Gender dysphoria in adolescence: current perspectives

Riittakerttu Kaltiala-Heino, Hannah Bergman, Marja Työläjärvi, Louise Frisén, Riittakerttu Kaltiala-Heino, Hannah Bergman, Marja Työläjärvi, Louise Frisén

Abstract

Increasing numbers of adolescents are seeking treatment at gender identity services in Western countries. An increasingly accepted treatment model that includes puberty suppression with gonadotropin-releasing hormone analogs starting during the early stages of puberty, cross-sex hormonal treatment starting at ~16 years of age and possibly surgical treatments in legal adulthood, is often indicated for adolescents with childhood gender dysphoria (GD) that intensifies during puberty. However, virtually nothing is known regarding adolescent-onset GD, its progression and factors that influence the completion of the developmental tasks of adolescence among young people with GD and/or transgender identity. Consolidation of identity development is a central developmental goal of adolescence, but we still do not know enough about how gender identity and gender variance actually evolve. Treatment-seeking adolescents with GD present with considerable psychiatric comorbidity. There is little research on how GD and/or transgender identity are associated with completion of developmental tasks of adolescence.

Keywords: adolescence; developmental tasks; gender dysphoria; gender identity.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

References

    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Press; 2013.
    1. World Health Organization . The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.
    1. Drescher J, Cohen-Kettenis PT, Reed GM. Gender incongruence of childhood in the ICD-11: controversies, proposal, and rationale. Lancet Psychiatry. 2016;3(3):297–304.
    1. Arcelus J, Bouman WP, Van Den Noortgate W, Claes L, Witcomb G, Fernandez-Aranda F. Systematic review and meta-analysis of prevalence studies in transsexualism. Eur Psychiatry. 2015;30(6):807–815.
    1. Zucker KJ. Epidemiology of gender dysphoria and transgender identity. Sex Health. 2017;14(5):404–411.
    1. Kuyper L, Wijsen C. Gender identities and gender dysphoria in the Netherlands. Arch Sex Behav. 2014;43(2):377–385.
    1. Crissman HP, Berger MB, Graham LF, Dalton VK. Transgender demographics: a household probability sample of US adults, 2014. Am J Public Health. 2017;107(2):213–215.
    1. Wood H, Sasaki S, Bradley SJ, et al. Patterns of referral to a gender identity service for children and adolescents (1976–2011): age, sex ratio, and sexual orientation. J Sex Marital Ther. 2013;39(1):1–6.
    1. Aitken M, Steensma TD, Blanchard R, et al. Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. J Sex Med. 2015;12(3):756–763.
    1. Connolly MD, Zervos MJ, Barone CJ, Johnson CC, Joseph CL. The mental health of transgender youth: advances in understanding. J Adolesc Health. 2016;59(5):489–495.
    1. Sumia M, Lindberg N, Tyolajarvi M, Kaltiala-Heino R. Current and recalled childhood gender identity in community youth in comparison to referred adolescents seeking sex reassignment. J Adolesc. 2017;56:34–39.
    1. Kroger J. Identity Development: Adolescence Through Adulthood. 2nd ed. Thousand Oaks, CA: Sage Publications; 2007.
    1. Kroger J, Martinussen M, Marcia JE. Identity status change during adolescence and young adulthood: a meta-analysis. J Adolesc. 2010;33(5):683–698.
    1. Martin CL, Ruble DN. Patterns of gender development. Annu Rev Psychol. 2010;61:353–381.
    1. Gray SAO, Carter AS, Levitt H. A critical review of assumptions about gender variant children in psychological research. J Gay Lesbian Ment Health. 2012;16(1):4–30.
    1. Wharton A. The Sociology of Gender–An Introduction to Theory and Research. 2nd ed. Chichester: Wiley-Blackwell; 2012.
    1. Alanko K, Santtila P, Harlaar N, et al. Common genetic effects of gender atypical behavior in childhood and sexual orientation in adulthood: a study of Finnish twins. Arch Sex Behav. 2010;39(1):81–92.
    1. McCarthy MM, Auger AP, Bale TL, et al. The epigenetics of sex differences in the brain. J Neurosci. 2009;29(41):12815–12823.
    1. Meyer-Bahlburg HF. Introduction: gender dysphoria and gender change in persons with intersexuality. Arch Sex Behav. 2005;34(4):371–373.
    1. Knickmeyer R, Wang J, Zhu H, et al. Impact of sex and gonadal steroids on neonatal brain structure. Cereb Cortex. 2014;24:2721–2731.
    1. Marrocco J, McEven BS. Sex in the brain: hormones and sex differences. Dialogues Clin Neurosci. 2016;18(4):373–338.
    1. Ratnu V, Emami MR, Bredy TV. Genetic and epigenetic factors underlying sex differences in the regulation of gene expression in the brain. J Neurosci Res. 2017;95:301–310.
    1. Fausto-Sterling A, Crews D, Sung J, Garcia-Coll C, Seifer R. Multi-modal sex-related differences in infant and in infant-directed maternal behaviors during months three through twelve of development. Dev Psychol. 2015;51(10):1351–1366.
    1. Drescher J. Controversies in gender diagnoses. LGBT Health. 2013;1(1):10–14.
    1. Steensma TD, McGuire JK, Kreukels BP, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013;52(6):582–590.
    1. Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: a qualitative followup study. Clin Child Psychol Psychiatry. 2011;16(4):499–516.
    1. Steensma TD, Cohen-Kettenis PT. More than two developmental pathways in children with gender dysphoria? J Am Acad Child Adolesc Psychiatry. 2015;54(2):147–148.
    1. Ristori J, Steensma TD. Gender dysphoria in childhood. Int Rev Psychiatry. 2016;28(1):13–20.
    1. Singh D. A Follow-up Study of Boys with Gender Identity Disorder [Academic dissertation] University of Toronto; 2012. [Accessed January 11, 2018]. Available from: .
    1. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–3903.
    1. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend. 2011;13(4):165–232.
    1. de Vries AL, Cohen-Kettenis PT. Clinical management of gender dysphoria in children and adolescents: the Dutch approach. J Homosex. 2012;59(3):301–320.
    1. Korte A, Lehmkuhl U, Goecker D, Beier KM, Krude H, Gruters-Kieslich A. Gender identity disorders in childhood and adolescence: currently debated concepts and treatment strategies. Dtsch Arztebl Int. 2008;105(48):834–841.
    1. Viner R, Brain C, Carmichael P, Di Ceglie D. Sex on the brain: dilemmas in the endocrine management of children and adolescents with gender identity disorder. Arch Dis Child. 2005;90(2):A78.
    1. Costa R, Carmichael P, Colizzi M. To treat or not to treat: puberty suppression in childhood-onset gender dysphoria. Nat Rev Urol. 2016;13(8):456–462.
    1. Vrouenraets LJ, Fredriks AM, Hannema SE, Cohen-Kettenis PT, de Vries MC. Early Medical treatment of children and adolescents with gender dysphoria: an empirical ethical study. J Adolesc Health. 2015;57(4):367–373.
    1. Shumer DE, Spack NP. Paediatrics: transgender medicine–long-term outcomes from ‘the Dutch model’. Nat Rev Urol. 2015;12(1):12–13.
    1. Spack NP, Edwards-Leeper L, Feldman HA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics. 2012;129(3):418–425.
    1. Kaltiala-Heino R, Sumia M, Tyolajarvi M, Lindberg N. Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child Adolesc Psychiatry Ment Health. 2015;9:9.
    1. Zucker KJ, Bradley SJ, Owen-Andersen A, Singh D. Puberty-blocking hormonal therapyfor adolescents with gender identity disorder: a descriptive clinical study. J Gay Lesbian Ment Health. 2011;15:58–82.
    1. de Vries AL, Doreleijers TA, Steensma TD, Cohen-Kettenis PT. Psychiatric comorbidity in gender dysphoric adolescents. J Child Psychol Psychiatry. 2011;52(11):1195–1202.
    1. Chen M, Fuqua J, Eugster EA. Characteristics of referrals for gender dysphoria over a 13-year period. J Adolesc Health. 2016;58(3):369–371.
    1. Meyenburg B. Gender dysphoria in adolescents: difficulties in treatment. Prax Kinderpsychol Kinderpsychiatr. 2014;63(6):510–522.
    1. Khatchadourian K, Amed S, Metzger DL. Clinical management of youth with gender dysphoria in Vancouver. J Pediatr. 2014;164(4):906–911.
    1. Olson J, Schrager SM, Belzer M, Simons LK, Clark LF. Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria. J Adolesc Health. 2015;57(4):374–380.
    1. Holt V, Skagerberg E, Dunsford M. Young people with features of gender dysphoria: demographics and associated difficulties. Clin Child Psychol Psychiatry. 2016;21(1):108–118.
    1. Steensma TD, Zucker KJ, Kreukels BP, et al. Behavioral and emotional problems on the Teacher’s Report Form: a cross-national, cross-clinic comparative analysis of gender dysphoric children and adolescents. J Abnorm Child Psychol. 2014;42(4):635–647.
    1. de Vries AL, Steensma TD, Cohen-Kettenis PT, VanderLaan DP, Zucker KJ. Poor peer relations predict parent- and self-reported behavioral and emotional problems of adolescents with gender dysphoria: a cross-national, cross-clinic comparative analysis. Eur Child Adolesc Psychiatry. 2016;25(6):579–588.
    1. Rodríguez MF, Mora PG, Sánchez EM, Gidseen G. Características de los menores de edad con disforia de género que acuden a la unidad de tratamiento de identidad de género. Rev Esp Salud Publica. 2017;91(1):e1–e9.
    1. Zucker KJ, Bradley SJ, Owen-Anderson A, et al. Demographics, behavior problems, and psychosexual characteristics of adolescents with gender identity disorder or transvestic fetishism. J Sex Marital Ther. 2012;38:151–189.
    1. Clark TC, Lucassen MF, Bullen P, et al. The health and well-being of transgender high school students: results from the New Zealand adolescent health survey (Youth’12) J Adolesc Health. 2014;55(1):93–99.
    1. Diemer EW, Grant JD, Munn-Chernoff MA, Patterson DA, Duncan AE. Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. J Adolesc Health. 2015;57(2):144–149.
    1. Van Der Miesen AI, Hurley H, De Vries AL. Gender dysphoria and autism spectrum disorder: a narrative review. Int Rev Psychiatry. 2016;28(1):70–80.
    1. Lai M, Lombardo MV, Baron-Cohen S. Autism. Lancet. 2014;383(9920):896–910.
    1. Strang JF, Kenworthy L, Dominska A, et al. Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Arch Sex Behav. 2014;43(8):1525–1533.
    1. van der Miesen AIR, deVries ALC, Steensma TD, Hartman CA. Autistic symptoms in children and adolescents with gender dysphoria. J Autism Dev Disord. 2017 Nov 30; Epub.
    1. Havighurst RJ. Developmental Tasks and Education. Chicago: University of Chicago Press; 1948.
    1. Scheiffge-Krenke I, Gelhaar T. Does successful attainment of developmental tasks lead to happiness and success in later developmental tasks? A test of Havighurst’s (1948) theses. J Adolesc. 2008;31:33–52.
    1. Harvey RG, Stone Fish L. Queer youth in family therapy. Fam Process. 2015;54(3):396–417.
    1. Gray SA, Sweeney KK, Randazzo R, Levitt HM. “Am I doing the right thing?” Pathways to parenting a gender variant child. Fam Process. 2016;55(1):123–138.
    1. Mayer KH, Garofalo R, Makadon HJ. Promoting the successful development of sexual and gender minority youths. Am J Public Health. 2014;104(6):976–981.
    1. Gonzalez KA, Rostosky SS, Odom RD, Riggle ED. The positive aspects of being the parent of an LGBTQ child. Fam Process. 2013;52(2):325–337.
    1. Travers R, Bauer G, Pyne J, et al. Impacts of strong parental support for trans youth: a report prepared for children’s aid society of Toronto and delisle youth services. 2012. [Accessed October 4, 2017]. Available from: .
    1. Wilson EC, Iverson E, Garofalo R, Belzer M. Parental support and condom use among transgender female youth. J Assoc Nurses AIDS Care. 2012;23(4):306–317.
    1. Le V, Arayasirikul S, Chen YH, Jin H, Wilson EC. Types of social support and parental acceptance among transfemale youth and their impact on mental health, sexual debut, history of sex work and condomless anal intercourse. J Int AIDS Soc. 2016;19(2):20781.
    1. Simons L, Schrager SM, Clark LF, Belzer M, Olson J. Parental support and mental health among transgender adolescents. J Adolesc Health. 2013;53(6):791–793.
    1. Sumia M, Lindberg N, Työläjärvi M, Kaltiala-Heino R. Early pubertal timing is common among adolescent girl-to-boy sex reassignment applicants. Eur J Contracept Reprod Health Care. 2016;21(6):483–485.
    1. Hall-Lande JA, Eisenberg ME, Christenson SL, Neumark-Sztainer D. Social isolation, psychological health, and protective factors in adolescence. Adolescence. 2007;42(166):265–286.
    1. Laursen B, Hartl AC. Understanding loneliness during adolescence: developmental changes that increase the risk of perceived social isolation. J Adolesc. 2013;36(6):1261–1268.
    1. Kornienko O, Santos CE, Martin CL, Granger KL. Peer influence on gender identity development in adolescence. Dev Psychol. 2016;52(10):1578–1592.
    1. Shevlin M, Murphy S, Mallett J, Stringer M, Murphy J. Adolescent loneliness and psychiatric morbidity in Northern Ireland. Br J Clin Psychol. 2013;52(2):230–234.
    1. Harris RA, Qualter P, Robinson SJ. Loneliness trajectories from middle childhood to pre-adolescence: impact on perceived health and sleep disturbance. J Adolesc. 2013;36(6):1295–1304.
    1. Kaltiala-Heino R, Frojd S. Correlation between bullying and clinical depression in adolescent patients. Adolesc Health Med Ther. 2011;2:37–44.
    1. Shiffman M, VanderLaan DP, Wood H, Lumley MM, Lollis SP, Zucker KJ. Behavioral and emotional problems as a function of peer relationships in adolescents with gender dysphoria: a comparison with clinical and nonclinical controls. Psychol Sex Orient Gender Divers. 2016;3(1):27–36.
    1. McGuire JK, Anderson CR, Toomey RB, Russell ST. School climate for transgender youth: a mixed method investigation of student experiences and school responses. J Youth Adolesc. 2010;39(10):1175–1188.
    1. Bos H, Sandfort T. Gender nonconformity, sexual orientation, and Dutch adolescents’ relationship with peers. Arch Sex Behav. 2015;44(5):1269–1279.
    1. Toomey RB, Ryan C, Diaz RM, Card NA, Russell ST. Gender-nonconforming lesbian, gay, bisexual, and transgender youth: school victimization and young adult psychosocial adjustment. Dev Psychol. 2010;46(6):1580–1589.
    1. Baams L, Beek T, Hille H, Zevenbergen FC, Bos HM. Gender nonconformity, perceived stigmatization, and psychological well-being in Dutch sexual minority youth and young adults: a mediation analysis. Arch Sex Behav. 2013;42(5):765–773.
    1. Reisner SL, Vetters R, Leclerc M, et al. Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study. J Adolesc Health. 2015;56(3):274–279.
    1. Lawrence AA. Sexual orientation versus age of onset as bases for typologies (subtypes) for gender identity disorder in adolescents and adults. Arch Sex Behav. 2010;39(2):514–545.
    1. Romeo KE, Kelley MA. Incorporating human sexuality content into a positive youth development framework: implications for community prevention. Child Youth Serv Rev. 2009;31(9):1001–1009.
    1. Madkour AS, Farhat T, Halpern CT, Godeau E, Gabhainn SN. Early adolescent sexual initiation as a problem behavior: a comparative study of five nations. J Adolesc Health. 2010;47(4):389–398.
    1. Savioja H, Helminen M, Frojd S, Marttunen M, Kaltiala-Heino R. Delinquency and sexual experiences across adolescence: does depression play a role? Eur J Contracept Reprod Health Care. 2017;22(4):298–304.
    1. Korchmaros JD, Ybarra ML, Mitchell KJ. Adolescent online romantic relationship initiation: differences by sexual and gender identification. J Adolesc. 2015;40:54–64.
    1. Savioja H, Helminen M, Fröjd S, Marttunen M, Kaltiala-Heino R. Sexual experience and self-reported depression across adolescent years. Health Psychol Behav Med. 2015;3(1):337–347.
    1. Bungener SL, Steensma TD, Cohen-Kettenis PT, de Vries ALC. Sexual and romantic experiences of transgender youth before gender-affirmative treatment. Pediatrics. 2017;139(3):e20162283.
    1. Robinson JP, Espelage DL. Peer victimization and sexual risk differences between lesbian, gay, bisexual, transgender, or questioning and nontransgender heterosexual youths in grades 7–12. Am J Public Health. 2013;103(10):1810–1819.
    1. Veale J, Watson RJ, Adjei J, Saewyc E. Prevalence of pregnancy involvement among Canadian transgender youth and its relation to mental health, sexual health, and gender identity. Int J Transgend. 2016;17(3–4):107–113.
    1. Mitchell KJ, Ybarra ML, Korchmaros JD. Sexual harassment among adolescents of different sexual orientations and gender identities. Child Abuse Negl. 2014;38(2):280–295.
    1. Dank M, Lachman P, Zweig JM, Yahner J. Dating violence experiences of lesbian, gay, bisexual, and transgender youth. J Youth Adolesc. 2014;43(5):846–857.
    1. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–697.
    1. Poteat T, Scheim A, Xavier J, Reisner S, Baral S. Global epidemiology of HIV infection and related syndemics affecting transgender people. J Acquir Immune Defic Syndr. 2016;72(3):S210–S219.
    1. Gowen LK, Winges-Yanez N. Lesbian, gay, bisexual, transgender, queer, and questioning youths’ perspectives of inclusive school-based sexuality education. J Sex Res. 2014;51(7):788–800.
    1. Kosciw JG, Palmer NA, Kull RM. Reflecting resiliency: openness about sexual orientation and/or gender identity and its relationship to well-being and educational outcomes for LGBT students. Am J Community Psychol. 2015;55(1–2):167–178.
    1. Poteat VP, Scheer JR, Mereish EH. Factors affecting academic achievement among sexual minority and gender-variant youth. Adv Child Dev Behav. 2014;47:261–300.
    1. Theunissen MJ, de Man I, Verdonk P, Bosma H, Feron F. Are Barbie and Ken too cool for school? A case-control study on the relation between gender and dropout. Eur J Public Health. 2015;25(1):57–62.
    1. Carvalho L. Childhood circumstances and the intergenerational transmission of socioeconomic status. Demography. 2012;49(3):913–938.
    1. Jacob M, Cox SR. Examining transgender health through the international classification of functioning, disability, and health’s (ICF) contextual factors. Qual Life Res. 2017;26(12):3177–3185.
    1. Zucker KJ, Bradley SJ, Owen-Anderson A, Kibblewhite SJ, Cantor JM. Is gender identity disorder in adolescents coming out of the closet? J Sex Marital Ther. 2008;34(4):287–290.
    1. Marchiano L. Outbreak: on transgender teens and psychic epidemics. Psychol Perspect. 2017;60:345–366.
    1. 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(2):e16885.
    1. de Vries AL, Steensma T, Doreleijers T, Cohen-Kettenis P. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011;8:2276–2283.
    1. Hidalgo MA, Ehrensaft D, Tishelman AC, et al. The gender affirmative model: what we know and what we aim to learn. Hum Dev. 2013;56(5):285–290.
    1. Steensma TD, Cohen-Kettenis PT. Gender transitioning before puberty? Arch Sex Behav. 2011;40:649–650.
    1. Zucker KJ. Persistence and desistence in children and adolescents with gender variance: a comparative-developmental perspective. J Am Acad Child Adolesc Psychiatry. 2016;55(10):S80.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera