Background: Both The Endocrine Society and the World Professional Association for Transgender Health (WPATH) published guidelines for the treatment of children and adolescents with gender dysphoria (GD). The guidelines recommend the use of GnRH agonists in adolescence to suppress puberty, and the use of cross-sex hormones starting around age 16 for eligible patients. In actual practice, there is no consensus whether to use these early medical interventions. The aim of our study was to gain insight in the contexts of treatment disagreements surrounding early medical interventions and the underlying considerations of proponents and opponents.
Methods: i) Systematic literature review on treatment discussions in children with GD; ii) qualitative study (semi-structured interviews) to identify considerations of key-informants (pediatric endocrinologist, psychologist, psychiatrist, ethicist) of 14 treatment teams worldwide
Results: The literature and the interviews show six fundamental topics that give rise to different, and even opposing, views on treatment of adolescents: i) the (non-)availability of an explanatory model for GD; ii) the nature of GD (normal variation, social construct or (mental) illness); iii) the role of physiologic puberty to form a consistent gender identity; iv) the role of comorbidity; v) ideas about harms of early medical interventions as well as of refraining from interventions; vi) ideas about decision making authority and child competence. Strikingly, the guidelines are debated both for being too liberal and for being too limiting. Many teams using the guidelines are exploring the possibility of expanding the current age limits.
Conclusion: Judgment on GD treatment is affected by fundamental ideas on the nature of gender and GD. There is an urgent need for systematic, interdisciplinary, multicenter research and debate, not only on long-term outcomes, but also on the nature of gender (dysphoria). The guidelines will only have a sound foundation once consensus is reached on these fundamental issues.
20 - 22 Sep 2014
European Society for Paediatric Endocrinology