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Nyquist CB, Torgersen L, David LW, Diseth TH, Magnus P, Biele GPE, Waehre A. Population-adjusted numbers, demographics and mental health among children and adolescents referred to the Norwegian National Center for Gender Incongruence over two decades. Eur Child Adolesc Psychiatry 2024:10.1007/s00787-024-02508-5. [PMID: 39008097 DOI: 10.1007/s00787-024-02508-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 06/17/2024] [Indexed: 07/16/2024]
Abstract
Over the last decade, there has been a sharp increase in young people seeking medical treatment for gender dysphoria/gender incongruence (GD/GI). The aims of this study were to calculate yearly population-adjusted numbers of children and adolescents referred to the Norwegian National Center for Gender Incongruence (NCGI) at Oslo University Hospital (OUS) from 2000 to 2022; to describe the demographic characteristics and prevalence of psychiatric diagnoses, self-harm and suicide attempts among the referred from 2000 to 2020; and to investigate time trends. The study used data from the Gender Incongruence Registry for Children and Adolescents (GIRCA) in Norway. All persons under 18 years (n = 1258) referred to the NCGI between 2000 and 2020 were included: 68.4% assigned female gender at birth (AFAB) and 31.6% assigned male gender at birth (AMAB). We found a sharp increase in referrals to the NCGI favouring AFAB over AMAB. Nearly two in three (64.5%) had one or more registered psychiatric diagnoses. Self-harm was registered among 35.5%, and 12.7% had attempted suicide. Registered psychiatric diagnoses were significantly (p ≤ 0.001) more prevalent among AFAB (67.8%) than AMAB (57.4%). The number of registered diagnoses per person decreased significantly over time, with an average reduction of 0.02 diagnoses per person per year. Although there was a downward time trend in registered diagnoses per person, the total mental health burden among children and adolescents with GI emphasizes the need for a holistic approach.
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Affiliation(s)
- Cecilie Bjertness Nyquist
- Department of Child and Adolescent Mental Health in Hospitals, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
- Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Leila Torgersen
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
| | - Linda W David
- Department of Child and Adolescent Mental Health in Hospitals, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Trond Haaken Diseth
- Department of Child and Adolescent Mental Health in Hospitals, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Per Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Anne Waehre
- Department of Child and Adolescent Mental Health in Hospitals, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
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Pilgrim D. Identity Politics: The Sex/Gender Controversy Is Unusual but Not Unique. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:2431-2443. [PMID: 38811491 DOI: 10.1007/s10508-024-02894-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/07/2024] [Accepted: 05/07/2024] [Indexed: 05/31/2024]
Affiliation(s)
- David Pilgrim
- Department of Psychology, University of Southampton, Southampton, SO17 1BJ, UK.
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Jorgensen SCJ, Athéa N, Masson C. Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:1941-1956. [PMID: 38565790 PMCID: PMC11106199 DOI: 10.1007/s10508-024-02850-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Abstract
In this essay, we consider the clinical and ethical implications of puberty blockers for pediatric gender dysphoria through the lens of "the child's right to an open future," which refers to rights that children do not have the capacity to exercise as minors, but that must be protected, so they can exercise them in the future as autonomous adults. We contrast the open future principle with the beliefs underpinning the gender affirming care model and discuss implications for consent. We evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment. In discussing these issues, we include relevant empirical evidence and raise questions for clinicians and researchers. We conclude that treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle.
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Affiliation(s)
- Sarah C J Jorgensen
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | - Céline Masson
- Département de Psychologie, Université de Picardie Jules-Verne, Amiens, France
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Hall R, Taylor J, Heathcote C, Langton T, Hewitt CE, Fraser L. Gender services for children and adolescents across the EU-15+ countries: an online survey. Arch Dis Child 2024:archdischild-2023-326348. [PMID: 38594051 DOI: 10.1136/archdischild-2023-326348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/25/2023] [Indexed: 04/11/2024]
Abstract
BACKGROUND Over the last 10-15 years, there has been an increase in the number of children and adolescents referred to gender services, particularly among adolescent birth-registered females. This population shows a higher prevalence of co-occurring mental health difficulties and neurodevelopmental conditions. Some countries have recently restricted access to medical treatments in recognition of the uncertain evidence base. AIM To understand the current provision of gender services for children and adolescents across the EU-15+ countries that have comparable high-income healthcare systems, to inform service development in the UK. METHODS An e-survey of paediatric gender services was conducted between September 2022 and April 2023. It covered service structure, care pathways, interventions and data collection. Data were described and compared to identify similarities and differences among participating services. RESULTS 15 services in eight countries (Australia, Belgium, Denmark, Norway, Northern Ireland, The Netherlands, Spain and Finland) responded. While a multidisciplinary team was present in all services, its composition and organisation varied. Clinical practice was informed by international guidelines, with four countries following their own national guidelines. Differences were observed in referral criteria, care pathways for prepubertal children and those with co-occurring conditions. Eligibility criteria for medical interventions also varied. Psychosocial support and interventions were limited, and outcome data collection was scarce. CONCLUSIONS This survey revealed both similarities and key variations in the clinical practice of paediatric gender services across eight different countries. The study emphasises the need for service development that both considers the management of co-occurring conditions and embeds routine data collection in practice.
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Affiliation(s)
- Ruth Hall
- Department of Health Sciences, University of York, York, UK
| | - Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | | | - Trilby Langton
- Department of Health Sciences, University of York, York, UK
| | | | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
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Brierley J, Larcher V, Hadjipanayis AA, Grossman Z. European Academy of Paediatrics statement on the clinical management of children and adolescents with gender dysphoria. Front Pediatr 2024; 12:1298884. [PMID: 38374879 PMCID: PMC10875134 DOI: 10.3389/fped.2024.1298884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/25/2024] [Indexed: 02/21/2024] Open
Abstract
Gender issues have become a polarised and political subject in modern paediatrics and indeed, in broader society. These include the management of infants with disorders of sex development and transgender sports participation, but especially recently regarding the management of gender dysphoria. The European Academy of Paediatrics (EAP) acknowledges that there are deeply held beliefs about this issue based on conscience and social norms. Several European countries, led by the UK, have recently reviewed the management of gender dysphoria in children and young people. Recognising the need for far more research into treatments such as pubertal suppression and cross-sex hormones in children and young people, we review the current ethical and legal dilemmas facing children with gender dysphoria, their families and the clinical teams caring for them. We suggest an approach that maintains the child's right to an open future whilst acknowledging that the individual child is the crucial person affected by decisions made and must receive appropriate support in decision-making and care for any associated mental health or psychological issues. Noting that national approaches to this vary and are in flux, the EAP advocates a child-centred individual rights-based analytical approach.
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Affiliation(s)
- Joe Brierley
- European Academy of Paediatrics, EAP, Brussels, Belgium
- Paediatric Bioethics Centre, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, United Kingdom
| | - Vic Larcher
- European Academy of Paediatrics, EAP, Brussels, Belgium
- Paediatric Bioethics Centre, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, United Kingdom
| | - Adamos A. Hadjipanayis
- European Academy of Paediatrics, EAP, Brussels, Belgium
- Paediatric Department, Larnaca General Hospital, Larnaca, Cyprus
| | - Zachi Grossman
- European Academy of Paediatrics, EAP, Brussels, Belgium
- Adelson School of Medicine, Ariel University, Ariel, Israel
- Maccabi Health Services, Tel Aviv, Israel
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Singer J, Pilgrim D, Hakeem A, Harvey P. Constraints on Free Academic and Professional Debate in the UK About Sex and Gender. ARCHIVES OF SEXUAL BEHAVIOR 2023; 52:2269-2279. [PMID: 37682506 DOI: 10.1007/s10508-023-02687-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 09/09/2023]
Affiliation(s)
- Juliet Singer
- Child and Adolescent Mental Health Service, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.
| | - David Pilgrim
- Department of Psychology, University of Southampton, Southampton, UK
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Cohn J. The Detransition Rate Is Unknown. ARCHIVES OF SEXUAL BEHAVIOR 2023; 52:1937-1952. [PMID: 37308601 PMCID: PMC10322769 DOI: 10.1007/s10508-023-02623-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 06/14/2023]
Affiliation(s)
- J Cohn
- Society for Evidence-Based Gender Medicine, Twin Falls, ID, 83301-5235, USA.
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Kulesa R. Toward a Standard of Medical Care: Why Medical Professionals Can Refuse to Prescribe Puberty Blockers. New Bioeth 2023; 29:139-155. [PMID: 36315442 DOI: 10.1080/20502877.2022.2137906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient's well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical care must not cause dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria.
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Affiliation(s)
- Ryan Kulesa
- Middlebush Hall, University of Missouri, Columbia, MO, USA
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Block J. Gender dysphoria in young people is rising-and so is professional disagreement. BMJ 2023; 380:382. [PMID: 36822640 DOI: 10.1136/bmj.p382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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Elkadi J, Chudleigh C, Maguire AM, Ambler GR, Scher S, Kozlowska K. Developmental Pathway Choices of Young People Presenting to a Gender Service with Gender Distress: A Prospective Follow-Up Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:314. [PMID: 36832443 PMCID: PMC9955757 DOI: 10.3390/children10020314] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023]
Abstract
This prospective case-cohort study examines the developmental pathway choices of 79 young people (13.25-23.75 years old; 33 biological males and 46 biological females) referred to a tertiary care hospital's Department of Psychological Medicine (December 2013-November 2018, at ages 8.42-15.92 years) for diagnostic assessment for gender dysphoria (GD) and for potential gender-affirming medical interventions. All of the young people had attended a screening medical assessment (including puberty staging) by paediatricians. The Psychological Medicine assessment (individual and family) yielded a formal DSM-5 diagnosis of GD in 66 of the young people. Of the 13 not meeting DSM-5 criteria, two obtained a GD diagnosis at a later time. This yielded 68 young people (68/79; 86.1%) with formal diagnoses of GD who were potentially eligible for gender-affirming medical interventions and 11 young people (11/79; 13.9%) who were not. Follow-up took place between November 2022 and January 2023. Within the GD subgroup (n = 68) (with two lost to follow-up), six had desisted (desistance rate of 9.1%; 6/66), and 60 had persisted on a GD (transgender) pathway (persistence rate of 90.9%; 60/66). Within the cohort as a whole (with two lost to follow-up), the overall persistence rate was 77.9% (60/77), and overall desistance rate for gender-related distress was 22.1% (17/77). Ongoing mental health concerns were reported by 44/50 (88.0%), and educational/occupational outcomes varied widely. The study highlights the importance of careful screening, comprehensive biopsychosocial (including family) assessment, and holistic therapeutic support. Even in highly screened samples of children and adolescents seeking a GD diagnosis and gender-affirming medical care, outcome pathways follow a diverse range of possibilities.
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Affiliation(s)
- Joseph Elkadi
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Catherine Chudleigh
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Ann M. Maguire
- The Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
- Department of Endocrinology, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Geoffrey R. Ambler
- The Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
- Department of Endocrinology, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Stephen Scher
- McLean Hospital, Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
- Department of Psychiatry, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
| | - Kasia Kozlowska
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
- The Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
- Brain Dynamics Centre, Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
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Abbruzzese E, Levine SB, Mason JW. The Myth of "Reliable Research" in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies-and research that has followed. JOURNAL OF SEX & MARITAL THERAPY 2023:1-27. [PMID: 36593754 DOI: 10.1080/0092623x.2022.2150346] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Two Dutch studies formed the foundation and the best available evidence for the practice of youth medical gender transition. We demonstrate that this work is methodologically flawed and should have never been used in medical settings as justification to scale this "innovative clinical practice." Three methodological biases undermine the research: (1) subject selection assured that only the most successful cases were included in the results; (2) the finding that "resolution of gender dysphoria" was due to the reversal of the questionnaire employed; (3) concomitant psychotherapy made it impossible to separate the effects of this intervention from those of hormones and surgery. We discuss the significant risk of harm that the Dutch research exposed, as well as the lack of applicability of the Dutch protocol to the currently escalating incidence of adolescent-onset, non-binary, psychiatrically challenged youth, who are preponderantly natal females. "Spin" problems-the tendency to present weak or negative results as certain and positive-continue to plague reports that originate from clinics that are actively administering hormonal and surgical interventions to youth. It is time for gender medicine to pay attention to the published objective systematic reviews and to the outcome uncertainties and definable potential harms to these vulnerable youth.
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Affiliation(s)
- E Abbruzzese
- Society for Evidence-Based Gender Medicine, Twin Falls, ID, United States
| | - Stephen B Levine
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, United States
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Cohn J. Some Limitations of "Challenges in the Care of Transgender and Gender-Diverse Youth: An Endocrinologist's View". JOURNAL OF SEX & MARITAL THERAPY 2022:1-17. [PMID: 36565052 DOI: 10.1080/0092623x.2022.2160396] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
There is significant disagreement about how to support trans-identified or gender-dysphoric young people. Different experts and expert bodies make strikingly different recommendations based upon the same (limited) evidence. The US-originating "gender-affirmative" model emphasizes social transition and medical intervention, while some other countries, in response to evidence reviews of medical intervention outcomes, have adopted psychological interventions as the first line of treatment. A proposed model of gender-affirming care, comprising only medical intervention for "eligible" youth, is described in Rosenthal (2021). Determining eligibility for these medical interventions is challenging and engenders considerable disagreement among experts, neither of which is mentioned. The review also claims without support that medical interventions have been shown to clearly benefit mental health, and leaves out significant risks and less invasive alternatives. The unreliability of outcome studies and the corresponding uncertainties as to how gender dysphoria develops and responds to treatment are also unreported.
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Affiliation(s)
- J Cohn
- Society for Evidence-based Gender Medicine (SEGM), Twin Falls, ID, USA
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