Gender dysphoria in children

Children with persistent gender dysphoria are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria.[2] Some (but not all) gender variant youth will want or need to transition, which may involve social transition (changing dress, name, pronoun), and, for older youth and adolescents, medical transition (hormone therapy or surgery).[3]

According to the American Academy of Pediatrics, most children have a stable sense of their gender identity by age 4. They explain that research shows prepubertal children who assert a transgender or gender diverse identity know their gender as clearly and as consistently as their cisgender peers.[10][11]

Other research has shown that if gender dysphoria persists during puberty, it is very likely permanent.[12][13][14] Factors that are associated with gender dysphoria persisting through puberty include intensity of gender dysphoria, amount of cross-gendered behavior, and verbal identification with the desired/experienced gender (i.e. stating that they are a different gender rather than wish to be a different gender).[14][15]

Some studies have found that gender dysphoria in children is more heavily linked to adult homosexuality than to an adult transgender identity, especially with regard to boys.[16][17][18] These studies state that the majority of children diagnosed with gender dysphoria did not desire to be the other sex by puberty, with most growing up to identify as gay, lesbian, or bisexual, with or without therapeutic intervention.[12][13][19][15][20] However, they have been criticized as irrelevant on the basis that they counted as 'desistance' cases where the child was simply gender-nonconforming rather than dysphoric and tracked diagnoses rather than gender identity or desire to transition, leading to inflation of the desistance statistics. The majority of desistance research relies on four studies published since 2008. While the subjects met the criteria for gender identity disorder as defined in the DSM-III or DSM-IV, many would not have met the updated criteria for gender dysphoria in the DSM-5, established in 2013, which unlike prior versions explicitly requires identification with a gender other than assigned at birth. In one study, 40% of those classified as "desisters" were subthreshold even for the DSM-IV criteria. The four studies all offered evidence that statement of transgender identity in childhood predicted transgender identity in adolescence andadulthood and the intensity of gender dysphoria in childhood likewise predicted its intensity later in life. The studies published from the 1960-1980's never used the term desistance, instead focusing on "gender-deviant behavior" - childhood femininity in people assigned male at birth - and how this more often predicts homosexuality rather than "transsexualism" in adulthood. Additionally, some of the research since 2000 and all the research prior has been criticized for citing studies that used conversion therapy, a disproven method consisting of either discouraging social transition, explicitly trying to prevent or discourage the child from identifying as transgender as an adult by adulthood or adolescence, or actively employing techniques to limit their "gender-deviant" behavior. The term "desistance" itself has been criticized as pathologizing for its roots in criminal research and oppositional defiance disorder, where desistance is considered a positive outcome.[21][22][23][24]

A systematic review of research relating to desistance was published in 2022. It found that desistance was poorly defined: studies sometimes did not define it or equally defined it as desistance of transgender identity or desistance of gender dysphoria. They also found none of the definitions allowed for dynamic or nonbinary gender identities and the majority of articles published were editorial pieces. They stated the concept was based on biased research from the 1960-80s and poor quality research in the 2000s. They concluded there was a "dearth of high-quality hypothesis-driven research that currently exists" on the subject, and suggested that desistance should "be removed from clinical and research discourse to focus instead on supporting [transgender and gender-expansive] youth rather than attempting to predict their future gender identity."[22] According to a review published in 2022 considering more recent studies, the majority of pre-pubertal children who socially transition persist in their identity in 5-to 7-year follow-ups, disproving the results of the prior studies.[14]

According to a review published in 2020 relying on recent statistical surveys, 1.2% to 2.7% of children and adolescents worldwide identify as transgender. The data was drawn more from studies of adolescents than pre-pubertal youth and noted a difference in methodological quality between studies published before and after 2010. The review notes rising numbers of youth are self-identifying as trans and calls for more systematic studies and reviews in future.[25]

The WPATH Standards of Care and other therapeutic interventions do not seek to change a child's gender identity.[26][27] Instead, clinicians advise children and their parents to avoid goals based on gender identity and to instead cope with the child's distress by embracing psychoeducation and to be supportive of their gender variant identity and behavior as it develops.[3][28] A clinician may suggest that the parent be attentive, listen, and encourage an environment for the child to explore and express their identified gender identity, which may be termed the true gender. This can remove the stigma associated with their dysphoria, as well as the pressure to conform to a gender identity or role they do not identify with, which may be termed the false gender self.[3] WPATH Standards of Care also recommend assessing and treating any co-existing mental health issues.[27] The majority of major medical associations define attempts to change an individual's gender identity or gender expression as conversion therapy and strongly discourage it citing concerns of a lack of scientific credibility and clinical utility with these practices.[29][30]

Treatment may also take the form of puberty blockers (such as leuprorelin), cross-sex hormones (i.e., administering estrogen to a child assigned male at birth or testosterone to a child assigned female at birth), or sex reassignment surgery when the child has reached the age of medical majority, with the aim of bringing one's physical body in line with their identified gender.[3][28] Delaying puberty allows for the child to mentally mature while preventing them from developing a body they may not want, so that they may make a more informed decision about their gender identity once they are an adolescent.[3] It can also help reduce anxiety and depression.[28] Short-term side effects of puberty blockers include headaches, fatigue, insomnia, muscle aches and changes in breast tissue, mood, and weight.[31] Research on the long-term effects on brain development, cognitive function, fertility, and sexual function is limited.[32][33][34]

According to the American Psychiatric Association, "Due to the dynamic nature of puberty development, lack of gender-affirming interventions (i.e. social, psychological, and medical) is not a neutral decision; youth often experience worsening dysphoria and negative impact on mental health as the incongruent and unwanted puberty progresses. Trans-affirming treatment, such as the use of puberty suppression, is associated with the relief of emotional distress, and notable gains in psychosocial and emotional development, in trans and gender diverse youth".[35]

In its position statement published December 2020, the Endocrine Society stated that there is durable evidence for a biological underpinning to gender identity and that pubertal suppression, hormone therapy, and medically indicated surgery are effective and relatively safe when monitored appropriately and have been established as the standard of care. They noted a decrease in suicidal ideation among youth who have access to gender-affirming care and comparable levels of depression to cisgender peers among socially transitioned pre-pubertal youth.[36] In its 2017 guideline on treating those with gender dysphoria, it recommends puberty blockers be started when the child has started puberty (Tanner Stage 2 for breast or genital development) and cross-sex hormones be started at 16, though they note "there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence". They recommend a multidisciplinary team of medical and mental health professionals manage the treatment for those under 18. They also recommend "monitoring clinical pubertal development every 3 to 6 months and laboratory parameters every 6 to 12 months during sex hormone treatment".[37]

For adolescents, WPATH says that physical interventions such as puberty blockers, hormone therapy, or surgery may be appropriate. Before any physical interventions are initiated, however, a psychiatric assessment exploring the psychological, family, and social issues around the adolescent's gender dysphoria should be undertaken.[27] WPATH's Standards of Care 8, published in 2022, declare puberty blocking medication as "medically necessary", and recommends them for usage in transgender adolescents once the patient has reached Tanner stage 2 of development, and state that longitudinal shows improved outcomes for transgender patients who receive them.[38]

While few studies have examined the effects of puberty blockers for gender non-conforming or transgender adolescents, the studies that have been conducted generally indicate that these treatments are reasonably safe, are reversible, and can improve psychological well-being.[39][40][41]

A 2020 review published in Child and Adolescent Mental Health found that puberty blockers are reversible and associated with such positive outcomes as decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life.[42] A 2020 survey published in Pediatrics found that puberty blockers are associated with better mental health outcomes and lower odds of lifetime suicidal ideation.[43] A 2022 study published in the Journal of the American Medical Association found a 60% reduction in moderate and severe depression and a 73% reduction in suicidality among transgender youth aged 13–20 who took puberty blockers and gender-affirming hormones over a 12-month follow-up.[44] A 2022 study published in The Lancet involving 720 transgender adolescents who took puberty blockers and hormones found that 98 percent continued to use hormones at a follow-up appointment.[45]

In 2020, a review article commissioned by NHS England was published by the National Institute for Health and Care Excellence, concluding that the quality of evidence for puberty blocker outcomes (for mental health, quality of life and impact on gender dysphoria) was of very low certainty based on the GRADE scale.[46] The Finnish government commissioned a review of the research evidence for treatment of minors and the Finnish Ministry of Health concluded that there are no research-based health care methods for minors with gender dysphoria.[47] Nevertheless, they recommend the use of puberty blockers for minors on a case-by-case basis, and the American Academy of Pediatrics state that "pubertal suppression in children who identify as TGD [transgender and gender diverse] generally leads to improved psychological functioning in adolescence and young adulthood."[48] The National Board of Health and Welfare in Sweden took similar action in 2022.[49][50]

• Childhood gender nonconformity
• Transgender youth
• List of transgender-related topics

• Gender Dysphoria and Transsexualism Archived 17 June 2019 at the Wayback Machine via Merck Manual
• What is Gender Dysphoria via the American Psychiatric Organisation
• Mental Health Care for People Who Identify as Lesbian, Gay, Bisexual, Transgender, and (or) Queer via the Canadian Psychological Organisation
• More Children Seek Help for Gender Dysphoria via WebMD.com
• First U.S. Study of Transgender Youth Funded by NIH via University of California, San Francisco
• Where Transgender Is No Longer a Diagnosis via Scientific American