Overview of the management of gender nonconformity in children and adolescents
- Johanna Olson-Kennedy, MD
Johanna Olson-Kennedy, MD
- Assistant Professor of Clinical Pediatrics
- University of Southern California, Keck School of Medicine
- Michelle Forcier, MD, MPH
Michelle Forcier, MD, MPH
- Associate Professor of Pediatrics
- Warren Alpert School of Medicine, Brown University
- Section Editors
- David Brent, MD
David Brent, MD
- Section Editor — Childhood Mental Disorders
- Professor of Psychiatry, Pediatrics and Epidemiology
- University of Pittsburgh School of Medicine
- Mitchell E Geffner, MD
Mitchell E Geffner, MD
- Section Editor — Pediatric Endocrinology
- Professor of Pediatrics
- Keck School of Medicine, University of Southern California
- Diane Blake, MD
Diane Blake, MD
- Section Editor — Adolescent Medicine
- Professor of Pediatrics
- University of Massachusetts Medical School
Children generally are assigned a gender at birth based upon genital anatomy or chromosomes. For most children, gender assignment correlates with gender identity, which is the innate sense of maleness or femaleness. However, some children have a gender identity that does not correlate with assigned gender. These children are called gender-nonconforming, gender-variant, or sometimes transgender (table 1). (See "Overview of gender development and clinical presentation of gender nonconformity in children and adolescents", section on 'Terminology'.)
The trajectory of gender nonconformity in childhood is unpredictable; some children with gender nonconformity will grow up to be transgender adults and some will grow up to be cis-gendered adults (ie, adults in whom gender identity matches genital anatomy). (See "Overview of gender development and clinical presentation of gender nonconformity in children and adolescents", section on 'Trajectory'.)
This topic will provide an overview of the management of gender nonconformity in children and adolescents. Gender development and the clinical presentation of gender nonconformity in children and adolescents are discussed separately. (See "Overview of gender development and clinical presentation of gender nonconformity in children and adolescents", section on 'Referral'.)
There is little evidence to guide the management of gender nonconformity in children and adolescents and opinions about the best treatment vary [1,2]. Most experience comes from case series of adults who underwent sex reassignment surgery . However, as the number of multidisciplinary centers providing treatment for gender-nonconforming youth increases, information about outcomes in this population is increasing [4-11]. (See "Transgender women: Evaluation and management".)
Clinicians have differing views on whether gender nonconformity should be regarded as a normal variation of gender expression, a medical condition, or a psychiatric disorder . In the absence of a clear understanding of the etiology of gender nonconformity, these views influence the management approach. Approaches to treating gender-nonconforming children and adolescents have been outlined by the Endocrine Society, the American Academy of Child and Adolescent Psychiatry, and the World Professional Association for Transgender Health [2,13,14]. Our approach is generally consistent with the recommendations in these guidelines.
- Olson J, Forbes C, Belzer M. Management of the transgender adolescent. Arch Pediatr Adolesc Med 2011; 165:171.
- World Professional Association for Transgender Health (WPATH). WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th Version. Available at: www.wpath.org/documents/Standards%20of%20Care_FullBook_1g-1.pdf (Accessed on November 27, 2012).
- Smith YL, Van Goozen SH, Kuiper AJ, Cohen-Kettenis PT. Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med 2005; 35:89.
- Spack NP, Edwards-Leeper L, Feldman HA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics 2012; 129:418.
- Cohen-Kettenis PT, Steensma TD, de Vries AL. Treatment of adolescents with gender dysphoria in the Netherlands. Child Adolesc Psychiatr Clin N Am 2011; 20:689.
- de Vries AL, Cohen-Kettenis PT. Clinical management of gender dysphoria in children and adolescents: the Dutch approach. J Homosex 2012; 59:301.
- de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med 2011; 8:2276.
- Hewitt JK, Paul C, Kasiannan P, et al. Hormone treatment of gender identity disorder in a cohort of children and adolescents. Med J Aust 2012; 196:578.
- Edwards-Leeper L, Spack NP. Psychological evaluation and medical treatment of transgender youth in an interdisciplinary "Gender Management Service" (GeMS) in a major pediatric center. J Homosex 2012; 59:321.
- Cohen-Kettenis PT, van Goozen SH. Sex reassignment of adolescent transsexuals: a follow-up study. J Am Acad Child Adolesc Psychiatry 1997; 36:263.
- Smith YL, van Goozen SH, Cohen-Kettenis PT. Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study. J Am Acad Child Adolesc Psychiatry 2001; 40:472.
- Drescher J, Byne W. Gender dysphoric/gender variant (GD/GV) children and adolescents: summarizing what we know and what we have yet to learn. J Homosex 2012; 59:501.
- Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2009; 94:3132.
- American Academy of Child and Adolescent Psychiatry. Practice parameter on gay, lesbian or bisexual sexual orientation, gender-nonconformity, and gender discordance in children and adolescents www.aacap.org/galleries/PracticeParameters/glbt_practice_parameter_june_2012.pdf (Accessed on November 27, 2012).
- Spack N. Transgenderism. Med Ethics (Burlingt Mass) 2005; 12:1.
- de Vries AL, Cohen-Kettenis PT, Delemarre-Van de Waal H. Caring for transgender adolescents in BC: Suggested guidelines. Available at: transhealth.vch.ca/resources/library/tcpdocs/guidelines-adolescent.pdf (Accessed on October 05, 2012).
- Shechner T. Gender identity disorder: a literature review from a developmental perspective. Isr J Psychiatry Relat Sci 2010; 47:132.
- Vance SR Jr, Ehrensaft D, Rosenthal SM. Psychological and medical care of gender nonconforming youth. Pediatrics 2014; 134:1184.
- Hill DB, Menvielle E, Sica KM, Johnson A. An affirmative intervention for families with gender variant children: parental ratings of child mental health and gender. J Sex Marital Ther 2010; 36:6.
- Tuerk C. Considerations for affirming gender nonconforming boys and their families: new approaches, new challenges. Child Adolesc Psychiatr Clin N Am 2011; 20:767.
- Gender Identity Disorder in Young Boys: A parent- and peer-based treatment protocol. Clin Child Psychol Psychiatry 2002; 7:360.
- Rekers GA, Lovaas OI. Behavioral treatment of deviant sex-role behaviors in a male child. J Appl Behav Anal 1974; 7:173.
- Rekers GA, Lovaas OI, Low B. The behavioral treatment of a "transsexual" preadolescent boy. J Abnorm Child Psychol 1974; 2:99.
- Society for Adolescent Health and Medicine. Recommendations for promoting the health and well-being of lesbian, gay, bisexual, and transgender adolescents: a position paper of the Society for Adolescent Health and Medicine. J Adolesc Health 2013; 52:506.
- Substance Abuse and Mental Health Services Administration. Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth. HHS Publication No. (SMA) 15-4928, Substance Abuse and Mental Health Services Administration, Rockville, MD 2015.
- Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental Health of Transgender Children Who Are Supported in Their Identities. Pediatrics 2016; 137:e20153223.
- Coates S, Person ES. Extreme boyhood femininity: isolated behavior or pervasive disorder? J Am Acad Child Psychiatry 1985; 24:702.
- Rosen AC, Rekers GA, Friar LR. Theoretical and Diagnostic Issues in Child Gender Disturbances. J Sex Res 1977; 13:89.
- Yunger JL, Carver PR, Perry DG. Does gender identity influence children's psychological well-being? Dev Psychol 2004; 40:572.
- Zucker KJ. Gender identity disorder in children and adolescents. Annu Rev Clin Psychol 2005; 1:467.
- Steensma TD, van der Ende J, Verhulst FC, Cohen-Kettenis PT. Gender variance in childhood and sexual orientation in adulthood: a prospective study. J Sex Med 2013; 10:2723.
- Zucker KJ. On the "natural history" of gender identity disorder in children. J Am Acad Child Adolesc Psychiatry 2008; 47:1361.
- Steensma TD, McGuire JK, Kreukels BP, et al. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry 2013; 52:582.
- Steensma TD, Cohen-Kettenis PT. Gender transitioning before puberty? Arch Sex Behav 2011; 40:649.
- Simons L, Schrager SM, Clark LF, et al. Parental support and mental health among transgender adolescents. J Adolesc Health 2013; 53:791.
- Perrin EC. Sexual Orientation in Child and Adolescent Health Care, Springer, New York 2002.
- Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry 2011; 16:499.
- Zucker KJ. The DSM diagnostic criteria for gender identity disorder in children. Arch Sex Behav 2010; 39:477.
- Gridley SJ, Crouch JM, Evans Y, et al. Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth. J Adolesc Health 2016; 59:254.
- Stevens J, Gomez-Lobo V, Pine-Twaddell E. Insurance Coverage of Puberty Blocker Therapies for Transgender Youth. Pediatrics 2015; 136:1029.
- Garofalo R, Deleon J, Osmer E, et al. Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health 2006; 38:230.
- Rotondi NK, Bauer GR, Scanlon K, et al. Nonprescribed hormone use and self-performed surgeries: "do-it-yourself" transitions in transgender communities in Ontario, Canada. Am J Public Health 2013; 103:1830.
- Cohen-Kettenis PT, van Goozen SH. Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent. Eur Child Adolesc Psychiatry 1998; 7:246.
- Delemarre-van de Waal, Cohen-Kettenis PT. Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. Eur J Endocrinol. 2006; 155 Suppl 1:S131.
- Malpas J. Between pink and blue: a multi-dimensional family approach to gender nonconforming children and their families. Fam Process 2011; 50:453.
- Manasco PK, Pescovitz OH, Feuillan PP, et al. Resumption of puberty after long term luteinizing hormone-releasing hormone agonist treatment of central precocious puberty. J Clin Endocrinol Metab 1988; 67:368.
- Khatchadourian K, Amed S, Metzger DL. Clinical management of youth with gender dysphoria in Vancouver. J Pediatr 2014; 164:906.
- de Vries AL, McGuire JK, Steensma TD, et al. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics 2014; 134:696.
- Menvielle E, Gomez-Lobo V. Management of children and adolescents with gender dysphoria. J Pediatr Adolesc Gynecol 2011; 24:183.
- Meyer WJ 3rd. Gender identity disorder: an emerging problem for pediatricians. Pediatrics 2012; 129:571.
- Jain J, Dutton C, Nicosia A, et al. Pharmacokinetics, ovulation suppression and return to ovulation following a lower dose subcutaneous formulation of Depo-Provera. Contraception 2004; 70:11.
- Mieszczak J, Eugster EA. Treatment of precocious puberty in McCune-Albright syndrome. Pediatr Endocrinol Rev 2007; 4 Suppl 4:419.
- Richman RA, Underwood LE, French FS, Van Wyk JJ. Adverse effects of large doses of medroxyprogesterone (MPA) in idiopathic isosexual precocity. J Pediatr 1971; 79:963.
- Australasian Paediatric Endocrine Group. Gender Identity Disorder Guidelines. http://www.apeg.org.au/Portals/0/guidelines.pdf (Accessed on October 08, 2012).
- Delemarre-van DE Waal, Cohen-Kettenis PT. Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. Eur J Endocrinol 2006; 155:S131.
- Cohen-Kettenis PT, Schagen SE, Steensma TD, et al. Puberty suppression in a gender-dysphoric adolescent: a 22-year follow-up. Arch Sex Behav 2011; 40:843.
- Kiesel LA, Rody A, Greb RR, Szilágyi A. Clinical use of GnRH analogues. Clin Endocrinol (Oxf) 2002; 56:677.
- Daly E, Vessey MP, Hawkins MM, et al. Risk of venous thromboembolism in users of hormone replacement therapy. Lancet 1996; 348:977.
- Gerstman BB, Piper JM, Tomita DK, et al. Oral contraceptive estrogen dose and the risk of deep venous thromboembolic disease. Am J Epidemiol 1991; 133:32.
- Richman RA, Kirsch LR. Testosterone treatment in adolescent boys with constitutional delay in growth and development. N Engl J Med 1988; 319:1563.
- Toorians AW, Thomassen MC, Zweegman S, et al. Venous thrombosis and changes of hemostatic variables during cross-sex hormone treatment in transsexual people. J Clin Endocrinol Metab 2003; 88:5723.
- Hormone administration. UCSF Center of Excellence for Trandgender Health. http://transhealth.ucsf.edu/trans?page=protocol-hormones (Accessed on October 11, 2012).
- Price TM, Blauer KL, Hansen M, et al. Single-dose pharmacokinetics of sublingual versus oral administration of micronized 17 beta-estradiol. Obstet Gynecol 1997; 89:340.
- Moore E, Wisniewski A, Dobs A. Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. J Clin Endocrinol Metab 2003; 88:3467.
- Meyer WJ 3rd, Webb A, Stuart CA, et al. Physical and hormonal evaluation of transsexual patients: a longitudinal study. Arch Sex Behav 1986; 15:121.
- Tangpricha V, Ducharme SH, Barber TW, Chipkin SR. Endocrinologic treatment of gender identity disorders. Endocr Pract 2003; 9:12.
- Spack N. Personal Communication. 2011.
- Edwards-Leeper L, Spack NP. Gender identity disorder. In: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 3rd ed, Augustyn M, Zuckerman B, Caronna EB (Eds), 2011. p.229.
- GUIDING PRINCIPLES
- TYPES OF INTERVENTIONS
- Mental health interventions
- Phenotypic interventions
- - Social transition
- - Hormonal interventions
- - Surgical interventions
- APPROACH IN PREPUBERTAL CHILDREN
- General suggestions
- Social transition
- Indications for referral
- APPROACH IN PUBERTAL CHILDREN AND ADOLESCENTS
- Approach for youth with nonbinary gender identity
- OVERVIEW OF HORMONAL INTERVENTIONS FOR ADOLESCENTS
- Potential indications
- Counseling and consent
- Availability of care
- Suppression of endogenous puberty
- - Rationale
- - Timing
- - Regimen
- - Potential adverse effects
- - Monitoring
- Gender-affirming hormone therapy
- - Rationale and eligibility
- - Timing
- - Male-to-female
- - Female-to-male
- - Monitoring
- SURGICAL INTERVENTIONS
- SUMMARY AND RECOMMENDATIONS