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Try out PMC Labs and tell us what you think. Learn More. Increasing s of adolescents present in adolescent gender identity services, desiring sex reasment SR. The aim of this study is to describe the adolescent applicants for legal and medical sex reasment during the first two years of adolescent gender identity team in Finland, in terms of sociodemographic, psychiatric and gender identity related factors and adolescent development.

Structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of The of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common.

Autism spectrum problems were very common. The findings do not fit the commonly accepted image of a gender dysphoric minor. Treatment guidelines need to consider gender dysphoria in minors in the context of severe psychopathology and developmental difficulties. The desire has to be persistent and not a symptom of a mental disorder. Psychotherapeutic approaches have not proven successful in relieving gender dysphoria, and social, juridical, medical and surgical sex reasment SR is nowadays the treatment of choice [ 3 ]. Consultations due to gender identity are generally more often sought for boys than girls, which may suggest greater gender variation in boys, but also that effeminate behaviours in boys are Women seeking sex Natal as more of a problem than tom-boyishness in girls [ 56 ].

Reliable indicators are not so far available regarding which gender dysphoric children cease to be so in puberty and who develop transsexual identity [ 8 ]. Medical interventions are therefore not warranted in pre-pubertal children. In light of current knowledge, transsexual identity in adolescence is persistent and medical interventions may be appropriate.

According to the treatment model developed in the Netherlands Dutch modelearly treatment may include delaying puberty after its first stages with GnRh analogues, and administering cross-sex hormones from about age 16 [ 910 ]. The rationale with GnRh analogue treatment is to prevent the undesired development of secondary sex characteristics and thereby facilitating later transition to the desired role, and postponing complicated and irreversible treatment decisions to a more mature age. Psychopathology largely attributed secondary to gender dysphoria is expected to be relieved by puberty blocking and resolved by sex reasment [ 51112 ].

In the past decade, the s of referrals to child and adolescent gender identity services have been on the increase across Europe Women seeking sex Natal communications in and from UK, NL, Spain, Sweden child and adolescent gender identity teams and in Canada [ 13 ]. It is not known whether this represents a true increase in gender dysphoria, lowered thresholds for seeking help for it or perhaps cultural developments that promote the conceptualization of developmental challenges as being rooted in sex and gender.

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A psychiatric assessment by a specialized gender identity team is a prerequisite for legal as well as surgical sex reasment, both of which have a lower age limit of Sincespecialized adolescent psychiatric gender identity teams have been available for minors at the above mentioned two university hospitals. The excessive of referrals, exceptional sex ratio and severity Women seeking sex Natal general psychopathology among the applicants compared to what might have been anticipated on the basis of the literature called for clinical attention from the beginning of the service.

The aim of this study is to describe the adolescent applicants for legal and medical sex reasment in terms of sociodemographic, psychiatric and gender identity related factors and adolescent development in order to initiate a scientific discussion on the meaning of these observations.

The study comprises a retrospective chart review of all the SR applicants attending for assessment by one of the two adolescent gender identity services in Finland Tampere University Hospital, Department of Adolescent Psychiatry in — Altogether 49 adolescents were referred to assessment for sex reasment and invited to their first meeting during the study periods, but two adolescents declined to start the evaluation. Thus 47 adolescents are included in this study. Of these, one was mutistic and did not provide any information; for this young person, information on personal experiences is missing but information from case records and parents could be used.

The assessments take place in an outpatient Women seeking sex Natal and comprise structured and free format assessments and interviews with an adolescent psychiatrist, a psychiatric nurse, a social worker and a psychologist. After completing all the assessments, the multi-disciplinary team discusses the diagnosis as to gender identity and mental disorders, eligibility for hormonal SR treatments and possible other needs to be met and recommendations to be given regarding gender identity needs and mental health needs when appropriate. All the below described measures were collected using all the material available after the assessment.

The study received approval from the ethics committee of Pirkanmaa Hospital District. If the adolescent was already living in the desired role Table 1it was recorded for how long. Variable descriptions for childhood gender dysphoria, bullying and social isolation. and current psychiatric history was recorded. files were not always complete, and diagnoses were not always accurately defined in terms of ICD diagnostic codes. Of bullying it was recorded whether it happened before, after or both before and after of the onset of gender dysphoria, and whether it was related to gender presentation or sexual orientation.

Of social isolation it was recorded whether it occurred before, after or both before and after the onset of gender dysphoria. All the variables were recorded in a structured form developed for this research. Descriptive analysis was conducted using statistical methods for quantitative data. We report frequencies and means sd where appropriate.

The qualitative content analysis approach [ 14 ] was applied to illustrate, based on all material recorded in case histories, different groups of gender dysphoric adolescents, or different developmental pathways resulting in the adolescent now perceiving the need to apply for sex reasment.

This was carried out by condensing and extracting from all material recorded in the case histories similar and different developmental patterns and descriptions of experiences that could be used to create mutually exclusive model stories, or trajectories that would include all the studied adolescents and not allow for asing a given adolescent to more than one trajectory. The model stories were not defined in advance but they were formed in a data-driven process, the outcome of which is presented. Of the applicants included in the present study, 41 were natal girls and 6 were natal boys.

Their mean age sd at entering assessment was None of the applicants had transsexual or homosexual parents. Most commonly one in five these concerns had started at age There was no difference between natal girls and natal boys in this regard. There was no difference between natal girls and natal boys. Natal girls and natal boys had been bullied equally frequently. Social isolation was equally common among natal boys and girls applicants.

One severe case of anorexia nervosa was noted. The mean of distinct psychiatric problems was 2. They are presented in Table 2. We carried out logistic regression analyses to detect what kind of presenting features were associated with belonging to the last, confused group of adolescents with gender dysphoria e when entered in the model simultaneously.

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This was appropriate because psychiatric symptoms and psychosocial functioning are strongly interrelated. Age and natal sex were not predictive of belonging to the confused group. Each psychiatric problem, being subjected to bullying, presenting with periods of isolation, of different psychiatric problems, and months living in desired role were each in turn entered as independent variables, controlling for age and natal sex.

When controlling for age and natal sex, group memberships was predicted by anxiety OR 4. However, when presenting Women seeking sex Natal periods of social isolation was entered into any other model, the other independent variables were leveled out, suggesting that social isolation was the strongest factor predicting membership of the problematic, identity confused group. The of referrals exceeded expectations. Given the most cited epidemiological figures among adults, — MtF and — FtM [ 6 ], in Finnish population, 6—18 boy-to-girl adolescents and 2—4 girl-to-boy adolescents aged 13—18 would be expected.

The of referrals to the study unit already doubled the less conservative estimates based on adult figures. Referrals to the other adolescent gender identity unit amount to equal s, and the natal girl:boy ratio in referrals is also similar in the other unit Tainio V-M, personal communication.

Valid epidemiological research on incidence and prevalence of transsexualism or gender dysphoria at large among adolescents is not available [ 6 ]. The adult figures cited above are based on treatment seeking, as are the s presented in the present study. Gender dysphoria may be more common among adolescents than among adults, or it may be increasing in younger age cohorts.

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Not all applicants could be seen as presenting with established transsexual identity, even though they suffered gender dysphoria. Excluding the confused e group in our data, 3 boy-to-girl and 21 girl-to-boy applicants were identified who displayed transsexual identity that appeared established, unique, and not part of more general identity confusion or secondary to severe mental disorders.

The natal girl:boy ratio among the adolescent SR applicants was very high. In prepubertal children referred to gender identity services, boy:girl ratio is reportedly 3—, with some variation across countries presumably due to cultural reasons [ 513 ]. ly a more even boy:girl ratio has been suggested in adolescents seeking sex reasment than among child samples [ 13 ], and a recent paper from Germany reported natal boy:natal girl ratio of 0.

Among adults, there seems to be remarkable variation across countries in the ratio of natal men:natal women seeking for sex reasment [ 16 ]. In Western countries natal male transsexuals exceed natal females transsexuals. However, the overrepresentation of girls on our sample differs still from these more recent trends, and it is similar in both the two Finnish centers. We have so far no explanation for this great overrepresentation of natal girls seen in our material, and equalizing of sex ratio demonstrated by others [ 131516 ].

Cultural trends may somehow influence this. However, why this would concern primarily girls remains an open question. Of the adolescent SR applicants, more than a half had been subjected to bullying. However, in more than two thirds of the cases, bullying had occurred before the onset of gender dysphoria, and was not targeted at gender or sexual identity.

Bullying is an unspecific risk factor for developmental problems rather than a problem specifically related to gender identity. That natal boys were more commonly bullied because of gender presentation suggests that effeminate characteristics Women seeking sex Natal boys are less tolerated than masculine self-presentation in girls.

Peer relationships are of the outmost importance during adolescent development [ 18 - 20 ], and social isolation from peer relationships suggests developmental difficulties and impaired mental health [ 21 - 24 ]. Specialist level child and adolescent psychiatric services are provided exclusively for severe disorders in Finland [ 2526 ]. The recorded comorbid disorders were thus severe and could seldom be considered secondary to gender dysphoria.

This utterly contradicts the findings in the Dutch child and adolescent gender identity service, where two thirds of adolescent SR applicants did not have psychiatric comorbidity [ 27 ]. For the time being, we are unable to explain why Finnish adolescent SR applicants appear psychiatrically much more disturbed than has been reported elsewhere, but our findings warrant attention. The treatment guidelines for adolescent gender dysphoria may require extensions taking into the needs of those with severe psychopathology and identity confusion, very unlikely currently eligible to medical SR.

The overlap between autism spectrum disorders and gender dysphoria has been recognized before Women seeking sex Natal 28 ]. In a Dutch gender identity service, 9. We could not systematically review with which protocols the diagnoses had been made elsewhere in the country, but in our clinical opinion there was no reason to doubt them.

It is currently not known why autism spectrum is overrepresented in gender dysphoric children and adolescents. The conditions could be truly co-occurring. Prenatal exposure to high levels of testosterone could be involved in the development of both conditions, especially for girls with autism spectrum disorder, but this leaves the comorbidity in males unexplained. The cross-gender behaviour in ASD minors could also rather represent non-normative sexual interests or unusual sensory preferences [ 28 ]. Our clinical impression is that a long-standing feeling of being different and an outsider among peers could play a role in ASD children developing gender dysphoria in adolescence.

Autism spectrum needs to be taken seriously in considering treatment guidelines for child and adolescent gender dysphoria. Our findings suggest that there are many more developmental pathways that may also need different treatment approaches.

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In our data, most of the adolescents first presented with gender dysphoria and cross-gender identification well after the onset of puberty, and the vast majority suffered ificant psychopathology and broader identity confusion than gender identity issues alone. It is important to be able to openly discuss these alternative presentations of gender dysphoria in order to find appropriate treatment options. Adolescence is a period of identity formation. From early to late adolescence, identity develops from fragmented and contextual identity experience to endogenous, permanent and integral identity that remains constant across contexts and interactions [ 33 ].

Identity is formed through diverse physical and psychological developments and in relation to other people and the social environment [ 3435 ]. An adolescent also faces fundamental identity challenges in the domains of religion, worldview, ethnicity, sexuality and the like. Identification with various Women seeking sex Natal is often passionate during adolescence, but the object of identification may also change, even several times [ 34 - 37 ]. Adolescents are more suggestible and submit more readily to group pressure to gain acceptance [ 38 ]. Adolescence is a period of maturation of social cognition, and a prerequisite for the maturation of social cognition is the maturation of the central nervous system that continues to the third decade of life [ 39 ].

During puberty and adolescent development there may be some overlap between normative testing of sexuality and gender roles in the one end, and gender dysphoria as a disorder in the other end of the spectrum. This would implicate that GD in adults and in adolescence may not be the same issue in general.

For these reasons it is more challenging to assess whether the gender identity of an adolescent is so firmly established that physical intervention is indicated than it is to assess this among adults.

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