Gender dysphoria in children

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV (TR)) makes a differential diagnosis coding based on current age:

• 302.6 Gender Identity Disorder in Children
• 302.85 Gender Identity Disorder in Adolescents or Adults

In the DSM of mental disorders used by psychologists in the United States, gender identity disorder is given two sets of criteria. Criterion A indicates that a child identifies as a member of the opposite sex. The child needs to demonstrate a number of the following symptoms: dressing as a member of the opposite sex, primarily befriending members of the opposite sex, demonstrating a desire to engage in play activities characteristic of the opposite sex, and actively stating that they wish to be the opposite sex. Criterion B, on the other hand, indicates that the child does not identify with the sex they were born. This could manifest itself as a dislike of styles of dress characteristic of the sex they were born, avoidance of association with members of their born sex, and distress towards the aspects of their physiology which indicate their born gender.[11]

In May 2013, the American Psychiatric Association published the DSM-5 in which the GIDC diagnosis was removed and replaced with gender dysphoria, for the first time in its own distinct chapter.[12] Subtyping by sexual orientation was deleted. The diagnosis for children was separated from that for adults. The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing, or ability to express it in the event that they have insight.[13]

The International Statistical Classification of Diseases and Related Health Problems (ICD-10) lists several disorders related to gender identity, including gender identity disorder of childhood (F64.2): Persistent and intense distress about one's assigned gender, manifested prior to puberty.[14] The current edition has five different diagnoses for gender identity disorder, including one for when it manifests during childhood.[15] The diagnoses of gender identity disorder is not given to intersex individuals (those born with "ambiguous" genitalia). Additionally, as with all psychological disorders, these symptoms must cause direct distress and an impairment of functioning of the individual exhibiting the symptoms.[11]

F64.2 Gender identity disorder of childhood: A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual's own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behavior in boys is not sufficient. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but in F66.0.

The ICD-11, which will come into effect on 1 January 2022, significantly revises classification of gender identity-related conditions.[16] Under "conditions related to sexual health", the ICD-11 lists "gender incongruence", which is coded into three conditions:[17]

• Gender incongruence of adolescence or adulthood (HA60): replaces F64.0
• Gender incongruence of childhood (HA61): replaces F64.2
• Gender incongruence, unspecified (HA6Z): replaces F64.9

Therapeutic approaches for GD differ from those used on adults and have included behavior therapy, psychodynamic therapy, group therapy, and parent counseling.[19] This includes aiming to reduce gender dysphoria, making children more comfortable with their bodies, lessening ostracism, and reducing the child's psychiatric comorbidity.[10]

Traditional therapeutic intervention seeks to identify and resolve underlying factors (including familial factors), encourage the child to identify with their assigned sex, and encourage same-sex friendships.[11][20] Parent counseling involves setting limits on the child's cross-gender behavior, encouraging gender-neutral or sex-typical activities, examining familial factors, and examining parental factors such as psychopathology. Researchers Kenneth Zucker and Susan Bradley state that it has been found that boys with GD often have mothers who, to an extent, reinforced behavior more stereotypical of young girls. They also state that children with GD tend to come from families where cross-gender role behavior was not explicitly discouraged. However, they also acknowledge that one could view these findings as merely indicative of the fact that parents who were more accepting of their child's cross-gender role behavior are also more likely to bring their children to a clinical psychiatrist as opposed to parents who are less accepting of cross-gender role behavior in their children.[11][20]

In 2002, Zucker acknowledged limited data on gender dysphoria in children, stating that "apart from a series of intrasubject behaviour therapy case reports from the 1970s, one will find not a single randomized controlled treatment trial in the literature".[20] He has stated that "the therapist must rely on the 'clinical wisdom' that has accumulated and to utilize largely untested case formulation conceptual models to inform treatment approaches and decisions."[21]

The consensus of the World Professional Association for Transgender Health is that treatment aimed at trying to change a person's gender identity and expression to become more congruent with sex assigned at birth "is no longer considered ethical."[9] Edgardo Menvielle, a child-adolescent psychiatrist at the Children's National Medical Center in Washington states, "Therapists who advocate changing gender variant behaviours should be avoided."[22] Developmental and clinical psychologist Diane Ehrensaft told the Psychiatric Times, "The mental health profession has been consistently doing harm to children who are not 'gender normal,' and they need to retrain."[23]

Other therapeutic interventions do not seek to change a child's gender identity.[10] Instead, clinicians advise children and their parents to avoid goals based on gender identity and to instead cope with the child's distress by embracing psychoeducation and to be supportive of their gender variant identity and behavior as it develops.[8][19] A clinician may suggest that the parent be attentive, listen, and encourage an environment for the child to explore and express their identified gender identity, which may be termed the true gender. This can remove the stigma associated with their dysphoria, as well as the pressure to conform to a gender identity or role they do not identify with, which may be termed the false gender self.[8]

Treatment may also take the form of puberty blockers (such as leuprorelin), cross-sex hormones (i.e., administering estrogen to a child assigned male at birth or testosterone to a child assigned female at birth), or sex reassignment surgery with the aim of bringing one's physical body in line with their identified gender.[8][19] Delaying puberty allows for the child to mentally mature while preventing them from developing a body they may not want, so that they may hopefully make a more informed decision about their gender identity once they are an adolescent.[8] It can also help reduce anxiety and depression.[19]

The Endocrine Society does not recommend endocrine treatment of prepubertal children because clinical experience suggests that GD can be reliably assessed only after the first signs of puberty. It recommends treating transgender adolescents by suppressing puberty with puberty blockers until age 16 years old, after which cross-sex hormones may be given.[8][24] In its 2017 updated version of its guideline on treating those with gender dysphoria, it states, "We recognize that there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence, even though there are minimal published studies of gender-affirming hormone treatments administered before age 13.5 to 14 years." The organization states, "As with the care of adolescents ≥16 years of age, we recommend that an expert multidisciplinary team of medical and MHPs manage this treatment."[25]

Some medical professions disagree that adolescents are cognitively mature enough to make a decision with regard to hormone therapy or surgery, and advise that irreversible genital procedures should not be performed on individuals under the age of legal consent in their respective country.[8]

In the UK, Bell v Tavistock[26] considered the case of a patient who had changed their mind, now believing they were too young to have made such a decision, and concluded "Where the decision is significant and life changing then there is a greater onus to ensure that the child understands and is able to weigh the information". Following the ruling, NHS England announced that children under 16 would no longer be given puberty blockers without court authorization.[27]

Pickstone-Taylor has called Zucker and Bradley's therapeutic intervention "something disturbingly close to reparative therapy for homosexuals."[32] Other academics, such as Maddux et. al, have also compared it to such therapy.[8] They argue that the goal is preventing a transgender identity because reparative therapy is believed to reduce the chances of adult GD, "which Zucker and Bradley characterize as undesirable."[33]

Author Phyllis Burke wrote, "The diagnosis of GID in children, as supported by Zucker and Bradley, is simply child abuse."[34] Zucker dismisses Burke's book as "simplistic" and "not particularly illuminating;" and journalist Stephanie Wilkinson said Zucker characterized Burke's book as "the work of a journalist whose views shouldn't be put into the same camp as those of scientists like Richard Green or himself."[35]

Critics argue that the GIDC diagnosis was a backdoor maneuver to replace homosexuality in the DSM; Zucker and Robert Spitzer counter that the GIDC inclusion was based on "expert consensus," which is "the same mechanism that led to the introduction of many new psychiatric diagnoses, including those for which systematic field trials were not available when the DSM-III was published."[36] Katherine Wilson of GID Reform Advocates stated:[37]

In the case of gender non-conforming children and adolescents, the GID criteria are significantly broader in scope in the DSM-IV (APA, 1994, p. 537) than in earlier revisions, to the concern of many civil libertarians. A child may be diagnosed with Gender Identity Disorder without ever having stated any desire to be, or insistence of being, the other sex. Boys are inexplicably held to a much stricter standard of conformity than girls. Most psychologists who specialize in gender identity disorder in children note a higher level of male patients brought to them, rather than female patients. A possible explanation would be that cross-sex behavior is less acceptable and therefore more noticeable and more likely to be viewed by problematic by the child’s parents (Bradley, Zucker, 1997).[11] Preference for cross-dressing or simulating female attire meets the diagnostic criterion for boys but not for girls, who must insist on wearing only male clothing to merit diagnosis. References to "stereotypical" clothing, toys and activities of the other sex are imprecise in an American culture where much children's clothing is unisex and appropriate sex role is the subject of political debate. Equally puzzling is a criterion which lists a "strong preference for playmates of the other sex" as symptomatic, and seems to equate mental health with sexual discrimination and segregation.

Some clinicians, such as Wilson et al., argue that GIDC "has served to pressurize boys to conform to traditional gender and heterosexual roles."[38] Feder states that the diagnosis is based on the reactions of others to the child, not the behavior itself.[39] Langer et al. state "Gender atypicality is a social construction that varies over time according to culture and social class and therefore should not be pathologized."[40] Zucker refuted their claims in a response.[41] Psychiatrist Domenico Di Ceglie opined that for therapeutic intervention, "efficacy is unclear,"[42] and psychologist Bernadette Wren says, "There is little evidence, however, that any psychological treatments have much effect in changing gender identity although some treatment centres continue to promote this as an aim (e.g. Zucker, & Bradley, 1995)."[43]

Therapeutic intervention for GIDC came under renewed scrutiny in May 2008, when Kenneth Zucker was appointed to the DSM-5 committee on GIDC.[44] According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career."[45] Zucker is accused by LGBT activists of promoting "gender-conforming therapies in children"[46] and "treating children with GID with an eye toward preventing adult homosexuality or transsexuality."[47] Zucker "rejects the junk-science charge, saying that there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"[45] However, opponents continue to argue that the diagnosis "harms the very children it purports to help".[48]

The DSM-5 change to "gender dysphoria" was endorsed by transgender activists and allies as a way to lessen stigma but maintain a diagnostic route to trans-specific medical care.[49] However, Lev states that the diagnosis of gender dysphoria continues to pathologize transgender experiences.[50]

Referencing contemporary Western views on gender diversity, psychologist Diane Ehrensaft stated: "I am witnessing a shake-up in the mental health community as training sessions, workshops and conferences are proliferating all over this country and around the world, demanding that we reevaluate the binary system of gender, throw out the idea that gender nonconformity is a disorder, and establish new guidelines for facilitating the healthy development of gender-creative children."[51] Child-adolescent psychiatrist Edgardo Menvielle and psychotherapist Catherine Tuerck offer a support group for parents of gender non-conforming children at the Children's National Medical Centre in Washington D.C., aimed "not at changing children's behaviours but at helping parents to be supportive".[52] Other publications began to call for a similar approach, to support parents to help their child become their authentic self.[51][53]

Community organizations established to support these families have begun to develop, such as Gender Spectrum,[54] Trans Youth Family Allies,[55] Gender Creative Kids Canada,[56] and Trans Kids Purple Rainbow,[57] as well as conferences such as Gender Odyssey Family Conference[58] and summer camps such as Camp Aranu'tiq,[59] all with the goal of supporting healthy families with gender non conforming or transgender children. Popular media accounts of parents assisting their children to live in their felt gender role have also emerged.[60][61] Menvielle maintains that "the therapist should focus on helping the child and family cope with intolerance and social prejudice, not on the child's behaviours, interests or choice of playmates".[22] A host of additional terms have been applied to these children, including gender variant,[22] gender non-conforming,[52] gender-creative[51] and gender-independent.[62]

The historical and contemporary existence of alternative gender roles has been documented worldwide;[63] for example: the kathoey in Thailand and Laos, the hijra of India, the muxe of the Zapotec people in Mexico, the mukhannathun of what is now Saudi Arabia, the māhū in Hawaii, the fakaleiti in Tonga and the fa'afafine in Samoa.

The introduction of the GIDC diagnosis into the DSM-III in 1980[64] was preceded by numerous US studies and treatments on feminine boys beginning as early as the 1950s and 1960s, most prominently by John Money and Richard Green at the Johns Hopkins Hospital and the University of California, Los Angeles (UCLA).[65] The prevention of transsexuality and / or homosexuality was explicitly stated as the goal of many of these studies: "My focus will be what we might consider the prevention of transsexualism."[66] Bryant states that feminine boys were not a new phenomenon at this time; however, the public emergence of adult transsexual women (male to female) in the 1950s was new and created a number of problems for psychologists, motivating some to undertake efforts at preventing their further emergence.[48] Meyerowitz chronicles the deep disagreements which erupted between psychologists and physicians after Christine Jorgensen's public gender transition, namely over whether transsexuals should be permitted to align their bodies with their inner identities or whether their inner identities must be brought in line with their bodies.[67] At the time, transsexual women were beginning to publish first-person narratives which highlighted their awareness of their femininity at a young age[68] and Bryant states that some clinicians and researchers thus turned their attention to feminine boys, constructing sissies as a new "medicalized patient and research population."[48]

One early researcher was George Alan Rekers, who focused his 1972 doctoral research on the treatment of feminine boys.[69] In this work, Rekers describes a litany of feminine behaviours which he catalogues including: feminine posture, gait, arm and hand gestures, feminine inflection in speech, as well as interest in feminine clothing, games and conversation topics. Using classical behaviour modification techniques he and a team of research assistants set about extinguishing 'problem' feminine behaviours in three boys in particular, enlisting the help of parents and occasionally teachers to provide rewards and punishments corresponding to behaviours identified as wanted or unwanted. Rekers' dissertation describes in detail, the case of Kraig (a pseudonym for Kirk Andrew Murphy[70]) whose mother was instructed over earphones to alternately praise or ignore him depending on whether he played with a table of toys deemed to be feminine (typically dolls) or masculine (typically weapons). She was also trained to monitor his behaviour at home, with research assistants visiting weekly to ensure she was correctly completing her four times daily observations of Kraig's gendered behaviour. Physical punishment from Kraig's father is named as one of the primary consequences for feminine behaviour at home. Throughout Rekers future work, he cites his treatments with Kraig as a success, claiming that "Kraig's feminine behaviours have apparently ceased entirely […]."[71]

In contrast to this, a number of facts about Kraig have become public information, including: that he was a gay man; that according to his family, he never recovered from these treatments; and that in 2003, at the age of 38, he committed suicide.[70] Even without confirmed knowledge of such outcomes, by the mid 1970s Rekers' publications on his treatment modality were already attracting harsh criticism from scholarly[72] and popular[73] media sources, and Bryant speculates that this is one possible explanation for why many clinicians do not publish on their treatment techniques, focusing instead on less controversial aspects of GD, such as diagnostic criteria.[48]