Gender dysphoria in children

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Gender dysphoria in children
Other namesGender identity disorder in children, gender incongruence of childhood
SpecialtyPsychiatry Edit this on Wikidata
Usual onsetChildhood

Gender dysphoria in children (GD), also known as gender incongruence of childhood, is a formal diagnosis for children who experience significant discontent (gender dysphoria) due to a mismatch between their assigned sex and gender identity. The diagnostic label gender identity disorder in children (GIDC) was used by the Diagnostic and Statistical Manual of Mental Disorders (DSM) until it was renamed gender dysphoria in children in 2013 with the release of the DSM-5. The diagnosis was renamed to remove the stigma associated with the term disorder.[1]

Controversy surrounding the pathologization and treatment of a transgender identity and associated behaviors, particularly in children, has been evident in the literature since the 1980s. The majority of major medical associations such as the American Psychological Association, Substance Abuse and Mental Health Services Administration, and the World Professional Association for Transgender Health consider attempts to change a person's gender identity to be conversion therapy. The practice is considered unethical, pathologizing, and seriously harmful to transgender youth.[2][3][4][5][6] Researchers also argue that therapeutic interventions that aim to alter a child's gender identity rely on the assumption that an adult transgender identity is undesirable, challenging this assumption along with the lack of clinical data to support outcomes and efficacy.[6]

Proponents of the older therapeutic approach to intervention argue that therapeutic intervention helps children be more comfortable in their bodies, have better peer relations and therefore better self-esteem, that research indicates there exist forms of distress associated directly with children's gender variance, and that treatment can prevent adult GD.[1] More modern therapeutic interventions do not seek to change a child's gender identity, but are instead focused on creating a supportive and safe environment for the child to explore their gender identity and gender expression.[7]

Classification[edit]

Children with persistent gender dysphoria are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria.[8] Some (but not all) gender variant youth will want or need to transition, which may involve social transition (changing dress, name, pronoun), and, for older youth and adolescents, medical transition (hormone therapy or surgery).[6]

DSM-5 (2013)[edit]

In May 2013, the American Psychiatric Association published the DSM-5 update to the Diagnostic and Statistical Manual of Mental Disorders, in which the GIDC diagnosis was removed and replaced with gender dysphoria, for the first time in its own distinct chapter.[9] Subtyping by sexual orientation was deleted. The diagnosis for children was separated from that for adults. The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing, or ability to express it in the event that they have insight.[10]

Signs and symptoms, as outlined by the DSM-5, include a marked incongruence between experienced/expressed gender and assigned gender, of at least six months duration, as manifested by at least six of the following (one of which must be criterion A1):[7]

  • A strong desire to be of the other gender or an insistence that one is the other gender
  • A strong preference for wearing clothes typical of the opposite gender
  • A strong preference for cross-gender roles in make-believe play or fantasy play
  • A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
  • A strong preference for playmates of the other gender
  • A strong rejection of toys, games and activities typical of one's assigned gender
  • A strong dislike of one's sexual anatomy
  • A strong desire for the physical sex characteristics that match one's experienced gender

B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.[7]

International Classification of Diseases (ICD)[edit]

The International Classification of Diseases (ICD-10) lists several disorders related to gender identity, including gender identity disorder of childhood (F64.2): Persistent and intense distress about one's assigned gender, manifested prior to puberty.[11] The current edition has five different diagnoses for gender identity disorder, including one for when it manifests during childhood.[12] The diagnoses of gender identity disorder is not given to intersex individuals (those born with "ambiguous" genitalia). Additionally, as with all psychological disorders, these symptoms must cause direct distress and an impairment of functioning of the individual exhibiting the symptoms.[13]

F64.2 Gender identity disorder of childhood: A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual's own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behavior in boys is not sufficient. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but in F66.0.

The ICD-11 significantly revises classification of gender identity-related conditions.[14] Under "conditions related to sexual health", the ICD-11 lists "gender incongruence", which is coded into three conditions:[15]

  • Gender incongruence of adolescence or adulthood (HA60): replaces F64.0
  • Gender incongruence of childhood (HA61): replaces F64.2
  • Gender incongruence, unspecified (HA6Z): replaces F64.9

Persistence[edit]

According to the American Academy of Pediatrics, "by age four most children have a stable sense of their gender identity" and "research substantiates that children who are prepubertal and assert [a transgender or gender diverse identity] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance".[16][17]

If gender dysphoria persists during puberty, it is very likely permanent.[18][19][20] For children with gender dysphoria, the period between 10 and 13 years is crucial with regard to long-term gender identity.[20][21] Factors that are associated with gender dysphoria persisting through puberty include intensity of gender dysphoria, amount of cross-gendered behavior, and verbal identification with the desired/experienced gender (i.e. stating that they are a different gender rather than wish to be a different gender).[22][20]

Prospective studies have reported that gender dysphoria in children is more heavily linked to adult homosexuality than to an adult transgender identity, especially with regard to boys.[23][24][25] The studies state that the majority of children diagnosed with gender dysphoria did not desire to be the other sex by puberty, with most growing up to identify as gay, lesbian, or bisexual, with or without therapeutic intervention.[18][19][21][22][26]

The prospective studies have been criticized on the basis that they counted as 'desistance' cases where the child was simply gender-nonconforming rather than dysphoric. While they met the criteria for gender identity disorder as defined in the DSM-III or DSM-IV, many would not have met the updated criteria for gender dysphoria in the DSM-5, established in 2013.[27] In addition, prior to the DSM-III in 1980, there was no diagnostic criteria for gender dysphoria, so research on desistance rates published prior to 2000 reported inflated numbers of desistance.[28] Additionally, the evidence offered has been criticized for citing studies which have been labelled conversion therapy for discouraging social transition and trying to prevent a transgender outcome. [29][30][31]

The studies have been used to argue for more caution in socially or medically transitioning transgender youth; however, they have been criticized as irrelevant due to tracking diagnoses rather than tracking evolution of gender identity or desire to transition.[32] In addition, Bonifacio et al. state that "there is research to suggest" that some desistance of GD "may be caused, in part, by an internalizing pressure to conform rather than a natural progression to non–gender variance."[33]

According to a review published in 2022 considering more recent studies, the majority of pre-pubertal children who socially transition persist in their identity in 5 to 7 year follow ups.[20]

Prevalence[edit]

According to a review published in 2020 relying on recent statistical surveys, 1.2% to 2.7% of children and adolescents identify as transgender. The data was drawn more from studies of adolescents than pre-pubertal youth and noted a difference in methodological quality between studies published before and after 2010. The review notes rising numbers of youth are self-identifying as trans and calls for more systematic studies and reviews in future. [34]

Management[edit]

The WPATH Standards of Care and other therapeutic interventions do not seek to change a child's gender identity.[7][3] Instead, clinicians advise children and their parents to avoid goals based on gender identity and to instead cope with the child's distress by embracing psychoeducation and to be supportive of their gender variant identity and behavior as it develops.[6][35] A clinician may suggest that the parent be attentive, listen, and encourage an environment for the child to explore and express their identified gender identity, which may be termed the true gender. This can remove the stigma associated with their dysphoria, as well as the pressure to conform to a gender identity or role they do not identify with, which may be termed the false gender self.[6] WPATH Standards of Care also recommend assessing and treating any co-existing mental health issues.[3] By contrast, the majority of major medical associations define attempts to change an individual's gender identity or gender expression as conversion therapy.[4][5]

Treatment may also take the form of puberty blockers (such as leuprorelin), cross-sex hormones (i.e., administering estrogen to a child assigned male at birth or testosterone to a child assigned female at birth), or sex reassignment surgery with the aim of bringing one's physical body in line with their identified gender.[6][35] Delaying puberty allows for the child to mentally mature while preventing them from developing a body they may not want, so that they may hopefully make a more informed decision about their gender identity once they are an adolescent.[6] It can also help reduce anxiety and depression.[35] Short-term side effects of puberty blockers include headaches, fatigue, insomnia, muscle aches and changes in breast tissue, mood, and weight.[36] Research on the long-term effects on brain development, cognitive function, fertility, and sexual function is limited.[37][38][39]

According to the American Psychiatric Association, "Due to the dynamic nature of puberty development, lack of gender-affirming interventions (i.e. social, psychological, and medical) is not a neutral decision; youth often experience worsening dysphoria and negative impact on mental health as the incongruent and unwanted puberty progresses. Trans-affirming treatment, such as the use of puberty suppression, is associated with the relief of emotional distress, and notable gains in psychosocial and emotional development, in trans and gender diverse youth".[40]

In its position statement published December 2020, the Endocrine Society stated that there is durable evidence for a biological underpinning to gender identity and that pubertal suppression, hormone therapy, and medically indicated surgery are effective and relatively safe when monitored appropriately and have been established as the standard of care. They noted a decrease in suicidal ideation among youth who have access to gender-affirming care and comparable levels of depression to cisgender peers among socially transitioned pre-pubertal youth.[41] In its 2017 guideline on treating those with gender dysphoria, it recommends puberty blockers be started when the child has started puberty ( Tanner Stage 2 for breast or genital development) and cross-sex hormones be started at 16, though they note "there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence". They recommend a multidisciplinary team of medical and mental health professionals manage the treatment for those under 18. They also recommend "monitoring clinical pubertal development every 3 to 6 months and laboratory parameters every 6 to 12 months during sex hormone treatment".[42]

For adolescents, WPATH says that physical interventions such as puberty blockers, hormone therapy, or surgery may be appropriate. Before any physical interventions are initiated, however, a psychiatric assessment exploring the psychological, family, and social issues around the adolescent's gender dysphoria should be undertaken.[3] Some medical professionals disagree that adolescents are cognitively mature enough to make a decision with regard to hormone therapy or surgery, and advise that irreversible genital procedures should not be performed on individuals under the age of legal consent in their respective country.[6] WPATH's Standards of Care 8, published in 2022, declare puberty blocking medication as "medically necessary", and recommends them for usage in transgender adolescents once the patient has reached Tanner stage 2 of development, and state that longitudinal shows improved outcomes for transgender patients who receive them.[43]

While few studies have examined the effects of puberty blockers for gender non-conforming or transgender adolescents, the studies that have been conducted generally indicate that these treatments are reasonably safe, are reversible, and can improve psychological well-being in these individuals.[44][45][46]

A 2020 review published in Child and Adolescent Mental Health found that puberty blockers are reversible and associated with such positive outcomes as decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life.[47] A 2020 survey published in Pediatrics found that puberty blockers are associated with better mental health outcomes and lower odds of lifetime suicidal ideation.[48] A 2022 study published in the Journal of the American Medical Association found a 60% reduction in moderate and severe depression and a 73% reduction in suicidality among transgender youth aged 13–20 who took puberty blockers and gender-affirming hormones over a 12-month follow-up.[49] A 2022 study published in The Lancet involving 720 transgender adolescents who took puberty blockers and hormones found that 98 percent continued to use hormones at a follow up appointment.[50]

In 2020, a review article commissioned by NHS England was published by the National Institute for Health and Care Excellence, concluding that the quality of evidence for puberty blocker outcomes (for mental health, quality of life and impact on gender dysphoria) was of very low certainty based on the GRADE scale.[51] The Finnish government commissioned a review of the research evidence for treatment of minors and the Finnish Ministry of Health concluded that there are no research-based health care methods for minors with gender dysphoria.[52] Nevertheless, they recommend the use of puberty blockers for minors on a case-by-case basis, and the American Academy of Pediatrics state that "pubertal suppression in children who identify as TGD [transgender and gender diverse] generally leads to improved psychological functioning in adolescence and young adulthood."[53]

In 2022, the National Board of Health and Welfare in Sweden issued new guidelines recommending that puberty blockers only be given in "exceptional cases" and said that their use was grounded in "uncertain science." Instead, they recommended child psychiatric treatment, psychosocial interventions, and suicide prevention measures to be offered by clinicians.[54][55]

In the UK, Bell v Tavistock[56] considered the case of a patient who had changed her mind, now believing she was too young to have made such a decision, and concluded "Where the decision is significant and life changing then there is a greater onus to ensure that the child understands and is able to weigh the information". Following the ruling, NHS England announced that children under 16 would no longer be given puberty blockers without court authorization.[57] This ruling was overturned on appeal in 2021, once again allowing children under 16 to consent to puberty blockers.[58]

Data from the Tavistock clinic found that children who were given puberty blockers were very likely to transition, with 43/44 (98%) of children who were given puberty blockers ultimately going on to take cross-sex hormones.[59][relevant?]

History[edit]

Past attempts at therapeutic intervention often included conversion therapy, viewing gender non-conformity as a problem to be fixed rather than natural variation. In addition, gender identity, gender expression, and sexual orientation were often conflated as problems to be corrected and replaced with the "correct" gendered behavior. Noting that many transgender and homosexual adults reported gender-nonconformity in childhood, clinicians at the time viewed early childhood intervention as a way to prevent a later LGBT identification. Notable proponents of the view that a trans "outcome" should be discouraged have included Richard Green, John Money, George Rekers, Ole Ivar Lovaas, Kenneth Zucker and Susan Bradley.[60]

The introduction of the GIDC diagnosis into the DSM-III in 1980[61] was preceded by numerous US studies and treatments on feminine boys beginning as early as the 1950s and 1960s, most prominently by John Money and Richard Green at the Johns Hopkins Hospital and the University of California, Los Angeles (UCLA).[62] The prevention of transsexuality and / or homosexuality was explicitly stated as the goal of many of these studies: "My focus will be what we might consider the prevention of transsexualism."[63] Bryant states that feminine boys were not a new phenomenon at this time; however, the public emergence of adult transsexual women (male to female) in the 1950s was new and created a number of problems for psychologists, motivating some to undertake efforts at preventing their further emergence.[64] Meyerowitz chronicles the deep disagreements which erupted between psychologists and physicians after Christine Jorgensen's public gender transition, namely over whether transsexuals should be permitted to align their bodies with their inner identities or whether their inner identities must be brought in line with their bodies.[65] At the time, transsexual women were beginning to publish first-person narratives which highlighted their awareness of their femininity at a young age[66] and Bryant states that some clinicians and researchers thus turned their attention to feminine boys, constructing sissies as a new "medicalized patient and research population."[64]

In 1960, Green and Money published a paper titled "Incongruous Gender Role: Nongenital Manifestations in Prepubertal Boys," detailing their observations of 5 children assigned male at birth(AMAB) who "showed incongruities in gender role", ranging from preferring to play with girls to praying God would change them into a girl. Citing that adult gay men and transgender women recollect gender incongruity in childhood, they later concluded early intervention is best in cases of gender incongruity and that "part of the successful rearing of a child is orienting him, from birth, to his biologically and culturally acceptable gender role. This, as far as we know, is best achieved by providing a relationship between husband and wife exemplifying these respective roles."[67]

In 1968, Green published "Childhood Cross-Gender Identification", a paper reviewing the therapy of nine AMAB children who were younger than 8 and "clearly prepubertal". The first six were from the collaborative papers between Green and Money, the last 3 were from Robert Stoller. Citing the failure of attempts to "cure" adult trans women, he reported early diagnosis and treatment may be effective in preventing manifestations of adulthood cross-gender identification. The stated goals of family therapy are for "for the husband and wife to gain some perspective on the second class citizen of the husband and of the significance of their unbalanced roles in shaping their son's personality. Additional focus is on the masculinity-inhibiting of mother's anxiety over her son's healthy aggression and her greater comfort with what to her is his less threatening behavior."[68]

Another early researcher was George Alan Rekers, who later became an administrator at NARTH, who focused his 1972 doctoral research on the treatment of feminine boys.[69] In this work, Rekers describes a litany of feminine behaviours which he catalogues including: feminine posture, gait, arm and hand gestures, feminine inflection in speech, as well as interest in feminine clothing, games and conversation topics. Using classical behaviour modification techniques he and a team of research assistants set about extinguishing 'problem' feminine behaviours in three boys in particular, enlisting the help of parents and occasionally teachers to provide rewards and punishments corresponding to behaviours identified as wanted or unwanted. Rekers' dissertation describes in detail, the case of Kraig (a pseudonym for Kirk Andrew Murphy[70]) whose mother was instructed over earphones to alternately praise or ignore him depending on whether he played with a table of toys deemed to be feminine (typically dolls) or masculine (typically weapons). She was also trained to monitor his behaviour at home, with research assistants visiting weekly to ensure she was correctly completing her four times daily observations of Kraig's gendered behaviour. Physical punishment from Kraig's father is named as one of the primary consequences for feminine behaviour at home. Throughout Rekers's future work, he cites his treatments with Kraig as a success, claiming that "Kraig's feminine behaviours have apparently ceased entirely […]."[71]

In 1974, Rekers and Ole Ivar Lovaas published the article "Behavioral Treatment of Deviant Sex-Role Behaviors in a Male Child." The article cited Green and Money as a source of the "growing evidence that childhood cross-gender manifestations are indicative of later adult sexual abnormalities; e.g., transvestism, transsexualism, or some forms of homosexuality."[72] It noted that many transgender women and gay men reported their "cross-gender behaviors began in early childhood"[73] and the research showed it was difficult or impossible to shift in adults; the authors felt the best way to prevent "future sexual deviance", or at least make it unlikely as possible, was to correct gender noncomforming behavior at a young age. The method the paper detailed was a token based reinforcement system administered by the parents which rewarded gender conformity and punished deviancy. Blue chips were a sign of good behavior and could be swapped for chocolate bars, red chips were a sign of bad behavior and resulted in isolation and beatings.[71][74][75]

In contrast to this, a number of facts about Kraig have become public information, including: that he was a gay man; that according to his family, he never recovered from these treatments; and that in 2003, at the age of 38, he committed suicide.[70] Even without confirmed knowledge of such outcomes, by the mid-1970s Rekers's publications on his treatment modality were already attracting harsh criticism from scholarly[76] and popular[77] media sources, and Bryant speculates that this is one possible explanation for why many clinicians do not publish on their treatment techniques, focusing instead on less controversial aspects of GD, such as diagnostic criteria.[64]

Therapeutic approaches for GD differ from those used on adults and have included behavior therapy, psychodynamic therapy, group therapy, and parent counseling.[35] This includes aiming to reduce gender dysphoria, making children more comfortable with their bodies, lessening ostracism, and reducing the child's psychiatric comorbidity.[7]

Therapeutic intervention seeks to identify and resolve underlying factors (including familial factors), encourage the child to identify with their assigned sex, and encourage same-sex friendships.[13][78] Parent counseling involves setting limits on the child's cross-gender behavior, encouraging gender-neutral or sex-typical activities, examining familial factors, and examining parental factors such as psychopathology. Researchers Zucker and Susan Bradley state that it has been found that boys with GD often have mothers who, to an extent, reinforced behavior more stereotypical of young girls. They also state that children with GD tend to come from families where cross-gender role behavior was not explicitly discouraged. However, they also acknowledge that one could view these findings as merely indicative of the fact that parents who were more accepting of their child's cross-gender role behavior are also more likely to bring their children to a clinical psychiatrist as opposed to parents who are less accepting of cross-gender role behavior in their children.[13][78]

In 2002, Zucker acknowledged limited data on gender dysphoria in children, stating that "apart from a series of intrasubject behaviour therapy case reports from the 1970s, one will find not a single randomized controlled treatment trial in the literature".[78] He has stated that "the therapist must rely on the 'clinical wisdom' that has accumulated and to utilize largely untested case formulation conceptual models to inform treatment approaches and decisions."[79] In 2018, in a narrative systemic review titled "Conversion therapies and access to transition-related healthcare in transgender people", Zucker's work was provided as a case study in conversion therapy including open-ended play psychotherapy, parent counselling, and parent-guided interventions to prevent "transsexualism". The study was criticized by the reviewers for relying on flawed estimates of desistance as well as actively trying to reduce cross-gender identification.[80]

In 2015, the American Psychological Association and the Substance Abuse and Mental Health Services Administration collaborated on a report stating "conversion therapy—efforts to change an individual's sexual orientation, gender identity, or gender expression—is a practice that is not supported by credible evidence and has been disavowed by behavioral health experts and associations. Conversion therapy perpetuates outdated views of gender roles and identities as well as the negative stereotype that being a sexual or gender minority or identifying as LGBTQ is an abnormal aspect of human development. Most importantly, it may put young people at risk of serious harm."[2] Already by 2017, the majority of major medical associations had defined attempts to change an individual's gender identity or gender expression as conversion therapy.[4][5]

In 2021, the World Professional Association for Transgender Health concluded that treatment aimed at trying to change a person's gender identity and expression to become more congruent with sex assigned at birth "is no longer considered ethical."[3] Edgardo Menvielle, a child-adolescent psychiatrist at the Children's National Medical Center in Washington advised that "Therapists who advocate changing gender variant behaviours should be avoided."[81] Developmental and clinical psychologist Diane Ehrensaft told the Psychiatric Times, "The mental health profession has been consistently doing harm to children who are not 'gender normal,' and they need to retrain."[82]

Society and culture[edit]

Diagnostic dispute[edit]

Pickstone-Taylor has called Zucker and Bradley's therapeutic intervention "something disturbingly close to reparative therapy for homosexuals."[83] Other academics, such as Maddux et al., have also compared it to such therapy.[6][84] They argue that the goal is preventing a transgender identity because reparative therapy is believed to reduce the chances of adult GD, "which Zucker and Bradley characterize as undesirable."[85]

Author Phyllis Burke wrote, "The diagnosis of GID in children, as supported by Zucker and Bradley, is simply child abuse."[86] Zucker dismisses Burke's book as "simplistic" and "not particularly illuminating;" and journalist Stephanie Wilkinson said Zucker characterized Burke's book as "the work of a journalist whose views shouldn't be put into the same camp as those of scientists like Richard Green or himself."[87]

Critics argue that the GIDC diagnosis was a backdoor maneuver to replace homosexuality in the DSM;[88] Zucker and Robert Spitzer counter that the GIDC inclusion was based on "expert consensus," which is "the same mechanism that led to the introduction of many new psychiatric diagnoses, including those for which systematic field trials were not available when the DSM-III was published."[89] Katherine Wilson of GID Reform Advocates stated:[90]

In the case of gender non-conforming children and adolescents, the GID criteria are significantly broader in scope in the DSM-IV (APA, 1994, p. 537) than in earlier revisions, to the concern of many civil libertarians. A child may be diagnosed with Gender Identity Disorder without ever having stated any desire to be, or insistence of being, the other sex. Boys are inexplicably held to a much stricter standard of conformity than girls. Most psychologists who specialize in gender identity disorder in children note a higher level of male patients brought to them, rather than female patients. A possible explanation would be that cross-sex behavior is less acceptable and therefore more noticeable and more likely to be viewed as problematic by the child's parents (Bradley, Zucker, 1997).[13] Preference for cross-dressing or simulating female attire meets the diagnostic criterion for boys but not for girls, who must insist on wearing only male clothing to merit diagnosis. References to "stereotypical" clothing, toys and activities of the other sex are imprecise in an American culture where much children's clothing is unisex and appropriate sex role is the subject of political debate. Equally puzzling is a criterion which lists a "strong preference for playmates of the other sex" as symptomatic, and seems to equate mental health with sexual discrimination and segregation.

Some clinicians, such as Wilson et al., argue that GIDC "has served to pressurize boys to conform to traditional gender and heterosexual roles."[91] Feder states that the diagnosis is based on the reactions of others to the child, not the behavior itself.[92] Langer et al. state "Gender atypicality is a social construction that varies over time according to culture and social class and therefore should not be pathologized."[93] Zucker refuted their claims in a response.[94] Psychiatrist Domenico Di Ceglie opined that for therapeutic intervention, "efficacy is unclear,"[95] and psychologist Bernadette Wren says, "There is little evidence, however, that any psychological treatments have much effect in changing gender identity although some treatment centres continue to promote this as an aim (e.g. Zucker, & Bradley, 1995)."[96]

Therapeutic intervention for GIDC came under renewed scrutiny in May 2008, when Kenneth Zucker was appointed to the DSM-5 committee on GIDC.[97] According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career."[98] Zucker is accused by LGBT activists of promoting "gender-conforming therapies in children"[99] and "treating children with GID with an eye toward preventing adult homosexuality or transsexuality."[100] Zucker "rejects the junk-science charge, saying that there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"[98] However, opponents continue to argue that the diagnosis "harms the very children it purports to help".[64]

The DSM-5 change to "gender dysphoria" was endorsed by transgender activists and allies as a way to lessen stigma but maintain a diagnostic route to trans-specific medical care.[101] However, Lev states that the diagnosis of gender dysphoria continues to pathologize transgender experiences.[102]

Alternative views[edit]

Referencing contemporary Western views on gender diversity, psychologist Diane Ehrensaft stated: "I am witnessing a shake-up in the mental health community as training sessions, workshops and conferences are proliferating all over this country and around the world, demanding that we reevaluate the binary system of gender, throw out the idea that gender nonconformity is a disorder, and establish new guidelines for facilitating the healthy development of gender-creative children."[103] Child-adolescent psychiatrist Edgardo Menvielle and psychotherapist Catherine Tuerck offer a support group for parents of gender non-conforming children at the Children's National Medical Center in Washington D.C., aimed "not at changing children's behaviours but at helping parents to be supportive".[104] Other publications began to call for a similar approach, to support parents to help their child become their authentic self.[103][105]

Community organizations established to support these families have begun to develop, all with the goal of supporting healthy families with gender non conforming or transgender children. Popular media accounts of parents assisting their children to live in their felt gender role have also emerged.[106][107] Menvielle maintains that "the therapist should focus on helping the child and family cope with intolerance and social prejudice, not on the child's behaviours, interests or choice of playmates".[81] A host of additional terms have been applied to these children, including gender variant,[81] gender non-conforming,[104] and gender-creative.[103]

See also[edit]

References[edit]

  1. ^ a b Bryant K (2018). "Gender Dysphoria". Encyclopædia Britannica Online. Retrieved 16 August 2018.
  2. ^ a b "Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth" (PDF). Substance Abuse and Mental Health Services Administration. October 2015. Archived from the original (PDF) on 14 October 2021. Retrieved 26 December 2021. Specifically, conversion therapy—efforts to change an individual's sexual orientation, gender identity, or gender expression—is a practice that is not supported by credible evidence and has been disavowed by behavioral health experts and associations. Conversion therapy perpetuates outdated views of gender roles and identities as well as the negative stereotype that being a sexual or gender minority or identifying as LGBTQ is an abnormal aspect of human development. Most importantly, it may put young people at risk of serious harm.
  3. ^ a b c d e "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People" (PDF). World Professional Association for Transgender Health. pp. 10–21. Retrieved 15 March 2021.
  4. ^ a b c "Health and Medical Organization Statements on Sexual Orientation, Gender Identity/Expression and 'Reparative Therapy'". lambdalegal.org. Lambda Legal.
  5. ^ a b c "Policy and Position Statements on Conversion Therapy". Human Rights Campaign. Human Rights Campaign. Retrieved 12 April 2017.
  6. ^ a b c d e f g h i Maddux JE, Winstead BA (2015). Psychopathology: Foundations for a Contemporary Understanding. Routledge. pp. 464–465. ISBN 978-1317697992.
  7. ^ a b c d e Kliegman RM, Stanton B, Geme JS, Schor NF (2015). Nelson Textbook of Pediatrics E-Book. Elsevier Health Sciences. pp. 933–934. ISBN 978-0323263528.
  8. ^ Alderson K (2012). Counseling LGBTI Clients. Sage Publications. p. 152. ISBN 978-1412987189.
  9. ^ American Psychiatric Association. (2013). "Diagnostic and statistical manual of mental disorders" (5th ed.). Washington, DC.,
  10. ^ "P 00 Gender Dysphoria in Children". American Psychiatric Association. Retrieved 2 April 2012.
  11. ^ "International Classification of Diseases (ICD) F64 Gender identity disorders". World Health Organization. Retrieved 9 August 2018.
  12. ^ World Health Organization (May 1990). Disorders of adult personality and behaviour F60-F69 .
  13. ^ a b c d Bradley SJ, Zucker KJ (July 1997). "Gender identity disorder: a review of the past 10 years". Journal of the American Academy of Child and Adolescent Psychiatry. 36 (7): 872–80. doi:10.1097/00004583-199707000-00008. PMID 9204664.
  14. ^ "International Classification of Diseases". World Health Organization. Retrieved 11 August 2018.
  15. ^ "Gender incongruence (ICD-11)". icd.who.int. WHO. Retrieved 28 August 2018.
  16. ^ Rafferty, Jason. "Gender Identity Development in Children". American Academy of Pediatrics.
  17. ^ Rafferty, Jason; Committee on Psychological Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness; et al. (2018). "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents". Pediatrics. 142 (4). doi:10.1542/peds.2018-2162. PMID 30224363. S2CID 52288840.
  18. ^ a b Jameson L, de Kretser DM, Marshall JC, De Groot LJ (2013). Endocrinology Adult and Pediatric: Reproductive Endocrinology. Elsevier Health Sciences. p. 483. ISBN 978-0323221528.
  19. ^ a b Dulcan, MK (2015). Dulcan's Textbook of Child and Adolescent Psychiatry, Second Edition. American Psychiatric Pub. p. 591. ISBN 978-1585624935.
  20. ^ a b c d Roberts, Christina (11 May 2022). "Persistence of Transgender Gender Identity Among Children and Adolescents". Pediatrics. 150 (2). doi:10.1542/peds.2022-057693. ISSN 0031-4005. PMID 35538638. S2CID 248694688.
  21. ^ a b Fuss J, Auer MK, Briken P (November 2015). "Gender dysphoria in children and adolescents: a review of recent research". Current Opinion in Psychiatry. 28 (6): 430–434. doi:10.1097/YCO.0000000000000203. PMID 26382161. S2CID 23690783.
  22. ^ a b Ristori J, Steensma TD (2 January 2016). "Gender dysphoria in childhood". International Review of Psychiatry. 28 (1): 13–20. doi:10.3109/09540261.2015.1115754. PMID 26754056. S2CID 5461482.
  23. ^ Kreukels B, Steensma TD, de Vries A (2013). Gender Dysphoria and Disorders of Sex Development: Progress in Care and Knowledge. Springer Science & Business Media. p. 61. ISBN 978-1461474418.
  24. ^ Fatemi H, Clayton PJ (2016). The Medical Basis of Psychiatry. Springer. p. 302. ISBN 978-1493925285.
  25. ^ LeVay S (2010). Gay, Straight, and the Reason Why: The Science of Sexual Orientation. Oxford University Press. p. 91. ISBN 978-0199753192.
  26. ^ Marcdante K, Kliegman RM (2014). Nelson Essentials of Pediatrics E-Book. Elsevier Health Sciences. p. 75. ISBN 978-0323226981.
  27. ^ Temple Newhook, Julia; Pyne, Jake; Winters, Kelley; Feder, Stephen; Holmes, Cindy; Tosh, Jemma; Sinnott, Mari-Lynne; Jamieson, Ally; Pickett, Sarah (3 April 2018). "A critical commentary on follow-up studies and "desistance" theories about transgender and gender-nonconforming children". International Journal of Transgenderism. 19 (2): 212–224. doi:10.1080/15532739.2018.1456390. ISSN 1553-2739. S2CID 150338824. Due to such shifting diagnostic categories and inclusion criteria over time, these studies included children who, by current DSM-5 standards, would not likely have been categorized as transgender (i.e., they would not meet the criteria for gender dysphoria) and therefore, it is not surprising that they would not iden- tify as transgender at follow-up. Current criteria require identification with a gender other than what was assigned at birth, which was not a necessity in prior versions of the diagnosis.
  28. ^ Butler, Catherine; Hutchinson, Anna (2020). "Debate: The pressing need for research and services for gender desisters/Detransitioners" (PDF). Child and Adolescent Mental Health. 25 (1): 45–47. doi:10.1111/camh.12361. PMID 32285632. S2CID 210484832.
  29. ^ Ashley, Florence (2 September 2021). "The clinical irrelevance of "desistance" research for transgender and gender creative youth". Psychology of Sexual Orientation and Gender Diversity. doi:10.1037/sgd0000504. ISSN 2329-0390. S2CID 239099559. Archived from the original on 3 March 2022. Retrieved 3 March 2022.
  30. ^ Newhook, Julia Temple; Pyne, Jake; Winters, Kelley; Feder, Stephen; Holmes, Cindy; Tosh, Jemma; Sinnott, Mari-Lynne; Jamieson, Ally; Pickett, Sarah (3 April 2018). "A critical commentary on follow-up studies and "desistance" theories about transgender and gender-nonconforming children". International Journal of Transgenderism. 19 (2): 212–224. doi:10.1080/15532739.2018.1456390. ISSN 1553-2739. S2CID 150338824.
  31. ^ Steensma, Thomas (2018). "A critical commentary on "A critical commentary on follow-up studies and "desistence" theories about transgender and gender non-conforming children"". International Journal of Transgenderism. 19 (2): 225–230. doi:10.1080/15532739.2018.1468292. S2CID 150062632 – via Taylor & Francis Online.
  32. ^ Ashley, Florence (2 September 2021). "The clinical irrelevance of "desistance" research for transgender and gender creative youth". Psychology of Sexual Orientation and Gender Diversity. doi:10.1037/sgd0000504. ISSN 2329-0390. S2CID 239099559.
  33. ^ Bonifacio HJ, Rosenthal SM (August 2015). "Gender Variance and Dysphoria in Children and Adolescents". Pediatric Clinics of North America. 62 (4): 1001–1016. doi:10.1016/j.pcl.2015.04.013. PMID 26210629.
  34. ^ Zhang, Qi; Goodman, Michael; Adams, Noah; Corneil, Trevor; Hashemi, Leila; Kreukels, Baudewijntje; Motmans, Joz; Snyder, Rachel; Coleman, Eli (2 April 2020). "Epidemiological considerations in transgender health: A systematic review with focus on higher quality data". International Journal of Transgender Health. 21 (2): 125–137. doi:10.1080/26895269.2020.1753136. hdl:1854/LU-8659023. ISSN 2689-5269. PMC 7430478. PMID 33015664.
  35. ^ a b c d Hutson JM, Warne GL, Grover SR (2012). Disorders of Sex Development: An Integrated Approach to Management. Springer Science & Business Media. p. 38. ISBN 978-3642229633.
  36. ^ "Puberty Blockers". www.stlouischildrens.org. Retrieved 18 August 2022.
  37. ^ "As children line up at gender clinics, families confront many unknowns". Reuters. 6 October 2022. Retrieved 10 October 2022.
  38. ^ Rosenthal SM (December 2016). "Transgender youth: current concepts". Annals of Pediatric Endocrinology & Metabolism. 21 (4): 185–192. doi:10.6065/apem.2016.21.4.185. PMC 5290172. PMID 28164070. The primary risks of pubertal suppression in gender dysphoric youth treated with GnRH agonists include adverse effects on bone mineralization, compromised fertility, and unknown effects on brain development.
  39. ^ de Vries AL, Cohen-Kettenis PT (2012). "Clinical management of gender dysphoria in children and adolescents: the Dutch approach". Journal of Homosexuality. 59 (3): 301–20. doi:10.1080/00918369.2012.653300. PMID 22455322. S2CID 11731779.
  40. ^ "Position Statement on Treatment of Transgender (Trans) and Gender Diverse Youth" (PDF).
  41. ^ "Transgender Health: An Endocrine Society Position Statement". www.endocrine.org. The Endocrine Society. 15 December 2020. Retrieved 15 June 2022.
  42. ^ Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer JW, Murad MS, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG (September 2017). "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline". The Journal of Clinical Endocrinology & Metabolism. 102 (11): 3869–3903. doi:10.1210/jc.2017-01658. PMID 28945902.
  43. ^ Coleman, E; Radix, A.E.; Bouman, W.P.; et al. (2022). "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8". International Journal of Transgender Health. 23 (Suppl 1): S18, S64, S111. doi:10.1080/26895269.2022.2100644. PMC 9553112. PMID 36238954.
  44. ^ Mahfouda S, Moore JK, Siafarikas A, Zepf FD, Lin A (October 2017). "Puberty suppression in transgender children and adolescents". The Lancet Diabetes & Endocrinology. 5 (10): 816–826. doi:10.1016/s2213-8587(17)30099-2. PMID 28546095. S2CID 10690853. The few studies that have examined the psychological effects of suppressing puberty, as the first stage before possible future commencement of CSH therapy, have shown benefits.
  45. ^ Rafferty J (October 2018). "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents". Pediatrics. 142 (4): e20182162. doi:10.1542/peds.2018-2162. PMID 30224363. Often, pubertal suppression...reduces the need for later surgery because physical changes that are otherwise irreversible (protrusion of the Adam's apple, male pattern baldness, voice change, breast growth, etc) are prevented. The available data reveal that pubertal suppression in children who identify as TGD generally leads to improved psychological functioning in adolescence and young adulthood.
  46. ^ Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. (November 2017). "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology and Metabolism. 102 (11): 3869–3903. doi:10.1210/jc.2017-01658. PMID 28945902. Treating GD/gender-incongruent adolescents entering puberty with GnRH analogs has been shown to improve psychological functioning in several domains", "In the future, we need more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols. Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development);
  47. ^ Rew, Lynn; Young, Cara C.; Monge, Maria; Bogucka, Roxanne (February 2021). "Review: Puberty blockers for transgender and gender diverse youth-a critical review of the literature". Child and Adolescent Mental Health. 26 (1): 3–14. doi:10.1111/camh.12437. ISSN 1475-357X. PMID 33320999. S2CID 229282305.
  48. ^ Turban, Jack L.; King, Dana; Carswell, Jeremi M.; Keuroghlian, Alex S. (February 2020). "Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation". Pediatrics. 145 (2): e20191725. doi:10.1542/peds.2019-1725. ISSN 1098-4275. PMC 7073269. PMID 31974216.
  49. ^ Tordoff, Diana M.; Wanta, Jonathon W.; Collin, Arin; Stepney, Cesalie; Inwards-Breland, David J.; Ahrens, Kym (25 February 2022). "Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care". JAMA Network Open. 5 (2): e220978. doi:10.1001/jamanetworkopen.2022.0978. PMC 8881768. PMID 35212746.
  50. ^ Loos, Maria Anna Theodora Catharina van der; Hannema, Sabine Elisabeth; Klink, Daniel Tatting; Heijer, Martin den; Wiepjes, Chantal Maria (20 October 2022). "Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands". The Lancet Child & Adolescent Health. 6 (12): 869–875. doi:10.1016/S2352-4642(22)00254-1. ISSN 2352-4642. PMID 36273487. S2CID 253068811.
  51. ^ "Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria". Retrieved 2 April 2021. The critical outcomes for decision making are the impact on gender dysphoria, mental health and quality of life. The quality of evidence for these outcomes was assessed as very low certainty using modified GRADE. For a lay summary, see Cohen, Deborah; Barnes, Hannah (1 April 2021). "Evidence for puberty blockers use very low, says NICE". BBC News Online.
  52. ^ "Finnish guidelines for treatment of child and adolescent gender dysphoria" (PDF). Council for Choices in Health Care (COHERE). March 2021. Archived (PDF) from the original on 3 December 2020. Retrieved 22 April 2021. p. 6: Terveydenhuoltolain mukaan (8§) terveydenhuollon toiminnan on perustuttava näyttöön ja hyviin hoito- ja toimintakäytäntöihin. Alaikäisten osalta tutkimusnäyttöön perustuvia terveydenhuollon menetelmiä ei ole. [According to the Health Care Act (Section 8), health care activities must be based on evidence and good care and operating practices. There are no research-based health care methods for minors. [translation provided by Wikipedia]]
  53. ^ Rafferty, Jason; Committee on Psychosocial Aspects of Child and Family Health; Committee On Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness; et al. (1 October 2018). "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents". Pediatrics. 142 (4): e20182162. doi:10.1542/peds.2018-2162. ISSN 0031-4005. PMID 30224363. Archived from the original on 19 July 2019. Retrieved 11 June 2021.
  54. ^ Ghorayshi, Azeen (28 July 2022). "England Overhauls Medical Care for Transgender Youth". The New York Times. Retrieved 12 October 2022.
  55. ^ Milton, Josh (23 February 2022). "Swedish health board wants doctors to stop prescribing life-saving puberty blockers". PinkNews. Retrieved 12 October 2022.
  56. ^ [2020] EWHC 3274 (Admin)
  57. ^ Woode D (1 December 2020). "Children under 16 will no longer be given puberty blockers without court authorisation". inews.co.uk. Retrieved 4 December 2020.
  58. ^ Siddique, Haroon (17 September 2021). "Appeal court overturns UK puberty blockers ruling for under-16s". Guardian. Retrieved 17 September 2021.
  59. ^ Carmichael P, Butler G, Masic U, Cole TJ, De Stavola BL, Davidson S, et al. (2 February 2021). "Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK". PLOS ONE. 16 (2): e0243894. Bibcode:2021PLoSO..1643894C. doi:10.1371/journal.pone.0243894. PMC 7853497. PMID 33529227.
  60. ^ Florence Ashley (2020). "Homophobia, conversion therapy, and care models for trans youth: defending the gender-affirmative approach". Journal of LGBT Youth. 17 (4): 361–383. doi:10.1080/19361653.2019.1665610. S2CID 203689248.
  61. ^ Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: American Psychiatric Association. 1980.
  62. ^ Green R, Money J (August 1960). "Incongruous gender role: nongenital manifestations in prepubertal boys". The Journal of Nervous and Mental Disease. 131 (2): 160–168. doi:10.1097/00005053-196008000-00009. PMID 13708206. S2CID 45302178.
  63. ^ Green R (June 1971). "Diagnosis and treatment of gender identity disorders during childhood". Archives of Sexual Behavior. 1 (2): 167–173. doi:10.1007/bf01541061. PMID 24179060. S2CID 31328829.
  64. ^ a b c d Bryant K (2006). "Making gender identity disorder of childhood: Historical lessons for contemporary debates". Sexuality Research & Social Policy. 3 (3): 23–39. doi:10.1525/srsp.2006.3.3.23. S2CID 144613679.
  65. ^ Meyerowitz J (2004). How sex changed: A history of transsexuality in the United States. Harvard University Press.
  66. ^ Star HJ (1955). I changed my sex. Chicago, Illinois: Novel Books.
  67. ^ Green & Money 1960, p. 167.
  68. ^ Green, Richard (November 1968). "Childhood Cross-Gender Identification". The Journal of Nervous and Mental Disease. 147 (5): 500–509. doi:10.1097/00005053-196811000-00006. ISSN 0022-3018. PMID 5726921. S2CID 32066172.
  69. ^ Rekers GA (1973). Pathological sex-role development in boys: Behavioral treatment and assessment (Doctoral thesis). University of California, Los Angeles.
  70. ^ a b Bronstein S, Joseph J. "Therapy to change 'feminine' boy created a troubled man, family says". CNN.
  71. ^ a b Rekers GA, Lovaas OI (1974). "Behavioral Treatment of Deviant Sex-Role Behaviors in a Male Child". Journal of Applied Behavior Analysis. 7 (2): 173–190. doi:10.1901/jaba.1974.7-173. PMC 1311956. PMID 4436165.
  72. ^ Rekers & Lovaas 1974, pp. 173
  73. ^ Rekers & Lovaas 1974, pp. 174
  74. ^ Szalavitz, Maia (8 June 2011). "The 'Sissy Boy' Experiment: Why Gender-Related Cases Call for Scientists' Humility". Time. Retrieved 9 June 2011.
  75. ^ Warren Throckmorton (9 June 2011). "Experts and Homosexuality: Don't Try This at Home". Huffington Post. Retrieved 9 June 2011.
  76. ^ Nordyke NS, Baer DM, Etzel BC, LeBlanc JM (1977). "Implications of the stereotyping and modification of sex role". Journal of Applied Behavior Analysis. 10 (3): 553–557. doi:10.1901/jaba.1977.10-553. PMC 1311225. PMID 924924.
  77. ^ Rorvik, David Michael (9 October 1975). "The gender enforcers: Seeing to it the boys will be boys". Rolling Stone.
  78. ^ a b c Zucker, Ken J. (2002). Gender Identity Disorder. In Michael Rutter, Eric A. Taylor (Eds). Child and adolescent psychiatry: modern approaches. Blackwell Publishing. ISBN 0-86542-880-8
  79. ^ Zukcer KJ (2008). "Children with gender identity disorder: Is there a best practice?". Neuropsychiatrie de l'Enfance et de l'Adolescence. 56 (6): 358–364. doi:10.1016/j.neurenf.2008.06.003.
  80. ^ Wright, Talen; Candy, Bridget; King, Michael (1 December 2018). "Conversion therapies and access to transition-related healthcare in transgender people: a narrative systematic review". BMJ Open. 8 (12): e022425. doi:10.1136/bmjopen-2018-022425. ISSN 2044-6055. PMC 6318517. PMID 30580262.
  81. ^ a b c Menvielle EJ, Tuerk C, Perrin EC (2005). "To the best of a different drummer: The gender-variant child". Contemporary Pediatrics. 22 (2): 38–45.
  82. ^ Wingerson L (19 May 2009). "Gender identity disorder: Has accepted practice caused harm?". Psychiatric Times.
  83. ^ Pickstone-Taylor SD (March 2003). "Children with gender nonconformity". Journal of the American Academy of Child and Adolescent Psychiatry. 42 (3): 266, author reply 266–8. doi:10.1097/00004583-200303000-00005. PMID 12595778.
  84. ^ Psychology and Gender Dysphoria: Feminist and Transgender Perspectives. Routledge, page 62. Tosh , J. (2016).
  85. ^ Hill DB, Rozanski C, Carfagnini J, Willoughby B (2006). "Gender Identity Disorders in Childhood and Adolescence: A Critical Inquiry.". In Karasic D, Drescher J (eds.). Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM): A Reevaluation. Haworth Press. pp. 7–34. ISBN 0-7890-3214-7.
  86. ^ Burke P (1996). Gender Shock. Anchor. ISBN 978-0-385-47718-5.
  87. ^ Wilkinson S (2001). "Drop the Barbie!". Brain, Child. Archived from the original on 8 July 2011.
  88. ^ Tomboy: The Surprising History and Future of Girls Who Dare to Be Different. Grand Central Publishing, page 174. Davis , LS. (2020).
  89. ^ Zucker KJ, Spitzer RL (2005). "Was the gender identity disorder of childhood diagnosis introduced into DSM-III as a backdoor maneuver to replace homosexuality? A historical note". Journal of Sex & Marital Therapy. 31 (1): 31–42. doi:10.1080/00926230590475251. PMID 15841704. S2CID 22589255.
  90. ^ Wilson KK (June 1998). The disparate classification of gender and sexual orientation in American psychiatry. Annual meeting of the American Psychiatric Association. Workshop IW57, Transgender Issues. Toronto, Ontario, Canada.
  91. ^ Wilson I, Griffin C, Wren B (2002). "The Validity of the Diagnosis of Gender Identity Disorder (Child and Adolescent Criteria)". Clinical Child Psychology and Psychiatry. 7 (3): 335–351. doi:10.1177/1359104502007003003. S2CID 144490019.
  92. ^ Feder EK (1997). "Disciplining the family: The case of gender identity disorder". Philosophical Studies. 85 (2–3): 195–211. doi:10.1023/a:1004275024875. S2CID 169450859.
  93. ^ Langer SJ, Martin JI (2004). "How Dresses Can Make You Mentally Ill: Examining Gender Identity Disorder in Children". Child and Adolescent Social Work Journal. 21 (1): 5–23. doi:10.1023/b:casw.0000012346.80025.f7. S2CID 144802813.
  94. ^ Zucker KJ (2006). "Commentary on Langer and Martin's (2004) "How Dresses Can Make You Mentally Ill: Examining Gender Identity Disorder in Children". Child and Adolescent Social Work Journal. 23 (5/6): 533–555. doi:10.1007/s10560-006-0074-5. S2CID 143018320.
  95. ^ Di Ceglie D (1995). "Gender identity disorders in children and adolescents". British Journal of Hospital Medicine. 53 (6): 251–6. PMID 7767569.
  96. ^ Wren B (2000). "Early Physical Intervention for Young People with Atypical Gender Identity Development". Clinical Child Psychology and Psychiatry. 5 (2): 220–231. doi:10.1177/1359104500005002007. S2CID 144345920.
  97. ^ Chibbaro Jr L (30 May 2008). "Activists alarmed over APA: Head of psychiatry panel favors 'change' therapy for some trans teens". Washington Blade.
  98. ^ a b Alexander B (22 May 2008). "What's 'normal' sex? Shrinks seek definition: Controversy erupts over creation of psychiatric rule book's new edition". NBC News. Retrieved 14 June 2008.
  99. ^ Szymanski, Zak (3 July 2008). Trans March rallies around inclusion. Archived 11 October 2008 at the Wayback Machine Bay Area Reporter
  100. ^ Osborne D (15 May 2008). "Flap Flares Over Gender Diagnosis". Gay City News. Archived from the original on 24 October 2008. Retrieved 14 June 2008.
  101. ^ Winters K (2008). Gender madness in American psychiatry: Essays from the struggle for dignity (Report). Dillon, Colorado: GID Reform Advocates.
  102. ^ Lev A (2013). "Gender Dysphoria: Two steps forward, one step back". Clinical Social Work Journal. 41 (3): 288–296. doi:10.1007/s10615-013-0447-0. S2CID 144556484.
  103. ^ a b c Ehrensaft D (2011). Gender born, gender made: Raising healthy gender-nonconforming children. New York: The Experiment. ISBN 978-1-61519-060-7.
  104. ^ a b Menvielle E, Tuerk C (2002). "A support group for parents of gender-nonconforming boys. (clinical perspectives)". Journal of the American Academy of Child and Adolescent Psychiatry. 41 (8): 1010–1014. doi:10.1097/00004583-200208000-00021. PMID 12162618.
  105. ^ Brill S, Pepper R (2008). The transgender child. San Francisco: Cleis Press.
  106. ^ Park M (September 2011). "Transgender kids: Painful quest to be who they are". CNN.
  107. ^ Brian Prowse-Gany (23 October 2014). "The New Face of Transgender Youth". Yahoo! News.

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