Treating Transgender Youth: An Analysis of the Gender Affirmative Care Model

INTRODUCTION

Gender identity refers to an individual’s psychological sense of one’s gender as male, female, or other (Connolly et al., 2016). Gender identity is understood to be a complex intersection of biology, development, and socialization within a cultural context and research suggests that children develop a strong sense of gender identity at a young age, primarily influenced by cognitions and emotions, rather than by physically identifiable sex characteristics (Hidalgo et al., 2013). Because gender identity develops between 1.5 – 3 years old (with sexual orientation developing as early as age 8), understanding how to work with transgender youth is essential for any professional working with children in the medical or mental health fields (Keo-Meier et al.

, 2018).

Transgender refers to individuals whose sex assigned at birth is different from their current gender identity or gender expression (Turban & Ehrensaft, 2017). The term “transgender” has been used as an umbrella term to describe all individuals who experience incongruence between their internal gender identity and birth-assigned sex, however this term also includes people who identify in between boy/girl or man/woman (Turban, 2017).

New terms are emerging, including gender nonconforming, gender fluid, gender queer or gender non-binary that capture the broader group of gender-variant youth, beyond only individuals who identify as transgender (Connolly et al., 2016).

Prevalence of TGNC Youth and Psychiatric Co-Morbidity

The size of the transgender or gender nonconforming (TGNC) population has been historically difficult to measure and likely underestimated due to the range of stigma, discrimination and prejudice these individuals experience, which reduces self-identifying substantially (Cicero & Wesp, 2017).

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According to recent research, the prevalence of young people who identify as TGNC in the United States is between 0.17% – 1.3%, significantly higher than previously estimated (Connolly et al. 2016). In another important large school-based study of adolescents to determine the prevalence of TGNC identity in Minnesota was 2.7% and varied significantly across gender, race/ethnicity, and economic indicators (Eisenberg et al., 2017). Other previous research identified the rate of adults who identify as transgender as closer to 0.6% (Timmins et al., 2017).

With additional research designed to specifically identify TGNC youth found for those seeking gender-affirming surgeries, middle and high school students were as high as 1% and 0.17% of college students vs. 0.015% of adults (Connolly et al., 2016). While incidence may still be fairly low as percentage of overall population, there has been a significant increase in the number of TGNC youth seeking medical and mental health services in the past decade (Shumer et al., 2016). As such, the mental health field is at a crossroads in defining standards of care given the ever-evolving understanding of gender development (Edwards-Leeper et al., 2016). While research identifies that there is no one specific biological, psychological or social factor that explains the development of gender-identity in youth, adolescence is considered the peak of identity formation and a particularly vulnerable time for TGNC youth (Edwards-Leeper et al., 2016).

While still small as percentage of the overall population, TGNC adolescents experience elevated rates of mental health problems as compared to their cisgender peers (Chodzen et al., 2018); cisgender describes individuals who have a gender identity congruent with the sex they were assigned at birth (Cicero & Wesp, 2017). Research has continually identified higher rates of depression, anxiety, self-harm behaviors and suicidality that are statistically significant in the TGNC group vs the general population (Turban & Ehrensaft, 2017). While research has continually found higher rates of mental health issues among TGNC samples (Timmins et al., 2017), estimates of depression rates have varied from as low as 25.7% to as high as 64%, with a recent, important longitudinal study of TGNC youth identifying depressive symptoms in 41.3% of TGNC students (vs 11.8% for cisgender students) (Connolly et al., 2016).

Similarly, this study found higher rates of suicidality of 19.8% in TGNC (vs just 4.1% for cisgender students) and self-harm rates of 45.5% (vs. 23.4% for cisgender students) (Connolly et al., 2016). Other studies have shown TGNC youth are at an increased risk of sucidality as young as age 5, increasing with age (Turban & Ehrensaft, 2017). Other research has found that 38% of TGNC youth had an anxiety disorder diagnosis (Reisner et al., 2016) and of youth who present at gender clinics, anxiety disorders were present in 16.3 to 55% of patients (Turban & Ehrensaft, 2017). Given the significant rates of depression, anxiety, self-harm behaviors and suicidality in the TGNC youth population, understanding how best to approach treatment with this vulnerable population is imperative (Turban, 2017).

The World Professional Association for Transgender Health (WPATH) recognizes that much psychological distress is socially induced and not inherent to being transgender or gender nonconforming (Weber-Main et al., 2018). However, the TGNC community is one of the most stigmatized and marginalized groups in the United States and the health of TGNC individuals is at risk due to exposure to such discrimination (Cicero & Wesp, 2017). Many, but not all, TGNC individuals experience gender dysphoria (GD), which has been defined as: emotional distress stemming from incongruence between an individual’s birth-assigned sex and their subjective sense of self as male, female, or an alternate gender (Chen et al., 2016). Because there is no one experience of gender, WPATH recognizes that there are a variety of therapeutic options for individuals seeking care for GD, with differences in both the number and type of interventions, as well as the order in which these take place (Shumer et al., 2016). Other research confirms the lack of consensus regarding the best approach to clinical care with gender-diverse and transgender youth (Chen, et al., 2016).

WHAT CAUSES IT? Bechard, et al., GD, but also other factors

(NO?) According to the DSM-5, both children and teens meet the criteria for gender dysphoria (previously referred to as Gender Identity Disorder) if they experience a substantial difference between their experienced and assigned-at-birth gender, which causes significant distress or impaired functioning that lasts for at least 6 months (Shumer et al., 2017). [HERE OR LATER??? While it is estimated that of children who suffer from GD, only between 10-20% will have GD that persists into adolescence (Bizic et al., 2018).]]]

Despite the lack of definitive consensus among mental health providers regarding treatment, both WPATH Standards of Care and The Endocrine Society clinical practice guidelines define comprehensive approaches aimed to alleviate mental health discrepancies and improve outcomes (Shumer et al., 2016). Due to the wide variety of gender identity and expressions, affirming a child’s communication of his/her authentic gender is paramount for healthy growth and development (Cicero & Werp, 2017). Pioneering research indicates the benefits of gender affirmative care, which encourages the best prospect for individuals to follow their own paths to find positive emotional welfare (Edwards-Leeper et al., 2016). Under the belief that gender may be fluid rather than binary, supporting a TGNC youth living in the gender that feels most real and comfortable “promotes exploration of gender without presuming a fixed trajectory with regard to gender identity” is the very definition of affirmative care (Chen et al., 2016). According to WPATH, gender affirmative care involves different protocols and can include physical/medical (both reversible and irreversible) interventions, social/environmental support, as well as psychological interventions (Weber-Main et al., 2018).

Gender affirmative protocols, including early social transition, pubertal blockade, cross-sex hormonal therapy, and gender-affirming surgery in adulthood show promising early data on more favorable outcomes for transgender or TGNC youth (Turban & Ehrensaft, 2017). In addition, the first longitudinal study of patients undergoing comprehensive therapy for GD has shown data to support the notion that appropriate medical treatment for transgender or TGNC youth can lead to improved psychological functioning, with some question about the impact that puberty suppression (as part of the treatment protocols) have on this improved functioning (Connolly et al., 2016). Research indicates that the purpose of puberty suppression (or hormone blockers) is to relieve suffering caused by the development of secondary sex characteristics in puberty, to provide additional time to make a balanced decision regarding the permanent gender reassignment surgeries and to make living in the new gender identity more passable (Vrouenraets et al., 2015).

There is evidence that TGNC youth who receive puberty blockers (as one component of gender affirmative care) show improvement in symptoms of psychological distress, including a reduction in self-report depression, anxiety, self-harm behaviors and suicidality. Given that puberty suppression falls into the category of fully reversible medical/physical interventions and often is an initial step into treatment (Connolly et al., 2016), it is important to understand how pubertal suppression impacts rates of depression, anxiety, self-harm behaviors and suicidality in transgender or TGNC youth (ages 9-12 years old at the start of the study).

Treating Psychiatric Co-morbidity

Due to the higher rates of psychiatric comorbidity, the positive results or gender-affirming therapy and supported social transition in childhood are encouraging (Connolly et al., 2016). The first longitudinal study of patients receiving comprehensive therapy treating GD supports the conclusion that providing gender variant youth with proper medical treatment can improve psychological functioning. In addition, this study found that psychiatric symptoms might actually be driven by medical incongruence between mind and body, not primarily psychiatric (Connolly et al., 2016). Evidence also suggests that social transition in transgender youth (name, clothing, physical appearance, pronouns, etc) contributes to improved psychological functioning that comparable to medical interventions (Connolly et al., 2016 GD While it is estimated that of children who suffer from GD, only between 10-20% will have GD that persists into adolescence (Bizic et al., 2018).

Evidence suggests improved psychological outcomes (with less internalizing psychopathology) for transgender adolescents who receive both puberty suppression and cross-sex hormonal treatment, outlined by the World Professional Association of Transgender Health Standards and the Endocrine Society guidelines from 2009. However, the author highlights the lack of consensus around treating prepubertal transgender children (WPATH). There are roughly 3 clinical approaches; 1) utilizing psychotherapeutic interventions to help transgender children identity with their birth-assigned sex (assuming gender identity is malleable), 2) exploring gender identity with the youth without any specific interventions to lessen cross-gender identification, but advising against social transition, 3) promoting open exploration of gender identity, including support of social transition for children who desire it. The benefits of early social transition yielding desirable outcomes was first published in 2016 by , et all. Subsequent studies have revealed further support, including child-report metrics for transgender youth who have socially transitioned showing depression and anxiety rates on par with cisgender peers; levels of self-worth also matched controls. These findings are significant, given that postpubertal social transition for transgender adolescents has been generally accepted as advantageous, however prepubertal social transition has been fairly contentious and unsupported until now (Olson & Gülgöz, 2017)

New terms are emerging, including gender nonconforming, gender fluid, gender-queer or gender non-binary and additional research is needed to understand both prevalence and psychiatric comorbidity in the broader group of gender-variant youth (Connolly et al., 2016).

While there has been an increase in recent research on optimal treatment protocols for transgender youth, few studies have been conducted on gender non-binary youth, such as understanding the effects of gender-affirming therapy; including, how to support a child in social transition if the child does not identify with any one specific gender? How do hormone blockers or affirming hormone therapy affect this population? In addition to expanding awareness for the need for more research on the experiences of subgroups of gender nonconforming youth, it is important to gather information from individuals in the general population, not just young people who present at gender clinics (a dominant source of past samples). Implications for understanding prevalence, psychological functioning, and treatment options are significant. While the authors provide an improved understanding of the prevalence of gender nonconformity/ transgender in adolescents/young adults, there is a lack of knowledge about transgender children younger than 10. As illustrated, more research on these subgroups of gender nonconforming youth will be critical before treatment protocols can be generalized.

References

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