Many children and teens with gender dysphoria also experience mental health issues

GettyImages-811322022.jpgBy Alex Fradera

New research on gender identity disorder (also known as gender dysphoria, in which a person does not identify with their biological sex) questions how best to handle the condition when it arises in children and adolescents. Should biological treatments be used as early as possible to help a young client transition, or is caution required, in case of complicating psychological issues?

Melanie Bechard of the University of Toronto and her colleagues examined the prevalence of “psychosocial and psychological vulnerabilities” in 50 child and teen cases of gender dysphoria, and writing in a recent issue of the Journal of Sex and Marital Therapy, they argue their findings show that physicians should be considering these factors more seriously when deciding on a treatment plan. Salting the situation, one of the paper’s co-authors is Kenneth Zucker, an expert on gender dysphoria who was last year considered too controversial for Canadian state television.

As recently as 2013, Zucker headed the American Psychiatric Association’s group deciding the diagnostic criteria for gender dysphoria, but he fell from grace in 2015 when he was fired from his clinic at the Toronto Centre for Addiction and Mental Health for failing to follow the now prominent “gender-affirmative” approach that places a clinical emphasis on smoothing the process of gender transition for children and adolescents who say they no longer identify with their biological sex.

Zucker’s approach, in contrast, was more hesitant and he questioned the ease with which young people can draw conclusions about their gender identity during a universally tumultuous stage of life. He also placed more emphasis on the costs that transition may bear upon an individual. To say that he considered transition a last resort would be as much of a caricature as saying the gender affirmative approach considers it a first resort, but they clearly represent different points on this spectrum.

To Zucker’s critics he was a transphobe, his approach analogous to gay conversion therapy (the now widely condemned use of psychological therapy to attempt to alter a client’s sexual orientation) – for example, he reportedly advised some parents to discourage their younger children from behaving in ways that contradicted their assigned gender.

Last year, hostility toward Zucker’s views was substantive enough to lead the Canadian broadcaster CBC to pull a BBC documentary that reported his perspective. For his part,  Zucker continues to maintain that his priority has always been the wellbeing of his clinical charges. The recent article that he co-authored with Bechard and others puts into the scientific record one of the concerns of his clinic, that gender dysphoric youth are a psychologically vulnerable population.

The paper examines the case files of 17 people assigned a male gender and 33 people assigned a female gender, at birth, based on their biological sex. Following their experience of gender dysphoria, the clients had been referred to a specialist gender identity service for young people, at which time they were aged 13 to 20. Sixty-four per cent of the clients were homosexual with respect to the gender they were assigned at birth.

The researchers looked for evidence of 15 factors that can signify or contribute to psychological issues, from self-harm to a previous outpatient therapy visit, and found that over half their sample had six or more of these factors. The majority had two or more prior diagnoses of a psychological disorder, the most common being a mood disorder such as depression. More than half had reported thinking about suicide, a third had dropped out of high school, a quarter had self harmed. A history of sexual abuse was rarer, observed in ”only” 10 per cent of cases.

All these measures are likely to be underestimates because they depended on the clients’ own descriptions during their initial interview at the gender identity clinic. Without a control group, it’s hard to say whether these rates of psychological distress are higher than for other client groups. Certainly though, the findings are consistent with the sense that these individuals were already in a state of psychological vulnerability when they were referred for gender dysphoria.

Bechard’s team present in-depth examples of two clients, both assigned as female at birth, that bring these psychological complexities to life, demonstrating the kinds of situations these cases often involve.

The first individual was very intelligent but struggling socially, especially around girls. They were fixated on emphasising their femininity in selfies, leading the parents to suspect body dysmorphic disorder (a troubling belief that there is something wrong with one’s body). This individual’s boyfriend then came out as gay. Sometime following this, the client disclosed that they identified as a boy. This change in identity happened “overnight” with no developmental history of cross-gender identification.

The second client’s history is more convoluted: at around age 14-15 this individual had disclosed that they were transgender (now identifying as male), and had felt this way for a while. This individual also had a history of anxiety, social problems interacting with girls, and extreme anxiety about sexuality. From the point of disclosing their gender dysphoria, they also reported that they were gay (oriented towards men) but had no interest in romantic/sexual relations.

In both these cases, after an initial assessment the individual was given testosterone treatment by a physician against the wishes of the parents – in the first case, the physician actually refused to meet the parents, and in the second, the physician recorded that the issues raised by the parents regarding anxiety, sexual and social problems weren’t relevant for the course of action. Sadly, in the case of the second individual, a few months after the start of the hormone treatment, they made a suicide attempt that required hospitalisation; the reasons for this were not reported.

Are the indicators of psychological vulnerability identified in these case histories the consequence, cause or simply coincident to gender identity disorder? If they are all solely a fall-out from the gender dysphoria, then the decisive approach of the physicians described above has a certain sense to it. But if some of the psychological complications pre-dated the gender dysphoria, or were separate from it, then at the very least this would suggest that the consulted physicians should have considered a broader treatment plan, and considered the psychological complications when judging their clients’ “readiness” to commence biomedical treatments.

The possibility that disclosure of gender dysphoria may in some cases be driven by earlier psychological vulnerabilities and social problems seems likely to be greater than zero. This is a controversial idea among many online trans activists, but actually it isn’t among health practitioners, even those who espouse the gender affirmation philosophy, who recognise that some young gender identity referrals may be transiently mixed-up individuals.

The issue of pre-existing or concurrent psychological vulnerabilities also speaks to the fact that a substantial proportion, perhaps even the majority, of children who experience some form of gender identity challenge, later come to endorse the gender they were raised as (further commentary and discussion); the new findings may also be relevant to the experience of detransitioning individuals, who reach similar conclusions, but often after a much greater investment in the process of transition – a phenomenon that is struggling to get scientific attention.

However, when a child with gender dysphoria is “insistent, persistent, and consistent” over an extended period, then (under the gender affirmative approach) this is typically treated as a good indicator that it is appropriate to begin facilitating the transition process. The trouble is, psychological vulnerabilities can also be persistent, and if a young person feels like they’ve found the solution, it’s understandable that they might not want to let go.

Life can sometimes feel as complicated as the Gordian knot, the legendary challenge that was seemingly impossible to disentangle. It’s understandable to weigh up a radical solution, like Alexander the Great cleaving the knot with a single sword-stroke: to abandon your external environment for a new home, to step outside of the confines of an identity that may be the source of the myriad issues plaguing you.

This research from Bechard, Zucker and company provides preliminary evidence about the psychological vulnerabilities of children and teens with gender dysphoria, extending previous work that’s shown high rates of self-harm and suicidal ideation in this group, but more research is required to give us the full clinical picture. As such, this new paper represents just the latest sally in a difficult, complicated conversation that’s far from over: a conversation about how we can most compassionately treat those who feel out of step with where they find themselves in the social world.

Psychosocial and Psychological Vulnerability in Adolescents with Gender Dysphoria: A “Proof of Principle” Study

Alex Fradera (@alexfradera) is Staff Writer at BPS Research Digest

Update, July 2020: This post generated substantial discussion upon publication, as can be seen in the comments below, and more than two years later it continues to receive a lot of attention. With this in mind, we’ve updated the headline, which was slightly ambiguous if read without the full context of the article. As highlighted in the post, the particular paper covered here is just one part of a broader ongoing conversation, and we will continue our attempts to reflect that discussion and research evidence.

68 thoughts on “Many children and teens with gender dysphoria also experience mental health issues”

  1. Agree totally with this take on gender dysphoria, based upon what we know is ‘normal’ developmentally, for most children. All children will go through a stage of varying length(sometimes years), occurring at different times at some point in their development, of being attracted to or identifying with a gender different form their birth- assigned gender.

    This is a normal part of growing up and exploring self- identity. Only if it persists into adulthood should the decision be made to pursue it further. This pharmaceutical and western- led medicalisation and psychological classification of normal ranges of behaviour is NOT healthy.

    If others have a problem with children experiencing confusion about heir gender identity, their prejudice born of misunderstanding, is their problem, not the ‘dysmorphic’ child’s. To be fair, it is usually the parents, not the children that have these issues.

    We all know someone from school, who when we look back in hindsight was obviously ‘gay’ or ‘lesbian’ and have undoubtedly experienced some confusion ourselves, possibly having had crushes on people of both sexes and experimented with cross dressing and role play,masculinity and femininity, being largely culturally, not biologically defined.

    Hindsight is a wonderful thing, a universal confirmation- bias that is being used in the current ‘gender identity ‘zeitgeist’ to justify pre-emptive ‘treatment’ of very young children.
    The consequences of that decision will last a lifetime and we can never know because we impatiently failed to explore all avenues, if was really necessary or ultimately desirable for that child.

    1. When your daughter all of the sudden says she’s a boy at age 12 without a single symptom of gender dysphoria prior to that (this is called Rapid Onset Gender Dysphoria – ROGD), you start to take this seriously and not as a political cause, a civil rights movement, or an interesting scholarly debate.

      These findings demonstrate what I have lived. Kids are being diagnosed with anxiety and depression now more than ever before. It’s these kids that are struggling with fitting in, with being perfect, with hating their bodies that find the siren song of trans.

      Thankfully, we saw our daughter’s depression (and flirtation with an eating disorder) just before her claim she was transgender. In the US, psychologists typically follow the APA treatment guidelines of affirmation therapy and so her licensed therapist affirmed her as a boy and recommended a gender expert to start her on testosterone and plan her future surgeries. We quit therapy.

      This is real. This is what is happening in nice, normal, non-bigoted, loving homes all across the world.

      After a year of family suffering with no professional help and simply removing her access to transgender promotion on You Tube (Miles McKenna was her favorite vlogger) and some family bonding, she came to the realization on her own that she was not transgender. I can guarantee that had we kept her in therapy and affirmed her belief, that she would be transitioning to male.

      Here are her words, “I realized that I just wanted a reason for the way I felt, that the second I found this seemingly possible solution, I grasped onto it and wouldn’t let go. It seemed like the perfect solution; it came with something to fight for as well. There were others like me, and it felt good to finally belong somewhere. I was finally a part of something bigger than myself. It seemed perfectly imperfect. But now I was realizing that this was not the solution. I was suddenly grateful that I had not transitioned. It would have ruined me.”

      Wake up. There is a terrible mistake and a terrible consequence to medicalizing children with such a paucity of data. Forget data – there is NO reliable diagnosis. The assumption that children are infallible in their understanding of who they are is ludicrous.

      As a PhD Neuroscientist, I am well aware that the brain, especially the cortical structures that foster reasoning and judgement, are not fully developed until approximately age 25. No one should be providing experimental medicines with known side effects (some irreversible) to children with an neurophysiologically un-diagnosable, theoretical, undefined “condition” of feeling like they are “in the wrong body.”

      1. A voice of reason, in an era of insanity. Very few kids make it through childhood without dysphoria, confusion, rebellion against group think, etc. Offering conversion treatment to a child is absolutely insane.

  2. There are many inaccuracies in this article, unfortunately. As gender identity is arguably solidified by age 4 and is a combination of cognitive, psychosocial and biological interplay, saying that pre-existing mental health conditions can manifest into a young person’s gender dysphoria is in my view analogous to saying that the egg created the chicken, and not the opposite. It can be argued, but misses the point.

    In the vast majority of cases, I believe children and adolescents ‘know’ what is right for them, when appropriately listened to. The fact that we live in an inherently cissexist, transphobic world where gender expectations and early socialisation are generally guided by normative binary principles, often denying gender variance as a possibility in fear of deviation from an idealised ‘happy normality’, should be able to give us a hint towards the challenges gender questioning children face growing up.

    Change, any change, needs two things that work in synergy; action, and acceptance. Acceptance of things that can be faithfully embraced as being right as they are, and changing of things that require altering. Unless both these happen, change is incomplete and potentially fails to achieve a desired equilibrium.

    In treating children who are potentially gender-variant, the one thing we need to look at as clinicians is our own gender prejudice. We need to be able to question sources of articles that suggest that a whopping 80% of gender dysphoric children decide to identify as cisgender by the onset of adulthood. Beyond our normative fears, lies a world of young people who want to be heard and listened to without judgement. Once this job is done, once compassion towards them, not fear, drives our plight; and once we understand that we are all similar in many ways and that gender is a slowly decaying human identifier. Then and only then can we stop focusing on generalised extremes, studies of questionable intend and pursuing subconscious agendas driven by own biases.

    Then, we can truly listen to the ones that matter.

    1. As a parent of a teen with gender dysphoria, my teen thanked me for presenting my views and the views presented by both sides of the debate.
      Our gender identity is grounded in the way we interact with society but also influenced by society itself..
      A person with any comorbid psychology issues is not something that should be negated. Surely all good professionals will take this into account? Is this not part of the assessment?
      If I listened to everything my kids said about their desires, wishes, feelings and beliefs, trust me society would think I was a negligent parent. My child would now be obese,diabetic, sleep deprived, uneducated and watching programmes or playing games that were totally inappropriate for the age. This is just a small example.
      Promoting caution, careful watching is not transphobic.
      The more I read articles or comments that use this term, the more I realise their stance is questionable as the transphobic term is used for impact and is an attempt to stifle reason.
      As a parent, it would be helpful if more and more professionals, like the authors of this article, present a possibility that not everyone who has dysphoria will be transgender. For those who are and for those who don’t, how can we tell,unless we practice watchful waiting.
      If I was to weigh up any life, altering medication and surgery would it not be prudent to learn about the risks and complications that come with this? Would it not be prudent to know that any underlying medical condition may cause greater harm if I was to follow through? Would it not be prudent to know that the professional has thoroughly researched all sides of the scientific evidence and present this?
      In the case of gender dysphoria, would it not be prudent to question why alter the body first when thoughts, wishes and beliefs change as we experience more self awareness, wisdom and confidence in finding out what it means to be me? Certainly, I am no longer the same person as I was when I was a teen. My body is the same, albeit older but my thoughts and beliefs have matured as I learn how to be a more critical thinker.
      As a parent how can I fully support eradicating one hormone naturally predominant in the body only to deluge the body with a hormone that was never meant to take precedence? The natural rise and fall of hormonal balancing will play havoc on our pituitary gland and do we really know how this effects each individual. One size does not fit all.
      Taking away healthy breasts and tissues should nor be seen as solution.
      I am not transphobic. I know my child so I wish that people who continue to talk the talk as if they really know our kids, cut parents more slack and see this from the other side. Asking us to forgo our understanding is wrong.
      I thank those like the authors of the study for being prudent.

      1. I agree with listentometoo. As someone who was in a relationship with someone with Gender Dysphoria for 9 years and grew up questioning gender, I am SO glad that my whims as a child and teenager were not listened to in this regard because the lasting consequences would’ve been dire.

        My wonderful ex partner always felt it would’ve been tragic if he had transitioned at a young age and was glad he didn’t, even though he still had GD as an adult.

        Children and young adults are not fully equipped to make this HUGE decision and many other factors may be at play. Being politically correct is not good in this context as it can lead people down a path that is not good long term. Psychological factors must be taken into consideration so that the client is taken care of as much as they can be from all angles. To aide someone in full transition is a long and arduous task and needs long and careful consideration.

        I worry that political ideology and media drives this current zeitgeist rather than a rational diagnostical process.

    2. ‘Gender is a slowly decaying human identifier’. What a mad thing to say.

      No, to be on the fringes is more fashionable these days. It will go out of fashion like everything else.

    3. Then why won’t the media allow the growing number of detransitioning people to speak out about how transitioning ruined their lives, even when they still suffer from gender dysphoria?

      Professionals don’t know what they’re doing and if you really want a fair discussion, then we need to also look at why people develop gender dysphoria, because there are many reasons. I and many others like myself developed it due to sexual abuse. All the transgender people I know who are currently transitioning hate their natal bodies because they were sexually abused. We need to look at all of the factors and not just quote things such as ‘cissexist’ or other words created by people pushing a radical ideology on others. That’s a huge part of the present problem.

  3. Hi Natasha,

    I’m suprised that you begin your comment saying you’ve picked up many inaccuracies, because reading it closely I can’t see you’ve identified a single one. That claim is a way to throw suspicion on an argument – people generally assume you have reasons to speak so authoritatively. But it’s a poor tactic for encouraging discourse and discovering the truth.

    I’m going to walk through what you’ve written and try and address it in any case.

    Paragraph one: Your use of a chicken and egg analogy is revealing, as the analogy, as normally used, is a very good summary of my position: that the causality isn’t yet clear and could go both ways. Your twist on it – “and not the opposite” – implies that I say the causality goes one way, when I clearly have not, something you yourself concede in the first part of your statement (“can manifest” not “only manifests”).

    Paragraph two states a number of your opinions, but no inaccuracy. It also seems to insinuate that the article is denying that gender questioning children may face any challenges, which is again simply untrue.

    Paragraph three is a homily that I broadly agree with, but doesn’t seem to speak to any inaccuracies in the article.

    Paragraph four starts with an interesting statement. “We need to be able to question sources of articles that suggest that a whopping 80% of gender dysphoric children decide to identify as cisgender by the onset of adulthood. ” I’m interested in understanding what this means.

    If you mean we shouldn’t take any research as gospel without looking at it first, then I’m behind you on that one. If you mean, however, that we should rely on our political intuitions to apply targeted skepticism to evidence that contests what we already believe – well, we already do that, sadly. It’s long been clear that people discount evidence that clashes with their belief, and in recent years its become clear that this isn’t specific to authoritarian right-wingers, but to those of multiple political persuasions.

    The fact is, we shouldn’t. You close the paragraph with accusations of questionable studies, biases and subconscious agendas with nothing to back this up, to parallel the unsubstantiated charge you make at the start of the comment. But if we’re ever going to come to a common understanding on these contentious issues, we need to have substance. A clash of ideologies won’t do it.

    There was another thing that jumped out of that final paragraph: the plea about young people wanting to be heard, which no-one disagrees with, and to be listened to without judgment, which is an interesting claim. Perhaps you meant this in the sense of “listened to without being belittled and insulted.” But I only have your words to go on, and I am extremely skeptical of the idea that young people genuinely want the adults in their life to put aside their faculties of judgment and put all responsibilities firmly in their hands. Taken seriously, it’s a claim that is profoundly hostile to the prospect of the accumulation of wisdom, the value of expertise, and any kind of hierarchy of competence. Most clinicians I know recognise that a large part of their job is applying judgment. It’s by using this judgment in participation with the individuals they work with that they produce some good. I hope you agree.

    1. Hi Alex,

      Thanks so much for taking time to read my comment and get back to me, with your views.

      Let me be clear about what I personally think about your article, in bullet points, to avoid any confusion:

      – The sources mentioned in your article are (to me) highly debatable, historically heavily contested (Google is our friend), and (again in my view, but also most important to me) dubious in intentionality. My opinion that your article contains inaccuracies is personal, and does not need to be peer reviewed. You can make what you wish of it. 🙂

      – Cissexism is an often unconscious bias you, me, everyone needs to be aware of when thinking, talking, writing about such important subjects.
      May I ask you (rhetorically) where you stand with regards to your gender bias, and how have you managed to keep it in check, or been keeping it in check thus far? (My personal view, again, is that in some ways evidenced in your article it isn’t – or that it is still ‘work in progress’, which is ok as learning from each other is what we are here for).

      – ‘But if we’re ever going to come to a common understanding on these contentious issues, we need to have substance. A clash of ideologies won’t do it.’

      I disagree with you on this. Substance, like reality itself is highly subjective. And if by substance you mean consensus, then in my view there are myriads of ways to get there. My response was not a battle of references or an attempt to attack you in any way other than expressing own, arguably strong (due to personal sensitivity) ideas. It was adding my own subtext to an article that brought up a lot of stuff for me and I felt naturally inclined to contest in an almost general, reflective way. If I was to sum up my response it would be called ‘we agree to disagree + some reflections on the above piece’.

      And now to the crux of it, as I see it:

      “I am extremely skeptical of the idea that young people genuinely want the adults in their life to put aside their faculties of judgment and put all responsibilities firmly in their hands.”

      Yes, you are. And it shows. And that is what probably triggered me the most in your article, so kudos to us both for getting here.

      Your use of black and white thinking in “put aside judgement / put ALL responsibilities firmly in their hands” is to me indicative of your fear that something like this might ever happen in the real world, which also resonates in your article. A catastrophic projection of sorts, which I attribute to some of your implicit gender bias.

      How about the middle ground?

      How about first making sure adult judgement is not clouded by all sorts of ingrained socialised prejudice, before we allow children express how they feel and experience the world as ‘own experts’. How about employing a humanistic approach to this, actually believing that the child often knows more than we would give them credit for, once we are able to make them feel safe and deeply heard of as clinicians working ‘with them’ and not ‘for them’.

      Feeling ‘belittled and insulted’ was not the type of judgement I was referring to. I was referring to judgements that go way deeper, like the ‘expert / patient – parent / child’ power differentials, and the group of implicit biases coming with such dynamics. Was also referring to, very clearly I believe, to the normative gender bias we all carry in varying degrees as a result of growing up and being socialised in this time and place.

      You say ‘It’s by using this judgment in participation with the individuals they work with that they produce some good.’

      And I simply add that as long as our judgement is free of prejudice, to the best of our ability; then I can only but agree with you, to the nth degree.

      1. Hi Natasha

        Thanks for responding.

        I’m honestly unsure how to respond back, because of the two tones in your comment.

        “We agree to disagree + some reflections on the above piece” is a far better place for conversation than the first impression given by “There are many inaccuracies in this article, unfortunately”, something which immediately caused me concern given the sensitivity of the topic and the time I spent to try and avoid any such inaccuracies. So it is helpful to have that clarified, that we are dealing with differences in opinion – always welcome – not misreporting of the facts. It’s a basis to maybe have a conversation from.

        One fruitful conversation might have been for us to take a step back on the issue around the term “judgment”, where it looks like I did take something different from the conversation than you intended, and look at the more interesting ideas beyond the disagreement.

        One thing I see is that you are concerned that adults are prey to socially produced facts and beliefs that cloud their judgment. It could be interesting to explore what you think about children: are they less contaminated by such social conditioning, or simply exposed to another set? And if relatively uncontaminated, where are their thoughts, attitudes, preferences coming from: their genes? The pure, Roussean state of nature? God? I’m not asking these questions facetiously. I don’t have a set of predetermined answers. (I’ve set up kid’s councils where they are given the remit to solve adults’ problems, reversing the typical hierarchy; I have hundreds of hours working creatively with young people to see the kinds of habits and insights they produce.) And I don’t think this is baggy waffle to explore, I do think ultimately it has something to say about the matter in hand. So that could be a good conversation to have.

        On the other hand, I’m unhappy that you’ve decided a good move in this discussion was to analyse me. I was careful not to generalise from my disagreements with your statements to the kind of person you must be. But meanwhile you claim to have discovered my hidden fears, biases and catastrophic projections, which has personalised the discussion. I have no obligation to talk to you, however many smiley faces are sprinkled into the text, and this robs me of appetite to go further, as I can’t see a good-faith discussion happening under those conditions. It’s a shame.

        I’ll close on where we do agree. We benefit from ridding ourselves of prejudice: “preconceived opinion that is not based on reason or actual experience.” Seeing things that are not the case because we wish them to be. I would wish any clinician to be as free of prejudice as possible. That’s why I report on the evidence as clearly as I can. If it is contestable and highly debatable, then show that: I’m happy to have the debate.



      2. Hi Natasha,

        I appreciate and stand by the comments, insights and notions you’ve addressed in your responses!
        I was wondering if you have social media at all I would be able to follow you on?

        Thank you for articulating your argument clearly (in what I personally believe to be a very nuanced and measured way)!

      3. The way you put it…, backed by the freshly squeezed paradigm: non-bias (or anarchic bias) as the new trend,… just starts the countdown to extinction…

        Altering hormones, chromosomes and genes – just if kids will say they felt unusual lately – will lead to situations almost impossible to control for the new generations of children to come.

  4. In this study, “No adolescent withdrew from puberty suppression, and all started cross-sex hormone treatment, the first step of actual gender reassignment.” from a group of 70.

    (I don’t know how they determined eligible candidates)

    Puberty suppression by means of gonadotropin-releasing hormone analogues (GnRHa) is used for young transsexuals between 12 and 16 years of age. The purpose of this intervention is to relieve the suffering caused by the development of secondary sex characteristics and to provide time to make a balanced decision regarding actual gender reassignment.

    To compare psychological functioning and gender dysphoria before and after puberty suppression in gender dysphoric adolescents.

    Of the first 70 eligible candidates who received puberty suppression between 2000 and 2008, psychological functioning and gender dysphoria were assessed twice: at T0, when attending the gender identity clinic, before the start of GnRHa; and at T1, shortly before the start of cross-sex hormone treatment.

    Behavioral and emotional problems (Child Behavior Checklist and the Youth-Self Report), depressive symptoms (Beck Depression Inventory), anxiety and anger (the Spielberger Trait Anxiety and Anger Scales), general functioning (the clinician’s rated Children’s Global Assessment Scale), gender dysphoria (the Utrecht Gender Dysphoria Scale), and body satisfaction (the Body Image Scale) were assessed.

    Behavioral and emotional problems and depressive symptoms decreased, while general functioning improved significantly during puberty suppression. Feelings of anxiety and anger did not change between T0 and T1. While changes over time were equal for both sexes, compared with natal males, natal females were older when they started puberty suppression and showed more problem behavior at both T0 and T1. Gender dysphoria and body satisfaction did not change between T0 and T1. No adolescent withdrew from puberty suppression, and all started cross-sex hormone treatment, the first step of actual gender reassignment.

    Puberty suppression may be considered a valuable contribution in the clinical management of gender dysphoria in adolescents.

      1. It doesn’t seem that the authors of that study would agree:

        “At the Amsterdam gender identity clinic, adolescents are eligible for puberty suppression when they are diagnosed with GID, have shown persistent gender dysphoria since childhood, live in a supportive environment, and have no serious comorbid psychiatric disorders that may interfere with the diagnostic assessment. For example, it can be complicated to disentangle whether the gender dysphoria evolves from a general feeling of being just “different” or a
        whether a true “core” cross-gender identity exists in adolescents who suffer from an autistic spectrum disorder”

      2. Yes – from their introduction p2277. I wish more of this work was open-access, it’s frustrating to cut so many people off from this information!

      3. Yes, lack of access is frustrating. I did a Google scholar search before following up to get a citation trail to see recent papers that cite the 2010 one I found, but I can’t really get to those easily. This means I can’t make an informed reply.

        My emotional knee-jerk reaction is that parents might have a knee-jerk reaction not to support their kids based on thinking they are crazy.

      4. It’s a complicated situation with different competing social forces acting upon the situation. And the costs/risks are still something we’re getting to grips with, so I can well understand some parents tending to, if not “you’re crazy”, some sort of resistant or (over-) cautious attitude. So I think there is something in your intuition, just the question is whether it’s correct to build institutional pushback against those attitudes. Because we don’t really know how cautious is over-cautious yet.

      5. As an aside, it would be a cheap move here if you are trying something to demonstrate motivated cognition and dealing with issues like identity-protection a la “Motivated numeracy and enlightened self-government’.

        KAHAN, D., PETERS, E., DAWSON, E., & SLOVIC, P. (2017). Motivated numeracy and enlightened self-government. Behavioural Public Policy, 1(1), 54-86. doi:10.1017/bpp.2016.2

        (I follow their blog too)

      6. Sorry about that, I went off on a tangent pondering how hard it is for me to think about this subject with any skill, and it got me to thinking about bias and motivated reasoning. And then I remembered that paper where they had people evaluate results where they showed people reached different conclusions based on whether the numbers were described as results on gun control findings versus findings on a treatment for a skin rash, iirc. Those types of findings often leave me with little confidence in my ability to reason about things in which I am not an expert.

        Anyway, after going down that tangent it had me wondering how differently I’d reason if you were presenting us with results about something much more neutral.

      7. Although an alternative interpretation is that puberty suppressors may actually increase the likelihood of persisting with a trans identity and needing long term, sterilising medical treatment. If left to their own devices, the majority of gender non-conforming kids/trans kids will ‘desist’, or not identify as trans by adulthood. So it seems odd that this does not happen to anyone on puberty suppressors. If they were a neutral waiting tool, you would expect the same rates of desistance.

        It may well be that developing an adult sexed body is actually crucial to helping children negotiate, and come to terms with, the complexities of gender and sexuality. Of course, some people may get to adulthood and still feel transition is the only possibility for them to live well. But it seems like a huge gamble to assume we can tell who these people will be at age 13.

      8. Laura, I question your assertion about the majority of children choosing normal gender identities, but I want to set that aside and recommend that you discuss those fears with your child’s or relative’s doctors. I am not an endocrinologist. If I had a child, I would read up on the outcomes of people who take GnRHa (they are used in the treatment of adults and adolescents for many different conditions), and discuss all of this with multiple doctors.

        One of the risks of going without treatment is higher risk of suicide. I don’t have a child (or a relative) who is in need of treatment, thus I don’t have a lot of details for you on all risks but that is a big one.

    1. This study was only following kids for 10 years at the most, these children have not had enough time to mature and express themselves to know if they will change their views. Many de-transitioners are talking about this in hindsight, afraid to embarrass themselves, trans identified males are doing utube uploads on how this was a mistake for them. It’s a small sample too.

      1. Trans identified females are uploading detransitions stories even more so…also can be seen in BBC documentary Transgender Kids.

      2. In response to the BBC documentary reference, it is too bad that it keeps getting pulled and cancelled. At least half of it presents a pro-transition approach! The transactivists are so threatened by any attempt at a balanced debate.

        A parent has no where to turn. Go ahead and conduct an internet search on helping your child who has said they are transgender -please! You will see no professional help for anyone thinking that their child might not actually be transgender! It is all protransition as if it is a foregone conclusion that your child is infallible and, of course, transgender. The APA guidelines recommend affirmation therapy as a first-line approach regardless of research to the contrary as shown on page 842 of “Guidelines for Psychological Practice With Transgender and Gender Nonconforming People,” American Psychologist, December 2015.

        The name-calling and attacks on people speaking out (, the firing of a highly esteemed gender expert (“How the Fight Over Transgender Kids Got a Leading Sex Researcher Fired,” New York Magazine, February 7, 2016″), the blocking of research into detransition at a University (, the sensationalism in the media (see You Tube sensation Miles McKenna who targets adolescents and who is on tour now), and the civil rights campaign (Facebook memes and etc.), are absurd examples of the lack of a scientific approach to a psychological problem. Add to that the no platforming at gender conferences (pulling scheduled speakers on two topics: how to treat the detransitioned patient and alternative treatments to affirmation therapy at the Philadelphia 2017 conference

        A good scientist listens and responds to critical thinking and acknowledges flaws in research. This black-out of parents, gender experts who don’t line-up with the pro-transition approach, and the whole public relations push shows there are no quality scientist leading this “cause.”

  5. I’m questioning the title.. if, as I suspect based on past research, the “multiple other psychological issues” are due to stigma and other effects of gender roles and discrimination based on lack of conformity .. doesn’t the title invite further bias by people who are ignorant and/or cissexist?

    1. Hi Meghan,

      The title simply describes the factual findings of the study. What would you prefer the title to be doing if not stating the facts?

  6. I remain greatly concerned that the memorandum of understanding signed by the BPS here:
    is preventing therapists from exploring other causes of gender difficulties and alternatives to transition with their clients for fear of being accused of conversion therapy, (whether in fact they are actually prevented from doing so, this appears to be the effect).
    This is especially relevant to young adults, who, although over the age of 18, do not have (rightly) the involvement of their parents in their care, and may have significant comorbid mental health or developmental difficulties and delayed emotional maturity. Being offered surgery and hormones in these circumstances seems to favour a social justice solution, in preference to continued psychotherapeutic support for those difficulties until such time as they are managed and a greater maturity reached.

  7. Pingback: CAMHS Update
  8. FTA: “However, when a child with gender dysphoria is “insistent, persistent, and consistent” over an extended period, then (under the gender affirmative approach) this is typically treated as a good indicator that it is appropriate to begin facilitating the transition process.”

    Transition process…from what to what?

    There is no possible way to scientifically “transition” a man into a woman nor vice-versa, though you can butcher them and fill them with hormones to give somewhat of the appearance. Biologically, that man remains a man, or the woman who “transitions’ remains a woman.

    You can alter the appearance, that’s it. Seems a drastic way to solve an emotional problem.

  9. Wow, what an great article , I really like it very much. The information you have provided in your article regarding teen agers is really helping me a lot. I am also a mom of two children’s and I am afraid of their behavior. Keep sharing you tips like this and i definitely going to follow your tips.

  10. I think the belief boys should be strong allows more and increased aggressive treatment of boys by family members, teachers, peers, others, society from one year of age. This also includes much less kind, stable, verbal interaction and less mental emotional support for fear of coddling. At the same time as girls we are given much more kind, stable, verbal interaction and other continuous supports from infancy through adulthood. While this differential treatment is creating many more failing boys in school and more successful girls in school, this is also creating other social outcomes. I feel boys or girls, but mostly boys, may feel at such a young age much more and very intently, this differential, more aggressive, less supportive treatment as early as two years of age. Note, the aggressiveness and/or more neglect in areas allowed upon boys, even very young boys falls on a continuum of from very little differential treatment to much more, even severe, differential treatment. So we cannot reflect our personal experience upon those experiencing the more severe cases, especially at such young ages. Such boys may intensely recognize sufficiently large differences in love, protection, support, care, interaction, attention, etc. between themselves and those of the opposite gender (girls) that it creates very significant feelings of inadequacy and vulnerability. I feel such recognition of “sufficient enough differential treatment” could easily create long-term if not permanent or traumatic feelings of inadequacy in a young child, thus feeling more long-term adequacy and security in the role of the other gender. I can only imagine a two year old who is unable to understand cognitively the reasons for this more harsh, differential treatment would probably feel much more vulnerable and much more insecure in their present position of gender or as a boy. So the problem may not be not being tough enough on a boy, but rather creating sufficient contrast in love, honor, protection, attention, support, etc. They may then seek to escape that given position “as a Male” in different ways so as to remove the more harsh treatment and gain the more supportive treatment they may see girls and women receiving. So anything male would create a more psychological connection to more feelings of more vulnerability and by dressing, acting, other actions as opposite gender, they then have more feelings of at least the modeled care, attention, love, etc. they see those of the opposite gender receiving. This may include many forms of immature or childish ways to remove signs of male presentation and create more feminine characteristics as a way to remove those feelings of vulnerability and create in their minds greater psychological feelings of more safety, love, attention, etc. This belief could easily increase over time in different ways. Such observations may be “sufficiently intense” so that even over time, with no indications, the feelings of vulnerability, hurt, and feelings of inadequacy would remain although perhaps overtly covered. Note, this has nothing to do with homosexuality, unless “some may go in that direction later on their own”. In these instances, this would represent something very different, “other than the more driving purpose, to relieve in their minds, those early feelings of inadequacy. So we have two distinct areas: one is to remove psychological distress; and the “second later”, the unscriptural idea of relationships with same gender. Of course in some families such as this, the child may be allowed more easily to verbalize, communicate, and identify more with the gender they may feel is given more protection, support, care, love, attention, etc. We cannot reflect our own lives upon others. I feel unless we begin to recognize how the gross differential treatment of boys and girls is creating very different academic outcomes and now very real differences in economic outcomes greatly favoring girls and women due to better treatment, we will eventually create a very different two class society by gender.
    As for girls desiring to be boys, could this also be some form of sociological desire for forms of protection, support, etc. from extreme experiences they may have had and so feel more comfortable removing from their minds, their present gender for some reason.

  11. I believe what you wrote waas very reasonable. However, think about this, whyat if you typed a
    catchier title? I mean, I don’t want to tell you how to
    run your website, but suuppose yoou added a headline that makes people want more?
    I mean Most children and teens with gender dysphoria apso hage multiple other sychological issues –
    Research Digest iss kinda boring. You might glance at Yahoo’s front page
    and see how they creqte news headlines too grab people
    to click. Yoou might add a video or a related picture
    or two to get people interestted about what you’ve written. Just my opinion, it might make yor posys a little livelier.

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