L. Hatzenbuehler and John E. Pachankis’ article, “ Stigma and Minority Stress as Social Determinants of Health among LGBT Youth: Research Evidence and Clinical Implications ,” in this issue) is fundamentally different from distress caused by gender incongruence itself. A pragmatic improvement in the proposed upcoming eleventh edition of the World Health Organization International Classification of Diseases might be the use of the term “gender incongruence” and the removal from the mental health conditions section.
Increasing numbers of youth with gender incongruence and gender dysphoria are seeking mental health support and medical care. This current increase in interest in gender dysphoria is reflected while searching PubMed on “gender dysphoria”; it shows a sharp increase in the number of publications since the 1970s ( Fig. 1 ), especially in the last 2 years (PubMed search, October 19, 2015). When the filter “birth – 18 years” is added, there are 182 hits, with 48 of these publications in 2014 and 2015. However, most articles are opinion or review papers and not original data research and hitherto there is only little research evidence for cause, course, and treatment of gender dysphoria.
