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Gender dysphoria in childhood and adolescence: Current approaches and ethical issues

Year 2023, Volume: 28 Issue: 3, 433 - 440, 28.09.2023

Adem Az M. İhsan Karaman

https://doi.org/10.21673/anadoluklin.1279878

Abstract

Gender dysphoria refers to a significant discomfort that results from a discrepancy between an individual’s gender identity and the gender assigned to them at birth. Gender dysphoria in childhood and adolescence is a complex and challenging issue, which raises important ethical questions about how we should respond to the needs of young people experiencing this condition. There is currently no consensus among medical professionals on the optimal approach for treating gender dysphoric children and adolescents. While earlier approaches to gender dysphoria tended to attribute differences in gender expression to psychosocial causes, recent studies suggest that the developmental course of gender dysphoria is influenced by multiple psychosocial factors that interact with biological factors. In this way, some professionals and the Dutch model advocate for early intervention to promote gender affirmation and reduce the risk of psychological distress, while others recommend a more cautious approach that prioritizes the discovery of gender identity over medical intervention. However, both current treatment recommendations and the Dutch model raise ethical concerns related to gender dysphoria, as they may conflict with the principles of the best interest of the child, being beneficial and not causing harm. In this article, we will critically examine the clinical and ethical considerations surrounding the treatment of gender dysphoric children and adolescents, and discuss the potential risks and benefits of different approaches.

Keywords

Adolescence childhood ethics gender dysphoria treatment

References

  • Reale C, Invernizzi F, Panteghini C, Garavaglia B. Genetics, sex, and gender. J Neurosci Res. 2023;101(5):553–62.
  • Money J. Hermaphroditism, gender and precocity in hyperadrenocorticism: Psychologic findings. Bull Johns Hopkins Hosp. 1955;96:253–64.
  • Haig D. The inexorable rise of gender and the decline of sex: social change in academic titles, 1945–2001. Arch Sex Behav. 2004;33:87–96.
  • Vaidakis N. Conceptual controversies regarding the terms Gender and Sex. Psychiatriki. 2020;31(3):271–4.
  • Eagly AH, Wood W. The nature-nurture debates: 25 years of challenges in understanding the Psychology of gender. Perspect Psychol Sci. 2013;8(3):340–57.
  • Garg G, Elshimy G, Marwaha R. (2023), Gender dysphoria. Treasure Island (FL): StatPearls Publishing. Erişim tarihi: 09 Nisan 2023. Erişim linki: https://pubmed.ncbi.nlm.nih.gov/30335346/
  • American Psychiatric Association. (2013), Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Press.
  • 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):3869–903.
  • Zucker KJ. Epidemiology of gender dysphoria and transgender identity. Sex Health. 2017;14(5):404–11.
  • van de Grift TC, Cohen-Kettenis PT, Steensma TD, et al. Body satisfaction and physical appearance in gender dysphoria. Arch Sex Behav. 2016;45(3):575–85.
  • Drescher J, Pula J. Ethical issues raised by the treatment of gender-variant prepubescent children. Hastings Cent Rep. 2014;44 Suppl 4:S17–22.
  • Byne W, Karasic DH, Coleman E, et al. Gender dysphoria in adults: An overview and primer for Psychiatrists. Transgend Health. 2018;3(1):57–70.
  • Reed GM, Drescher J, Krueger RB, et al. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016;15(3):205–21.
  • Hayes K. Ethical implications of treatment for gender dysphoria in youth. Journal of Health Ethics. 2018;14(2). Erişim tarihi: 09 Nisan 2023. Erişim linki: http://dx.doi.org/10.18785/ojhe.1402.03
  • Hembree WC. Management of juvenile gender dysphoria. Curr Opin Endocrinol Diabetes Obes. 2013;20(6):559–64.
  • Streed CG Jr, Anderson JS, Babits C, Ferguson MA. Changing medical practice, not patients - putting an end to conversion therapy. N Engl J Med. 2019;381(6):500–2.
  • Ryan C, Toomey RB, Diaz RM, Russell ST. Parent-initiated sexual orientation change efforts with LGBT adolescents: Implications for young adult mental health and adjustment. J Homosex. 2020;67(2):159–73.
  • Rafferty J; Comiittee on psychosocial aspects of child and family health; committee on adolescence; section on lesbian, gay, bisexual, and transgender health and wellness. Ensuring comprehensive care and support for Transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4):e20182162.
  • de Vries AL, Cohen-Kettenis PT. Clinical management of gender dysphoria in children and adolescents: the Dutch approach. J Homosex. 2012;59(3):301–20.
  • Olson J, Forbes C, Belzer M. Management of the transgender adolescent. Arch Pediatr Adolesc Med. 2011;165(2):171–6.
  • 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.
  • Ristori J, Steensma TD. Gender dysphoria in childhood. Int Rev Psychiatry. 2016;28(1):13–20.
  • Rekers GA, Lovaas OI. Behavioral treatment of deviant sex-role behaviors in a male child. J Appl Behav Anal. 1974;7(2):173–90.
  • Brik T, Vrouenraets LJJJ, de Vries MC, Hannema SE. Trajectories of adolescents treated with Gonadotropin-Releasing Hormone Analogues for gender dysphoria. Arch Sex Behav. 2020;49(7):2611–8.
  • Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam cohort of gender dysphoria study (1972-2015): Trends in prevalence, treatment, and regrets. J Sex Med. 2018;15(4):582–90.
  • Olson-Kennedy J, Warus J, Okonta V, et al. Chest reconstruction and chest dysphoria in transmasculine minors and young adults: Comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr. 2018;172(5):431–6.
  • De Cuypere G, T’Sjoen G, Beerten R, et al. Sexual and physical health after sex reassignment surgery. Arch Sex Behav. 2005;34(6):679–90.
  • Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender dysphoria in adolescence: current perspectives. Adolesc Health Med Ther. 2018;9:31–41.
  • Rodriguez-Wallberg K, Obedin-Maliver J, Taylor B, et al. Reproductive health in transgender and gender diverse individuals: A narrative review to guide clinical care and international guidelines. Int J Transgend Health. 2022;24(1):7–25.
  • Steinberg L. A dual systems model of adolescent risk-taking. Dev Psychobiol. 2010;52(3):216–24.
  • 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;38:151–89.
  • 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):489–95.
  • 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):93–9.
  • 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):579–88.
  • Freud S. Some psychical consequences of the anatomical distinction between the sexes. International Journal of Psychoanalysis. 1925;6:21–6
  • Money J, Ehrhardt AA. (1972), Man and woman, boy and girl: Differentiation and dimorphism of gender identity from conception to maturity. Baltimore, MD: Johns Hopkins University Press.
  • Vlot MC, Klink DT, den Heijer M, et al. Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents. Bone. 2017;95:11–9.
  • Rew L, Young CC, Monge M, Bogucka R. Review: Puberty blockers for transgender and gender diverse youth-a critical review of the literature. Child Adolesc Ment Health. 2021;26(1):3–14.
  • Kimberly LL, Folkers KM, Friesen P, et al. Ethical issues in gender-affirming care for youth. Pediatrics. 2018;142(6):e20181537.
  • 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):1175–88.
  • 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.
  • 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):1351–66.
  • 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.

Çocukluk ve ergenlikte cinsiyet disforisi: Güncel yaklaşımlar ve etik sorunlar

Year 2023, Volume: 28 Issue: 3, 433 - 440, 28.09.2023

Adem Az M. İhsan Karaman

https://doi.org/10.21673/anadoluklin.1279878

Abstract

Cinsiyet disforisi, bir bireyin cinsiyet kimliği ile doğumda kendisine atanan cinsiyet arasındaki tutarsızlıktan kaynaklanan önemli bir rahatsızlığı ifade eder. Çocukluk ve ergenlik çağı cinsiyet disforisi, bu durumu yaşayan gençlerin ihtiyaçlarına nasıl yanıt vermemiz gerektiğine dair önemli etik soruları gündeme getiren karmaşık ve zorlu bir konudur. Şu anda tıp uzmanları arasında cinsiyet disforik çocukları ve ergenleri tedavi etmek için en uygun yaklaşım konusunda bir fikir birliği yoktur. Cinsiyet disforisine yönelik daha önceki yaklaşımlar, cinsiyet ifadesindeki farklılıkları psikososyal nedenlere atfetme eğilimindeyken, son araştırmalar, cinsiyet disforisinin gelişimsel seyrinin, biyolojik faktörlerle etkileşime giren çok sayıda psikososyal faktörden etkilendiğini savunmaktadır. Bu şekilde, bazı profesyoneller ve Hollanda modeli, cinsiyetin onaylanmasını teşvik etmek ve psikolojik sıkıntı riskini azaltmak için erken müdahaleyi savunurken, diğerleri tıbbi müdahale yerine cinsiyet kimliğinin keşfedilmesine öncelik veren daha temkinli bir yaklaşım önermektedir. Güncel tedavi önerileri ve Hollanda modeli, cinsiyet disforisi ile ilgili etik sorunlara çözümler üretemediği gibi çocuğun üstün yararı, yararlı olma ve zarar vermeme ilkeleri ile çelişen yeni problemler ortaya çıkarmaktadır. Bu makalede, cinsiyet disforik çocuk ve ergenlerin tedavisini çevreleyen klinik ve etik hususları eleştirel bir şekilde inceleyeceğiz ve farklı yaklaşımların potansiyel risklerini ve faydalarını tartışacağız.

Keywords

Cinsiyet disforisi çocukluk ergenlik etik tedavi

Supporting Institution

Bu makale ile ilgili herhangi bir finansal kaynaktan yararlanılmamıştır

References

  • Reale C, Invernizzi F, Panteghini C, Garavaglia B. Genetics, sex, and gender. J Neurosci Res. 2023;101(5):553–62.
  • Money J. Hermaphroditism, gender and precocity in hyperadrenocorticism: Psychologic findings. Bull Johns Hopkins Hosp. 1955;96:253–64.
  • Haig D. The inexorable rise of gender and the decline of sex: social change in academic titles, 1945–2001. Arch Sex Behav. 2004;33:87–96.
  • Vaidakis N. Conceptual controversies regarding the terms Gender and Sex. Psychiatriki. 2020;31(3):271–4.
  • Eagly AH, Wood W. The nature-nurture debates: 25 years of challenges in understanding the Psychology of gender. Perspect Psychol Sci. 2013;8(3):340–57.
  • Garg G, Elshimy G, Marwaha R. (2023), Gender dysphoria. Treasure Island (FL): StatPearls Publishing. Erişim tarihi: 09 Nisan 2023. Erişim linki: https://pubmed.ncbi.nlm.nih.gov/30335346/
  • American Psychiatric Association. (2013), Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Press.
  • 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):3869–903.
  • Zucker KJ. Epidemiology of gender dysphoria and transgender identity. Sex Health. 2017;14(5):404–11.
  • van de Grift TC, Cohen-Kettenis PT, Steensma TD, et al. Body satisfaction and physical appearance in gender dysphoria. Arch Sex Behav. 2016;45(3):575–85.
  • Drescher J, Pula J. Ethical issues raised by the treatment of gender-variant prepubescent children. Hastings Cent Rep. 2014;44 Suppl 4:S17–22.
  • Byne W, Karasic DH, Coleman E, et al. Gender dysphoria in adults: An overview and primer for Psychiatrists. Transgend Health. 2018;3(1):57–70.
  • Reed GM, Drescher J, Krueger RB, et al. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016;15(3):205–21.
  • Hayes K. Ethical implications of treatment for gender dysphoria in youth. Journal of Health Ethics. 2018;14(2). Erişim tarihi: 09 Nisan 2023. Erişim linki: http://dx.doi.org/10.18785/ojhe.1402.03
  • Hembree WC. Management of juvenile gender dysphoria. Curr Opin Endocrinol Diabetes Obes. 2013;20(6):559–64.
  • Streed CG Jr, Anderson JS, Babits C, Ferguson MA. Changing medical practice, not patients - putting an end to conversion therapy. N Engl J Med. 2019;381(6):500–2.
  • Ryan C, Toomey RB, Diaz RM, Russell ST. Parent-initiated sexual orientation change efforts with LGBT adolescents: Implications for young adult mental health and adjustment. J Homosex. 2020;67(2):159–73.
  • Rafferty J; Comiittee on psychosocial aspects of child and family health; committee on adolescence; section on lesbian, gay, bisexual, and transgender health and wellness. Ensuring comprehensive care and support for Transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4):e20182162.
  • de Vries AL, Cohen-Kettenis PT. Clinical management of gender dysphoria in children and adolescents: the Dutch approach. J Homosex. 2012;59(3):301–20.
  • Olson J, Forbes C, Belzer M. Management of the transgender adolescent. Arch Pediatr Adolesc Med. 2011;165(2):171–6.
  • 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.
  • Ristori J, Steensma TD. Gender dysphoria in childhood. Int Rev Psychiatry. 2016;28(1):13–20.
  • Rekers GA, Lovaas OI. Behavioral treatment of deviant sex-role behaviors in a male child. J Appl Behav Anal. 1974;7(2):173–90.
  • Brik T, Vrouenraets LJJJ, de Vries MC, Hannema SE. Trajectories of adolescents treated with Gonadotropin-Releasing Hormone Analogues for gender dysphoria. Arch Sex Behav. 2020;49(7):2611–8.
  • Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam cohort of gender dysphoria study (1972-2015): Trends in prevalence, treatment, and regrets. J Sex Med. 2018;15(4):582–90.
  • Olson-Kennedy J, Warus J, Okonta V, et al. Chest reconstruction and chest dysphoria in transmasculine minors and young adults: Comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr. 2018;172(5):431–6.
  • De Cuypere G, T’Sjoen G, Beerten R, et al. Sexual and physical health after sex reassignment surgery. Arch Sex Behav. 2005;34(6):679–90.
  • Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender dysphoria in adolescence: current perspectives. Adolesc Health Med Ther. 2018;9:31–41.
  • Rodriguez-Wallberg K, Obedin-Maliver J, Taylor B, et al. Reproductive health in transgender and gender diverse individuals: A narrative review to guide clinical care and international guidelines. Int J Transgend Health. 2022;24(1):7–25.
  • Steinberg L. A dual systems model of adolescent risk-taking. Dev Psychobiol. 2010;52(3):216–24.
  • 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;38:151–89.
  • 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):489–95.
  • 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):93–9.
  • 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):579–88.
  • Freud S. Some psychical consequences of the anatomical distinction between the sexes. International Journal of Psychoanalysis. 1925;6:21–6
  • Money J, Ehrhardt AA. (1972), Man and woman, boy and girl: Differentiation and dimorphism of gender identity from conception to maturity. Baltimore, MD: Johns Hopkins University Press.
  • Vlot MC, Klink DT, den Heijer M, et al. Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents. Bone. 2017;95:11–9.
  • Rew L, Young CC, Monge M, Bogucka R. Review: Puberty blockers for transgender and gender diverse youth-a critical review of the literature. Child Adolesc Ment Health. 2021;26(1):3–14.
  • Kimberly LL, Folkers KM, Friesen P, et al. Ethical issues in gender-affirming care for youth. Pediatrics. 2018;142(6):e20181537.
  • 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):1175–88.
  • 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.
  • 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):1351–66.
  • 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.
There are 43 citations in total.

Details

Primary Language Turkish
Subjects Clinical Sciences (Other)
Journal Section REVİEW
Authors

Adem Az 0000-0002-7204-6185

M. İhsan Karaman 0000-0001-5700-0835

Publication Date September 28, 2023
Acceptance Date June 1, 2023
Published in Issue Year 2023 Volume: 28 Issue: 3

Cite

Vancouver Az A, Karaman Mİ. Çocukluk ve ergenlikte cinsiyet disforisi: Güncel yaklaşımlar ve etik sorunlar. Anatolian Clin. 2023;28(3):433-40.
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