American Psychiatric Association Task Force on GID Report: Gender Variance in Childhood
July 6, 2012
Excerpts From the APA Task Force on GID report issued this week:
Edgardo J. Menvielle, M.D., M.S.H.S. and Richard R. Pleak, M.D.
The optimal approach to treating pre-pubertal children with GV, including DSM-defined GID, is much more controversial than treating these phenomena in adolescents and adults for several reasons. Intervention, or the lack thereof, in childhood as opposed to later may have a greater impact on long range outcome (Crouch, Liao, Woodhouse, Conway, & Creighton, 2008); however, consensus is lacking regarding the definition of desirable outcomes. Further, children have limited capacity to participate in decision making regarding their own treatment and must rely on caregivers to make treatment decisions on their behalf. An additional obstacle to consensus is the lack of randomized controlled treatment outcome studies of children with GID or with any degree of GV (Zucker, 2008b). In the absence of such studies, the highest level of evidence currently available for treatment recommendations for these children can best be characterized as expert opinion. Such opinions do not occur in a complete vacuum of relevant data, but are enlightened by a body of literature (mostly APA level C and lower), including systematic experimental single-case trials as well as both uncontrolled and inadequately controlled treatment studies, longitudinal studies without intervention, and clinical case reports.
Opinions vary widely among experts depending on a host of factors, including their theoretical orientation as well as their assumptions and beliefs (including religious) relating to the origins, meanings, and fixity/malleability of gender identity. For example, do gender variations represent natural variations, not assimilated into the social matrix, or pathological mental processes? Even among secular practitioners there is a lack of consensus regarding some of the most fundamental issues: What are indications for treatment? What outcomes with respect to gender identity, gender role behaviors, and sexual orientation are desirable? Is the likelihood of a particular outcome altered by intervention? What constitutes ethical treatment aimed at bringing about the desired changes/outcomes? Adding to this complexity, service seekers as well as providers differ in their religious and cultural beliefs as well as in their world-views regarding gender identity, appropriate gender role behaviors, and sexual orientation. Primary caregivers may, therefore, seek out providers for their children who mirror their own world views, believing that goals consistent with their views are in the best interest of their children.
We begin by examining the natural history of GID as defined by outcome without treatment. We then discuss the goals of interventions in treating these children and the factors that influence clinicians in goal selection. Next, we describe various interventions that have been proposed. The empirical data available to inform the selection of goals and interventions are then reviewed and an opinion is offered regarding the status of current credible evidence upon which treatment recommendations could be based.
Outcome Without Treatment
The natural history or outcome of untreated children with GID is that a minority will identify as transsexual or transgender in adulthood (a phenomenon termed persistence), while the majority will become comfortable with their natal gender over time (a phenomenon termed desistence) (Davenport, 1986; Green, 1987; Wallien & Cohen-Kettenis, 2008; Zuger, 1978). As reviewed by Wallien and Cohen-Kettenis (2008), the rate of persistence into adulthood was initially reported to be exceedingly low, but more recent studies suggest that it may be 20 % or higher. In one recent study of gender dysphoric children (59 boys, 18 girls; M age, 8.4 years; age range, 5–12 years), 27 % (out of 54 who agreed to participate in the follow-up study) remained gender dysphoric at follow-up 10 years later. At follow-up, nearly all male and female participants in the persistence group reported having a homosexual or bisexual sexual orientation. In the desistance group, all of the girls and half of the boys reported having a heterosexual orientation. The other half of the boys in the desistance group had a homosexual or bisexual sexual orientation.
A more recent study (Drummond, Bradley, Peterson-Badali, & Zucker, 2008) assessed 25 girls in childhood (M age, 8.88 years; range, 3–12 years) and again as adolescents or adults (M age, 23.24 years; range, 15–36 years). At the assessment in childhood, 60 % of the girls met the DSM criteria for GID, and 40 % were subthreshold for the diagnosis. At follow-up, 3 participants (12 %) were judged to have GID or gender dysphoria. Regarding sexual orientation, 8 (32 %) participants were classified as bisexual/homosexual in fantasy, and 6 (24 %) were classified as bisexual/homosexual in behavior. The remaining participants were classified as either heterosexual or asexual. At follow-up, the rates of GID and bisexual/homosexual sexual orientation were substantially higher than base rates in the general female population derived from epidemiological or survey studies.
Desistence develops gradually over the preadolescent period (primarily between 8 and 12 years) for unknown reasons which have been postulated to include social ostracism, early pubertal hormonal changes, and cognitive development (Wallien & Cohen-Kettenis, 2008). It has also been noted that, compared to “persisters,” “desisters” may experience less gender dysphoria in childhood (Wallien & Cohen-Kettenis, 2008). The reliability of adult transsexuals’ reports of childhood gender nonconformity has been discussed by Lawrence (2010). A substantial proportion of adult transsexuals retrospectively report that, as children, gender conformity and/or gender dysphoria that were kept private, never leading to clinical referral (Cole, Denny, Eyler, & Samons, 2000; Denny, 1992). Some may also reinterpret childhood memories in light of later life events and recall greater degrees of gender non-conformity than were apparent in childhood, thereby making the decision to transition gender more easily explicable to self and others (Bancroft, 1972). Some patients report exaggerating the history of gender non-conformity in order to be regarded by mental health and other professionals as appropriate candidates for medical services related to gender transition (Fisk, 1974).
In Green’s (1987) longitudinal study of gender-referred boys, psychotherapy as children did not appear to have any effect on gender identity or sexual orientation in young adulthood, but the numbers of boys in various types of therapy were too small to draw strong conclusions. To date, no long-term follow-up data have demonstrated that any modality of treatment has a statistically significant effect on later gender identity or sexual orientation.
Treatment Goals and Objectives
The overarching goal of psychotherapeutic treatment for childhood GID is to optimize the psychological adjustment and well-being of the child. The literature reflects a broad consensus regarding several other goals, including appropriate diagnosis and treatment of concomitant psychopathology as well as disorders or conflicts whose manifestations may be confused with GID, and building the child’s self-esteem (Hembree et al., 2009; Meyer-Bahlburg, 2002b; Perrin, Smith, Davis, Spack, & Stein, 2010; Richardson, 1999; Zucker, 2008a). Although the child is the designated patient, there is also consensus regarding the need for parental psychoeducation, assessment, and adequate attention to parental psychopathology and parent–child conflicts (Coates et al., 1991; Zucker, 2008a).
What is viewed as essential for optimizing the well-being of the child differs among clinicians, as does the manner in which the various potential goals of treatment should be prioritized relative to one another. For example, should re-shaping the child’s gender behaviors (e.g., increasing gender-conforming behaviors and/or decreasing gender non-conforming behaviors) be a primary therapeutic goal? Some have argued against directly targeting non-conforming behaviors (Ehrensaft, 2011; Hill et al., 2010; Pleak, 1999), while recognizing that some forms of co-existing psychopathology in children with GID (e.g., depression) may be secondary to poor peer relations resulting from peer rejection due to the cross-gender identification. Modifying the child’s cross-gender behaviors has been suggested by others to alleviate short term distress by improving peer relations and perhaps preventing the development of other psychopathological sequelae (Zucker, 1990).
Opinions also differ regarding the question of whether or not prevention of adult transsexualism should be a goal of therapy. Zucker concludes that “there is little controversy in this rationale, given the emotional distress experienced by gender-dysphoric adults and the physically and often socially painful measures required to align an adult’s phenotypic sex with his or her subjective gender identity” (Zucker, 1990). Given the absence of any evidence that therapy is effective in preventing transsexualism in adulthood together with concerns that therapy with that aim may be damaging to self-esteem, others challenge prevention as an acceptable goal. Among clinicians who share this second view, some endorse allowing the child to live in their preferred gender role to the extent that it is deemed safe to do so (Edwards-Leeper & Spack, 2011; Ehrensaft, 2011). Some children may choose to present in the gender congruent with their biological sex in most social settings in order to avoid teasing and ridicule, but may present as their preferred gender at home and in other “safe” environments. Other children may become extremely depressed and even suicidal if not permitted to live in their preferred gender in all settings. Thus, some clinicians endorse childhood gender transition in at least some cases (Edwards-Leeper & Spack, 2011; Ehrensaft, 2011).
The rationale for supporting transition before puberty is based on the belief that in some children a long term transgender outcome is to be expected and that these children can be identified so that primary caregivers and clinicians may opt for early social transition. An additional argument is that children who transition this way can always revert to their originally assigned gender if necessary, since the transition is only done at a social level and without medical intervention (Brill & Pepper, 2008) although this may not be without complications (Steensma et al., 2011). The main counterarguments to this approach hinge on the finding that GID in children usually does not persist into adolescence and adulthood. Thus, supporting gender transition in childhood might hinder the child’s development or perhaps increase the likelihood of persistence (Pleak, 2010). Furthermore, the peer-reviewed literature does not support the view that desisters and persisters can currently be distinguished reliably as children (Cohen-Kettenis & Pfäfflin, 2010; Wallien & Cohen-Kettenis, 2008; Zucker, 2007, 2008b).
Yet another approach to working with children with GID is to remain neutral with respect to gender identity and to have no goal with respect to gender identity outcome. Instead, the goal is to allow the developmental trajectory of gender/sexuality to unfold naturally without pursuing or encouraging a specific outcome (Ehrensaft, 2011; Hill et al., 2010; Pleak, 1999). The position in favor of supporting free gender expression is centered on the assumption that self-esteem may be damaged by conveying to the child that his/her likes and dislikes as well as mannerisms are somehow intrinsically wrong. The counter argument proposes that self-esteem can be best served by improved social integration, including the ability to make same sex friendships. Here the assumption is that the derived psychological benefits brought about by conforming to social expectations outweigh the benefits of expressing the putative “true gender self” (Ehrensaft, 2011) freely when it deviates significantly from social gender norms. Alternatively, the child’s self-recognition of a gender variant and stigmatized status may be actively encouraged with the goal of mastery (e.g., developing cognitive, emotional and behavioral coping tools) (Ehrensaft, 2011). As reviewed by Zucker (1990), there is currently widespread recognition among mental health professionals that homosexuality is not inherently related to general psychopathology or mental disorders. Nevertheless, it has been suggested that treatment of gender variant children for the prevention of homosexuality can be justified on other grounds, including parental values (Green, 1987) as well as religious values (Rekers, 1982). Given the absence of evidence that any form of therapy has an effect on future sexual orientation, however, such efforts are presently controversial, and this point should be addressed in the psychoeducation of primary caregivers. Further, it has been argued that offering therapy aimed at preventing homosexuality could have the effect of labeling homosexuality as an inferior and undesirable condition, thereby increasing prejudice and discrimination towards lesbians and gay men (Byne & Stein, 1997). Parallel arguments could be made regarding attempts aimed at preventing transsexualism.
Types of Interventions
A variety of intervention modalities has been proposed to achieve the above goals. Therapeutic approaches to work with children with GID include individual insight-oriented psychoanalytic or psychodynamic psychotherapy (Coates et al., 1991); protocol-driven psychotherapy such as behavior modification (Rekers, 1979); parent and peer-relations focused therapy (Meyer-Bahlburg, 2002b), and parent and child therapeutic groups (Ehrensaft, 2011; Menvielle & Tuerk, 2002; Pleak, 1999). Other proposed interventions are best characterized as self-advocacy and educational: support groups for primary caregivers; community education through websites and conferences; school-based curricula; and specialized youth summer camps. As in other disorders, the recommendation for a particular therapy often hinges on the therapist’s preferences and training. This is especially true for GID, however, in light of the lack of consensus on the goals for therapy, the malleability of gender identity, and the controversies surrounding the ethics of aiming to influence identity development.
Even though the child should be the ultimate beneficiary of treatment, the primary focus of intervention is sometimes the primary caregivers (e.g., via parenting support and psychoeducation as well as guidance in reinforcing behavior modification, and building self-acceptance and resilience in the child) and often multi-pronged interventions are necessary that involve, not only the child and family, but the community (e.g., via bullying prevention and diversity education). Some approaches may center on the primary caregivers to minimize therapist contact with the child in order to avoid placing the child squarely in the clinical spotlight which can be stigmatizing (Ehrensaft, 2011; Meyer-Bahlburg, 2002b). This is particularly true of work with very young children in which the primary caregivers may be targeted with the aim of empowering them with the understanding and skills necessary for optimally parenting their child with GID (Ehrensaft, 2011). Additionally, psychodynamic theories have sometimes focused on the primary caregivers (Stoller, 1985) or parent–child conflict (Haber, 1991) as possible causal factors in GID, providing a different rationale for primary caregivers as the target(s) of intervention. Problems in parent–child attachment interacting with temperamental dispositions in the child have been suggested to be causally implicated in GID and have been cited as a focus for psychodynamic therapy of the child (Coates et al., 1991). Zucker and Bradley (1995) observed higher levels of psychopathology in clinical samples of primary caregivers and suggested that parental psychological abnormalities may contribute to GID. These observations, however, do not distinguish between cause and effect. Whatever the directionality of the cause and effect relationship, parental distress and psychopathology should be assessed and appropriately addressed as part of a comprehensive treatment approach.
Very few studies have systematically researched any given mode of intervention with respect to an outcome variable in GID and no studies have systematically compared results of different interventions. Some of the earliest treatment studies of children with GID were done in the 1970s by Rekers and colleagues in individual and small case series using behavioral methods (Rekers, 1977; Rekers, Rosen, Lovaas, & Bentler, 1978). These authors tested behavior modification in boys through contingency management, including punishment [e.g., “response cost” procedures (Rekers & Lovaas, 1974)] of feminine behaviors with a stated goal being prevention of later homosexuality and transsexualism. Short-term treatment success was reported with a decrease in gender non-conforming behaviors. Long term follow-up studies, however, were not reported so there is no evidence that these effects were enduring or that intervention influenced either gender identity or sexual orientation. Although Rekers’ reports were widely criticized (Morin & Schultz, 1978; Pleak, 1999; Wolfe, 1979) for using punishment and religious persuasion with the goal of prevention of homosexuality, his general goals for interventions with children with GID have been shared by a few other clinicians (e.g., Nicolosi & Nicolosi, 2002; Socarides, 1995) and endorsed by controversial mental health organizations such as the National Association for Research and Therapy of Homosexuality (www.narth.org).
A parent-and peer-relations focused protocol for boys with GID was tested by Meyer-Bahlburg (2002b). The treatment focused on the interaction of the child with the primary caregivers and with the same-gender peer group. The goals were developing a positive relationship with the father (or father figure), developing positive relationships with male peers, developing gender-typical skills and habits, fitting into the male peer group, and feeling good about being a boy. To minimize the child’s stigmatization, only the primary caregivers attended treatment sessions which focused on such issues as parents’ gender attitudes, changing family dynamics when the father increases positive interaction with the boy, selection of appropriate same-sex peers for play dates, selection of summer camp, supporting artistic interests and talents, etc. The therapy also involved ignoring rather than prohibiting or bluntly criticizing the boy’s cross-gender behaviors and distracting him in contexts typically leading to cross-gender behaviors, while giving him positive attention when he engaged in gender-neutral or masculine activities.
The sample consisted of 11 boys. Age at evaluation ranged from 3 years, 11 months to 6 years with a median of 4 years, 9 months. Eight boys were diagnosed as having GID of childhood and three as having GIDNOS. Treatment was terminated in most cases when the goals stated above were judged to have been fully reached. Ten of the 11 cases showed such marked improvement; only one did not and was, therefore, judged to be unsuccessful. The total number of treatment visits per family ranged from 4 to 19 (with a median of 10). In some cases, treatment for other family problems, such as marital conflict or individual psychiatric problems of the primary caregivers, continued after treatment of the child’s GID was completed. Follow-up was done mostly by telephone. The duration of follow-up was left to the primary caregivers and varied up to several years. There was no significant recurrence of GID or GIDNOS in the 10 successful cases, although several primary caregivers reported occasional recurrence of some cross-gender activities, especially during the first winter following treatment when the children were homebound and peer contacts diminished.
Some therapists, including the present authors, modify Meyer-Bahlburg’s (2002b) parent- and peer-centered approach. This entails working with the family in a psychoeducational and supportive approach, promoting the child’s self-esteem and decreasing family dysfunction, while assisting the family with the child’s positive adaptation regardless of gender identity. This approach involves much work with the primary caregivers and other family members, as well as with the school or other facilities, and can include support groups for the primary caregivers (Hill et al., 2010; Menvielle, Perrin, & Tuerk, 2005; Pleak, 1999). The goals are to allow the child to have a variety of experiences and to promote positive adaptation to whatever gender identity and sexual orientation the child will have as an adolescent and adult, and to assist the family in accepting and supporting their child regardless of outcome. The present authors (unpublished) have observed improved self-esteem, decreased behavioral disturbance, improved family functioning, and generally less cross-gender behavior using this approach. One of the authors (Pleak, unpublished) has followed up 10 boys with GID who were in treatment between ages 3 and 12 years old. In young adulthood, 7 identify as gay men, 1 as bisexual; 1 has undergone sex reassignment and is now a woman; and 1 who has Asperger’s disorder, has no romantic or sexual relationships with other people, but identifies entirely as male and reports sexual fantasies about women. As adults, all acknowledge their previous GV in behavior and identity, and the 9 who did not become transsexual say they have not felt cross-gendered since adolescence.
Web-based literature searches failed to reveal any randomized controlled studies related to any of the issues germane to treatment of children with GID. The majority of studies would be categorized as APA evidence category G, such as individual case reports, and APA evidence category C, such as longitudinal follow-up studies without any specific intervention (Green, 1987). A few reports might be categorized as APA level B (clinical trials); however, these lacked control groups (or an adequate control group) and/or the follow-up interval was brief (Meyer-Bahlburg,2002b; Rekers, 1979; Rekers & Mead, 1979). In light of the limited empirical evidence and disagreements about treatment approaches and goals among experts in the field and other stakeholders, recommendations supported by the available literature are largely limited to the areas of consensus identified above and would be in the form of general suggestions and cautions. One such caution would be to inform primary caregivers and children (in an age-appropriate manner) of the realistic therapeutic goals, available treatment options, and the lack of rigorous evidence favoring any particular treatment over another for attaining a particular goal. Families should be informed about potential outcomes, including the possibility that the child’s experience/perception of the gendered self may change as they mature. The range of possible long-term outcomes discussed should include homosexuality, heterosexuality, varying degrees of comfort/discomfort with sex of birth, and variance in gender expression in relation to stereotypes, including the pursuit of medical/surgical interventions for sex reassignment. Clinicians should be sensitive to the primary caregivers’ values and wishes but also be alert to the possibility of parental decisions being driven by a wish to normalize the child through therapy intended to increase gender conformity (or heterosexuality) or through premature gender role transition. At the same time, clinicians should be cautioned against wholesale rejection of gender role transition when this may be in the best interest of the child, even if in a relatively small number of cases (Steensma & Cohen-Kettenis, 2011). Clearly, therapy cannot be offered with the promise of preventing either transsexualism or homosexuality. Even offering treatment with such aims raises ethical concerns and these have been addressed elsewhere (Dreger,2009; Pleak, 1999).”
Children have limited capacity to participate in decision making regarding their own treatment, and no legal ability to provide informed consent. They must rely on caregivers to make treatment decisions on their behalf, including those that will influence the course of their lives in the long term. The optimal approach to treating pre-pubertal children with GV, including DSM-defined GID, is, therefore, more controversial than treating these phenomena in adults and adolescents. An additional obstacle to consensus regarding treatment of children is the lack of randomized controlled treatment outcome studies of children with GID or with any presentation of GV (Zucker, 2008b). In the absence of such studies, the highest level of evidence available for treatment recommendations for these children can best be characterized as expert opinion.
Opinions vary widely among experts, and are influenced by theoretical orientation, as well as assumptions and beliefs (including religious) regarding the origins, meanings, and perceived fixity or malleability of gender identity. Primary caregivers may, therefore, seek out providers for their children who mirror their own world views, believing that goals consistent with their views are in the best interest of their children.
The outcome of childhood GID without treatment is that only a minority will identify as transsexual or transgender in adulthood (a phenomenon termed persistence), while the majority will become comfortable with their natal gender over time (a phenomenon termed desistence) (Davenport,1986; Green, 1987; Wallien & Cohen-Kettenis, 2008; Zuger, 1978). GID that persists into adolescence is more likely to persist into adulthood (Zucker, 2008b). Compared to the general population, the rate of homosexual orientation is increased in adulthood whether or not GID was treated (Green, 1987; Zucker, 2008b). It is currently not possible to differentiate between preadolescent children in whom GID will persist and those in whom it will not. To date, no long-term follow-up data have demonstrated that any modality of treatment has a statistically significant effect on later gender identity.
The overarching goal of psychotherapeutic treatment for childhood GID is to optimize the psychological adjustment and well-being of the child. What is viewed as essential for promoting the well-being of the child, however, differs among clinicians, as does the selection and prioritization of goals of treatment. In particular, opinions differ regarding the questions of whether or not minimization of gender atypical behaviors and prevention of adult transsexualism are acceptable goals of therapy.
Several approaches to working with children with GID were identified in the professional literature. The first of these focuses on working with the child and caregivers to lessen gender dysphoria and to decrease cross-gender behaviors and identification. The assumption is that this approach decreases the likelihood that GID will persist into adolescence and culminate in adult transsexualism (Zucker, 2008a). For various reasons (e.g., social stigma, likelihood of hormonal and surgical procedures with their associated risks and costs), persistence is considered to be an undesirable outcome by some (Green, 1987; Rekers, 1982; Zucker, 2008a) but not all clinicians who work in this area of practice (Brill & Pepper, 2008; Ehrensaft, 2007; Spack, 2005).
A second approach makes no direct effort to lessen gender dysphoria or gender atypical behaviors. This approach is premised on the evidence that GID diagnosed in childhood usually does not persist into adolescence and beyond (Green, 1987; Wallien & Cohen-Kettenis, 2008), and on the lack of reliable markers to predict in whom it will or will not persist. A variation of this second approach is to remain neutral with respect to gender identity and to have no therapeutic target with respect to gender identity outcome. The goal is to allow the developmental trajectory of gender identity to unfold naturally without pursuing or encouraging a specific outcome (Ehrensaft, 2011; Hill & Menvielle, 2010; Hill, Menvielle, Sica, & Johnson, 2010; Pleak, 1999). Such an approach entails combined child, parent, and community-based interventions to support the child in navigating the potential social risks. Support for this approach is centered on the assumption that self-esteem may be damaged by conveying to the child that his or her likes and dislikes, behaviors, and mannerisms are somehow intrinsically wrong (Richardson, 1999). A counter argument proposes that self-esteem can be best served by improved social integration, including positive relationships with same-sex peers (Meyer-Bahlburg,2002b). Alternatively, proponents of this second approach suggest that the child’s self-recognition of a gender variant and stigmatized status may be actively encouraged, with the goal of mastery (e.g., developing cognitive, emotional and behavioral coping tools for living as a gender variant person) (Edwards-Leeper & Spack, 2011; Ehrensaft, 2011). A third approach may entail affirmation of the child’s cross-gender identification by mental health professionals and family members. Thus, the child is supported in transitioning to a cross-gendered role, with the option of endocrine treatment to suspend puberty in order to suppress the development of unwanted secondary sex characteristics if the cross-gendered identification persists into puberty (Ehrensaft, 2011). The rationale for supporting transition before puberty is the belief that a transgender outcome is to be expected in some children, and that these children can be identified so that primary caregivers and clinicians may opt to support early social transition. A supporting argument is that children who transition this way can revert to their originally assigned gender if necessary since the transition is done solely at a social level and without medical intervention (Brill & Pepper, 2008). The primary counterargument to this approach is based on the evidence that GID in children usually does not persist into adolescence and adulthood. Thus, supporting gender transition in childhood might increase the likelihood of persistence (Pleak, 2010). Furthermore, the peer-reviewed literature does not support the view that desisters and persisters can currently be reliably distinguished as children (Cohen-Kettenis & Pfäfflin, 2010; Wallien & Cohen-Kettenis, 2008; Zucker, 2007; Zucker & Cohen-Kettenis, 2008). Moreover, after transitioning gender in childhood, reverting to the natal gender may entail complications (Steensma, Biemond, Boer, & Cohen-Kettenis, 2011).
Primary modes of therapy utilized in working with children with GID include individual insight-oriented psychoanalytic or psychodynamic psychotherapy (Coates, Friedman, & Wolfe, 1991); protocol-driven psychotherapy such as behavior modification (Rekers, 1979); parent and peer-relations focused therapy(Meyer-Bahlburg, 2002b), and parent and child therapeutic groups (Ehrensaft, 2011; Menvielle & Tuerk, 2002; Pleak,1999). Additional interventions include support groups for primary caregivers, community education through websites and conferences, school-based curricula, and specialized youth summer camps. The primary focus of intervention is sometimes the primary caregivers. Depending on the treatment approach chosen, work may include parenting support and psychoeducation, guidance in reinforcing behavior modification, and instruction in techniques for building self-acceptance and resilience in the child. Some interventions are multi-faceted and involve the school and community, as well as the child and family. These include diversity education and steps to prevent bullying.
The Task Force identified the following as the major tasks for mental health professionals working with children referred for gender concerns: (1) to accurately evaluate the gender concerns that precipitated the referral; (2) to accurately diagnose any gender identity related disorder in the child according to the criteria of the most current DSM; (3) to accurately diagnose any coexisting psychiatric conditions in the child, as well as problems in the parent–child relationship, and to recommend their appropriate treatment; (4) to provide psychoeducation and counseling to the caregivers about the range of treatment options and their implications; (5) to provide psychoeducation and counseling to the child appropriate to his or her level of cognitive development; (6) when indicated, to engage in psychotherapy with the appropriate persons, such as the child and/or primary caregivers, or to make appropriate referrals for these services; (7) to educate family members and institutions (e.g., day care and preschools, kindergartens, schools, churches) about GV and GID; (8) to assess the safety of the family, school, and community environments in terms of bullying and stigmatization related to gender atypicality, and to address suitable protective measures.
With respect to comparing alternative approaches to accomplishing the above tasks, the Task Force found no randomized (APA level A) or adequately controlled nonrandomized longitudinal (APA level A-) studies, and very few follow-up studies without a control group either with (APA level B) or without (APA level C) an intervention. The majority of available evidence is derived from qualitative reviews (APA level F) and experimental systematic single case studies that do not fit into the APA evidence grading system.
Opinion Regarding Treatment Recommendations
Despite deficiencies in the evidence base and the lack of consensus regarding treatment goals, the present literature review suggests consensus on a number of points. Areas where existing literature supports development of consensus recommendations include, but are not limited to, the following: (1) assessment and accurate DSM diagnosis of the child referred for gender concerns, including the use of validated questionnaires and other validated assessment instruments to assess gender identity, gender role behavior, and gender dysphoria; (2) diagnosis of any coexisting psychiatric conditions in the child and seeing to their appropriate treatment or referral; (3) identification of mental health concerns in the caregivers and difficulties in their relationship with the child, ensuring that these are adequately addressed, (4) provision of adequate psychoeducation and counseling to caregivers to allow them to choose a course of action and to give fully informed consent to any treatment chosen. This entails disclosing the full range of treatment options available (including those that might conflict with the clinician’s beliefs and values), the limitations of the evidence base that informs treatment decisions, the range of possible outcomes, and the currently incomplete knowledge regarding the influence of childhood treatment on outcome; (5) provision of age appropriate information to the child; (6) assessment of the safety of the family, school and community environments in terms bullying and stigmatization related to gender atypicality, and to address suitable protective measures.
For purposes of this Task Force report, adolescence is defined as the developmental period from 12 to 18 years of age. Adolescents with GID comprise two groups, those in whom GID began in childhood and has persisted, and those with the onset of GID in adolescence. Only two clinics (one in Canada and one in The Netherlands) have systematically gathered data on sufficient numbers of subjects to provide an empirical “experience base” on the main issues in adolescence. Both of these teams concur that management of those in whom GID has persisted from childhood is more straightforward than management of those in whom GID is of more recent onset. In particular, the latter group is more likely to manifest significant psychopathology in addition to GID.
This group should be screened carefully to detect the emergence of the desire for sex reassignment in the context of trauma as well as for any disorder such as schizophrenia, mania or psychotic depression that may produce gender confusion. When present, such psychopathology must be addressed and taken into account prior to assisting the adolescent’s decision as to whether or not to pursue sex reassignment or actually assisting the adolescent with the gender transition. Both the Canadian and Dutch groups are guided by the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) which endorse a program of staged gender change in which fully reversible steps are taken first, followed in turn by partially reversible and irreversible steps.
With the beginning of puberty, development of the secondary sex characteristics of the natal gender often triggers or exacerbates the anatomic dysphoria of adolescents with GID (Cohen-Kettenis, Delemarre-van de Waal, & Gooren, 2008; Spack, 2005). Recently, the option has become available for pubertal patients with severe gender dysphoria and minimal, if any, additional psychopathology to have puberty suspended medically in order to prevent or to minimize development of unwanted secondary sex characteristics, some of which are not fully reversible with subsequent hormonal or surgical sex reassignment therapies (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2010). A practice guideline developed by the Endocrine Society (Hembree et al., 2009) suggests that pubertal suspension can be done for a period of up to several years during which time the patient, with the clinicians, can decide whether it is preferable for the adolescent to revert to living in the birth sex or to continue gender transition with cross-sex hormone therapy. There are currently little data regarding the timing of cross-sex hormone treatment in adolescents and no studies comparing outcomes when such treatment is initiated in adolescence as opposed to adulthood, with or without prior suspension of puberty. We know, however, that many adult transsexuals express regret over the body changes that occurred during puberty, some of which are irreversible. In the absence of a DSD (addressed in a separate section), at present, sex reassignment surgery (SRS) is not performed prior to the age of 18 in the United States. It is noted, however, that one study on carefully selected individuals in the Netherlands suggests that, as assessed by satisfaction with surgery and lack of regrets, outcome was generally better in individuals who initiated sex reassignment as adolescents than as adults (Smith, van Goozen, & Cohen-Kettenis, 2001; Smith, van Goozen, Kuiper, & Cohen-Kettenis, 2005a). Even in these studies, however, SRS was not initiated prior to the age of 18.
The major tasks identified by the Task Force to be germane to provision of mental health services to adolescents with the desire to transition in gender, or who are in the process of transitioning, are (1) psychiatric and psychological assessment to both assure that any psychopathology is adequately diagnosed and addressed, and to determine whether the clinicians’ approach will be neutral or supportive with respect to the desire to transition in gender; (2) provision of psychotherapy as indicated by the initial assessment and as indicated by changes over time. This includes providing psychological support during the real life experience and suspension of puberty and/or the administration of cross-sex hormones; (3) assessment of eligibility and readiness for each step of treatment.
Database searches failed to reveal any RCTs related to any of these issues. The quality of the evidence is primarily individual case reports (APA level G); follow-up studies with control groups of limited utility and without random assignment, or longitudinal follow-up studies after an intervention without control groups (APA level B); and reviews of the above (APA level F). Between 2001 and 2009, over 80 adolescents selected based on conservative criteria have been treated with pubertal suspension with overall positive results in the most detailed follow-up study published to date (APA evidence level B) (de Vries, Kreukels, Steensma, Doreleijers, & Cohen-Kettenis, 2011). In a consecutive series of 109 adolescents (55 females, 54 males) with GID, the Toronto group identified demographic variables correlated with clinical decisions to recommend, or not recommend, gonadal hormone blocking therapy (Zucker et al., 2011). Follow-up data, to date, however, are not adequate for statistical analyses of outcome variables.
Opinion Regarding Treatment Recommendations
Existing literature is insufficient to support development of an APA Practice Guideline for treatment of GID in adolescence but is sufficient for consensus recommendations in the following areas: (1) psychological and psychiatric assessment of adolescents presenting with a wish for sex reassignment, including assessment of co-occurring conditions and facilitation of appropriate management; (2) psychotherapy (including counseling and supportive therapy as indicated) with these adolescents, including enumeration of the issues that psychotherapy should address. These would include issues that arise with adolescents who are transitioning gender, including the real life experience; (3) assessment of indications and readiness for suspension of puberty and/or cross-sex hormones as well as provision of documentation to specialists in other disciplines involved in caring for the adolescent; (4) psychoeducation of family members and institutions regarding GV and GID; (5) assessment of the safety of the family/school/community environment in terms of gender-atypicality-related bullying and stigmatization, and to address suitable protective measures.”
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