“Psychology Works” Fact Sheet: Gender Dysphoria in Children

Understanding Gender

Before addressing the concept of gender dysphoria in children, some definitions related to gender are important to review. Gender identity is how a person identifies (internally) in their heart, head, and soul; as male, female, both or neither. Gender identity is “who you know yourself to be”; and is increasingly recognized as existing on a continuum, not on a binary. Gender expression is how a person expresses their gender to others (externally) through behavior, clothing, hairstyle, chosen name and pronouns.

For most individuals, their assigned sex at birth (typically initially based on their external genitalia) is congruent with their physical body and their gender identity; the term cisgender is sometimes used to describe them. For individuals whose assigned sex at birth is not the same as their gender identity, the term transgender is sometimes used to describe them. Gender identity is impacted by biological, social, and psychological factors (Edwards-Leeper et al., 2016). One’s sense of their own gender identity begins to emerge during the preschool years; children learn gender constancy and stability during the early school age years (Brill & Peppler, 2008). Gender identity tends to stabilize in preadolescence, and with the onset of puberty, becomes increasingly fixed and consolidated during adolescence. Age 10-13 years appears to be an important developmental stage in which the gender identity of gender diverse youth is determined (Steensma et al., 2011).

Understanding gender diversity is also important. Gender diverse, gender fluid, gender creative, and gender independent are all terms that have been offered to describe children and youth whose gender expression challenges (heteronormative) gender norms. Increasingly, researchers and clinicians have put forth the view that childhood gender nonconformity and gender variance should be understood as part of human diversity and not a reflection of pathology or disorder (e.g., Pyne, 2014). Being gender non- conforming or gender diverse is not a mental health problem. There is nothing wrong or harmful about having traits and behaving in ways that do not conform to gender norms, and children or youth who are gender diverse do not necessarily feel distress or dysphoria. Children and youth who consistently and persistently express a gender identity that is different from their assigned sex at birth, however, may be more likely to experience gender dysphoria (i.e., distress related to their physical body or assigned sex not being aligned with their authentic, internal sense of gender).

What is gender dysphoria?

Gender dysphoria is “discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth and the associated gender role and/or primary and secondary sex characteristics” (WPATH SOC7, 2011). Gender dysphoria is a psychiatric diagnosis that replaced the (arguably more pathologizing) DSM-IV diagnosis of Gender Identity Disorder. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association, 2013) outlines the criteria for gender dysphoria in children as follows: (A) a marked incongruence between one’s experienced and expressed gender and assigned gender (of at least 6 months’ duration) and (B) clinically significant distress or impairment in social, school, or other important areas of functioning associated with this incongruence.

Of note, Rapid Onset Gender (ROGD) s not is not a diagnostic classification or subtype in either the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD), nor is it under consideration for inclusion in future editions. There is no empirical support for the existence of ROGD and no evidence that ROGD aligns with the lived experiences of transgender children and adolescents (Coalition for the Advancement and Application of Psychological Science, July 2021 position statement). In addition to CAAPS, CPATH, WPATH, and APA have expressed concern about the use of ROGD as a pathologizing, invalidating, and harmful term that is not in line with evidence-based affirmative practices.

The cause of gender “atypical” gender development and gender dysphoria are unknown (de Vries & Cohen-Kettenis, 2012). Estimating the prevalence of gender independence and gender dysphoria among children and youth is difficult due to barriers to research, treatment, and disclosure (Meier & Harris, APA fact sheet). It is not possible to predict whether gender independent children will come to identify as cisgender (non-trans) adults, as gender fluid into adulthood, or as transgender individuals who seek social and/or medical gender transition (Pyne, RHO fact sheet). Persistence, insistence, consistency of cross-gender identity, significant body dysphoria, and/or greater distress during puberty is more commonly seen among gender diverse children who go on to identify as transgender teens/adults (Edwards-Leeper et al., 2016, Ehrensaft, 2011).

Treatment of Gender Dysphoria

The World Professional Association of Transgender Health Standards of Care, Version 7 (WPATH SOC 7, 2011) offers guidance for mental health professionals in the care of gender diverse and transgender people, including children and youth. Version 8 of these Standards, due to come out in 2021, had not yet been released at the time of this update. In addition to WPATH, psychologists should be aware of practice guidelines from the Endocrine Society (Endocrine Treatment of Gender Dysphoric/ Gender- Incongruent Persons: An Endocrine Society Clinical Practice Guideline, 2017), The Pediatric Endocrine Society (2017), and The American Psychological Association (Guidelines for Psychological Practice with Transgender and Gender Nonconforming People, 2015).

Transgender youth have optimal outcomes when affirmed in their gender identity, through support by their families and their environment, as well as when they can access appropriate mental health and medical care. There is increasing evidence that gender affirming care, including social transition (gender expression, name, clothing), psychotherapy (affirmative models), and medical transition (hormone blockers or replacement, surgery to change sex characteristics) lessens distress, and improves mental health outcomes (Edwards-Leeper et al, 2016). In contrast, children and youth who are not able to freely express their gender in key contexts (family, school) appear to be at greater risk of negative psychosocial outcomes. Lack of parental support is a key area of distress for trans and gender diverse youth (for example, there is a 14x greater rate of attempted suicide among youth whose gender identity is not supported by parents; Travers et al., 2012).

Evidence overwhelmingly indicates that children are “harmed by family and societal rejection and by attempts to change their gender identity or gender expression” (Minter, 2012, p. 422). Psychologists should be aware that The World Professional Association of Transgender Health (WPATH) has declared treatments that aim to change an individual’s gender identity or gender expression (sometimes referred to as “conversion therapies”) are not ethical. Beyond WPATH, other practice statements that condemn conversion therapy have been put forth, and several provinces (Manitoba, Nova Scotia, Ontario, PEI, as well as municipalities of Calgary and Vancouver) also done so. The federal government had been poised to ban conversion therapy prior to the 2021 Federal Election but was unsuccessful in obtaining enough legislative support to do so.

Many youth with gender dysphoria will want or need to transition, which may involve social transition (changing dress, name, pronoun), and, for older youth and adolescents, medical transition (hormonal and surgical intervention; RHO fact sheet). Gender affirming treatment may take the form of hormone

blockers or hormones or surgery, with the aim of bringing one’s physical body in line with their felt gender. The ability to transition (socially and medically) are often essential in the treatment of gender dysphoria. Gender affirming models of treatment, which aim to destigmatize gender variance, help children build resilience and become comfortable with themselves and their preferred identity, and help parents support their child, have been associated with better mental health outcomes among children and youth.

What is the Psychologist’s Role?

A psychologist can assist in doing an assessment to clarify a gender dysphoria diagnosis and to rule out or in other mental health concerns. The purpose of diagnostic clarification is not to pathologize or stigmatize but rather to validate and support access to gender affirming care including eligibility for medical treatment.

Children with gender dysphoria and their families may benefit from psychological treatments aimed at helping them with mood- and anxiety-related problems, which are not uncommon, but may or may not be related to gender issues. Psychologists can help children and their families cope with distress related to gender dysphoria and associated problems, and situations where others are less understanding of the child’s self-expression and behaviour.

The psychologist can also help the child and family navigate decisions regarding timing and extent of social and medical transition should they choose to pursue it. A psychologist also may help the child cope with any difficulties resulting from expressing their gender differently from their peers. Psychologists can provide opinions about a child’s eligibility and readiness for hormone blockers, and for adolescents’ eligibility and readiness for hormone therapy or gender affirming surgery.

Parents and caregivers have increasingly been identified as an important system for intervention. The importance of family support and acceptance for transgender youth in terms of better mental health, self-esteem, and significantly decreased suicidality have been demonstrated in recent studies (e.g., Veale et al., 2015). Psychologists may provide assistance to parents in terms of helping them accept, validate and best support their child and their gender expression.

Finally, psychologists can provide consultation to pediatricians and general medical practitioners about the development of gender identity, and guidance around gender affirming care and empirically validated practices for the care of gender diverse and transgender children and youth. Psychologists may also play an advocacy role for children and their families in ensuring the school environment and other systems (e.g., CFS) are accepting and accommodating of gender diversity.

REFERENCES

American Psychiatric Association. (2003). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Brill, S., & Peppler, R. (2008). The transgender child. A handbook for Families and Professionals. San Francisco, California: Cleis Press.

Coalition for the Advancement and Application of Psychological Science (CAAPS) Position Statement on Rapid Onset Gender Dysphoria (ROGD), July 2021.

de Vries, A., & Cohen-Kettenis, P.T. (2012) Clinical management of gender dysphoria in children and adolescents: the Dutch approach. J Homosex 59:301–320.

Edwards-Leeper, L., Leibowitz, S., Sangganjanavanich, V. F., Singh, A., Gonsiorek, J. C., dickey, l. (2016). Affirmative Practice with Transgender and Gender Nonconforming Youth: Expanding the Model.

Psychology of sexual orientation and gender diversity, 2016-06, Vol.3 (2), p.165-172

Ehrensaft, D. (2011). Gender born, gender made: Raising healthy gender non-conforming children. Meier, C., & Harris, J. APA Fact Sheet: Gender diversity and transgender identity in children.

Minter, S. (2012). Supporting transgender children: New legal, social, and medical approaches. Journal of Homosexuality, 59, 422-433.

Pyne, J. (2014). Gender independent kids: A paradigm shift in approaches to gender non-conforming children. Canadian Journal of Human Sexuality, 23(1), 1-8.

Pyne, J., and Rainbow Health Ontario (2015). RHO Fact Sheet: Supporting gender independent children and their families.

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; 16:499–516.

Travers R, Bauer G, Pyne J, Bradley K. For the Trans PULSE Project (2012). In: Gale, L., Papadimitriou M, editors. Impacts of strong parental support for trans youth: a report prepared for children’s aid society of Toronto and Delisle youth services.

Veale, J. Saewyc, D., Frohard-Dourlent, H., Dobson, S., Clark, B & the Canadian Trans Youth Health Survey Research Group (2015). Being safe, being me: Results of the Canadian Trans Youth Health Survey.

Vancouver, BC: Stigma and Resilience Among Vulnerable Youth Centre, School of Nursing, University of British Columbia.

World Professional Association for Transgender Health (2011). Standards of care for the health of transsexual, transgender, and gender nonconforming people. Available at: https://www.wpath.org/

RESOURCES

Canadian Professional Association for Transgender Health (CPATH). CPATH is an interdisciplinary professional organization devoted to the health care of individuals with gender variant identities. https://cpath.ca/en/

World Professional Association for Transgender Health (WPATH; formerly known as the Harry Benjamin International Gender Dysphoria Association). WPATH is an international multidisciplinary professional association devoted to promoting evidence-based care for transgender health. WPATH provides clinical and ethical guidelines (Standards of Care, currently 7th edition, SOC7, 2011) for the care of transgender individuals and those with gender dysphoria. WPATH SOC8 (8th edition of the Standards of Care), anticipated in 2021, was not yet released at the time of this update. https://www.wpath.org/

Rainbow Health Ontario. This provincial program offers educational trainings, public policy advocacy and an online resource database to improve the health of LGBT people and access to competent care. https://www.rainbowhealthontario.ca/

Vancouver Coastal Health Transgender Health Information Program. This BC-wide information hub providing access to information about gender affirming care and supports.  http://transhealth.vch.ca

Canadian Pediatric Society resource on gender identity development https://caringforkids.cps.ca/handouts/behavior-and-development/gender-identity

Where can I get more information?

You can consult with a registered psychologist to find out if psychological interventions might be of help to you. Provincial, territorial and some municipal associations of psychology often maintain referral services. For the names and coordinates of provincial and territorial associations of psychology, go to  https://cpa.ca/public/whatisapsychologist/PTassociations/.

 

This fact sheet was developed for the Canadian Psychological Association by Jennifer Ducharme, Ph.D., C Psych., Department of Clinical Health Psychology, College of Medicine, Faculty of Health Sciences, University of Manitoba.

Revised: October 2021

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