Most children and teens with gender dysphoria also have multiple other psychological issues

By Alex Fradera

New research on gender identity disorder (also known as gender dysphoria, in which a person does not identify with their biological sex) questions how best to handle the condition when it arises in children and adolescents. Should biological treatments be used as early as possible to help a young client transition, or is caution required, in case of complicating psychological issues?

Melanie Bechard of the University of Toronto and her colleagues examined the prevalence of “psychosocial and psychological vulnerabilities” in 50 child and teen cases of gender dysphoria, and writing in a recent issue of the Journal of Sex and Marital Therapy, they argue their findings show that physicians should be considering these factors more seriously when deciding on a treatment plan. Salting the situation, one of the paper’s co-authors is Kenneth Zucker, an expert on gender dysphoria who was last year considered too controversial for Canadian state television.



As recently as 2013, Zucker headed the American Psychiatric Association’s group deciding the diagnostic criteria for gender dysphoria, but he fell from grace in 2015 when he was fired from his clinic at the Toronto Centre for Addiction and Mental Health for failing to follow the now prominent “gender-affirmative” approach that places a clinical emphasis on smoothing the process of gender transition for children and adolescents who say they no longer identify with their biological sex.

Zucker’s approach, in contrast, was more hesitant and he questioned the ease with which young people can draw conclusions about their gender identity during a universally tumultuous stage of life. He also placed more emphasis on the costs that transition may bear upon an individual. To say that he considered transition a last resort would be as much of a caricature as saying the gender affirmative approach considers it a first resort, but they clearly represent different points on this spectrum.

To Zucker’s critics he was a transphobe, his approach analogous to gay conversion therapy (the now widely condemned use of psychological therapy to attempt to alter a client’s sexual orientation) – for example, he reportedly advised some parents to discourage their younger children from behaving in ways that contradicted their assigned gender.

Last year, hostility toward Zucker’s views was substantive enough to lead the Canadian broadcaster CBC to pull a BBC documentary that reported his perspective. For his part, Zucker continues to maintain that his priority has always been the wellbeing of his clinical charges. The recent article that he co-authored with Bechard and others puts into the scientific record one of the concerns of his clinic, that gender dysphoric youth are a psychologically vulnerable population.

The paper examines the case files of 17 people assigned a male gender and 33 people assigned a female gender, at birth, based on their biological sex. Following their experience of gender dysphoria, the clients had been referred to a specialist gender identity service for young people, at which time they were aged 13 to 20. Sixty-four per cent of the clients were homosexual with respect to the gender they were assigned at birth.

The researchers looked for evidence of 15 factors that can signify or contribute to psychological issues, from self-harm to a previous outpatient therapy visit, and found that over half their sample had six or more of these factors. The majority had two or more prior diagnoses of a psychological disorder, the most common being a mood disorder such as depression. More than half had reported thinking about suicide, a third had dropped out of high school, a quarter had self harmed. A history of sexual abuse was rarer, observed in ”only” 10 per cent of cases.

All these measures are likely to be underestimates because they depended on the clients’ own descriptions during their initial interview at the gender identity clinic. Without a control group, it’s hard to say whether these rates of psychological distress are higher than for other client groups. Certainly though, the findings are consistent with the sense that these individuals were already in a state of psychological vulnerability when they were referred for gender dysphoria.

Bechard’s team present in-depth examples of two clients, both assigned as female at birth, that bring these psychological complexities to life, demonstrating the kinds of situations these cases often involve.

The first individual was very intelligent but struggling socially, especially around girls. They were fixated on emphasising their femininity in selfies, leading the parents to suspect body dysmorphic disorder (a troubling belief that there is something wrong with one’s body). This individual’s boyfriend then came out as gay. Sometime following this, the client disclosed that they identified as a boy. This change in identity happened “overnight” with no developmental history of cross-gender identification.

The second client’s history is more convoluted: at around age 14-15 this individual had disclosed that they were transgender (now identifying as male), and had felt this way for a while. This individual also had a history of anxiety, social problems interacting with girls, and extreme anxiety about sexuality. From the point of disclosing their gender dysphoria, they also reported that they were gay (oriented towards men) but had no interest in romantic/sexual relations.

In both these cases, after an initial assessment the individual was given testosterone treatment by a physician against the wishes of the parents – in the first case, the physician actually refused to meet the parents, and in the second, the physician recorded that the issues raised by the parents regarding anxiety, sexual and social problems weren’t relevant for the course of action. Sadly, in the case of the second individual, a few months after the start of the hormone treatment, they made a suicide attempt that required hospitalisation; the reasons for this were not reported.

Are the indicators of psychological vulnerability identified in these case histories the consequence, cause or simply coincident to gender identity disorder? If they are all solely a fall-out from the gender dysphoria, then the decisive approach of the physicians described above has a certain sense to it. But if some of the psychological complications pre-dated the gender dysphoria, or were separate from it, then at the very least this would suggest that the consulted physicians should have considered a broader treatment plan, and considered the psychological complications when judging their clients’ “readiness” to commence biomedical treatments.

The possibility that disclosure of gender dysphoria may in some cases be driven by earlier psychological vulnerabilities and social problems seems likely to be greater than zero. This is a controversial idea among many online trans activists, but actually it isn’t among health practitioners, even those who espouse the gender affirmation philosophy, who recognise that some young gender identity referrals may be transiently mixed-up individuals.

The issue of pre-existing or concurrent psychological vulnerabilities also speaks to the fact that a substantial proportion, perhaps even the majority, of children who experience some form of gender identity challenge, later come to endorse the gender they were raised as (further commentary and discussion); the new findings may also be relevant to the experience of detransitioning individuals, who reach similar conclusions, but often after a much greater investment in the process of transition – a phenomenon that is struggling to get scientific attention.

However, when a child with gender dysphoria is “insistent, persistent, and consistent” over an extended period, then (under the gender affirmative approach) this is typically treated as a good indicator that it is appropriate to begin facilitating the transition process. The trouble is, psychological vulnerabilities can also be persistent, and if a young person feels like they’ve found the solution, it’s understandable that they might not want to let go.

Life can sometimes feel as complicated as the Gordian knot, the legendary challenge that was seemingly impossible to disentangle. It’s understandable to weigh up a radical solution, like Alexander the Great cleaving the knot with a single sword-stroke: to abandon your external environment for a new home, to step outside of the confines of an identity that may be the source of the myriad issues plaguing you.

This research from Bechard, Zucker and company provides preliminary evidence about the psychological vulnerabilities of children and teens with gender dysphoria, extending previous work that’s shown high rates of self-harm and suicidal ideation in this group, but more research is required to give us the full clinical picture. As such, this new paper represents just the latest sally in a difficult, complicated conversation that’s far from over: a conversation about how we can most compassionately treat those who feel out of step with where they find themselves in the social world.

SOURCE:

https://digest.bps.org.uk/2018/01/17/most-children-and-teens-with-gender-dysphoria-also-have-multiple-other-psychological-issues/(accessed 24.6.20)

Norwegian Clinical Psychologists Reveal The Complexities Involved In Working With Children And Teens Experiencing Gender Dysphoria

With the number of referrals to the UK’s only gender identity development service (GIDS, at the Tavistock and Portman NHS Trust) increasing sharply in recent years – a pattern seemingly mirrored in other European countries and the US (anecdotally, at least — many countries don’t keep comprehensive data the way the UK does) – debate has inevitably intensified over how best to help transgender and gender nonconforming (TGNC) youth. As some expert clinicians have pointed out, there has been a tendency for commentators, campaigners and the general public to adopt an oversimplified view in which therapists are seen as fitting one of two categories: those who don’t believe their clients when they say they are trans (and who are therefore condemned by trans advocacy groups for practicing conversion therapy), and others who simply accept their clients’ statements about their gender, and who are therefore affirming or affirmative.

The clinical reality is more complicated: these days, there is a welcome consensus against actual conversion therapy— forcing a young person to “go back” to being cisgender — but at the same time responsible clinicians do not simply nod along to what a young person with gender dysphoria says. There are complexities inherent to childhood and adolescent development, and many experts warn it’s important not to accidentally medicalise perfectly normal qualms about growing up, hitting puberty, and being exposed to powerful and often frustratingly restrictive gender roles. Young people present at gender clinics with a wide variety of issues ranging from comorbid mental-health issues to unexamined trauma, and the process of helping them determine the best path forward, particularly with regard to medical interventions like puberty blockers or cross-sex hormones, is a lot more complicated than making a rapid decision to deny or approve such interventions.

Indeed, in an open-access practice review published in the BMJ last year, clinicians at UCL, GIDS and Great Ormond Street Hospital explained that the thorough psychosexual assessment period for such clients “usually takes 6 months or more over a minimum of four to six sessions” and involves a range of psychometric measures and interviews, covering the client’s expectations and understanding of social and physical transition, their mood and emotional functioning. The review adds that, “With the adolescents, there is an in-depth consideration of their sexuality and fertility, and possible preservation approaches are discussed. The attitude of important people in the child’s life towards gender dysphoria needs to be explored and understood.”

Now a study published in Psychology & Sexuality by a pair of Norwegian researchers, Reidar Schel Jessen and Katrina Roen, has explored these complexities from clinical psychologists’ perspective, including what it means to help a young person work through the issues they are facing and to make important decisions about medical treatment.



For the study, “Five clinical psychologists working with gender non-conforming youth in an interdisciplinary team at a specialized gender identity clinic in Europe participated in interviews.” In reading their work, I was struck repeatedly by how similar their experiences were to what I heard when I spoke with American clinicians for an in-depth article about transgender youth for The Atlantic. For example, Jessen and Roen write that “Sometimes the clients themselves want to transition, but sometimes the possibility seems driven by the family or others in the young person’s life, such as school staff.” The pair include a poignant example of this:


One young person I worked with […] was referred by school. Biological male, who presented in very… like stereotypically… call it female clothes, like pink and yellow, long hair. Often was read as female, and the school didn’t know what to do with the young person. But when I met the young person, the young person didn’t have any issues with the body or […] developing in a masculine way. So all, so I was kind of again looking at where the stress lies, and it was really in the separation or gender division at school […] and they would ask him to cut his hair short, because he is a boy […] and I think in my report I wrote that… you know, I would really advise you not to address… the pupils as girls and boys, but just call them pupils, students. (Participant C)

I didn’t come across any examples quite so dramatic in my own reporting, but this was a common general storyline: I noted that “Several of the clinicians I spoke with, including Nate Sharon, Laura Edwards-Leeper, and Scott Leibowitz, recounted new patients’ arriving at their clinics, their parents having already developed detailed plans for them to transition. ‘I’ve actually had patients with parents pressuring me to recommend their kids start hormones,’ Sharon said.”

Kids who are gender nonconforming often make adults uncomfortable, and in some cases one way adults attempt to dispel this discomfort is to push for transition. “The [clinical psychologist] participants have the impression that sometimes the school or family expect these young boys to transition to girls,” write Jessen and Roen, “because they do not want them to be feminine boys. This illustrates how difficult it can sometimes be to understand which expectations belong to whom, and how gender non-conforming youth can be referred to the clinic by adults who hold the opinion that gender non-conformity is a problem to be addressed clinically.”

Similarly, as I wrote in my Atlantic article, clinicians told me about instances in which “the child might be capably navigating a liminal period of gender exploration; it’s the parents who are having trouble not knowing whether their kid is a boy or a girl.” Sure enough, this theme of pressure to choose a gender ‘side,’ too, popped up among the Norwegian clinicians:


Participants were concerned about the possibility that binary gender norms force gender non-conforming youth to become “the opposite gender,” instead of allowing them space to explore their unique gender expression. According to the clinical psychologists interviewed, many clients and families believe that gender is binary, and that there are only two gender identities. This belief does seem to influence clients’ expectations of outcomes, and may encourage them to seek physical treatment at the expense of exploratory work. According to the participants, many clients and their families experience societal and community pressure to conform to gender norms.

Exploration and nuance and liminality are key concepts that come up over and over again in interviews with experienced youth TGNC clinicians. But it can be challenging to tell a child who is in distress, or his or her parents, that it’s worth taking a bit more time to explore before proceeding to physical interventions or making other major decisions about transition — perhaps doubly so given the belief in some quarters that “exploration” or “therapy” are near-synonyms for “transphobia” and “conversion therapy.”

As “Participant B” told the researchers, “Not surprisingly, exploratory strategies can be aggravating to clients and families. We are always very subject to this discourse of the bigot […] this idea of you know transphobia […] so people that are bigoted are very narrow-minded […] this is where then you know the power that we then have starts to really create lots of tension and problems.” That is, at the end of the day, clinicians stand between young people (and their parents) and medical treatments they feel they need, so it’s an understandable reaction for delays caused by responsible, thorough clinical work to be misread as transphobia. This tension was partly what motivated last year’s practice review in the BMJ: “Faced with very distressed young people, they [clinicians] may feel under pressure to initiate physical intervention without consultation with psychosocial colleagues,” the review states.

If gender clinics in three very different countries with three very different healthcare systems are experiencing the same sorts of scenarios over and over, that’s a signal that everyone should try to better understand what’s going on. Many of the young people mentioned in this study likely will, in the long run, benefit from puberty blockers and hormones. But some won’t — their gender exploration will lead them elsewhere, whether or not they come to identify with their biological sex. It’s important to understand what separates these two groups, and scientists have only barely begun to do so.

SOURCE:

https://digest.bps.org.uk/2019/02/25/norwegian-clinical-psychologists-reveal-the-complexities-involved-in-working-with-children-and-teens-experiencing-gender-dysphoria/(accessed 4.3.19)