Gender dysphoria

“I think the greatest thing about being transgender is that one day I will have a grizzly bear type beard and a voice deeper than the Grand Canyon and I will be able to look someone in the eye and say ‘back in the day when I was a girl scout’ and be completely serious.” (Anej Smith, 2016).

The remarkable story of Willa Naylor, the eight-year-old Maltese girl who stole the headlines with her brave decision to go public about her personal experience transitioning to the female gender, has quite surprisingly elicited a rather mute response from the public.

It is quite clear that despite last year’s enactment of the Sexual Orientation, Gender Identity and Gender Expression Act, our nation is ill at ease discussing transsexuality and its challenges. Indeed, the main headlines following this story centered more on the snide comments submitted on Facebook by the so-called online trolls and on the statement issued by the Children’s Commissioner to the effect that it would be harmful if the girl becomes a symbol of the situation of transgender children, rather than on the consequences of “treating” a child with gender dysphoria (GD).

There is now a widespread consensus in psychiatry that gender dysphoria is not a mental illness but still requires treatment. The World Health Organisation (WHO) is proposing to remove the category of gender identity disorders from the section dealing with mental and behavioural disorders in the eleventh revision of its International Statistical Classification of Diseases and Related Health Problems (ICD-11), due by 2018.

Instead it is proposing a new “gender incongruence” category under a new section dealing with “conditions related to sexual health”.

The American Psychiatry Association, publisher of the Diagnostic and Statistical Manual of Mental Disorders (DSM), has made it clear in its latest version of the manual (DSM-5) that while “gender nonconformity is not in itself a mental disorder”, it would be counter-productive removing the condition as a psychiatric diagnosis as this would jeopardise access to care and insurance coverage for treatment.

There is now a widespread consensus in psychiatry that gender dysphoria is not a mental illness but still requires treatment

According to the association, “the critical element of gender dysphoria is the presence of clinically significant distress [i.e. dysphoria] associated with the condition”. In children, this means a “marked incongruence between one’s experiences/expressed gender and assigned gender, of at least six months’ duration”.

Such incongruence must satisfy at least six of the established criteria, including most importantly a strong desire to be of the other gender and the association of the condition with clinically significant distress or impairment in social, school or other important areas of functioning. Treatment for gender dysphoria ranges from therapeutic interventions and psychotherapy to gender reassignment surgery and hormone therapy.

The Endocrine Society approves transgender hormone treatment in the form of puberty-blocking drugs but states that this should not be given before puberty.

In the case of children, almost all treatment options (other than treatment targeting exclusively the distress of the patient) are controversial and offer ethical dilemmas. For instance, children who are diagnosed with GD may in reality be experiencing uncomfortable feelings dealing with narrowly defined gender roles. Others may be homosexual and are coerced into treatment by parents who prefer having children undergoing a sex change rather than having a homosexual child in the household.

Thus it is also important to examine the parents’ motives. While supporters of early medical intervention point out to the elimination of physical and verbal abuse, depression and suicide attempts in the case of children who undergo surgery to start living life as the opposite sex, opponents argue that it’s harmful to have such irreversible treatment too early especially in light of research that suggests that the great majority of children diagnosed with GD cease to desire to be of the other sex by puberty, with most growing up to identify themselves as homosexual.

In a 2013 consensus meeting hosted by the World Professional Association of Transgender Health (WPATH) it was held that at least 80 per cent of children lose their wish to be the opposite sex around puberty and turn out homosexual.

An increasing number of studies including two recent large scale follow-ups confirm this surprising finding. Steensma et. al (2013) found that from a sample of 127 adolescents who were referred for GD in childhood, 63 per cent had lost their trans feelings and developed into gay or lesbian youths. Devita Singh (2012) reported that out of a sample of 139 boys, at follow-up (mean age 21 years) only 17 participants (12.2 per cent) were judged to have persistent gender dysphoria.

In light of these studies, the American Academy of Child and Adolescent Psychiatry holds that further research is required on predictors of persistence and desistance of childhood gender discordance as well as the long-term risks and benefits of intervention before any treatment to eliminate gender discordance can be endorsed.

On its part, WPATH recommends that irreversible treatment (i.e. genital surgery) is not carried out until patients reach the legal age of majority to give consent for medical procedures and have lived continuously for at least 12 months in their desired gender identity.

It also states that children may be eligible for reversible treatment (i.e. puberty-suppressing hormones) but only when pubertal changes have begun. Partially-reversible treatment (i.e. femin-ising/masculinising hormone therapy) may also be applicable although WPATH insists that a decision for such treatment should be made with great caution among the adolescent, the family, and the treatment team.

Julie Ehrt, executive director of Transgender Europe, argues that the World Health Organisation should remove the childhood diagnosis completely from the ICD 11 as it is an unnecessary category: “Children need the freedom to be who they are. But before puberty there is no need for medical treatment and therefore no need for inclusion in the ICD.”

Ultimately while it is arguable whether it is appropriate to give a psychiatric diagnosis and treatment to children with GD, it is obvious that such children and their families need support irrespective of the nomenclature chosen and treatment choices made.

Such support must go beyond the gender’s legal recognition by the State and should at all times involve a multidisciplinary team that specialises in this field.

Claire Axiak is a psychiatrist and psychotherapist at Mental Health Services.