Young people who believe they were born into the wrong sex are at risk for abuse, post-traumatic stress, and self-harming behavior, and an American clinic is now offering medical treatment for these individuals, researchers found.
In a study that asked young adults about their gender behavior and beliefs in childhood, 39% of women who had exhibited the highest level of nonconformity experienced some type of abuse, as did 30% of men, according to Andrea L. Roberts, PhD, of Harvard School of Public Health in Boston, and colleagues.
And among children and teens evaluated for medical intervention to suppress puberty or for hormone therapy, 44% had been given a psychiatric diagnosis -- most often depression -- and 21% reported self-mutilation, reported Norman P. Spack, MD, of Harvard Medical School and Children's Hospital Boston, and colleagues.
"A new pediatric problem is in town," wrote Walter J. Meyer III, MD, of the University of Texas in Galveston.
"The two articles in this [March] issue of Pediatrics bring to the pediatrician a new awareness of a significant childhood condition, gender-variant behavior," Meyer observed, in an accompanying commentary.
Research into childhood gender nonconformity is limited, but increasingly is being recognized as a potentially significant health risk.
To explore this, Roberts' group analyzed data from the Growing Up Today Study, a longitudinal cohort that enrolled almost 17,000 young people, with a mean age of 23.
The participants were asked a series of questions about their gender roles and behaviors up to age 11, and various types of abuse throughout life, along with post-traumatic stress symptoms.
Compared with respondents who had low levels of gender nonconformity in childhood, 22% of women with high levels reported physical abuse, as did 20% of men.
Psychological abuse was reported by 23% of women and 15% of men and a lifetime history of post-traumatic stress disorder was seen in 13% and 7% respectively (P<0.001).
After adjustment for age, sex, and race, the relative risks for abuse in children having the highest level of gender nonconformity were:
- Physical abuse, RR 1.4 (95% CI 1.3 to 1.6, P<0.001)
- Psychological abuse, RR 1.4 (95% CI 1.2 to 1.5, P<0.001)
- Sexual abuse in boys, RR 2.8 (95% CI 1.9 to 4.1, P<0.001)
- Sexual abuse in girls, RR 1.6 (95% CI 1.3 to 1.8, P<0.001)
The higher risk for sexual abuse in boys confirmed the findings of other studies.
"Prior research generally indicates gender nonconformity may be less socially accepted in boys than girls, with boys receiving more disapproval for gender nonconformity at a younger age from parents and peers," Roberts and colleagues wrote.
They acknowledged that their study did not demonstrate a causal link between gender nonconformity and abuse, and noted that the reports of abuse and gender nonconformity were retrospective.
"Further research to understand how gender nonconformity might increase risk of abuse and to develop family interventions to reduce abuse risk is needed," they concluded.
In the companion article, Spack's group reported on 97 patients evaluated in a gender identity disorder clinic for possible medical intervention.
Gender identity disorder was recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and defined as persistent identification with the opposite sex and distress with one's own gender.
More than a decade ago, a clinic in Amsterdam began offering GnRH treatment for children 12 and older diagnosed with this condition.
Then, in 2009, guidelines on the treatment of adolescents with this disorder were published by the Endocrine Society, recommending delay of puberty with reversible gonadotropin-releasing hormone (GnRH) analogs at Tanner stages 1-2 in eligible adolescents.
"This fully reversible treatment allowed patients time until age 16 to decide, in consultation with health professionals and their families, whether to begin hormone treatment that would allow them to transition physically," explained Spack and colleagues.
Children in the U.S. cohort ranged in age from 4 to 12, and all underwent extensive psychological testing.
There were equal numbers of boys and girls in the cohort. More than half had already reached Tanner stage 5, while 22% were stage 1 or 2.
At the time of presentation, 92% were living exclusively in their preferred gender; 45% had begun exhibiting opposite-sex behavior before age 5.
A total of 58% had a history of depression and 16% had been diagnosed with generalized anxiety disorder.
Almost 10% had previously attempted suicide.
A total of 58% of the patients began treatment within a week, 20% with GnRH analogs and 70% with hormones.
For those not immediately beginning treatment, the mean time until intervention was nine months, and the delay usually was because they were insufficiently developed to start on GnRH therapy or were too young for the irreversible hormone therapy.
"Our observations reflect the Dutch finding that psychological functioning improves with medical intervention and suggests that the patients' psychiatric symptoms might be secondary to a medical incongruence between mind and body, not primarily psychiatric," Spack and colleagues wrote.
They emphasized that the high rate of psychiatric difficulties and self-harming among these young patients was "striking," and should be a particular focus of treatment.
They also stated that they were not in favor of these medical interventions in children who have not yet reached puberty, but rather argued that children exhibiting cross-gender behavior be evaluated early, and by specialized professionals.
The study by Roberts et al had support from the NIH. The journal said the authors indicated they had no relevant financial relationships to disclose.
The study by Spack et al had support from Children's Hospital Boston. The journal said the authors indicated they had no relevant financial relationships to disclose.
The journal said the commentary author indicated he had no external support and no relevant financial relationships to disclose.
Zalman S. Agus, MD Emeritus Professor
University of Pennsylvania School of Medicine and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
PediatricsSource Reference: Roberts AL, et al "Childhood gender nonconformity: A risk indicator for childhood abuse and posttraumatic stress in youth" Pediatrics 2012; 129: 410–417.
PediatricsSource Reference: Spack NP, et al "Children and adolescents with gender identity disorder referred to a pediatric medical center" Pediatrics 2012; 129: 418–425.
PediatricsSource Reference: Meyer WJ "Gender identity disorder: an emerging problem for pediatricians" Pediatrics 2012; 129: 571-473.