Gabriel J. Martín.
Psicología Afirmativa gay.

Algunos bulos sobre personas trans.


 

Hago una revisión de las afirmaciones que se recogen en  la web de la agrupación Amanda (https://www.amandafamilias.org/) y de las afirmaciones que muchas veces aparecen repetidas en redes sociales.

 


 

Afirmación 1: Personas derivadas a unidades trans se incrementó 5.337%

 

Respuesta razonada:

 

 

 


 

 

Afirmación 2: 80% es el porcentaje de niños y niñas que superan la disforia de género una vez terminada la pubertad de manera natural.

 

Respuesta razonada:

 

 

  • Rechina el “superan la disforia” porque parece que hablan del sarampión pero entraré en el fondo más que en las formas. Se está refiriendo a la persistencia de “disforia de género” de estos niños/as llegados a la edad adulta. Este 80% se ha convertido en un mantra que repiten sectores conservadores. Vayamos por partes.
  • En el artículo citado: (researchgate.net/publication/323513958_Gender_dysphoria_in_adolescence_current_perspectives) se dice “Evidence from the 10 available prospective follow-up studies from childhood to adolescence (reviewed in the study by Ristori and Steensma) indicates that for ~80% of children who meet the criteria for GDC, the GD recedes with puberty. Instead, many of these adolescents will identify as non-heterosexual”.
  • Si vamos al artículo original, el de Ristori y Steensma (https://www.tandfonline.com/doi/abs/10.3109/09540261.2015.1115754?journalCode=iirp20) encontramos que lo que se afirma es: “The conclusion from these studies is that childhood GD is strongly associated with a lesbian, gay, or bisexual outcome and that for the majority of the children (85.2%; 270 out of 317) the gender dysphoric feelings remitted around or after puberty (see Table 1).”
  • De los estudios sobre los que se basa esa conclusión, dos fueron anteriores a que existiera un criterio claro para definir la disforia de género.
  • La autora expresa una duda razonable sobre la persistencia de la DG una vez estas criaturas se hacen adultas y de la conveniencia de aplicar tratamientos irreversibles.
  • Esta misma cautela se expresa en otros artículos recientes (Singh et al 2021  https://www.frontiersin.org/articles/10.3389/fpsyt.2021.632784/full) pero se reconocen defectos metodológicos: “In recent years, there have been various criticisms of these follow-up studies; for a rebuttal, see, particularly with regard to the putatively high percentage of desistance. It has been questioned, for example, to what extent the patients in these studies truly had GID/GD. For example, in the early studies, prior to the publication of DSM-III, one could reasonably argue that the diagnostic status of the patients was unclear because there were no formal diagnostic criteria to rely upon. However, one could argue in return that the behavior of these boys was phenomenologically consistent with the subsequent DSM criteria”. Puede ser que no haya desaparecido la "disforia" sino que nunca había estado presente y a la persona se le había incluído injustificadamente en la cohorte de seguimiento.
  • La discusión en el ámbito académico está bullendo y eso no es malo. Se habla de diferentes mediciones al haber cambiado los criterios a lo largo de los estudios longitudinales. Algunos estudios niegan que las cifras de persistencia sean tan bajas.
  • Recientemente se ha publicado: Winters, K. (2019). The "80% desistance" dictum: Is it science? In A. I. Lev & A. R. Gottlieb (Eds.), Families in transition: Parenting gender diverse children, adolescents, and young adults (pp. 88–101). Harrington Park Press, cuyo abstract dice: “The most pervasive and damaging stereotype about transgender children that is used to frighten parents, therapists, and medical professionals is that the vast majority of them are "going through a phase." The "80% desistance" dictum alleges that gender dysphoria, defined as distress with their physical sex characteristics or associated social roles, and identification as trans will remit for approximately 80% of young trans children. It predicts that most young trans boys will spontaneously revert to identifying as girls by puberty and develop into cisgender lesbian women, and that most young trans girls will spontaneously revert to identifying as boys by puberty and develop into cisgender gay men. A growing body of research is focused on transgender children with supportive families and care providers and is refuting the stereotype that most trans or gender dysphoric children are "confused" and will become cisgender gay or lesbian adults. Socially transitioned trans children supported by their families exhibit far less psychopathology than previously reported among closeted and unsupported youth. Prospective studies in progress will no doubt shed much more light on the outcomes of trans children who are supported in socially authentic gender roles”. No es, por tanto, cierto que el 80% se “cure” sino que, en todo caso, existe un porcentaje (bastante menor de esa cifra como se verá) desiste debido a las presiones de sus familiares y entornos sociales.
  • También es interesante el artículo Ashley, F. (2021). The clinical irrelevance of “desistance” research for transgender and gender creative youth. Psychology of Sexual Orientation and Gender Diversity. Advance online publication. Su abstract dice “In recent years, the suggestion that over 80% of trans and gender creative children will grow up cisgender has been strongly criticized in the academic literature. Although concerns over the methodology of these studies, known as desistance research, has shed considerable doubt regarding the validity of the reported number, less attention has been paid to the relevance of desistance research to the choice of clinical model of care. This article analyzes desistance research and concludes that the body of research is not relevant when deciding between models ofcare. Three arguments undermining the relevance of desistance research are presented. Drawing on a variety of concerns, the article highlights that “desistance” does not provide reasons against prepubertal social transition or peripubertal medical transition, that transition for “desisters” is not comparably harmful to delays for trans youth, and that the wait-and-see and corrective models of care are harmful to youth who will grow up cis. The assumed relevance of desistance research to trans youth care is therefore misconceived. Thinking critically about the relationship between research observations and clinical models of care is essential to progress in trans health care”. Es mucho más irreparable el daño de no poder transicionar.
  • Las directrices de la APA, en lo referente a menores son muy cautelosas (ver anexo) y recuerdan que el papel de la Psicología es el de acompañar, no el de prescribir tratamientos médicos: “Because gender nonconformity may be transient for younger children in particular, the psychologist’s role may be to help support children and their families through the process of exploration and self-identification (Ehrensaft, 2012). Additionally, psychologists may provide parents with information about possible long-term trajectories children may take in regard to their gender identity, along with the available medical interventions for adolescents whose TGNC identification persists (Edwards-Leeper & Spack, 2012)”.
  • Muy recientemente la American Academy of Pediatrics ha publicado este estudio que desmiente el mito del 80%: https://publications.aap.org/pediatrics/article/doi/10.1542/peds.2021-056082/186992/Gender-Identity-5-Years-After-Social-Transition : "These results suggest that retransitions are infrequent. More commonly, transgender youth who socially transitioned at early ages continued to identify that way. Nonetheless, understanding retransitions is crucial for clinicians and families to help make them as smooth as possible for youth".

 

 

Afirmación 3: Solo son dos el número de cromosomas sexuales demostrado por la ciencia -dos cromosomas X en las mujeres y un X y un Y en los hombres- en casi todas las células de nuestro cuerpo. Las personas intersexuales no tienen un tercer cromosoma, ni un tercer sexo, solo varía el número de X o Y en su ADN.
Respuesta razonada: también existimos personas intersex "mujeres XY" y "hombres XX" pero bueno, este no es el fondo de la cuestión. Están equiparando “sexo” con “sexo cromosómico” y pasando por alto el sexo gonadal, el sexo fenotípico y, por supuesto, el sexo identitario (que ahora llamamos “identidad de género”). Es una visión hiperreduccionista del sexo que no se sostiene ni siquiera desde unas pretendidas bases biológicas.

 

 

Afirmación 4:  0,001 % Prevalencia de la transexualidad (0,0009% en mujer-a-hombre).
Respuesta razonada: esto ya se ha visto que es falso, la prevalencia es mucho más alta.

 

 

Afirmación 5: 50% Personas que abandonaron la transición debido a que ésta no aliviaba su disforia de género. Estudio de Elie Vandenbussche
Respuesta razonada:

 

  • El estudio se realizó desde plataformas destinadas a personas que han “detransicionado. El artículo completo está disponible en https://www.tandfonline.com/doi/full/10.1080/00918369.2021.1919479 y se afirma lo siguiente: “A cross-sectional survey was conducted, using online social media to recruit detransitioners. Access to the questionnaire was open from the 16th of November until the 22nd of December 2019. Any detransitioner of any age or nationality was invited to take part in the study. The survey was shared by Post Trans (www.post-trans.com)—a platform for female detransitioners—via public posts on Facebook, Instagram and Twitter. Participants were also recruited through private Facebook groups and a Reddit forum for detransitioners (r/detrans). Some of the latter platforms were addressed exclusively to female detransitioners”. Con este método de reclutamiento hasta sorprende que solo el 50% de la población afirme haber detransicionado.
  • Encuentro confusa la definición de “detransicionador/a”: “The term “detransitioner” will be used here to refer to someone who possibly underwent some of these medical and/or social detransition steps and, more importantly, who identifies as a detransitioner. It is important to add this dimension, because the act of medical/social detransition can be performed by individuals who did not cease to identify as transgender and who do not identify as detransitioners or as members of the detrans community. Furthermore, some individuals might identify as detransitioners after having ceased to identify as trans, while not being in a position to medically or socially detransition due to medical or social concerns. As Hildebrand-Chupp (2020) puts it: “Becoming a detransitioner involves a fundamental shift in one’s subjective understanding of oneself, an understanding that is constructed within these communities.” (p.802). More qualitative research should be conducted in order to better understand how members of the detrans community define themselves and make sense of their own detransition process. However, this goes beyond the scope of this study”. Si las variables que se miden no están claramente definidas, es poco aconsejable tomar en serio las conclusiones.
  • La información sobre las razones para detransicionar todavía añaden más confusión: “The most common reported reason for detransitioning was realized that my gender dysphoria was related to other issues (70%). The second one was health concerns (62%), followed by transition did not help my dysphoria (50%), found alternatives to deal with my dysphoria (45%), unhappy with the social changes (44%), and change in political views (43%). At the very bottom of the list are: lack of support from social surroundings (13%), financial concerns (12%) and discrimination (10%). 34 participants (14%) added a variety of other reasons such as absence or desistance of gender dysphoria, fear of surgery, mental health concerns related to treatment, shift in gender identity, lack of medical support, dangerosity of being trans, acceptance of homosexuality and gender non-conformity, realization of being pressured to transition by social surroundings, fear of surgery complications, worsening of gender dysphoria, discovery of radical feminism, changes in religious beliefs, need to reassess one’s decision to transition, and realization of the impossibility of changing sex”. El mayor motivo para detransicionar fue “mi disforia de género estaba relacionada con otros asuntos” pero no especifica cuáles eran esos asuntos. Además, no niega la persistencia de la disforia, solo que la transición médica no fue la panacea. Solo en el 14% que eligió la opción “cajón de sastre” de la encuesta se menciona que el motivo fuese que la disforia de género hubiese desaparecido. Desde luego 14% es una cifra mucho menor que 50%.
  • En un artículo con población española (https://www.elsevier.es/es-revista-endocrinologia-diabetes-nutricion-13-articulo-transexualidad-transiciones-detransiciones-arrepentimientos-espana-S2530016420301166) se recogen 8 detransiciones de 796 casos atendidos, eso supone el 1%.
  • En población USA (Jack L. Turban, Stephanie S. Loo, Anthony N. Almazan, and Alex S. Keuroghlian (2021). Factors Leading to “Detransition” Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis. LGBT Health.Jun 2021.273-280) se ofrecen los siguientes resultados “A total of 17,151 (61.9%) participants reported that they had ever pursued gender affirmation, broadly defined. Of these, 2242 (13.1%) reported a history of detransition. Of those who had detransitioned, 82.5% reported at least one external driving factor. Frequently endorsed external factors included pressure from family and societal stigma. History of detransition was associated with male sex assigned at birth, nonbinary gender identity, bisexual sexual orientation, and having a family unsupportive of one's gender identity. A total of 15.9% of respondents reported at least one internal driving factor, including fluctuations in or uncertainty regarding gender identity”. Las detransiciones informadas fueron el 13,1% y los motivos tuvieron que ver con presiones externas como la falta de apoyo familiar, el estigma social o haber descubierto que eran personas no binarias.
  • No se sostiene, por tanto, la afirmación de que el 50% de personas que abandonaron la transición debido a que ésta no aliviaba su disforia de género. El único artículo que lo afirma es metodológicamente cuestionable y no sería representativo. Además, sus hallazgos se ven contradichos por otras investigaciones.

 


 

 

Afirmación 6: 59% Personas que detransitaron debido al hecho de encontrar mecanismos alternativos para afrontar la disforia. Fuente: Comité Nacional de Salud y Bienestar de Suecia
Respuesta razonada: esta aseveración conduce a un laberinto. La fuente que se cita y la fuente que aparece enlazada en la web donde se enumeran todas estas informaciones no coinciden.

 

  • La fuente enlazada es un artículo de una persona radfem (feminista radical): “Hechos y mitos sobre el suicidio de las personas trans” https://www.radicalmentefeminista.com/post/hechos-y-mitos-sobre-el-suicidio-de-personas-trans donde afirma que el único estilo serio hasta la fecha sobre este tema se ha hecho en Suecia y “que, tras la transición, las personas transgénero multiplican por 19 las probabilidades de suicidio que los grupos de control”. Un poco más adelante vuelve a referirse a la encuesta online con problemas metodológicos de la afirmación anterior: “De lejos, las dos razones más comunes para hacer la detransición fueron el cambio de creencias ideológicas/políticas, con casi el 63%, y el hecho de encontrar mecanismos alternativos para afrontar la disforia, en un 59%. Las tres razones más citadas para la detransición por parte de los transactivistas—los problemas financieros, la falta de apoyo social y la discriminación institucional— fueron los menos valorados por los detransicionadores—con un 18%, 17% y 7% --de hecho, la discriminación institucional era la categoría menos valorada”. Ya hemos visto que estas afirmaciones no se sostienen.
  • Pero vayamos al estudio sueco mencionado (Dhejne C, Lichtenstein P, Boman M, Johansson ALV, Långström N, Landén M (2011) Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e16885): https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0016885 donde se concluye que: “Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group”. No afirma que la reasignación sea un elemento facilitador del suicidio como parecen indicar algunos sectores sino que las personas trans son un colectivo tan vulnerable y tan victimizado que no basta con una reasignación para solucionar sus problemas de salud mental. Muchas necesitan apoyo psicológico durante más tiempo.
  • Vemos que han tomado un estudio que pretende ser de utilidad para las personas trans y lo han manipulado para tratar de convertirlo en un argumento contra las transiciones.

 


 

 

Afirmación 7: x19. Tasa de suicidios consumados en grupo con reasignación de sexo, 10 años después de que ésta se produjera, en  comparación con la población general. Estudio Dhejne.
Respuesta razonada: de nuevo la fuente que se cita y la que aparece citada no son la misma y nos conduce a otro laberinto. Esta estrategia me suena de aquellas webs ultracatólicas que hablaban de lo “pernicioso que era el estilo de vida gay” y conducen de un enlace a otro para confundir. 

 

  • El estudio al que se refieren (“Dhejne”) es el mismo del de la afirmación anterior y habrá que repetir que “han tomado un estudio que pretende ser de utilidad para las personas trans y lo han manipulado para tratar de convertirlo en un argumento contra las transiciones.”.
  • Otra vez: lo que demuestran los estudios es que la cirugía no es la panacea, que en un entorno tránsfobo siguen existiendo problemas para las personas trans, que muchas no encuentran ni trabajo ni inclusión social, que los problemas de estrés postraumático no se arreglan con una operación. Estos estudios lo que precisamente nos recuerdan es la necesidad de crear mejores atenciones psicológicas para seguir apoyando a las personas trans y la necesidad de un mundo con menos transfobia. Es importante recordar que los estudios a largo plazo incluyen personas que han sufrido cirugías experimentales que no les han aportado mayor calidad de vida.
  • No se menciona que un problema también puede ser la mala calidad de esas operaciones y la pérdida de sensibilidad erógena, etc. que se han dado especialmente en décadas anteriores.

 


 

 

Afirmación 8: x3 Tasa de mortalidad por todas las causas y de atención psiquiátrica hospitalaria en el grupo de reasignación de sexo, tras 10 años de que ésta se produjera, respecto a la población general.  Estudio Dhejne
Respuesta razonada: otra vez el mismo estudio y la misma manipulación presente las afirmaciones anteriores. No merece la pena comentarlo.

 

 

Afirmación 9: 62,5% Tasa de pacientes jóvenes diagnosticados con disforia de género que tienen otros problemas psicológicos PREVIOS. Estudio Lisa Littman
Respuesta razonada: Efectivamente, este es el resultado que arroja el estudio: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095578/

 

  • Este estudio fue fuertemente criticado y dio incluso nombre a una polémica (“Rapid-onset gender dysphoria controversy”), forzada a introducir cambios por los editores, Littman publicó lo siguiente: “The post-publication review identified issues that needed to be addressed to ensure the article meets PLOS ONE's publication criteria. Given the nature of the issues in this case, the PLOS ONE Editors decided to republish the article, replacing the original version of record with a revised version in which the author has updated the Title, Abstract, Introduction, Discussion, and Conclusion sections, to address the concerns raised in the editorial reassessment. The Materials and methods section was updated to include new information and more detailed descriptions about recruitment sites and to remove two figures due to copyright restrictions. Other than the addition of a few missing values in Table 13, the Results section is unchanged in the updated version of the article”.
  • Por su parte, el editor de PLOS One's editor escribió "the corrected article now provides a better context of the work, as a report of parental observations, but not a clinically validated phenomenon or a diagnostic guideline”. Es decir, las conclusiones del estudio se habían basado en lo que los padres pensaban, no en la presencia de un trastorno diagnosticado por un profesional.
  • La corrección se puede leer en https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424391/ y se afirma: “This study of parent observations and interpretations serves to develop the hypotheses that rapid-onset gender dysphoria is a phenomenon and that social influences, parent-child conflict, and maladaptive coping mechanisms may be contributing factors for some individuals. Rapid-onset gender dysphoria (ROGD) is not a formal mental health diagnosis at this time. This report did not collect data from the adolescents and young adults (AYAs) or clinicians and therefore does not validate the phenomenon”. O, lo que es lo mismo: (1) desde la perspectiva de los padres, para muchos parece como si su hijo/a se hubiese vuelto trans de repente y (2) que el concepto “rapid onset gender dysphoria” carece por completo de validez. De hecho, es muy probable que los menores trans no informen a sus progenitores de que lo son hasta que lo han elaborado mentalmente por completo y que los progenitores se queden desconcertados. Esta es la única conclusión a la que se puede llegar: muchos de los padres y madres de menores trans no se lo veían venir y no saben cómo procesar lo que está ocurriendo.
  • Por último recordar que “In 2021, the Coalition for the Advancement and Application of Psychological Science released a statement calling for the elimination of the concept of ROGD from clinical and diagnostic use, as "there are no sound empirical studies of ROGD and it has not been subjected to rigorous peer-review processes that are standard for clinical science." The statement also states that the term "ROGD" is likely to stigmatize and cause harm to transgender people, and that misinformation surrounding ROGD is used to justify laws suppressing the rights of transgender youth. The statement was cosigned by the American Psychiatric Association, the American Psychological Association, the Society of Behavioral Medicine, the Association for Behavioral and Cognitive Therapies, and the National Association of School Psychologists”. El concepto “rapid onset on gender dysphoria” no tiene validez NINGUNA.
  • Lo que es peor es que toda. esta información es igualmente fácilmente accesible para quienes difunden estos bulos y tergiversaciones ¿con qué motivación ocutan esta parte de la información?

 


 

 

ANEXO, directriz 8 de la APA: Life Span Development Guideline 8. Psychologists working with gender-questioning 4 and TGNC youth understand the different developmental needs of children and adolescents, and that not all youth will persist in a TGNC identity into adulthood.

 

 

Texto completo y referencias aquí
Rationale.

 

  • Many children develop stability (constancy across time) in their gender identity between Ages 3 to 4 (Kohlberg, 1966), although gender consistency (recognition that gender remains the same across situations) often does not occur until Ages 4 to 7 (Siegal & Robinson, 1987). Children who demonstrate gender nonconformity in preschool and early elementary years may not follow this trajectory (Zucker & Bradley, 1995). Existing research suggests that between 12% and 50% of children diagnosed with gender dysphoria may persist in their identification with a gender different than sex assigned at birth into late adolescence and young adulthood (Drummond, Bradley, 4 Gender-questioning youth are differentiated from TGNC youth in this section of the guidelines. Gender-questioning youth may be questioning or exploring their gender identity but have not yet developed a TGNC identity. As such, they may not be eligible for some services that would be offered to TGNC youth. Gender-questioning youth are included here because gender questioning may lead to a TGNC identity (Peterson-Badaali, & Zucker, 2008; Steensma, McGuire, Kreukels, Beekman, & Cohen-Kettenis, 2013; Wallien & Cohen-Kettenis, 2008). However, several research studies categorized 30% to 62% of youth who did not return to the clinic for medical intervention after initial assessment, and whose gender identity may be unknown, as “desisters” who no longer identified with a gender different than sex assigned at birth (Steensma et al., 2013; Wallien & CohenKettenis, 2008; Zucker, 2008a). As a result, this research runs a strong risk of inflating estimates of the number of youth who do not persist with a TGNC identity. Research has suggested that children who identify more intensely with a gender different than sex assigned at birth are more likely to persist in this gender identification into adolescence (Steensma et al., 2013), and that when gender dysphoria persists through childhood and intensifies into adolescence, the likelihood of long-term TGNC identification increases (A. L. de Vries, Steensma, Doreleijers, & CohenKettenis, 2011; Steensma et al., 2013; Wallien & CohenKettenis, 2008; Zucker, 2008b). Gender-questioning children who do not persist may be more likely to later identify as gay or lesbian than non-gender-questioning children (Bailey & Zucker, 1995; Drescher, 2014; Wallien & Cohen-Kettenis, 2008).
  • A clear distinction between care of TGNC and genderquestioning children and adolescents exists in the literature. Due to the evidence that not all children persist in a TGNC identity into adolescence or adulthood, and because no approach to working with TGNC children has been adequately, empirically validated, consensus does not exist regarding best practice with prepubertal children. Lack of consensus about the preferred approach to treatment may be due in part to divergent ideas regarding what constitutes optimal treatment outcomes for TGNC and gender-questioning youth (Hembree et al., 2009). Two distinct approaches exist to address gender identity concerns in children (Hill, Menvielle, Sica, & Johnson, 2010; Wallace & Russell, 2013), with some authors subdividing one of the approaches to suggest three (Byne et al., 2012; Drescher, 2014; Stein, 2012).
  • One approach encourages an affirmation and acceptance of children’s expressed gender identity. This may include assisting children to socially transition and to begin medical transition when their bodies have physically developed, or allowing a child’s gender identity to unfold without expectation of a specific outcome (A. L. de Vries & Cohen-Kettenis, 2012; Edwards-Leeper & Spack, 2012; Ehrensaft, 2012; Hidalgo et al., 2013; Tishelman et al., 2015). Clinicians using this approach believe that an open exploration and affirmation will assist children to develop coping strategies and emotional tools to integrate a positive TGNC identity should gender questioning persist (Edwards-Leeper & Spack, 2012).
  • In the second approach, children are encouraged to embrace their given bodies and to align with their assigned gender roles. This includes endorsing and supporting behaviors and attitudes that align with the child’s sex assigned at birth prior to the onset of puberty (Zucker, 2008a; Zucker, Wood, Singh, & Bradley, 2012). Clinicians using this approach believe that undergoing multiple medical interventions and living as a TGNC person in a world that stigmatizes gender nonconformity is a less desirable outcome than one in which children may be assisted to happily align with their sex assigned at birth (Zucker et al., 2012). Consensus does not exist regarding whether this approach may provide benefit (Zucker, 2008a; Zucker et al., 2012) or may cause harm or lead to psychosocial adversities (Hill et al., 2010; Pyne, 2014; Travers et al., 2012; Wallace & Russell, 2013). When addressing psychological interventions for children and adolescents, the World Professional Association for Transgender Health Standards of Care identify interventions “aimed at trying to change gender identity and expression to become more congruent with sex assigned at birth” as unethical (Coleman et al., 2012, p. 175). It is hoped that future research will offer improved guidance in this area of practice (Adelson & AACAP CQI, 2012; Malpas, 2011).
  • Much greater consensus exists regarding practice with adolescents. Adolescents presenting with gender identity concerns bring their own set of unique challenges. This may include having a late-onset (i.e., postpubertal) presentation of gender nonconforming identification, with no history of gender role nonconformity or gender questioning in childhood (Edwards-Leeper & Spack, 2012). Complicating their clinical presentation, many gender-questioning adolescents also present with co-occurring psychological concerns, such as suicidal ideation, self-injurious behaviors (Liu & Mustanski, 2012; Mustanski, Garofalo, & Emerson, 2010), drug and alcohol use (Garofalo et al., 2006), and autism spectrum disorders (A. L. de Vries, Noens, CohenKettenis, van Berckelaer-Onnes, & Doreleijers, 2010; Jones et al., 2012). Additionally, adolescents can become intensely focused on their immediate desires, resulting in outward displays of frustration and resentment when faced with any delay in receiving the medical treatment from which they feel they would benefit and to which they feel entitled (Angello, 2013; Edwards-Leeper & Spack, 2012). This intense focus on immediate needs may create challenges in assuring that adolescents are cognitively and emotionally able to make life-altering decisions to change their name or gender marker, begin hormone therapy (which may affect fertility), or pursue surgery.
  • Nonetheless, there is greater consensus that treatment approaches for adolescents affirm an adolescents’ gender identity (Coleman et al., 2012). Treatment options for adolescents extend beyond social approaches to include medical approaches. One particular medical intervention involves the use of puberty-suppressing medication or “blockers” (GnRH analogue), which is a reversible medical intervention used to delay puberty for appropriately screened adolescents with gender dysphoria (Coleman et al., 2012; A. L. C. de Vries et al., 2014; Edwards-Leeper, & Spack, 2012). Because of their age, other medical interventions may also become available to adolescents, and psychologists are frequently consulted to provide an assessment of whether such procedures would be advisable (Coleman et al., 2012).

 


Application
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  • Psychologists working with TGNC and gender-questioning youth are encouraged to regularly review the most current literature in this area, recognizing the limited available research regarding the potential benefits and risks of different treatment approaches for children and for adolescents. Psychologists are encouraged to offer parents and guardians clear information about available treatment approaches, regardless of the specific approach chosen by the psychologist. Psychologists are encouraged to provide psychological service to TGNC and gender-questioning children and adolescents that draws from empirically validated literature when available, recognizing the influence psychologists’ values and beliefs may have on the treatment approaches they select (Ehrbar & Gorton, 2010). Psychologists are also encouraged to remain aware that what one youth and/or parent may be seeking in a therapeutic relationship may not coincide with a clinician’s approach (Brill & Pepper, 2008). In cases in which a youth and/or parent identify different preferred treatment outcomes than a clinician, it may not be clinically appropriate for the clinician to continue working with the youth and family, and alternative options, including referral, might be considered. Psychologists may also find themselves navigating family systems in which youth and their caregivers are seeking different treatment outcomes (Edwards-Leeper & Spack, 2012). Psychologists are encouraged to carefully reflect on their personal values and beliefs about gender identity development in conjunction with the available research, and to keep the best interest of the child or adolescent at the forefront of their clinical decisions at all times.
  • Because gender nonconformity may be transient for younger children in particular, the psychologist’s role may be to help support children and their families through the process of exploration and self-identification (Ehrensaft, 2012). Additionally, psychologists may provide parents with information about possible long-term trajectories children may take in regard to their gender identity, along with the available medical interventions for adolescents whose TGNC identification persists (Edwards-Leeper & Spack, 2012).
  • When working with adolescents, psychologists are encouraged to recognize that some TGNC adolescents will not have a strong history of childhood gender role nonconformity or gender dysphoria either by self-report or family observation (Edwards-Leeper & Spack, 2012). Some of these adolescents may have withheld their feelings of gender nonconformity out of a fear of rejection, confusion, conflating gender identity and sexual orientation, or a lack of awareness of the option to identify as TGNC. Parents of these adolescents may need additional assistance in understanding and supporting their youth, given that late-onset gender dysphoria and TGNC identification may come as a significant surprise. Moving more slowly and cautiously in these cases is often advisable (Edwards-Leeper & Spack, 2012). Given the possibility of adolescents’ intense focus on immediate desires and strong reactions to perceived delays or barriers, psychologists are encouraged to validate these concerns and the desire to move through the process quickly while also remaining thoughtful and deliberate in treatment. Adolescents and their families may need support in tolerating ambiguity and uncertainty with regard to gender identity and its development (Brill & Pepper, 2008). It is encouraged that care should be taken not to foreclose this process.
  • For adolescents who exhibit a long history of gender nonconformity, psychologists may inform parents that the adolescent’s self-affirmed gender identity is most likely stable (A. L. de Vries et al., 2011). The clinical needs of these adolescents may be different than those who are in the initial phases of exploring or questioning their gender identity. Psychologists are encouraged to complete a comprehensive evaluation and ensure the adolescent’s and family’s readiness to progress while also avoiding unnecessary delay for those who are ready to move forward.
  • Psychologists working with TGNC and gender-questioning youth are encouraged to become familiar with medical treatment options for adolescents (e.g., pubertysuppressing medication, hormone therapy) and work collaboratively with medical providers to provide appropriate care to clients. Because the ongoing involvement of a knowledgeable mental health provider is encouraged due to the psychosocial implications, and is often also a required part of the medical treatment regimen that may be offered to TGNC adolescents (Coleman et al., 2012; Hembree et al., 2009), psychologists often play an essential role in assisting in this process.
  • Psychologists may encourage parents and caregivers to involve youth in developmentally appropriate decision making about their education, health care, and peer networks, as these relate to children’s and adolescents’ gender identity and gender expression (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). Psychologists are also encouraged to educate themselves about the advantages and disadvantages of social transition during childhood and adolescence, and to discuss these factors with both their young clients and clients’ parents. Emphasizing to parents the importance of allowing their child the freedom to return to a gender identity that aligns with sex assigned at birth or another gender identity at any point cannot be overstated, particularly given the research that suggests that not all young gender nonconforming children will ultimately express a gender identity different from that assigned at birth (Wallien, & Cohen-Kettenis, 2008; Zucker & Bradley, 1995). Psychologists are encouraged to acknowledge and explore the fear and burden of responsibility that parents and caregivers may feel as they make decisions about the health of their child or adolescent (Grossman, D’Augelli, Howell, & Hubbard, 2006). Parents and caregivers may benefit from a supportive environment to discuss feelings of isolation, explore loss and grief they may experience, vent anger and frustration at systems that disrespect or discriminate against them and their youth, and learn how to communicate with others about their child’s or adolescent’s gender.