Vries et al, 2011

Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study

Summary

The researchers report on psychological outcomes of a group of 70 adolescents (33 male and 37 female) given puberty blockers between 2000 and 2008 in Amsterdam for a mean 1.9 years. The group is the same one reported in Vries et al., (2014).

Rationale

The paper is one of the first to document the use of puberty blockers for treating gender dysphoria and sets out the rationale for the treatment with a frankness rarely found in later studies.

First, the paper mentions that gender dysphoria is likely to desist in most prepubertal children:

“Gender dysphoria will remit in most prepubertal children…but not in most gender dysphoric adolescents.”

This acknowledgement raises questions regarding clinical confidence in the long-term persistence of dysphoria: if the gender dysphoria of a 9-year-old will likely remit, how confident are we that a 12-year-old will continue to experience dysphoria throughout their life to the degree that it requires medical intervention in adolescence?

To evidence the claim that adolescent dysphoria will likely persist (and therefore does require intervention), the authors cite Smith et al. (2001) and Cohen-Kettenis and van Goozen (1997) . These studies concern the same cohort of 22 adolescents, 20 of whom went on to surgical interventions in adulthood. However, neither study investigated the persistence or desistance of gender dysphoria in adolescents specifically. If anything, Smith et al. (2001) show that dysphoria subsided in the control group of 14 (Table 2. p. 476), despite the more severe psychological problems reported by this group.

Second, the study highlights how autism and feeling “different” can be mistaken for a persistent form of gender dysphoria:

…it can be complicated to disentangle whether the gender dysphoria evolves from a general feeling of being just “different” or a whether a true “core” cross-gender identity exists in adolescents who suffer from an autistic spectrum disorder.

Later literature, such as the Waikato Guidelines, fails to mention these issues. Issues which could make a significant difference in decisions to undertake medical interventions. These omissions are further examples of clinicians not giving effect to the right to be fully informed, and future articles will cover the complexity of adolescent gender dysphoria in greater depth.

Results and Analysis

The study used the following measures to assess psychological functioning:

  • Beck Depression Inventory (BDI-II)
  • the trait anger and anxiety aspects of the Scales of State Personality Inventory (SSPI),
  • Child Behavior Checklist (CBCL),
  • and the Youth Self-Report (YSR)
  • Utrecht Gender Dysphoria Scale (UGS)
  • Body Image Scale (BIS)

Mean CBCL improved significantly from 61 to 55. Mean YSR score improved significantly from 56 to 50. BDI improved from 8.31 to 4.95

The SSPI measures and gender dysphoria did not change. Body image in females significantly worsened.

CBCL and YSR scores below 65 are considered normal. BDI scores below 14 are also normal. The majority of subjects prior to treatment had normal mental health and after ~2 years of aging, psychosocial support and puberty suppression continued to have normal mental health. The study does not demonstrate dramatic improvements in mental health from severely depressed to normal mental health.

Similar to Staphorsius et al. (2015), the vast majority of participants were homosexual (62) or bisexual (6). The same concerns regarding this population’s childhood gender non-conformity, anti-homosexual attitudes and the possibility of misdiagnosis also apply here.

Conclusion

Without a control group, we cannot attribute the results to puberty blockers. To give effect to the right to be fully informed clinicians must inform parents that dysphoria may desist with psychosocial support, and body dissatisfaction could increase under pubertal suppression.