What the Primary Care Pediatrician Needs to Know About Gender Incongruence and Gender Dysphoria in Children and Adolescents

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Key points

  • Many children diagnosed with gender incongruence do not become transgender adolescents or adults.

  • Delaying puberty as part of multidisciplinary care can help transgender adolescents develop into well-functioning young adults.

  • During medical endocrine treatment few adverse events occur, but long-term outcomes are currently unknown.

  • Research evidence is limited concerning what is best transgender care for children and adolescents who have gender dysphoria; existing guidelines are consensus based.

Introduction and terminology

For an ever more visible group of children and adolescents their sense of being male or female, named gender identity, is incongruent with their birth-assigned sex and sexual body characteristics. They may suffer from gender dysphoria, the distress resulting from this incongruence. These youth form a subgroup of the children and adolescents with gender variance or gender nonconformity, which refers to the entire spectrum of variation in gender role behavior or gender expression, with or without

Prevalence, etiologic factors, and course

Based on the number of referrals to specialized gender identity services, the prevalence rate of gender dysphoria in children and adolescents seems to be low. However, 1% of parents in a large twin study (around 14,000 pairs) endorsed that their prepubertal child “wished to be the opposite sex”5 and 1.2% of 8000 high school students in another study answered positively when asked “are you transgender” (although 1.7% answered to not understand the question).6 From these simple questions one

Clinical approach

The general practitioner, the primary care pediatrician, or the adolescent medicine specialist may be the first medical professional to whom a child or adolescent with gender dysphoria or other gender identity variance presents. This first encounter is of great importance. Out of shame and fear for stigmatization many transgender adolescents have waited a long time before they seek care. The care provider should therefore be nonjudgmental and respectful. Because the terminology that is used in

Diagnosis

The core element of gender dysphoria in the DSM-5 is the incongruence between experienced and assigned gender.2 There are different indicators of gender dysphoria in children and adolescents/adults. Boxes 1 and 2 provide a description of the key elements required to make a diagnosis.

Several challenges may complicate the clinical diagnosis of gender dysphoria based on the DSM-5 criteria. Not all children are able to verbalize their thoughts and feelings well. Assessments are usually done by

Psychological Interventions

Both for children and adolescents treatment goals may range from dealing with the gender incongruence to focusing on its emotional and social consequences. Psychological interventions may be indicated before (eg, in prepubertal children), during (eg, when adolescents are still rather vulnerable), or even after medical interventions (hormones and surgery).

Young children and their parents often struggle with the question of how to deal with the child’s gender incongruence. Parents may not want to

Monitoring and follow-up

So far effects of GnRHa treatment followed by CSH treatment and surgery have been positive,13, 30, 31 although evaluation studies largely come from one clinic and confirmation of these results from other clinics is much needed. The promising results, however, do not imply that nobody experiences any problems after treatment. Despite repeated explanations and discussions about what can and cannot be expected of the treatment, certain outcomes (eg, difficulties in finding a partner or undesirable

Physical check-ups

Before starting GnRHa a health assessment takes place. It is advised to include in the history the frequency of weight bearing exercise and calcium intake. Fig. 4 provides further physical examination and additional investigations, also before starting CSH. Because the long-term metabolic consequences are still unknown, it is advisable to encourage the adolescent under medical gender-affirmative treatment to adopt a healthy lifestyle with vigilance for excessive weight gain and to refrain from

Controversies

The clinical approach of transgender youth has not been without controversy. In children the debate focuses on whether there should be a gender dysphoria or gender incongruence diagnosis at all in the diagnostic systems (DSM and International Classification of Diseases). Proponents of retaining the child diagnosis consider access to care (needed for proper psychological treatment and reimbursement) as more important than the potential stigma associated with having a child diagnosis.

Summary

The recognition and acknowledgment of gender incongruence and gender dysphoria in children and adolescents has evolved impressively over the last two decades. Not long ago youth and parents were hardly aware that children and adolescents could experience gender dysphoria. Media attention and the Internet have informed society in this respect and have also led to more acceptance and destigmatization of youth with gender dysphoria and transgender youth. In parallel, transgender care for children

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    The authors have nothing to disclose.

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