Gender dysphoria in children
Other namesGender identity disorder in children, gender incongruence of childhood
SpecialtyPsychiatry Edit this on Wikidata
Usual onsetChildhood

Gender dysphoria in children (GD), also known as gender incongruence of childhood, is a formal diagnosis for children who experience significant discontent (gender dysphoria) due to a mismatch between their assigned sex and gender identity. The diagnostic label gender identity disorder in children (GIDC) was used by the Diagnostic and Statistical Manual of Mental Disorders (DSM) until it was renamed gender dysphoria in children in 2013 with the release of the DSM-5. The diagnosis was renamed to remove the stigma associated with the term disorder.[1]

Classification

Children with persistent gender dysphoria are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria.[2] Some (but not all) gender variant youth will want or need to transition, which may involve social transition (changing dress, name, pronoun), and, for older youth and adolescents, medical transition (hormone therapy or surgery).[3]

DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association in 2013 introduced a diagnosis of Gender Dysphoria in Children.

Compared to the prior diagnosis of GIDC in the DSM-IV, subtyping by sexual orientation was deleted. The diagnosis for children was separated from that for adults.The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing, or ability to express it in the event that they have insight.[4] Further, the DSM-5 considered non-binary gender identities.

The main diagnostic criterion is a marked incongruence between experienced/expressed gender and assigned gender, of at least six months duration, as manifested by at least six of the following (one of which must be the first criterion):[5]: 512 

  • A strong desire to be of the other gender or an insistence that one is the other gender
  • A strong preference for wearing clothes typical of the opposite gender
  • A strong preference for cross-gender roles in make-believe play or fantasy play
  • A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
  • A strong preference for playmates of the other gender
  • A strong rejection of toys, games and activities typical of one's assigned gender
  • A strong dislike of one's sexual anatomy
  • A strong desire for the physical sex characteristics that match one's experienced gender

In order to meet the criteria, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.[5]: 512 

International Classification of Diseases (ICD)

The International Classification of Diseases (ICD-11) lists "gender incongruence" under "conditions related to sexual health", which is coded into three conditions:[6]

  • Gender incongruence of adolescence or adulthood (HA60): replaces F64.0
  • Gender incongruence of childhood (HA61): replaces F64.2
  • Gender incongruence, unspecified (HA6Z): replaces F64.9

The previous version of the International Classification of Diseases, ICD-10, used to have five different diagnoses for "gender identity disorder", including one for when it manifests during childhood.[7] The diagnoses of gender identity disorder were not given to intersex individuals (those born with "ambiguous" genitalia). Additionally, as with all psychological disorders, these symptoms must cause direct distress and an impairment of functioning of the individual exhibiting the symptoms.[8]

F64.2 Gender identity disorder of childhood

A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual's own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behavior in boys is not sufficient. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but in F66.0.[9]

Persistence

According to the American Academy of Pediatrics, most children have a stable sense of their gender identity by age 4. They explain that research shows prepubertal children who assert a transgender or gender diverse identity know their gender as clearly and as consistently as their cisgender peers.[10][11]

Other research has shown that if gender dysphoria persists during puberty, it is very likely permanent.[12][13][14] Factors that are associated with gender dysphoria persisting through puberty include intensity of gender dysphoria, amount of cross-gendered behavior, and verbal identification with the desired/experienced gender (i.e. stating that they are a different gender rather than wish to be a different gender).[14][15]

Some studies have found that gender dysphoria in children is more heavily linked to adult homosexuality than to an adult transgender identity, especially with regard to boys.[16][17][18] These studies state that the majority of children diagnosed with gender dysphoria did not desire to be the other sex by puberty, with most growing up to identify as gay, lesbian, or bisexual, with or without therapeutic intervention.[12][13][19][15][20] However, they have been criticized as irrelevant on the basis that they counted as 'desistance' cases where the child was simply gender-nonconforming rather than dysphoric and tracked diagnoses rather than gender identity or desire to transition, leading to inflation of the desistance statistics. The majority of desistance research relies on four studies published since 2008. While the subjects met the criteria for gender identity disorder as defined in the DSM-III or DSM-IV, many would not have met the updated criteria for gender dysphoria in the DSM-5, established in 2013, which unlike prior versions explicitly requires identification with a gender other than assigned at birth. In one study, 40% of those classified as "desisters" were subthreshold even for the DSM-IV criteria. The four studies all offered evidence that statement of transgender identity in childhood predicted transgender identity in adolescence andadulthood and the intensity of gender dysphoria in childhood likewise predicted its intensity later in life. The studies published from the 1960-1980's never used the term desistance, instead focusing on "gender-deviant behavior" - childhood femininity in people assigned male at birth - and how this more often predicts homosexuality rather than "transsexualism" in adulthood. Additionally, some of the research since 2000 and all the research prior has been criticized for citing studies that used conversion therapy, a disproven method consisting of either discouraging social transition, explicitly trying to prevent or discourage the child from identifying as transgender as an adult by adulthood or adolescence, or actively employing techniques to limit their "gender-deviant" behavior. The term "desistance" itself has been criticized as pathologizing for its roots in criminal research and oppositional defiance disorder, where desistance is considered a positive outcome.[21][22][23][24]

A systematic review of research relating to desistance was published in 2022. It found that desistance was poorly defined: studies sometimes did not define it or equally defined it as desistance of transgender identity or desistance of gender dysphoria. They also found none of the definitions allowed for dynamic or nonbinary gender identities and the majority of articles published were editorial pieces. They stated the concept was based on biased research from the 1960-80s and poor quality research in the 2000s. They concluded there was a "dearth of high-quality hypothesis-driven research that currently exists" on the subject, and suggested that desistance should "be removed from clinical and research discourse to focus instead on supporting [transgender and gender-expansive] youth rather than attempting to predict their future gender identity."[22] According to a review published in 2022 considering more recent studies, the majority of pre-pubertal children who socially transition persist in their identity in 5-to 7-year follow-ups, disproving the results of the prior studies.[14]

Prevalence

According to a review published in 2020 relying on recent statistical surveys, 1.2% to 2.7% of children and adolescents worldwide identify as transgender. The data was drawn more from studies of adolescents than pre-pubertal youth and noted a difference in methodological quality between studies published before and after 2010. The review notes rising numbers of youth are self-identifying as trans and calls for more systematic studies and reviews in future.[25]

Management

The WPATH Standards of Care and other therapeutic interventions do not seek to change a child's gender identity.[26][27] Instead, clinicians advise children and their parents to avoid goals based on gender identity and to instead cope with the child's distress by embracing psychoeducation and to be supportive of their gender variant identity and behavior as it develops.[3][28] A clinician may suggest that the parent be attentive, listen, and encourage an environment for the child to explore and express their identified gender identity, which may be termed the true gender. This can remove the stigma associated with their dysphoria, as well as the pressure to conform to a gender identity or role they do not identify with, which may be termed the false gender self.[3] WPATH Standards of Care also recommend assessing and treating any co-existing mental health issues.[27] The majority of major medical associations define attempts to change an individual's gender identity or gender expression as conversion therapy and strongly discourage it citing concerns of a lack of scientific credibility and clinical utility with these practices.[29][30]

Treatment may also take the form of puberty blockers (such as leuprorelin), cross-sex hormones (i.e., administering estrogen to a child assigned male at birth or testosterone to a child assigned female at birth), or sex reassignment surgery when the child has reached the age of medical majority, with the aim of bringing one's physical body in line with their identified gender.[3][28] Delaying puberty allows for the child to mentally mature while preventing them from developing a body they may not want, so that they may make a more informed decision about their gender identity once they are an adolescent.[3] It can also help reduce anxiety and depression.[28] Short-term side effects of puberty blockers include headaches, fatigue, insomnia, muscle aches and changes in breast tissue, mood, and weight.[31] Research on the long-term effects on brain development, cognitive function, fertility, and sexual function is limited.[32][33][34]

According to the American Psychiatric Association, "Due to the dynamic nature of puberty development, lack of gender-affirming interventions (i.e. social, psychological, and medical) is not a neutral decision; youth often experience worsening dysphoria and negative impact on mental health as the incongruent and unwanted puberty progresses. Trans-affirming treatment, such as the use of puberty suppression, is associated with the relief of emotional distress, and notable gains in psychosocial and emotional development, in trans and gender diverse youth".[35]

In its position statement published December 2020, the Endocrine Society stated that there is durable evidence for a biological underpinning to gender identity and that pubertal suppression, hormone therapy, and medically indicated surgery are effective and relatively safe when monitored appropriately and have been established as the standard of care. They noted a decrease in suicidal ideation among youth who have access to gender-affirming care and comparable levels of depression to cisgender peers among socially transitioned pre-pubertal youth.[36] In its 2017 guideline on treating those with gender dysphoria, it recommends puberty blockers be started when the child has started puberty (Tanner Stage 2 for breast or genital development) and cross-sex hormones be started at 16, though they note "there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence". They recommend a multidisciplinary team of medical and mental health professionals manage the treatment for those under 18. They also recommend "monitoring clinical pubertal development every 3 to 6 months and laboratory parameters every 6 to 12 months during sex hormone treatment".[37]

For adolescents, WPATH says that physical interventions such as puberty blockers, hormone therapy, or surgery may be appropriate. Before any physical interventions are initiated, however, a psychiatric assessment exploring the psychological, family, and social issues around the adolescent's gender dysphoria should be undertaken.[27] WPATH's Standards of Care 8, published in 2022, declare puberty blocking medication as "medically necessary", and recommends them for usage in transgender adolescents once the patient has reached Tanner stage 2 of development, and state that longitudinal shows improved outcomes for transgender patients who receive them.[38]

While few studies have examined the effects of puberty blockers for gender non-conforming or transgender adolescents, the studies that have been conducted generally indicate that these treatments are reasonably safe, are reversible, and can improve psychological well-being.[39][40][41]

A 2020 review published in Child and Adolescent Mental Health found that puberty blockers are reversible and associated with such positive outcomes as decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life.[42] A 2020 survey published in Pediatrics found that puberty blockers are associated with better mental health outcomes and lower odds of lifetime suicidal ideation.[43] A 2022 study published in the Journal of the American Medical Association found a 60% reduction in moderate and severe depression and a 73% reduction in suicidality among transgender youth aged 13–20 who took puberty blockers and gender-affirming hormones over a 12-month follow-up.[44] A 2022 study published in The Lancet involving 720 transgender adolescents who took puberty blockers and hormones found that 98 percent continued to use hormones at a follow-up appointment.[45]

In 2020, a review article commissioned by NHS England was published by the National Institute for Health and Care Excellence, concluding that the quality of evidence for puberty blocker outcomes (for mental health, quality of life and impact on gender dysphoria) was of very low certainty based on the GRADE scale.[46] The Finnish government commissioned a review of the research evidence for treatment of minors and the Finnish Ministry of Health concluded that there are no research-based health care methods for minors with gender dysphoria.[47] Nevertheless, they recommend the use of puberty blockers for minors on a case-by-case basis, and the American Academy of Pediatrics state that "pubertal suppression in children who identify as TGD [transgender and gender diverse] generally leads to improved psychological functioning in adolescence and young adulthood."[48] The National Board of Health and Welfare in Sweden took similar action in 2022.[49][50]

See also

References

  1. ↑ Bryant K (2018). "Gender Dysphoria". Encyclopædia Britannica Online. Retrieved 16 August 2018.
  2. ↑ Alderson K (2012). Counseling LGBTI Clients. SAGE Publications. p. 152. ISBN 978-1412987189.
  3. 1 2 3 4 5 Maddux JE, Winstead BA (2015). Psychopathology: Foundations for a Contemporary Understanding. Routledge. pp. 464–465. ISBN 978-1317697992.
  4. ↑ "P 00 Gender Dysphoria in Children". American Psychiatric Association. Retrieved 2 April 2012.
  5. 1 2 American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC: American Psychiatric Association. doi:10.1176/appi.books.9780890425787. ISBN 978-0-89042-575-6. S2CID 249488050.
  6. ↑ "Gender incongruence (ICD-11)". icd.who.int. WHO. Retrieved 28 August 2018.
  7. ↑ World Health Organization (May 1990). Disorders of adult personality and behaviour F60-F69 .
  8. ↑ Bradley SJ, Zucker KJ (July 1997). "Gender identity disorder: a review of the past 10 years". Journal of the American Academy of Child and Adolescent Psychiatry. 36 (7): 872–80. doi:10.1097/00004583-199707000-00008. PMID 9204664.
  9. ↑ "International Classification of Diseases (ICD) F64 Gender identity disorders". World Health Organization. Retrieved 9 August 2018.
  10. ↑ Rafferty, Jason. "Gender Identity Development in Children". American Academy of Pediatrics.
  11. ↑ Rafferty, Jason; Committee on Psychological Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness; et al. (2018). "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents". Pediatrics. 142 (4). doi:10.1542/peds.2018-2162. PMID 30224363. S2CID 52288840.
  12. 1 2 Jameson L, de Kretser DM, Marshall JC, De Groot LJ (2013). Endocrinology Adult and Pediatric: Reproductive Endocrinology. Elsevier Health Sciences. p. 483. ISBN 978-0323221528.
  13. 1 2 Dulcan, MK (2015). Dulcan's Textbook of Child and Adolescent Psychiatry, Second Edition. American Psychiatric Pub. p. 591. ISBN 978-1585624935.
  14. 1 2 3 Roberts, Christina (11 May 2022). "Persistence of Transgender Gender Identity Among Children and Adolescents". Pediatrics. 150 (2). doi:10.1542/peds.2022-057693. ISSN 0031-4005. PMID 35538638. S2CID 248694688.
  15. 1 2 Ristori J, Steensma TD (2 January 2016). "Gender dysphoria in childhood". International Review of Psychiatry. 28 (1): 13–20. doi:10.3109/09540261.2015.1115754. PMID 26754056. S2CID 5461482.
  16. ↑ Kreukels B, Steensma TD, de Vries A (2013). Gender Dysphoria and Disorders of Sex Development: Progress in Care and Knowledge. Springer Science & Business Media. p. 61. ISBN 978-1461474418.
  17. ↑ Fatemi H, Clayton PJ (2016). The Medical Basis of Psychiatry. Springer. p. 302. ISBN 978-1493925285.
  18. ↑ LeVay S (2010). Gay, Straight, and the Reason Why: The Science of Sexual Orientation. Oxford University Press. p. 91. ISBN 978-0199753192.
  19. ↑ Fuss J, Auer MK, Briken P (November 2015). "Gender dysphoria in children and adolescents: a review of recent research". Current Opinion in Psychiatry. 28 (6): 430–434. doi:10.1097/YCO.0000000000000203. PMID 26382161. S2CID 23690783.
  20. ↑ Marcdante K, Kliegman RM (2014). Nelson Essentials of Pediatrics E-Book. Elsevier Health Sciences. p. 75. ISBN 978-0323226981.
  21. ↑ Ashley, Florence (2 September 2021). "The clinical irrelevance of "desistance" research for transgender and gender creative youth". Psychology of Sexual Orientation and Gender Diversity. 9 (4): 387–397. doi:10.1037/sgd0000504. ISSN 2329-0390. S2CID 239099559. Archived from the original on 3 March 2022. Retrieved 3 March 2022.
  22. 1 2 Karrington, Baer (1 June 2022). "Defining Desistance: Exploring Desistance in Transgender and Gender Expansive Youth Through Systematic Literature Review". Transgender Health. 7 (3): 189–212. doi:10.1089/trgh.2020.0129. ISSN 2688-4887. PMC 9829142. PMID 36643060. S2CID 236417972.
  23. ↑ Temple Newhook, Julia; Pyne, Jake; Winters, Kelley; Feder, Stephen; Holmes, Cindy; Tosh, Jemma; Sinnott, Mari-Lynne; Jamieson, Ally; Pickett, Sarah (3 April 2018). "A critical commentary on follow-up studies and "desistance" theories about transgender and gender-nonconforming children". International Journal of Transgenderism. 19 (2): 212–224. doi:10.1080/15532739.2018.1456390. ISSN 1553-2739. S2CID 150338824. Due to such shifting diagnostic categories and inclusion criteria over time, these studies included children who, by current DSM-5 standards, would not likely have been categorized as transgender (i.e., they would not meet the criteria for gender dysphoria) and therefore, it is not surprising that they would not identify as transgender at follow-up. Current criteria require identification with a gender other than what was assigned at birth, which was not a necessity in prior versions of the diagnosis.
  24. ↑ Steensma, Thomas (2018). "A critical commentary on "A critical commentary on follow-up studies and "desistence" theories about transgender and gender non-conforming children"". International Journal of Transgenderism. 19 (2): 225–230. doi:10.1080/15532739.2018.1468292. S2CID 150062632.
  25. ↑ Zhang, Qi; Goodman, Michael; Adams, Noah; Corneil, Trevor; Hashemi, Leila; Kreukels, Baudewijntje; Motmans, Joz; Snyder, Rachel; Coleman, Eli (2 April 2020). "Epidemiological considerations in transgender health: A systematic review with focus on higher quality data". International Journal of Transgender Health. 21 (2): 125–137. doi:10.1080/26895269.2020.1753136. hdl:1854/LU-8659023. ISSN 2689-5269. PMC 7430478. PMID 33015664.
  26. ↑ Kliegman RM, Stanton B, Geme JS, Schor NF (2015). Nelson Textbook of Pediatrics E-Book. Elsevier Health Sciences. pp. 933–934. ISBN 978-0323263528.
  27. 1 2 3 Coleman, E.; et al. (19 August 2022). "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People". International Journal of Transgender Health. World Professional Association for Transgender Health. 23 (sup1): 10–21. doi:10.1080/26895269.2022.2100644. PMC 9553112. PMID 36238954.
  28. 1 2 3 Hutson JM, Warne GL, Grover SR (2012). Disorders of Sex Development: An Integrated Approach to Management. Springer Science & Business Media. p. 38. ISBN 978-3642229633.
  29. ↑ "Health and Medical Organization Statements on Sexual Orientation, Gender Identity/Expression and 'Reparative Therapy'". lambdalegal.org. Lambda Legal.
  30. ↑ "Policy and Position Statements on Conversion Therapy". Human Rights Campaign. Retrieved 12 April 2017.
  31. ↑ "Puberty Blockers". www.stlouischildrens.org. Retrieved 18 August 2022.
  32. ↑ "As children line up at gender clinics, families confront many unknowns". Reuters. 6 October 2022. Retrieved 10 October 2022.
  33. ↑ Rosenthal SM (December 2016). "Transgender youth: current concepts". Annals of Pediatric Endocrinology & Metabolism. 21 (4): 185–192. doi:10.6065/apem.2016.21.4.185. PMC 5290172. PMID 28164070. The primary risks of pubertal suppression in gender dysphoric youth treated with GnRH agonists include adverse effects on bone mineralization, compromised fertility, and unknown effects on brain development.
  34. ↑ de Vries AL, Cohen-Kettenis PT (2012). "Clinical management of gender dysphoria in children and adolescents: the Dutch approach". Journal of Homosexuality. 59 (3): 301–20. doi:10.1080/00918369.2012.653300. PMID 22455322. S2CID 11731779.
  35. ↑ "Position Statement on Treatment of Transgender (Trans) and Gender Diverse Youth" (PDF). APA Official Actions. American Psychiatric Association. 2020.
  36. ↑ "Transgender Health: An Endocrine Society Position Statement". www.endocrine.org. The Endocrine Society. 15 December 2020. Retrieved 15 June 2022.
  37. ↑ Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer JW, Murad MS, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG (September 2017). "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline". The Journal of Clinical Endocrinology & Metabolism. 102 (11): 3869–3903. doi:10.1210/jc.2017-01658. PMID 28945902.
  38. ↑ Coleman, E; Radix, A.E.; Bouman, W.P.; et al. (2022). "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8". International Journal of Transgender Health. 23 (Suppl 1): S18, S64, S111. doi:10.1080/26895269.2022.2100644. PMC 9553112. PMID 36238954.
  39. ↑ Mahfouda S, Moore JK, Siafarikas A, Zepf FD, Lin A (October 2017). "Puberty suppression in transgender children and adolescents". The Lancet Diabetes & Endocrinology. 5 (10): 816–826. doi:10.1016/s2213-8587(17)30099-2. PMID 28546095. S2CID 10690853. The few studies that have examined the psychological effects of suppressing puberty, as the first stage before possible future commencement of CSH therapy, have shown benefits.
  40. ↑ Rafferty J (October 2018). "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents". Pediatrics. 142 (4): e20182162. doi:10.1542/peds.2018-2162. PMID 30224363. Often, pubertal suppression...reduces the need for later surgery because physical changes that are otherwise irreversible (protrusion of the Adam's apple, male pattern baldness, voice change, breast growth, etc) are prevented. The available data reveal that pubertal suppression in children who identify as TGD generally leads to improved psychological functioning in adolescence and young adulthood.
  41. ↑ Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. (November 2017). "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology and Metabolism. 102 (11): 3869–3903. doi:10.1210/jc.2017-01658. PMID 28945902. Treating GD/gender-incongruent adolescents entering puberty with GnRH analogs has been shown to improve psychological functioning in several domains", "In the future, we need more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols. Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development);
  42. ↑ Rew, Lynn; Young, Cara C.; Monge, Maria; Bogucka, Roxanne (February 2021). "Review: Puberty blockers for transgender and gender diverse youth-a critical review of the literature". Child and Adolescent Mental Health. 26 (1): 3–14. doi:10.1111/camh.12437. ISSN 1475-357X. PMID 33320999. S2CID 229282305.
  43. ↑ Turban, Jack L.; King, Dana; Carswell, Jeremi M.; Keuroghlian, Alex S. (February 2020). "Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation". Pediatrics. 145 (2): e20191725. doi:10.1542/peds.2019-1725. ISSN 1098-4275. PMC 7073269. PMID 31974216.
  44. ↑ Tordoff, Diana M.; Wanta, Jonathon W.; Collin, Arin; Stepney, Cesalie; Inwards-Breland, David J.; Ahrens, Kym (25 February 2022). "Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care". JAMA Network Open. 5 (2): e220978. doi:10.1001/jamanetworkopen.2022.0978. PMC 8881768. PMID 35212746.
  45. ↑ Loos, Maria Anna Theodora Catharina van der; Hannema, Sabine Elisabeth; Klink, Daniel Tatting; Heijer, Martin den; Wiepjes, Chantal Maria (20 October 2022). "Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands". The Lancet Child & Adolescent Health. 6 (12): 869–875. doi:10.1016/S2352-4642(22)00254-1. ISSN 2352-4642. PMID 36273487. S2CID 253068811.
  46. ↑ "Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria". Retrieved 2 April 2021. The critical outcomes for decision making are the impact on gender dysphoria, mental health and quality of life. The quality of evidence for these outcomes was assessed as very low certainty using modified GRADE. For a lay summary, see Cohen, Deborah; Barnes, Hannah (1 April 2021). "Evidence for puberty blockers use very low, says NICE". BBC News Online.
  47. ↑ "Finnish guidelines for treatment of child and adolescent gender dysphoria" (PDF). Council for Choices in Health Care (COHERE). March 2021. Archived (PDF) from the original on 3 December 2020. Retrieved 22 April 2021. p. 6: Terveydenhuoltolain mukaan (8§) terveydenhuollon toiminnan on perustuttava näyttöön ja hyviin hoito- ja toimintakäytäntöihin. Alaikäisten osalta tutkimusnäyttöön perustuvia terveydenhuollon menetelmiä ei ole. [According to the Health Care Act (Section 8), health care activities must be based on evidence and good care and operating practices. There are no research-based health care methods for minors. [translation provided by Wikipedia]]
  48. ↑ Rafferty, Jason; Committee on Psychosocial Aspects of Child and Family Health; Committee On Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness; et al. (1 October 2018). "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents". Pediatrics. 142 (4): e20182162. doi:10.1542/peds.2018-2162. ISSN 0031-4005. PMID 30224363. Archived from the original on 19 July 2019. Retrieved 11 June 2021.
  49. ↑ Ghorayshi, Azeen (28 July 2022). "England Overhauls Medical Care for Transgender Youth". The New York Times. Retrieved 12 October 2022.
  50. ↑ Milton, Josh (23 February 2022). "Swedish health board wants doctors to stop prescribing life-saving puberty blockers". PinkNews. Retrieved 12 October 2022.
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