It is essential to build an awareness of the current state of the science on the etiology or causes of gender dysphoria, available treatments and outcomes, as well as current issues in order to provide support for family members.  The list below includes some publications that address these topics as well as interventions for non-transgender family members to cope with grief and ambiguous loss (these are separated by whether the transgender family member is a child or adolescent versus an adult), and current issues such as how clinicians' treatment of transgender people affects their family members, the "desister" debate, and the effect on families of state bills banning medical treatments for transgender youth. However note that the publications' inclusion here does not necessarily imply an endorsement by the Regeneration Resource Center.  There are few available resources written from a Christian perspective except for the Transgender Resources from the Christian Medical & Dental Associations and Yarhouse (2015) below.  Consider that even if you disagree with the viewpoint on transgender identity that some of the authors offer in their publications, you can still learn from the information that is presented.  

• Etiology​​ (causes) of Gender Dysphoria

  • Gender identity disorder and psychosexual problems in children and adolescents.  See especially chapters 6-7 on etiology related to biological (chap. 6) and psychosocial research (chap. 7).​

  • Although the book referenced above was written in 1995, its summary of the research conducted so far on etiology and the gaps in scientific literature is still mostly accurate. A more recent article by Hruz (2020) provides a few updates on the research on biological etiology.  See especially pp. 35-36.

  • From mental disorder to iatrogenic hypogonadism: Dilemmas in conceptualizing gender identity variants as psychiatric conditions.

    • This article from the peer-reviewed literature provides a balanced, scientific explanation of several of the current controversies surrounding how clinicians think about gender identity.  See especially the pathologic condition vs. natural variation section on pp. 5-9.  This article suggests that there may be many factors involved in the development of gender identity disorder and until the research support strengthens, it may be premature to assert that any particular model of the development of variations in gender identity has strong empirical support.  These models include the hypothesis that gender identity variation has a biological basis, or is the result of a particular temperament or type of parent-child interaction.  At the moment gender identity disorder may be best understood as the result of a complex interaction of biological, individual, and environmental factors. 

  • Lev, A. (2004).  Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families.  New York: Routledge.  See Ch. 4 Etiologies.  

• Treatments for Gender Dysphoria & Outcomes

  • Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People.

    • This clinical guidance is distributed by the World Professional Association for Transgender Health.  It may be useful for assisting family members to understand health care options for transgender people.

  • Transgenderism and intersexuality in childhood & adolescence.  See especially chapters 6-7 on the clinical management of gender problems in children and adolescents.

  • Advancing the practice of pediatric psychology with transgender youth: State of the science, ongoing controversies, and future directions.  

    • This article from the peer-reviewed literature explains the current treatment options for transgender youth and may be helpful in explaining these options to family members.​

  • Adolescents with gender dysphoria: Reflections on some contemporary clinical and research issues.

    • See this article for a discussion of some current trends with this population such as the rise in referrals to specialty gender clinics, the increasing number of referrals of biological females, increasing rates of suicide, and the development of gender dysphoria with rapid onset. 

  • The Battle Over Gender Therapy.

    • This article from the New York Times summarizes some of the current debates in the clinical community surrounding medical treatment for gender dysphoria.

  • They Paused Puberty, but Is There a Cost?

    • This article from the New York Times discusses some of the tradeoffs with use of puberty blockers for transgender youths, as well as the possible long-term consequences and other possible effects.​

  • Transgender resources from the Christian Medical & Dental Associations.

  • Brown, M. & Rounsley, C.A. (2003).  True selves: Understanding transsexualism-- for families, friends, coworkers, and helping professionals.  San Francisco: Jossey-Bass.  

    • This book is aimed at helping readers understand transgender people and is written from a secular perspective.

  • Yarhouse, M. (2015). Understanding Gender Dysphoria: Navigating Transgender Issues in a Changing Culture. Downer's Grove, IL: InterVarsity Press.  

    • This book helps readers understand transgender people from a conservative Christian perspective.  Chapter 5 covers treatment of gender dysphoria.

  • Yarhouse, M. & Sadusky, J. (2022).  Gender identity & faith: Clinical postures, tools, and case studies for client-centered care.  Downer's Grove, IL: InterVarsity Press.

    • This book is for clinicians who work with clients and families who are trying to reconcile their faith and gender identity.

• Interventions for Families with a Transgender Child or Adolescent

  • Brill, S. A., & Pepper, R. (2008). The transgender child. San Francisco, CA.: Cleis Press.

    • ​This book is written from a secular perspective.  See especially Chap. 2, Family acceptance: From crisis to empowerment.

  • ​​Coolhart, D. & Shipman, D. L. (2017). Working toward family attunement: Family therapy with transgender and gender-nonconforming children and adolescents. Psychiatr Clin North Am, 40(1), 113-125. 

    • ​This article describes a secular family therapy model for working with families with transgender and gender-nonconforming children and adolescents.

  • Ehrensaft, D. (2011). Gender born, gender made: Raising healthy gender-nonconforming children. New York: Experiment.

    • This book is written from a secular perspective.  See especially Ch. 2, The family’s path is covered with roses and thorns.

  • Gottlieb, A. R., & Lev, A. I. (2019). Families in transition: Parenting gender diverse children, adolescents, and young adults. New York: Harrington Park Press.

    • This book is written from a secular perspective.  See especially Ch. 5 on the effect of a child’s gender identity on extended family relationships, Ch. 11 on its effect on the parents’ identity, and Ch. 17 on how to support the siblings of a child with a transgender identity.​

  • Raj, R. (2008). Transforming couples and families: A trans-formative therapeutic model for working with the loved-ones of gender-divergent youth and trans-identified adults. Journal of GLBT Family Studies, 4(2), 133-163. ​

    • This article presents the (secular) Trans-Formative Therapeutic Model for working with non-transgender family members.  It includes psychotherapeutic and psychoeducational interventions related to this client group and is written from the perspective of a transgender clinician.

• ​Substance Abuse and Mental Health Services Administration.  (2014).  A Practitioner’s Resource Guide: Helping Families to Support Their LGBT Children. HHS Publication No. PEP14-LGBTKIDS. Rockville, MD: Substance Abuse and Mental Health Services Administration.  Available at this link.  

  • This guide assists clinicians to implement best practices to help families support their LGBT children.  It is written from a secular perspective.

• ​Wahlig, J. L. (2015). Losing the child they thought they had: Therapeutic suggestions for an ambiguous loss perspective with parents of a transgender child. Journal of GLBT Family Studies, 11(4), 305-326.

  • This article discusses parents' experiences of grief related to their transgender child in the context of ambiguous loss from a secular perspective.​​

• Other secular interventions for families with a transgender child or adolescent include:

  • Cooper, K. (2009). Social work practice with transgender and gender variant youth and their families. In G. P. Mallon (Ed.), Social work practice with transgender and gender variant youth (2nd ed., pp. 122-138). New York: Routledge.  

  • Golden, R. L., & Oransky, M. (2019). An intersectional approach to therapy with transgender adolescents and their families. Archives of Sexual Behavior, 48(7), 2011-2025. https://doi.org/10.1007/s10508-018-1354-9 .

  • MacNish, M., & Gold-Peifer, M. (2014). Families in transition: Supporting families of transgender youth. In T. Nelson & H. Winawer (Eds.), Critical topics in family therapy (pp. 119-129). New York: Springer International Publishing. https://doi.org/10.1007/978-3-319-03248-1_13 .

  • Malpas, J. (2011). Between pink and blue: A multi-dimensional family approach to gender nonconforming children and their families. Family Process, 50(4), 453–470. https://doi.org/10.1111/j.1545-5300.2011.01371.x .

  • Vanderburgh, R. (2009). Appropriate therapeutic care for families with pre-pubescent transgender/gender-dissonant children. Child and Adolescent Social Work Journal, 26(2), 135–154. https://doi.org/10.1007/s10560-008-0158-5.

• Interventions for Families with a Transgender Adult​​

  • Lev, A. (2004).  Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families.  New York: Routledge.  See Ch. 8 Family Emergence.  

    • ​This book is written from a secular perspective and is one of earliest books or articles that specifically addressed therapeutic guidelines for working with families with a transgender member.​  It is also one of few books that focus on families with a transgender adult.

  • ​See Raj (2008) mentioned in the section above on Interventions for Families with a Transgender Child or Adolescent since this article also discusses the Trans-Formative Therapeutic Model as it applies to families with a transgender adult.​

 

Current Issues: How does clinicians’ treatment of transgender people affect their family members?

 

Another issue that family members may wish to discuss with you is their reaction to their transgender relative’s ability to access physical and mental health care related to his/her potential transition from Christian or non-Christian providers in the community.  Research suggests that the lack of providers who are sufficiently knowledgeable on the topic is the largest barrier to health care for transgender people, followed by discrimination and other socioeconomic and health system barriers.  Their family members may feel a range of emotions (from the positive ones to the negative) about this issue.  Here are a few examples:

• their transgender relative seeks transition-related care but is unable to find it because it is not available in the area in which the family lives, 

• the Christian or non-Christian providers in the area are able to provide transition-related care but are unwilling to do so,  

• the transgender family member experiences rejection or judgment from healthcare providers during the search for transition-related care, or

• perhaps in some cases the non-transgender family member may be glad or relieved (or alternatively surprised or shocked) that the transgender relative was able to obtain any transition-related care. 

Family members may bring these issues to you in order to process their feelings about them. This issue might be framed in this way: How would you as a clinician want another healthcare provider to treat one of your transgender loved ones?

 

The lack of knowledgeable providers and transgender people's experience of discrimination raises the question, under what circumstances should a clinician refer a transgender patient for transition-related care?  The question of whether a healthcare provider should refer a transgender client who has contacted the clinician for this kind of treatment is a challenging one without a simple answer.  This question also represents a controversial topic that is raised by Cox (2013) and Dessel and colleagues (2017) [both of these articles are discussed further below]: where is the line between freedom of religion and discrimination?  Some medical professional groups believe that Christian healthcare professionals should not be required to provide treatment that they believe is morally wrong or harmful to patients, such as the case of physicians who may be asked to prescribe medications to transgender patients (especially youth) who wish to transition or provide letters in support of transition.  

​

However what is an appropriate course of action when the physician is able to competently provide transition-related care but believes it to be possibly harmful or morally wrong?  If a physician believes this type of treatment could possibly be harmful, might s/he discuss the risks and benefits of the treatment with the patient and/or his/her family (as appropriate for the patient’s age), just as s/he would with any other kind of health procedure?  Does providing a referral in the case when a physician believes the treatment to be morally wrong represent an act of discrimination or something else altogether?  Secular ethicists suggest that the physician’s obligation to provide care in a non-emergent situation is not clearly defined (McCoy, 2006).  Moreover, as McCoy points out, the American Medical Association’s Principles of Medical Ethics states that the physician is free to choose whom to provide appropriate patient care except in emergencies.  However, this issue must also be considered in light of the Affordable Care Act, Section 1557 that contains non-discrimination principles related to gender identity that apply to health insurance coverage (for more information on this topic, scroll down to the clinical history section in Resources for Clinicians). 

 

Regardless of whether a physician may object to the treatment on moral grounds, perhaps s/he is unfamiliar with the standards of health care for transgender patients.  In this case, an option for such physicians may be to provide a referral.  Secular ethicists recommend that physicians emphasize a harm reduction approach in providing referrals to transgender patients when the treatment options may be few (Dietz & Halem, 2016). 

 

Meanwhile for mental health clinicians who provide psychotherapy, both of the articles mentioned below provide some examples of the challenges that arise when a clinician considers a transgender client’s request for treatment.  For example, the clinician may start from the assumption that s/he is unable to provide psychotherapy to a transgender client prior to assessing what the presenting problem is.  This consideration may also be relevant for other physical healthcare providers as there is evidence that some transgender people may not regularly receive preventive care such as health screenings, and so the provision of this routine care is much needed and a way to engage a vulnerable health population group to address all their health needs (Hruz, 2020; Rahman et al 2019).  Another challenge may arise when the transgender client professes a strong faith in God and the clinician may believe these two characteristics to be incompatible.  These articles discuss times when it is ethical to refer the client and when a referral may also represent an act of discrimination.

• Cox, Michelle R. (2013, May 1).  When religion and sexual orientation collide. Counseling Today. 

• Dessel, Adrienne B. et al (2017). LGBTQ Topics & Christianity in Social Work: Tackling the tough questions.  Social Work & Christianity, 44, 1-2, 11-30.  In particular, see the section “Referring LGBTQ Clients” on pp. 17-19.

​

Other publications on this topic that may be of interest include:

• Barsky, Allan. (2019).  Ethics Alive! Religious freedom and Social Work: Ethics of referring clients.  The New Social Worker, (Winter).  Available at https://www.socialworker.com/feature-articles/ethics-articles/ethics-alive-religious-freedom-and-social-work-ethics-of-referring-clients/

• Gerritse, Karl et al. (2018).  Moral challenges in transgender care: A thematic analysis based on a focused ethnography. Archives of Sexual Behavior, 47, 2319–2333. ​​Available at https://link.springer.com/article/10.1007/s10508-018-1287-3

• Hruz, P.  (2020). Deficiencies in the scientific evidence for medical management of gender dysphoria.  The Linacre Quarterly, 87(1), 34-42. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7016442/

• Kaplan, Jay. (2014). Freedom of religion: A right to discriminate?  In A.B. Dessel & R.B. Bolen (Eds.), Conservative Christian beliefs and sexual orientation in Social Work. (pp. 219-232), Alexandria, VA: Council on Social Work Education.

• Kimberly, Laura L. et al. (2018).  Ethical issues in gender-affirming care for youth.  Pediatrics, 142 (6) e20181537.  Available at https://pediatrics.aappublications.org/content/142/6/e20181537

• Reamer, Frederic G. (2014).  Ethical issues and challenges: Managing moral dilemmas.  In A.B. Dessel & R.B. Bolen (Eds.), Conservative Christian beliefs and sexual orientation in Social Work. (pp. 233-256), Alexandria, VA: Council on Social Work Education.

• Swann, Stephanie K. & Hebert, Sarah E. (2009).  Ethical issues in the mental health treatment of trans adolescents.  In G.P. Mallon (Ed.), Social Work practice with transgender and gender variant youth (2nd ed., pp. 38-52), New York: Routledge.

​

Current Issues: The "Desister" Debate

Some parents of transgender youth may ask you whether their children will persist with their gender dysphoria or "desist," a term that is used to refer to youth who start to transition and then later change their minds.  Perhaps these parents may have read "When Children Say They're Trans", an article from The Atlantic that discusses the trend of gender identity issues among youth, the challenges for parents, as well as the "desister" debate.  This debate stems from a series of peer-reviewed research articles that documented the phenomenon of some youth desisting in their gender dysphoria over time (Drummond, et al 2008; Steensma et al, 2011; Steensma et al, 2013; Wallien & Cohen-Kettenis, 2008).  This research suggests that while a proportion of youth may persist in their gender dysphoria (range between 12-58% depending on the study), the majority (more than half in three of four studies) do not appear to do so.  This research led to a debate about whether the occurrence of desisting would overshadow the needs of the group of youth whose gender dysphoria persists.   In addition to this debate, the critique of these studies of desisting has focused on methodological and other concerns (Temple Newhook, et al 2018).  

 

Subsequently a recent study published in the journal, Pediatrics, examined the progression of gender expansive behavior to gender dysphoria and gender affirming hormone treatment in a group of gender diverse children (Wagner et al., 2021).  Over an average follow up time period of 3.5 years, the study found that less than a third (29%) of the participants received a gender dysphoria-related diagnosis and just 25% received gender affirming hormone therapy.  The authors found that their study results were consistent with the results from Wallien & Cohen-Kettenis (2008) and Steensma et al (2013).

​

Given that some youth appear to persist in their gender dysphoria but the majority of youth do not, as well as the methodological concerns that have been raised about certain studies, researchers have called for further research into the factors associated with youth who desist and persist in order to understand this phenomenon better (Butler & Hutchison, 2019).  A follow up study of boys with gender identity disorder found that 12.2% continued to have gender dysphoria at the reassessment timepoint (referred to as “persisters”) and 87.8% did not continue to have gender dysphoria (referred to as desisters”) (Singh, Bradley, & Zucker, 2021).  “Compared to the reference group (bisexual/homosexual desisters), the bisexual/homosexual persisters tended to be older at the time of the assessment in childhood, were from a lower social class background, and, on a dimensional composite of sex-typed behavior in childhood were more gender-variant. The bisexual/homosexual desisters were more gender-variant compared to the heterosexual desisters.”

​

A secondary analysis of the U.S. Transgender Survey found that 13.1% of participants reported a history of detransition (Turban, Loo, Almazan, & Keuroghlian, 2021).  Of those who detransitioned, 82.5% reported an external factor that led to the decision such as family pressure or social stigma. Detransition was associated with factors such as male sex assigned at birth, nonbinary gender identity, bisexual sexual orientation, and having a family unsupportive of one's gender identity.  In addition to external factors,  a decision to detransition may also be driven by internal factors such as developmental processes (Turban & Keuroghlian, 2018).

​

What might some of the clinical implications of this debate be for families with a transgender member?  Since our knowledge about individuals who desist in their gender dysphoria is still developing, and the factors associated with it may be internal, external, or both, based on what is known at this time clinicians might consider several approaches.  First, recognize that not all individuals with a transgender identity may maintain it over time and help the family to understand this pliability.  Assist them to handle the uncertainty and the related anxiety that this situation may produce as it may precede ambiguous loss (for more about this concept, see the section, Other Related Clinical Concepts in Resources for Clinicians).  If the family desires it, encourage the family to contact their clergy member for support. 

 

Second, support the transgender person and his/her family through the process of exploring his/her gender identity.  For example, in addition to a range of psychotherapeutic interventions (e.g., psychotherapy, group therapy) for adolescents, also consider social transition along with its strengths and weaknesses as a possible, reversible step, one that is increasingly being recommended by clinicians for pre-pubertal youth (Chen, Edwards-Leeper, Stancin, & Tishelman, 2018; Singh et al., 2021).  Ensure that the family is aware of what medical interventions are available and what their limits are (e.g., medication side effects), especially which treatments are reversible and which are not.  While some clients may only present with a request for a referral letter to begin medical intervention, allow for the possibility that other youth may wish to explore their gender identity and this process could take many months.  The resolution of this process may or may not lead to a decision to proceed with medical intervention, and even after the family may decide on medical intervention, in some cases it may not be a permanent decision.  For example, consider the case of an adolescent whose family has decided to begin medical intervention, where this process proceeded through starting puberty blockers only to later decide to end their use in order to resume the birth gender puberty (Turban, Carswell, & Keuroghlian, 2018).

 

Current Issues: The Effect on Families of State Bills Banning Medical Treatments for Transgender Youth

​

Do these bans maintain traditional views of biological sex or promote child welfare?

Families with transgender youth are increasingly finding themselves in the middle of a bewildering situation. They are getting caught up in the middle of a national debate on access to medical treatments for these youth while the caregivers are trying to sort out what is best for their child.  Families are open to criticism from all sides regardless of whether they choose a medical and/or psychotherapeutic treatment, or no treatment at all.  

 

Starting in January 2021, a group of states began proposing legislation that would restrict medical treatments for transgender youth (i.e., puberty blockers, hormone therapies, and transition-related surgeries). Puberty blockers are a class of medications called gonadotropin-releasing hormone agonists that first started to be used medically in the 1980s to delay the start of early onset puberty in children.  Synthetic hormones were first used medically to treat intersex children in the 1930s and just a few years later they were used to treat transgender youth.  Today therapy may include hormones such as testosterone, estrogen, and progesterone.  As of April 2022, twenty states (mostly concentrated in the Southeast and Midwest, and Mountain West) have proposed such laws, but only three states have enacted them (i.e., Alabama, Arkansas, Tennessee).  The specific restrictions vary by state, age, and treatment type.  Some ban insurance coverage for treatments.  Generally speaking, the restrictions do not apply to cases of youth with chromosomal ambiguity or sexual development disorders.  Violations of these laws may be considered a felony or may open the health care provider up to lawsuits for damages.

 

These bills have been cast as promoting child welfare in the sense of protecting vulnerable children from medical procedures that are perceived to be dangerous because they lack adequate scientific support.  The bills aim to give children a “natural” childhood that arises from their biological sex.  For example, the Arkansas bill was framed as keeping children safe from medical experimentation.  It encouraged youth to seek mental health services prior to medical intervention due to pre-existing psychopathology.  It notes that “no randomized clinical trials have been conducted on the efficacy or safety of the use of cross-sex hormones in adults or children for the purpose of treating such distress or gender transition.”  One such study is currently underway.

 

Among those states that are still considering bills banning certain medical treatments for transgender youth, Georgia would make the provision of gender-related surgery, hormone therapy, or puberty blockers to minors under age 18 a felony.  Like the Arkansas bill’s focus on saving adolescents from medical experimentation, the Georgia bill was entitled as the “Vulnerable Child Protection Act.” Following on the child welfare theme, a proposed bill in Texas would consider the provision of gender-related surgery, hormone therapy or puberty blockers to be a form of child abuse.  In February 2022, the governor of Texas directed state agencies to conduct investigations into the use of gender affirming care for transgender children.  This direction came after an opinion issued by the state attorney general that these treatments are a kind of child abuse. A month later, a state judge ruled that the policy had been adopted improperly and that it violated state constitution.  This injunction temporarily halted the investigations.

 

In contrast with the child protection view, another view is that these bills serve to maintain traditional views of gender role as influenced only by biological sex.  Puberty blockers, hormone therapy, and gender-related surgeries all disrupt a connection that is assumed to be natural.  Child protection laws generally assume that the parent’s care of the child is abusive or neglectful to the point that the state must step in to care for the child.  However parental consent is required in order for physicians to begin treatments with puberty blockers and hormone therapy in youth who have started puberty.  As a result, the restrictions seem to suggest that a parent’s decision to proceed with medical treatment of his/her transgender child constitutes abuse rather than the provision of medical care that the parent believes is needed.  Why would the state choose to override parental rights regarding their decisions about medical treatment for their children in this instance but support them in others?  

 

While the bills’ proponents raise concerns about insufficient scientific support for these treatments, perhaps they are unaware that half of the medical treatments for any condition lack sufficient scientific support.  The off-label prescribing of medications is defined as prescribing medications for a disease or symptom without FDA approval.  Off-label prescribing is common, affecting approximately 21% of prescription medications.  If the purpose of such bills is to ban treatments without evidence of effectiveness, then there appear to be many more treatments that could or should be banned.  Moreover, some of the bills note that the proportion of transgender youth in the population is relatively quite small.  In this case, why might these treatments raise such grave concern that bans are warranted given that so few people are affected?  There appear to be many other medical treatments without evidence of effectiveness that affect a far greater number of people.

​

How do treatment restrictions compare with current medical guidelines?

The laws enacted so far will likely result in little change in the medical treatments available to transgender youth, but may cause harm to families.  The restrictions appear to cover certain instances of treatment that may rarely or never occur. For example in Arkansas, gender-related surgeries are banned for youth under 18 years old, yet current medical guidelines do not recommend gender-related surgery for those under 18 years of age.  Current medical guidelines do recommend treatment of transgender youth with puberty blockers and/or hormone therapy who meet specific diagnostic criteria after puberty has begun, but the restriction prohibits this treatment in Arkansas.  

 

Meanwhile in Tennessee the law bans only hormone therapy for prepubertal youth, but medical guidelines do not recommend puberty blockers and hormone therapy use in prepubertal youth.  

​

What effects do treatment bans have on families?

Regardless of a family member’s feelings about the decision to pursue medical treatment, its effectiveness, morality, and any potential long-term side effects (which are not fully known at this time), these treatment bans may create a situation that can have a negative impact on families:

• Parents of transgender youth may be concerned for their child’s emotional health and physical safety.  In particular, consider the experience of leaders of faith communities who have a child who identifies as a transgender person, and who live in a state that is considering a bill that would limit gender-affirming care.

• It may exacerbate conflict within the family between the transgender family member and other members.

• Transgender youth may feel alienated or rejected possibly leading to higher rates of anxiety, depression, and/or suicide risk, or substance use.  They may develop a mistrust the health care system, which could lead to forgoing other kinds of health care in the future.

• Non-transgender family members may feel 

  • stigma, 

  • a sense of helplessness (e.g., unable to assist child/sibling, obstructed in the process of finding care for the child to address gender dysphoria), 

  • left to deal with a child’s problem on their own (e.g., abandonment by the health care system, mistrust of the health care system and the state government, sense of being alone).

• Some family members may contemplate moving to a different state without treatment restrictions.  For some people, such a move could lead to isolation through a weakening of the family support network and their local social support network, which could compromise the family’s ability to cope with the situation.

• Restrictions on hormone therapy may lead to attempts to purchase these drugs outside the health system without proper medication monitoring (e.g., liver, kidney function) and medical support.

 

On the other hand, psychotherapeutic interventions for gender dysphoria are not mentioned in the two states’ laws that restrict certain medical interventions for transgender youth.  As a result, while transgender youth may be unable to receive medical treatments, they may be able to receive psychotherapeutic treatment.  This situation could lead to higher demand for psychotherapeutic treatment for gender dysphoria, as well as depression, anxiety, and substance use that may stem from the laws’ implementation.  Also transgender children will still be able to pursue social transition without immediate medical transition.  

 

​

Current Issues: Rapid Onset Gender Dysphoria Controversy

 

The term, “rapid onset gender dysphoria,” appears to have been coined in 2016 as part of the study recruitment materials for an online survey that explored parents’ perceptions that their child developed symptoms of gender dysphoria in a swift manner with  the parents observing few or no signs of this condition before the child disclosed a transgender identity to the parents (Ashley, 2020).  The descriptive study, “Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria,” was published in the journal, PLOS ONE several years ago (Littman, 2018). Its purpose was to “collect data about parents’ observations, experiences, and perspectives about their adolescent and young adult children showing signs of an apparent sudden or rapid onset of gender dysphoria that began during or after puberty, and develop hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among this demographic.”  The study found that about 83.5% of the parents observed that their children had two or more indicators of gender dysphoria (DSM-5) and a high degree of mental health comorbidity (especially anxiety, depression).  Just under a third of parents reported that their child did not seem to have symptoms of gender dysphoria when s/he disclosed a transgender identity, and at that time a third of the parents reported that their child requested immediate transition.  More than two-thirds of the parents’ children were part of a friendship group where one or more other members had announced a transgender identity at the same time their child did, and 43.7% of the parents indicated that their child was the second member of the friend group to identify as transgender.  The study hypothesized that social influence may be a factor in the development of gender dysphoria and that “maladaptive coping mechanisms may underlie the development of gender dysphoria for some adolescents and young adults.”

 

The study’s publication sparked a controversy including a critique of the study by some researchers and advocates.  The methodological critique suggested that the author had used a pathologizing framework to study this topic and that it had led to bias in the results (Restar, 2020).  In addition, it was suggested that selection bias may have affected the study’s results because the author had recruited potential survey participants using snowball sampling that started at three social media sites (of the four sites where recruitment was begun) that were oriented toward caution and concern about the speed with which referral of youth with gender dysphoria led to treatment with puberty blockers and possible gender reassignment surgery.  One social critique of the study suggested that the possible identification of rapid onset gender dysphoria as a separate clinical condition represented an attempt to use science to dismiss a growing body of empirical evidence of the positive effects of gender transition, and that the Littman (2018) study’s findings were best explained by the selection of social media sites that were “antagonistic” about referral and treatment (Ashley, 2020). 

 

These methodological and social critiques led the journal editors to republish a corrected version of the article with a clarified response from the author.  This version of the article emphasized that the study focused on parent observations for the purpose of developing hypotheses, clarified whether the article described adolescent onset gender dysphoria or some other condition, expanded the qualitative analyses, clarified the study design, methods and related limitations, provided updated information on recruitment, discussed parental approaches to gender dysphoria and views on medical interventions, as well as offered expanded discussion about limitations and biases (Littman, 2019).  Furthermore, the journal editor issued a separate apology to the transgender and research communities for the shortcomings in the manuscript review process (Heber, 2019).  Simultaneously, the editor acknowledged that the journal’s readers should consider that there are different views on this topic.

 

In addition to the criticism, another response from readers was calls for additional research on the characteristics associated with rapid onset gender dysphoria in order to understand these features better.  Some clinicians suggested that Littman’s study (2018) described characteristics that aligned with their clinical experience and they called for more research into patients with this presentation of gender dysphoria (Hutchinson, Midgen, & Spiliadis, 2020). Meanwhile, others suggested that the clinical community still doesn’t have agreement on the best diagnostic and treatment approaches in cases of youth with gender dysphoria of the type studied, and as a result further investigation was needed (Brandelli Costa, 2019).

 

So far there has been just one study that attempted to validate Littman’s (2018) hypothesis that rapid onset gender dysphoria was a distinct clinical phenomenon (Bauer, Lawson, & Metzger, 2021).  However, the study results didn’t support the hypothesis that rapid onset gender dysphoria may be a separate condition.  However, the two study groups in Littman’s and Bauer and colleagues’ studies may have been different in terms of the severity of gender dysphoria symptoms, and underscoring the concern regarding limitations with diagnostic precision and definitions of transgender (Brandelli Costa, 2019; Collin, Reisner, Tangpricha, & Goodman, 2016).  Rather than using study inclusion criteria that were based on the parent’s report of youth’s symptoms of gender dysphoria, Bauer and colleagues’ study administered the Trans Youth CAN! Gender Distress Scale to the youth themselves who had been referred to a gender clinic and used diagnoses from clinical records.  The researchers reported the mean scale score (4.05, range 0-5 with 5 representing complete agreement with gender distress-related items) but did not mention the proportion of youth with a clinically significant scale score or the proportion of youth with a gender dysphoria diagnosis.  Nevertheless, this group may have been one with more clinically significant symptoms than the one in Littman’s (2018) study.  In this study, parents were asked to endorse whether they observed in their child any of six symptoms based on the DSM-5 criteria for gender dysphoria, three symptoms of which the parents may not have been able to observe unless the child had told the parent since they refer to the child’s wishes (e.g., a strong desire to be the other gender).  The average number of positive indicators was 3.5 (range 0-6 indicators).  Also the diagnostic requirement for the six month duration of symptoms was not included, nor was there any assessment of the youth’s clinical distress level, both of which are factors taken into account in making a gender dysphoria diagnosis.  As a result, this study population may have included a higher proportion of youth with sub-clinical gender dysphoria symptoms or those without a gender dysphoria diagnosis at all than Bauer and colleague’s study population.

 

What might some of the clinical implications of this controversy be for families with a transgender member?  Since our knowledge about cases when an adolescent discloses a transgender identity abruptly with his/her parent recognizing few or any symptoms of gender dysphoria before the disclosure is still developing, several responses may be possible.  One response may be to acknowledge that there may be different presentations of gender dysphoria in youth and use a validated gender identity questionnaire with known psychometric properties when conducting an assessment of an adolescent who presents with issues regarding his/her gender identity.  This process should help clinicians distinguish whether this client has an adolescent onset gender dysphoria diagnosis or some other condition.  One such instrument is the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (Deogracias et al., 2007).  Another complementary approach may be to include parent and primary care physician perspectives as part of the diagnostic process, as is the procedure when making an attention deficit/hyperactivity disorder diagnosis. 

 

Consider that if the onset of gender dysphoria has been recent, this news could be a jolt to family stasis and they may be in a state of emergency or panic.  Assist the family to manage anxiety and tolerate uncertainty (Brandelli Costa, 2019).  Recognize that they may be anticipating the possibility of a kind of ambiguous loss (for more about this concept, see the section, Other Related Clinical Concepts in Resources for Clinicians).  Encourage the family to engage their clergy member for support if the family wishes it.  Assist the family to weigh out the advantages and disadvantages of different kinds of any immediate steps they might take.  As in the case of the desister debate, the process of exploring the client’s gender identity could take many months in some cases or might not be as long in others.  The resolution of this process may or may not lead to a decision to proceed with medical intervention, and even after the family may decide on medical intervention, in some cases it may not be a permanent decision.  For example, consider the case of an adolescent whose family decided to begin medical intervention, where the process proceeded through starting puberty blockers only to later decide to end their use in order to resume the birth gender puberty (Turban et al., 2018).  As a result, consider preparing the family for a range of potential outcomes, including the possibility that the child may return to his/her birth gender.