As compared to the corresponding literature on both children and adults, the clinical and research literature on adolescents with GID is quite small. Among adolescents with GID, there are two basic subgroups of patients. The first subgroup consists of adolescents with a childhood history of GID (or its subclinical manifestation). The second subgroup consists of adolescents with either a childhood and/or adolescent onset of fetishistic cross-dressing. Only treatment of the first subgroup will be discussed here. The reader is referred to Zucker and Bradley (1995) and Zucker and Blanchard (1997) for consideration of the second subgroup.
In adolescents with GID, there are three broad clinical issues that require evaluation: 1) the phenomenology pertaining to the GID itself, 2) sexual orientation, and 3) psychiatric comorbidity. Apart from the GID itself, gender-dysphoric adolescents with a childhood onset of cross-gender behavior typically have a homosexual orientation (i.e., they are attracted to members of their own “birth sex”). Some such adolescents may not report any sexual feelings, but follow-up of such patients will typically find the emergence of same-sex attractions. Thus, the clinician must evaluate simultaneously two dimensions of the patient’s psychosexual development: current gender identity and current sexual orientation.
The treatment literature on adolescents with GID has been very poorly developed and is confined to a few case reports (Barlow et al. 1973; Bradley 1980; Davenport and Harrison 1977; Dulcan and Lee 1984; Kronberg et al. 1981; Lothstein 1980; Meyenburg 1999; Morra 1998; Newman 1970; Philippopoulos 1964; Reyes 1998; Westhead et al. 1990). In general, the prognosis for adolescents resolving the GID is more guarded than it is for children. In some respects, this state of affairs is similar to other child psychiatric disorders: the longer a disorder persists, the likelihood lessens that the disorder will remit, with or without treatment. From a clinical management point of view, two key issues need to be considered: 1) some adolescents with GID are not particularly good candidates for therapy because of comorbid disorders and general life circumstances; 2) some adolescents with GID have little interest in psychologically oriented treatment and are quite adamant about proceeding with hormonal and surgical sex reassignment. Bradley and Zucker (1997) found that, compared with children with GID, adolescents with GID were less intelligent, had more general behavioral difficulties, were more likely to come from a lower socioeconomic background, and were more likely to come from a broken home.
Prior to recommending hormonal and surgical interventions, many clinicians encourage adolescents with GID to consider alternatives to this invasive and expensive treatment. One area of inquiry can, therefore, explore the meaning behind the adolescent’s desire for sex reassignment and if there are viable alternative lifestyle adaptations. The most common area of exploration in this regard pertains to the patient’s sexual orientation. Some adolescents with GID recall that they always felt uncomfortable growing up as boys or as girls, but that the idea of “sex change” did not occur until they became aware of homoerotic attractions. For some of these youngsters, the idea that they might be gay or homosexual is abhorrent.
Case Example 12
Carlos was a 14-year-old boy with an IQ of 122. He lived with his mother, who was of a lower-middle-class background, and an older sister. His father had died after a long illness when he was 9 years old. Carlos had a childhood history of cross-gender behavior (e.g., female peer group affiliation, cross-dressing) and an avoidance of rough-and-tumble play and group sports. Retrospectively, it did not appear that he would have met formal diagnostic criteria for GID. As he entered adolescence, his peer group relations became more problematic. He was aware of sexual feelings for other boys, and his former female friends had become less interested in socializing with him, as they were now dating other boys. Carlos alternated between describing himself as “transsexual” and “gay.” The idea that he might be gay was very distressing to him, and he held the view that if he had a sex change, then he would be “normal” because his sexual orientation would then be heterosexual. His mother supported the idea of a sex change because her religious views were that homosexuality was against “God’s will.”
For some such adolescents, psychoeducational work can explore their attitudes and feelings about homosexuality. Group therapy, in which such youngsters have the opportunity to meet gay adolescents, can be a useful adjunct in such cases. In some cases, the gender dysphoria will resolve and a homosexual adaptation ensues. For other adolescents, however, a homosexual adaptation is not possible and the gender dysphoria does not abate.
For adolescents in whom the gender dysphoria appears chronic, there is considerable evidence that it interferes with general social adaptation, including general psychiatric impairment, conflicted family relations, and dropping out of school. For these youngsters, therefore, the treating clinician can consider two main options: 1) management until the adolescent turns 18 and can be referred to an adult gender identity clinic or 2) “early” institution of contrasex hormonal treatment.
Gooren and Delemarre-van de Waal (1996) recommended that one option with gender-dysphoric adolescents is to prescribe puberty-blocking luteinizing hormone-release agonists (e.g., depot leuprolide or depot triptorelin) that facilitate more successful passing as the opposite sex. Thus, for example, in male adolescents, such medication can suppress the development of secondary sex characteristics, such as facial hair growth and voice deepening, which make it more difficult to pass in the female social role. Cohen-Kettenis and van Goozen (1997, 1998) reported that early cross-sex hormone treatment for adolescents under the age of 18 years, judged free of gross psychiatric comorbidity, facilitates the complex psychosexual and psychosocial transition to living as a member of the opposite sex and results in a lessening of the gender dysphoria.
Although such early hormonal treatment is controversial, it may well be the treatment of choice once the clinician is confident that other options have been exhausted. One issue that is not yet resolved is who are the best candidates for early hormonal treatments. Cohen-Kettenis and van Goozen suggested that the least-risky subgroup of adolescents with GID are those who show little evidence of psychiatric impairment. In my own clinic, the vast majority of adolescents with GID would not qualify on this basis. However, by adolescence, the issue is a tricky one, because it is not clear to what extent the psychiatric impairment is a consequence of the chronic gender dysphoria. A randomized controlled trial would be useful in resolving the matter.
Since the GID diagnosis first appeared in the DSM 20 years ago, a great deal has been learned, despite the fact that the number of research clinicians in the field is quite small. The extant literature provides the clinician with a range of therapeutic approaches although the empirical database on which to appraise their validity remains quite patchy. It is hoped that this gap in the literature will be filled in the years to come.
Revision date: June 18, 2011
Last revised: by Jorge P. Ribeiro, MD