Caring for Transgender Kids: Is Clinical Practice Outpacing the Science?

Becky McCall, BSc, MSc; Lisa Nainggolan


August 28, 2018

Causes, Diagnosis, and Decision-Making

More Questions Than Answers

This unprecedented increase in referrals begs the question: Why is this happening? What has changed in the psychosocial, biological, or cultural environment to precipitate it? Davidson is clear that the antecedents (as opposed to "causes") are elusive. "In fact, it is highly unlikely that there is one particular cause, and more likely that a myriad of factors are interacting to produce the outcome," she remarks.

Without a doubt, many more questions than answers on managing gender dysphoria remain. Diagnosis is high on the list of controversies. In 2013, the DSM-5 Workgroup on Sexual and Gender Identity Disorders was asked to revise what the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) called "sexual and gender-identity disorders." In particular, the committee was asked to reconcile calls to remove the diagnosis from the DSM because of its stigmatizing nature, not dissimilar to the removal of homosexuality as a diagnosis from the DSM-II in 1973. However, removal would have restricted access to services, so "gender-identity disorder" was changed to "gender dysphoria," the diagnostic criteria were narrowed, and the specifier for sexual orientation was removed.[3]

Medicalizing Gender Dysphoria

Davidson asserts that the majority of young people at the Tavistock Centre choose not to start any medical intervention. On this note, she cautions that there is a risk of overmedicalizing gender dysphoria.

"We are directing young people to services where they are signposted to a psychologist and a medical doctor, whereas previously, because it wasn't a phenomenon, they would have worked it through with their friends and experimented. The real worry is crystallizing and solidifying a situation before it has been fully worked through."

A patient should have entered puberty before starting any intervention because gender dysphoria may resolve once puberty starts. This has been shown to happen in 73% to 88% of children who attend clinic.

Jay Stewart, PhD, is the chief executive officer of Gendered Intelligence, a not-for-profit community interest company that aims to increase understanding of gender diversity. He points out the importance of not medicalizing gender dysphoria but assuring access to services.

"At the moment, 'gender dysphoria' is a condition listed in the DSM-V, and 'transsexualism' is due to be removed from the ICD [International Classification of Diseases]. This is the right thing to do, but it shouldn't compromise our right to access health services for gender care."

The Tavistock Centre uses a staged approach to managing young people with gender dysphoria. Before any medical intervention is considered, the person's development and gender identification are explored in the context of the individual's family background and life experiences. During this stage, behavioral and emotional functioning—including features of autistic spectrum disorder and self-harm—are assessed. Of note, approximately 35% of people referred present with moderate to severe autistic traits.


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