Richard R. Pleak

Gender-Variant Children and Transgender Adolescents

This issue is the third since the beginning of the Child and Adolescents Psychiatric Clinics of North America in 1992 to deal substantially with gender identity issues in youth. The first was Volume 2(3), Sexual and Gender Identity Disorders, in 1993; the second was Volume 13(3), Sex and Gender, in 2004. Two authors in the Volume 2, 1993 issue are contributors here: Drs Zucker and Meyer-Bahlburg; two authors in the Volume 13, 2004 issue are contributors here: Drs Zucker and Reiner. This issue differs from the others in being exclusively about gender identity issues: gender variance and transgenderism. The consulting Clinics editor, Dr Harsh Trivedi, identified a need for his issue in light of recent developments in the field and the increasing numbers of ental health clinicians requesting more information pertaining to these youth. Variations in behavior and personal identity are hallmarks of the human race. When hose variations are to a degree considered by society out of proportion to a erceived normality or to an extreme that may cause harm to the individual or society, he variation is generally regarded as objectionable, abnormal, or pathological. The oncept of what is male or female in most societies today is ingrained in culture argely as dichotomous, male vs female, “Mars” vs “Venus,” one or the other, pposite sexes. Individual variations in maleness or femaleness in behavior and dentity, therefore, challenge this dichotomy and become troublesome for other ndividuals and for society. Over time, such challenges may become gradually more ommonplace, accepted, and eventually normal for a given society. Consider the ft-referenced example of homosexuality, listed as a psychiatric disorder in Diagnosic and Statistical Manual for Mental Disorders until 1973 and seen as challenging conventional opposite-sex eroticism. Since the 1973 depathologizing of homosexuality and since homosexual civil rights events such as Stonewall in 1969, gays and lesbians have been more open and visible, and homosexuality has slowly become more accepted as normal by society. As another example, consider women entering

Acting (to) Out: Approaching Homosexuality in a 15-Year-Old Boy with Anxiety and Depression

JM is a 15-year-old, mixed-race boy who lives with his mother and his 11-year-old sister in a suburb of a large East Coast city. At the time of his initial evaluation, he had been living temporarily in a nearby town with a maternal aunt— an arrangement meant to spare him contact with his abusive father. JM told his aunt that he had been feeling very anxious at school. His aunt noticed that JM also seemed increasingly sad and withdrawn at home, so she decided to bring him in for psychiatric evaluation. JM was examined at the outpatient child psychiatry clinic of a local teaching hospital as part of an academic seminar designed to teach interviewing skills to child psychiatry res-

Assessment and Treatment of Gender Dysphoria and Gender Variant Patients: A Primer for Psychiatrists

The Board of Trustees of the American Psychiatric Association (APA) has approved as a Resource Document a report of the APA Workgroup on Treatment of Gender Dysphoria titled “Assessment and Treatment of Gender Dysphoria and Gender Variant Patients: A Primer for Psychiatrists.” The APA Workgroup was assembled to work toward fulfillment of the recommendations of the APA Task Force on Treatment of Gender Identity Disorder. Although diagnosis and treatment are inextricably linked, they are separate issues. Both the diagnosis and treatment of gender identity disorder were controversial, and the respective DSM-5workgroup set up in May 2008 drew much professional and public attention. Because diagnosis, but not treatment, is within the purview of the DSM, the APA Board of Trustees formed the Task Force on Gender Identity Disorder to 1) conduct a literature review to assess the quality of evidence pertaining to the treatment of gender identity disorder in different age groups and 2) express an opinion as to whether sufficient credible literature existed for APA to take the next step and develop treatment recommendations for gender identity disorder in children, adolescents, or adults as well as for individuals of any age with somatic intersex conditions who experience dysphoria related to their assigned gender. The Task Force reported that, given the nature of gender identity disorder, evidence of the highest quality—the randomized double-blind controlled trial—was not available. The Task Force concluded, nevertheless, that the empirical database supplemented by clinical consensus was sufficient for the development of treatment recommendations. In addition to recommending the development of treatment recommendations, the Gender Identity Disorder Task Force recommended that APA take a number of additional actions, including tasking a specific APA component or other group within the APA to monitor progress with regard to implementing its recommendations, which led to the formation of the APA Workgroup on Treatment of Gender Dysphoria. Despite the recommendation of the Task Force, treatment of gender dysphoria could not be selected for APA Clinical Guideline development because it did not meet prevalence and quality of evidence criteria to be prioritized for consideration by the APA Committee on Practice Guidelines. Several clinical guidelines and standards of care exist to assist mental health professionals in providing care to individuals with gender dysphoria but are not targeted specifically toward psychiatrists. These include the World Professional Association for Transgender Health Standards of Care, version 7, published in 2012, and the American Psychological Association’s Guidelines for Psychological Practice with Transgender and Gender Nonconforming People published in 2015. Although the practice of psychiatry overlaps with that of other mental health fields, psychiatry is unique in several respects. Psychiatrists often have the primary role in the diagnosis and treatment of themajormental illnesses in which gender identity concerns may arise as epiphenomena (e.g., psychotic disorders) as well as in the pharmacological management of psychiatric disorders that may coexist with gender dysphoria, including mood and anxiety disorders, and in monitoring symptoms that may emerge with endocrine manipulation. While targeted specifically to psychiatrists, the APA Workgroup’s Resource Document should be helpful to providers in other disciplines, since all are likely to encounter gender diverse patients. The Resource Document begins with a review of the history and evolution of conceptualizations of gender and gender variance and its classification and related terminology, including differences between DSM-IV and DSM-5. It then examines the prevalence of gender dysphoria and other manifestations of gender variance before reviewing what is known about gender development. The largest portion of the document addresses the mental health assessment and treatment of gender dysphoria in adults, including those with somatic intersex conditions. This includes mental health evaluations and referrals forgender-affirmingsomatic treatments.Thedocument concludes with an examination of current societal trends, including increased social acceptance of gender variance, civil protections for gender diverse individuals, and increased access to gender transition services for adults (specific guidance on thesematters for child and adolescent psychiatrists can be found in the American Academy of Child and Adolescent Psychiatry Practice Parameter on Gay, Lesbian, or Bisexual Sexual Orientation, Gender Nonconformity, and Gender Discordance in Children and Adolescents). The report includes a glossary of gender terminology and tables of the currently most widely accepted criteria for gender-affirminghormonal and surgical treatments. The full Resource Document accompanies the online version of this APA Official Action (ajp.psychiatryonline.org). A version of the report revised through peer review is also available https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944396.