Management of Gender Dysphoria

by Philip Morris, President of napp | Nov 23, 2020 | 

Managing gender dysphoria/incongruence in children and adolescents: a perspective for debate

1. This approach to managing gender dysphoria [1] or gender incongruence [2] in children and adolescents aims to
   protect and safeguard the health, safety and welfare of the child. These guidelines prioritise the best interests of the
   child in accordance with human rights obligations under the International Convention of the Rights of the Child[3]           
         
2. Gender dysphoria/incongruence in young people is a debated area of medical practice. This approach avoids
   political, social or religious ideological positions.
   
   
3. As health professionals this approach acknowledges and respects young people’s views about their gender
   identity, as part of the totality of their developmental and holistic clinical picture, and incorporates these into the
   clinical formulation. This approach requires that a comprehensive bio-psycho-social assessment be conducted
   before recommending specific treatment.
   
   
4. The approach appreciates that childhood and adolescence is a time of rapid physical and psycho-social growth
   and profound personal development. It is characterised by examining many aspects of identity, including sexual
   orientation and gender. As the child matures and progresses through puberty this questioning usually transforms
   and resolves and the young person, in the majority of cases, accepts his/her biological sex and adult body [4,5].
   
   
5. The approach recognises that gender dysphoria/incongruence can often be a manifestation of complex preexisting
   family, social, psychological or psychiatric conditions. A holistic approach includes a comprehensive
   exploration for these potential conditions in order to more fully understand a child presenting with gender
   dysphoria/incongruence [6].
   
   
6. Extensive assessment of family, social, psychological and psychiatric factors is an essential step in effective and
   safe management of children and adolescents presenting with gender dysphoria/incongruence.
   
   
7. The approach proposes that psychotherapy should be a first-line treatment for young people with gender
   dysphoria/incongruence. This intervention should be undertaken before medical interventions (puberty-blocking
   drugs, cross-sex hormones, sex reassignment surgery) are planned.
   
   
8. The approach is aware that medical interventions to block puberty and to achieve feminization and
   masculinization according to the young person’s perceived gender are not fully reversible and can cause significant
   adverse effects on physical, cognitive, reproductive and psychosexual development [7,8,9,10,11,12,13].
   
   
9. Currently, while some individuals report a successful transition, we are not aware of published long-term
   outcome studies that have followed up adults who have undergone childhood or adolescent transition that show
   substantial benefit. As a consequence, there is no consensus that medical treatments such as the use of pubertyblocking drugs, cross-sex hormones or sexual reassignment surgery lead to better future psychosocial adjustment [14,15,16,17].
   
   
10. Increasing numbers of individuals who have undergone hormonal treatment and surgical interventions
    subsequently report experiencing regret and a wish to de-transition. They describe significant psychological and
    physical suffering, including loss of fertility and sexual function as a consequence of decisions made when younger
    [18,19,20,21,22,23].
    
    
11. Clinicians should therefore reflect carefully before contemplating or recommending treatments for gender
    dysphoria/incongruence, including irreversible medical interventions.
    
    
12. The still unproven risks and benefits make it imperative that parents and children and adolescents are made
    aware of the current evidence regarding gender transition and provide fully informed consent before potentially
    damaging and irreversible treatment is commenced.
    
    
13. This cautious approach is also mirrored in general clinical guidance by national bodies that recommend health
    services for public funding [24].
    
    

In preparing this statement advice was obtained from a number of senior medical colleagues in child and adolescent
psychiatry, adult psychiatry, forensic psychiatry, and from physicians who have cared for individuals experiencing
gender dysphoria/incongruence.

References

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2. World Health Organization. (2018). International classification of diseases for mortality and morbidity
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3. UN Commission on Human Rights, Convention on the Rights of the Child., 7 March
   1990, E/CN.4/RES/1990/74, available at: https://www.refworld.org/docid/3b00f03d30.html [accessed 3 November
   2020]
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16. Correction to Bränström and Pachankis. American Journal Of Psychiatry. 2020;177(8), 734-734.
    https://doi.org/10.1176/appi.ajp.2020.1778correction
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18. Lesbian Strength 2019 – Charlie Evans. YouTube. https://www.youtube.com/watch?v=-JazgA3AdUE.
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