Assessing Gender Dysphoria: Development and Validation of the Gender Preoccupation and Stability Questionnaire - 2nd Edition (GPSQ-2)

The Gender Preoccupation and Stability Questionnaire (GPSQ) is a 14-item measure used to assess the effectiveness of medical, surgical, social, and psychological interventions in trans and gender diverse adults who experience gender dysphoria. One major limitation of the GPSQ is that it was not developed for use with adolescents. This study aims to validate a revised version of the GPSQ, the Gender Preoccupation and Stability Questionnaire-2nd Edition (GPSQ-2) with the aim of adapting the measure to be applicable to individuals aged 13 and above. This research was conducted in three stages: 1) development of the GPSQ-2 to address previously identified issues with validity and comprehensibility of the GPSQ and to increase the applicability of the measure to adolescents; 2) pilot testing, using a purposive sample and semi-structured interviews, to assess the relevance, comprehensibility, and comprehensiveness of the GPSQ-2; and 3) validation using a community sample to assess the psychometric properties of the GPSQ-2. The pilot study was conducted with seven participants (Mage = 28.43, SD = 15.50; age range: 13-59). The GPSQ-2 was found to be easy to understand, relevant to individuals who experienced gender dysphoria, and that it did not have any identifiable omissions. The validation study was conducted with 141 participants (Mage = 36.44; SD = 14.76; age range 14-73). The GPSQ-2 was found to be a reliable and valid 14-item scale with two factors: preoccupation and stability. The GPSQ-2 is a structurally sound measure of gender dysphoria that can be used in populations aged 13 and above.

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.

Detransition and Desistance Among Previously Trans-Identified Young Adults

Persons who have renounced a prior transgender identification, often after some degree of social and medical transition, are increasingly visible. We recruited 78 US individuals ages 18-33 years who previously identified as transgender and had stopped identifying as transgender at least six months prior. On average, participants first identified as transgender at 17.1 years of age and had done so for 5.4 years at the time of their participation. Most (83%) participants had taken several steps toward social transition and 68% had taken at least one medical step. By retrospective reports, fewer than 17% of participants met DSM-5 diagnostic criteria for Gender Dysphoria in Childhood. In contrast, 53% of participants believed that "rapid-onset gender dysphoria" applied to them. Participants reported a high rate of psychiatric diagnoses, with many of these prior to trans-identification. Most participants (N = 71, 91%) were natal females. Females (43%) were more likely than males (0%) to be exclusively homosexual. Participants reported that their psychological health had improved dramatically since detransition/desistance, with marked decreases in self-harm and gender dysphoria and marked increases in flourishing. The most common reason given for initial trans-identification was confusing mental health issues or reactions to trauma for gender dysphoria. Reasons for detransition were more likely to reflect internal changes (e.g., the participants' own thought processes) than external pressures (e.g., pressure from family). Results suggest that, for some transgender individuals, detransition is both possible and beneficial.

Demographics and gender-related measures in younger and older adolescents presenting to a gender service

Transgender adolescents may present to gender identity specialty services earlier or later in adolescence. The aim of this study was to examine whether, 'younger' and 'older' presenters could be identified in a large cohort of transgender adolescents and if differences exist between the two groups. The study sample consisted of 1487 adolescents (506 birth-assigned males, 981 birth-assigned females) referred between 2000 and 2018. The distribution of age at intake was evaluated. Demographic, diagnostic, and treatment characteristics, the Recalled Childhood Gender Identity/Gender Role Questionnaire (RCGI) to measure childhood gender nonconformity and the Body Image Scale (BIS) to measure body image were collected. Based on a stem-and-leaf plot and a histogram, two groups were identified: adolescents presenting at ≤ 13.9 years ('younger presenters') and adolescents presenting at 14 years or older ('older presenters'). The sex ratio was more extreme in the group of older presenters favoring birth-assigned females (Χ2(1, N = 1487) = 19.69, p < 0.001). Furthermore, more adolescents from the younger presenting group lived with both biological parents (Χ2(1, N = 1427) = 24.78, p < 0.001), were diagnosed with gender dysphoria and started with medical gender-affirming treatment (Χ2(1, N = 1404) = 4.60, p = 0.032 and Χ2(1, N = 1487) = 29.16, p < 0.001). Younger presenters showed more gender nonconformity in childhood (β 0.315, p < 0.001, 95% CI 0.224-0.407). Older presenters were more dissatisfied with various aspects of their bodies (p < 0.001). The differences between older and younger presenting adolescents suggest that there may be different developmental pathways in adolescents that lead to seeking gender-affirming medical care and argues for more tailored care.

Co-occurring Autism Spectrum Disorder and Gender Dysphoria in Adolescents

BACKGROUND AND OBJECTIVES

Autism spectrum disorder (ASD) and gender dysphoria (GD) frequently cooccur. However, existing research has primarily used smaller samples, limiting generalizability and the ability to assess further demographic variation. The purpose of this study was to (1) examine the prevalence of cooccurring ASD and GD diagnoses among US adolescents aged 9 to 18 and (2) identify demographic differences in the prevalence of cooccurring ASD and GD diagnoses.

METHODS

This secondary analysis used data from the PEDSnet learning health system network of 8 pediatric hospital institutions. Analyses included descriptive statistics and adjusted mixed logistic regression testing for associations between ASD and GD diagnoses and interactions between ASD diagnosis and demographic characteristics in the association with GD diagnosis.

RESULTS

Among 919 898 patients, GD diagnosis was more prevalent among youth with an ASD diagnosis compared with youth without an ASD diagnosis (1.1% vs 0.6%), and adjusted regression revealed significantly greater odds of GD diagnosis among youth with an ASD diagnosis (adjusted odds ratio = 3.00, 95% confidence interval: 2.72-3.31). Cooccurring ASD/GD diagnoses were more prevalent among youth whose electronic medical record-reported sex was female and those using private insurance, and less prevalent among youth of color, particularly Black and Asian youth.

CONCLUSIONS

Results indicate that youth whose electronic medical record-reported sex was female and those using private insurance are more likely, and youth of color are less likely, to have cooccurring ASD/GD diagnoses. This represents an important step toward building services and supports that reduce disparities in access to care and improve outcomes for youth with cooccurring ASD/GD and their families.

Dimensional approach to gender dysphoria in Nigeria: Association with socio-demographic and psycho-sexual variables

Background

Recent changes across the world with respect to gender transitioning of children and adolescents have generated a bio-psycho-socio-cultural discourse among interest groups.

Aim

This study sought to examine gender dysphoric symptoms among adolescents and young persons in an African population, using a dimensional approach.

Method

A total of 747 primary/secondary school and university students aged 10-24 years were studied using the 27-item Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA). Participants were divided into early, mid- and late adolescents. The composite and domain scores were calculated using the criteria described by Deogracias, and comparison of the median scores was done using Mann-Whitney U-test and Kruskal-Wallis test as appropriate. Dunnett's post-hoc test was used for pairwise comparisons.

Results

The prevalence of self-identified transgender and self-reported non-heterosexuals was 0.9% (95%CI: 0.36-1.92) and 18.6% (15.85-21.59), respectively. The participants as a group scored 4.56 out of a possible 5 on the gender dysphoria scale, indicating less gender dysphoric symptoms in this cohort. However, participants in mid- and late adolescents had significantly lower scores when compared with early adolescents (P = 0.009). Self-reported transgender had significantly lower scores in the social (P = 0.001) and socio-legal (P < 0.001) indicators of the scale.

Conclusion

The findings of this study, although, preliminary demonstrated less gender dysphoric symptoms in this cohort of Nigerian adolescents and young adults compared to the Western population. Nevertheless, some degree of GD was noticed, revealing that this condition is existent in our society.

Validation of Two Measures of Gender Dysphoria/Incongruence in Transgender and Cisgender Populations in China

This study examined gender dysphoria (GD) in transgender and cisgender populations in China and aimed to provide validity evidence for two dimensional measures of GD. A total of 293 transgender people (170 transmen, 65 transwomen, and 58 non-binary trans people; mean age, 21.3 years) and 538 cisgender people (296 ciswomen and 242 cismen; mean age, 23.5 years) completed the Utrecht Gender Dysphoria Scale (UGDS), the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA), and demographic information online. The UGDS and the GIDYQ-AA had good reliability and validity for the Chinese population. Transgender people reported higher intensity of GD than cisgender people. Cisgender women reported higher intensity of GD than cisgender men. Non-binary transgender people reported lower intensity than binary transgender people. However, transmen reported higher intensity than transwomen for the UGDS but not for the GIDYQ-AA. Transgender people with gender-affirming hormonal treatment experience reported higher intensity of GD than those without treatment. Moreover, transgender people coming out to parents reported higher intensity than those who did not. The cutoff values of the UGDS and the GIDYQ-AA in the original version show high sensitivity for transgender people and specificity for cisgender people. Our findings indicate that the UGDS and the GIDYQ-AA are validated measures of GD in China.

Clinical Follow-up of Two Adolescents Diagnosed with Gender Dysphoria

Rapid physical, psychological and sexual changes in adolescents due to the developmental process differentiate the approach to adolescents with gender dysphoria (GD) from the approach to adults. In this article, two adolescents who applied for GD and followed up for a long time are presented. The first case was assigned male at birth and defined herself as female. At the age of fifteen, a gonadotropin-releasing hormone analog was started for puberty suppression, and sex hormone was started in the follow-up. The second case's assigned sex was female and defined himself as male. At the age of sixteen years and six months, puberty suppressive treatment was started, followed by sex hormones. Both cases were able to continue their psychosocial development without any problems after the psychiatric and physical treatments they could reach on time. Although GD in adolescents cannot be resolved with puberty suppression alone, it creates time to resolve the acute problems and to search for appropriate treatment approaches in the future. Puberty suppression partially relieves and prevents the exacerbation of the dysphoria experienced by the youth diagnosed as GD, and creates time to search appropriate treatment approaches in the follow-up. Through these two cases, it is aimed to introduce the gender affirmation processes of adolescents with GD, to discuss the medical interventions in adolescence and the psychosocial effects of the process on individuals. Keywords: Gender dysphoria, gender incongruence, adolescence, gender affirmation process, puberty supression, puberty blockers.

[Gender variance or gender dysphoria and autism spectrum disorder in children and adolescents]

BACKGROUND

Clinical experience suggests that gender variance (GV) and/or gender dysphoria (GD) and autism spectrum disorder (ASD) characteristics co-occur more frequently than expected.

AIM

This literature review examines the available publications focusing on the co-occurrence of GD/GV and ASD in children and adolescents.

METHOD

PubMed and Embase were systematically searched for relevant publications with search terms related to 'autism spectrum disorder' and 'gender dysphoria/gender variance'.

RESULTS

A total of 12 publications were included. A higher incidence of comorbidity was reported compared to what is epidemiologically expected, starting from an ASD study population and a population of children and adolescents with GD/GV. The results should be interpreted with caution due to methodological limitations in the studies as e.g. in the diagnostic assessment and the frequent lack of a control group.

CONCLUSION

The more frequent co-occurrence of ASD and GD/GV has consequences for clinical practice. In both diagnostic and supportive care pathways, it is advisable to recognize and acknowledge both conditions and to work out an adapted pathway. More targeted research into specific characteristics in this group is necessary in order to fine-tune (mental) health care and long-term perspectives.

Approach to the Patient: Pharmacological Management of Trans and Gender-Diverse Adolescents

Internationally, increasing numbers of children and adolescents with gender dysphoria are presenting for care. In response, gender-affirming therapeutic interventions that seek to align bodily characteristics with an individual's gender identity are more commonly being used. Depending on a young person's circumstances and goals, hormonal interventions may aim to achieve full pubertal suppression, modulation of endogenous pubertal sex hormone effects, and/or development of secondary sex characteristics congruent with their affirmed gender. This is a relatively novel therapeutic area and, although short-term outcomes are encouraging, longer term data from prospective longitudinal adolescent cohorts are still lacking, which may create clinical and ethical decision-making challenges. Here, we review current treatment options, reported outcomes, and clinical challenges in the pharmacological management of trans and gender-diverse adolescents.

Body Hair and Identity in Transgender Men: A Cross-Sectional Survey

Transgender and gender diverse people can experience increased depression, anxiety, suicidal ideation, and suicide from gender dysphoria (GD). GD occurs due to a discrepancy between a person&rsquo;s gender identity, assigned gender, and physical characteristics. Gender affirming medical care, including dermatologic care, can increase body-gender congruence and decrease negative outcomes associated with GD.

Recommendations of the Polish Sexological Society on medical care in transgender adults - position statement of the expert panel

Attempts at unifying the diagnostic and therapeutic procedures for transgender individuals experiencing gender dysphoria were first undertaken in Poland in the 1980s. Since then, there has been a change in the perception of transgenderism, almost paradigmatic, expressed in subsequent editions of the diagnostic systems (DSM, ICD), which is also associated with the fundamental changes in the principles of conducting trans-specific healthcare. This triggered the need to formulate recommendations for specialists practicing in Poland, which would at least partly reflect the evolution of views and guidelines on clinical care in transgender adults seeking help due to gender dysphoria.

Gender incongruence and gender dysphoria in childhood and adolescence-current insights in diagnostics, management, and follow-up

Gender incongruence (GI) is defined as a condition in which the gender identity of a person does not align with the gender assigned at birth. Awareness and more social acceptance have paved the way for early medical intervention about two decades ago and are now part of good clinical practice although much robust data is lacking. Medical and mental treatment in adolescents with GI is complex and is recommended to take place within a team of mental health professionals, psychiatrists, endocrinologists, and other healthcare providers. The somatic treatment generally consists of the use of GnRH analogues to prevent the progression of biological puberty and subsequently gender-affirming hormonal treatment to develop sex characteristics of the self-identified gender and surgical procedures. However to optimize treatment regimens, long-term follow-up and additional studies are still needed. What is known • The prevalence of gender dysphoria increased significantly in the past years and can lead to significant complaints and burdens especially during puberty. • Pubertal suppression and gender-affirmed treatment can be effectively used in adolescence with gender dysphoria. What is new • Transgender mental and medical healthcare is a long-lasting process during which not only the child/adolescent with GI but also their parents/family have to be counseled in making choices about their social, medical, and legal transitions. • There are an increasing number of transgender persons defining as nonbinary. Therefore, an individualized approach by an experienced team is necessary.

Adolescent Gender Dysphoria and the Informed Consent Model of Care

The informed consent model of care for people who identify as transgender is predicated on the idea that a careful mental health assessment and a formal diagnosis of gender dysphoria are not necessary preconditions before starting a person on cross-sex hormones. This article considers the legality of the informed consent model in relation to adolescents under 18 in Australia in the light of the decisions of the Family Court in Re Kelvin (2017) 327 FLR 15; [2017] FamCAFC 258 (Re Kelvin) and Re Imogen (No 6) (2020) 61 Fam LR 344; [2020] FamCA 761. The approach taken by the Family Court is predicated on the treatment being a response to a clinically diagnosed disorder, diagnosed after proper assessment. Re Kelvin indicates that assessment and treatment should be conducted by a multidisciplinary team in accordance with internationally recognised standards and guidelines. For these reasons, practising under an informed consent model of care without a mental health assessment or working within a multidisciplinary team, is unlawful.

[Role of the psychiatrist-psychotherapist in the assessment and treatment of gender dysphoria]

This article is the result of the joint work of psychiatrists-psychotherapists working with patients with gender dysphoria (children, adolescents and adults) in Lausanne and Geneva university hospitals. It emphasizes the importance of their clinical interventions when hormone therapy and sex reassignment surgery are requested.

5α-Reductase-2 deficiency: is gender assignment recommended in infancy? Two case-reports and review of the literature

PURPOSE

Gender assignment represents one of the most controversial aspects of the clinical management of individuals with Differences of Sex Development, including 5α-Reductase-2 deficiency (SRD5A2). Given the predominant female appearance of external genitalia in individuals with SRD5A2 deficiency, most of them were assigned to the female sex at birth. However, in the last years the high rate of gender role shift from female to male led to recommend a male gender assignment.

METHODS

We here describe two cases of subjects with SRD5A2 deficiency assigned as females at birth, reporting their clinical histories and psychometric evaluations (Body Uneasiness Test, Utrecht Gender Dysphoria Scale, Bem Sex-Role Inventory, Female Sexual Distress Scale Revised, visual analogue scale for gender identity and sexual orientation) performed at the time of referral at the Florence Gender Clinic.

RESULTS

Both patients underwent early surgical interventions without being included in the decision-making process. They had to conform to a binary feminine gender role because of social/familiar pressure, with a significant impact on their psychological well-being. Psychometric evaluations identified clinically significant body uneasiness and gender incongruence in both subjects. No sexually related distress and undifferentiated gender role resulted in the first subject and sexually related distress and androgynous gender role resulted in the second subject.

CONCLUSIONS

The reported cases suggest the possibility to consider a new approach for gender assignment in these individuals, involving them directly in the decision-making process and allowing them to explore their gender identity, also with the help of GnRH analogues to delay pubertal modifications.

Subjective Ratings of Gender Dysphoria Scales by Transgender Individuals

The present research explored transgender individuals' subjective ratings of two clinical measures of gender dysphoria: the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) and the Utrecht Gender Dysphoria Scale (UGDS). Participants read each scale and provided a global rating regarding how well they captured their experiences of gender dysphoria. Participants included 622 transgender individuals who identified as transfeminine (n = 221), transmasculine (n = 206), and non-binary/agender (n = 195). Findings indicated clear patterns of responses across gender identity and assigned sex, but not clinical diagnosis. For the GIDYQ-AA, transfeminine and transmasculine individuals rated the scales more positively than did non-binary/agender individuals. In addition, participants who were assigned male rated the scale to be a more accurate measure of their dysphoria than did participants who were assigned female. For the UGDS, transfeminine individuals rated the scale most positively, followed by transmasculine individuals, and then non-binary/agender individuals. All pairwise comparisons were significant. Likewise, participants who were assigned male rated the scale to be a more accurate measure than did those who were assigned female. It is important to note that subjective ratings were relatively low (M = 3.40, SD = 1.09 for GIDYQ-AA; M = 3.43, SD = 1.22 for UGDS on a 5-point scale) where little more than half of the participants (52.5% GIDYQ-AA; 54% UGDS) agreed or strongly agreed that the scales captured their experience. Discussion focused on the implications for using these measures of gender dysphoria in both clinical and research settings.

The Medico-Legal 'Making' of 'The Transgender Child'

Thirty years ago, the transgender child would have made no sense to the general public, nor to young people. Today, children and adolescents declare themselves transgender, the National Health Service diagnoses 'gender dysphoria', and laws and policy are developed which uphold young people's 'choice' to transition and to authorize stages at which medical intervention is permissible and desirable. The figure of the 'transgender child' presumed by medicine and law is not a naturally occurring category of person external to medical diagnosis and legal protection. Medicine and law construct the 'transgender child' rather than that the 'transgender child' exists independently of medico-legal discourse. The ethical issue of whether the child and young person can 'consent' to social and medical transition goes beyond legal assessment of whether a person under16 years has the mental capacity to consent, understand to what s/he is consenting, and can express independent wishes. It shifts to examination of the recent making of 'the transgender child' through the complex of power/knowledge/ethics of medicine and the law of which the child can have no knowledge but within which its own desires are both constrained and incited.

[Approach to the causes of discharge and health needs of transgender people through the National Hospital Discharge Survey in Spain during the period 2001 to 2013]

OBJECTIVE

The health of transgender people is a little studied topic and hospital records can be an opportunity to make an approach. The aim of this study was to describe the cause for admission and the associated comorbidities of transgender people in Spain between 2001 and 2013.

METHODS

Retrospective observational study with population-based administrative records (Minimum Basic Data Set). The discharges generated by the transgender in Spanish public and private hospitals were selected using one of the following ICD-9-CM codes in any diagnostic field: Trans-sexualism (302.5), Disorders of psychosexual identity (302.6) and Gender identity disorder in adolescents or adults (302.85). The causes of admission and comorbidity according were described. The qualitative variables were described in their frequency distribution according to their number(n) and proportion(%) and the quantitative variables according to their mean and standard deviation (SD) or median (MD) and interquartile range (RIQ) according to their distribution.

RESULTS

A total of 2,010 highs were recorded corresponding to 1,878 patients. The mean age was 33 years (SD = 10). 51% were male, 46% female and 3% undetermined or unspecified. The discharges were motivated in 59% by the process of body modification, followed by HIV (4%) and personality disorders (3%). The most common comorbidities were those associated with body modification (49%), mental health problems (40%) and infectious diseases (15%).

CONCLUSIONS

It is necessary to address the health of transgender people in a comprehensive way that takes into account their specific health needs, including bodily modification, mental health, HIV and other infections, through strategies that include improve research, tailor health information systems and develop guidelines and training of healthcare providers in this transgender health.

Stigma, gender dysphoria, and nonsuicidal self-injury in a community sample of transgender individuals

We investigated rates of nonsuicidal self-injury (NSSI) and correlates of past-year NSSI among transgender people to better understand factors contributing to this health disparity. A community-based sample of 332 transgender people participated in quantitative in-person interviews. The mean age of participants was 34.56 years (SD = 13.78, range = 16-87). The sample was evenly divided between transfeminine spectrum (50.3%) and transmasculine spectrum identities (49.7%) and was diverse in race/ethnicity. We evaluated associations between sociodemographic characteristics, stigma, hypothesized resilience factors, and identity variables with past-year NSSI. 53.3% of participants reported ever having self-injured in their lifetime. Past-year NSSI was reported by 22.3% of the sample and did not significantly differ based on gender identity. In logistic regression models, past-year NSSI was associated with younger age and felt stigma (perceived or anticipated rejection), but not enacted stigma (actual experiences of discrimination), and with gender dysphoria. Efforts to address the high rates of NSSI among transgender people should aim to reduce felt stigma and gender dysphoria, and promote transgender congruence. Future research using a developmental approach to assess variations in NSSI across the life course and in relation to transgender identity development may illuminate additional processes that affect NSSI in this population.

Moral Challenges in Transgender Care: A Thematic Analysis Based on a Focused Ethnography

Treatment teams providing transgender-affirming medical care are inherently faced with various kinds of moral and ethical dilemmas and questions, which are becoming even more pressing due to increasing treatment numbers and public attention for transgender care. Little is known about what kinds of moral and ethical challenges manifest in clinical practice. The aim of the present research was to map the moral and ethical challenges of healthcare professionals working in a specialized multidisciplinary transgender care center. Over a period of 7 months, during a focused ethnographic study, data were collected through participant observation of multidisciplinary team meetings, observation of individual psychodiagnostic assessment sessions with clients, and analysis of transcripts and reports of a series of moral case deliberations. A thematic content analysis of the data identified various implicit and explicit moral and ethical challenges around the following six themes: (1) assessing eligibility; (2) content of treatment; (3) sequential order of the treatment steps; (4) role of the clinical guidelines; (5) differing notions regarding gender identity, and (6) decision-making process. Our research provides a detailed insight into the way healthcare professionals experience these moral and ethical challenges and how they are related to (local) guidelines, the multidisciplinary character of GD care, and its inherent implicit and explicit gender norms. Our findings suggest that good transgender care may profit from continuous multidisciplinary deliberation of and sensitivity toward the normative dimension of transgender care. The paper ends with recommendations for ethics support mechanisms in transgender care.

A Qualitative Study of the Acceptability of the Proposed ICD-11 Gender Incongruence of Childhood Diagnosis Among Transgender Adults Who Were Labeled Due to Their Gender Identity Since Childhood

For the forthcoming ICD-11, the ICD-10 category of Gender Identity Disorder of Childhood has been reformulated as Gender Incongruence of Childhood (GIC) and moved out of the mental disorders chapter. Proponents of eliminating the GIC diagnosis altogether claim that it is unnecessary and inherently harmful, although they do not eschew the diagnosis for adolescents and adults. Using a qualitative methodology, this study examined the impact of receiving a diagnosis related to gender identity as a child among transgender people who had had this experience, and evaluated participants' views of the acceptability and usefulness of the ICD-11 GIC proposal. Participants receiving health services at a specialized public clinic for transgender health in Mexico City who had received some form of diagnosis in childhood were referred to participate in a semistructured interview. A sample of 12 transgender people (eight transgender women and four transgender men; ages 18-49) was necessary to reach saturation. Diagnoses received were non-specific rather than formal gender identity diagnoses, were experienced by participants as negative, and were used to justify potentially harmful interventions. However, when participants reviewed the ICD-11 proposals for GIC, all indicated that the category was necessary and important and could have a range of personal, familial, and social benefits. They agreed with its placement in a new chapter on Conditions Related to Sexual Health and endorsed the proposed definition and name of the category. Although this study involved a small and specific sample, the results raise questions about the claim that the diagnosis is inherently harmful and universally deplored by transgender people.

MANAGEMENT OF ENDOCRINE DISEASE: Approach to the management of children and adolescents with Gender Dysphoria

Over the past 20 years, the care for transgender adolescents has developed throughout many countries following the "Dutch Approach" initiated in the 90's in pioneer countries as the Netherlands, United States and Canada, with increasing numbers of children and adolescents seeking care in transgender clinics. This medical approach has considerable positive impacts on the psychological outcomes of these adolescents and several studies have been recently published underlining the relative safety of such treatments. This paper reviews the current standards of care for transgender children and adolescents with particular emphasis on disparities among countries and short to medium-term outcomes. Finally it highlights ethical considerations regarding categorization of gender dysphoria, timing of treatment initiation, infertility, and how to deal with the long-term consequences.

Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents

As a traditionally underserved population that faces numerous health disparities, youth who identify as transgender and gender diverse (TGD) and their families are increasingly presenting to pediatric providers for education, care, and referrals. The need for more formal training, standardized treatment, and research on safety and medical outcomes often leaves providers feeling ill equipped to support and care for patients that identify as TGD and families. In this policy statement, we review relevant concepts and challenges and provide suggestions for pediatric providers that are focused on promoting the health and positive development of youth that identify as TGD while eliminating discrimination and stigma.

[Gender dysphoria: approach in complex cases]

Gender dysphoria can be a devastating condition but the symptoms are not always straightforward or visible. In this clinical lesson three cases are presented in which GPs suspect gender dysphoria in their patient but are not sure of the best approach. These cases illustrate how gender identity can sometimes vary or develop over time, and how in complex cases psychiatric co-morbidity can interfere with gender identity development and with the treatment of gender dysphoria. The article gives examples of how to discuss the topic with the patient. Furthermore, it describes the referrals and the general support a GP can give during a gender reassignment process.

Innovations, Reviews and Proposals on the DSM-5: the Case of Sexual Dysfunctions, Gender Dysphoria and Paraphilic Disorders

Human behaviours have different meanings according to the historical moment and context. In this article sexual behaviours are taken as a category in order to analyse how psychiatric nosology is structured, as manifested in texts such as the DSM-5. The development of these diagnostic manuals are tools that are far from being free of subjectivities and interference of elements of power, expressed in the way health, illness, mental health, and mental disorders, are assumed; in short, the normal and pathological. Each new diagnosis, or even its elimination, and the recomposing of the different diagnostic criteria, especially in the field of sexual behaviour, present visions of how individual and collective human life is conceived, as well as an expression of accurate attempts to control human sexualities through the medicalisation of behaviour, coupled with moral, religious, and even legal considerations. Categories such as gender dysphoria, paraphilia or paraphilic disorders are examples of how the limits intended to establish a biomedical perspective are also incomplete and imprecise. These violate individual and social construction of sexualities and the conception of mental health, showing persistent difficulties and controversies that are evident in the way psychiatric classifications are made.

Gender dysphoria in youth: a review of recent literature

PURPOSE OF REVIEW

Transgender individuals including pubertal young people require hormonal therapy, in conjunction with mental health support. These youths are a unique population, with specific and individual desires and needs as they move through the physical and mental transition to the gender with which they identify.

RECENT FINDINGS

The number of transgender youth presenting for treatment is increasing rapidly. They continue to have a high prevalence of mental health disorders, though not when supported in their sex identities by family in younger age. Older children are more susceptible to peer support or lack thereof. Treatment with gonadotropin-releasing hormone agonists remains a mainstay of early therapy, but is associated with high costs and decrease in bone mineral density; androgenic progestogens could be used as a lower cost alternative. Fertility preservation is discussed with the majority of transgender youth, but use of such services is low.

SUMMARY

Transgender youth are an increasingly identified population in need of medical and mental health treatment, as well as social support throughout life.

Legal and Medical Aspects of Diverse Gender Identity in Childhood

Diagnosis of gender identity dysphoria among children and young people appears to be increasing around the developed world. For a small proportion of children, the mismatch between their natal physical characteristics and desired gender causes significant distress. Though there are now accepted medical interventions that can assist in these cases, there is a lack of congruence between clinical practice and legal regimes governing the treatment of children and young people in this area. This article seeks to demonstrate the difficulties that may arise by providing a detailed explanation of medical interventions, juxtaposed with a discussion of the legalities of children's consent in some overseas common law jurisdictions.

Psychological characteristics of Italian gender dysphoric adolescents: a case-control study

PURPOSE

Gender dysphoria (GD) is associated with clinically significant distress and impairment in social, scholastic, and other important areas of functioning, especially when early onset is reported. The aim of the present study is to assess the psychopathological features associated with GD in adolescence, comparing a group of gender dysphoric adolescents (GDs) with a group of non-referred adolescents (NRs), in terms of body uneasiness, suicide risk, psychological functioning, and intensity of GD.

METHODS

A sample of 46 adolescents with GD and 46 age-matched NRs was evaluated (mean ± SD age = 16.00 ± 1.49 and 16.59 ± 1.11 respectively, p > 0.05). Subjects were asked to complete the Body Uneasiness Test (BUT) to explore body uneasiness, the Youth Self Report (YSR) to measure psychological functioning, the Multi-Attitude Suicide Tendency Scale (MAST) for suicide risk, and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) for GD assessment.

RESULTS

Adolescents with GD reported significantly higher levels of body uneasiness (BUT-GSI, F = 380.13, p < 0.0001), as well as a worse psychological functioning (YSR, F = 13.06 and p < 0.0001 for "total problem scale" and F = 12.53, p = 0.001 for "internalizing" scale) as compared to NRs. When YSR subscales were considered, GDs showed significantly higher scores in the "withdrawal/depression", "anxiety/depression", and "social problems" (all p < 0.0001). In addition, GDs showed significantly higher levels in the "attraction to death" and "repulsion by life" scales and lower scores in the "attraction to life" scale (all p < 0.0001). Finally, GIDYQ-AA score was significantly lower (meaning a higher level of gender dysphoria symptoms) in GDs vs. NRs (p < 0.0001).

CONCLUSIONS

GD adolescents reported significantly higher body dissatisfaction and suicidal risk compared to NRs. In addition, results confirmed a significant impairment in social psychological functioning in adolescents with GD.

[Gender confirming surgery : Female-to-male and male-to-female]

BACKGROUND

Gender confirming surgery (GCS) represents a new and interdisciplinary urological field of activity.

OBJECTIVES

Based on more than 20 years of experience, the development of interdisciplinary strategies in the surgical management of male-to-female (MtF) and female-to-male (FtM) transgenders is summarized.

MATERIALS AND METHODS

The current national and international literature, as well as the surgical experience of the authors in the field of GCS, were evaluated, and aspects relevant for urologists are presented in a comprehensive review.

RESULTS

Since 1990 more than 1200 primary GCS in MtF transgenders and more than 230 primary GCS in FtM transgenders have been performed in the authors' institutions. Presuming an incidence of at least 1:20,000 for patients with gender dysphoria (GD) in the general population, the overall number of patients is limited. The complex surgical procedures should be realized in an interdisciplinary team, trained and specialized in this field of surgery, given the high rate of complications and secondary procedures with MtF GCS.

CONCLUSION

Postoperative satisfaction rates of FtM and MtF transgenders at over 80% are satisfactory. During the last few decades, surgical procedures have been widely standardized. In the field of penile reconstruction, the free forearm lap represents the preferred method, while several surgical alternatives arise from the current literature in this field.

[Characteristics of Adolescents with Gender Dysphoria Referred to the Gender Identity Treatment Unit]

OBJECTIVE

The demand for treatment among people with gender dys-phoria has increased during the last years. The aim of the present research was to carry out an analysis of the demand of the teenagers that requested consultation at the UTIGPA (Gender Identity Treatment Unit of Principality of Asturias) as they presented complains of gender dysphoria.

METHODS

The sample included 20 minors that were treated between March 2007 and December 2015. The clinical history was made to collect informa-tion. It was made descriptive analysis and the reason sex/gender was used.

RESULTS

The 20 teenagers represented the 14,6% of the whole sample (of 137 demands). The age average was 15,20 years (SD=1,473) and the range of years was between 12-17. The reason sex/gender was 1/1 (10 into the man to woman group and 10 into the woman to man group). At the arrival at the Treatment Unit, 100% of the individuals lived with their nuclear or extended family and in the 60% of the cases, their parents were separated. 70% of the cases were referred from mental health services. 10% hadn´t got any past medical history and 35% had never received any prescription for a psychopharmacological treatment. 95% hadn't done any hormonal self-treatment. 100% defined themselves as heterosexual. 25% requested exclusively for psychological interventions and 75% asked for medical treatments.

CONCLUSIONS

The profile of the minor was a teenager of approximately 15 years old that was referred from mental health services. Contrary to the fin-dings of other national and international researches, the rate sex/gender was equated in our research. The minor had got a past medical history and their prio-rity request was for medical treatments, both hormonal and surgical therapies.

Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients

Informed consent as a model of care has evolved as an alternative to the standard model of care recommended by the World Professional Association for Transgender Health's Standards of Care, version 7, which emphasizes the importance of mental health professionals' role in diagnosing gender dysphoria and in assessing the appropriateness and readiness for gender-affirming medical treatments. By contrast, the informed consent model for gender-affirming treatment seeks to acknowledge and better support the patient's right to, and capability for, personal autonomy in choosing care options without the required involvement of a mental health professional. Clinicians' use of the informed consent model would enable them both to attain a richer understanding of transgender and gender-nonconforming patients and to deliver better patient care in general.

Gender and Sexual Health: Care of Transgender Patients

Transgender and gender-nonconforming individuals experience significant health disparities. They are more likely to use drugs and alcohol, smoke, be diagnosed with HIV infection or other sexually transmitted infections, and experience depression or attempt suicide. Many also experience discrimination within the health care system. Office-level strategies to create a safe and affirming space for gender-expansive patients include posting of a nondiscrimination statement, use of intake forms that ask about current gender identity and birth-assigned sex, provision of gender-neutral restrooms, and staff training in use of appropriate language. Hormone or surgical therapy can be initiated for patients with persistent gender dysphoria who are of age and have the capacity to make informed decisions, and have reasonable control of coexisting medical and psychiatric conditions. Estrogens, antiandrogens, and progestins are used for feminization, and testosterone for masculinization. Hormone treatment should be followed by careful monitoring for potential adverse effects. Surgical options include male-to-female and female-to-male procedures. The family physician may need to provide a referral letter, preoperative and postoperative examinations and care, and advocacy with health insurance providers. Preventive care for transgender patients includes counseling for cardiovascular health, cancer screening, provision of appropriate contraception, and screening for sexually transmitted infections.

Gender Dysphoria in a 62-Year-Old Genetic Female With Congenital Adrenal Hyperplasia

We report a case of gender dysphoria (GD) in a 62-year-old genetic female patient, raising the pros and cons of performing corrective surgery later in life. This 46,XX DSD patient was registered and reared as a girl; CAH was diagnosed late in childhood. Poor adherence to treatment and lack of proper psychological management contributed to evident GD. Living for years as a male, the patient applied for a legitimate male identification document in his late 50s; thereafter, he requested a sex-reassignment surgery "to disguise his female body upon his death." We informed the patient and family about surgery hazards, while analytical therapy allowed the group to evaluate the actual wish for surgery. When the wish was brought up, the role of death urged the group to rethink the course of treatment. During the process, it became clear that the patient's desire for surgery, more than a wish for changing the genitalia, expressed an impulse related to issues of endorsement and acceptance of his male identity. This report raises interesting questions about sexuality in a social context and prompts the idea that sexuality is broader than sex itself, raising new questions on the psychological risks faced when considering a body change after years of living with a disorder of sex development.

The Proposed ICD-11 Gender Incongruence of Childhood Diagnosis: A World Professional Association for Transgender Health Membership Survey

ICD-11 (the eleventh edition of the World Health Organization International Statistical Classification of Diseases and Related Health Problems) is due for approval in 2018. For transgender health care, the most important proposals for ICD-11 are as follows: (1) the five ICD-10 diagnoses (most notably Transsexualism and Gender Identity Disorder of Childhood) currently in Chapter 5 (Mental and Behavioural Disorders) will be replaced by two Gender Incongruence diagnoses, one of Adolescence and Adulthood and the other of Childhood (GIC), and (2) these two diagnoses will be located in a new chapter provisionally named Conditions Related to Sexual Health. Debate on the GIC proposal has focused on whether there should be a diagnosis for young children exploring their identity and has drawn on a number of arguments for and against the proposal. The World Professional Association for Transgender Health conducted a survey to examine members' views concerning the GIC proposal, as well as an alternative framework employing non-pathologizing Z Codes. The survey was completed by 241 (32.6 %) out of 740 members. Findings indicated an even split among members regarding the GIC proposal (51.0 % [n = 123] opposing and 47.7 % [n = 115] supporting the proposal). However, non-US members were overall opposed to the proposal (63.9 % [n = 46] opposing, 36.1 % [n = 26] supporting). Across the sample as a whole, and among those expressing a view about Z Codes, there was substantial support for their use in healthcare provision for children with gender issues (35.7 % [n = 86] of the sample supporting vs. 8.3 % [n = 20] rejecting).