By Alex Fradera

New research on gender identity disorder (also known as gender dysphoria, in which a person does not identify with their biological sex) questions how best to handle the condition when it arises in children and adolescents. Should biological treatments be used as early as possible to help a young client transition, or is caution required, in case of complicating psychological issues?

Melanie Bechard of the University of Toronto and her colleagues examined the prevalence of “psychosocial and psychological vulnerabilities” in 50 child and teen cases of gender dysphoria, and writing in a recent issue of the Journal of Sex and Marital Therapy, they argue their findings show that physicians should be considering these factors more seriously when deciding on a treatment plan. Salting the situation, one of the paper’s co-authors is Kenneth Zucker, an expert on gender dysphoria who was last year considered too controversial for Canadian state television.

As recently as 2013, Zucker headed the American Psychiatric Association’s group deciding the diagnostic criteria for gender dysphoria, but he fell from grace in 2015 when he was fired from his clinic at the Toronto Centre for Addiction and Mental Health for failing to follow the now prominent “gender-affirmative” approach that places a clinical emphasis on smoothing the process of gender transition for children and adolescents who say they no longer identify with their biological sex.

Zucker’s approach, in contrast, was more hesitant and he questioned the ease with which young people can draw conclusions about their gender identity during a universally tumultuous stage of life. He also placed more emphasis on the costs that transition may bear upon an individual. To say that he considered transition a last resort would be as much of a caricature as saying the gender affirmative approach considers it a first resort, but they clearly represent different points on this spectrum.

To Zucker’s critics he was a transphobe, his approach analogous to gay conversion therapy (the now widely condemned use of psychological therapy to attempt to alter a client’s sexual orientation) – for example, he reportedly advised some parents to discourage their younger children from behaving in ways that contradicted their assigned gender.

Last year, hostility toward Zucker’s views was substantive enough to lead the Canadian broadcaster CBC to pull a BBC documentary that reported his perspective. For his part, Zucker continues to maintain that his priority has always been the wellbeing of his clinical charges. The recent article that he co-authored with Bechard and others puts into the scientific record one of the concerns of his clinic, that gender dysphoric youth are a psychologically vulnerable population.

The paper examines the case files of 17 people assigned a male gender and 33 people assigned a female gender, at birth, based on their biological sex. Following their experience of gender dysphoria, the clients had been referred to a specialist gender identity service for young people, at which time they were aged 13 to 20. Sixty-four per cent of the clients were homosexual with respect to the gender they were assigned at birth.

The researchers looked for evidence of 15 factors that can signify or contribute to psychological issues, from self-harm to a previous outpatient therapy visit, and found that over half their sample had six or more of these factors. The majority had two or more prior diagnoses of a psychological disorder, the most common being a mood disorder such as depression. More than half had reported thinking about suicide, a third had dropped out of high school, a quarter had self harmed. A history of sexual abuse was rarer, observed in ”only” 10 per cent of cases.

All these measures are likely to be underestimates because they depended on the clients’ own descriptions during their initial interview at the gender identity clinic. Without a control group, it’s hard to say whether these rates of psychological distress are higher than for other client groups. Certainly though, the findings are consistent with the sense that these individuals were already in a state of psychological vulnerability when they were referred for gender dysphoria.

Bechard’s team present in-depth examples of two clients, both assigned as female at birth, that bring these psychological complexities to life, demonstrating the kinds of situations these cases often involve.

The first individual was very intelligent but struggling socially, especially around girls. They were fixated on emphasising their femininity in selfies, leading the parents to suspect body dysmorphic disorder (a troubling belief that there is something wrong with one’s body). This individual’s boyfriend then came out as gay. Sometime following this, the client disclosed that they identified as a boy. This change in identity happened “overnight” with no developmental history of cross-gender identification.

The second client’s history is more convoluted: at around age 14-15 this individual had disclosed that they were transgender (now identifying as male), and had felt this way for a while. This individual also had a history of anxiety, social problems interacting with girls, and extreme anxiety about sexuality. From the point of disclosing their gender dysphoria, they also reported that they were gay (oriented towards men) but had no interest in romantic/sexual relations.

In both these cases, after an initial assessment the individual was given testosterone treatment by a physician against the wishes of the parents – in the first case, the physician actually refused to meet the parents, and in the second, the physician recorded that the issues raised by the parents regarding anxiety, sexual and social problems weren’t relevant for the course of action. Sadly, in the case of the second individual, a few months after the start of the hormone treatment, they made a suicide attempt that required hospitalisation; the reasons for this were not reported.

Are the indicators of psychological vulnerability identified in these case histories the consequence, cause or simply coincident to gender identity disorder? If they are all solely a fall-out from the gender dysphoria, then the decisive approach of the physicians described above has a certain sense to it. But if some of the psychological complications pre-dated the gender dysphoria, or were separate from it, then at the very least this would suggest that the consulted physicians should have considered a broader treatment plan, and considered the psychological complications when judging their clients’ “readiness” to commence biomedical treatments.

The possibility that disclosure of gender dysphoria may in some cases be driven by earlier psychological vulnerabilities and social problems seems likely to be greater than zero. This is a controversial idea among many online trans activists, but actually it isn’t among health practitioners, even those who espouse the gender affirmation philosophy, who recognise that some young gender identity referrals may be transiently mixed-up individuals.

The issue of pre-existing or concurrent psychological vulnerabilities also speaks to the fact that a substantial proportion, perhaps even the majority, of children who experience some form of gender identity challenge, later come to endorse the gender they were raised as (further commentary and discussion); the new findings may also be relevant to the experience of detransitioning individuals, who reach similar conclusions, but often after a much greater investment in the process of transition – a phenomenon that is struggling to get scientific attention.

However, when a child with gender dysphoria is “insistent, persistent, and consistent” over an extended period, then (under the gender affirmative approach) this is typically treated as a good indicator that it is appropriate to begin facilitating the transition process. The trouble is, psychological vulnerabilities can also be persistent, and if a young person feels like they’ve found the solution, it’s understandable that they might not want to let go.

Life can sometimes feel as complicated as the Gordian knot, the legendary challenge that was seemingly impossible to disentangle. It’s understandable to weigh up a radical solution, like Alexander the Great cleaving the knot with a single sword-stroke: to abandon your external environment for a new home, to step outside of the confines of an identity that may be the source of the myriad issues plaguing you.

This research from Bechard, Zucker and company provides preliminary evidence about the psychological vulnerabilities of children and teens with gender dysphoria, extending previous work that’s shown high rates of self-harm and suicidal ideation in this group, but more research is required to give us the full clinical picture. As such, this new paper represents just the latest sally in a difficult, complicated conversation that’s far from over: a conversation about how we can most compassionately treat those who feel out of step with where they find themselves in the social world.

—Psychosocial and Psychological Vulnerability in Adolescents with Gender Dysphoria: A “Proof of Principle” Study

Alex Fradera (@alexfradera) is Staff Writer at BPS Research Digest

Update, July 2020: This post generated substantial discussion upon publication, as can be seen in the comments below, and more than two years later it continues to receive a lot of attention. With this in mind, we’ve updated the headline, which was slightly ambiguous if read without the full context of the article. As highlighted in the post, the particular paper covered here is just one part of a broader ongoing conversation, and we will continue our attempts to reflect that discussion and research evidence.