ADOLESCENT HEALTH – PART II

Transgender and Nonconforming : Psychosocial and Medical Considerations

AGNIESZKA JANICKA, MD; MICHELLE FORCIER, MD

31 34 EN ABSTRACT traditionally underserved and vulnerable population. Health Primary care providers are increasingly called upon to care professionals should be able to screen and identify gen- care for youth that are gender nonconforming. While der nonconforming youth, provide appropriate education to these youth have the same health concerns as their cis- youth and families and facilitate connection with existing gender peers, gender nonconforming youth face addition- referral networks that may aid gender diverse youth and al challenges. Traditionally, this has been an underserved their families. and marginalized population at significant risk for mul- tiple negative mental and physical health outcomes. De- spite the history of disheartening health outcomes, there GENDER DEVELOPMENT is hope in interventions that may serve to ameliorate the For most children, , the internal sense of risks for youth. Studies indicate that with being male or female is consistent with the physical charac- collaborative multidisciplinary interventions by physi- teristics of gender assignment at birth. However, a minority cians and mental health professionals that promote early of children will experience gender identity that differs from identification, emphasize parental support and directly the gender characteristics that initially provide them with an address the patient’s with medical and expected gender. It appears that a multifaceted interplay of psychological interventions, transgender youth can reach genetic, neurobiological, prenatal and possibly postnatal hor- adulthood without psychological sequela. monal environment, along with cultural and psychological 5 KEYWORDS: transgender, gender, dysphoria, transition factors work together to determine gender identity. It is fairly common for children in to engage in cross-gender play or gender exploration, and chil- dren may even express a wish to be a different gender. While most children who engage in gender play do not experience INTRODUCTION gender dysphoria in , for some, gender noncon- In recent years, growing awareness of and exposure to gender formity persists. Medical and psychological research is only nonconforming children and has spurred more public beginning to understand the developmental trajectories of and medical dialogue regarding health and human rights for gender identity in gender nonconforming children. One of transgender individuals. Research, the media, and a growing the main factors identified for persistence into adolescence awareness of the needs of the transgender community raise is the intensity and degree of gender dysphoria in the pre- additional questions about the optimal treatment for these pubertal years. The children who persist with gender dys- individuals. phoria into adolescence have more “extreme” signs of While the prevalence of gender variant youth is largely gender dysphoria and are consistent, persistent and insistent debated, recent reports suggest that the prevalence of trans- in cross-gender activities, behavioral preferences, gender gender individuals may be higher than previously estimated. identification and dress. Prior reported prevalence rates have ranged from 1:7,000 to 1:20,000 for transgender females, and from 1:33,000 to 1:50,000 for transgender males.1 In a recent survey of The Diagnostic and Statistical Manual of Mental Disorders 18-64 year old Massachusetts residents (n=28,622), 1 in 200 (DSM-V) replaced the term Gender Identity Disorder with self-identified as transgender.2 Additionally, gender specialty Gender Dysphoria. This change reflected an effort to clinics have witnessed a notable increase in the number of depathologize the condition while simultaneously ensuring youth presenting with gender nonconformity.3,4 appropriate access to clinical care. While both diagnosis focus Medical and mental health professionals may be a first on a condition manifested by a marked incongruence between point of contact for gender diverse youth, playing a critical one’s experienced gender and assigned gender, the gender role in defining treatment trajectories. Thus, it is becom- dysphoria diagnosis has the clinical focus on the distress that ing increasingly necessary that physicians and mental may occur rather than identity. 19-20 health professionals become familiar with the needs of this

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Some children may not experience a significant amount of gender nonconformity in childhood, but may present with TERMINOLOGY significant gender dysphoria as approaches. Age 10 Asserted gender: the gender that people communicate to through 14, the average age of puberty onset, appears to be others as their authentic gender in expression and/or identity. a crucial period for identification of teens who will expe- : adjective used to describe an individual whose rience ongoing gender dysphoria.6,7 For transgender youth, natal gender matches their asserted gender identity. the growing awareness and concern over secondary sexual characteristics often results in hatred of and disgust with Gender: characteristics behaviorally, culturally and their bodies.6 Conversations about “becoming a woman” or psychologically associated with femaleness or maleness. “becoming a man” can be particularly distressing to these : the manner in which a person represents as they begin to struggle with more obvious disso- gender to others (including activities, behavior, dress, hairstyles, nance between their gender identity and physical gender. mannerisms or voice). Either anticipated or existing irreversible physical changes Gender identity: intrinsic sense of self as male, female or other. may lead adolescents to feel increasingly hopeless regarding Gender dysphoria: distress related to discrepancy between an their body and future trajectory. Asserted males may expe- individual’s gender identity and natal gender (not all gender rience extreme distress regarding the growth of breasts and nonconforming individuals experience gender dysphoria). hips and the start of menarche; asserted females may have an intensification of aversion towards their genitals, distress Natal gender: assigned by a physician at ’s birth. over body and facial hair growth and voice deepening.6 Transfemale or transmale: identity label for natal males with Previous studies have consistently identified elevated risk asserted female gender identity or natal females with asserted of multiple negative mental health outcomes among trans- male gender identity. 8 gender youth compared to their cisgender counterparts. In a Transition: a process whereby an individual changes their social sample of 360 transgender youth there was a two- to three- and/or physical characteristics in order to live in congruence fold increased risk of depression, anxiety disorder, suicidal with their authentic gender identity. Transitioning may/may not ideation, attempts, non-suicidal self-injury, and both involve hormonal and/or surgical procedures. inpatient and outpatient mental health treatment compared Cross-gender hormones: exogenous hormones administered to the cisgender controls.9 A study of transgender youth to promote development of secondary sexual characteristics revealed that 45% had experienced suicidal ideation and consistent with an individual’s asserted gender identity. 26% had attempted suicide.10 The effects of chronic brain- body incongruence, resultant anxiety and low self-esteem, : classification of gender into two distinct and lack of family support, discrimination and marginalization opposite forms of masculine and feminine, with individuals in society are hypothesized to contribute to these disheart- strictly gendered as either/or, in contrast to gender spectrum eningly high rates of psychiatric disorders. which allows for more non-binary or fluid movement along a continuum of gender. Gender nonconforming: adjective used to describe individuals INTERVENTIONS whose gender identity differs from what is normative for their Despite the history of significant health and social disadvan- natal gender. tage in this population, poorer health outcomes are not inev- Social transition: a process whereby an individual changes their itable. Recent research demonstrates that a focus on early gender expression to align with asserted gender identity which identification, family support and well-timed interventions can involve change in appearance (hair, dress, mannerisms etc.), addressing both the patient’s gender dysphoria and other behavior, pronoun, and/or name. components of an adolescent’s psychological and social Transgender: adjective used to describe individuals whose gender wellbeing seem to offer long-term health benefits.11,12 identity differs from their physical sex characteristics. (This term Ideally, gender variant youth would be identified early, at times is used as synonymous with gender nonconforming.) well before puberty, with concurrent medical and mental health involvement. Early identification and anticipatory guidance creates a thoughtfully planned, timely social and medical transition. Guidelines published by World Profes- demonstrate gender dysphoria with pubertal onset, and have sional Association for Transgender Health (WPATH) recom- adequate mental health and social support to help them mend a staged transition. WPATH Standards of Care echo safely transition.13,14 the 2009 Endocrine Society guidelines for puberty suppres- Puberty suppression provides additional time for the gen- sion for gender dysphoric youth. Guidelines suggest that der nonconforming youth to explore gender identity without youth may benefit from puberty suppression with gonado- the pressure and distress of ongoing pubertal development. tropin releasing hormone (GnRH) analogs if they have begun As an added benefit, this “pause” provided by GnRH ana- puberty with genital development tanner stage 2 or higher, logue suppression of continued pubertal development may

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provide the family with additional time to adjust. Parents Interventions by healthcare professionals that promote are often reassured that GnRH analogues are fully reversible parental support may significantly affect the mental well- allowing for endogenous pubertal development to resume being of transgender youth. This approach requires an once these puberty blockers are stopped. Puberty blockers increased focus on providing support and guidance for par- offer youth significant benefit as they relieve some gender ents and families on how best to support their child’s gender dysphoria by preventing the irreversible physical changes of identity. When discussing gender identity, parents may feel puberty if started at tanner stage 2. If started later in puberty, uncertain as to what the appropriate course of action is and GnRH analogues offer more limited benefit but continue to may be paralyzed by many fears about their child’s future. suppress permanent feminization and masculinization char- Parents may resist supporting their child’s gender identity acteristics that would require future surgical intervention to due to fears about the difficulties the child may experience in alter. Later in adolescence gender affirming hormones can the world beyond their home. Parents frequently voice fears be added.5 For teens who have already gone through some about harassment, peer rejection, physical harm, as well as pubertal changes, stopping continued development of the regret. Highlighting the crucial role of parental support in “wrong” secondary gender characteristics still offers benefit the mitigation of negative psychological outcomes can pro- by relieving distress, and facilitating the person’s ability to vide empowerment for parents who may be overwhelmed by present in accordance with their gender identity.5 the prospect of their child’s gender identity and transition. Studies indicate that puberty suppression followed by While approaching transition may be a tumultuous time cross-gender hormones may have not just physical benefits for some families, specially trained mental health profes- for gender nonconforming teens but additional psychologi- sionals can assist in supporting parents through the tran- cal benefit. A study of 70 gender dysphoric adolescents who sition process for the whole family. Assessment of family underwent puberty suppression demonstrated a decrease in function and the impact of the child’s gender nonconform- behavioral and emotional problems and depressive symp- ing behavior on the family unit is crucial.8 It is important toms and improvement in general function with puberty to acknowledge that parents may be undergoing their own suppression.15 In this group of youth, none discontinued grieving process; experiencing the child’s transition as losing puberty suppression and all eventually started on cross-gen- a son/daughter prior to gaining a child of another gender. der hormones.15 A follow-up study looked at 55 of these Processing this perceived loss may be assisted by mental youth who had undergone puberty suppression followed by health professionals working with the parents in individual cross gender hormones and gender affirming surgery and or couples therapy. evaluated their function in young adulthood. These youth Since gender nonconforming youth have lived with their showed a steady improvement in their psychological func- gender dysphoria for an extended period of time, some youth tion over time with rates of clinical symptomatology that show limited patience with their parents’ slower process were indistinguishable from the general population. Their of adjustment to disclosure and making a transition plan. quality of and satisfaction with life and subjective happiness Anticipating this lag between youth and parent acceptance measures were comparable to same age peers.12 is important in making transition plans. Just as gender These studies support the idea that with early identifica- nonconforming youth may face rejection from their peers tion, medical treatment and support, transgender youth can and social environment, parents may experience rejection reach adulthood with a reduction in psychological sequela. from family members who are not accepting of their child’s A growing body of evidence identifies that family support asserted identity. It may become necessary for the parents is a significant protective factor that can mitigate the neg- to identify those family members who are supportive of the ative psychological sequela. Gender nonconforming youth child’s asserted identity, and protect the child from those who described their families as strongly supportive of their family members who may outright reject the child. Parents gender identity in childhood, went on to have less depres- can also experience increased conflict if their approaches to sive symptoms, higher self-esteem, higher life satisfaction helping the transgender youth differ, and in those cases mar- and lower perceived burden of being transgender.16,17 A ital or co-parenting counseling may be of assistance. recent study of prepubescent children who had socially tran- The role of the mental health professional varies with sitioned and were supported by their families in their gender each case. For children who do not have any co-occurring identity were found to have normative levels of depression psychiatric difficulties and who are in a supportive and and only minimally elevated levels of anxiety (well below accepting environment, support around gender dysphoria the preclinical range). The authors concluded that allowing and assistance with safe and thoughtful social and medical children to present in everyday life in accordance with their transition planning may be sufficient. Before and during the asserted gender identity was associated with normative lev- time of transition, mental health providers can function as els of depression and anxiety.18 By supporting their child’s liaisons with schools in order to advocate for the specific authentic gender self, parents and families of gender non- needs of the youth. For children for whom social transition conforming youth have a crucial opportunity to improve may impact their safety, mental health professionals can mental health outcomes. work with parents to create a supportive environment in the

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home so that the child can experience a sense of acceptance, ing behaviors. Suicide Life Threat Behav. 2007; 37: 527-537. while a safer plan is developed for outside the home. Given 11. Ryan C, Russell ST, Huebner D, Diaz R, Sanchez J. Family ac- ceptance in adolescence and the health of LGBT young adults. the crucial aspect of parental support, mental health profes- Journal of Child and Adolescent Psychiatric Nursing. 2010;23: sionals and physicians can help mobilize parents to become 205-213. greater sources of support and advocacy. 12. De Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Dorelei- For some youth and families co-occurring psychiatric jers TA, Cohen-Kettenis PT. Young psychological outcome after puberty suppression and gender reassignment. Pediatrics. struggles present additional challenges. Mental health pro- 2014;134(4):696-704. fessionals can be an important asset in assessing comorbid- 13. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, De- ities and treating separate psychiatric concerns. As with Cuypere G, Feldman J, Fraser L, Green J, Knudson G, Meyer their cisgender peers, early identification and treatment of WJ, Monstrey S. Standards of care for the health of , transgender, and gender-nonconforming people, version 7. Inter- adolescent mental health concerns remains essential and national Journal of Transgenderism. 2012;13(4):165-232. predictive of improved long term health outcomes. 14. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer III WJ, Spack NP, Tangpricha V, Montori VM. Endocrine treatment of transsexual persons: an Endocrine Soci- ety clinical practice guideline. The Journal of Clinical Endocri- CONCLUSION nology & Metabolism. 2009 Sep;94(9):3132-54. 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