Addressing psychiatric and psychosocial issues related to children and adolescents
A 2013 article in Rolling Stone magazine brought gender dysphoria to national attention by focusing on the age at which children begin to question their gender identity (Erdely, 2013). The story described Coy Mathis, a kindergartner in Colorado, who had made statements about his gender identity confusion at age 3. The obvious question then is: If a child is truly transgendered, why should he or she have to wait until adulthood to make the transition and endure the gender-discordant characteristics that occur during puberty? Gender dysphoric children are often targeted for violence and bullying. Would earlier intervention be a way to prevent these traumatizing experiences?
As of now, that question has no definitive answer, but in 2014, the American Psychiatric Association (APA) is expected to release guidelines on the health of transgender youth. Some changes have been made in the management of youth with gender-dysphoric issues. The purpose of this article is to explore these changes in nomenclature and the supporting research and to acquaint readers with the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) diagnosis of gender dysphoria.
Gender Identity and Gender Dysphoria
Historically, gender identity has described the internal recognition of oneself as having one of two gender roles, either masculine or feminine (Money & Russo, 1981). Sex and gender are not synonymous; sex is typically described as the physical (i.e., reproductive) anatomy that differentiates males from females, as indicated by the external appearance of the genitalia and gonads (i.e., ovaries/female and testes/male). Gender identity, gender roles, and sex characteristics comprise the traits that are conventionally considered to be consistent with the underlying male or female chromosomal pattern (Prince, 2005). Gender dysphoria occurs when individuals experience their gender identity as discordant with their anatomical sex.
Diagnosis and Impact of Age
The term gender identity disorder, a diagnosis that appears in the DSM, fourth edition, text revision (APA, 2000), has been replaced by the term gender dysphoria. According to the DSM-5, gender dysphoria in children is characterized by the desire to be the other gender to such degree that the incompatibility causes distress in social, school, occupational, and personal domains for at least 6 months. Children must exhibit a preference for cross-dressing, along with opposition to wearing clothing of the natal gender. Furthermore, they demonstrate stereotypical play themes opposite of natal sex, a strong dislike of their existing sexual anatomy, and the desire for the primary and/or secondary sex characteristics that match the internally experienced gender.
As early as age 3, children who are affected begin manifesting incongruities with their gender identity and attempt to normalize these experiences by adopting the social characteristics of their psychological gender (i.e., wearing clothes of the opposite sex and strongly rejecting any belonging to their natal sex) (Spack et al., 2012). However, despite this early age of onset, children typically do not present to a specialty clinic until age 10 (Hewitt et al., 2012). By that age, children with gender dysphoria may have already experienced depression, peer-directed violence, school departure, drug use, suicidal thoughts, and anxiety that have compromised their mental health (de Vries & Cohen-Kettenis, 2012; Edwards-Leeper & Spack, 2012). However, even when treatment is provided, the controversy surrounding the etiology of gender dysphoria remains. Even so, the ability to diagnose transgenderism at an early age is limited, and safe, long-term treatment protocols are lacking (Korte et al., 2008; Meyer-Bahlburg, 2013).
Steensma, Biemond, de Boer, and Cohen-Kettenis (2011) and Shumer and Spack (2013) have proposed that the interval between ages 10 and 13 is a critical time for individuals to self-determine their desistance or persistence in gender dysphoria. One concept is that the early (approximately age 3) period and later pubertal period constitute hormonally sensitive growth episodes for children (Berenbaum & Beltz, 2011). These sensitive time periods may offer opportunities for further research to determine their relationship to gender formation or as developmental (i.e., neurological) points for gender identity.
Kreukels and Cohen-Kettenis (2011) conducted follow-up studies and concluded that early intervention in judiciously selected patients may be of value. Their review suggests that early identification and intervention is possible; however, more rigorous and systematic data are needed to identify these individuals conclusively. Meyer-Bahlburg (2013) suggested that a childhood diagnosis of gender dysphoria should be assigned with relative caution, given the wide range of gender expression within this age group. The childhood diagnosis should not be considered definitive; rather, it should serve as a basis for further evaluation and management.
The treatment objective for patients with gender dysphoria in early adolescence is to establish alignment with the desired gender and support of a multi-disciplinary team of medical, surgical, and psychological services (usually in tertiary care centers) (World Professional Association for Transgender Health, 2012). Once the diagnosis of gender dysphoria is confirmed and the individual has chosen to explore the desired gender, treatment options are made available in the form of pubertal suppression hormones (i.e., pubertal blockade). Pubertal hormones, which would have expressed natal gender characteristics, are blocked to allow for further exploration of gender identity. The hormones can only be given in Tanner Stage 2 of puberty, which is the first stage when physical signs of puberty are evident. Individuals must undergo a trial period of social transition and live as the opposite gender for at least 2 years. Individuals must adopt the characteristics of the desired gender and live in accordance to social expectations of that gender role to simulate the ramifications of the decision.
If gender dysphoria persists after exploration and the individual confirms a continued desire to live opposite of his or her natal sex, hormones of the opposite sex will be administered beginning at age 16. Androgens are given to female-to-male patients, and estrogen is given to male-to-female patients. The purpose of this treatment is to align physical sex characteristics with the desired gender to reduce the social stigma associated with gendered behaviors that are incongruent with the natal sex. These hormonal treatments are considered partially reversible because some residual physical features of the desired sex may remain even if the individual with gender dysphoria decides to forego further transitioning treatment. Once the individual has reached age 18 and persists in the desire to be of the opposite sex, sexual reassignment surgery (an irreversible measure) is offered. Surgery is considered the final step in the transition process (World Professional Association for Transgender Health, 2012).
According to Hewitt et al. (2012), these hormonal interventions are safe, and patients experience minimal levels of regret. Furthermore, follow-up studies suggest that adolescents reported fewer behavioral and emotional symptoms, as well as reductions in feelings of depression, anger, and anxiety, after treatment (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2011). Fisher et al. (2014) suggested that the use of cross-sex hormones effectively diminishes the body-related concerns associated with gender dysphoria, with patients reporting a higher satisfaction with their bodies.
In the longer term, after the completed gender reassignment process, male-to-female patients reported an 87% satisfaction rate; in female-to-male patients, the analogous satisfaction rates were 97% (Royal College of Psychiatrists, 2013). The high rates could correspond to an immediacy effect and the anticipation of living in the desired gender. Much longer-term satisfaction reports are not as positive. In a meta-analysis, Murad et al. (2010) indicated >80% improvement in psychological, gender dysphoric, and quality of life indices. The suicide rate of transgendered patients remained higher than the national average, but a decrease in suicide rate after reassignment surgeries was reported.
Controversy remains regarding pubertal delay and cross-sex hormones in youth (Berenbaum & Beltz, 2011; Geddes, 2008). Wallien and Cohen-Kettenis (2008) proposed that the use of pubertal suppression and additional hormones might promote cross-gendering. Furthermore, despite cross-sex hormone treatment, feelings of gender dysphoria may still persist (Hewitt et al., 2012). The persistence of dysphoria after treatment could reflect maladaptive coping skills, developed as a function of living as the incongruent gender, which may require new coping skills in the aligning gender. Understanding this process should be the focus of ongoing studies. Regarding gender reassignment, a paucity of research exists related to the age at which interventions were started (Gooren, 2011). The majority of follow-up studies do not differentiate interventions that were started early in puberty from those that occurred after sex characteristics developed. The negative outcomes might be related to later intervention, which requires a more complicated process due to peaked hormonal development. Suicide attempts and completions were higher in individuals who lived with gender dysphoria longer and did not receive early treatment (Kreukels & Cohen-Kettenis, 2011; Mustanski, Garofalo, & Emerson, 2010).
Implications for Nursing
The topics of gender dysphoria and transgenderism will likely be discussed more frequently, and psychiatric-mental health nurses (PMHNs) are well positioned to make a positive impact on the public’s perception of this delicate issue. We encourage PMHNs to:
Educate themselves and the public about the social, medical, and psychological implications of gender dysphoria; note that it is a combination of developmental and biological processes.
Help parents understand that some gender identity questioning may occur in young children. If it persists until early adolescence, transgenderism should be considered.
In younger patients, the acceptance of the reality of gender dysphoria leads to significant reduction in psychological trauma (Drescher, 2010). However, stigma is often encountered and can cause emotional trauma. It is important for PMHNs to maintain a supportive and nonjudgmental approach and educate families and communities about the psychological ramifications of an individual living with an incongruent gender.
Furthermore, the safety of peergroups and adolescents who are transgender is a key issue (McGuinness, 2008). In California public schools, children who display gender nonconformity are the most likely to be targeted for physical violence and bullying, even by faculty and staff (McGuire, Clarke, Anderson, & Russell, 2010). Harassment of those with gender nonconformity is so widespread in California that the Safe Schools Improvement Act, a measure seeking to combat violence associated with transgenderism, was passed in 2009 as a result of the case of Lawrence King, a 15-year-old transgender youth who was murdered in a classroom by a 14-year-old boy.
Bullying and violence toward youth are unacceptable—they should not be tolerated in any setting. Transgender youth are visible targets. Understanding the phenomenon of gender dysphoria and transgenderism and offering anticipatory guidance will serve to diminish the emotional pain of these children and their families.
Understanding gender dysphoria is still in its early stages. The best age of initiating treatment has yet to be determined with respect to risks and benefits; however, recent evidence supports an improvement in overall quality of life after treatment. Health care providers must understand that the diagnosis of gender dysphoria exists and sometimes occurs at an early age. Further research regarding identification and treatment approaches from both the medical and psychiatric communities is necessary because the resultant anxiety of gender dysphoria can lead to significant impairments in young lives.
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