More Than Two Developmental Pathways in Children With Gender Dysphoria?

Abstract

Current prospective studies on the development of children fulfilling diagnostic criteria of gender identity disorder according to the DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR have indicated that the most common psychosexual outcome is homosexuality or heterosexuality without gender dysphoria (GD). 1 Steensma T.D. McGuire J.K. Kreukels B.P.C. Beekman A.J. Cohen-Kettenis P.T. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013; 52: 582-590 Abstract Full Text Full Text PDF PubMed Scopus (230) Google Scholar Across all studies, the persistence rate of GD has been approximately 16%. What should be emphasized is that these studies did not use the fairly strict criteria of the DSM-5, and children could receive the diagnosis based only on gender-variant behavior. With DSM-5 criteria, the persistence rate probably would have been higher. The design in nearly all follow-up studies was to have a first assessment in childhood (before puberty) and a second one in adolescence or young adulthood. The conclusion seemed to be that children with GD are “persisters” (children who remain gender dysphoric in adolescence and seek treatment) or “desisters” (children for whom the GD feelings desisted in adolescence and who do not reapply for treatment), and that the outcome becomes clear in the early stages of puberty. 2 Steensma T.D. Biemond R. de Boer F. Cohen-Kettenis P.T. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry. 2011; 16: 499-516 Crossref PubMed Scopus (247) Google Scholar If one considers retrospective accounts of adult applicants for treatment, many have claimed that they experienced GD in childhood. 3 Nieder T.O. Herff M. Cerwenka S. et al. Age of onset and sexual orientation in transsexual males and females. J Sex Med. 2011; 8: 783-791 Crossref PubMed Scopus (89) Google Scholar Because in most countries treatment for adolescents was not available until very recently, this could be an important practical reason why treatment in these cases was not pursued until adulthood. The question arises as to whether these adults with childhood GD would have sought treatment with puberty blockers as young adolescents 4 Kreukels B.P. Cohen-Kettenis P.T. Puberty suppression in gender identity disorder: the Amsterdam experience. Nat Rev Endocrinol. 2011; 7: 466-472 Crossref PubMed Scopus (106) Google Scholar had it been available, or whether there is a developmental route that is different from the often-described “desistence” and “persistence.”