Nov 20, 2019
Jack Drescher, MD, returns to
the MDedge Psychcast, this time to discuss ethical issues raised by
the treatment of gender-variant prepubescent children with MDedge
Psychiatry editor in
chief Lorenzo Norris, MD. The two spoke at the 2019 Group for
Advancement in Psychiatry (GAP)
meeting in White Plains, N.Y.
Dr. Drescher is a Distinguished Life Fellow of the American
Psychiatric Association, past president of GAP, and a past
president of the APA’s New York County Psychiatric Society. He has
a private practice in New York.
And later, in the “Dr. RK”
segment, Renee Kohanski, MD, says
is much more powerful than we
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Three approaches used to address gender-variant
Despite the acceptance of gender
dysphoria as a diagnosis with standardized treatments, the
treatment of gender-variant prepubescent children remains a
controversial area. There are several treatment approaches
regarding how and when a child should have a social transition to
their desired gender.
- The oldest treatment approach
is based on research that shows that most children will grow out of
their gender dysphoria when the therapies applied help the children
get used to living in the body of their assigned gender.
Essentially, this approach
discourages public or private social transition.
is based on research that shows the
difficulty in predicting which children will continue to have
gender dysphoria and which will not. Some children will have
persistent gender dysphoria and become transgender; some may become
homosexual; and others may identify with their own biological sex.
The Dutch approach encourages children to have cross-gender
interests and to privately identify with their desired gender, but
there is not a public social transition.
- Families and clinicians use watchful waiting to
see whether the gender dysphoria persists. It’s based on the idea
that one cannot predict the future and so parents accept the child
wherever they are.
final approach focuses on social transition without a medical or
surgical treatment. Therefore, if the child’s gender dysphoria
desists, they can “detransition,” since there was no medical
gender-affirmative approach, mostly found in the United States,
presupposes that it is possible to identify which children will
persist in their transgender presentations and encourages a public,
social transition to living as their identified gender. In case the
child “makes a mistake,” they can transition back to their
social transition occurs when a child, with the help of clinicians,
explains to the family that they believe the gender dysphoria is
going to last and that the child should be allowed to present
publicly as their desired gender. This includes communicating with
the school, family, and friends to help the child to be treated
respectfully in the gender they desire.
Treatments for gender-variant children
- Puberty suppression is a medical treatment used
by physicians in all three approaches. These medications block sex
hormone action and are used to delay puberty and prevent the
development of undesired secondary sex characteristics of the
biologic sex. Adolescents frequently experience anxiety,
depression, even suicidal ideation during this period because they
feel pressured to choose their gender and avoid developing the
secondary sexual characteristics of their biological
- Social changes are
frequently, children show up at gender clinics already socially
transitioned by their parents; these children outnumber the
subjects in the persist and desist literature. Regardless of the
approach used, parents and clinicians should try to act on the
exigent circumstances to relieve the distress of the
- Patients who are transitioning should be
referred to a specialist, because this is a sensitive topic and
treatment requires expertise.
Shumer DE et al. Advances in the
care of transgender children and adolescents. Adv Pediatr. 2016
Reed GM et al. Disorders related
to sexuality and gender identity in the ICD-11: Revising the ICD-10
classification based on current scientific evidence, best clinical
practices, and human rights considerations.
World Psychiatry. 2016 Oct;15(3):205-21.
Zraick K. Texas father says
7-year-old isn’t transgender, igniting a political outcry.
New York Times. 2019 Oct
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