Adolescents with gender dysphoria

As soon as young children acquire language most will start understanding that they are a boy or a girl and they will increasingly feel and behave in accordance with  the gender assigned to them at birth. Some children, however, will have gender feelings and show gender behaviors that are not congruent with their birth sex. If they are distressed about this discrepancy between how they feel, look and are expected to behave, they may suffer from gender dysphoria (GD). In prepubertal children, signs of a developing GD may be apparent as early as 2 years. As soon as boys are able to talk they may repeatedly state that they are or will later become girls, prefer to play with girls, behave like girls and prefer girl-typical play and toys, dislike rough-and- tumble play, and are sad when they are not allowed to act on their preferences. Girls with GD may be very tomboyish and are regularly mistaken for boys. Many children, however,  show gender variant or gender non-conforming behaviors, but have no anatomic dysphoria or other serious distress. These children are not gender dysphoric.

It is more likely that gender variant and gender dysphoric children will later be homosexual rather than gender dysphoric or transgender. Yet, they may want to transition socially long before puberty (that is, live on a daily basis completely as a member of the experienced gender). It is not possible to predict  in which child the GD will persist or desist. Future persisters may be harmed if they undergo treatment aiming to change their cross-gender interests and such treatments are undesirable. However, it is equally possible that  some future desisters are encouraged to socially transition, even though they may have to transition back to their natal gender once they reach puberty.  There is much debate about this topic, because it is not known whether that process is harmful or not.  Decisions on social transitioning should therefore be taken after consulting specialists. Adolescents  with GD who were gender dysphoric in childhood are referred to as the ‘early onset’ group.

There are also adolescents who start wearing clothes of the other gender after puberty, which may (at least in natal boys) be accompanied with sexual arousal. Over time the sexual aspect of dressing in female clothing diminishes or disappears and the desire to be a woman permanently evolves. They are referred to as the ‘late onset’ group.

Finally there are adolescents who do  not completely identify as males or females, but experience themselves – often after a period of searching – as in-between the sexes or as a third gender.

The treatment that is sought depends on the type of GD. Not all want the ‘classical’ treatment consisting of cross-sex hormones first and gender affirming surgeries later, but most in the early-onset group do.

Many centers may then start with prescribing puberty blocking hormones (Gonadotropin-Releasing Hormone analogues or GnRHa),  if the adolescent has reached the first puberty stages (Tanner stage 2 or 3) and fulfils eligibility criteria. The effects of GnRHa are still reversible in case the desire for gender affirming treatment disappears. If it does not, cross-sex hormones may be prescribed,usually around 15-16 years, and, at the age of legal adulthood, surgery may be performed.

Until now it is unclear why some adolescents do and others do not develop GD. There is evidence that some parts of the brains of transgender youth have developed or are functioning unlike their natal sex, but other factors may also influence atypical gender development.

PT. Cohen-Kettenis, PhD

Department of Medical Psychology, VU University Medical Center
Amsterdam, The Netherlands



Adolescents with gender dysphoria.
Cohen-Kettenis PT, Klink D.
Best Pract Res Clin Endocrinol Metab. 2015 Jun


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