Treating Transgender Children and Adolescents

An Interdisciplinary Discussion

Jack Drescher, William Byne, Jack Drescher, William Byne

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317980629
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychische Gesundheit in der Psychologie

Extremely gender variant children and adolescents (minors), increasingly referred to as 'trans' or 'transgender children, ' are small in number. In recent years, their situation has become highly sensationalized, whilst the matter of how to best treat them remains an area of controversy. A growing body of research supports emerging treatment approaches, but more research is still needed to answer a host of questions: Do trans minors have a psychiatric disorder or a normal variation of gender presentation? Should treatment be aimed at helping them accept the bodies into which they were born or should parents, clinicians and schools accommodate their wishes of transition? At what age should transition begin? What are the implications – physical, psychological, social and ethical – of various treatment approaches?

The first part of this volume explores different clinical approaches to transgender minors in the USA and abroad. The second part contains responses to these approaches by commentators from various fields including biology, child psychiatry, civil rights activism, ethics, law, gender studies, queer theory and psychoanalysis. The work will be an invaluable source for parents and families looking at how to proceed with a trans child, as well as clinicians seeking to make appropriate referrals.

This book was originally published as a special issue of the Journal of Homosexuality.

Introduction

The Treatment of Gender Dysphoric/Gender Variant Children and Adolescents

JACK DRESCHER, MD

New York Medical College, New York, New York, USA

WILLIAM BYNE, MD, PhD

Mount Sinai School of Medicine, New York, New York, USA

We were both honored and intrigued when John Elia invited us to guest edit an issue of the Journal of Homosexuality on any subject of our choice. We decided to invite contributions from diverse clinicians who describe their approach to gender dysphoric/gender variant children and adolescents as well as several discussants to comment on those clinical approaches with a focus on the philosophical and ethical issues they raise.

One of us (Drescher) has been serving for several years as a member of the DSM-5 Work Group on Sexual and Gender Identity Disorders (WGSGID) and was recently appointed to serve on the World Health Organization’s Working Group on the Classification of Sexual Disorders and Sexual Health for the ICD-11. The other (Byne) recently chaired an American Psychiatric1 Association (APA) Task Force on the Treatment of Gender Identity Disorder whose charge was to perform a critical review of the literature on the treatment of Gender Identity Disorder (GID) at different ages and to present a report to APA’s board of trustees. The report would include an opinion as to whether or not there is sufficient credible literature to take the next step and develop treatment recommendations. This report (Byne et al., in press) was approved by the APA’s board of trustees in September 2011 and will be published in the Archives of Sexual Behavior and available through the APA’s Web site.

We were not entirely surprised by the task force’s findings. Although the current state of research is sufficient to support evidence-based psychiatric guidelines for the treatment of gender dysphoric/gender variant (GID/GV) in adults, and while the task force noted several areas of clinical consensus regarding the treatment of GID/GV in children and adolescents, there is clearly a current lack of consensus regarding fundamental issues in treating these age groups. These issues include realistic and ethical treatment goals as well as questions regarding effective and ethical methods of treatment to achieve them.¹

As Drescher (2010) previously noted, the APA’s 2008 announcement of the appointment of the DSM-5 WGSGID generated several controversies in the lesbian, gay, bisexual, and transgender (LGBT) community (Chibbaro, 2008; Osborne, 2008) and, shortly afterward, these controversies were taken up by the mainstream media as well (Carey, 2008). One contentious issue, that “clinical efforts with gender variant children aimed at getting them to reject their felt gender identity and to accept their natal sex were unscientific, unethical, and misguided” (Drescher, 2010, p. 428), was only briefly mentioned in Drescher’s otherwise exhaustive review. However, the following questions were left unanswered, hopefully to be addressed in future discussion:

• Are all presentations of gender variance in children nonpathological?

• Is the psychological distress associated with gender incongruence in children the result of internal processes or unaccepting social responses?

• Is it possible to clinically distinguish a pathological gender identity disorder of childhood (GIDC) from normative gender atypical behavior of children who may or may not grow up to be gay or transgender?

• Given that most cases of childhood gender incongruence do not persist into adulthood, are there subtypes of GIDC? If so, can they be distinguished from each other?

• Does empirical research support the claim that clinical interventions with gender variant children can prevent persistence of gender incongruence into adolescence and adulthood? If so, is it advisable or ethical to treat children in order to prevent adult transsexualism?

• To whom does it matter if a child grows up either gay or transgender?

• Does the current state of empirical research support treating prepubescent children with hormone blockers to prevent the onset of puberty and the facilitation of transition in later life? Does such treatment in and of itself increase the likelihood of persistence?

• What of the gender variant child whose social environment both accepts and encourages an early transition but may be unaware that the child, unwilling to disappoint, has had a change of heart (P. T. Cohen-Kettenis, personal communication)?

• Who should be designated as the best advocates for gender variant children? Parents? Teachers? Government agencies? Mental health professionals? Adult transgender activists? Queer theorists?

• These and many other questions are not easily answered and all will require further study as well as thoughtful analysis and discussion (Drescher, 2010, p. 454).

With APA revising the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev; DSM-IV-TR; APA, 2000) and considering the possibility of drafting treatment recommendations, and with the World Health Organization in the midst of revising the International Classification of Diseases (ICD), we, as guest editors, decided to venture on a scholarly exploration of some of the clinical controversies surrounding the assessment and treatment of children and younger adolescents with gender dysphoria (GD) as well as of children referred by their caregivers due to perceived gender variance (GV). While adults with GD/GV can make decisions on their own behalf, we see a lack of consensus among clinicians regarding the most basic issues of treatment goals and approaches to treatment of children that can pose a difficult dilemma for parents seeking to make the best decisions for their children. One goal of this issue is to assist caregivers who face this dilemma by providing authoritative detailed descriptions of the various treatment goals and approaches to treatment of children together with several scholarly comparative analyses of these various approaches.

Finally, why the use of the “GD/GV” terminology? As Meyer-Bahlburg (2010) notes, “The nomenclature in the area of gender variations continues to be in flux, in regard to both the descriptive terms used by professionals, and, even more so, the identity terms adopted by persons with GIV [Gender-Identity-Variants]” (p. 461). For example, the DSM-5 WGSGID initially proposed that the designation “GID” be replaced in the DSM-5 by “Gender Incongruence” but currently proposes that it be replaced by “Gender Dysphoria.” In order to give our contributors free rein, we placed no restrictions on their use of terminology and only asked that they be clear and consistent in defining their usage.

THE 5 CLINICAL ARTICLES

In putting together this special issue of the Journal of Homosexuality, we invited several clinicians who are currently working directly with children and younger adolescents to draw on their own clinical experience and to present their clinical and theoretical points of view, providing illustrative examples where possible. Citation of published data to support the clinicians’ perspective was encouraged; however, given the limits of empirical research in this area, this was not always possible.

The clinical articles, in alphabetical order by first author, are as follows:

• “Clinical Management of Gender Dysphoria in Children and Adolescents: The Dutch Approach,” by Annelou L. C. de Vries and Peggy T. Cohen-Kettenis

• “Psychological Evaluation and Medical Treatment of Transgender Youth in an Interdisciplinary ‘Gender Management Service’ (GeMS) in a Major Pediatric Center,” by Laura Edwards-Leeper and Norman P. Spack

• “From Gender Identity Disorder to Gender Identity Creativity: True Gender Self Child Therapy,” by Diane Ehrensaft

• “A Comprehensive Program for Children with Gender Variant Behaviors and Gender Identity Disorders,” by Edgardo Menvielle

• “A Developmental, Biopsychosocial Model for the Treatment of Children with Gender Identity Disorder,” by Kenneth J. Zucker, Hayley Wood, Devita Singh, and Susan J. Bradley

We asked the clinical contributors to consider the following specific issues as they pertain to GD/GV in children and younger adolescents. However, this was not presented as a rigid guideline and all of the contributors were told they could organize their remarks in any way they deemed appropriate.

• What constitutes an assessment?

• On what basis is it decided that treatment is indicated?

• What is the disposition of referred cases for which no clinically significant GD/GV is observed?

• When treatment is indicated, what are the rationale and goals for treatment, and, as specifically as possible, how does treatment proceed?

• How are the relative risks and benefits of treatment as well as the impact of treatment on outcome explained to caregivers?

• Is prevention of adult transsexualism a reasonable treatment goal, and given the low frequency with which GID persists into adulthood, how is it possible to determine the efficacy of treatment in attaining that goal?

• What are the risks and benefits for using hormonal blockers to delay the onset of puberty in GD/GV children or to block the progression of puberty in adolescents? What is the rationale for offering o...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• Citation Information
• Notes on Contributors
• Introduction: The Treatment of Gender Dysphoric/Gender Variant Children and Adolescents
• Part I: Clinical Approaches
• Part II: Responses
• Index