Identity, Conformity, and Nonconformity: A Closer Look

As clinicians, we have been vigilant to screen for underlying psychopathology in children and adolescents who meet criteria for gender dysphoria (GD) based on the risk these individuals have for developing externalizing and/or internalizing disorders, likely driven by a stigmatizing society. However, we have not paid careful attention to an often overlooked population, namely gender-nonconforming (GNC) children-especially those in community samples-who do not meet criteria for GD per se but who, according to the well-done and thought-provoking study featured in this issue, van der Miesen et al.'s "Behavioral and Emotional Problems in Gender-Nonconforming Children: A Canadian Community-Based Study,"¹ appear to share some similar psychiatric vulnerabilities as their peers with GD, with some unique features noted for natal boys versus natal girls. The few studies that have looked at this group of children have relied on clinical samples, which complicates whether the increased rates of psychopathology are in fact due to GNC-related factors versus inherently higher rates of psychopathology in clinical samples. Because of this, previous studies using clinical samples might overestimate the rates of psychopathology in GNC youths. Van der Miesen et al. smartly attempted to avoid that bias by drawing participants from the community and by excluding participants with any previous mental health diagnoses, including GD.¹ This study is a refreshing shift, delving into community samples and using a validated measure, the Gender Identity Questionnaire for Children (GIQC), thus allowing comparisons to be made with prior clinical samples.

Gender Nonconformity and Birth Order in Relation to Anal Sex Role Among Gay Men

Androphilia is associated with an elevated number of older brothers among natal males. This association, termed the fraternal birth order effect, has been observed among gay men who exhibit marked gender nonconformity. Gender nonconformity has been linked to gay men's preferred anal sex role. The present study investigated whether these two lines of research intersect by addressing whether the fraternal birth order effect was associated with both gender nonconformity and a receptive anal sex role (243 gay men, 91 heterosexual men). Consistent with previous research, we identified the fraternal birth order effect in our sample of gay men. Also, gay men were significantly more gender-nonconforming on adulthood and recalled childhood measures compared to heterosexual men. When gay men were compared based on anal sex role (i.e., top, versatile, bottom), all groups showed significantly greater recalled childhood and adult male gender nonconformity than heterosexual men, but bottoms were most nonconforming. Only gay men with a bottom anal sex role showed evidence of a fraternal birth order effect. A sororal birth order effect was found in our sample of gay men, driven by versatiles. No significant associations were found between fraternal birth order and gender nonconformity measures. These results suggest that the fraternal birth order effect may apply to a subset of gay men who have a bottom anal sex role preference and that this subgroup is more gender-nonconforming. However, there were no significant associations between fraternal birth order and gender nonconformity at the individual level. As such, based on the present study, whether processes underpinning the fraternal birth order effect influence gender nonconformity is equivocal.

Biotechnologies that empower transgender persons to self-actualize as individuals, partners, spouses, and parents are defining new ways to conceive a child: psychological considerations and ethical issues

Today, thanks to biomedical technologies advances, some persons with fertility issues can conceive. Transgender persons benefit also from these advances and can not only actualize their self-identified sexual identities but also experience parenthood. Based on clinical multidisciplinary seminars that gathered child psychiatrists and psychoanalysts interested in the fields of assisted reproduction technology (ART) and gender dysphoria, philosophers interested in bioethics, biologists interested in ART, and endocrinologists interested in pubertal suppression, we explore how new biotechnical advances, whether in gender transition or procreation, could create new ways to conceive a child possible. After reviewing the various medical/surgical techniques for physical gender transition and the current ART options, we discuss how these new ways for persons to self-actualize and to experience parenthood can not only improve the condition of transgender persons (and the human condition as a whole through greater equity) but also introduce some elements of change in the habitual patterns of thinking especially in France. Finally, we discuss the ethical issues that accompany the arrival of these children and provide creative solutions to help society handle, accept, and support the advances made in this area.

Editorial: Minding the gap - research on sexual minority and gender nonconforming children and adolescents

There is often a gap between politics and science, but the influence across the gap is bidirectional. This editorial considers a longitudinal, community-based sample of children and adolescents and asks about risks from early childhood gender non-conformity and adolescent reported sexual minority status for subsequent anxiety disorders. It is especially valuable to have longitudinal data from a non-referred sample to address questions of risk, and the investigators must be complemented for having foresight about these questions twenty years ago. The topics of our investigations are informed and motivated by cultural assumptions, pressures and conflicts. In the example discussed, transgender people are not new, but research on their development is fairly recent, as they are culturally now more accepted as different rather than pathological. Research findings also matter to the culture. Dropping homosexuality as a mental disorder in formal nosologies occurred with significant scientific substantiation. The value of this research to enhance clinical care and offer informed parental guidance about children of a minority status cannot be overemphasized.

Gender identity and the management of the transgender patient: a guide for non-specialists

In this review, we introduce the topic of transgender medicine, aimed at the non-specialist clinician working in the UK. Appropriate terminology is provided alongside practical advice on how to appropriately care for transgender people. We offer a brief theoretical discussion on transgenderism and consider how it relates to broader understandings of both gender and disease. In respect to epidemiology, while it is difficult to assess the exact size of the transgender population in the UK, population surveys suggest a prevalence of between 0.2 and 0.6% in adults, with rates of referrals to gender identity clinics in the UK increasing yearly. We outline the legal framework that protects the rights of transgender people, showing that is not legal for physicians to deny transgender people access to services based on their personal beliefs. Being transgender is often, although not always, associated with gender dysphoria, a potentially disabling condition in which the discordance between a person's natal sex (that assigned to them at birth) and gender identity results in distress, with high associated rates of self-harm, suicidality and functional impairment. We show that gender reassignment can be a safe and effective treatment for gender dysphoria with counselling, exogenous hormones and surgery being the mainstay of treatment. The role of the general practitioner in the management of transgender patients is discussed and we consider whether hormone therapy should be initiated in primary care in the absence of specialist advice, as is suggested by recent General Medical Council guidance.

Gender dysphoria in children

Gender dysphoria (GD) of childhood describes a psychological condition in which children experience a marked incongruence between their experienced gender and the gender associated with their biological sex. When this occurs in the pre-pubertal child, GD resolves in the vast majority of patients by late adolescence. Currently there is a vigorous, albeit suppressed, debate among physicians, therapists, and academics regarding what is fast becoming the new treatment standard for GD in children. This new paradigm is rooted in the assumption that GD is innate, and involves pubertal suppression with gonadotropin releasing hormone (GnRH) agonists followed by the use of cross-sex hormones-a combination that results in the sterility of minors. A review of the current literature suggests that this protocol is founded upon an unscientific gender ideology, lacks an evidence base, and violates the long-standing ethical principle of "First do no harm."

[Puberty Suppression for Adolescents with Gender Dysphoria A Japanese Perspective]

Some children who have had gender dysphoria since early childhood experience distress at the first signs of their secondary sex characteristics. This might have a strong negative effect on their emotional and social functioning as well as on their school lives. Physical inter- vention should be considered for such adolescents ; however, gender identity can also fluctuate during that period. Therefore, it is difficult to use cross-sex hormone therapy as a way to mas- culinize or feminize the body for early adolescents, because such hormones have partially irre- versible effects. Worldwide, puberty suppression therapy is recommended for such pubescent children, as it is recognized as reversible physical intervention. For puberty suppression, gonadotropin-releasing hormone agonists (GnRHa), which stop luteinizing hormone secretion, are used. This consequently stops the secretion of testosterone in genetically male patients and production of estrogens and progesterone in genetically female patients ; as a result, the physi- cal changes of puberty are delayed. When GnRHa is stopped, the progress of puberty restarts. This therapy is also mentioned in the 4th edition of the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder (The Japanese Society of Psychiatry and Neurol- ogy). According to those guidelines, we can use this therapy for early adolescents after they have reached Tanner Stage 2. Although this intervention is new to Japan, there is some evi- dence from other countries supporting such applications. Furthermore, in Japan, pediatric endocrinologists have used GnRHa for young patients with precocious puberty for a long period of time, and this has proved the safety of this treatment for children. More experience and data in this area are needed. Furthermore, we have to establish closer cooperation with child mental health specialists, such as pediatric psychiatrists, school counselors, and teachers, so that proper treatment may begin at the right time for more patients. Psychotherapy or psy- chosocial support, on its own, is sometimes not enough to reduce the physical dysphoria of transgender patients, and the innate sex steroids also have irreversible effects on gender dys- phoric children. When we decide not to intervene in cases of gender dysphoric children with hormonal treatments including puberty suppression, we are actually deciding to intervene by leaving them with their inherent hormones. We have to be conscious of the fact that"withhold- ing puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents (Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7)."

Understanding sexual, paraphilic, and gender dysphoria disorders in DSM-5

With every Diagnostic and Statistical Manual of Mental Disorders that has been published, there has been controversy within controversy; however, what appears to be lacking is the importance of truly understanding what, why, and how the changes impact the community at large. Issues such as homosexuality, the five axial diagnostic system, and transitioning from a medical model to a biopsychosocial model have been hot topics that have led clinicians to challenge the reliability and validity of the manual throughout history. As clinicians and medical professionals, it is important to objectively look at the manual and become educated on how and why these changes exist. With that being said, this commentary aims to challenge the article "

COMMENTARY

Problems with the Sexual Disorders Sections of DSM-5" by Colin A. Ross (2015). The structure of this commentary purposefully mirrors the structure of the commentary that it is challenging.

Response to Ross's "Commentary: Problems with the sexual disorders sections of DSM-5"

The recent commentary by Ross (2015) addresses concerns regarding the newly created Paraphilic Disorders section of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, and "inconsistencies." The author's statements reflect notable confusion regarding issues related to human sexuality and the categories thereof in the DSM-5 (e.g., gender dysphoria and pedophilic disorder). This is a response to Ross's commentary.