Gender dysphoria: the Dutch Protocol

Lieke Vrouenraets

Lieke Josephina Jeanne Johanna Vrouenraets is with the Department of Pediatric and Adolescent Psychiatry, Curium-Leiden University Medical Centre, Oegstgeest, The Netherlands.

Martine C de Vries is with the Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands

“Your gender is like drinking water; when you drink water it is not supposed to taste like anything. But when it tastes different, you notice. That is what being transgender is like: when your water tastes different.” -Trans-boy, age 18

Gender dysphoria (GD) is a condition in which people experience an incongruence between their “assigned” and “experienced” gender.¹ GD may exist in childhood, but in only a minority of prepubertal children GD does it persist into adolescence. The percentage of “persisters” appears to be between 10% and 27%.^5,10,13 Children who are still experiencing GD when entering puberty almost invariably go on to become gender dysphoric adults.⁴

The diagnostic process and treatment of gender dysphoric individuals are complex. The risk of co-occurring psychiatric problems in children and adolescents with GD is high. Forty-three percent of children and adolescents seen in gender identity clinics suffer from major psychopathology.⁸ Most professionals believe that adolescents’ ability to make decisions regarding their medical treatment should be determined based on their cognitive abilities, emotional maturity, and the presence or absence of comorbidities.¹² A multidisciplinary gender treatment team consisting of psychologists, psychiatrists, and endocrinologists is required to care for these patients.

Diagnostic process and treatment approach

The Standards of Care of the World Professional Association for Transgender Health (WPATH; www.wpath.org), an international professional organization in the field of transsexualism and gender dysphoria, recommend a standard procedure to come to a gender reassignment decision consisting of various phases.⁹ The Standards are based on the first protocol describing the treatment of transgender youth: the Dutch Protocol.²

                  Gender dysphoric children. Because GD persists into adolescence in only a minority of prepubertal children, treatment for them consists of providing information, psychological support, advice and/or family counseling.¹²

                  Gender dysphoric adolescents. Medical treatment is possible in adolescents aged 12 years and older who are in or beyond the early stages of puberty and still suffering from persisting GD. Puberty suppression by means of gonadotropin-releasing hormone analogues (GnRHa) is part of the protocol for these patients. The purpose of puberty suppression is to relieve suffering caused by the development of secondary sex characteristics, to provide time to make a balanced decision regarding the actual gender reassignment (by means of cross-sex hormones and surgery), and to make “passing” in the new gender role easier. Cross-sex hormones are used for adolescents aged 16 and older who are still suffering from persisting GD. Transsexuals aged 18 years and older may undergo sex reassignment surgery.²

Ethical debate

In recent years, the possibility of medical treatment for young adolescents has generated a new but controversial dimension to the clinical management of adolescents with GD. Although an increasing number of gender clinics have adopted the Dutch Protocol and international guidelines exist in which puberty suppression is mentioned as a treatment option^3,6 many professionals working with gender dysphoric youth remain critical of it.^7,11,13 Controversy regarding the use of drugs for puberty touches on fundamental ethical concepts in pediatrics: best interests, autonomy, and the role of social context. Professionals recognize the distress of gender dysphoric youths and feel the urge to treat them. At the same time, most of these professionals have doubts because of the lack of data on long-term physical and psychological outcomes.¹²

“The question cannot be posed as ‘do something which may cause harm’ against ‘doing no harm’, as doing nothing results in very high levels of distress and poor outcome as well.” -Psychiatrist¹²

“The fact that somebody wants something badly does not mean that a health care provider should do it for that reason; a medical doctor is not a candy seller.” -Professor of health care ethics and health law¹²

Recommendations

Patients with gender dysphoric feelings should be referred to a specialized multidisciplinary team that will focus not only on the hormonal aspects of the diagnostic process and potential medical treatment, but also on the psychological aspects.

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychological Association.

2. Cohen-Kettenis PT, Steensma TD, de Vries, AL. (2011). Treatment of adolescents with gender dysphoria in the Netherlands. Child and Adolescent Psychiatry Clinics of North America, 20, 689-700.

3. Coleman E, Bockting W, Botzer M, et al. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. International Journal of Transgenderism, 13, 165-232.

4. De Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. (2011). Puberty Suppression in adolescents with gender identity disorder: A prospective follow-up study. J Sex Med, 8, 2276-2283.

5. Drummond KD, Bradley SJ, Peterson-Badali M, Zucker KJ. (2008). A follow-up study of girls with gender identity disorder. Developmental Psychology, 44, 34–45.

6. Hembree WC, Cohen-Kettenis PT, Delemarre-van de Waal HA, et al. (2009). Endocrine treatment of transsexual persons: An Endocrine Society Clinical Practice Guideline. J Clinical Endocrinology and Metabolism, 94, 3132-3154.

7. Korte A, Goecker D, Krude H, Lehmkuhl U, Grüters-Kieslich A, Beier KM. (2008). Gender identity disorders in childhood and adolescence: currently debated concepts and treatment strategies. Deutsches Ärzteblatt International, 105, 834–41.

8.  Meyenburg B. (2014). Gender dysphoria in adolescents: Difficulties in treatment. Prax Kinderpsychol Kinderpsychiatr, 63, 510-522.

9. Meyer W, Bockting WO, Cohen-Kettenis PT, et al. (2001). Standard of care for gender identity disorders of the Harry Benjamin International Gender Dysphoria Association, 6h edition. World Professional Association for Transgender Health. J Psychol and Human Sexuality, 13, 1-30.

10. Steensma TD, McGuire JK, Kreukels BPC, Beekman AJ, Cohen-Kettenis PT. (2013). Factors associated with desistance and persistence of childhood gender dysphoria: a quantitative follow-up study. J American Academy of Child and Adolescent Psychiatry, 52, 582-90.

11. Viner RM, Brain C, Carmichael P, Di Ceglie D. (2005). Sex on the brain: Dilemmas in the endocrine management of children and adolescents with gender identity disorder. Archives of Disease in Childhood, 90, A78.

12. Vrouenraets LJJJ, Fredriks AM, Hannema SE, Cohen-Kettenis PT, de Vries MC. (2015). Early medical treatment of children and adolescents with gender dysphoria: An empirical ethical study. Journal of Adolescent Health, 57, 367-373.

13. Wallien MSC, Cohen-Kettenis PT (2008). Psychosexual outcome of gender dysphoric children. J American Academy of Child and Adolescent Psychiatry, 47, 1413–1423.