Gender Transitioning before Puberty?

Abstract

Inthelastdecade,delayingpubertybymeansofGnRHanalogsingenderdysphoricadolescentshasbecomeanincreasinglyaccepted treatment (Hembree et al., 2009). The induced puber-tal delay is meant to give gender dysphoric adolescents time toreflect on their wish for gender reassignment, quietly and with-outthealarmingphysicalpubertydevelopment.Duringpubertysuppression,acompletesocialtransition(changeinclothingand hair style, first name, and use of pronouns) is not required.However, most youth who are on puberty delaying hormonesappear not to wait with transitioning until they can start cross-sex hormone treatment.A similar trend can be observed in gender variant prepu-bertalchildren.Forquitesometim e,gendervariantchildrenwhocametoclinicalattentionweret reatedbypsychotherapywiththepurpose of decreasing cross-ge nder behavior and identification(Zucker, 2008). More recently, a more gender affirmativeapproachhasbeen proposed (e.g., Saeger, 2006). Thisapproachmayinvolvecompletesocialtrans itioning(includingachangeoffirst name and pronouns) of children as young as 4 or 5years ofage.Evenwithoutcontactingclinicians,anincreasingnumberofparents also support young children in their wish to live in thedesired gender role on a daily basis. Before the year 2000, 2(1.7%) prepubertal boys out of 112 referred children to theAmsterdam gender identity clin ic were living completely in thefemale role. Between 2000 and 2004, 3.3% (4 out of 121 chil-dren; 3 boys and 1 girl) had completely transitioned (clothing,hairstyle,changeofname,anduseofpronouns)whentheywerereferred, and 19% (23 out of 121 children; 9 boys and 14 girls)were living in the preferred gender role in clothing style and hair-style,butdidnotannouncethattheywantedanameandpronounchange.Between2005and2009,thesepercentagesincreasedto8.9%(16outof180children;10boysand6girls)and33.3%(60out of 180, 17 boys and 43 girls) respectively.Suchanapproach assumes a high persistence of gender dys-phoria or gender identity disorder (GID) after puberty. How-ever, follow-up studies show tha t the persistence rate of GID isabout 15.8% (39 out of the 246 children who were reported onin the literature) (for an overview, see Steensma, Biemond, deBoer, & Cohen-Kettenis, 2011), and that a more likely psy-chosexual outcome in adulthood is a homosexual sexual ori-entationwithoutgenderdysphoria(Wallien&Cohen-Kettenis,2008).We wondered what would happen to children who transi-tioned in childhood, but discover at an older age that they pre-ferredtoliveinthegenderroleof theirnatalsexagain.Recently,we conducted a qualitative study among older adolescents whohadbeengenderdysphoricinchildhood(Steensmaetal., 2011).Someofthesechildrenappearedtobepersistersandtheyappliedforgenderreassignmentwhenenteringpuberty.Othersappearedtobedesistersandwereonlyinter viewedforthefollow-upstudy.Inthedesistinggroup,twogirls, whohadtransitionedwhentheywereinelementaryschool,reportedthattheyhadbeenstrugglingwith the desire to return to their original gender role, once theyrealized that they no longer wanted to live in the‘‘other’’genderrole. Fear of teasing and shame to admit that they had been‘‘wrong’’resultedinaprolongedperiodofdistress.Onlywhentheystartedhighschooldidtheydaretomakethechangeback.Although gender affirmative treatment, including a com-pletesocialtransition,maybebeneficialforchildrenwhowillturnout tobepersisters, cliniciansand caregiversshouldreal-ize that prediction of an individual child’s psychosexual out-come is very difficult in young children. It is conceivable thatthe drawbacks of having to wait until early adolescence (butwithsupportincopingwiththegen dervarianceuntilthatphase)maybelessseriousthanhavingto makeasocialtransitiontwice.