A Critical Review of Assumptions About Gender Variant Children in Psychological Research

Phenomenological Interview and Gender Dysphoria: A Third Pathway for Diagnosis and Treatment

Gender dysphoria (GD) is marked by an incongruence between a person's biological sex at birth, and their felt gender (or gender identity). There is continuing debate regarding the benefits and drawbacks of physiological treatment of GD in children, a pathway, beginning with endocrine treatment to suppress puberty. Currently, the main alternative to physiological treatment consists of the so-called "wait-and-see" approach, which often includes counseling or other psychotherapeutic treatment. In this paper, we argue in favor of a "third pathway" for the diagnosis and treatment of GD in youths. To make our case, we draw on a recent development in bioethics: the phenomenological approach. Scholars such as Slatman and Svenaeus have argued that the extent to which the body can (or should be) manipulated or reconstructed through medical intervention is not only determined by consideration of ethical frameworks and social and legal norms. Rather, we must also take account of patients' personal experience of their body, the personal and social values associated with it, and their understanding of its situation in their life: their narrative identities. We apply this phenomenological approach to medicine and nursing to the diagnosis and treatment of GD in youth. In particular, we discuss Zahavi and Martiny's conception of the phenomenological interview, in order to show that narrative techniques can assist in the process of gender identification and in the treatment of youth presenting with GD. We focus on two case studies that highlight the relevance of a narrative-based interview in relations between patients, HCPs, and family, to expose the influence of social ideologies on how young people presenting with GD experience their bodies and gender.

Key socio-demographic characteristics of children and adolescents with gender dysphoria: A British Isles surveillance study

The present research used linked surveillance systems (British Paediatric Surveillance Unit; and the Child and Adolescent Psychiatry Surveillance System) over a 19 month period (1 November 2011-31 May 2013) to notify of young people (4-15.9 years) presenting to secondary care (paediatrics or child and adolescent mental health services) or specialist gender services with features of gender dysphoria (GD). A questionnaire about socio-demographic, mental health, and GD features was completed. Presence of GD was then assessed by experts in the field using then-current criteria (DSM-IV-TR). Incidence across the British Isles was 0.41-12.23 per 100,000. 230 confirmed cases of GD were noted; the majority were white (94%), aged ≥12 years (75.3%), and were assigned female at birth (57.8%). Assigned males presented most commonly in pre-adolescence (63.2%), and assigned females in adolescence (64.7%). Median age-of-onset of experiencing GD was 9.5 years (IQR 5-12); the majority reported long-standing features (2-5 years in 36.1%, ≥5 years in 26.5%). Only 82.5% attended mainstream school. Bullying was reported in 47.4%, previous self-harm in 35.2%, neurodiversity in 16%, and 51.5% had ≥1 mental health condition. These findings suggest GD is rare within this age group but that monitoring wellbeing and ensuring support for co-occurring difficulties is vital.

Two dilemmas for medical ethics in the treatment of gender dysphoria in youth

Both the diagnosis and medical treatment of gender dysphoria (GD)-particularly in children and adolescents-have been the subject of significant controversy in recent years. In this paper, we outline the means by which GD is diagnosed in children and adolescents, the currently available treatment options, and the bioethical issues these currently raise. In particular, we argue that the families and healthcare providers of children presenting with GD currently face two main ethical dilemmas in decision making regarding treatment: the pathway dilemma and the consent dilemma.

Transforming Connections: A Trauma-Informed and Attachment-Based Program to Promote Sensitive Parenting of Trans and Gender Non-conforming Youth

Gender non-conforming and trans youth experience high rates of bullying and victimization, placing them at risk for serious mental health challenges. Parent support is one of the most significant protective factors in this population, and yet few programs are specifically developed to promote parenting sensitivity, understanding, and acceptance. Connect, a trauma-informed and attachment-based group program for caregivers of at-risk adolescents, has been shown to reduce parent stress and depressed mood, increase parents' sense of efficacy and satisfaction, and reduce parent-teen conflict. Teens benefit from increased attachment security and improved mental health and well-being. Treatment effects have been documented to continue for up to 2 years post-treatment. This paper describes the adaptation of the Connect program to create a new program, Transforming Connections, for caregivers of transgender and gender non-conforming youth. Participants in the first three groups were 20 parents of 16 gender non-conforming youth (ages 12-18). Common themes in group discussions related to gender included: coming out, connecting with peers, affirming pronouns/names, medical transition, parental reactions (e.g., confusion, isolation, grief, acceptance), and concerns about safety and mental health. All parents completed the full program, attending on average 9 of 10 sessions. Caregivers reported feeling respected, safe, and welcomed in the program and indicated that learning about attachment enhanced their understanding of their teen and their gender journey as well as themselves as a parent. Additionally, all parents reported applying the ideas discussed in the group frequently (60%) or somewhat frequently (40%). The majority indicated that their relationship with their teen had improved somewhat (65%) or a great deal (20%). Findings provide positive preliminary evidence of the fit and value of Transforming Connections for these families.

Gender identities in adolescent population: Methodological issues and prevalence across age groups

Background:

Increasing numbers of adolescents are seeking treatment from gender identity services, particularly natal girls. It is known from survey studies some adolescents exaggerate their belonging to minorities, thereby distorting prevalence estimates and findings on related problems. The aim of the present study was to explore the susceptibility of gender identity to mischievous responding, and prevalences of cis-gender, opposite-sex and other/ non-binary gender identities as corrected for likely mischievous responding among Finnish adolescents.

Method:

The School Health Promotion Survey 2017 data was used, comprising data on 135,760 adolescents under 21 years (mean 15.73, ds 1.3 years), 50.6% females and 49.4% males. Sex and perceived gender were elicited and gender identities classified based thereon. Likely mischievous responding was analysed using inappropriate responses to biodata and handicaps.

Results:

Of the participants, 3.5% had most likely given facetious responses, boys more commonly than girls, and younger adolescents more commonly than older. This particularly concerned reporting of non-binary gender identity. Corrected prevalence of opposite-sex identification was 0.6% and that of non-binary identification was 3.3%. In boys, displaying non-binary gender identity increased from early to late adolescence, while among girls, opposite-sex and non-binary identifications decreased in prevalence from younger to older age groups.

Conclusion:

Prevalence of gender identities contrary to one’s natal sex was more common than expected.

Time trends in referrals to child and adolescent gender identity services: a study in four Nordic countries and in the UK

Purpose: To explore whether the increase observed in referrals to child and adolescent gender identity services (GIDSs) has been similar in four Nordic countries and in the UK.Materials and methods: Numbers of referrals per year in 2011-2017 were obtained from all GIDS in Denmark, Finland, Norway, Sweden and the UK and related to population aged <18.Results: A similar pattern of increase in referral rates was observed across countries, resulting in comparable population adjusted rates in 2017. In children, male:female birth sex ratio was even; in adolescents, a preponderance of females (birth sex) was observed, particularly in Finland.Conclusions: The demand for GIDSs has evolved similarly across Nordic countries and the UK. The reasons for the increase are not known but increased awareness of gender identity issues, service availability, destigmatization as well as social and media influences may play a role.

Sex, Sexuality and Gender-Related Issues in Child Psychiatric Practice: A Review

In child and adolescent psychiatric practice, it is important for a clinician to be aware of contexts in which children are brought with concerns related to sexual behaviors. Johnson described a continuum of natural and healthy behaviors to sexually aggressive behaviors. Sexual development begins in fetal life and continues through infancy, childhood, and adolescence along characteristic pathways. Typically, developing children exhibit a wide range of sexual behaviors. Children and adolescents may display increased or deviant sexual behavior as a result of certain stressors, traumatic experiences, or psychiatric illnesses. This has been emerging as an important clinical issue over the past few years. It is important to distinguish between normal behaviors and disordered behaviors before planning any intervention. This article summarizes the sexuality- and gender-related issues that are encountered in child and adolescent psychiatric practice.

Gender dysphoria in adolescent population: A 5-year replication study

The aim of this study was to explore whether there has been an increase in prevalence and changes in sex ratio in feelings of gender dysphoria (GD) in an adolescent population in Northern Europe, and to study the impact of invalid responding on this topic. We replicated an earlier survey among junior high school students in Tampere, Finland. All first and second year students, aged 16-18, in the participating schools were invited to respond to an anonymous classroom survey on gender experience during the 2012-2013 school year and in the spring and autumn terms of 2017. Gender identity/GD was measured using the GIDYQ-A. A total of 318 male and 401 female youth participated in 2012-2013, and 326 male and 701 female youth in 2017. In the earlier survey, the GIDYQ-A scores, both among males and females, were strongly skewed toward a cis-gender experience with very narrow interquartile ranges. Of males, 2.2%, and of females, 0.5% nevertheless reported possibly clinically significant GD. The 2017 GIDYQ-A distribution was similarly skewed. The proportion of those reporting potentially clinically significant GD was 3.6% among males and 2.3% among females. Validity screening proved to have a considerable impact on conclusions. GD seems to have increased in prevalence in the adolescent population.

Sissies, Mama's Boys, and Tomboys: Is Children's Gender Nonconformity More Acceptable When Nonconforming Traits Are Positive?

The evaluation of gender nonconformity in children was examined in two studies. In Study 1, 48 young adults evaluated the positivity of culturally popular labels for gender nonconformity, including "tomboy," "sissy," and two new labels generated in a pilot study, "mama's boy" and "brat." The "mama's boy" was described as a boy who has positive feminine traits (gentle and well-mannered) as opposed to the "sissy" who was described as having negative feminine traits (crying and easily frightened). In Study 2, 161 young adults read descriptions of gender-typical and nonconforming children, evaluating them in several domains. The label "mama's boy" was considered negative in Study 1 but an unlabeled positive nonconforming boy was rated as likable and competent in Study 2. However, participants worried about nonconforming boys, saying they would encourage them to behave differently and describing such children with derogatory sexual orientation slurs. "Tomboy" was generally considered a positive label in Study 1. In Study 2, gender nonconforming girls were considered neither likable nor dislikeable, and neither competent nor incompetent, reflecting ambivalence about girls' nonconformity. It may be that we use gender nonconformity labels as indicators of sexual orientation, even in young children. Therefore, even when an individual displays objectively positive traits, the stigma associated with homosexuality taints judgments about their nonconforming behavior.

To treat or not to treat: puberty suppression in childhood-onset gender dysphoria

Puberty suppression using gonadotropin-releasing-hormone analogues (GnRHa) has become increasingly accepted as an intervention during the early stages of puberty (Tanner stage 2-3) in individuals with clear signs of childhood-onset gender dysphoria. However, lowering the age threshold for using medical intervention for children with gender dysphoria is still a matter of contention, and is more controversial than treating the condition in adolescents and adults, as children with gender dysphoria are more likely to express an unstable pattern of gender variance. Furthermore, concerns have been expressed regarding the risks of puberty suppression, which are poorly understood, and the child's ability to make decisions and provide informed consent. However, even if the limited data available mean that it is not possible to make a conclusive treatment recommendation, some safety criteria for puberty suppression can be identified and applied.

"Am I Doing the Right Thing?": Pathways to Parenting a Gender Variant Child

Gender variant (GV) children have a subjective sense of gender identity and/or preferences regarding clothing, activities, and/or playmates that are different from what is culturally normative for their biological sex. Despite increases in rates of GV children and their families presenting at clinics, there is little research on how raising a GV child affects the family as a whole or how families make decisions regarding their care. This study took an ecological-transactional framework to explore the question, "what is the experience of parents who raise a GV or transgender child?" Eight mothers and three fathers of GV male and female children (ages 5-13) referred through a GV support group participated in interviews. Transcripts were analyzed using an adaptation of grounded theory analysis. These parents attempted to pave the way to a nonstigmatized childhood for their GV child, typically through two pathways: rescuing the child from fear of stigma and hurt or accepting GV and advocating for a more tolerant world. Many participants used both pathways to different degrees or shifted paths over time, and the paths selected were related to parents' own understanding of GV and their experiences and backgrounds as well as characteristics of the children they were parenting and the communities they inhabited. Limitations, clinical implications, and future directions are discussed.

Gender Variance and Dysphoria in Children and Adolescents

Gender variant and transgender youth are seeking medical care at younger ages. Pediatricians and other primary care physicians are often the first professionals who encounter such youth and their families. The goals of this article are to provide information on the epidemiology and natural history of gender variant and transgender youth, current clinical practice guidelines regarding the use of puberty blockers and cross-sex hormones for transgender youth, and limitations and challenges to optimal care.

Being transgender: the experience of transgender identity development

This article is based on a grounded theory analysis of interviews with transgender-identified people from different regions of the United States. Participants held a variety of gender identities under the transgender rubric (e.g., crossdresser, transman, transwoman, butch lesbian). Interviews explored the participants' experiences in arriving at their gender identity. This article presents three clusters of findings related to the common processes of transgender identity development. This process was made possible by accessibility of transgender narratives that injected hope into what was a childhood replete with criticism and scrutiny. Ultimately, participants came to their identities through balancing a desire for authenticity with demands of necessity--meaning that they weighed their internal gender experience with considerations about their available resources, coping skills, and the consequences of gender transitions. The implications of these findings are considered in terms of their contribution to gender theory, research, and clinical support for transgender clients.