Thomas D. Steensma

Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment

BACKGROUND: In recent years, puberty suppression by means of gonadotropin-releasing hormone analogs has become accepted in clinical management of adolescents who have gender dysphoria (GD). The current study is the first longer-term longitudinal evaluation of the effectiveness of this approach. METHODS: A total of 55 young transgender adults (22 transwomen and 33 transmen) who had received puberty suppression during adolescence were assessed 3 times: before the start of puberty suppression (mean age, 13.6 years), when cross-sex hormones were introduced (mean age, 16.7 years), and at least 1 year after gender reassignment surgery (mean age, 20.7 years). Psychological functioning (GD, body image, global functioning, depression, anxiety, emotional and behavioral problems) and objective (social and educational/professional functioning) and subjective (quality of life, satisfaction with life and happiness) well-being were investigated. RESULTS: After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. Well-being was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being. CONCLUSIONS: A clinical protocol of a multidisciplinary team with mental health professionals, physicians, and surgeons, including puberty suppression, followed by cross-sex hormones and gender reassignment surgery, provides gender dysphoric youth who seek gender reassignment from early puberty on, the opportunity to develop into well-functioning young adults.

Puberty Suppression in Adolescents With Gender Identity Disorder: A Prospective Follow‐Up Study

INTRODUCTION Puberty suppression by means of gonadotropin-releasing hormone analogues (GnRHa) is used for young transsexuals between 12 and 16 years of age. The purpose of this intervention is to relieve the suffering caused by the development of secondary sex characteristics and to provide time to make a balanced decision regarding actual gender reassignment. AIM To compare psychological functioning and gender dysphoria before and after puberty suppression in gender dysphoric adolescents. METHODS Of the first 70 eligible candidates who received puberty suppression between 2000 and 2008, psychological functioning and gender dysphoria were assessed twice: at T0, when attending the gender identity clinic, before the start of GnRHa; and at T1, shortly before the start of cross-sex hormone treatment. MAIN OUTCOME MEASURES Behavioral and emotional problems (Child Behavior Checklist and the Youth-Self Report), depressive symptoms (Beck Depression Inventory), anxiety and anger (the Spielberger Trait Anxiety and Anger Scales), general functioning (the clinicians rated Childrens Global Assessment Scale), gender dysphoria (the Utrecht Gender Dysphoria Scale), and body satisfaction (the Body Image Scale) were assessed. RESULTS Behavioral and emotional problems and depressive symptoms decreased, while general functioning improved significantly during puberty suppression. Feelings of anxiety and anger did not change between T0 and T1. While changes over time were equal for both sexes, compared with natal males, natal females were older when they started puberty suppression and showed more problem behavior at both T0 and T1. Gender dysphoria and body satisfaction did not change between T0 and T1. No adolescent withdrew from puberty suppression, and all started cross-sex hormone treatment, the first step of actual gender reassignment. CONCLUSION Puberty suppression may be considered a valuable contribution in the clinical management of gender dysphoria in adolescents.

Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study.

The aim of this qualitative study was to obtain a better understanding of the developmental trajectories of persistence and desistence of childhood gender dysphoria and the psychosexual outcome of gender dysphoric children. Twenty five adolescents (M age 15.88, range 14–18), diagnosed with a Gender Identity Disorder (DSM-IV or DSM-IV-TR) in childhood, participated in this study. Data were collected by means of biographical interviews. Adolescents with persisting gender dysphoria (persisters) and those in whom the gender dysphoria remitted (desisters) indicated that they considered the period between 10 and 13 years of age to be crucial. They reported that in this period they became increasingly aware of the persistence or desistence of their childhood gender dysphoria. Both persisters and desisters stated that the changes in their social environment, the anticipated and actual feminization or masculinization of their bodies, and the first experiences of falling in love and sexual attraction had influenced their gender related interests and behaviour, feelings of gender discomfort and gender identification. Although, both persisters and desisters reported a desire to be the other gender during childhood years, the underlying motives of their desire seemed to be different.

Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study

OBJECTIVE To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence. METHOD The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence. RESULTS We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls. CONCLUSION Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.

Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria.

INTRODUCTION The number of adolescents referred to specialized gender identity clinics for gender dysphoria appears to be increasing and there also appears to be a corresponding shift in the sex ratio, from one favoring natal males to one favoring natal females. AIM We conducted two quantitative studies to ascertain whether there has been a recent inversion of the sex ratio of adolescents referred for gender dysphoria. METHODS The sex ratio of adolescents from two specialized gender identity clinics was examined as a function of two cohort periods (2006-2013 vs. prior years). Study 1 was conducted on patients from a clinic in Toronto, and Study 2 was conducted on patients from a clinic in Amsterdam. RESULTS Across both clinics, the total sample size was 748. In both clinics, there was a significant change in the sex ratio of referred adolescents between the two cohort periods: between 2006 and 2013, the sex ratio favored natal females, but in the prior years, the sex ratio favored natal males. In Study 1 from Toronto, there was no corresponding change in the sex ratio of 6,592 adolescents referred for other clinical problems. CONCLUSIONS Sociological and sociocultural explanations are offered to account for this recent inversion in the sex ratio of adolescents with gender dysphoria.

Treatment of Adolescents With Gender Dysphoria in the Netherlands

In the Netherlands, gender dysphoric adolescents may be eligible for puberty suppression at age 12, subsequent cross-sex hormone treatment at age 16, and gender reassignment surgery at age 18. Initially, a thorough assessment is made of the gender dysphoria and vulnerabilities in functioning or circumstances. Psychological interventions and/or gender reassignment may be offered. Psychological interventions are offered if the adolescent needs to explore gender identity and treatment wishes, suffers from coexisting problems, or needs support and counseling during gender reassignment. Although more studies are necessary, this approach seems to contribute significantly to the well-being of gender dysphoric adolescents.

Gender Transitioning before Puberty

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.

2D:4D finger-length ratios in children and adults with gender identity disorder

Previous research suggests that prenatal testosterone affects the 2D:4D finger ratio in humans, and it has been speculated that prenatal testosterone also affects gender identity differentiation. If both things are true, then one would expect to find an association between the 2D:4D ratio and gender identity. We measured 2D:4D in two samples of patients with gender identity disorder (GID). In Study 1, we compared the 2D:4D ratios of 96 adult male and 51 female patients with GID to that of 90 heterosexual male and 112 heterosexual female controls. In Study 2, we compared the 2D:4D ratios of 67 boys and 34 girls with GID to that of 74 control boys and 72 control girls. In the sample of adults with GID, we classified their sexual orientation as either homosexual or non-homosexual (in relation to their birth sex) to examine whether or not there were any within-group differences as a function of sexual orientation. In the sample of adult men with GID (both homosexual and non-homosexual) and children with GID, we found no evidence of an altered 2D:4D ratio relative to same-sex controls. However, women with GID had a significantly more masculinized ratio compared to the control women. This last finding was consistent with the prediction that a variance in prenatal hormone exposure contributes to a departure from a sex-typical gender identity in women.

Psychosexual Development in Adolescents and Adults with Disorders of Sex Development—Results from the German Clinical Evaluation Study

INTRODUCTION Both biological and psychosocial factors influence psychosexual development. High levels of pre- and postnatal androgens lead to more male-typical behavior. So far, the influence of androgens on gender identity and sexual orientation is unclear. Disorders of sex development (DSDs) are heterogeneous genetic conditions with different levels of prenatal androgens resulting in variations of genital development. Through DSD, the role of the different factors, especially androgen exposure, on psychosexual development can be evaluated. AIM The purpose of the study was to assess psychosexual development in adolescents and adults with different forms of DSD. METHODS For the examination of psychosexual development of 66 adolescents and 110 adults with DSD, the authors used the Utrecht Gender Dysphoria Scale for adolescents, the Questionnaire of Gender Identity for adults, and a condition-specific DSD study questionnaire. Individuals were analyzed in four subgroups reflecting the karyotype, absence/presence of androgen effects, and gender of rearing. MAIN OUTCOME MEASURES Main outcome measures used were gender identity, friendships, love and sexual relationships, and sexual orientation in adolescents and adults with DSD. RESULTS Individuals with DSD did not show increased gender dysphoria. However, partnership and sexuality were identified to be difficult areas of life. Both adolescents and adults with DSD reported fewer experiences regarding love or sexual relationships compared with unaffected individuals. Especially men with DSD and undervirilization and women with DSD and androgen effects less often had a love relationship. Adult women with DSD and androgen effects more frequently engaged in love and sexual relationships with individuals of the same gender compared with women without DSD. CONCLUSION Individuals with DSD experience atypical hormonal influences (higher levels of androgens in girls/women and lower levels in androgens in boys/men); however, they did not show increased gender dysphoria in this study. However, partnership and sexual relationships are difficult areas of life for adolescents and adults with DSD. We recommend that individuals with DSD should get support from a multiprofessional team with competency in assessing and counseling issues regarding relationships and sexuality. Contact to other individuals with DSD can be helpful for nonprofessional support and exchange of experiences.

Gender Variance in Childhood and Sexual Orientation in Adulthood: A Prospective Study

INTRODUCTION Several retrospective and prospective studies have reported on the association between childhood gender variance and sexual orientation and gender discomfort in adulthood. In most of the retrospective studies, samples were drawn from the general population. The samples in the prospective studies consisted of clinically referred children. In understanding the extent to which the association applies for the general population, prospective studies using random samples are needed. AIM This prospective study examined the association between childhood gender variance, and sexual orientation and gender discomfort in adulthood in the general population. METHODS In 1983, we measured childhood gender variance, in 406 boys and 473 girls. In 2007, sexual orientation and gender discomfort were assessed. MAIN OUTCOME MEASURES Childhood gender variance was measured with two items from the Child Behavior Checklist/4-18. Sexual orientation was measured for four parameters of sexual orientation (attraction, fantasy, behavior, and identity). Gender discomfort was assessed by four questions (unhappiness and/or uncertainty about ones gender, wish or desire to be of the other gender, and consideration of living in the role of the other gender). RESULTS For both men and women, the presence of childhood gender variance was associated with homosexuality for all four parameters of sexual orientation, but not with bisexuality. The report of adulthood homosexuality was 8 to 15 times higher for participants with a history of gender variance (10.2% to 12.2%), compared to participants without a history of gender variance (1.2% to 1.7%). The presence of childhood gender variance was not significantly associated with gender discomfort in adulthood. CONCLUSIONS This study clearly showed a significant association between childhood gender variance and a homosexual sexual orientation in adulthood in the general population. In contrast to the findings in clinically referred gender-variant children, the presence of a homosexual sexual orientation in adulthood was substantially lower.