Managing Gender Dysphoria in Young People:
A Clinical Guide
Introduction
Gender dysphoria and gender incongruence in young people remain contested areas of medical practice. This guide is designed to provide a structured, evidence-based approach to clinical care while avoiding political, social, religious, or ideological positions. The focus is on safeguarding the health, safety, and welfare of the child in accordance with human rights obligations under the United Nations Convention on the Rights of the Child.
Guiding Principles
- Respect for young people’s views on gender identity is integrated into a comprehensive, bio-psycho-social assessment. This approach ensures that gender concerns are considered within the totality of the developmental and clinical picture.
- Childhood and adolescence involve rapid physical and psycho-social changes. Many young people explore aspects of identity, including gender, during this period. Evidence suggests that most individuals ultimately accept their biological sex and adult body.
- Gender dysphoria/incongruence may present as both a symptom and a syndrome. A confirmed diagnosis requires a significant, established, and prolonged pattern of gender incongruence, accompanied by persistent distress. Conditions that present with symptoms of gender dysphoria/incongruence need to be identified and managed.
- Gender dysphoria/incongruence is often associated with complex family, social, psychological, or psychiatric factors. A thorough clinical assessment should explore these potential contributors before considering gender-related interventions.
Clinical Assessment and Management
- Comprehensive Bio-Psycho-Social Assessment
- Conducted before recommending specific treatment.
- Explores family dynamics, mental health history, social influences, and coexisting psychological or psychiatric conditions.
- Ensures alternative diagnoses are considered.
- Psychotherapy and Psycho-Social Interventions
- First-line treatments include individual psychotherapy, psychoeducation, school-home liaison, and family therapy.
- Exploratory psychotherapy helps identify sources of distress including gender concerns and other stressors.
- Interventions may include explorative and supportive psychotherapy, cognitive-behavioural therapy (CBT), psychodynamic psychotherapy, and family therapy.
- Psychotherapy is distinct from conversion therapy, as it does not seek to achieve any predetermined gender identity or sexual orientation outcome.
- Medical Interventions: Risks and Considerations
- Puberty blockers and gender affirming hormones may have a limited role as second-line treatments.
- Puberty blockers and cross-sex hormones are not fully reversible and may have significant consequences on physical, cognitive, reproductive, and psychosexual development.
- No long-term studies demonstrate substantial benefit from medical transition in youth.
- Reports of regret and de-transitioning highlight the need for caution.
- The experimental nature of puberty blockers and hormonal treatments necessitates fully informed consent.
Medico-Legal Considerations
Health professionals are exposed to legal risks if:
- A child or adolescent is found not competent to provide informed consent.
- Parents of a child under 16 years do not both agree to treatment.
- Gender-affirming treatment is not preceded by a thorough assessment.
- The patient is not informed of all risks associated with medical intervention.
International Perspectives
- Finland: Advises against puberty blockers and hormonal treatment in cases of significant psychiatric comorbidity.
- Norway: Considers puberty blockers, hormones, and surgeries for minors as experimental.
- United Kingdom: Tavistock Clinic closed due to concerns over its affirmative-only approach; regional clinics now implement a more holistic model of care. Following the Cass Review pubrty blockers are now banned in the United Kingdom.
- Sweden, France, Denmark: Recommend a cautious approach to youth medical transition.
- Queensland: Puberty blockers are now not available for gender dysphoria youth under age 18 receiving treatment in Queensland Health services.
Clinical Decision-Making
Dr. Hilary Cass emphasizes that medical intervention requires:
- A clear diagnosis and differential diagnosis.
- Consideration of all potential causes of distress.
- A partnership approach with the young person and their family.
The Endocrine Society’s guidelines reinforce the importance of distinguishing gender dysphoria from conditions with similar features.
Conclusion
This guide adopts a personalised, cautious, and non-ideological approach to the care of youth with gender dysphoria. It prioritises a thorough assessment, first-line psychological interventions, and careful consideration before recommending medical treatments. Clinicians should remain vigilant in protecting young people’s long-term well-being while ensuring informed decision-making in this complex field.
Dr Philip Morris AM
2 March 2025