Many adolescents are adamant about their desire to undergo a partial or complete gender transition (De Vries, Cohen-Kettenis, & Delemarre-van de Waal, 2006a). In one recent survey of gender minority adolescents, 68% of the sample indicated that they had or were currently taking hormones (Grossman et al., 2006). Treatment protocols continue to emerge for gender transitioning in youth (e.g., the Gender Identity Research and Education Society’s guidelines on hormonal medication for adolescents, 2005). The most well-established guidelines were those crafted by the Harry Benjamin International Gender Dysphoria Association, or HBIGDA (now known as the World Professional Association for Transgender Health). This group of multidisciplinary professionals from around the world was formed in 1980. The WPATH established the Standards of Care (SOC) in order to provide minimal criteria for determining how and when to recommend interventions like hormone therapy and sex reassignment surgery to gender minorities. The current SOC (Meyer et al., 2001) contains guidelines specifically for the treatment of children and adolescents with GID.
The SOC for adult treatment are often referred to as a triadic therapy because these consist of hormone therapy, real-life experience, and sex reassignment surgery. Generally, all candidates for sex reassignment are required to have a written endorsement from mental health providers as a requirement for access to hormonal therapy and surgery. For those who are born biological male, an evaluation is required by an experienced therapist to verify the diagnosis of GID. Then they can begin taking feminizing hormones, which cause loss of muscle, redistribution of fatty tissue, and softening of the skin. The next step is the real-life experience in which the client begins living as a woman. If sex reassignment surgery is desired, the client must have two letters of documentation, one of which must be from a doctoral-level mental health specialist. Electrolysis and cosmetic procedures may follow.
In the case of a biological woman, a psychological evaluation is required before testosterone can be administered. Once testosterone is given, the patient typically experiences an increase in muscle mass, body and facial hair growth, voice lowering, and acne. Two separate recommendations are needed before a bilateral mastectomy can be performed. This usually occurs before the real-life experience. Penile constructive surgeries may be performed, although they are not regarded as fully successful (Seil, 2004).
The SOC (Meyer et al., 2001) for children and adolescents contain recommendations for two different forms of treatment interventions. The first category, termed psychological/social, refers to interventions that involve providing parents with support for managing the child’s gender expression. For example, practitioners might help parents identify areas that are most problematic in terms of the child’s gender nonconformity and “help the family establish some rules they can all live with about ways to act, dress, and behave at home and in public” (Fish & Harvey, 2005, p. 83).
The second category, physical intervention, includes three options. The first option is fully reversible interventions, including lutein hormone releasing hormone (LHRH) agonists. These hormones prevent the development of physical characteristics that have to be removed later. The second option is partially reversible interventions. The third is irreversible or surgical procedures. Adolescents may be eligible for partially reversible interventions at the age of 16. According to the SOC, surgical procedures are not to be employed until the age of 18, and this should include a real-life experience of at least two years.
Current Controversies: Hormone Therapy
The idea of giving hormone therapy to persons who are little more than children is highly controversial and deemed by many to be unethical. Several writers (Fish & Harvey, 2005; Swann & Herbert, 1999) have discussed such complexities in working with gender minority youth and their families. One of the major challenges concerns the pursuit of options for gender transition when the youth is below the age of consent. Swann and Herbert (1999) suggest that the use of hormonal therapy with persons under 18 years of age raises several ethical questions. Their article “Ethical Issues in the Mental Health Treatment of Gender Dysphoric Adolescents” advises practitioners to be cautious with underaged clients and their caregivers and to be sure to explain the options and risks associated with this therapy. Because hormone treatment raises complex issues, some practitioners (Fish & Harvey, 2005) recommend adhering to the World Professional Association of Transgender Health (WPATH) SOC. Israel and Tarver (1997) suggest that a qualified senior gender specialist evaluate individuals on a case-by-case basis in order to determine whether hormones should be administered. They also recommend a two-year wait for transgender youth before hormone administration.
Griggs (1998), a proponent of hormonal therapy in adolescence, argues that youth should be permitted to transition on the grounds that the therapy would retard secondary sex characteristics and eliminate the need for cosmetic surgery in the future. Cohen-Kettenis and van Goozen (1997) and Cohen-Kettenis and Pfafflin (2003) have treated adolescent transsexual patients at their medical clinic. With some, they advocate the use of puberty-delaying hormones such as LHRH agonists. These hormones are used to prevent the development of physical characteristics that have to be removed later. This early intervention can help prevent the stress and discomfort of waiting until adulthood to begin the transition process. For example, hormones that block the development of facial hair and lowered voices would help young biological males pass more easily. De Vries et al. (2006b) argue that this treatment may be appropriate in cases when youth have just entered puberty and have had intense cross-gender identities since early childhood. Familial consent and support are also necessary. They also recommend the use of partially reversible feminizing or masculinizing hormones in cases involving youth over 16 years of age.
Current Controversies: Gender Identity Disorder
Youth who are referred to therapy specifically for issues related to sexual orientation and gender identity are often diagnosed and treated for gender identity disorder. Treatment approaches for children diagnosed with GID are based on the assumption that such children will grow to adulthood and become homosexual and/or transsexual (Haldeman, 2000; Lev, 2004).
The inclusion of GID in the Diagnostic and Statistical Manual of Mental Disorders (DSM) has become increasingly controversial. GID and transsexualism first appeared in the 1980 edition of the DSM, seven years after the removal of homosexuality. In the 1994 edition, the diagnosis of transsexualism was replaced by the more generic GID. Although the diagnosis of GID was not to be confused with sexual orientation, the current edition of the DSM includes “specifiers” that practitioners use to denote sexual orientation in “mature individuals.” In the current edition of the DSM, the DSM–IV–TR (American Psychiatric Association, 2000), the criteria for GID in children include the following:
- A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). The disturbance is manifested by four (or more) of the following:
- repeatedly stated desire to be, or insistence that he or she is the other sex;
- in boys, the preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypically masculine clothing;
- strong and persistent preferences for cross-sex roles in make believe play or persistent fantasies of being the other sex;
- intense desire to participate in the stereotypical games and pastimes of the other sex;
- strong preference for playmates of the other sex.
Adolescents and adults: GID is manifested by such symptoms as: (1) a stated desire to be the other sex; (2) the conviction that one has the typical feelings and reactions of the other sex; (3) a desire to live or be treated as the other sex; (4) frequent passing as the other sex.
- Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.
- The disturbance is not concurrent with a physical intersex condition.
- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. (pp. 581–582)
Under the current diagnostic guidelines, children who are gender nonconforming but do not want to be the opposite sex and do not have an aversion to their own biological sex can meet the criteria for GID, provided there is evidence of clinically significant distress.
Not all children who are diagnosed with GID will grow up and become sexual and gender minorities in adulthood (Fish & Harvey, 2005). However, Cohen-Kettenis, a leading gender specialist in the Netherlands, argues that there are more children with GID who undergo sex reassignment surgery in adulthood than had been previously assumed. Research estimates of children diagnosed as GID who elect to transition in adulthood range from a low of 6% (Zucker & Bradley, 1995) to a high of 23% (Cohen-Kettenis & Pfafflin, 2003).
What Proponents Say
Proponents of the diagnosis argue that GID is a biopsychosocially determined disorder (DiCeglie et al., 2002; Seil, 2004). They state that in many cases the GID diagnosis is required in adulthood in order to secure third-party reimbursement for services associated with hormonal therapy and sex reassignment surgery (Dean et al., 2000; Haldeman, 2000; Schrock, Reid, & Boyd, 2005). Others (e.g., Cole et al., 2000) note that many insurance companies exclude coverage of psychiatric and medical services related to GID.
In response to demands for refinement of the GID diagnostic criteria, Rekers (1995) recommended that mental health professionals make a distinction between gender role behavior disturbance, characterized by children who exhibit cross-gender behavior but do not have a stated desire to change sex, and cross gender identification disturbance, in which children exhibit cross-gender behavior and want to change sex.
What Opponents Say
Those who disagree with the inclusion of GID in the DSM (e.g., Bartlett, Vasey, & Bukowksi, 2000; Spade, 2006; Tarver, 2002) argue that it pathologizes gender-atypical children. These opponents recommend revision, if not deletion, of the disorder and its criteria. Spade (2006) argues:
The diagnostic criteria for GID produce a fiction of natural gender, in which normal, non-transsexual people grow up with minimal to no gender trouble or exploration, do not cross-dress as children, do not play with the wrong gendered kids, and do not like the wrong kinds of toys or characters. This story isn’t believable, but because medicine produces it through a generalized account of the transgression, and instructs the doctor/parent/teacher to focus on the transgressive behavior, it establishes a surveillance and regulation effective for keeping both nontransexuals and transsexuals in adherence to their roles. In order to get authorization for body alteration, this childhood must be produced, and the GID diagnosis accepted, maintaining an idea of two discrete gender categories that normally contain everyone but occasionally are wrongly assigned, requiring correction to reestablish the norm. (p. 321)
Current Controversies: The Treatment of Gender Identity Disorder
Rekers, Coates, and Zucker are considered leading proponents of what Raj (2002) called rehabilitative treatment of GID. A rehabilitative treatment objective in GID cases means to put the child “on track” in terms of his or her gender role behaviors. Ultimately, the treatment also helps defend against the negative effects of the social ostracism that gender-nonconforming children typically experience. Most reparative treatment approaches incorporate behavioral techniques (e.g., Rekers, 1995; Zucker & Bradley, 1995) and have been the subject of criticism (e.g., Burke, 1996).
Tarver (2002) recommends eliminating gender dysphoria, transsexualism, and transvestism as diseases and limiting treatment to recovery from the traumas people encounter at the hands of an intolerant culture. As Lev (2004) asserts, the assumption that such gender-nonconforming behaviors are not problematic means that the whole focus of treatment is radically altered. Recent examples of alternative interventions for children have been the focus of intense media attention. In a 2008 radio broadcast, parents described how, with the help of psychologists, they were able to support their son’s cross-gender identification by enrolling him in kindergarten as a girl (Spiegel, 2008).
Treatment Protocols for Use with Intersex Youth
In recent years, the treatment protocols for infants who are born intersexed have changed radically. The Consortium on the Management of Disorders of Sex Development has created clinical guidelines that call for a multidisciplinary team to work with parents in making decisions about the sex assignment of their child (Intersex Society of North America, 2006). The consortium comprises clinical specialists who work with patients diagnosed with disorders of sexual development (DSDs), adults with DSDs, and parents of children with DSDs. Its guidelines now call for honest disclosure by physicians and other personnel and emphasize the child’s right to make decisions about the preferred gender at a time when he or she is developmentally able to do so.
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