IACAPAP Textbook of Child and Adolescent Mental Health

OTHER DISORDERS

Chapter

H.3

TRANSGENDER AND GENDERNON-CONFORMING YOUTH
2018 edition
Jack L Turban, Annelou LC de Vries, Kenneth J Zucker &Shervin Shadianloo
Jack L Turban

Division of Child & Adolescent
Psychiatry, Massachusetts
General Hospital, Boston, MA,
2114, USA
Conflict of interest: none
declaredAnnelou LC de Vries

Department of Child andAdolescent Psychiatry, Centerof Expertise on Gender
Dysphoria, VU University
Medical Center, Amsterdam,
The Netherlands.
Conflict of interest: none
declared
Kenneth J Zucker
Professor, Department of
Psychiatry, University ofToronto, Toronto, Ontario,
CanadaConflict of interest: none
declared

Photo Gillian Laub, Le Monde, 10.12.2014
This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2018. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Turban JL, de Vries ALC, Zucker KJ, Shadianloo S. Transgender and gender non-conforming youth. In Rey
JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent
Psychiatry and Allied Professions 2018.

Transgender and gender non-conforming youth		 H.31

IACAPAP Textbook of Child and Adolescent Mental HealthTransgender and gender nonconforming youth include children andadolescents who experience a marked incongruence between the genderassigned at birth and their gender identity (American Psychiatric
Association, 2013). Over the past decade, there has been a remarkableincrease in attention to transgender issues across the lifespan. Television has
begun to highlight transgender individuals from childhood to adulthood (Zucker,
2007; Morrison, 2010). News outlets from The New York Times Magazine to Le
Monde have explored the life experiences of transgender youth (Padawer, 2010;
Rosin, 2008; Chayet, 2014). Legislative bodies have examined transgender rights
through restroom access, hate crime legislation, insurance regulations, and antidiscrimination policies, with physicians playing key roles in these discussions(Schuster et al, 2016). These initiatives have ranged from protection of rights
for transgender patients to discriminatory policies that put the wellbeing oftransgender children at risk. In India, The Rights of Transgender Bill 2014 wasrecently introduced. The Canadian Senate passed Bill C-16 to expand antidiscrimination laws to cover transgender individuals. Legislation in the UnitedStates has fluctuated between Obama-era protections for transgender patients andTrump era restrictions, most recently a proposed ban on transgender service people
in the military.

Shervin Shadianloo
Department of Child andAdolescent Psychiatry, Center
for Transgender Care, Hofstra
Northwell School of Medicine,75-59 263rd St Glen Oaks, NY
11004, USA
Conflict of interest: none
declaredThis chapter was adapted withrevision from the chapter entitled
Gender Dysphoria & Gender
Incongruence in the 5th Editionof Lewis’s Child & Adolescent
Psychiatry: A Comprehensive
Textbook written by Jack L. Turban,
Annelou L.C. deVries, and Kenneth
Zucker.

Parallel to this growing attention, there has been a marked increase in theestablishment of specialized gender identity clinics for children and adolescentsin North America and in Europe (Hsieh & Leininger, 2016), which likely reflects
the marked increase in referrals that has been noted internationally (Aitken etal, 2015; Chen et al, 2016). The scientific literature on gender incongruence has
expanded as well, with an influx of new studies on co-occurring psychological
functioning, long-term follow-up studies, biological correlates, and outcomes of
medical interventions. Practicing child and adolescent psychiatrists should befamiliar with the basics of this field to appropriately assess and help these patients.

TERMINOLOGY AND DEFINITIONS
Terminology in this specialized area is continuously evolving. This section
describes terms and definitions that are in common usage in 2018, but different
regions, cultures, and families may have their own preferred terminology (seeTable H.3.1).
The term gender assigned at birth refers to a newborn’s gender (boy, girl,indeterminate), as generally declared by a medical professional. Other relevantterms include natal sex and birth sex. The term biological sex is somewhat vague, as
it is unclear whether it would be based on karyotyping of the sex chromosomes,
internal reproductive structures, the configuration of the external genitalia, etc.
The vast majority of newborns are assigned the gender of boy or girl throughprenatal diagnostics or, at birth, based on genital anatomy. A small number ofnewborns may be classified as having a “disorder of sex development” or what
others have called “differences of sex development” (Hughes, 2006), congenitalconditions in which biological parameters of sex (e.g., the sex chromosomes, thegonads, the configuration of the external genitalia, etc.) are incongruent with
one another. These conditions include complete or partial androgen insensitivity
syndrome, mixed gonadal dysgenesis, 5-alpha-reductase deficiency, penile
agenesis, and congenital adrenal hyperplasia, among others. Such patients may

Transgender and gender non-conforming youth		 H.32

IACAPAP Textbook of Child and Adolescent Mental Healthexperience gender identity issues different from those experienced by individuals
without a disorder of sex development (Meyer-Bahlburg et al, 2016).
Experienced gender or gender identity refers to one’s sense of self as a boy,as a girl, or some alternative gender that is different from the traditional boy-girldichotomy (e.g., “gender fluid,” “agender,” or “non-binary”). Other terms include
affirmed gender (typically used for individuals who have transitioned socially toliving as the desired gender). For the majority of individuals, experienced gendermatches the gender assigned at birth. These individuals are referred to as cisgender.
For some patients, experienced gender is opposite to the gender assigned at birth,and are referred to as transgender.
Gender expression refers to the way in which one presents to the outside
world in a gendered fashion and may include pronoun use, clothing, and otherexternal markers. Gender nonconformity refers to a person’s gender expression thatdiffers from socially anticipated gender expressions, which are binary in many
cultures. These anticipated gender expressions vary from culture to culture andmay vary from time to time within a single culture. Gender expression is different
from gender identity in that an individual may carry and express themselves in a
way that is not expected in their culture but continue to identify as their genderassigned at birth.
This may also be part of the psychosexual development of a child before,
during and after puberty. The term gender role is also used in a similar way togender expression but may be limited to behavior and is less inclusive than gender
expression.

“Until I was about four orfive I didn’t know I wasn’t
a girl, to be honest withyou. One of my earliest
memories, about five years
old, was being yelled at bya teacher for going to thetoilet with the girls. Aboutthe same age I realised I
was different to these otherboys. At the age of nine
I refused to have my haircut. I didn’t have it cut until
I was 16, because having
it cut was such a torment
to me.
School was extremely
difficult. I got bullied a lot.
I was picked on for being
too thin, for being feminine,for not liking football, for
hanging round with girls,
for having long hair. They
mocked everything they
could think of in terms ofgender and sexuality.”
The Guardian

Transgender and gender variant identities are sometimes used as terms forindividuals whose experienced gender does not strictly match the gender assigned
at birth. Persons who experience psychological distress in relation to their gender
identity may be referred to as gender dysphoric. “Gender dysphoria” is the diagnostic
term adopted in the DSM-5 (see below) (American Psychiatric Association, 2013).
Sexual attraction or sexual orientation is a separate concept from gender
identity. Sexual orientation refers to the type of individuals toward whom one isromantically or sexually attracted. Terms such as androphilia (attraction to males),gynephilia (attraction to females), biphilia (attraction to males and females), andaphilia (attraction to neither males nor females) have become more common, slowly
replacing older terms such as heterosexual, bisexual, homosexual, and asexual,
though this terminology can also be confusing as it does not explain if individuals
are attracted to a specific gender assigned at birth, a specific gender identity, aspecific gender expression, etc. In the scientific literature, the sexual orientationof individuals who identify as transgender has been described in relation to theirexperienced gender or their gender assigned at birth. For example, an adolescentfemale who identifies as male and is sexually attracted to females may be described
as “heterosexual” in relation to experienced gender but as “homosexual” in relation
to birth sex (Lawrence, 2010). From either a clinical or research perspective, it
is critical to identity the frame of reference when describing a patient’s sexual
orientation. Most individuals who identify as transgender will describe their sexual
orientation in relation to their gender identity, not their gender assigned at birth(e.g., a transgender woman who is attracted to men would likely consider herself
to be heterosexual).

Transgender and gender non-conforming youth		 H.33

IACAPAP Textbook of Child and Adolescent Mental Health

Figure H.3.1 The “Genderbread Person”

The “genderbread person” is a tool designed by Sam Killermann to explain the distinctions between experienced gender(termed gender identity here), gender expression, gender assigned at birth (termed biological sex here), and sexual or
romantic orientation. This educational tool may be useful for students new to the field and when explaining these phenomena
to families with gender nonconforming and gender dysphoric children. These terms are further described in table H.3.1.

The “genderbread person” has been developed as an educational tool toclarify the distinctions among gender assigned at birth, experienced gender, andsexual orientation (Figure H.3.1). Note that as a published educational instrument,
this graphic diverges somewhat from the contemporary terminology we describe.
Nonetheless, this tool has proven useful for introducing this terminology to families
and students new to the topics of gender and sexuality. The gender unicorn isanother popular graphic that highlights the dimensional aspects of gender identity,
gender assigned at birth, and sexual or romantic attraction.

UNDERSTANDING GENDER IDENTITY AND
GENDER NON-CONFORMITY AROUND THE WORLD
Most of the current literature regarding gender non-conforming, gendervariant and transgender youth is predominantly from Western countries. Given
the intangible nature of gender, gender identity and its expression, culturaldifferences in how gender is understood and expressed may effect the approachto these individuals. National Geographic recently tackled the complex topic ofgender in a special issue.
To work with gender non-conforming, gender variant and transgenderindividuals from different cultures, or to apply current practice guidelines indifferent cultures, various factors need to be taken into consideration. Gender may
be defined differently based on the language spoken. Language is the major modeof creating and describing concepts as well as the emotions associated with them.

Transgender and gender non-conforming youth		 H.34

IACAPAP Textbook of Child and Adolescent Mental Health

Table H.3.1 Terminology
TERM

DEFINITION•

Gender assigned at birth•

Natal sex•

Birth sex•

Experienced gender•

Gender identity•

Affirmed gender•

Sexuality•

Sexual orientation•

Gender incongruence

Refers to individuals whose gender assigned at birth and gender identity do
not match•

Gender role

A characteristic that is considered “male” or “female” by a particular culture•

Gender expression

An individual’s outward presentation of their gender identity. Typical examples
include, but are not limited to, clothing, hairstyles, and activities•

Transgender

Refers to individuals whose gender identity is incongruent with that assigned
at birth. This term is often used for individuals who are transgender in a binary
fashion but may also be used as an umbrella term for persons with any gender
identity other than cisgender (see below).

•

Transsexual

Typically used to refer to individuals who desire medical interventions toalign their anatomy with their gender identity. This term has been usedsynonymously with transgender by some and has largely fallen out of favor•

Transman

A transgender individual who identifies as male (typically with a female genderassigned at birth)•

Transwoman

A transgender individual who identifies as female (typically with a male genderassigned at birth)•

Gender dysphoria

Refers to psychological distress in relation to one’s experienced gender; isalso the classification used in DSM-5 (when fulfilling certain clinical criteria).
Note that not all patients with gender incongruence will experience dysphoria.

•

Cisgender

Refers to individuals whose experienced gender matches the gender assigned
at birth•

Gender non-conforming•

Gender variant•

Cross-sex hormones

This term refers to the estrogen or testosterone treatment that induces thedevelopment of female and male secondary sex characteristics respectively•

Gender affirming care

Refers to treatments aimed at supporting a patient in that patient’s gender
identity. This may include mental health, medical, legal, and surgical aspectsof care.

Gender identity exploration

Refers to a process in which a patient is allowed to explore gender identity.
Treatment should not have a gender identity (cisgender, transgender, orotherwise) as a goal of therapy. Rather, patients should be permitted to
explore the different possibilities to better understand the best fit for them•

Gender assigned to an infant at birth, generally based on observed physicalcharacteristics (genitalia etc.)

Individuals’ psychological understanding of their own gender
Individuals’ psychological understanding of their own gender, typically referring
to living socially as that understood gender
Refers to the type of individuals towards whom one is romantically and/or
sexually attracted

Refers to variation from developmental norms in gender role behavior that
may be considered as non-gender stereotypical. This may include identifying
as both genders or identifying with neither, among others. Some transgenderindividuals who identify on the gender binary (i.e., male or female) also identify
with these terms.

Transgender and gender non-conforming youth		 H.35

IACAPAP Textbook of Child and Adolescent Mental Health

Gender, being a core feature of identity, is influenced by the language spoken. In
some languages the words for sex and gender are the same. This may make it harder
to differentiate between gender identity versus anatomical sex. It is important toalso note that some languages are grammatically gendered and some are not. In
languages that are grammatically gendered (e.g., Spanish), use of pronouns can be
an important topic and become a milestone in transitioning; however, this mayvary if the language spoken is non-gendered. About one quarter of the world’s
languages are grammatically gendered. In these languages each noun is assigned to
one gender, typically, masculine, feminine, neuter. Most cultures appear to havefollowed a binary anatomical sex and created their language and culture basedon this presumed dichotomy. In contrast, other cultures have specific words todescribe aspects of gender identity that may fall outside of a binary concept ofgender such as hijra in India, two-spirit in some Native American tribes, and menwomen in Balkan communities.
Historically, Middle Eastern, North African and European cultures
recognized and had terms for transgender people. This includes hijra in India,
Mukhannath in Islam and Arabic cultures, Phrygia in ancient Greek, and Cybele
in ancient Roman. These individuals were often intersex people or natal males
castrated for religious or other reasons. It is important to note that the recognition
did not necessarily protect these individuals from stigma and marginalization, andin some places like India, Hijras, although believed to have power to remove a “badspell” from newborns, were highly stigmatized. Meanwhile there have been new
movements to support and protect transgender people in this region. The Rights ofTransgender Persons Bill, which provisions anti-discrimination and employment
for transgender people, was introduced in 2014 in India; it may result in positivechanges in the future. Another example is the Fatwa from the Iranian Supreme
Leader, Ayatollah Khomeini, after the 1979 Islamic Revolution, that allows
transgender people to transition to their identified gender.

Click on the picture toaccess Mermaids, UK sitethat provides informationand support for children
and teenagers with gender
identity issues

It is beyond the scope of this chapter to review the concept of gender identity
in all different cultures; we bring these examples to highlight the cultural variation
about how gender identity is understood. There are many countries that have noliterature on the care of gender non-conforming, gender variant, and transgenderpeople. Transgender identity and gender non-conformity continue to be highly
stigmatized around the world. In East Asia alone, perspectives vary significantly.
Thailand has the highest number of gender affirming surgeries in the world. In
China, there are limited if any services for transgender people.
Working with children and youth presenting with gender issues requires
knowledge of the child’s psychosexual development, cultural aspects of gender andits expression in that specific society and family unit, as well as their exposureand understanding of the expanding information and media awareness aroundgender non-conformity and transgender identity. In the case of working withimmigrant families, understanding the interaction of the host and home cultures
is also important.

HISTORY OF GENDER IDENTITY AND MEDICINEJohn Money (1921-2006) was a psychologist and sexologist whose empiricaland theoretical contributions regarding gender identity, gender role, and gender

Transgender and gender non-conforming youth		 H.36

IACAPAP Textbook of Child and Adolescent Mental Healthdevelopment were innovative and of great influence, beginning in the 1950s.
Money originally proposed a theory of “gender neutrality,” suggesting that gender
identity was predominantly determined by social factors, including the genderassigned at birth and subsequent socialization processes (Money et al, 1957).
Money proposed that, for individuals with a disorder of sex development, earlysurgical interventions to correct genital ambiguity were often needed so that achild could then be supported with rearing in the gender assigned at birth.
Over the past few decades, Money’s original theory of gender neutrality atbirth has been challenged by various lines of evidence suggesting the importanceof biological factors, particularly patterns of prenatal hormone exposure, that
also contribute to gender identity formation and differentiation. For example,
chromosomal females with congenital adrenal hyperplasia who were assigned
female at birth are exposed to elevated levels of prenatal testosterone; many ofthese girls are “behaviorally masculinized” and a higher percentage than the general
population develop gender dysphoria and transition from female to male (Dessens
et al, 2005; Pasterski et al, 2015).
Perhaps the most widely cited case pertains to a biologically “normal” male(one of a pair of identical twins) who, after a circumcision accident at the age of
7 months that led to penile ablation, underwent a vaginoplasty and was sociallyre-assigned to female at the age of 17 months. Although this patient was describedby Money as a “tomboy” during childhood, subsequent follow-up revealed thatthe patient rejected estrogen therapy at the time of puberty and subsequently
transitioned back to living as a male (Colapinto, 2000; Diamond & Sigmundson,2004). Tragically, he committed suicide at the age of 38 (The Associated Press,
2004). The “John-Joan” case, as it was called, has been used as evidence of theimportance of biological factors in contributing to a person’s sense of gender
identity. A subsequent summary of seven similar patients reared as female after
traumatic loss of the penis have shown both male and female gender identities inadolescence and adulthood, further complicating the picture (Meyer-Bahlburg,
2005).
In the 1960s, research into the developmental histories of adults with“transsexualism” suggested that childhood cross-gender identification wascommon in these individuals (Green, 1974). This work was followed by researchwith children who showed patterns of gender-related behavior similar to therecalled patterns of transsexual adults (Green, 1974). During this period, there
was much less attention given to adolescents with a marked history of cross-gender
identification.
By the late 1990s, however, more attention was given to adolescents with a
DSM diagnosis of gender identity disorder, including the possibility of treatment
with gonadotropin releasing hormone analogs, as reported by a research team in
the Netherlands (Cohen-Kettenis & van Goozen, 1998). This approach, described
below, was ultimately outlined in the 2009 Endocrine Society Guidelines for theTreatment of Transsexual Persons (Wylie et al, 2009), and in the periodically updated
World Professional Association for Transgender Health (WPATH) Standards ofCare (Coleman et al, 2011). Research into these hormonal interventions has sincegarnered significant attention, including increased NIH funding to study the longterm benefits and risks of these treatments (Reardon, 2016).

Transgender and gender non-conforming youth		 H.3“I have lived two thirds of
my life as female and athird as male. I graduatedfrom high school as a girland from college as a guy;
those five years were themost difficult yet joyous andrewarding of my life.
I was afraid to take this step
toward medical transition;
afraid I would lose
everyone I loved, afraidof what I would look like,afraid of what people would
say and what a freak theywould think I am. I thought
I would have to move faraway and never talk to myparents, extended family, or
friends again. I am happy to
say I was very wrong.
It has taken a lot oftime, patience, andcommunication, but forthe most part I did notlose anyone I love, andthe people I did lose were
not real friends in thefirst place. Nothing hasturned out like I thought itwould when I first started
transitioning; instead ofbeing shunned and vilified
by people from my past, I
have been received warmly
and lovingly. I have mademany amazing friends
and had many incredible
experiences along the way.”
The New York Times
It should be notedthat a large number oftransgender individuals are
rejected by their families.
This leads to high rates
of homelessness among
them.

7

IACAPAP Textbook of Child and Adolescent Mental Health

DIAGNOSIS AND ASSESSMENT
Assessment of youth presenting with gender-related concerns requires adevelopmental history that explores general psychological development, genderdevelopment, and a careful analysis of the child’s environment and safety related
to expressed gender non-conforming behaviors. Various developmental theories
may provide assistance in understanding and categorizing children based on theirage in regards to gender development. The DSM-5 has criteria for diagnosis ofgender dysphoria in both children and adolescents. Gender dysphoria is a clinicaldiagnosis and requires in depth and longitudinal evaluation of these youth.
Several scales have also been developed to help with the assessment of gender nonconforming youth (The Utrecht Gender Dysphoria Scale, The Gender Identity/
Gender Dysphoria Questionnaire for Adolescents and Adults, among others),
though none of these alone can establish a diagnosis. The evaluation of gender,in addition to the usual developmental and mental health evaluation of a child,needs to include a thorough chronological history of the child’s gender expression
and identity from parents and caregivers as well as a developmentally informed
evaluation of the child’s gender individually. The evaluator may use tools such as
toys, books, drawing or playing materials to assist in the evaluation and gather
information about behavior at school, with peers and at home.
Families play a key role in the evaluation. A child’s gender variance has asignificant impact on the family dynamics and may lead to conflicts and disruptionof emotional attachments. It is important that these issues be identified and efforts
be made to include all parties involved in the child’s life regardless of the child’sage.
Safety is a complex matter in the lives of gender non-conforming andtransgender youth. Mental health practitioners need to be aware and look forovert and covert aggression and risk to the child due to being a sexual and genderminority, in addition to the usual safety issues. Bullying, risk of being kicked out of
home, societal violence, and local legislation prosecuting or endangering a youth
need to be considered and documented.

CLASSIFICATION
Gender identity diagnoses first entered the DSM in its third edition withthree diagnoses: transsexualism, gender identity disorder of childhood, andatypical gender identity disorder (American Psychiatric Association, 1980). The
essential feature of these three diagnoses was “an incongruence between anatomic
sex and gender identity” (American Psychiatric Association, 1980). Revisions in
the DSM-III-R were modest, though, in this edition, exclusion of individuals
with schizophrenia or a disorder of sex development was removed, noting that
individuals with either of these diagnoses could also have a “gender identity
disorder” (American Psychiatric Association, 1987).
In the DSM-IV, the three diagnoses from DSM-III were collapsed into
the overarching diagnosis “gender identity disorder,” with distinct criteria sets forchildren versus adolescents and adults (American Psychiatric Association, 1987).
This edition also added a criterion stating “The disturbance causes clinicallysignificant distress or impairment in social, occupational, or other important areasof functioning” (Vance et al, 2010).
Transgender and gender non-conforming youth		 H.38

IACAPAP Textbook of Child and Adolescent Mental Health

Table H.3.2 Summary comparison of diagnostic criteria for gender dysphoria inchildren and in adolescents and adults according to DSM-5
GENDER DYSPHORIA IN CHILDREN

GENDER DYSPHORIA IN ADOLESCENTS AND
ADULTS

A marked incongruence between one’s
experienced/expressed gender and assigned
gender (one of which must be a strong desire
to be of the other gender or an insistence that
one is the other gender or some alternative
gender different from one’s assigned gender),of at least 6 months’ duration, as manifested byat least six of the following.

A marked incongruence between one’s experienced/
expressed gender and assigned gender, of at least 6months’ duration, as manifested by at least two of thefollowing:●●

In boys (assigned gender), a strong
preference for cross-dressing or dressing ●as female; or in girls (assigned gender),a strong preference for wearing only
masculine clothing and a strong resistanceto wearing feminine dresses.
●
A strong preference for cross-gender roles
in make-believe play or fantasy play.

A marked incongruence between one’s experienced/
expressed gender and primary and/or secondary
sex characteristics (or in young adolescents, theanticipated secondary sex characteristics).
A strong desire to be rid of one’s primary and/or
secondary sex characteristics because of a marked
incongruence with one’s experienced/expressedgender (or in young adolescents, a desire to preventthe development of the anticipated secondary sex
characteristics).

●

A strong preference for toys, games, or
activities stereotypically used by the othergender.

●A strong preference for playmates of theother gender.

●●
In boys (assigned gender), a strong
rejection of masculine toys, games, andactivities and a strong avoidance of roughand-tumble play; or in girls (assigned●
gender), a strong rejection of feminine
toys, games, and activities.

A strong desire to be of the other gender (or somealternative gender different from one’s assigned
gender).

●A strong dislike of one’s sexual anatomy.

●

A strong desire for the primary and/or
secondary sex characteristics that match
one’s experienced gender.

A strong conviction that one has the typical feelings
and reactions of the other gender (or some alternative
gender different from one’s assigned gender).

●●A strong desire for the primary and/or secondary sex
characteristics of the other gender.

A strong desire to be treated as the other gender (orsome alternative gender different from one’s assigned
gender).

The condition is associated with clinically significant distress or impairment in social, school, or otherimportant areas of functioning.

Transgender and gender non-conforming youth		 H.39

IACAPAP Textbook of Child and Adolescent Mental Health

DSM-5 renamed gender identity disorder as “gender dysphoria,” aiming todecrease stigma associated with the diagnosis while maintaining a diagnosis that
could be used to secure access to care for those who needed it (Vance et al, 2010).
DSM-5 removed sexual orientation subtyping but noted in the text its relevancein understanding variations in developmental trajectories, and for research on
biological factors and long-term outcomes (American Psychiatric Association,2013). DSM-5 also made the childhood diagnosis stricter, requiring more thanjust gender non-conforming behavior. The new criteria require that a child express
an actual desire or insistence in being of the other gender. The adolescent and adult
criteria simultaneously became more inclusive, allowing for non-binary gender
identities that would allow for gender variant, but not strictly binary, transgenderadolescents and adults to receive the diagnosis and subsequently access to care.
Current DSM-5 criteria for gender dysphoria in children require a marked
incongruence between one’s experienced/expressed gender and assigned gender,of at least six months’ duration, as evidenced by at least six of eight criteria, oneof which must be a strong desire to be of the other gender or an insistence that
one is the other gender (or some alternative gender different from one’s assigned
gender). Additionally, the patient must experience clinically significant distressor impairment in social, school, or other important areas of functioning as
introduced in the DSM-IV (see Table H.3.2). DSM-5 criteria for gender dysphoria
in adolescents and adults are similar, though with different requirements for the
manifestation of gender dysphoria. This diagnosis requires at least two of six
manifestations (see Table H.3.2).
Some have argued for use of the term “gender incongruence,” including
the Working Group on Sexual Disorders and Sexual Health for the forthcoming
11th edition of the International Classification of Diseases (ICD-11). This groupsuggested that the term “gender incongruence” highlights that not all transgenderindividuals experience dysphoria. The group notes that the term gender dysphoria
might increase inappropriate stigmatization and pathologization. The group
recognizes the necessity of diagnosis only for the purpose of preserving access to
medical care. The group additionally argues that this diagnosis be moved out of
the chapter on mental health and behavioral disorders and into another section,
provisionally termed “conditions related to sexual health” (Drescher et al, 2016).
though this brings up an additional issue of conflating gender identity withsexuality, as described in the terminology section above.

Click on the picture to accessthe site of the Gender
Identity Research and
Education Society (GIRES)EPIDEMIOLOGY
A range of methodological challenges including, but not limited to, shifting
terminology and stigma associated with self-identification, have made it difficult toestablish the true prevalence of gender dysphoria or gender incongruence.
Prevalence in Adults
In adults, most studies have used the number of individuals that seek
clinical care for gender affirming treatment as a proxy for determining prevalencein a certain country or catchment area. A recent meta-analysis based on 21 studies
that applied this method concluded that the prevalence of transsexualism (thedefinition used in most of these studies) was 6.8 trans women in 100,000 gender

Transgender and gender non-conforming youth		 H.310

IACAPAP Textbook of Child and Adolescent Mental Healthat birth assigned males (1:14,705) and 2.6 trans men in 100,000 gender at birth
assigned females (1:38,461) (Arcelus et al, 2015). A time trend was also found,with recent studies reporting higher prevalence rates. These studies are, of course,
limited by the fact that they do not include transgender individuals who do notseek gender affirmative healthcare. Indeed, much higher prevalence rates—ranging
from 4.2 % having an ambivalent gender identity, to around 0.5 % identifying
as transgender and considering medical interventions—are suggested by recent
studies that have used broader definitions and probability samples (Conron et al,2012; Kuyper & Wijsen, 2014; van Caenegem et al, 2015). A recent populationbased survey in the US found that 0.6% of adults self-identified as transgender,
with rates ranging from 0.3% to 0.8% in the states for which data were available.
Compared to older age groups, young adults aged 18 to 24 were more likely toidentify as transgender (Andres et al, 2016).
Prevalence in Children and Adolescents
Although formal epidemiological studies of gender dysphoria (previously
known as gender identity disorder) in children and adolescents have not been
conducted, looser or more liberal definitions of “caseness” have been examinedin several studies. In a random sample of 2,730 Grade 6-8 students from San
Francisco, Shields et al (2013) found that 1.3% self-identified as “transgender” in
response to the question “What is your gender?” with the other response options
being female or male. In a random sample of 8,166 high school students fromNew Zealand, Clark et al (2014) found that 1.2% self-identified as transgenderand 2.5% reported that they were not sure about their gender, in response to thequestion “Do you think you are a transgender?” which was followed by a definitionof the term. Interestingly, another 1.7% reported that they did not understandthe question. In a study of 80,929 American high school students from the 2016
Minnesota Student Survey, 2.7% self-identified as transgender or gender nonconforming (Rider et al, 2018).
Gender Assigned at Birth Ratio
Of pre-pubertal children referred to gender identity clinics, the majority
has a male gender assigned at birth. Among 577 Canadian children referred toa gender identity clinic between 1976 and 2011, the male-to-female ratio was
4.49:1 (Wood et al, 2013). This was significantly higher than the 2.02:1 ratio in
the Netherlands (Aitken et al, 2015). These differences are theorized, in part, tobe a reflection of increased parental anxiety regarding gender-variant behavior inmales compared to females, particularly in North America. For adolescents withgender dysphoria, the gender ratio is much closer to 1:1 and appears to be moreconsistent across nations (Aitken et al, 2015). However, it is of note that there
has been a recent temporal shift from more birth-assigned males prior to 2006, tomore birth-assigned females from 2006 to 2013, though the ratio remains closer
than 2:1 in either direction (Aitken et al, 2015).

BIOLOGICAL AND PSYCHOSOCIAL DETERMINANTS
The etiology of cross-gender identification and behavior continues to beelusive. While psychological and social factors were once the main focus of study,
attention has shifted more recently to biological mechanisms. At present, theTransgender and gender non-conforming youth		 H.311

IACAPAP Textbook of Child and Adolescent Mental Healthevidence suggests that both psychosocial and biological elements are involved.
A single mechanism is unlikely and gender dysphoria most likely results from acomplex interaction between these factors (Steensma et al, 2013a).
Biological Factors
Twin studies suggest a strong heritable component with additional
environmental contributors. In a large-scale CBCL study of Dutch twins(N=23,393) aged 7 and 10 (Coolidge et al, 2002), monozygotic (MZ) and dizygotic(DZ) twins were compared; genetic factors contributed to 70% of cross-gender
behavior (as assessed via the two CBCL gender items). Another study of 314 MZ
and DZ twins (mean ages 9.4 and 10.1 years, respectively) roughly replicated thisfinding, with genetic factors contributing up to 62% of the variance on a DSMIV-based gender dysphoria scale (Coolidge et al, 2002).
Many studies, both in animals and humans, have shown that differences inbrain anatomy and function in males and females underlie the sex differences intheir behavioral characteristics (Hines, 2011). Sex hormones play an importantrole in these differences. The organizational effect, predominantly prenatally but
also during puberty, leads to the sex differences in brain structures (Ruigrok et al,2014; Giedd et al, 2012). On average, males have larger brain volumes, more whitematter, gray matter, and cerebrospinal fluid than females, although when corrected
for total volume, females have more gray matter and a larger volume of the cortex(Ruigrok et al, 2014; Guillamon et al, 2016).
The sexual differentiation hypothesis suggests that transgender individuals
may have brain structures and brain functioning more closely aligned with
their gender identity than with their assigned gender at birth (Swaab & GarciaFalgueras, 2009). Post-mortem studies have suggested a sex reversal in several
hypothalamic nuclei in transsexuals (Kruijver et al, 2000; Zhou et al, 1995).
More recent neuroimaging techniques have allowed the in vivo study of brain
morphology and functioning of larger numbers of adolescents and adults withgender nonconforming feelings (Kreukels & Guillamon, 2016). Before theyreceived any medical gender affirmative treatment, brain anatomy with regard tovolume, gray and white matter, and cerebrospinal fluid did not differ compared totheir birth-assigned sex. Differences have been found with regard to white matter
microstructure showing that transgender individuals lie between males and females(Guillamon et al, 2016). In the realm of functional neuroimaging, task-related
studies show that transgender people may have either similar reactions as those of
their experienced gender (e.g., smelling odorous steroids; Berglund et al, 2008)or activity different from their assigned gender as well as their experienced gender(e.g., mental rotation; Schoninget al, 2010), or not different from their assigned
gender (e.g., verbal fluency; Soleman et al, 2013). Overall, results in the realm ofneuroimaging are mixed.
In animal studies, where prenatal hormones can be manipulated, thestrong effect of prenatal testosterone on gender role behavior is clear (Hines,2011). The effects on gender identity, however, can only be studied in humans.
Individuals with a disorder of sex development may be exposed to high levels of
prenatal testosterone, and individuals with two X chromosomes with congenital
adrenal hyperplasia (Merke & Bornstein, 2005) indeed have higher rates of gender
dysphoria and cross-gender identification (Pasterski et al, 2015). However, theTransgender and gender non-conforming youth		 H.312

IACAPAP Textbook of Child and Adolescent Mental HealthIn the US, the Trumpadministration withdrew in2017 a federal guidanceissued by the Obamaadministration in May 2016
requiring transgenderstudents to have unfetteredaccess to bathrooms andlocker rooms matching theirgender identity.

majority of female-raised individuals with congenital adrenal hyperplasia (~95%),
appear to develop a female gender identity (Dessens et al, 2005). Other evidence
for the importance of prenatal testosterone comes from studies in XY individuals
with complete androgen insensitivity syndrome who lack the receptors necessary
to respond to endogenous testosterone. The vast majority of these patients develop
a female gender identity, suggesting that downstream testosterone signaling may
be important for the development of a male gender identity (Mazur, 2005). Somehave noted that these patients were reared unambiguously as females and that social
factors may have played a strong role in their female identity formation (Hines,2009). Some studies have shown that those with complete androgen insensitivity
syndrome have lower scores on female identity scales (Richter-Appelt et al, 2005)
and there are case reports of gender dysphoria ultimately leading in these patientsto gender affirming surgeries (T’Sjoen et al, 2011). This could be secondary to
the psychological stress of learning about the diagnosis, as well as the possibilityof undetected functional androgen receptors (Steensma et al, 2013a). Overall,studies of gender identity in individuals with disorders of sex development, while
implicating androgens in the development of gender identity, have yet to show adirect relationship.
Psychosocial Factors
Past literature has investigated the potential role of parental characteristics
on the development of gender dysphoria (maternal wish for a child of the opposite
gender, paternal absence, and parental psychological functioning, among others).
None of these hypotheses have been validated (Steensma et al, 2013a). Mothers ofgender dysphoric boys have been noted to have higher scores on the Beck Depression
Inventory and the Diagnostic Interview for Borderlines (Marantz & Coates,
1991), but these higher scores might be due to external pressures placed on theseparents by unaccepting social environments and such studies cannot determine thedirection of causation. One study noted that gender dysphoric boys were rated as
more feminine and “beautiful” by blinded college students (Zucker et al, 1993),
while another study of gender dysphoric girls showed that these girls were rated asless “cute” (Fridell et al, 1996), raising the question of whether perceived physicalappearance and resultant social treatment may contribute to gender incongruence.
An alternative interpretation of this data is that those with a more male gender

Transgender and gender non-conforming youth		 H.313

IACAPAP Textbook of Child and Adolescent Mental Healthidentity might alter their appearance to appear more “masculine” (e.g., culturally
masculine haircuts), while those with a more female gender identity alter theirappearance to look more “feminine” (McDermid et al, 1998). Some have suggested
that a lack of parental limit setting, particularly around cross-gender behavior,is associated with gender dysphoria (Zucker & Bradley, 1995), though this does
not prove causation, as more insistence on cross-gender behavior (i.e., transgender
identity or stronger cross-gender behavior preferences) may make this limit setting
more difficult. Overall, there have been no proven causative psychosocial factors in
the development of gender incongruence

CLINICAL COURSE
Persistence of Gender Dysphoria from Childhood to Adolescence
The natural history of gender identity for children who express gendernonconforming or transgender identities is an area of active research (Olson,2016). To date, the long-term follow-up studies of clinic-referred children havebeen based on samples that have included children who were either threshold or
sub-threshold for the gender identity diagnosis in DSM-III, III-R or IV and someof the earliest studies began prior to the availability of formal diagnostic criteria.
These follow-up studies have classified participants as either “persisters” or“desisters” with regard to gender dysphoria using various metrics (semi-structured
interviews based on DSM criteria for gender identity disorder, dimensional scoreson standardized questionnaires, etc.). Ristori and Steensma (2016) summarized
10 follow-up studies and reported that the percentage of participants classified aspersisters ranged from 2% to 39% (collapsed across natal boys and girls). In one
study (Wallien & Cohen-Kettenis, 2008), the percentage of natal girls who were“persisters” was substantially higher than the percentage of natal boys (50% vs.
12%), but in two other studies from the same clinic the percentage was similar
across natal sex (Drummond et al, 2008; Singh, 2012).
One criticism of these studies is that either formal diagnostic criteria were notused (because they were not available at the time of the study) or that subthresholdcases were included. These subthreshold cases may have included individuals withcross-gender interests or behaviors who did not actually identify as transgender.
It is perhaps not surprising that these patients did not identify as transgender atfollow-up. Some studies have found that threshold cases were more likely to beclassified as persisters (Steensma et al, 2013b), but other have not (Singh, 2012). It
has also been suggested that more recent cohorts (after the year 2000) have foundhigher rates of persistence (12% to 39%) (Zucker & Bradley, 1995; Wallien &Cohen-Kettenis, 2008; Drummond et al, 2008; Singh, 2012) than older cohorts(2% to 9% prior to 2000) (Green, 1987; Zuger, 1984), suggesting that, as society
becomes more accepting of these individuals, fewer report “desisting,” which may
represent going back into the closet due to social pressures rather than a true
desistence of cross-gender identification. Comparisons of persisters with desisters
have found that the intensity of gender dysphoria (using dimensional metrics),
older age at the time of assessment in childhood, a lower social class background,and having a female gender assigned at birth are associated with higher rates of
persistence (Steensma et al, 2013b). Despite this work, it remains difficult toTransgender and gender non-conforming youth		 H.314

IACAPAP Textbook of Child and Adolescent Mental Healthpredict the likelihood of cross-gender identification persistence from childhood
into adolescence for an individual child (Steensma et al, 2013b).
Persistence of Gender Dysphoria from Adolescence to Adulthood
In contrast to the low rates of persistence from childhood into adolescence,
it appears that the majority of transgender adolescents persist in their transgender
identity (Cohen-Kettenis & Pfäfflin, 2003). In a study of 55 transgender adolescentsreceiving gender affirmative care, 100% continued to identify as transgender inyoung adulthood (deVries et al. 2014). Larger longitudinal studies such as this areneeded.
Childhood Gender Variant Behavior and Sexual Orientation
Childhood gender variant behavior has been found to be a strong predictorof a same-sex sexual orientation in adulthood (using gender assigned at birth as areference point). In a study of 879 Dutch boys and girls, gender variant behavior
was assessed using the CBCL and sexual orientation was assessed 24 years later(Steensma et al, 2013c). It was found that the prevalence of a same-sex sexual
orientation was, depending on the domain (attraction, fantasy, behavior, andidentity), between 8.4 and 15.8 times higher in the gender variant subgroup ascompared to the non-gender-variant subgroup. In summary, the current literature,
though limited, suggests that the majority of gender nonconforming pre-pubescentchildren will grow up to endorse identification as cisgender individuals with eithera bisexual or a same-sex sexual orientation (Wallien & Cohen-Kettenis, 2008;
Singh, 2012; Green, 1987).

COEXISTING PSYCHIATRIC CONDITIONSChildren and adolescents with gender incongruence exhibit higher
internalizing and externalizing psychopathology compared to non-referred
controls, with internalizing psychopathology being more common, particularly inbirth-assigned boys (Steensma et al, 2014; de Vries et al, 2016; Wallien et al, 2007;
Skagerberg & Carmichael, 2013). One hypothesis is that this problem behavior
is a result of stress due to being a minority and dysphoria toward their genderassigned at birth. These individuals are subjected to rates of peer bullying as highas 80% (Holt et al, 2016; Kaltiala-Heino et al, 2015; McGuire et al, 2010), andpoor peer relations is one of the strongest investigated predictors for behavioral
and emotional problems in gender nonconforming youth (de Vries et al, 2016). Ina study of 105 gender dysphoric Dutch adolescents whose parents completed the
Diagnostic Interview Schedule for Children, 32.4 % had one or more psychiatricdisorders, with 21% suffering from anxiety, 12.4% from mood disorders, and11.4% from disruptive disorders (de Vries, 2011).
Chart review studies of gender nonconforming youth presenting to
specialized gender identity clinics have shown similarly high or even higher rates ofpsychiatric conditions: mood (12.4-64%), anxiety (16.3%-55%), and disruptive
disorders (9-11.4%) (Holt et al, 2016; Kaltiala-Heino et al, 2015; de Vries et al,2015; Olson et al, 2015; Spack et al, 20102; Khatchadourian et al, 2014). The
range of prevalence across studies may be the result of cultural differences, varying
diagnostic criteria, and differing ages at assessment. These psychiatric conditions
appear to become more common in gender nonconforming individuals withTransgender and gender non-conforming youth		 H.315

IACAPAP Textbook of Child and Adolescent Mental Healthincreasing age. Some studies have shown that older transgender youth suffer agreater burden of co-occurring psychiatric conditions (McGuire et al, 2010),
and that gender nonconforming adults suffer a greater burden of co-occurring
psychiatric conditions compared to adolescents (de Vries et al, 2011b).
Self-harming Behavior and Suicidality
Self-harming and suicide attempts are very prevalent among gendernonconforming youth. Gender clinics report high rates of past suicide attempts
by patients presenting for care: Boston (9.3%, mean age 14.8; Spack et al, 2012),
London (10%, mean age 13.5; Holt et al, 2016), Los Angeles (30%, mean age
19.2; Olson et al, 2015). Rates of self-harm and suicidality also appear to increase
with age within this population (Aitken et al, 2016).

Click on the image to accessthe 2017 endocrine society
guidelines

Autism Spectrum Disorder
A number of studies show that autism spectrum disorder (ASD) symptoms
are over-represented among transgender individuals. The rate of ASD among
the general population is estimated at around 1% (Lai et al, 2014). Clinicallevel rates of ASD symptomatology in transgender adults have been reported in
5-20% (Jones et al, 2012; Pasterski et al, 2014; Pohl et al, 2014). It is important
to note, however, that these studies measure autism symptomatology and did notnecessarily make a diagnosis of true ASD. These scales can be elevated in non-ASD
conditions including anxiety and depression. Social deficits among transgenderyouth may be secondary to social ostracism and not due to an underlying ASD.
Two studies found increased gender variance (5.4%, 11.3%), defined by a positive
response to “wishes to be of the opposite sex” on the CBCL or YSR in referredchildren, adolescents, and adults with ASD compared to non-referred controls(Strang et al, 2014; van der Miesen et al, 2016a). However, the same was true
for an ADHD referred control group (Strang et al, 2018), raising the issue that ahigher probability of gender variance is characteristic of clinic referred samples ingeneral. It is also possible that youth with ASD may have rigid thinking that makes
them (or their parents) more likely to endorse the CBCL items of “sometimes
or often” wanting to be the opposite sex due to gender-atypical interests. This
does not necessarily suggest a core gender identity that diverges from their genderassigned at birth (Turban & van Schalkwy, 2018).
Clinically, the co-occurrence of gender dysphoria and ASD may complicate
transgender care, as diagnosing gender dysphoria can be difficult (e.g., in the context
of the rigid thinking characteristic of ASD). Additionally, language difficulties canmake expression of gender dysphoria difficult for patients with ASD. Nonetheless,a comprehensive narrative review of the literature has shown a role for transition
with pubertal blockade and cross-sex hormonal therapy in these patients following
an extended diagnostic process (van der Miesen et al, 2016b). Using a Delphi
method, a group of experts on ASD and gender dysphoria published initial clinicalguidelines for the assessment and treatment of patients with both conditions cooccuring (Strang et al, 2018). Careful diagnosis of both conditions by specificspecialists, collaboration between clinicians from both fields, and risk assessment
and safety issues are part of the suggested management protocol.

Transgender and gender non-conforming youth		 H.316

IACAPAP Textbook of Child and Adolescent Mental Health

THERAPEUTICS
Treatment of Prepubescent Children
The treatment for children with gender dysphoria has been the subject ofintense controversy recently (Drescher & Byne, 2012). As noted below, there arethree broad approaches that have been delineated in the literature:•

The oldest— characterized by Dreger (2009) as the “therapeutic model”— consists of efforts, either directly (e.g., via specific suggestions thatparents can implement in the day-to-day environment) or indirectly(e.g., via psychodynamically-informed approaches that treat the putative
underlying “causes” of the gender dysphoria) that actively attempt toreduce cross-gender identification.

•

An intermediate approach—described by some as “watchful waiting”(Drescher & Byne, 2012)—in which no direct efforts are made to“prohibit” a child’s gender-variant behavior, but that also advises parents
to keep options open about the child’s long-term gender identity and to
avoid early social transition.

•

More recently, an approach—characterized by Ehrensaft (2012) as the“affirmative model”— that considers all outcomes of gender identity tobe equally valid and desirable and allows children who express a desire
to socially transition to do so after careful counseling.

These approaches have been discussed in great detail in three reports(American Psychological Association, 2015; Adelson, 2012; Byne et al, 2012), ina special volume of the Journal of Homosexuality (Drescher & Byne, 2012), andin various other essays and case reports, the references for which can be found inthese major reviews.
For the non-specialist, there are several key issues to keep in mind whenappraising this literature:•

Some of these approaches may be influenced by particular theoreticalformulations regarding the determinants of gender dysphoria and theseformulations guide or influence recommended treatment plans.

•

There are no randomized controlled trials comparing the effects of thesetreatments with regard to both short-term and long-term outcomes.
Indeed, Byne et al (2012) noted that, by and large, “the highest level ofevidence […] can best be characterized as expert opinion.”•With some rare exceptions (Meyer-Bahlburg, 2002), there are no
manualized or even semi-manualized treatments that a clinician canfollow in developing a therapeutic plan.

Thus, clinicians need to educate themselves by reading about the therapeuticmodel that they intend to follow and tailor it on a case-by-case basis. Below, we
provide brief summaries of these three treatment approaches.
Promoting Identification with the Gender Assigned at BirthThis approach aims to reduce through psychosocial interventions thechild’s cross-gender identification and gender dysphoria. These treatments

Transgender and gender non-conforming youth		 H.317

IACAPAP Textbook of Child and Adolescent Mental Health(described in the literature since the 1960s) have been quite varied. They include
classical behavior therapy, psychodynamic therapy (including psychoanalysis anddynamically-informed play psychotherapy), parental counseling, and parentguided interventions in the naturalistic environment (e.g., encouragement of peer
relations of the same natal sex) (Meyer-Bahlburg, 2002). None of these treatments
have been found to be effective and are not recommended.
The underlying assumption of all these approaches rests on the view thatgender identity is not yet fixed in childhood and may be malleable throughpsychosocial treatment. There is also an implicit assumption or value judgmentthat might be inferred from this approach, namely, that all things considered, achild’s long-term adaptation might be easier if he or she could come to feel content
with a gender identity that matches their natal sex.

Click on the image to viewa clip about the treatment
issues facing transgenderadolescents in Australia.

Critics of this approach have argued that there is nothing inherently “wrong”
with a cross-gender identity and have challenged the view that trying to changesuch an identity is warranted. Indeed, there are now several US states and one
province in Canada that have legislated that it is inappropriate to try and change
a minor’s gender identity when the minor is unable to consent to the treatment.
Exempt from this directive is “identity exploration,” which is different in that it
does not consider cis-gender identification to be a preferable outcome (Green,2017). Critics have also noted that some of the earliest proponents of this treatment
held the belief that it might reduce the odds of the child later development a samesex sexual orientation (Pleak, 1999), although others rejected this as unethical(Zucker, 1990). Another concern has been that these treatments might cause achild to feel shame or other negative and maladaptive feelings (Adelson, 2012).
Watchful Waiting
The second approach takes an intermediate therapeutic position. On the
one hand, it does not recommend an early gender social transition on the grounds
that the extant follow-up studies have suggested that the majority of children withgender dysphoria may desist for one reason or another (see above for the limitations
on these studies). On the other hand, it does not explicitly recommend any typeof limit-setting on the child’s gender variant behavior, with the exception thatin certain environments it might be risky or dangerous to display such behavior,
which Hill and Menvielle (2009) described as the “only at home” rule.
This approach also does not favor one type of long-term outcome overanother, noting that it is difficult to predict outcome for an individual child and thatthe more important focus should be on the child’s general psychosocial adjustment
and wellbeing. This approach does, however, include recommendations to parents
to encourage in their child a variety of gender-related interests and social affiliation
with children of both genders. In some respects, the “watchful waiting” label
is a bit of a misnomer because clinical protocols appear to include information
provided to the parents that is more than “wait-and-see.” As noted by de Vries andCohen-Kettenis (2012), appropriate limit-setting with good explanation of why
the limits are set may be helpful, so that the child will learn “that not all desires
will be met,” which is important because “someone’s deepest desire or fantasy tohave been born in the body of the other gender will never be completely fulfilled.”
Although social transition according to this approach is not recommended at avery young age, an increasing number of children have already socially transitioned

Transgender and gender non-conforming youth		 H.318

IACAPAP Textbook of Child and Adolescent Mental Healthwhen they come to gender identity clinics (Steensma & Cohen-Kettenis, 2011).
Some of these children may have no clear memories of a time when they weresocially living in the birth assigned gender and have stopped talking about beingborn different from their experienced gender. In these cases, it is encouraged thatparents create an open situation where the child has the possibility of returning to
the birth assigned gender. It is discussed with the child that, when gender identity
feelings change, it is nothing to be ashamed of, that nobody will be angry, that thechild may speak out, and that it is good to have tried. A form of psychotherapy
that helps the child to verbalize his or her feelings may be advised so that, by thetime the child may come back for the administration of gonadotropin releasing
hormone analogs, the child is able to talk about his or her feelings and can giveinformed consent.
Affirmative Approach
The affirmative approach theorizes that clinician and parental attempts topush children with gender incongruence to conform with their gender assigned atbirth might produce shame and stigma that can ultimately lead to psychopathology(Ehrensaft, 2012). It considers all outcomes of gender identity to be equallydesirable and affirms any gender identity the child expresses.
Though similar to the watchful waiting model, an important difference is in
its attitude regarding early social transition. In the affirmative model, prepubertal
children who express a desire to socially transition and live full time in theirexperienced gender (i.e., using cross-gender pronouns, a cross-gender name, crossgender clothing, etc.) are allowed to do so. The approach to social transition must
be carefully individualized with a nuanced understanding of the child’s gender
identification and the level of support within the child’s community; there mustalso be an open discussion with the child highlighting that, despite the socialtransition, the patient is free to transition back at any time (Edwards-Leeper et al,2016).
This transition back to living as one’s birth gender can be difficult (Steensma& Cohen-Kettenis, 2011), though this must be weighed against the potential
negative consequences of refusing to affirm a child’s identity and desire to transitionsocially. The affirmative model hypothesizes that lack of affirmation might leadto shame and consequent psychopathology. The therapeutic relationship in thesecases could also be negatively affected if the clinician strongly discourages an earlytransition for a patient who persists in cross-gender identification.
Critics of social transition in prepubertal children have questioned whether
early social transition increases the rate of persistence of gender incongruence fromchildhood into adolescence. Indeed, a multivariate regression analysis revealed thatearly social transition was associated with persistence (Steensma et al, 2013b).
However, the direction of this association cannot be determined in this study.
While some believe that prepubertal social transition makes children more
likely to persist, the alternative interpretation is that those likely to persist arealso more likely to undergo early social transition, due to currently unidentified
factors. Additionally, this raises the ethical question of whether persistence should
be considered an undesirable outcome. The affirmative model suggests that all
outcomes of gender identity are equally desirable.

Transgender and gender non-conforming youth		 H.319

IACAPAP Textbook of Child and Adolescent Mental HealthSome people call it “transgender regret.” When you change from one gender to anotherand then feel, somehow, you’ve made a mistake. Others call it “detransitioning” or a “reversal”.
Zahra Cooper calls it, simply “going back”, as she told the New Zealand Herald. […] For four
years, she struggled between the genders, being bullied at school and online for being “weird”.
At 18, she asked her family to start calling her “Zane” and using male pronouns. She began
to think about formally transitioning — taking hormones to become more masculine. […] In
December 2015, Zahra began taking testosterone, at first swallowing pills three times a day,and then via injection. After what seemed such a long wait for treatment, she expected tofeel elated. But the euphoria many trans people describe at that point never really set in. “I
started getting really angry from the testosterone, which is a side effect,” she says. “But then I
started getting depressed. I was like, why am I depressed? I should be happy.” As the physicalchanges began, Zahra grew more and more anxious. She fought with family, often stormingout of the house. “I was getting a deeper voice, facial hair and many other changes but I justwasn’t happy with them,” she says. “I didn’t feel like myself.” Then eight months in, things hit
crisis point. Zahra tried to kill herself. Twice. […]Zahra had begun dating a transgender boy called Tyson Kay. Tyson is 17. He too was
assigned female at birth, and at the time of Zahra’s breakdown was in the middle of his own
transition to male. “I didn’t know how he would feel,” she says. Going off testosterone meant
more mood swings, and an unpredictable end result. She didn’t know whether he would wantto hang around, and worried over how to break the news. In the end, Zahra texted him saying:“I’m going to transition back”.

Separate from the question of persistence is the question of mental healthoutcome following social transition. There is a paucity of literature studying
the effect of prepubertal social transition. One study examined 73 American
prepubertal children who were transgender in a binary fashion and allowed totransition socially. Parents of these children completed short rating scales foranxiety and depression at an unspecified time following the transition (Olson,
2016a). Data from these scales revealed that these children had notably lower
rates of internalizing psychopathology than previously reported for children
who did not transition. Furthermore, socially transitioned children in this study
showed developmentally normal levels of depression and only minimally elevated(subclinical) levels of anxiety. It is important to note that families in this study had arelatively high income, raising the question of whether this cohort is representativeof a broader socio-demographic population (Olson, 2016a). Though this early
work suggests that socially transitioned children have better mental health metrics
than children who did not socially transition, future research is needed to fully
understand the dynamic and long-term effects of social transition in a broader
population (de Vries et al, 2014).
Treatment of Adolescents
Once children reach puberty, transgender identity persists in the majorityof cases and medical intervention is often considered. At present, the effectivenessof an approach that includes puberty suppression followed by hormone
administration and surgery has been evaluated in two studies in the same cohort ofDutch adolescents. The first study evaluated gender dysphoria and psychological
functioning at two times, first, when the 70 adolescents entered the clinic (meanage, 13.65 years) and, second, just before they started hormone treatment(mean age, 16.64 years). Of interest, while adolescents improved with regard to
psychological functioning on several domains, gender dysphoria did not improveand all adolescents went on with the next step of gender affirming hormones (deTransgender and gender non-conforming youth		 H.320

IACAPAP Textbook of Child and Adolescent Mental Health

Table H.3.3. Summary of Treatment for Transgender Youth
TIMING

INTERVENTION

Pre-pubertal

No endocrine intervention recommended. Patient should have regular psychotherapy
to discuss gender identity and assess possible future need for hormonal intervention

Early signs of puberty

Pubertal blockade with gonadotropin-releasing hormone analogs to prevent thedevelopment of secondary sex characteristics and provide additional time forpsychotherapy and consideration regarding partially reversible interventions

Age 14+ or 16+ (dependingon the center and patient)

Cross-sex hormonal therapy with estrogen or testosterone. Less frequently, with otherendocrine-acting medications that have less favorable side effect profiles.

Age 18 (for most centers)

Gender affirming surgeries may be considered. Note that some surgeries may be
performed earlier for select patients.

Vries et al, 2011a). The second study added a third assessment, around one year
after gender affirmative surgery, when the first 55 adolescents who had been inthis treatment protocol had reached young adulthood (mean age, 20.70 years).
This time, gender dysphoria had resolved and psychological functioning measures
had improved further, with scores comparable to normative samples. The sameaccounted for quality of life, subjective happiness, and satisfaction with life (deVries et al, 2014). These results are promising and suggest that starting treatment
at a relatively young age is possible. However, the results come from only one clinicand concern a highly selected cohort that received support from their parents—and often from their school and social environment—that started treatment only
after extensive assessment, and that had mental health counselling during the yearsof treatment. Whether the same positive results can be expected for the larger
number of adolescents who are currently being treated in clinics and who varyconsiderably in their quality of care and approach has yet to be determined.
Assessing Eligibility
According to Endocrine Society Guidelines, hormonally-based medical
intervention may be initiated at the earliest signs of puberty (i.e., Tanner 2 or 3)
with pubertal blockade (Hembree et al, 2017). Other conditions for eligibility
include meeting criteria for gender dysphoria, experiencing dysphoria toward early
pubertal changes, having adequate psychological and social support for treatment,
understanding the risks and benefits of treatment, and not suffering from a
psychiatric comorbidity that would interfere with treatment (Wylie et al, 2009).
To assess eligibility, most clinics offer assessment by a mental health professionalthat sees the adolescent and his or her family over a longer period of time before
decisions regarding medical interventions are made. This time is used to prepare
the adolescent for the long period of medical treatment and weigh the pros andcons of treatment so that an informed decision can be made. Although many

Transgender and gender non-conforming youth		 H.321

IACAPAP Textbook of Child and Adolescent Mental Healthadolescents come with a clear wish for medical treatment, some are not sure yet
and want to explore their gender dysphoric feelings more broadly. Sometimes cooccurring psychiatric difficulties like ASD with rigid thinking, severe depression
with acute suicidality, or anxiety with worrisome avoidance and school refusal,
complicate the diagnostic work and make attending regular check-ups and taking
medication impossible. Treatment of these psychiatric disorders may then benecessary before endocrine intervention. The importance of parental support forthe psychological well-being of these adolescents is widely acknowledged (Simons
et al, 2013). The time used for assessment may also be helpful to address parents’concerns and improve adolescent-parent relationship. The time needed before
medical intervention is provided will vary for each individual, but tends to belonger when other psychosocial conditions are present (Costa et al, 2015; de Vries
et al, 2011b).
Reversible Interventions (Pubertal Blockade)The first intervention (implemented at Tanner stages 2 or 3) is pubertal
blockade with gonadotropin-releasing hormone analogs.
Partially-Reversible Interventions (Cross-Sex Hormonal Therapy)
According to Endocrine Society guidelines, around the age of 16, patients
may choose to move onto the next intervention: cross-sex hormonal therapy withestrogen or testosterone. Some researchers have noted that cross-sex hormones canbe instituted earlier, as delaying puberty outside the developmentally appropriate
age may cause social problems for these youth (Rosenthal, 2014). The newly-

Gonadotropin Releasing Hormone Analogs (Puberty Blockers)
Gonadotropin-releasing hormone is produced by neurons in the hypothalamus. Thishormone is secreted at very low levels in prepubertal children. At the initiation of puberty,
release of gonadotropin-releasing hormone becomes cyclical. This cyclical release results
in production of follicle stimulating hormone (FSH) and luteinizing hormone (LH) by theanterior pituitary. These hormones then enter the peripheral circulation where they trigger the
production of sex hormones (estrogen in natal women and testosterone in natal men). These
hormones then initiate the irreversible development of secondary sex characteristics.
Gonadotropin-releasing hormone analogs (either as implants, depot injections, or
regular injections) maintain high levels of gonadotropin-releasing hormone in circulation.
Without physiological cyclical fluctuations in gonadotropin-releasing hormone analogs, FSH
and LH are not released and all downstream signaling is prevented. This allows the patient toremain in an early pubertal state.
Pubertal blockade prevents the development of irreversible secondary sex
characteristics (voice deepening, breast development, etc.) and provides additional time
for gender dysphoric children to decide if they wish to fully transition physically into thebody of the opposite sex. Therefore, it does not need to be considered actual genderaffirmative medical treatment, but rather may function as an extended diagnostic phase. If
the gonadotropin-releasing hormone analogs are discontinued, their effects are reversible.
The patient undergoes natal puberty if the gonadotropin-releasing hormone analogs
are discontinued. Follow-up studies into young adulthood on the first cohort of pubertysuppressed adolescents are reassuring in regard to side effects. Although there wassome decrease in bone density, there were no further concerns regarding liver and kidney
functioning and lipid profile (Klink et al, 2015; Schagen et al, 2016). Some clinicians advise toevaluate bone age every three months and regular blood monitoring to ensure that puberty is
sufficiently suppressed (Wylie et al, 2009).

Transgender and gender non-conforming youth		 H.322

IACAPAP Textbook of Child and Adolescent Mental Healthreleased 2017 Endocrine Society Guidelines agree with this approach. Additional
criteria for cross-sex hormonal therapy are identical to those for gonadotropinreleasing hormone analogs in the Endocrine Society Guidelines.
Cross-sex hormones will initiate the development of secondary sex
characteristics of the desired puberty. These interventions are mostly irreversible
and carry a more significant side effect profile. The most prominent side effectof estrogen therapy is hypercoagulability, though clinicians prescribing these
medications should be aware of the full spectrum of side effects. Of note,
hypercoagulability can be particularly problematic for patients undergoing highrisk surgery such as vaginoplasty. Patients on these medications should be regularly
monitored for serum hormone concentrations as well and maintained within
normal testosterone and estrogen serum concentrations for their desired gender.
Spironolactone has been used for its anti-androgenic properties in select cases but
is generally not considered a first line treatment given its unfavorable side-effectprofile as a diuretic (Wylie et al, 2009).
Irreversible Interventions (Gender Affirming Surgeries)
At the legal age of adulthood, patients may choose to undergo a variety
of surgical interventions, including vaginoplasty, phalloplasty, scrotoplasty,
breast augmentation, facial reconstruction, hysterectomy, and reduction thyroid
chondroplasty, among others. Patients should be carefully counseled on the risks
and benefits of surgery. Specific surgical interventions are many and are out of thescope of this chapter. Of note, some surgical interventions may be considered earlier
in the course of treatment. In the World Professional Association for Transgender
Health (WPATH) Standards of Care, mastectomies are being considered earlier
than age 18 (Coleman et al, 2011).
Fertility Considerations
There is a paucity of research on the effects of pubertal blockade and crosssex hormonal therapy on future fertility. Interested patients should be counseledon fertility preservation options early in treatment and before starting hormonal
treatment.

CULTURAL ASPECTS
In providing care for transgender and gender nonconforming people, one willneed to consider the local legal situation, family dynamics, and patients’ and theirfamilies’ attitudes, and adjust the services accordingly. When treating immigrantfamilies and ethnic minorities in Western countries, it is important to understandthe family’s culture and how they have been influenced by the host culture in
regards to sexuality and gender. One may not assume that immigration necessarily
altered background cultural concepts about sexuality and gender including stigma— in many cases they become more rigid. Legal issues remain very important inproviding care as, even in the United States, there have been several recent setbacks
in the legal protection of transgender and gender nonconforming individuals.

SUMMARY
Gender nonconforming and gender dysphoric youth represent a vulnerable
demographic with high rates of co-occurring psychiatric conditions and suicidal
behavior, likely secondary to minority stress and dysphoria related to living in a

Transgender and gender non-conforming youth		 H.323

IACAPAP Textbook of Child and Adolescent Mental Healthbody that does not match one’s experienced gender. Prepubescent children withgender variant behavior or identification are best supported with psychotherapy
and socio-familial interventions. For those children who continue to have strong
cross-sex identification in adolescence, pubertal blockade and cross-sex hormone
therapy to align patients’ bodies with their experienced identities have been shown
to improve mental health outcomes.

REFERENCES
Achenbach TM, Rescorla LA. Manual for the ASEBA SchoolAge Forms & Profiles: An Integrated System of MultiInformant Assesment. Burlington, VT, University ofVermont, Research Center for Children, Youth, &Families, 2001.
Adelson SL. Practice parameter on gay, lesbian, or bisexualsexual orientation, gender nonconformity, and genderdiscordance in children and adolescents. Journal of theAmerican Academy of Child and Adolescent Psychiatry
51:957-974, 2012.
Aitken M, Steensma TD, Blanchard R et al. Evidence for analtered sex ratio in clinic-referred adolescents withgender dysphoria. Journal of Sexual Medicine 12:756763, 2015.
Aitken M, VanderLaan DP, Wasserman L et al. Self-harm andsuicidality in children referred for gender dysphoria.
Journal of the American Academy of Child andAdolescent Psychiatry 55:513-520, 2016.
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Third ed. Washington,
DC, Author, 1980.
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Third ed., rev.
Washington, DC, Author, 1987.
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, 4th ed. Washington, DC,
Author, 1994.
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fifth ed. Arlington, VA,
American Psychiatric Press, 2013.
American Psychological Association. Guidelines for psychologicalpractice with transgender and gender nonconforming
people. American Psychologist 70:832-864, 2015.
Andres R, Flores JLH, Gates GJ et al. How Many Adults Identify
as Transgender in the United States? Los Angeles, The
Wiliams Institute, 2016.

Byne W, Bradley SJ, Coleman E et al. Report of the American
Psychiatric Association Task Force on Treatment ofGender Identity Disorder. Archives of Sexual Behavior
41:759-796, 2012.
Chayet S. Moi, Nikki, 13 ans, née Niko. Le Monde,
2014(December 10). Retrieved from http://www.
lemonde.fr/m-actu/article/2014/12/10/moi-nikki-13ans-nee-niko_4534297_4497186.html
Chen M, Fuqua J, Eugster EA. Characteristics of referrals forgender dysphoria over a 13-year period. Journal of
Adolescent Health 58:369-371, 2016.
Clark TC, Lucassen MFG, Bullen P et al. The health and wellbeing of transgender high school students: results fromthe New Zealand adolescent health survey (Youth’12).
Journal of Adolescent Health 55:93–99, 2014.
Cohen-Kettenis PT, Pfäfflin F. Transgenderism and Intersexuality
in Childhood and Adolescence: Making Choices.
London, Sage, 2003.
Cohen-Kettenis PT, van Goozen SH. Pubertal delay as an aid in
diagnosis and treatment of a transsexual adolescent.
European Child & Adolescent Psychiatry 7:246-248,
1998.
Colapinto J. As Nature Made Him: The Boy Who Was Raised as aGirl. New York, Harper Collins Publishers, 2000.
Coleman E, Bockting W, Botzer M et al. Standards of care forthe health of transsexual, transgender and gender nonconforming people, version 7. International Journal ofTransgenderism 13:165-232, 2011.
Conron KJ, Scott G, Stowell GS et al. Transgender health in
Massachusetts: Results from a household probability
sample of adults. American Journal of Public Health
102:118-122, 2012.
Coolidge FL, Thede LL, Young SE. The heritability of gender
identity disorder in a child and adolescent twinsample. Behavior Genetics 32:251-257, 2002.

Arcelus J, Bouman WP, Van Den Noortgate W et al. Systematic
review and meta-analysis of prevalence studies intranssexualism. European Psychiatry 30:807-815, 2015.

Costa R, Dunsford M, Skagerberg E et al. Psychological support,
puberty suppression, and psychosocial functioning inadolescents with gender dysphoria. Journal of Sexual
Medicine 12:2206-2214, 2015.

Berglund H, Lindstrom P, Dhejne-Helmy C et al. Male-tofemale transsexuals show sex-atypical hypothalamus
activation when smelling odorous steroids. Cerebral
Cortex 18:1900-1908, 2008

Dessens AB, Slijper FM, Drop SL. Gender dysphoria and genderchange in chromosomal females with congenital
adrenal hyperplasia. Archives of Sexual Behavior
34:389-397, 2005.

Transgender and gender non-conforming youth		 H.324

IACAPAP Textbook of Child and Adolescent Mental Healthde Vries ALC, Cohen-Kettenis PT. Clinical management ofgender dysphoria in children and adolescents: The
Dutch approach. Journal of Homosexuality 59:301320, 2012.
de Vries ALC, Doreleijers TA, Steensma TD et al. Psychiatriccomorbidity in gender dysphoric adolescents. Journalof Child Psychology and Psychiatry 52:1195-1202,
2011a.
de Vries ALC, Kreukels BPC, Steensma TD et al. Comparing
adult and adolescent transsexuals: An MMPI-2 and
MMPI-A study. Psychiatry Research 186:414-418,
2011b.
de Vries ALC, McGuire JK, Steensma TD, et al. Young adultpsychological outcome after puberty suppression andgender reassignment. Pediatrics 134:696-704, 2014.
de Vries ALC, Steensma TD, Cohen-Kettenis PT et al. Poor peer
relations predict parent- and self-reported behavioral
and emotional problems of adolescents with gender
dysphoria: A cross-national, cross-clinic comparative
analysis. European Child & Adolescent Psychiatry
25:579-588, 2016.
Diamond M, Sigmundson HK. Sex reassignment at birth:Long-term review and clinical implications. Archives ofPediatrics & Adolescent Medicine 151:298-304, 1997.
Dreger A. Gender identity disorder in childhood: Inconclusive
advice to parents. Hastings Center Report 39:26-29,
2009.
Drescher J, Byne W. Introduction to the special issue on “TheTreatment of Gender Dysphoric/Gender VariantChildren and Adolescents.” Journal of Homosexuality
59:295-300, 2012
Drescher J, Cohen-Kettenis PT, Reed GM. Gender incongruenceof childhood in the ICD-11: Controversies, proposal,
and rationale. Lancet Psychiatry 3:297-304, 2016.
Drummond KD, Bradley SJ, Peterson-Badali M et al. A followup study of girls with gender identity disorder.
Developmental Psychology 44:34-45, 2008

Green R. Banning therapy to change sexual orientation or gender
identity in patients under 18. Journal of the American
Academy of Psychiatry and the Law 45:7-11, 2017.
Guillamon A, Junque C, Gomez-Gil E. A review of the statusof brain structure research in transsexualism. Archives
of Sexual Behavior 2016, doi:10.1007/s10508-0160768-5.
Hembree WC, Cohen-Kettenis PT, Gooren L et al. Endocrine
treatment of gender-dysphoric/gender-incongruent
persons: an Endocrine Society clinical practiceguideline. The Journal of Clinical Endocrinology &Metabolism, 102(11):3869-3903, 2017.
Hill DB, Menvielle E. “You have to give them a place where
they feel protected and safe and loved”: The viewsof parents who have gender-variant children andadolescents. Journal of LGBT Youth 6:243-271, 2009.
Hines M. Gonadal hormones and sexual differentiation ofhuman brain and behavior. In: Pfaff DW, Arnold AP,
Etgen AM et al (eds) Hormones, Brain and Behavior,
2nd ed. San Diego, Academic Press, 2009, pp. 18691910.
Hines M. Gender development and the human brain. Annual
Review of Neuroscience 34:69-88, 2011.
Holt V, Skagerberg E, Dunsford M. Young people with featuresof gender dysphoria: Demographics and associateddifficulties. Clinical Child Psychology and Psychiatry
21:108-118, 2016.
Hsieh S, Leininger J. Resource list: Clinical care programs forgender-nonconforming children and adolescents.
Pediatric Annals 43:238-244, 2014.
Hughes IA, Houk C, Ahmed SF et al. Consensus statement on
management of intersex disorders. Archives of Disease
in Childhood 91:554-563, 2006.
Jones RM, Wheelwright S, Farrell K et al. Female-to-maletranssexual people and autistic traits. Journal of Autism
and Developmental Disorders 42:301-306, 2012.

Edwards-Leeper L, Leibowitz S, Sangganjanavanich VF.
Affirmative practice with transgender and gendernonconforming youth: Expanding the model.
Psychology of Sexual Orientation and Gender Diversity
3:165-172, 2016.

Kaltiala-Heino R, Sumia M, Tyolajarvi M et al. Two years ofgender identity service for minors: Overrepresentationof natal girls with severe problems in adolescentdevelopment. Child and Adolescent Psychiatry and
Mental Health 9:9, 2015, doi:10.1186/s13034-0150042-y.

Ehrensaft D. From gender identity disorder to gender identity
creativity: True gender self child therapy. Journal of
Homosexuality 59:337-356, 2012.

Khatchadourian K, Amed S, Metzger DL. Clinical managementof youth with gender dysphoria in Vancouver. Journalof Pediatrics 164:906-911, 2014.

Fridell SR, Zucker KJ, Bradley SJ et al. Physical attractiveness ofgirls with gender identity disorder. Archives of Sexual
Behavior 25:17-31, 1996.

Klink D, Caris M, Heijboer A et al. Bone mass in young
adulthood following gonadotropin-releasing hormone
analog treatment and cross-sex hormone treatment inadolescents with gender dysphoria. Journal of Clinical
Endocrinology & Metabolism 100:E270-E275, 2015,
doi: 10.1210/jc.2014-2439.

Giedd JN, Raznahan A, Mills KL, et al. Magnetic resonanceimaging of male/female differences in humanadolescent brain anatomy. Biology of Sex Differences3(1):19, 2012, doi: 10.1186/2042-6410-3-19.
Green R. Sexual Identity Conflict in Children and Adults. New
York, Basic Books, 1974.
Green R. The “Sissy Boy Syndrome” and the Development of
Homosexuality. New Haven, CT, Yale University Press,
1987.

Kreukels BPC, Guillamon A. Neuroimaging studies in people
with gender incongruence. International Review of
Psychiatry 28:120-128, 2016.
Kruijver FP, Zhou JN, Pool CW et al. Male-to-femaletranssexuals have female neuron numbers in a
limbic nucleus. Journal of Clinical Endocrinology &Metabolism 85:2034-2041, 2000.

Transgender and gender non-conforming youth		 H.325

IACAPAP Textbook of Child and Adolescent Mental Health

Kuyper L, Wijsen C. Gender identities and gender dysphoria in
the Netherlands. Archives of Sexual Behavior 43:377385, 2014.
Lai MC, Lombardo MV, Baron-Cohen S. Autism. Lancet
383:896-910, 2014.
Lawrence AA. Sexual orientation versus age of onset as bases
for typologies (subtypes) for gender identity disorderin adolescents and adults. Archives of Sexual Behavior
39:514-545, 2010.
Marantz S, Coates S. Mothers of boys with gender identity
disorder:A comparison of matched controls. Journalof the American Academy of Child and Adolescent
Psychiatry 30:310-315, 1991.
Mazur T. Gender dysphoria and gender change in androgen
insensitivity or micropenis. Archives of Sexual Behavior
34:411-421, 2005.
McDermid SA, Zucker KJ, Bradley SJ et al. Effects of physicalappearance on masculine trait ratings of boys andgirls with gender identity disorder. Archives of Sexual
Behavior 27:253-267, 1998.
McGuire JK, Anderson CR, Toomey RB et al. School climate fortransgender youth: A mixed method investigation of
student experiences and school responses. Journal ofYouth and Adolescence 39:1175-1188, 2010.
Merke DP, Bornstein SR. Congenital adrenal hyperplasia. Lancet
365:2125-2136, 2005.
Meyer-Bahlburg HFL. Gender identity disorder in young boys:
A parent-and peer-based treatment protocol. ClinicalChild Psychology and Psychiatry 7:360-376, 2002.

Olson KR, Durwood L, DeMeules M et al. Author response
to McKean, Vande Voort, and Croarkin (2016).
Pediatrics 138(1): doi:10.1542/peds.2016-1203B,
2016b.
Padawer R. Boygirl. The New York Times Magazine pp. 18-23,
36, 46, 2012 (August 12).
Pasterski V, Gilligan L, Curtis R. Traits of autism spectrum
disorders in adults with gender dysphoria. Archives of
Sexual Behavior 43:387-393, 2014.
Pasterski V, Zucker KJ, Hindmarsh PC et al. Increased crossgender identification independent of gender role
behavior in girls with congenital adrenal hyperplasia:
Results from a standardized assessment of 4- to
11-year-old children. Archives of Sexual Behavior
44:1363-1375, 2015.
Pleak R. Ethical issues in diagnosing and treating genderdysphoric children and adolescents. In: Rottnek
M (ed). Sissies & Tomboys: Gender Nonconformity& Homosexual Childhood. New York, New York
University Press, 1999, pp. 44-51.
Pohl A, Cassidy S, Auyeung B, et al. Uncovering steroidopathy
in women with autism: A latent class analysis.
Molecular Autism 5:27, 2014.
Reardon S. Largest ever study of transgender teenagers set to kickoff. Nature 531:560, 2016.
Richter-Appelt H, Discher C, Gedrose B. Gender identity andrecalled gender related childhood play-behaviour inadult individuals with different forms of intersexuality.
Anthropologischer Anzeiger 63:241-256, 2005.

Meyer-Bahlburg HFL. Gender identity outcome in female-raised
46, XY persons with penile agenesis, cloacal exstrophyof the bladder, or penile ablation. Archives of Sexual
Behavior 34: 423-438, 2005.

Rider GN, McMorris BJ, Gower AL et al. Health and careutilization of transgender and gender nonconforming
youth: a population-based study. Pediatrics, 2018p.e20171683.

Meyer-Bahlburg HFL, Baratz Dalke K, Berenbaum SA et al.
Gender assignment, reassignment and outcome indisorders of sex development: Update of the 2005
consensus conference. Hormone Research in Paediatrics
85:112-118, 2016.

Ristori J, Steensma TD. Gender dysphoria in childhood.
International Review of Psychiatry 28:13-20, 2016.
Rosenthal SM. Approach to the patient: Transgender youth:
Endocrine considerations. Journal of Clinical
Endocrinology & Metabolism 99:4379-4389, 2014.

Money J, Hampson JG, Hampson JL. Imprinting and theestablishment of gender role. Archives of Neurology andPsychiatry 77:333-336, 1957.

Rosin H. A boy’s life. The Atlantic 302(4):56-59, 62, 64, 6668, 70-71, 2008.

Morrison EG. Transgender as ingroup or outgroup? Lesbian,gay, and bisexual viewers respond to a transgendercharacter in daytime television. Journal of
Homosexuality 57:650-665, 2010.

Olson KR. Prepubescent transgender children:
What we do and do not know. Journalof the American Academy of Child andAdolescent Psychiatry 55:155-156, 2016.
Olson J, Schrager SM, Belzer M et al. Baseline physiologic andpsychosocial characteristics of transgender youth
seeking care for gender dysphoria. Journal of Adolescent
Health 57:374-380, 2015.
Olson KR, Durwood L, DeMeules M et al. Mental health oftransgender children who are supported in theiridentities. Pediatrics 137(3): doi:10.1542/peds.20153223, 2016a.

Ruigrok AN, Salimi-Khorshidi G, Lai MC, et al. A metaanalysis of sex differences in human brain structure.
Neuroscience & Biobehavioral Reviews 39:34-50,
2014.
Schagen SE, Cohen-Kettenis PT, Delemarre-van de Waal HA
et al. Efficacy and safety of gonadotropin-releasing
hormone agonist treatment to suppress puberty ingender dysphoric adolescents. Journal of Sexual
Medicine 13:1125-1132, 2016.
Schoning S, Engelien A, Bauer C et al. Neuroimaging
differences in spatial cognition between men andmale-to-female transsexuals before and duringhormone therapy. Journal of Sexual Medicine
7:1858-1867, 2010.
Schuster MA, Reisner SL, Onorato SE. Beyond bathrooms—
meeting the health needs of transgender people. New
England Journal of Medicine 375:101-103, 2016.

Transgender and gender non-conforming youth		 H.326

IACAPAP Textbook of Child and Adolescent Mental Health

Shields JP, Cohen R, Glassman JR et al. Estimating population
size and demographic characteristics of lesbian, gay,bisexual, and transgender youth in middle school.
Journal of Adolescent Health 52:248–250, 2013.

T’Sjoen G, De Cuypere G, Monstrey S et al. Male gender
identity in complete androgen insensitivity
syndrome. Archives of Sexual Behavior 40:635-638,
2011.

Simons L, Schrager SM, Clark LF et al. Parental supportand mental health among transgender adolescents.
Journal of Adolescent Health 53:791-793, 2013.

Turban JL, van Schalkwyk GI, 2018. “Gender dysphoria” andautism spectrum disorder: is the link real? Journalof the American Academy of Child & Adolescent
Psychiatry 57(1); 8-9, 2018.

Singh D. A Follow-up Study of Boys with Gender Identity
Disorder. Unpublished doctoral dissertation,
University of Toronto, 2012.
Skagerberg E, Carmichael P. Internalizing and externalizing
behaviors in a group of young people with gender
dysphoria. International Journal of Transgenderism
14:105-112, 2013.
Soleman RS, Schagen SE, Veltman DJ et al. Sex differencesin verbal fluency during adolescence: A functional
magnetic resonance imaging study in gender
dysphoric and control boys and girls. Journal of
Sexual Medicine 10:1969-1977, 2013.
Spack NP, Edwards-Leeper L, Feldman HA et al. Children andadolescents with gender identity disorder referred toa pediatric medical center. Pediatrics 129:418-425,
2012.
Steensma TD, Cohen-Kettenis PT. Gender transitioning before
puberty? [Letter to the Editor]. Archives of Sexual
Behavior 40:649-650, 2011.
Steensma TD, Kreukels BPC, de Vries ALC et al. Gender
identity development in adolescence. Hormones andBehavior 64:288-297, 2013a.
Steensma TD, McGuire JK, Kreukels BPC et al. Factors
associated with desistence and persistence ofchildhood gender dysphoria: A quantitative followup study. Journal of the American Academy of Childand Adolescent Psychiatry 52:582-590, 2013b.
Steensma TD, van der Ende J, Verhulst FC et al. Gendervariance in childhood and sexual orientation in
adulthood: A prospective study. Journal of Sexual
Medicine 10:2723-2733, 2013c.
Steensma TD, Zucker KJ, Kreukels BPC et al. Behavioral andemotional problems on the Teacher’s Report Form:
A cross-national, cross-clinic comparative analysis
of gender dysphoric children and adolescents.
Journal of Abnormal Child Psychology 42:635-647,
2014.

van Caenegem E, Wierckx K, Elaut E et al. Prevalenceof gender nonconformity in Flanders, Belgium.
Archives of Sexual Behavior 44:1281-1287, 2015.
van der Miesen AI, Hurley H, Bal A et al. Gender variance andautism spectrum disorder. Manuscript submitted for
publication, 2016a.
van der Miesen AI, Hurley H, de Vries ALC. Gender
dysphoria and autism spectrum disorder: A narrative
review. International Review of Psychiatry 28:7080, 2016b.
Vance SR, Cohen-Kettenis PT, Drescher J et al. Opinions
about the DSM gender identity disorder diagnosis:
Results from an international survey administered
to organizations concerned with the welfare oftransgender people. International Journal ofTransgenderism 12:1-14, 2010.
Wallien MS, Cohen-Kettenis PT. Psychosexual outcome ofgender-dysphoric children. Journal of the American
Academy of Child and Adolescent Psychiatry
47:1413-1423, 2008.
Wallien MS, Swaab H, Cohen-Kettenis PT. Psychiatriccomorbidity among children with gender identity
disorder. Journal of the American Academy of Childand Adolescent Psychiatry 46:1307-1314, 2007.
Wood H, Sasaki S, Bradley SJ et al. Patterns of referral to agender identity service for children and adolescents(1976-2011): Age, sex ratio, and sexual orientation.
Journal of Sex & Marital Therapy 39:1-6, 2013.
Wylie CH, Cohen-Kettenis PT, Delemarre-van de Waal H
et al. Endocrine treatment of transsexual persons:
An Endocrine Society Clinical Practice Guideline.
Journal of Clinical Endocrinology & Metabolism
94:3132-3154, 2009.
Zhou JN, Hofman MA, Gooren LJ et al. A sex difference inthe human brain and its relation to transsexuality.
Nature 378:68-70, 1995.

Strang JF, Kenworthy L, Dominska A et al. Increased gendervariance in autism spectrum disorders and attention
deficit hyperactivity disorder. Archives of Sexual
Behavior 43:1525-1533, 2014

Zucker KJ. Gender identity disorder. In: Martin A, Volkmar
FR (eds). Lewis’s Child and Adolescent Psychiatry: A
Comprehensive Textbook, 4th ed. Baltimore, MD,
Lippincott Williams & Wilkins, 2007, pp. 669-680.

Strang, JF, Meagher H, Kenworthy L et al. Initial clinicalguidelines for co-occurring autism spectrum
disorder and gender dysphoria in adolescents.
Journal of Clinical Child & Adolescent Psychology
47:105-115, 2018.

Zucker KJ. Treatment of gender identity disorders in children.
In: Blanchard R, Steiner BW (eds). ClinicalManagement of Gender Identity Disorders in Children
and Adults. Washington, DC, American PsychiatricPress, 1990, pp. 25-45.

Swaab DF, Garcia-Falgueras A. Sexual differentiation of thehuman brain in relation to gender identity and sexual
orientation. Functional Neurology 24:17-28, 2009.

Zucker KJ, Bradley SJ. Gender Identity Disorder and Psychosexual
Problems in Children and Adolescents. New York,
Guilford Press, 1995.

The Associated Press. David Reimer, 38, subject of the John/
Joan case. 2004 (May 12).

Zucker KJ, Wild J, Bradley SJ et al. Physical attractiveness ofboys with gender identity disorder. Archives of Sexual
Behavior 22:23-36, 1993.

Transgender and gender non-conforming youth		 H.327

IACAPAP Textbook of Child and Adolescent Mental Health

Zuger B. Early effeminate behavior in boys: Outcome andsignificance for homosexuality. Journal of Nervous andMental Disease 172:90-97, 1984.

Transgender and gender non-conforming youth		 H.328