The past decade has seen a marked surge in public interest in the issues surrounding gender dysphoria, as indicated by an increasing number of published articles in the medical literature, and media and political attention. In their recent review published in the Journal of Child Psychology and Psychiatry, Jack Turban and Diane Ehrensaft provide an update on how the field of pediatric gender identity is changing and discuss the approaches to supporting and managing the gender identity concerns of children and adolescents. They highlight that high rates of anxiety, depression and suicidal intentions in children with gender concerns may be reduced by following affirmative treatment protocols.
Issues surrounding gender identity have been in the public limelight over recent years, and this attention has been matched with an exponential increase in research articles published on the topic. In 2005, <10 new articles focusing on transgender youths were indexed in PubMed; conversely, >200 new articles were published in 2017 alone. Consistently, the number of referrals to pediatric clinics specializing in gender identity has also increased. “We set out to review this bank of literature and provide a succinct update for mental-health professionals treating children and adolescents”, says Turban. “Our main questions were: (1) what has the field learned about the epidemiology and mental-health concerns for transgender youths, (2) is there a model of care that is most robust for treating gender diverse children and adolescents, and (3) do we have evidence to support the use of medical interventions (such as puberty blockers and cross-sex hormones) in adolescents who are asserting a transgender identity?”
The researchers first analyzed the prevalence of transgender identification. One study by The Williams Institute (UCLA) published in 2016 estimated that there are ~1.4 million transgender adults residing in the USA, which accounts for ~0.6% of the population. Although the studies in children have been relatively less comprehensive than those involving adults, the reported prevalence of transgender identification among adolescents is similar to adults. For example, studies of school children residing in San Francisco and New Zealand found that 1.3% and 1.2% of adolescents, respectively, identified themselves as transgender. The researchers conclude that this overall prevalence rate (~1% young people) is much higher than previously thought.
Turban and Ehrensaft did, however, identify some limitations incurred by many studies estimating the prevalence of transgender identity in youths. First, the research field is limited by shifting terminology regarding cross-gender identification, which makes interpretation and comparisons between studies difficult. Second, many older studies relied on the child behavior checklist (CBCL), which asks the participants only two questions related to gender identity and records the answers using a scale of 0 (never), 1 (sometimes) and 2 (often). Such method of reporting can be unreliable, as some children transiently “wish” to be of the opposite sex (perhaps because they have interests associated with the opposite gender), but do not actually have a true core transgender identity. More recent studies, however, have used more relevant and direct questions such as “do you identify as transgender?” Third, there are strong societal pressures to conceal gender dysphoria in order to avoid the associated stigma. As such, prevalence values of transgender youths are estimates at best.
Turban et al also investigated the co-occurring conditions with transgender identity and found that transgender youths suffer high rates of anxiety and depression. In fact, estimates for mood disorders range from 12.4% to 64%, and estimates for anxiety disorders range from 16.3% to 55%. Much of these data have come from chart reviews of youths referred to gender clinics. Consistently, a study of 105 gender dysphoric adolescents in the Netherlands found similar prevalence rates of internalizing emotional difficulties: 12.4% suffered from mood disorders and 21% suffered from anxiety disorders. The wide range in prevalence may be due to differences in parameters such as age, diagnostic criteria and cultural beliefs. What does seem to be clear is that internalizing emotional difficuties worsen with age.
By contrast, two studies involving transgender youths who were supported by their families (and who were not included in clinic samples) found no significant differences in the incidence of internalizing emotional difficulties compared to non-transgender control participants. “Non-acceptance by family and peers is a major risk factor for such mental-health problems in this population”, describes Turban. “Family support, therefore, seems to be a critical buffer in reducing the psychiatric risk factors that many transgender and gender diverse children and adolescents experience”. Some have also suggested that bullying and victimization contributes to mental-health problems in transgender youths, with an estimated 80% of transgender children being the victims of bullying. As such, Turban and Ehrensaft propose that social reactions, rather than internal conflicts, could be the primary cause of internalizing emotional difficulties in these children.
Data identified by this review also show high suicide attempt rates in the transgender population. Affected adults have a lifetime suicide rate of ~41%, and chart review studies from various pediatric gender identity clinics have found suicide attempt rates ranging from 9.3% (by mean age 14.8 years) and 10% (by mean age 13.5 years) up to 30% (by mean age 19.2 years). Children as young as 5 years old are at risk of suicidality, and the risk increases with age. Again, Turban et al found that non-acceptance by family members of youths with transgender identity has a strong correlation with suicidality. Finally, some studies have suggested a link between autism spectrum disorders (ASD) and gender dysphoria. Turban et al highlight, however, that many of the studies suggesting this etiological link between autism and gender dysphoria have limitations and as yet, no correlation between the two conditions has been proven.
The researchers also assessed the psychotherapeutic approaches and interventions available to pre-pubertal youths. They found emerging data to support that early affirmation with a non-pharmacological social transition (i.e. allowing a child to take on a name, pronouns, dress, etc. associated with their gender identity) results in good outcomes for pre-pubertal transgender children who wish to transition. In addition, early data also suggest that puberty blockers and cross-sex hormones result in improved mental-health outcomes for transgender adolescents. Typical treatment involves gonadotropin-releasing hormone (GnRH) analogs, which maintain high levels of GnRH to temporarily stop the irreversible downstream development of secondary sex characteristics (such as breast development, menses, voice deepening) that many transgender youths find disturbing. By halting pubertal development in this way, affected youths have time to decide if they would like to proceed to the next steps of gender-affirming interventions. Conversely, stopping GnRH analog treatment allows normal puberty of the sex assigned-at-birth to resume. Despite data only arising from one study, it would seem that puberty blockers improve internalizing emotional difficulties among transgender youths.
“Clinicians do seem to be coming toward a consensus regarding hormonal treatment for transgender adolescents, with treatment protocols outlined in the 2017 Endocrine Society Guidelines and the periodically updated World Professional Association for Transgender Health (WPATH) Standards of Care”, says Turban. “But the psychotherapeutic treatment of pre-pubertal youth continues to be controversial. Pre-pubertal social transition is particularly controversial, but emerging evidence suggests that pre-pubertal transgender youths who are allowed to socially transition have developmentally normal mental health, at least in the short term”.
Despite the rapid increase in research in this field, Turban et al find that many questions still remain unanswered, including: what is the natural history of gender fluid children and adolescents who do not fall into a gender binary? Will these youths be helped by early social transition and hormonal interventions? And what are the longitudinal outcomes for children who socially transition before puberty? The researchers hope that work in these areas over the next decade will help answer some of these questions.
“In the next 10 years, we will hopefully have larger longitudinal studies of young children who are allowed to socially transition, and larger studies of adolescents and adults who have undergone affirmative hormonal treatments”, poses Turban. “In addition, we may have developed new models of gender development that take into account gender pathways that are not based on a gender-binary assumption and will have improved fertility options for transgender patients”.
After their extensive review of the literature, Turban et al find that the etiology of cross-gender identification continues to be unclear. “Unfortunately, biological and psychosocial studies have yielded limited insight”, says Turban. “The most accurate statement that can be made to date is that gender identity is a transactional interweaving of biological, social, and cultural factors”. But despite this lack of clarity regarding the etiology of cross-gender identification, the early data do at least suggest that affirmative care — so that children and adolescents are supported in living in the gender that they choose — results in good mental-health outcomes, and may help avoid notable psychiatric stress or distress.
Turban, J. L. & Ehrensaft, D. Research Review: Gender identity in youth: treatment paradigms and controversies. (2017) J Child Psychol and Psychiatr. doi:10.1111/jcpp.12833.