Management of so-called “gender incongruence, cross-gender behaviour, non-normative gender behaviour, gender dysphoria or transgender or transsexual behaviours”, hereinafter encompassed within the term “Desire for Sex Change” (DSC) is a complex task that affects the individual and his environment, and requires interventions at the educational, social, family and healthcare levels involving competent specialists (see HERE). Preserving the health and dignity of persons affected, avoiding situations of stigmatisation, violence and marginalisation, is an imperative and inalienable objective. The implementation of clinical interventions requires rigorous control by the specialists involved, avoiding hasty or under-diagnosis, and considering all the possible options within the enormous diversity of aetiologies and circumstances that may present.
Below, we set out some of the scientific data available today, which show the complexity of the problem and the lack of unity in diagnostic and therapeutic criteria applied, suggesting the need to adopt prudent decisions that do not jeopardise the health and future development of persons affected.
[See HERE a genetic approach to the matter]
Diagnosis in cases of DSC
The diagnosis of DSC should be based on both interdisciplinary medical and psychiatric data, criteria embodied in medical guidelines or the “International Statistical Classification of Diseases and Related Health Problems”, tenth edition (ICD-10). The first, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DMS-5), (1) includes it as a disorder that it calls “gender dysphoria”. A new criterion is also established that consists in confirming that the disorder does not coexist with an intersexual disease.
The second, the ICD-10, (2) which is the psychiatric disease classification system most widely used by specialists in this field, (3) includes DSC in chapter 5, entitled “Mental and behavioural disorders” and within it, in the section “Adult personality disorders”. (4) The proposal for ICD-11 consists in including the categories “Gender incongruence of childhood” and “Gender incongruence of adulthood” in another chapter that explicitly integrates the medical and psychological disorders: “Conditions related to sexual health”.
The exclusion of DSC from the current classifications in the diagnostic manuals would make it difficult to justify the need for complex, costly and prolonged clinical interventions — psychological as well as endocrinological and surgical — and their funding by public health systems or private insurance companies. On the other hand, all the efforts aimed at combating stigmatisation and its terrible consequences for people with gender incongruence should be coordinated for the good of those affected. Scrupulous respect for people and their inviolable dignity should not be confused with the ideological imposition of acceptance of anthropological models that dissociate the physical, mental and spiritual dimensions of the person, as with gender ideology, trying to impede dissimilar schools of thought, proper to a free society.
Some studies show that adults with gender dysphoria can have anxiety or depression, (5) suicidal tendencies or death as a result of suicide. (6)(7)(8)
The psychiatric comorbidity can hinder the diagnostic evaluation or treatment of gender dysphoria. (9) According to Spack et al., “of our patient population, 44.3% had a prior history of psychiatric diagnoses, 37.1% were taking psychotropic medications and 21.6% had a history of self-injurious behaviour”.
Specifically, research related with autism spectrum disorder (ASD) in children and adolescents with gender dysphoria showed a higher prevalence of ASD compared with the general population. This has implications in the treatment of patients with gender dysphoria and ASD, which may range from incomplete evaluation to uncertainty about whether to initiate potentially irreversible treatment with sex hormones and related surgical procedures, due to the risk of onset of possible adverse outcomes. (11)
Omission of the study of possible comorbidity when the first signs of gender incongruence appear, and acceptance — without further ado — of the existence of an unequivocal tendency towards DSC that must be fostered is, at the very least, imprudent, and assumes unacceptable risks for the child, who may be deprived of the care necessary for the treatment of other disorders that could compromise his or her subsequent health.
Diagnosis in childhood
According to the World Psychiatric Association (WPA)(16) “The diagnosis also serves to alert health professionals that a transgender identity in childhood often does not develop seamlessly into an adult transgender identity. Available research instead indicates that the majority of children diagnosed with gender identity disorder of childhood […] grow up to be cisgender (non-transgender) adults with homosexual orientation. (13)(14)(15) In spite of the claims of some clinicians to be able to distinguish between children whose transgender identity is likely to persist into adolescence and adulthood and those who likely to be gay or lesbian, […], etc., no valid method of making a prediction at an individual level has been published in the scientific literature. Therefore, while medical interventions are not currently recommended for prepubertal gender incongruent children, psychosocial interventions need to be undertaken with caution and based on considerable expertise so as not limit later choices. (16)(17)(18)”
Prevalence of the DSC tendency after adolescence
One aspect that we believe to be important is that, in most children with DSC, this tendency does not persist after late puberty (19), (20) (21)(22). According to Wallien et al, 30% of the 77 participants (19 boys and 4 girls) in his study, did not respond to our recruiting letter or were not traceable; 27% (12 boys and 9 girls) were still gender dysphoric (persistence group) and 43% (desistance group: 28 males and 5 females) were no longer gender dysphoric.” (19) However, Becerra-Fernández et al. state that, “Most (80-95%) prepubertal children reporting they feel transsexual will feel otherwise in adolescence. Moreover, several findings have suggested that, in addition to secondary sexual characteristics, cognitive and behavioural functions are being formed in adolescence. Altering the appearance and physiological development of the events of this stage by bringing forward hormonal and surgical treatment in transsexuals could adversely affect these functions. Parental attitudes, which could be a key influence in determining adolescents’ feelings and precipitating treatment, should be considered. The diagnostic approach takes longer in adolescents than in adults, and the therapeutic decision should be individualised. There is a firm consensus that surgical reassignment should not be carried out until individuals have come of age” (24).
The Working Group on Gender Identity and Sexual Development of the Spanish Society of Endocrinology and Nutrition (GIDSEEN) (25) and authors have expressed similar views. (26)(15)(17)(23)
As a result, psychological assessments must be even more thorough than in adults, should be carried out by staff specialised in gender dysphoria and should avoid harmful or irreversible medical interventions as far as possible.
Rightness of social transition in children
There is no consensus on the rightness of social transition in children, and it is, therefore, a controversial topic. In some cases, immediate social adaptation — without further requisites — of the child’s environment is postulated when there is non-normative gender behaviour, such as a DCS tendency. In other cases, specialists are against this idea. (22)
Therefore, imposition, as the only alternative, of immediate social adaptation of the child who manifests a DSC tendency, without a proper initial assessment, may not be right. We must once again appeal to the prudence that makes way for the consideration of different alternatives, which contribute in each case to the greater good of the child concerned.
Medical actions in cases of DSC
There is also no unanimity of criteria in the different medical specialities involved, as regards the timeliness and methods of clinical intervention. At present, medical actions on DSC follow international protocols, (30)(31) which are mainly aimed at reassignment of the phenotypic sex, with both hormonal and surgical treatment, (32)(33)(34)(35) the aim of which is to reduce the gender dysphoria while achieving social integration of the person with DSC into their environment. (36) These actions should be rounded off with psychotherapeutic support, giving rise to so-called “triad therapy” (hormonal, surgical and psychotherapeutic treatment). An important aspect to take into account is that persons with DSC who undergo hormone therapy or sex reassignment surgery know and accept the limitations and side effects of the different procedures, (18)(37) and also that ceasing hormone therapy may be traumatic, (5) and irreversible in many aspects.
Given the completely or partially irreversible consequences of hormone interventions, it is absolutely vital to make a careful diagnosis of Gender Identity Disorder (GID) (differential diagnosis, associated psychiatric comorbidity, etc.). In order to be able to increase the diagnostic certainty and better plan the intervention, the evaluation must be multi- and pluridimensional. (39)
Studies conducted by interdisciplinary teams, say that “Greater awareness of the benefit of early medical intervention is needed. Psychological and physical effects of pubertal suppression and/or cross-sex hormones in our patients require further investigation”. (10)
Zucker believes that “gender-dysphoric prepubertal children are better served by helping them to align their gender identity with their anatomic sex”. (40) This view eventually cost him his 30-year directorship of the Child Youth and Family Gender Identity Clinic (GIC) at the Centre for Addiction and Mental Health in Toronto. (41)
Hormone treatment of gender dysphoria in childhood involves probable sterilisation of youth who may be cognitively incapable of providing informed consent with sufficient guarantees. (40)
Possible adverse effects of the medical actions
The administration of hormone treatments to prepubertal children or at the onset of puberty, or performing surgical interventions that involve castration, mastectomy, mammoplasty, phalloplasty or vaginoplasty in late puberty or adulthood, could and do pose a permanent risk to their health, especially mental health, as observed in various scientific studies. (9)
One of the most robust studies in this field is that of the Karolinska Institute in Stockholm. In the opinion of these authors, sex reassignment, although alleviating gender dysphoria, is not sufficient to solve the psychiatric and somatic disorders that may occur in the population with DSC.
The social stress model
Doctors Mayer and McHugh state with respect to the social stress model: “One hypothesis, the social stress model — which posits that stigma, prejudice and discrimination are the primary causes of higher rates of poor mental health outcomes for these subpopulations — is frequently cited as a way to explain this disparity. While non-heterosexual and transgender individuals are often subject to social stressors and discrimination, science has not shown that these factors alone account for the entirety, or even a majority, of the health disparity between non-heterosexual and transgender populations and the general population. The differences described above were found even in social environments where there is no atmosphere of discrimination against these people”. (42)
Arguments against prepubertal treatment
As regards the side effects of treatment — which are many —, most notable are alterations in the development of bone mass and growth, fertility and the ability to experience sexual pleasure, lack of development of external genitals (which may compromise future surgical reassignment (43)), and effects on brain development.
Given the above, it can be concluded that:
-Since there is no unity of criteria in this respect, it is necessary to have the interdisciplinary and multidisciplinary (more than one specialist) diagnostic opinion of staff affiliated to different centres, within each speciality, who ensure maximum objectivity in the application of diagnostic clinical and therapeutic criteria.
-Premature intervention reaffirming DSC behaviour, both socially and clinically, involves a high risk for the child, who has not sufficiently formed his sexual or personal identity. The high percentage of children with non-normative gender behaviour who do not show a tendency towards DSC after puberty highlights the high risk of adopting measures that compromise their subsequent development.
-Special care and support, established in an interdisciplinary manner from the onset of the first symptoms, is what should provide guidance regarding the timing and intensity of the measures to adopt, including recognition of the gender identity, which should not refer exclusively to the simple manifestation of the person affected.
-Study of possible comorbidity should be established as an essential requirement for the adoption of any other measure. A reliable diagnosis is impossible without this requisite. Therefore, the right of minors to receive treatment should be determined by the previous diagnosis and follow-up, done according to updated protocols and duration.
-The possibility that the person with DSC, whether or not they have received hormonal and/or surgical treatment, may decide to reformulate their felt identity to make it coincide with their biological sex must be taken into account. It should be considered that this possibility also merits implementation of clinical intervention measures and related legal procedures.
Justo Aznar MD PhD Julio Tudela PhD
Bioethics Observatory Institute of Life Sciences
Catholic Univeristy of Valencia
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders Washington DC; 2013.
2. World Health Organization. International statistical classification of diseases and related health problems; 2014.
3.Reed G, Correa JM, Esparza J, Saxena S, Maj M. The WPA-WHO global survey of psychiatrists’ attitudes towards mental disorders classification. World Psychiatry. 2011; 10: p. 118-31.
4. Kohler R, Recher AEJ. Legal gender recognition in Europe. Transgender Europe. 2013.
5. Wylie K, Knudson G, Khan SI, Bonierbale MWSBS. Serving transgender people: clinical care considerations and service delivery models in transgender health. The Lancet. 2016; 388: p. 401-411.
6. Michel A, Ansseau M, Legros JJ, Pitchot W, Mormont C. The transsexual: what about the future? Eur Psychiatry. 2002; 17: p. 353-62.
7. Lundström B, Pauly I, Walinder J. Outcome of sex reassignment surgery. Acta Psychiatry Scand. 1984; 70: p. 289-94.
8. Pauly IB. Outcome of sex reassignment surgery for transsexuales. Aust N Z J Psychiatry. 1981; 15: p. 45-51.
9. Grossman AH, D’Augelli AR. Transgender youth and life-threatening behaviours. Suicide Life Threat Behav. 2007; 37: p. 527-537.
10. Spack N, Leeper L, Feldman H, Leibowitz S, Mandel F, Diamond D, et al. Children and Adolescents With Gender Identity Disorder Referred to a Pediatric Medical Center. Pediatrics. 2012; 129: p. 418-25.
11. Glidden D, Bouman W, Jones B, Arcelus J. Gender Dysphoria and Autism Spectrum Disorder: A Systematic Review of the Literature. Sex Med Rev. 2016; 4: p. 3-14.
12. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender and gender non-conforming people, version 7.. World Professional Association for Transgender Health. 2011.
13. Drescher J, Byne W. Gender dysphoric/gender variant (GD/GV) children and adolescents: summarizing what we know and what we have yet to learn. J Homosex. 2012; 59: p. 501-10.
14. Drescher J, Byne W. Treating transgender children and adolescents: an interdisciplinary discussion. New York: Routledge; 2013.
15. Steensma T, McGuire J, Kreukels B, et a. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013; 52: p. 582-90.
16. Reed G, Drescher J, Krueger R, et al. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry (WPA). 2016; 14(3): p. 205-21.
17. Steensma T, Biemond R, de Boer F, et al. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry. 2011; 16: p. 499-516.
18. Byne W, Bradley SJ, Coleman E, et al. Treatment of gender identity disorder. Am J Psychiatry. 2012; 169: p. 875-76.
19. Wallien MSC, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008; 47: p. 1413-23.
20. Drummond KD, Bradley SJPBM, Zucker KJ. A follow-up study of girls with gender identity disorder. Dev Psychol. 2008; 44: p. 34-45.
21. Green R. The “sissy boy syndrome” and the development of homosexuality. New Haven, CT: Yale University Press. 1987.
22. Zucker K, Bradley S. Gender identity disorder and psychosexual problems in children and adolescents.. New York: Guilford Press. 1995.
23. Kreukels B, Cohen-Kettenis P. Puberty suppression in gender identity disorder: the Amsterdam experience. Nature Reviews Endocrinology. 2011; 7: p. 466-72.
24. Becerra-Fernánez A, Lucio-Pérez M, Rodríguez-Molina J, Asenjo-Araquea N, Pérez-López G, Frenzi Rabitod M, et al. Transexualidad y adolescencia. Rev IntAndrol. 2010; 8(4): p. 165-71.
25. Esteva IANHF, Fernández-Rodríguez M, Vidal A, Moreno-Pérez Ó, Lucio M, Lopez J, et al. Documento de posicionamiento: Disforia de Género en la infancia y la adolescencia. (GIDSEEN). Endocrinología y Nutrición. 2015; 62(8): p. 380-3.
26. Cohen-Kettenis P, Delemarre-van de Waal H, Gooren L. The treatment of adolescent transsexuals: changing insights. J Sex Med. 2008; 5: p. 1892-7.
27. Esteva I, Gonzalo M, Yahyaoui R, Domínguez M, Bergero T, Giraldo F ea. Epidemiología de la transexualidad en Andalucía, atención especial al grupo de adolescentes. Cuad Med Psicosom. 2006; 78: p. 65-70.
28. Asenjo-Araque N, Rodríguez J, Portabales L, López B, Escolar M, Becerra A. La Transexualidad en niños y adolescentes: Nuestra experiencia en la Unidad de trastornos de identidad de género (UTIG) del Hospital Ramon y Cajal de Madrid. Avances en Psicología Clínica. 2013;: p. 773-78.
29. Asenjo-Araque N, García-Gibert C, Rodríguez-Molina J, Becerra-Fernández A, Lucio-Pérez M, Grupo GIDSEEN. Disforia de género en la infancia y adolescencia: una revisión de su abordaje, diagnóstico y persistencia. Revista de Psicología Clínica en Niños y Adolescentes ;2(1):33-36. 2015; 2(1): p. 33-6.
30. Asociación Mundial para la Salud Transgénero (WPATH). Normas de atención para la salud de personas trans y con variabilidad de género. ; 2012.
31. Moreno-Pérez O, Esteva I. Guías de práctica clínica para la valoración y tratamiento de la transexualidad. Grupo de Identidad y Diferenciación Sexual de la SEEN (GIDSEEN)*(anexo 1). EndocrinolNutr. 2012; 59: p. 367-82.
32. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, al e. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009; 94: p. 3132-54.
33. Wylie KR, Fung RJ, Boshierd C, Rotchell M. Recommendations of endocrine treatment for patients with gender dysphoria. Sex RelatchTher. 2009; 24: p. 175-87.
34. Gooren LJ. Clinical practice. Care of transsexual persons. N Engl J Med. 2011; 364: p. 1251-57.
35. Safer J, Weinland J. Hormone therapy in transgender adults is safe with provider supervision: a review of hormone therapy sequelae for transgender individuals. J Clin Trans Endocrinol. 2015; 2: p. 55-60.
36. Colizzi M, Costa R, Todarello O. Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health hormonal treatment on mental health: Results from a longitudinal study. Psychoneuroendocrinology. 2014; 39: p. 65-73.
37. Dhejne C, Lichtenstein P, Boman M, Johansson ALV, Långström N, Landén M. Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS One. 2011; 6: p. e16885.
38. Becerra A, SEEN GdTdl. Transexualismo: diagnóstico y tratamiento médico. Grupo de Trabajo sobre Sexualidad y Reproducción.. Endocrinología y Nutrición. 2004;(51): p. 26-32.
39. Maganto C, Cruz S. Multitécnicas y multimétodos en la evaluación de la primera infancia. Revista Iberoamericana de Diagnóstico y Evaluación Psicológica. 2001; 12: p. 149-81.
40. Cretella M. Gender Dysphoria in Children and Suppression of Debate. Journal of American Physicians and Surgeons. 2016; 21(2): p. 50-54.
41. Singal J. How the fight over transgender kids got a leading sex researcher fired. New York Magazine. 2016 Feb 7.
42. Mayer L, McHugh P. Sexuality and Gender Findings from the Biological, Psychological, and Social Sciences. The New Atlantis. 2016;(50): p. 4-144.
43. Mujika L, Mujika I. Los Bloqueadores Hormonales en Púberes y Adolescentes. Aldarte. 2014;: p. 1-23.