Managing gender dysphoria/incongruence in children and adolescents: a perspective for debate
- This approach to managing gender dysphoria  or gender incongruence  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
- Gender dysphoria/incongruence in young people is a debated area of medical practice. This approach avoids
political, social or religious ideological positions.
- 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.
- 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].
- 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
- 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.
- 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.
- 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].
- 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].
- 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
- Clinicians should therefore reflect carefully before contemplating or recommending treatments for gender
dysphoria/incongruence, including irreversible medical interventions.
- 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.
- This cautious approach is also mirrored in general clinical guidance by national bodies that recommend health
services for public funding .
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
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1990, E/CN.4/RES/1990/74, available at: https://www.refworld.org/docid/3b00f03d30.html [accessed 3 November
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- Kosky R. Gender-disordered children: does inpatient treatment help? Medical Journal of Australia
1987;146:565-69 (June 1, 1987). doi: 10.5694/j.1326-5377.1987.tb120415.x
- Vlot MC, Klink DT, den Heijer M, Blankenstein MA, Rotteveel J, Heijboer AC. Effect of pubertal
suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density
(BMAD) in transgender adolescents. Bone. 2017;95:11-19. doi: S8756-3282(16)30333-7 [pii].
- Vlot MC, Wiepjes CM, de Jongh RT, T’Sjoen G, Heijboer AC, den Heijer M. Gender-affirming hormone
treatment decreases bone turnover in transwomen and older transmen. J Bone Miner Res. 2019;34(10):1862-doi: 10.1002/jbmr.3762 [doi].
- Schneider M, Spritzer P, Soll B et al. Brain Maturation, Cognition and Voice Pattern in a Gender
Dysphoria Case under Pubertal Suppression. Front Hum Neurosci. 2017;11. doi:10.3389/fnhum.2017.00528
- Auer MK, Ebert T, Pietzner M, et al. Effects of sex hormone treatment on the metabolic syndrome in
transgender individuals: Focus on metabolic cytokines. J Clin Endocrinol Metab. 2018;103(2):790-802. doi:
10.1210/jc.2017- 01559 [doi].
- Alzahrani T, Nguyen T, Ryan A, et al. Cardiovascular disease risk factors and myocardial infarction in the
transgender population. Circ Cardiovasc Qual Outcomes. 2019;12(4):e005597. doi:
- Nota NM, Wiepjes CM, de Blok, C. J. M., Gooren LJG, Kreukels BPC, den Heijer M. Occurrence of acute
cardiovascular events in transgender individuals receiving hormone therapy. Circulation. 2019;139(11):1461-1462.
doi: 10.1161/CIRCULATIONAHA.118.038584 [doi].
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https://www.pcori.org/research-results/2013/examining-health-outcomes-people-who-are-transgender. Updated Accessed Nov 7, 2019.
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of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLoS One.
2011;6(2):e16885. doi: 10.1371/journal.pone.0016885 [doi].
- Bränström, R., & Pachankis, Reduction in Mental Health Treatment Utilization Among Transgender
Individuals After Gender-Affirming Surgeries: A Total Population Study. American Journal of Psychiatry.
2019;177(8), 727- 734. https://doi.org/10.1176/appi.ajp.2019.19010080
- Correction to Bränström and Pachankis. American Journal Of Psychiatry. 2020;177(8), 734-734.
- Kalin, N. Reassessing Mental Health Treatment Utilization Reduction in Transgender Individuals After
Gender Affirming Surgeries: A Comment by the Editor on the Process. American Journal Of Psychiatry.
2020;177(8), 764- 764. https://doi.org/10.1176/appi.ajp.2020.20060803
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