Keywords
gender dysphoria
gender incongruence
gender-affirming therapy
children and adolescents
How to Cite
Abstract
Gender identity is one of the essential aspects of human functioning. The diagnosis of gender dysphoria or gender incongruence applies to people who do not have any developmental defects of the genital organs or sex hormone secretion disorders, while the problem is the lack of acceptance of functioning in their own body and the desire to become a person of the opposite sex. This phenomenon is increasingly observed in children and adolescents. In recent years there has been a trend towards earlier use of puberty blockers and sex steroids in minors with gender dysphoria or gender inconsistency in order to inhibit the development of sexual characteristics in the direction of their own sex (referred to as the sex assigned at birth) and to mimic them to the opposite sex, i.e. according to their gender identification. In addition, surgical procedures are performed to remove the gonads and change the appearance of the genitals (and/or breast) in the desired direction (these procedures are allowed in adults, although there are many advocates of performing them in adolescents). Such therapies have been described as "gender-affirming", as opposed to "conversion" therapies, i.e. interventions aimed at restoring the acceptance of one's own sex. The literature emphasizes the lack of evidence regarding the effectiveness and safety of these procedures, allowing for an unequivocal recommendation of their application in children and adolescents, as well as the possible relationship between the increase in the frequency of gender identity disorders and the influence of peer groups, in particular the media creating a climate of affirmation of transsexualism (and non-binary gender identification). Therefore some countries (e.g. Sweden) have tightened their legal regulations in this area. The most serious long-term consequence of gender-affirming therapies is infertility. This paper aims to present these problems based on current medical literature. Extremely important bioethical and legal aspect of these issues will only be indicated, although they undoubtedly require special attention and separate studies.
References
Agencja Oceny Technologii Medycznych i Taryfikacji, Wydział Oceny Technologii Medycznych, (2023). Cyproteron i estradiol we wskazaniu: Transseksualizm (ICD10: F64.0). (From:) https://bipold.aotm.gov.pl/assets/files/off/2023/RPT/OT.422.1.9-10.2023_cyproteron_estradiol_07042023.pdf (access: 09.07.2023).
Åhs, J.W., Dhejne, C., Magnusson, C., Dal, H., Lundin, A., et al. (2018). Proportion of adults in the general population of Stockholm County who want gender-affirming medical treatment. PLoS One, 13(10), e0204606. https://doi.org/10.1371/journal.pone.0204606
Alcon, A., Kennedy, A., Wang, E., Piper, M., Loeliger, K., et al. (2021). Quantifying the Psychosocial Benefits of Masculinizing Mastectomy in Trans Male Patients with Patient-Reported Outcomes: The University of California, San Francisco, Gender Quality of Life Survey. Plastic and Reconstructive Surgery, 147(5), 731e-740e. https://doi.org/10.1097/PRS.0000000000007883
American Academy of Child & Adolescent Psychiatry, (2018). Policy Statement. Conversion Therapy. (From:) https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx (access: 09.07.2023).
American Psychiatric Association, (2006). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision). The American Journal of Psychiatry, 152(8). https://doi.org/10.1176/ajp.152.8.1228
American Psychiatric Association, (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://psycnet.apa.org/doi/10.1176/appi.books.9780890425596
American Psychiatric Association, (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.) https://doi.org/10.1176/appi.books.9780890425787
Barnard, J.T., Cakir, O.O., Ralph, D., Yafi, F.A. (2021). Technological Advances in Penile Implant Surgery. The Journal of Sexual Medicine, 18(7), 1158–1166. https://doi.org/10.1016/j.jsxm.2021.04.011
Baron, T., Dierckxsens, G. (2022) ‘Two dilemmas for medical ethics in the treatment of gender dysphoria in youth. Journal of Medical Ethics, 48(9), 603–607. https://doi.org/10.1136/medethics-2021-107260
van Bever, Y., Brüggenwirth, H.T., Wolffenbuttel, K.P., Dessens, A.B., Groenenberg, I.A.L., et al. (2020). Under-reported aspects of diagnosis and treatment addressed in the Dutch-Flemish guideline for comprehensive diagnostics in disorders/differences of sex development. Journal of Medical Genetics, 57(9), 581–589. https://doi.org/10.1136/jmedgenet-2019-106354
Black, J. (2023). Gender dysphoria in young people is rising – and so is professional disagreement. British Medical Journal, 380-382. https://doi.org/10.1136/bmj.p382
Butler, G., De Graaf, N., Wren, B., Carmichael, P. (2018). ‘Assssment and support of children and adolescents with gender dysphoria, Archives of Disease in Childhood, 103(7), 631–636. https://doi.org/10.1136/archdischild-2018-314992
van Caenegem, E., Wierckx, K., Elaut, E., Buysse, A., Dewaele, A., et al. (2015). Prevalence of Gender Nonconformity in Flanders, Belgium. Archives of Sexual Behavior, 44(5), 1281–1287. https://doi.org/10.1007/s10508-014-0452-6
Charakterystyka produktu leczniczego “Androtop”. (From:) https://rejestrymedyczne.ezdrowie.gov.pl/api/rpl/medicinal-products/35836/characteristic (access: 09.07.2023).
Charakterystyka produktu leczniczego “Testosteronum prolongatum”. (From:) https://rejestrymedyczne.ezdrowie.gov.pl/api/rpl/medicinal-products/19508/characteristic (access: 09.07.2023).
Chlebowski, R.T., Manson, J.E., Anderson, G.L., Cauley, J.A., Aragaki, A.K., et al. (2013). Estrogen plus progestin and breast cancer incidence and mortality in the Women’s Health Initiative Observational Study. Journal of the National Cancer Institute, 105(8), https://doi.org/10.1093/jnci/djt043
Cohen-Kettenis, P.T., van Goozen, S.H. (1997). Sex reassignment of adolescent transsexuals: a follow-up study. Journal of American Academy of Child & Adolescent Psychiatry, 36(2), 263-271.
Colebunders, B., Brondeel, S., D’Arpa, S., Hoebeke, P., Monstrey, S. (2017). An Update on the Surgical Treatment for Transgender Patients. Sexual Medicine Reviews, 5(1), 103–109. https://doi.org/10.1016/j.sxmr.2016.08.001
Coleman, E., Bockting, W.,. Botzer, M., Cohen-Kettenis, P., DeCuypere, G., et al. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13(4), 165-232, https://doi.org/10.1080/15532739.2011.700873
Coleman, E., Radix, A.E., Bouman, W.P., Brown, G.R., de Vries, A.L. C., et al. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health, 23(S1), S1-S259. https://doi.org/10.1080/26895269.2022.2100644
Conflitti, A.C., Spaziani, M., Pallotti, F., Tarsitano, M.G., Di Nisio, A., Paoli, D., Lombardo, F. (2023). Update on bioethical, medical and fertility issues in gender incongruence during transition age. Journal of Endocrinological Investigation, Apr 18 (ahead of print). https://doi.org/10.1007/s40618-023-02077-5
Crissman, H.P., Berger, M.B., Graham, L.F., Dalton, V.K. (2017). Transgender demographics: A household probability sample of US adults, 2014. American Journal of Public Health, 107(2), 213-215. https://doi.org/10.2105/AJPH.2016.303571
D’Angelo, R., Syrulnik, E., Ayad, S., Marchiano, L., Kenny, D.T., Clarke, P. (2021). One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. Archives of Sexual Behavior, 50(1), 7-16. https://doi.org/10.1007/s10508-020-01844-2
Day, D.-L., Klit, A., Lang, C.L., Mejdahl, M.K., Holmgaard, R. (2023). High Self-Reported Satisfaction After Top Surgery in Gender-Affirming Surgery: A Single-Center Study. Transgender Health, 8(2), 124-129. https://doi.org/10.1089/trgh.2021.0091
Dora, M., Grabski, B., Dobroczyński, B. (2021). Gender dysphoria, gender incongruence and gender nonconformity in adolescence – Changes and challenges in diagnosis. Psychiatria Polska, 55(1), 23–37. https://doi.org/10.12740/PP/OnlineFirst/113009
Eisenberg, M.E., Gower, A.L., McMorris, B.J., Rider, G.N., Shea, G., Coleman, E. (2017). Risk and Protective Factors in the Lives of Transgender/Gender Nonconforming Adolescents. The Journal of Adolescent Health, 61(4), 521–526. https://doi.org/10.1016/j.jadohealth.2017.04.014
Friesen, L., Söder, O., Rydelius, P. (2017). Kraftig ökning av könsdysfori bland barn och unga, Läkartidningen, 114, 1-5. (From:) https://lakartidningen.se/klinik-och-vetenskap-1/artiklar-1/klinisk-oversikt/2017/02/kraftig-okning-av-konsdysfori-bland-barn-och-unga (access: 09.07.2023).
Gawlik, A., Antosz, A., Kasparek, K., Nowak, Z., Grabski, B. (2022). Gender confirmation hormonal treatment use in young Polish transgender binary and non-binary persons. Endokrynologia Polska, 73(6), 922-927. https://doi.org/10.5603/EP.a2022.0088
Glintborg, D., T’Sjoen, G., Ravn, P. and Andersen, M.S. (2021). Management of Endocrine Disease: Optimal feminizing hormone treatment in transgender people. European Journal of Endocrinology, 185(2), R49–R63. https://doi.org/10.1530/EJE-21-0059
Gottlieb, L. and Cripps, C. (2023) ‘An update on gender-affirming phallus construction using the radial forearm free-flap.’, Neurourology and Urodynamics, 42(5), 963–972. https://doi.org/10.1002/nau.25103
Grabski, B., Rachoń, D., Czernikiewicz, W., Dulko, S., Jakima, S., et al. (2020). Zalecenia Polskiego Towarzystwa Seksuologicznego dotyczące opieki nad zdrowiem dorosłych osób transpłciowych–stanowisko panelu ekspertów. Psychiatria Polska, 187, 1-8. https://doi.org/10.12740/PP/OnlineFirst/125785
Hembree, W.C., Cohen-Kettenis, P.T., Gooren, L., Hannema, S.E., Meyer, W.J., et al. (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. https://doi.org/10.1210/jc.2017-01658
Indremo, M., Jodensvi, A.C., Arinell, H., Isaksson, J., Papadopoulos, F.C. (2022). Association of Media Coverage on Transgender Health With Referrals to Child and Adolescent Gender Identity Clinics in Sweden. JAMA Network Open, 5(2), e2146531. https://doi.org/10.1001/jamanetworkopen.2021.46531
Jarin, J., Pine-Twaddell, E., Trotman, G., Stevens, J., Conard, L.A., Tefera, E., Gomez-Lobo, V. (2017). Cross-Sex Hormones and Metabolic Parameters in Adolescents With Gender Dysphoria. Pediatrics, 139(5). https://doi.org/10.1542/peds.2016-3173
Jasuja, G.K., de Groot, A., Quinn, E.K., Ameli, O., Hughto, J.M.W., et al. (2020). Beyond Gender Identity Disorder Diagnoses Codes: An Examination of Additional Methods to Identify Transgender Individuals in Administrative Databases. Medical Care, 58(10), 903–911. https://doi.org/10.1097/MLR.0000000000001362
Johns, M.M., Lowry, R., Andrzejewski, J., Barrios, L.C., Demissie, Z., McManus, T., Rasberry, C.N., Robin, L., Underwood, J.M. (2019). Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students–19 States and Large Urban School Districts, 2017. Morbidity and Mortality Weekly Report, 68(3), 67–71. https://doi.org/10.15585/mmwr.mm6803a3
Kuyper, L., Wijsen, C. (2014). Gender identities and gender dysphoria in the Netherlands. Archives of Sexual Behavior, 43(2), 377–385. https://doi.org/10.1007/s10508-013-0140-y
Lehmann, K., Leavey, G. (2023). Systematic review: Psychological/psychosocial interventions for the families of gender diverse youth under 18 years old. Clinical Child Psychology and Psychiatry, 28(3), 1160–1174. https://doi.org/10.1177/13591045231169093
Littman, L. (2018). Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLoS One, 13(8), e0202330. https://doi.org/10.1371/journal.pone.0202330
Littman, L. (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Archives of Sexual Behavior, 50(8), 353-3369. https://doi.org/10.1007/s10508-021-02163
van der Loos, M.A. T.C., Klink, D.T., Hannema, S.E., Bruinsma, S., Steensma, T.D., et al. (2023). Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol. The Journal of Sexual Medicine, 20(3), 398–409. https://doi.org/10.1093/jsxmed/qdac029
Marianowicz-Szczygieł, A. (2022). Wzrost zaburzeń tożsamości płci wśród dzieci i młodzieży – dane z 10 krajów. Możliwe wyjaśnienia, wnioski dla rodziców. Kwartalnik Naukowy Fides et Ratio, 49(1), 122–141. https://doi.org/10.34766/fetr.v49i1.1060
Matsuno, E., Israel, T. (2018). Psychological interventions promoting resilience among transgender individuals: Transgender resilience intervention model (TRIM). The Counseling Psychologist, 46(5), 632–655. https://doi.org/10.1177/0011000018787261
Medycyna praktyczna. Indeks leków. Estradiol. (From:) https://indeks.mp.pl/leki/desc.php?id=256 (access: 09.07.2023).
Mędraś, M., Józków, P. (2010). Transseksualizm — aspekty diagnostyczne i terapeutyczne. Endokrynologia Polska, 61, 412-416.
Nordenström, A., Ahmed, S.F., van den Akker, E., Blair, J., Bonomi, M., et al. (2022). Pubertal induction and transition to adult sex hormone replacement in patients with congenital pituitary or gonadal reproductive hormone deficiency: an Endo-ERN clinical practice guideline. European Journal of Endocrinology, 186(6), G9–G49. https://doi.org/10.1530/EJE-22-0073
Pasternak, K., Francis, D.O. (2019). An update on treatment of voice-gender incongruence by otolaryngologists and speech-language pathologists. Current Opinion in Otolaryngology & Head and Neck Surgery, 27(6), 475–481. https://doi.org/10.1097/moo.0000000000000582
Poleszak, J., Szabat, P., Szabat, M., Wójcik, M., Boreński, G., Janowska, M., Karakuła, H. (2019). Suppression of puberty with GnRH analogues in adolescents with Gender Dysphoria. Journal of Education, Health and Sport, 9(9), 378–385.
Poudrier, G., Nolan, I.T., Cook, T.E., Saia, W., Motosko, C.C., et al. (2019). Assessing Quality of Life and Patient-Reported Satisfaction with Masculinizing Top Surgery: A Mixed-Methods Descriptive Survey Study. Plastic and Reconstructive Surgery, 143(1), 272–279. https://doi.org/10.1097/PRS.0000000000005113
Reisner, S.L., Poteat, T., Keatley, J., Cabral, M., Mothopeng, T., Dunham, E., Holland, C.E., Max, R., Baral, S.D. (2016). Global health burden and needs of transgender populations: a review. Lancet, 388(10042), 412–436. https://doi.org/10.1016/S0140-6736(16)00684-X
Richards, C., Maxwell, J., Mccune, N. (2019). Use of puberty blockers for gender dysphoria: A momentous step in the dark. Archives of Disease in Childhood, 104(6), 611–612. https://doi.org/10.1136/archdischild-2018-315881
Robacha, A. (2021). Zaburzenia płci psychicznej. (W:) J. Słowikowska-Hilczer (red.), Andrologia. Zdrowie mężczyzny od fizjologii do patologii, 103-119, Warszawa: PZWL.
Robinson, I.S., Blasdel, G., Cohen, O., Zhao, L.C., Bluebond-Langner, R. (2021). Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. The Journal of Sexual Medicine, 18(4), 800–811. https://doi.org/10.1016/j.jsxm.2021.01.183
Roden, R.C. (2023). Reversible interventions for menstrual management in adolescents and young adults with gender incongruence. Therapeutic Advances in Reproductive Health, 17, 26334941231158252. https://doi.org/10.1177/26334941231158251
Rodriguez-Wallberg, K., Obedin-Maliver, J., Taylor, B., Van Mello, N., Tilleman, K., Nahata, L. (2023). ‘Reproductive health in transgender and gender diverse individuals: A narrative review to guide clinical care and international guidelines. International Journal of Transgender Health, 24(1), 7–25. https://doi.org/10.1080/26895269.2022.2035883
Salas-Humara, C., Sequeira, G.M., Rossi, W. and Dhar, C.P. (2019). Gender affirming medical care of transgender youth, Current Problems in Pediatric and Adolescent Health Care, 49(9). https://doi.org/10.1016/j.cppeds.2019.100683
Smyczyńska, J. (2020). Okres prekoncepcyjny i ciąża jako czas troski o zdrowie prokreacyjne potomstwa – znaczenie mechanizmów epigenetycznych. Kwartalnki Naukowy Fides et Ratio, 43(3), 223–237. https://doi.org/10.34766/fetr.v43i3.307
Smyczyńska, J. (2021). Aspekty endokrynologiczne diagnostyki i terapii osób transseksualnych. (W:) B. Kmieciak (red.), Między chromosomem a paragrafem, 13-35, Warszawa: Wydawnictwo Instytutu Wymiaru Sprawiedliwości.
Smith, Y.L., van Goozen, S.H., Cohen-Kettenis, P.T. (2001). Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study. Journal of American Academy of Child & Adolescent Psychiatry, 40(4), 472-81.
Socialstyrelsen: National Board of Health and Welfare (2022). Care of children and adolescents with gender dysphoria. Report 2022-3-7799. (From:) https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/kunskapsstod/2022-3-7799.pdf (access: 09.07.2022).
Statistics Canada, (2022). Canada is the first country to provide census data on transgender and non-binary people. (From:) https://www150.statcan.gc.ca/n1/en/daily-quotidien/220427/dq220427b-eng.pdf?st=I3VW0jgh (access: 10.07.2023).
TRANZYCJA.PL Aktualności (2022) Co oznaczają zmiany w klasyfikowaniu transpłciowości w ICD-11? (From:) https://tranzycja.pl/aktualnosci/zmiany-w-klasyfikacji-icd11/ (access: 10.07.2023).
Turban, J.L., Beckwith, N., Reisner, S.L., Keuroghlian, A.S. (2020). Association between recalled exposure to gender identity conversion efforts and psychological distress and suicide attempts among transgender adults. JAMA Psychiatry, 77(1), 68–76. https://doi.org/10.1001/jamapsychiatry.2019.2285
U.S. Food and Drug Administration (2014). FDA evaluating risk of stroke, heart attack and death with FDA-approves testosterone products. Safety Announcement [01-31-2014].
Verveen, A., van der Miesen, A.I. R., de Graaf, N.M., Kreukels, B.P. C., de Vries, A.L. C., Steensma, T.D. (2023). Body Image in Adolescents with Gender Incongruence and Its Association with Psychological Functioning. International Journal of Environmental Research and Public Health, 20(4). https://doi.org/10.3390/ijerph20043349
Vita, R., Settineri, S., Liotta, M., Benvenga, S., Trimarchi, F. (2018). Changes in hormonal and metabolic parameters in transgender subjects on cross-sex hormone therapy: A cohort study. Maturitas, 107, 92-96. https://doi.org/10.1016/j.maturitas.2017.10.012
Wang, B., Hengel, R., Ren, R., Tong, S. and Bach, P.V. (2020). Fertility considerations in transgender patients. Current Opinion in Urology, 30(3), 349–354. https://doi.org/10.1097/MOU.0000000000000748
World Health Organization, (2018). International Classification of Diseases 11th Revision. (From:)https://icd.who.int/en (access: 09.07.2023).
World Health Organization, (2019). International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)-WHO Version for 2019-covid-expanded (From:) https://icd.who.int/browse10/2019/en#/F60-F69 (access: 09.07.2023).
Zazula, M. (2021). Transseksualizm i geny. ((W:) B. Kmieciak (red.), Między chromosomem a paragrafem, 37-60, Warszawa: Wydawnictwo Instytutu Wymiaru Sprawiedliwości.