The words sex and gender are often used interchangeably and incorrectly, which can lead to confusion when dealing with issues like this one. Before we begin, it is therefore necessary to clarify the meaning and differences betweenboth words¹:

• Sex: refers to the biological and physiological characteristics that define a person as male or female. Sex is a label assigned at birth based on factors,including hormones, genitals, sex chromosomes, and genetics.
• Gender: refers to the socially constructed characteristics that define a person’s role in society and classifythem as male and female.Gender includes identity, behavior and beliefs, and determines how people should interact with others of the same or opposite sex within households, communities and workplaces.

What is gender dysphoria?

With the above definitions in mind, gender dysphoria (GD) is described in the Diagnostic and Statistical Manual of Mental Disorders (DSMas a psychiatric diagnosis characterized by significantmental distress due to the dissonance between biological sex—assigned at birth—and gender identity. This incongruence typically starts at an early age, so children with GD display behaviors and preferences that do not match their biological sex²

Diagnostic criteria for gender dysphoria

Diagnostic criteria for gender dysphoria in children

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)³, the criteria for diagnosing gender dysphoria in children include:

1. A marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least six months, as manifested by at least six of the following criteria (one of which must be criterion A1):
2. A strong desire to be of the other gender or an insistence that he or she is the other gender (or some alternative genderdifferentfrom one’s assigned gender).
3. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
4. Strong preferences for cross-gender roles in make-believe play or fantasy play.
5. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
6. Astrong preference for playmates of the other gender.
7. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
8. A strong dislike of one’s sexual anatomy.
9. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
10. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Diagnostic criteria for gender dysphoria in adolescents and adults

In adolescents and adults, diagnostic criteria are the same and involve:

1. A marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least six months, as manifested by at least two of the following criteria:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).
7. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Causes of gender dysphoria

While efforts have been made to determine the causes of gender dysphoria, research results are inconclusive. Among the proposed hypotheses, hormonal factors have been suggested as a possible explanation, that an atypical production of sex hormones in the prenatal period leads to changes in the activation of brain circuits during puberty that explain the incongruence experienced by this population⁴.

In this context, several studies in adults have shown that transgender individuals reveal a distinct activation pattern different from those of men and ofwomen^5-7. These findings have been explored in the child population in a study by Nota and colleagues⁸, in which adolescents, but notpre-pubertal children, exhibited functional connectivity (FC) pattern ssimilar to their experienced gender and not to their natal sex. It should be noted that more studies are needed in this research to solidify this hypothesis.

Furthermore, it has been found that monozygotic twins are more likely to both have GD than dizygotic twins. This suggests that genetic factors are likely to play a relevant role in the development of GD, however, there is still not enough evidence to say so conclusively⁹.

Finally, an attempt has been made to explain it from a psychosocial and environmental perspective, arguing that GD develops when there is a tendency for anxiety in childrencombined with parental psychopathology, and is accompanied byother biological factors such as a feminine appearance in boys or masculine appearance in girls¹⁰. Likewise, it has been hypothesized that children with GD can display non-conformity with the binary system (male/female) imposed in most societies¹¹. However, as in the cases above,it is unclear whether these hypotheses are correct without further research.

Psychosocial consequences

Emotional problems

What is clear is that this situation can be very difficult for children and trigger a number of emotional and social problems that compromise their quality of life. However, it shouldbe noted that the psychological distress associated with the dissonance between sex and gender experienced by these children is different and independent from the emotional problems arising from the social rejection commonly experienced by both children and family members. In most cases, these children and adolescents are misunderstood by others and treated as “freaks” because they are not congruent with what is considered socially accepted. At school, rejection by peers and even teachers can result in children and adolescents associating school with negative experiences and perceiving it as an unsafe place for them. This, in turn, results in children and adolescents not wanting to go to school or not attending school, not paying attention in class, or having behavioral problems, all of which ultimately translates into school failure.

Family response

At home,parents and/or other family members may also reject the situation because of dealing with anguish or uncertainty and fail to provide their children with theneeded support.

Institutional response

At the institutional level, these children and adolescents also mustface obstacles in their everyday life which, no matter how insignificant they may seem, cause them distress. For example, the Gender Identity law of 2007 (Law 3/2007, Spain) prohibited minors from changing their sex and/orname on their national identity cards. It was not until October 2018 that a bill was draftedto allow minors tofile for a name changethrough their parents or legal guardians¹².

Anxiety and depression

Taken together, all these factors promote the development of anxiety and depression symptoms in children and adolescents, which in the most extreme cases can lead to suicide, as was the recent case of Ekaique, which shocked everyone in Spain¹³. In fact, children who have social support and grow up in a tolerant environment are less likely to suffer from emotional problems.

In addition, it has been documented that emotional problems diminish considerably as soon as the minors begin treatment. Although this is a long process, knowing that they are on their way to becoming who they really are is a relief for them¹⁴.

Treatments

Treatment isa gradual process consisting of the following phases¹:

• Social transition: children and adolescentsuse names and pronouns in line with their experienced gender, as well as changing their clothing, hairstyles, etc.
• Puberty suppression:treatment with gonadotropin-releasing hormone (GnRH) agonists is started, which prevents the development of unwanted physical and sexual characteristics, such as facial hair growth in boys or breast development in girls, among others. This therapy begins in adolescence, between the ages of 12 and 16.
• Gender reassignment:in the first instance, genderaffirmingor cross-sex hormonesare administered from age 16 onwards, and then when legal age is reached, gender affirming surgery can be performed.

Conclusion

Transgender people, and especially younger ones, are in a state of vulnerability due to a lack of knowledge of this issue on the part of society. The consequences, as explained above, are diverse and can be fatal;it is therefore essential to inform and raise awareness among the population so that these children do not have to deal with the consequences of intolerance toward what is regarded as different. The well-being and even the life of these individuals is at stake if there is no urgent change in the concept of “normality.”

But how can this be achieved? This is not an easytask;however, we can take small actions that will gradually make it possible to achieve this goal. For example, it is extremely important that schools and families teach younger kids the entire spectrum of possibilities regarding identity. It is therefore also important that parent associations host information sessions in which, in addition to explaining the subject to parents, they are taught how to explain it to their children. In this regard, it would also be useful to develop tools such as children’s books or movies that promote understandingof children and adolescents with gender dysphoria.

While we still have a long way to go, thanks to the struggle of many people, initiatives are being carried out and small changes are having a great impact on the lives of these children.

References

1. Trujillo MA, Tabaac AR, Wall CSJ. Disforia de género en niños. En Arango-Lasprilla JC, Romero I, Hewitt N, Rodríguez-Irizarry W. Trastornos psicológicos y neuropsicológicos en la infancia. México: Manual Moderno; 2018. 197-212.
2. Ristori J, Steensma TD. Gender dysphoria in childhood. IntRevPsychiatry. 2016;28(1):13-20.
3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
4. Swaab DF, García-Falgueras A. Sexual differentiation of the human brain in relation to the gender identity and sexual orientation. FunctNeurol. 2009;24(1):17.
5. Clemens B, Junger J, Pauly K, Neulen J, Neuschaefer-Rube C, Frölich D. Male-to-female gender dysphoria: Gender-specific differences in resting-state networks. BrainBehav. 2017 Apr 5;7(5):e00691.
6. Feusner JD, Lidström A, Moody TD, Dhejne C, Bookheimer SY, Savic I, et al. Intrinsic network connectivity and own body perception in gender dysphoria. Brain Imaging Behav. 2017 Aug;11(4):964-976.
7. Kreukels BP, Guillamon A. Neuroimaging studies in people with gender incongruence. Int Rev Psychiatry. 2016;28(1):120-8.
8. Nota NM, Kreukels BPC, den Heijer M, Veltman DJ, Cohen-Kettenis PT, Burke SM, Bakker J. Brain functional connectivity patterns in children and adolescents with gender dysphoria: Sex-atypical or not? Psychoneuroendocrinology. 2017 Dec;86:187-195.
9. Coolidge FL, Thede LL, Young SE. The heritability of gender identity disorder in a child and adolescent twin sample.Behav Genet. 2002 Jul;32(4):251-7.
10. Wallien MS1, van Goozen SH, Cohen-Kettenis PT. Physiological correlates of anxiety in children with gender identity disorder. Eur Child Adolesc Psychiatry. 2007 Aug;16(5):309-15.
11. Cruz TM. Assessing access to care for transgender and gender nonconforming people: a consideration of diversity in combating discrimination.SocSci Med. 2014 Jun;110:65-73.
12. Rader DJ, Hobbs HH. Trastornos del metabolismo de las lipoproteínas. En: Barnes PJ. Longo DL, Fauci AS, et al, editores. Harrison principios de medicina interna. Vol 2. 18a ed. México: McGraw‐Hill; 2012. p. 3145‐3161.
13. Benito E. Justicia facilitará que los menores trans cambien el nombre del registro. El País. 20118. Retrieved from https://elpais.com/sociedad/2018/10/17/actualidad/1539779587_691507.html
14. N. Ekai, el niño transexual que se suicidó tras una adolescencia esperando sus hormonas. El Español. 2017. Retrieved from https://www.elespanol.com/reportajes/20180217/ekai-nino-transexual-suicido-adolescencia-esperando-hormonas/285472481_0.html
15. de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014 Oct;134(4):696-704.