Gender dysphoria/gender incongruity: Transition and discontinuation, persistence and desistance

The International Classification of Diseases (ICD-10) defines “transsexualism” or transsexuality as the desire to live and be accepted as a member of the opposite sex, and to undergo hormonal and surgical treatment to adapt one's own body to personal gender identity.¹ The term was subsequently replaced by “gender dysphoria” (GD), referring to the condition in which a person manifests discrepancy between personal gender as assigned at birth and gender identity (DSM-5).² Such discrepancy causes profound discomfort, distress or clinically significant disability at both a personal and a social level, generating a strong desire to be treated as the other gender (or as an alternative gender other than the assigned gender) and/or to dispose of one's sexual characteristics. The next ICD-11 (to come into effect in 2022) introduces the term “genderincongruity” to classify the different forms related to gender identity.³ “Gender variants” refer to a spectrum of gender experiences as opposed to the binary conception of gender. The term “transgender” is used as an umbrella term to refer to a broader range of gender identities. However, GD may also refer to the anxiety or distress caused by these characteristics which are rejected. Not all those identified as transgender cases or who have gender incongruity or a gender variant suffer from dysphoria in this sense.

In Europe and in other Western countries, the prevalence of male-to-female transsexualism (MFT) is estimated to be 6.8 cases/100,000, while the prevalence of female-to-male transsexualism (FMT) is 2.6 cases/100,000 adults.^4,5 Recently, higher figures have been reported for the autonomous region of Madrid (MFT 31.2/100,000 and FMT 12.9/100,000 adult).⁶ Some population surveys suggest that 0.5–1.3% of all individuals in the general population identify as transgender.⁵

In recent years, the number of adolescents referred to gender identity clinics in both Europe and North America has increased considerably.⁷ In 2018, Beard⁸ reported 189 consultations versus just one or two a decade earlier. Graaf et al. reported 39 adolescents referred in 2009, versus 1497 in 2016.⁹

Some studies suggest that between 0.17–1.3% of all adolescents and young adults identify as transgender,⁷ and this increase has been described by some as a “flare-up”.¹⁰ Different explanations for this phenomenon have been proposed: the increased attention paid to transgender problems in the media; the social assimilation of the Internet, with the availability of countless information sites; the gradual depathologization and reduction of stigma regarding transgender identity; and the availability of biomedical treatment, including the blockade of pubertal somatic development and subsequent crossover hormone treatment.¹¹ Taken together, all of these factors may have facilitated the search for mental health care by adolescents and their families (reflected in the “affirmative” care model adopted by many gender identity clinics and teams).¹²

In Spain, this phenomenon has similar dimensions and similar explanations. The existence of Gender Identity Units (GIUs) in the public healthcare system in almost all Spanish Autonomous Communities has covered the healthcare needs of the population to a significant degree. In this respect, mention should also be made of the publication in the various Autonomous Communities of laws that have promoted both public healthcare and the consolidation of personal and social rights.

Another phenomenon occurred during the same period in which the number of adolescents referred due to GD began to increase: a change in gender ratio, with a considerable increase in women assigned as such at birth.¹³

The management model for GD during early puberty (approximately 12 years of age) is increasingly accepted. The model is based on the suppression of puberty with gonadotropin-releasing hormone analogs, crossover hormone treatment from 16 years of age, and subsequently surgical treatments on reaching legal adult age. However, practically nothing is known about GD and/or transgender identity starting in adolescence, the underlying causal factors, and its evolution.

“Transition” is understood as the process in which transgender individuals change their sexual characteristics and/or gender manifestation in accordance with their personal internal sense of gender identity. This usually involves social changes (such as clothing, personal name and nicknames), legal changes (such as legal name and legal gender), and medical and physical changes (such as crossover hormone therapy and gender-confirmation surgery). “Detransition” in turn is understood as the cessation or reversal of gender transition or identification as transgender, either socially, legally or medically-surgically. It can occur in any phase of the transition process and at any age, though it is more common at the start of transition, and particularly before surgery. Detransition is often associated with regret about transition, though regret and transition do not always coincide.¹³ Such detransition in turn may be temporary or permanent, and there are no direct and formal studies on its magnitude. Detransition is estimated to occur in 1–8% of all individuals who start transition.

Transition is not the only solution to gender incongruity/GD, and leads some transgender individuals to stop and/or partially or fully reverse this process, either temporarily or permanently. Detransition due to regret is a highly controversial issue of great social and healthcare interest because of its biopsychosocial, legal and economic impact.

For decades, follow-up studies of transgender children have shown that a substantial majority eventually stop identifying themselves as transgender individuals. This is the so-called “desistance phenomenon”, i.e., the abandonment of transgender identity among children once they are already adolescents or adults. These findings have become an integral part of the debate on “social transition”, a term for allowing children to live publicly as their own identified gender in all respects except medical treatment. In transgender adolescents the situation is considerably more complex. The development and consolidation of identity is particularly important at these ages.¹⁴

Adolescence is a crucial time for identity and psychosexual development among young people with gender identity problems. Evidence from 10 prospective follow-up studies covering the period from childhood to adolescence suggests that in 80% of all children meeting GD criteria in childhood, GD regresses on reaching puberty.¹⁵ The conclusion of these studies is that GD in childhood is strongly associated with a homosexual or bisexual orientation.¹¹

Different studies indicate important variations in the persistence rates, ranging from 2–39%, depending on the country and the period studied. The main clinical practice guides¹⁶ agree in proposing adequate and cautious evaluation, with adequate psychological support. These processes should be geared toward identity exploration; the exclusion of psychological comorbidities or other identity confounding factors; the achievement of emotional stability and the development of resilience; confirmation of the decision related to the transition process; the avoidance of unrealistic expectations; and the development and enrichment of self-esteem.¹⁷ The main causes of desistance or regret reported by the authors are related to deficiencies in diagnosis and differential diagnosis, and with a reduction in or shortcomings of the evaluative periods, with psychological evaluation and diagnosis being viewed as a discriminatory act.¹⁷ A sense of failure in terms of real-life experience, and not always satisfactory, and sometimes deficient, surgical outcomes also lie at the root of desistance.

In this regard, it is worrying that hormone therapy might be requested to hide or alleviate other problems or concerns of adolescence other than gender identity. Sometimes this request is really insistent and intense, almost obliging professionals to make decisions without proper and prudent assessment. This situation, referred to as “rapid onset gender dysphoria” (ROGD), represents a new presentation of a little studied condition. It may be related to increased use of social networks and/or contact with other adolescents who also feel themselves to be transgender individuals. These factors suggest that social contagion may contribute to the significant rise in this phenomenon, and could indeed be classified as an epidemic among our more vulnerable young people.^7,10

Studies in Europe and North America suggest that approximately 40–45% of these young individuals have concomitant psychopathological disorders, mainly depression, anxiety, self-injury, suicidal ideation, autism spectrum disorders, and possibly eating disorders. By contrast, behavioral disorders and antisocial development are not prevalent.

Some reflections should be made, based on all of the above. Gender identity specialists are particularly aware and sensitized to individualized care in the transition process, recognizing that early surgery may give rise to irreversible situations. Future studies in transgender medicine should focus on each treated individual, advancing in the safety and efficacy of hormonal interventions. The opinion of each transgender youth is essential, with recognition and respect for personal internal diversity, but the possible risks (in the short, middle and long term) should always be made clear, while being adjusted to the level of understanding of the patient.

In some cases, we should take into account that certain currents of opinion or media may lead to poorly pondered judgments. Half a century ago, the psychoanalyst Jung (as quoted by Marchiano)¹⁰ was already warning about the fact that in order to resist “encroaching external attractive ideas”, it is necessary to be well rooted in the interior world, and to cultivate consciousness based on “the eternal fact of the human psyche”. Now more than ever, this advice seems relevant when dealing with the current rise of young trans-identified young people.