How is gender dysphoria in childhood treated? What recommendations currently exist?
In children and adolescents, the degree to which timing, extent, and method are highly individualized contributes to the controversy about the best way to serve this population. There is no “typical” presentation of gender dysphoria, and the threshold at which parents seek help for their child varies. Finally, opinions conflict about the ability of prepubertal children and adolescents to consent to and appreciate the gravity of treatment.
Interventions for adolescents with gender dysphoria can be categorized into 3 subsets20:
• Reversible interventions, such as gonadotropin-releasing hormone analogues, spironolactone, or progestins to delay the physical changes associated with puberty
• Partially reversible interventions (eg, hormones), when the goal is to actively masculinize or feminize the body
• Irreversible interventions, ie, surgical procedures
Careful evaluation and thought are required when considering all treatment options. It is important to appreciate that delaying medical interventions for adolescents with gender dysphoria is not a neutral action, because the resulting prolonged dysphoria and gender-related discrimination are strongly correlated with exacerbation of psychiatric distress.18
When childhood or adolescent gender dysphoria is successfully diagnosed and favorably recognized by the family, the safest and most productive decision regarding timing, method, and extent of transition is a reflection of combined input from the patient, family, and treatment team. Regardless of the decision, mental health professionals should counsel and educate families about options, benefits, and implications. It is also recommended that mental health professionals concentrate on the following 6:
• Reducing distress related to gender dysphoria in childhood
• Helping families express a nurturing and accepting response
• Managing familial uncertainty and anxiety
• Facilitating decisions about the extent and context of gender role expression
• Encouraging families to communicate openly with teachers and other nonrelative adults in the child’s life
• Encouraging exploration of gender expression outside of the gender binary
What are some of the controversies surrounding the GID diagnosis? How will DSM-5 characterize this diagnosis?
Members of WPATH generally agree that inclusion of GID in DSM is stigmatizing and have suggested that it be eradicated from DSM. Insurance coverage for medical, psychiatric, surgical, and endocrinological services, in light of this recommendation, remains a concern.21 Many advocates have proposed removing GID from DSM and retaining it in the ICD-10-CM as a medical diagnosis to maintain a third-party payer pathway for gender-affirming treatment in a stigma-free manner. Another proposed change involves renaming the diagnosis so that the word “disorder” is excluded. Some organizations, such as the UK’s National Health Service, leave the classification of GID ambiguous—“a condition for which medical treatment is appropriate in some cases.”22
The DSM-5 Task Force has sought to placate critics who strongly disagree with the stigma associated with the DSM inclusion of GID while creating an avenue by which patients with gender-related distress can access services.21 To this end, it is likely that “gender dysphoria” will replace GID in DSM-5 and that this new diagnosis will adopt much of the same criteria previously outlined for GID.23 The diagnosis will continue to emphasize gender-nonconforming behavior and thoughts but only in the setting of “clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability.”21 Other major revisions are likely to include expansion of criteria, elimination of sexual-orientation specifiers, and separation of child and adult gender-related dysphoria.23 For ongoing and accurate proposed changes in DSM-5, visit the American Psychiatric Association’s Web page on sexual and gender identity disorders.24
How can I make my practice setting transfriendly?
CASE VIGNETTE
A self-identified transwoman is admitted to the inpatient psychiatry unit. She requests to be in a room for women. What is the best way to find an appropriate room for this patient?
Recommendations for trans-affirming policies and procedures
You can create a transfriendly practice by developing and implementing written organizational policies and ensuring that all staff are trained and proficient in appropriate protocol. The Table provides some recommendations for trans-affirming policies and procedures.
Issues such as restroom access and inpatient rooming assignments are likely to require more time to allow for productive modification. Both state laws and institutional policies vary greatly, and in combination, may present site-specific challenges that require consistent patient advocacy and administrative review. As policies are adjusted to allow appropriate access and room assignment for each patient (eg, transwomen room with nontransgender women), concurrent efforts may include labeling appropriately equipped single-stall restrooms with gender neutral signage and asking the patient where he or she would like to be housed. In jurisdictions with laws that protect transgender persons against discrimination, institutions are legally required to serve transgender patients on the basis of their gender identity. Take care to validate concerns and discomfort of nontransgender patients without violating the confidentiality of the transgender patient.25
