Clinical Management of Gender Dysphoria in Adolescents

Fig. 8.1

Annual referral rates at the Gender Identity Development Service – London

8.4 Long-Term Follow-Up Studies

A follow-up study of children with features of gender dysphoria was conducted by Green (1987) [21]. He reported that of the 66 males in the original ‘feminine boy’ group, two-thirds were reinterviewed in adolescence or young adulthood, when three-quarters of them were found to be homosexual or bisexual. Only one boy in this study had a transsexual outcome.

Zucker [38] collated all the long-term follow-up studies of children with gender identity disorder (gender dysphoria) referred to mental health professionals. The study showed that a small minority of children had a transsexual outcome (5.3 %), while the majority had a homosexual or bisexual outcome (45.7 %).

More recent studies show that gender dysphoria persists into adolescence and beyond in only about ten to thirty percent of prepubertal children with gender dysphoria [19, 34]. Given the variability of outcomes, some clinicians have defined their approach to the care of children as ‘watchful waiting’. Factors which may contribute to the persistence or desistence are unclear and the subject of current empirical research.

Gender dysphoria in adolescence tends to persist into adulthood in the vast majority of cases.

8.5 Associated Psychosocial Difficulties

Coates and Spector Person [6] have shown that children with gender identity disorders also present with separation anxiety, depression and emotional and behavioural difficulties. Suicide attempts and self-harming behaviours in adolescence are frequent, and in some cases this is how adolescents with gender identity disorders come to professional attention [29].

In a survey of the first 124 cases referred to the GIDS, we found that the most common associated features were relationship difficulties with parents or carers (57 %), relationship difficulties with peers (52 %), depression/misery (42 %), family mental health problems (38 %), family physical health problems (38 %), being the victim of harassment or persecution (33 %) and social sensitivity (31 %). This data suggest that children with gender identity problems may experience considerable isolation owing to difficulties in their relationships with significant adults and peers. They can also become the victims of persecution, which may contribute to feelings of depression and misery. In this sample, boys appear to experience more harassment than girls, and this may be due to the fact that gender nonconformity in boys is less socially acceptable than in girls. The high percentages of mental and physical health problems in the families of children and adolescents referred may indicate that factors such as parental depression or major physical illness could represent a traumatic event for the child, possibly contributing to their gender identity issues. This survey also showed that associated difficulties and case complexity increase during adolescence [16].

De Vries et al. [12] at the Gender Identity Clinic in Amsterdam reported the occurrence of autism spectrum disorders in 7.8 % in gender dysphoric children and adolescents. Jones et al. [22] reported elevated scores on the autism spectrum quotient (AQ) in female-to-male transsexual people (transmen).

For a detailed review of the associated psychosocial difficulties, see Zucker [41].

8.6 Explanatory Models

No single cause has yet been found with certainty for the development of gender dysphoria in children and adolescents.

Most authors would agree that a combination of biological, psychodynamic/psychological and social factors contributes to the development of gender dysphoria in young people. The significance of the co-occurrence in a number of cases of gender dysphoria and autistic spectrum conditions in some children is the subject of current study. Autistic spectrum features may lead to particular styles of thinking, which in some cases contributes to the persistence of gender dysphoria from childhood to adolescence and beyond.

Biological factors include differences in brain anatomy and genetic and hormonal influences during foetal development and childhood. Taziaux et al. [33] have shown that there are sex differences in the neurokinin B (NKB) system in the human infundibular nucleus. They state that these differences ‘reached only significance in adulthood and that male-to-female transsexuals had a female-typical infundibular NKB system. These results suggest that: (1) in addition to the well-known perinatal period of steroid-dependent brain organisation, sex steroid hormones during puberty might also contribute to the emergence of sex differences in adulthood; and (2) the sex reversal observed in MtF transsexuals may reflect, at least in part, an atypical sexual differentiation of the hypothalamus’. These data confirm previous findings regarding the difference between sexes in some hypothalamic nuclei, in that MtF transsexual people have a configuration of these nuclei similar to those of females [23, 37]. How these differences influence self-perception remains unclear.

Psychodynamic/psychological factors contributing to the development of gender dysphoria in children and adolescents have included attachment issues [24], difficulty mourning the loss of an important attachment figure ([3], Di Ceglie 1998), consequences of traumatic experiences [8, 7], maternal depression and particular family constellations [31]. Factors which contribute to the persistence of gender dysphoria from childhood into adolescence and beyond are unclear.

On the whole, the interaction between subjective experience, hormonal influences and brain structures is not well understood and will require further studies.

For a review of the literature on aetiological factors, see [11, 40].

Case Illustration 1: Mark

Mark, aged 16 years, presented with gender dysphoria. He hated his male body intensely. Socially isolated and in despair, he had attempted suicide. Since the age of 3 or 4 years, he had felt that he was a girl. At the age of 7 years, his father sexually abused him, and this experience confirmed for him that he was a girl as, at that time, he thought that men were sexually attracted only to women. At the time of the referral, he felt that his body should be changed immediately, as he could not bear living in a contradictory situation. At this stage Mark still lived in a male role. There was also a real possibility of further suicide attempts.

A structured therapeutic programme, including individual and family sessions, and also consultation with a paediatric endocrinologist, made him feel that mind and body had been taken into consideration and helped him to tolerate a transitional phase of uncertainty by containing his feelings of despair. It also supported his hope that the incongruence between his mind and body would eventually be overcome. It was important that network meetings of the professionals involved with his care were held at regular intervals.

Exploration of the young person’s expectations, gender identity and roles, body image, self-perception and other people’s perception of the individual is essential preparation for the young person to begin physical (hormonal) interventions and the referral to a gender identity service for adults at the age of 18 for further treatment. Surgical intervention could be offered in the adult service. In Mark’s case this exploration showed a well established – gender dysphoria.

8.7 Some Psychodynamic Considerations on the Nature of the Atypical Gender Identity Organisation: Continuity and Discontinuity

In 1964 Stoller proposed the concept of core gender identity. He saw this as:

Produced by the infant–parent relationship, the child’s perception of its external genitalia, and a biologic force, which results from the biologic variables of sex (chromosomes, gonads, hormones, internal accessory reproductive structures and external genitalia).

Stoller believed that the core gender identity is established before the fully developed phallic stage, age 3–6, although gender identity continues to develop into adolescence and beyond ([30]: 453). He further stated that the beliefs comprising the ‘mental structure’ of the core gender identity are the earliest part of gender identity to develop and are relatively permanent after the child reaches 4 or 5 years of age ([32]: 78).

Further research and clinical experience show that in about 10–30 % of children with gender dysphoria does the core gender identity have the enduring structural characteristics described by Stoller.

In 1998 the author proposed the concept of atypical gender identity organisation (AGIO) as a clinical entity that can be examined under a number of parameters relevant to clinical management (Box 8.1; [14]).

Box 8.1. Clinical Features of Atypical Gender Identity Organisation (AGIO; from [14])

Rigidity–flexibility
Timing of formation of the AGIO
Presence/absence of traumatic events in the child’s life in relation to formation of the AGIO
Position of the AGIO on continuum from the paranoid–schizoid to the depressive position

Rigidity–flexibility

This refers to the capacity of the AGIO to remain unchangeable or, alternatively, to be amenable to evolution in the course of development. Organisations which are more rigid will contribute to the persistence of the atypical gender identity development (gender dysphoria), while organisations which are more fluid will lead to shifts in gender identity development. As mentioned earlier, only in some prepubertal children (10–30 %) will it possess the unchangeable structural qualities of Stoller’s core gender identity. To use a different language, one could say that there is continuity in the AGIO from childhood to adolescence/adulthood in a small proportion of children and discontinuity in the rest.
Timing of the AGIO formation

Atypical organisations that develop very early in the child’s life may be more likely to become rigidly structured than organisations that develop later. The early onset of gender dysphoria is in fact one of the criteria for considering early pubertal suppression (see section on management).
Identifiable traumatic events in the child’s life in relation to the AGIO formation

In some cases the AGIO is formed as a psychological coping strategy in relation to a traumatic event in childhood. The earlier the trauma occurs, the more likely it is that the organisation will acquire rigid and unchangeable qualities.
Where the formation of the AGIO can be located on the continuum from the paranoid–schizoid to the depressive position within Klein–Bion model of psychological development

The hypothesis here is that if the AGIO is formed within a mental functioning dominated by paranoid–schizoid processes in response to a traumatic event, it is more likely to become very structured, and therefore not amenable to change. Alternatively, if it is formed within a mental functioning of the depressive position, it is likely that the organisation will be amenable to evolution.

Therapeutic exploration may be able to elucidate the characteristics of the organisation and therefore guide management. The following clinical example illustrates this point.

Case Illustration 2: Jennifer

Jennifer was 17 when she presented following three suicide attempts. She was a female-to-male transgender person who presented with depressive episodes and a number of borderline features. She was still living in a female role, maintained her female name and wished to be addressed using a female pronoun. She was uncertain about physical interventions. Her mother, who had died just before Jennifer came to the clinic, suffered depression after Jennifer’s birth, and her father had been physically violent towards his wife during Jennifer’s childhood, until they separated. During her psychotherapy sessions, she vividly remembered episodes when her father in fits of temper had kicked her mother, even in the stomach. In one session she admitted, not without a sense of embarrassment and shame that she had identified with him, an experience that she could not explain. She loved her mother, and her main aim in life was to do something extraordinary that would have made her mother happy. There was no recollection that Jennifer herself had been physically abused by her father, but witnessing violence between her parents had been a traumatic childhood experience.

It is possible to hypothesise that the way Jennifer coped with the fear of damage to her mother and possibly to herself was to identify with a male possessing the strength of a masculine body. This belief, once established, gave her a sense of survival and also of protecting her ‘damaged’ mother. A female representation of herself had to be strongly avoided, as this was equated in her mind with being weak and damaged.

Another important factor also seemed to play a part. After the birth of two older sisters, her mother had miscarried a baby boy. One year later, Jennifer was born. Jennifer seemed to feel that her mother had expected her to be a boy, and in one session she alluded to her mother having ‘psychic qualities’, as if she had been part of a magical experience in which she and her mother could read each others’ minds. She had probably received, and made her own, her mother’s wish that she were a boy. This wish was probably never consciously expressed by her mother but remained unconsciously active in the relationship between them.

Two years of psychotherapeutic exploration with this young person allowed the therapist, together with Jennifer, to make this partial reconstruction of her childhood relating to her atypical gender identity development. However, any attempts to explore this understanding further with Jennifer led to continuous interruptions to the therapeutic work, which may have indicated her extreme resistance and fears of having the foundation of her gender identity revisited.

Even if she retained some of this understanding, it certainly did not alter Jennifer’s gender identity development, that is to say, the sense of whom she was. Her atypical gender identity organisation was well established, and not amenable to evolution. It formed very early in her life, and traumatic events had played a large part in it. Its formation may have probably occurred under the dominance of the paranoid–schizoid position.

Towards the end of therapy, Jennifer was able to live in a male role with a male name, and his well-being improved. He did not attempt suicide again. He settled in a job, and he was more able to establish relationships with other people. One might say that therapy had helped him to cope with his well-established AGIO in a better way, to make the transition to a male role and to give him a sense of hope (an important therapeutic aim – see Box 8.3). He was eventually referred to an adult service for further treatment.

8.8 Management and Therapy: The Staged Approach

The research evidence regarding the management of gender dysphoria in young people is still poor to date. The Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder (gender dysphoria) states that ‘the highest level of evidence available for treatment recommendations for these children can best be characterised as expert opinion’ [5].

Our model of management at the Tavistock and Portman NHS Foundation Trust is based on the understanding of atypical gender identity development within a complex paradigm. It has been informed by the fact that the causation of the phenomenon of GID remains unclear, and it is probably multifactorial. It is also influenced by current cultural values and societal attitudes regarding the development of gender identity. Our therapeutic experience has shown that children are very sensitive and feel easily intruded upon by anyone attempting to change who they feel they are and by those who minimise their feelings. Therefore at the Gender Identity Development Service, we have developed a model of management in which altering an individual’s perceived gender identity is not a primary therapeutic objective. Instead, emphasis is placed on the following list of therapeutic aims (Box 8.2).

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