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Empirical evidence lags behind rise in preadolescents presenting with gender dysphoria.

SCOTTSDALE, ARIZ. -- The treatment of preadolescents who present with gender questions is often complicated by the absence of evidence-based data on who is most likely to remain gender dysphoric into adulthood and who is not, an expert said at the annual meeting of the American College of Psychiatrists.

"There are some [clinicians] who believe they can predict who will persist and who will not. But they have not published, to my satisfaction, a way to show anyone else how to tell the difference," said Jack Drescher, MD, a member of the World Health Organization's (WHO's) Working Group on the Classification of Sexual Disorders and Sexual Health and clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla.

According to a 2012 task force report of the American Psychiatric Association, no expert clinical consensus exists on the treatment of gender dysphoria in prepubescent children. However, there is some overlap in the prevailing approaches, said Dr. Drescher, who served as a member of the American Psychiatric Association's DSM-5 Work Group on Sexual and Gender Identity Disorders.

The WHO working group was tasked with categorizing sex and gender diagnoses in the forthcoming International Classification of Diseases (ICD-11). Dr. Drescher said that he and his fellow WHO working group members have identified at least three discrete transgender populations.

"There are persisters, desisters, and those who first develop gender dysphoria in adolescence and adulthood," he said. "It would be a clinical mistake to think that there is a seamless transition from childhood gender dysphoria into adolescent and adult gender dysphoria."

Dr. Drescher said that he believes the Dutch model for treating younger children diagnosed with what is interchangeably referred to as gender dysphoria or gender variance demonstrates the greatest sensitivity to how fluid the situation can be for many of these children. The absence of biomarkers for dysphoria that will persist into adulthood and the finding that a minority of prepubescent gender dysphoria diagnoses persist into adolescence inform the Dutch approach.

This approach, which originated at the VU University Medical Center Amsterdam, is based on 2 decades of research and practice. It assumes that it is better not to actively transition a child socially but to remain neutral to the way in which the child expresses gender identity. If children persist into late adolescence in this model, they are assisted in transitioning. If not, they are supported socially as they adjust to their natal gender. Puberty may sometimes have to be suppressed until the time one of the two paths has been decided.

"In my opinion, it is the most conservative approach," Dr. Drescher said of the Dutch model. "They are the most cognizant of how much we don't know, and they do a lot of good research."

An approach originating at the Child and Adolescent Gender Center Clinic, which is affiliated with the University of California, San Francisco, supports a child socially into a cross-gendered role without medical or surgical intervention but also suppresses puberty. This method is based on the presumption of an adult transgender outcome, despite the absence of a way to predict results, said Dr. Drescher, who also cautions about the iatrogenic effects of such a presumption. "It takes a lot of work to socially transition a child in one direction. It would take a lot to transition back in the other direction, and there is no good empirical data as to whether this is entirely a benign process," he said.

A third method originated in Toronto at the Centre for Addiction and Mental Health. This method actively discourages a child's atypical gender interests and views transsexualism as an undesirable outcome that can be prevented, despite what Dr. Drescher said is a complete lack of evidence to either support or refute this claim. This method largely has been abandoned, in part since Ontario and five U.S. states and the District of Columbia have passed laws banning efforts to change a minor's sexual orientation or gender identity. This method does have puberty suppression in children whose gender dysphoria appears to be persisting into adolescence in common with the other two.

Dr. Drescher said puberty suppression has helped decrease the levels of anxiety, depression, and suicidal ideation typically associated with this cohort. Postponing the development of secondary sexual characteristics gives those who ultimately will desist from their dysphoria more time to let it run its course. The Dutch first initiated this procedure 2 decades ago and have shown that any possible future side effects are outweighed by the psychosocial advantages it provides in the present.

The clinical view of gender dysphoria probably will get a jolt in 2018 upon publication of the ICD11. In an interview, Dr. Drescher said that, if the condition is no longer categorized by the WHO as a mental disorder and is instead called "gender incongruence" in a chapter dedicated to gender and sexuality issues as currently planned, "it is likely the [American Psychiatric Association] will follow suit and remove gender dysphoria from the DSM. However, I don't know how long that will take," he said.

In his presentation, Dr. Drescher said that the causes for gender dysphoria remain unknown, as do the ways in which gender identity develops. It is also unclear how biological, psychosocial, and environmental factors affect gender dysphoria. What is clear, he said, is that "we have to rethink our developmental literature."

Meanwhile, although gender dysphoria affects a relatively small percentage of the population --less than 1% of "nonreferred" children and adolescents, according to the DSM-5--the number of prepubescent children presenting to gender clinics is on the rise. This increase might be driven more by social forces than by scientific ones. Dr. Drescher made an anecdotal observation during the presentation that more children are presenting to gender clinics already socially transitioned by their parents than there are children in the research literature on persisters and desisters.

Dr. Drescher recalled in the interview that, during the public comment period for the DSM-5, gender dysphoria elicited the third most responses, compared with other diagnoses, despite its rarity as a condition. "Interest in the subject far outweighs its prevalence."

On Twitter @whitneymcknight



RELATED ARTICLE: Gender-related glossary of terms.

"THERE ARE SO MANY moving parts to our understanding of gender," said Jack Drescher, MD, during a plenary session at the annual meeting of the American College of Psychiatrists. For that reason, "language is very important" when addressing children who might have questions about their gender identity, he said.

To help establish as much clarity as possible when discussing gender in the clinical setting, Dr. Drescher offered the following glossary of terms. These are not listed alphabetically but in a stepwise fashion aimed at leading to a clearer understanding of successive terms.

SEX: The biological attributes of being male or female. This includes sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia.

GENDER: The public--and typically the legal--recognition of one's lived role as a boy, girl, man, or woman or of other biological factors in combination with psychosocial factors that are seen as contributing to identity development.

SEXUAL ORIENTATION: A person's erotic response tendency or sexual attractions, either directed toward individuals of the same sex (homosexual), the other sex (heterosexual), or both sexes (bisexual).

GENDER IDENTITY: Often an independent variable from sexual orientation, this refers to how an individual identifies as either male or female or, in some cases, some other category.

GENDER ASSIGNMENT: The natal presentation as either male or female. The historical terms are "biological male" or "biological female"; also occasionally known as "birth assigned male" or "birth assigned female."

GENDER ATYPICAL: The somatic features or behaviors not statistically typical in individuals with the same assigned gender in a given society or era.

GENDER NONCONFORMING: Typically used as an alternative descriptive term for "gender atypical."

GENDER DYSPHORIA: The conflict between a person's assigned gender and that person's gender identity and expression; replaced "gender identity disorder" in the DSM-5.

GENDER VARIANT: Often used by those who are concerned the term "gender dysphoria" will unnecessarily pathologize a child.

GENDER EXPRESSION: How an indi vidual demonstrates gender to others, including by way of dress, behavior, and appearance. Increasingly, the term is used in antidiscrimination documents.

DESISTER: Prepubescent children who present with gender dysphoria but who do not become transgender adults.

PERSISTER: This refers to children who present with gender dysphoria and progress to a transgender adulthood.

GENDER REASSIGNMENT: An official and often legal--change of gender by way of cross-sex endocrine therapy and/ or gender reassignment surgery.

TRANSSEXUAL: An individual who modifies the body via endocrine and/or surgical means to conform with gender identity either partially or completely.

TRANSWOMAN: A person, such as Caitlyn Jenner, who transitions from a male sex assignment to become female.

TRANSMAN: A person who transitions from a female sex assignment to become male.

TRANSGENDER: The "T" in the acronym LGBT; the popular--not scientific inclusive term for those whose gender identity, gender expression, or behavior does not conform to that which is typically associated with the natal sex assignment.

CISGENDER: From the Latin for "on the same side"; used in the transgender community to describe those whose gender identities align with their natal assignment.

GENDER BELIEFS: Used to refer to the implicit, typically binary, cultural views on the "essential" qualities of men and women.

--Whitney McKnight
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Author:McKnight, Whitney
Publication:Clinical Psychiatry News
Date:May 1, 2017
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