Early adolescent gender identity disorder

GID continuing into adolescence merges with GID of adulthood. Management issues address the young teenager's continuing gender dysphoria and the consequent social problems. There may be considerable peer group alienation. Depression may develop. School avoidance may develop. Awareness of sexual attraction to same-sex persons may be an additional source of conflict. Parents may be unaware of their teen's GID.

GID in adolescents presents medical, legal, and ethical dilemmas for clinicians. The somatic changes of puberty are very distressing to these young teenagers. And for those who will ultimately progress to adult GID or transsexualism, these changes may pose substantial obstacles to effective 'passing' in their desired gender role. The latter is especially true for males as the voice deepens, facial hair sprouts, and skeletal proportions masculinize. For females, menses is especially troublesome, though not visible, and breast development, when prominent, is very distressing.

The psychiatric management dilemma is in predicting which gender dysphoric adolescents will mature into adult transsexuals, and which will be able to live in the gender role expected from birth, perhaps as homosexual adult men and women. More time is needed to evaluate these adolescents' evolving gender identity, without the troubling somatic changes of puberty. Therefore, gonadal hormone antagonists have been utilized in a small number of such patients. (36)

The gonadotrophin hormone-releasing hormone agonists that block the release of gonadotrophins and gonadal hormones put puberty on hold. Although there is concern that more than a year, perhaps two, of gonadal steroid suppression may predispose to osteoporosis, this concern is, at this time, more theoretical than empirically based.

The next controversy in the management of adolescent GID is when cross-sex hormones should be administered. The somatic changes of this sex-reversed puberty are essentially irreversible and comparable to that with adult patients. Legally, there is no age barrier to a minor consenting to a medical intervention in the United Kingdom, providing that there is sufficient understanding of the implications of the treatment. Also at 16 years, adolescents can generally consent to medical treatment. In the United States 'emancipated minors' (i.e. those living independently from their parents) can consent to treatment.

A firmer base for decision-making with adolescents with GID will derive from the clinical experience being generated by the few centres engaged in their evaluation and treatment with same-sex hormone blockade and cross-sex hormone administration.

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