Comments on differences of gender dysphoria between children and teenagers

Dear Editor,

In connection with the paper by Sánchez Lorenzo et al.¹ on psycho-medical care in cases of gender identity dysphoria during adolescence that was recently published in your journal, we would like to comment on certain key points in this information, centring on the differences between gender identity dysphoria in children as opposed to teenagers that were not raised in the paper.

As the work describes, the development of gender dysphoria in these children and teenagers is variable and uncertain, given that only a few cases will be transsexual in adult life. It is therefore prudent to distinguish between children pre- and post-puberty. In the stage before puberty, prospective and retrospective follow-up studies report a persistence of gender dysphoria into adult age in from 12% to 27% of cases.^2,3 Nevertheless, this datum contrasts with the fact that gender dysphoria rarely changes or disappears in those teenagers whose gender dysphoria commenced during childhood and remained stable following puberty.^4,5 In fact, de Vries et al.,⁶ in a longitudinal prospective study of 70 young people with gender dysphoria who had been treated using hormonal suppression, observed that all of them achieved diagnostic stability and progression towards crossed hormone therapy.

Due to all of the above factors, the transition period from pre- to post-puberty is of key importance for teenagers to become aware of whether the gender dysphoria they presented during childhood will persist or cease. A study by Steensma et al.⁷ states that from the ages of 10 to 13 years old teenagers were aware of whether their gender dysphoria would remain stable or cease.

Another difference between children and teenagers with gender dysphoria lies in the proportion of sexes in each age group. In clinical terms, in children under the age of 12 years old with gender dysphoria the proportion of men to women varies from 6:1 to 3:1.⁸ In teenagers over the age of 12 years old with gender dysphoria the proportion of men to women stands at close to 1:1.⁹

To conclude, we agree with the authors that the evolution of gender identity dysphoria in these children and teenagers is variable and uncertain, that this is a complex clinical entity, that it requires a correct response to the demand expressed by the patient, and that this response must be given by a multidisciplinary team (endocrinology, surgery and mental health). Likewise, we consider it to be important to take into account the differences between individuals with gender dysphoria pre- and post puberty when informing the patients themselves and their family members, as well as when carrying out the diagnostic process and favouring the proper psycho-social development of the minor. We would like to underline that in spite of the fact that gender dysphoria usually manifests from the first stages of infancy, it is indispensible to consider that the younger the individual with gender dysphoria is, the more important it is to monitor the case and be conservative with medical treatments. This is because the said condition is unstable over time. We consider it to be fundamental to evaluate whether the said dysphoria consolidates and increases in the stages after puberty, to achieve a maximum degree of certainty before starting irreversible medical treatments.