Epidemiology

As previously mentioned, understanding the true prevalence of transgenderism and gender dysphoria has been challenging because there is limited research in this area. Most of the data that exist have been subject to both selection and recall bias as a result of how samples are chosen and the need to rely on self-reporting. Individuals may not be comfortable identifying themselves as a gender minority, which leads to an underestimation of the prevalence of this patient population. Early estimates in children and adolescence have been based more on behavior, making them more difficult to interpret because exhibiting behavior that is more typical of the other gender does not equate to having a transgender identity or meeting criteria for Gender Dysphoria . Some of these earlier estimates used the Child Behavior Checklist (CBCL), which contains questions for parents to indicate whether their child behaves like the opposite sex or wishes to be of the opposite sex. Zucker et al. found that using the CBCL, when asked, mothers reported the following: their child behaves like the opposites sex (for natal boys 3.8% sometimes, 1% often; for natal girls 8.3% sometimes, 2.3% often) and their child wishes to be the opposite sex (for natal boys 1% sometimes, 0% often; for natal girls 2.5% sometimes, 1% often). A large Dutch twin study also looked at parental endorsement of cross-gender behavior and identification and found similar results (for natal boys at 7 years old 3.4% behaving like the other gender and 1% wishing to be the opposite sex, at 10 years old 2.4% behaving like the opposite sex and 1% wishing to be the opposite sex; for natal girls at 7 years old 5.2% behaving like the opposite sex and 1.7% identifying as the opposite sex, and at 10 years old 3.4% behaving like the opposite sex and 0.9% identifying as the opposite sex). Again, we would like to emphasize that it is hard to interpret these data because cross-gender behavior is not necessarily a surrogate for Gender Dysphoria .

Social transitions in prepubertal youth

Social transition can refer to various decisions and choices one can make to show themselves as the gender they identify as. This can include changing one’s name to one that is more stereotypically associated with their experienced gender, changing the use of pronouns or changing the way they express their gender in a way that fits their experienced gender. One who is or has socially transitioned may make some of the aforementioned choices in some or in all settings. As visibility has increased around transgender identities, there has been a growing number of families that present to gender clinics and specialists looking for guidance in making some of these decisions at an early age.

There is controversy surrounding the best approach for working with children with gender dysphoria. As such, there are a number of different treatment approaches that specialists have taken in caring for young patients. Families sometimes present very anxious about their child’s behaviors when they are outside of the social norms for what is expected of the child’s assigned birth gender. A very frequent concern and question that many parents have is if it is too early in development for their child to truly know their gender identity. Current psychological theories do point to children having an early awareness of their gender identity and having an ability to label themselves as being a boy or girl as young as 2 or 3 years of age. However, parents often raise concerns that their child may change their mind and they worry about the damage that could be done if a “wrong” decision is made with regard to their child’s transition.

There have been a number of studies that have looked at the development of youth that exhibit gender nonconforming behaviors at an early age. Overall, these studies show that a significant percentage of these youth “desist” in their presentations and ultimately identify as their assigned gender at birth. Studies show variable rates of persistence in children identifying as the other gender, ranging from 2% to 39%. Of note, very few studies use the most up-to-date DSM 5 definition of Gender Dysphoria . More recent research has looked into the differences that exist between the groups of children that “persist” and those that do not. In a prospective study of 77 children referred for Gender Dysphoria , Wallien and Cohen-Kettenis showed that those children who persisted had a much higher incidence of being assigned a formal diagnosis of GID (as defined by DSM-IV at the time of the study), more gender variant behavior, and a higher intensity of dysphoria in childhood. Steensma et al. followed 127 adolescents and found that “persisters” tended to be more explicit in their belief that they were the other sex and had higher intensity of gender dysphoria in childhood, more gender variant behavior, and more dissatisfaction with their bodies compared with children that did not remain persistent.

The aforementioned findings have led many parents and providers to adopt the now commonly used phrase of looking for an “insistent, consistent, and persistent” pattern to help determine which children may be more likely to persist in their presentation through adolescence and adulthood. This concept has been further validated by researchers such as de Vries et al., who showed that in a cohort of 55 adolescents belonging to a Dutch gender clinic, all of the patients were children who continued to identify as transgender in young adulthood. Interestingly, review of persistence and desistance studies reveals that the rates of persistence have increased to a range of 12% to 39% compared with studies published before the year 2000 which showed lower persistence rates of 2% to 9%. Some have theorized that this may be a result of changes in our societies with more individuals identifying as transgender because of less stigma and social pressures.

Assessment of co-occurring psychiatric conditions

With suicide currently as the second leading cause of death in US youth, it is important to remember that sexual and gender minority youth are at a particularly higher risk for suicidal ideation, self-injurious behavior, and suicide attempts. Mental health can be a stigmatized subject, and transgender youth may have difficulty fully disclosing their concerns with providers. Major contributors to this are social factors such as a higher risk of bullying and victimization as a result of disclosure. Seventy-five percent of sexual and gender minority youth experience bullying and are afraid or may not feel supported if they disclose this at home or in their school community. Bullying and victimization at school and home put transgender youth at a particularly high risk for running away behavior, which contributes to their overrepresentation in the homeless youth population. Without a stable environment in which to develop, these youth are at risk for comorbid depression, anxiety, substance use (sexual minorities have the greatest risk of reporting lifetime substance use problems, especially sexual minority women of color), use of illegally obtained street-hormones, engaging in prostitution and “survival sex,” and associated physical health concerns such as communicable diseases.

A number of studies have looked at the presence of mental health comorbidities in youth with gender dysphoria. In one study, 44% of youth followed in a multidisciplinary gender clinic had a significant psychiatric history, 58% had been diagnosed with depression, 16% with generalized anxiety, 21% had a history of self-mutilation, and 9% had at least one previous suicide attempt. A Dutch study found that out of 120 children referred to a gender clinic, 52% had a mental health diagnosis other than GID (the term used at the time) and a higher incidence of internalizing disorders (e.g., anxiety and mood disorders) compared with externalizing disorders (e.g., disruptive behavioral disorders): 37% versus 23%. Similarly, a study performed in the Gender Identity Development Service (GIDS) in London examined adolescents with gender dysphoric features and also found higher rates of internalizing symptoms compared with externalizing symptoms.

Reisner et al. showed that transgender youth have significantly more comorbid psychiatric conditions when compared with cisgender controls. In their study, youth who identified as transgender were more likely to be diagnosed with a depressive disorder (50.6% vs. 20.6%) or anxiety (26.7% vs. 10%), to have presence of suicidal ideation (17.2% vs. 6.1%), presence of self-injurious behavior (16.7% vs. 4.4%), a history of inpatient psychiatric treatment (22.8% vs. 11.1%), or to report being in an outpatient psychiatric treatment at the time of the study (45.6% vs. 16.1%). In this study, there were no significant differences in the aforementioned mental health conditions between transgender males and females.

A number of studies have also been done looking at suicidality. One study interviewed a sample of youth and young adults who identified as transgender and found that 45% seriously thought of suicide, with even higher rates reported by those that identified as having experienced verbal or physical abuse by parents, and 26% reported a history of a suicide attempt.

A retrospective analysis by the GIDS in London also showed that youth with gender dysphoric features often have high rates of bullying (47%), low mood or depression (42%), and self-harm behavior (39%). Their study also compared youth aged 5 to 11 years and youth aged 12 to 18 years and showed that puberty was a time of increased distress with even higher rates of depression, self-harm, and suicidal thoughts in the younger age group. In a study published by Olson et al., 20% ( n = 96) of youth aged 12 to 24 years of age seeking care in a transgender youth clinic had Beck Depression Inventory rating scale scores in the moderate to extreme range, 51% had a history of suicidal thoughts, and 30% had a history of a suicide attempt.

Similarly, in a comprehensive review by Connolly et al., the authors found that transgender youth were more likely to be depressed than their cisgender peers, with up to 50.6% of youth diagnosed with depression. They also showed that transgender youth were at a higher risk for attempted suicide and suicidal ideation, with rates reported in some studies as high as 19.8% and 56%, respectively. In their 2016 study looking at the prevalence of suicidal thoughts and behaviors in children (aged 3 to 12 years) seen in a gender identity clinic, Aitken et al. noted that children referred to gender clinics had more behavior problems and had poorer peer relations than a nonreferred group of children. The referred group was also more likely to talk about killing themselves (22.7%), more likey to be deliberately harming themselves and attempting suicide (18.6%). There appeared to be an age relationship: as children got older, the gender-referred group was 15 times more likely to talk about suicide.

It is no surprise that social supports and perception of safety play a significant role in the well-being of transgender youth, and assessment of this is important when conducting a mental health evaluation. LGBT youth who report low levels of support from their families, communities, or social relationships are more likely to report depressive symptoms and suicidality. In their 2014 study of LGBT youth in Boston, Duncan and Hatzenbuehler found a correlation between suicidal ideation and suicide attempts in LGBT youth who lived in neighborhoods that had high rates of LGBT-related hate crimes.

Lastly, Connolly et al. also reported a higher prevalence of eating disorders among transgender adolescents, with overall rates as high as 15.8%. The authors revealed that 13.5% of youth reported using diet pills and 15.1% described purging behaviors.

Exploration of gender identity/expression

At the time of assessment, a diagnosis of Gender Dysphoria may or may not be made depending on whether the child or adolescent meets criteria for the diagnosis. Regardless of the formal diagnosis that is made, the mental health provider’s role is also to help children and adolescents further explore and discern their gender identity and gender expression. Some youth may not show much desire to “explore,” because they may express certainty about their gender identity. Conversely, other children and adolescents present to the mental health provider with difficulty in articulating their internal sense of their gender identity. This is often the case for those individuals who may not identify in the binary (male vs. female) sense of gender. Some children present identifying neither as male nor female and, when asked, may find difficulty in labeling their gender identity. Adolescents who feel certain with their gender identity may still desire counseling regarding ways to express their gender. Great care must be taken in eliciting conversations about gender identity. Some youth may choose to not to disclose their gender identity or express their gender the way they truly wish to out of fear of bullying or harassment. In other cases, it may be the parents who wish to limit certain expressions out of safety fears for their child.

There is a lot of controversy surrounding models of care for prepubertal youth who have gender variant behaviors. Past approaches have included efforts to help youth be more comfortable with their assigned gender at birth through different interventions, such as promoting interactions with same-sex peers, relationships with the same-sex parent, and encouraging more typical behaviors of the assigned sex at birth. The rationale behind these approaches are to help hasten desistence, which is based on previous literature that suggests that many prepubertal youth who have gender nonconforming behaviors desist through development and eventually stop identifying as the opposite gender thereby minimizing the potential risks of being rejected by peers and family and developing symptoms of anxiety or depression. It is important to note that these approaches lack strong evidence and have not been studied in randomized controlled trials designed to show efficacy. As noted earlier, the literature that exists on rates of persistence and desistance has a number of limitations. The biggest concern related to this approach is the potential risk of harm that could occur in the individual who does not desist, but rather persists. The approach sends a message of lack of acceptance or tolerance, and this type of rejection may be at the core of some of the disparities in mental health seen in transgender youth.

Other approaches have taken a “watchful waiting” stance, where risks of transitioning are taken into consideration given potential negative reactions or responses from others. In this approach, parents may have their child wait before undergoing a social transition until further development into puberty, while still trying to balance an accepting approach. Some approaches try to balance this by encouraging acceptance and tolerance of any behaviors or interests that are considered gender nonconforming, but potentially limiting expression or deferring timing of social transitions when accounting for potential risks.

Finally, the affirmative model focuses on building resilience and positive self-esteem, and youth desiring a social transition are affirmed and supported in their attempts to transition. More recent research has looked at prepubertal transgender youth who have undergone social transition. Compared with cisgender controls, affirmed transgender youth seem to have no significant differences in depressive symptoms and only mild elevation in anxiety ratings that are not considered clinically concerning.

Controversy remains among multiple professional societies regarding the acceptability of allowing a child to transition to their self-affirmed gender. However, what is agreed upon is that decisions around social transitions must be tailored to various factors, including the temperament of the child, the level of social supports, acceptance and understanding of those around the child, and of course, the child’s desires. Some children desire a social transition early and want to disclose their identity as transgender to many of their peers and those around, whereas other children may want to defer transitioning due to anxieties or fears of being stigmatized, harassed, or bullied and may express their gender identity only in limited settings.

Support for both the child/adolescent and parents

Families may bring their child to the mental health professional for a variety of reasons. Many families are concerned about whether their child truly is transgender and wonder if this may be “just a phase.” Other families may be convinced that their child is transgender and may have worries and anxieties around how to help their child face potential obstacles and barriers, such as teasing and bullying, or the fear of their child being assaulted or discriminated against. Still other families may present hoping that the mental health professional can in some way change the development of the child such that he or she no longer has cross-gender expressions or identification. Mental health professionals need to be prepared for the variety of presentations from families and how to best address their concerns, while maintaining what is in the best interest of the child.

In working with parents of gender nonconforming and transgender youth, it is important to realize that without working and addressing the parents’ concerns and questions, one may inadvertently push the family away from coming in to get the help that may be needed for the child. Eliciting parent expectations and concerns is key early on in therapeutic work to help shape and determine how the provider may proceed in working with both the child and the family. Coolhart and Shipman describe a model for working with families therapeutically where the tasks in therapy are divided into two stages: the first being assessing and increasing family “attunement” (their level of understanding and peace with the child’s gender identity and expression) and the second being helping explore and support options for gender expression or transition. Parents who may feel that their concerns or viewpoints are not being heard or taken into consideration may result in the parents preventing their child from getting the help or support that they need.

Furthermore, it should be noted that just because the child may be gender nonconforming or identify as transgender, it may not be necessary for the child to receive mental health treatment.

It is important to recognize that the “diagnosis” that is often being evaluated for is Gender Dysphoria focusing on the distress and impairment that can often occur in a transgender individual’s life. The clinician is not diagnosing the child’s gender identity, although parents may be looking for the clinician to provide them with reassurance that their child is or is not transgender. Psychotherapy is no longer an absolute requirement for access to interventions for transitioning, such as hormone therapy or surgery as outlined in the World Professional Association for Transgender Health (WPATH) standards of care. Depending on the individual child and the family, there will be different needs, and the flexibility of the mental health care provider is important in working with these families. The WPATH standards of care outline some potential roles that mental health care providers may play in working with gender nonconforming and transgender youth. These potential roles include ( Box 3.3 ): directly addressing gender dysphoria, providing family counseling, helping youth explore their gender identity, assessing and treating any coexisting mental health concerns, referring for physical interventions (puberty suppression and gender-affirming hormones), educating and advocating for the child and their family, and providing or referring youth and their families to peer support resources.

Box 3.3

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