Stefano Vicari Maria Pontillo in collaboration with Scuola Holden
Don’t call me by my name
Reading between the lines
the gender dysphoria
Reading between the lines is an editorial series dedicated to the mental health of children and adolescents. Resulting from the collaboration between Edizioni Erickson and Scuola Holden, it is addressed to anyone who is interested, for personal reasons (parents, adolescents), as well as for professional reasons (psychologists, educators, teachers), in getting to know at first hand the forms and symptoms of some of the most recurrent and frequent psychological disorders in the younger generations. In the wake of the Covid-19 pandemic and lockdown, the epidemiological data on the increase in incidence and severity of childhood disorders have become alarming: in order to be able to recognise them at an early stage and intervene effectively - whether one is a parent or a professional -, it is essential to read between the lines in the minds of girls and boys: interpreting the signs, picking up on requests for help, knowing how to listen and build a dialogue. In order to accompany adults in such complex challenges, this series of volumes has been created, which uses different languages to tackle topics such as self-harm, school anxiety, gender dysphoria, eating disorders and depression. Along the red thread of three stories - three stories of difficulty and suffering experienced by children, girls and teenagers - Stefano Vicari, an internationally renowned child neuropsychiatrist, describes in a clear and accessible way the characteristics of the disorders, the risk and protection factors, providing indications and suggestions to intervene in the best possible way, the Holden School - a storytelling academy that is a pioneer in Italy in the creation of new cultural languagesgives voice to the protagonists in three beautiful and delicate biographical tales, and the illustrators from the Academy of Fine Arts in Palermo sign the powerful and evocative plates that illustrate the stories. A ‘five-step guide’ completes each title: a practical vademecum on what to do, what not to do, and who to turn to for help.
Listen to the podcast
‘Two Points, End of Story’ tells with very short episodes very big problems faced during childhood and adolescence. The protagonists of these stories are 15, 16, 17 years old, but sometimes even younger than 10. Like the young people Dr Stefano Vicari meets every day in the wards of the neuropsychiatric emergency room where he works. This podcast is addressed to parents and adolescents, but also to psychologists, educators, teachers: to anyone who is interested or interested in learning more about the forms of some of the most recurrent psychological disorders in the younger generations.
Between the lines with teenagers
Stefano Vicari
I cross their eyes every time I go down to the ward. They are 15, 16, but sometimes even younger than 13; some have arrived during the night, admitted as emergencies, others have been there for a few days, waiting to stabilise and be discharged, started on a care path outside the hospital. Some are alas familiar faces, ‘veterans’ who have already passed through the emergency room doors more than once, trapped by relapses.
Then, fortunately, I also come across the guys who are coping: they come for weekly therapy and help groups, they have shy smiles that betray, without too much noise, the rebirth of hope.
Those who do my job learn to read these nuances: the distance between doctor and patient is naturally greater than that of family members, who are often overwhelmed by emotion and at these times too involved to understand and listen.
Even for us clinicians, however, it is not possible to resign ourselves to the idea that profound mental suffering such as that which gathers in the wards of Child and Adolescent Neuropsychiatry can affect such young children, often surrounded by loving families and with apparently normal life histories. It is not surprising, in this sense, that outside professional practices the subject of psychiatric pathologies is considered almost a taboo, about which many do not seem appropriate or useful to talk to their children or pupils. But the epidemiological data on the incidence and severity of mental disorders in the age of development record an alarming growth, accompanied by a continuous evolution in the manifestation of disorders and an increasingly early onset, to stem which it is essential that words are made available to the youngest to identify and communicate their malaise. It is the children themselves who ask us, bringing us a request for help sometimes launched in the most extreme and dramatic way, with a disruptive act that takes the place of those very missing and denied words. We cannot magically erase psychic distress from the experience of minors, but we have a duty to do all we can to prevent it and catch its first signs, so as to offer effective treatment paths in good time. We must therefore learn to read between the lines that children metaphorically write with their behaviour, silences or moments of conflict typical of this phase of their lives. It is around this concept that we have developed the editorial series to which we have given the title Leggere tra le righe (Reading between the lines) and which will be dedicated to the mental health of children and adolescents: among the topics covered are self-harm, school anxiety, gender dysphoria, eating disorders, depression.
Different languages are used in each volume: the Holden School dedicates three short stories to each theme, which are enriched by illustrations curated by the Academy of Fine Arts in Palermo. This narrative channel is flanked by the clinician’s reasoned commentary, with the aim of providing answers and tools for interpretation to anyone interested, for personal reasons (parents, family members, adolescents), as well as for professional reasons (psychologists, educators, teachers), in getting to know at first hand the forms of some of the most recurrent and frequent psychic disorders in the younger generations. The ambition of this series is to contribute to building a society that is more attentive and receptive to children’s difficulties and more capable of providing adequate and effective responses.
This volume talks about gender dysphoria: the discomfort perceived by a person who does not recognise himself or herself in his or her own phenotypic sex or in the gender assigned at birth. Starting from true stories, transformed just enough to make them unrecognisable, it talks about boys and girls, girls and boys who feel gender incongruity and wish to belong to the opposite gender. This is a condition that can cause significant discomfort and have consequences in the social, family and school spheres. In the text an attempt is made to restore the meaning of these behaviours, attention is drawn to what could be signs of suffering or vulnerability, and above all advice is given on how to dialogue, accompany and support pre-adolescents and adolescents in the conscious and serene development of their own identity.
Papà, mi sa che sono una femmina Dad, I guess I’m a girl
Stefano Vicari and Maria Pontillo
Who
is Sofia
‘I am Sandro, or rather not, Sofia, Sandro before and Sofia now’. With these words Sandro, 16 years old, spoke to me during a visit. It was his way of telling how he felt, or rather how he felt. In doubt. But in reality doubt never existed.
Sandro has always felt Sofia. Ever since he was a child, when at the age of eight he had a sulky face because his mother used to put him in plaid trousers and shirts. He also felt this way when unwrapping Christmas presents together with his cousins. He would get tracks, police cars, spiderman. And instead he would have wished for the Barbies or the trousseaux his cousins received. But he couldn’t say that.
He was eight years old but he understood that it would not be easy to be what he felt he was.
For the people I was around - for the Barbie trio, for the teachers, for my mum and dad - there was no doubt: Sandro is a boy, a very masculine boy, from head to toe.
His father had enrolled him in football, he dreamed of him becoming a footballer. So he went every day to train, either at the football school or at the field below the house. Sandro accepted, he did not want to disappoint his father, but inside he felt he was dying. He hated football, the talk about football, the matches. He used to peep at fashion shows. Rome, Milan, Paris. He dreamt of those. A woman’s body and the catwalks.
The years passed, Sandro became a teenager, a teenager with one mission. To hide his feelings, too painful for his father. They live together with their mother and sister: a ‘normal’ family with well-defined roles. It is the sister who does her make-up, changes all the time, goes to the beautician or orders beautiful clothes from Zara. He watches, suffers and continues to play football. Just as he continues to go to school, and nods when his classmates make comments about the physical appearance of his classmates.
At 14, he also decides to pretend to be in love, he courts a girl, they get together. Everything goes on, everything is still under his control. Everything is hidden. Hidden from others. He feels Sofia. He starts shaving in secret. And then even if they found out it would be for football. Actually shaving his whole body soothes him. In this way he looks less and less like a male. On an ordinary day, while he is in his room studying, his sister, two years younger than him, enters the room. She looks him fixed in the eyes and asks him what’s wrong, what is that sadness fixed in his eyes. What are those fake smiles at his father during the football game or pizza with his male companions. Sandro does not
answer. He begins to cry. The sister seems to remain silent. She has actually noticed everything but wants to leave it up to him to talk about it. She turns away. Sandro runs to the bathroom, and the very razor blade he usually shaves with becomes the tool to soothe his pain. He starts cutting his arms, wrists, thighs, everywhere. It is his way of appeasing his rage, rage at that body he hates, at the fear of judgement from his sister, his father, his classmates. Her thoughts run wild, she feels she has no way out, there is nothing left but to confess, to confess that she feels like Sofia.
To confess that when she pretends to study she is actually at the computer, on a platform where she can finally have the identity she wants. Being Sofia, talking about make-up, about art and not football, about beauty, about tight clothes and skin care. Yes, because he doesn’t want to be in that body. And the Internet is the place where he can do it. Now he just has to confess, but he can’t, he can’t do it.
So I started to pierce him, that body of a man. I cut him on his wrists and legs, with the same razor blade I used to shave myself. When I did it all that pain seemed bearable. Sandro was bleeding, but Sofia seemed more serene.
One day the cuts are deeper than usual. The father fetches him from football. He finds Sandro lying on the floor in the bathroom. The rush to hospital, the need to surgically treat the cuts. The ward appears to him as a descent into hell. But he feels the time has come. On one afternoon, during visiting hours, Sandro looks at his father and says: ‘Dad, I think I’m a girl’. The father is dismayed, angry, frightened. A mixture of emotions. The mother cannot speak, the sister
smiles: Sandro has managed to say it. They all need help: Sofia, the sister, the father and the mother.
What is gender dysphoria
In recent years, there has been increasing talk of gender dysphoria. Gender dysphoria occurs when there is an incongruence between a person’s gender identity and the gender assigned at birth, and this incongruence generates suffering, discomfort and stress. This is a very sensitive issue, especially when it concerns children and adolescents, since this phase of life is in itself a period full of continuous changes that affect the body, the mind and thus the perception of self and of the social context.
During childhood and adolescence, children and adolescents go through a process of physical, emotional and psychological development that helps them build their own identity. This means discovering who they are, what their interests, values and place in the social context are. Gender identity is a fundamental part of this journey and is gradually defined through experiences of growth and experimentation.
When a child or adolescent feels a difference between his or her perceived gender and the sex assigned at birth, the growth path can become more complicated. This feeling of ‘dissonance’ can generate negative emotions, such as anxiety, sadness and anger associated with confusion, which sometimes turn into deeper suffering. This is developmental gender dysphoria, which, if not recognised and addressed, can negatively affect children’s lives, making it more difficult to concentrate at school, make friends or feel good about themselves.
Moreover, adolescence is a time when one seeks the approval of others and feels a strong need to belong to the peer group. For those experiencing gender dysphoria, this can mean facing prejudice, misunderstandings and the pressure to conform to social rules that do not represent what one feels inside. This makes the role of adults, such as parents, teachers or health professionals, who can offer listening, understanding and support all the more important.
A welcoming environment, where those experiencing gender dysphoria feel free to be themselves without fear of being judged, is crucial in helping them to grow in a peaceful and positive way. Adults can do much to create this security: by learning more about gender dysphoria, showing empathy and ensuring access to appropriate resources, such as specialised counselling or support groups. In conclusion, helping children and adolescents experiencing gender dysphoria means offering them the chance to discover and embrace their identity in an authentic way. It is a task that concerns all of us as a community: welcoming and respecting specific sensitivities and orientations not only helps children feel more secure and understood, but also contributes to building a more inclusive and enriching society for all.
Gender role, sexual orientation and gender dysphoria
In clinical and scientific circles, the term sex is used to indicate whether a person can be described as ‘male’ or ‘female’ on the basis of the biological sexual characteristics assigned at birth. These characters are divided into two
distinct groups, referred to as primary (e.g. external genitalia) and secondary (e.g. hair growth and distribution, breast development, etc.). With regard to gender, this term refers to what a culture considers appropriate and characteristic as ‘male’ or ‘female’, defining canons and expectations to which people feel they must adhere, more or less rigidly. This process of adherence or distancing from the ‘typical’ characteristics of the male or female gender leads to the constitution of one’s gender identity, understood as the internal psychological perception of a sense of oneself as belonging to one or the other gender. In other words, everyone has a unique gender identity, something that can only be defined by the person themselves. Gender identity is what a person feels inside him or herself: he or she may feel male, female, a bit of both, or neither. Some scholars describe gender identity well as a multidimensional construction that encompasses: the ability to assign an individual to a gender category, feeling in tune with the group of one’s gender, and the attitude towards the gender of the group to which one belongs.
Gender identity begins to develop in the first years of life and, in most cases, is consolidated around the age of 3-4. To understand it better, it is important to distinguish between some ‘close’ but different concepts: gender role and sexual orientation.
• Gender role concerns the ways in which a person expresses their gender to others, whether or not they follow social expectations and norms. For example, if a boy does not like to play football or a girl prefers not to wear skirts, it only means that they do not conform to traditional gender roles, and this has nothing to do with the perception of their gender identity.
• Sexual orientation, on the other hand, is the emotional, affective or physical attraction a person feels towards others.
This attraction, which usually becomes manifest during puberty, can be to the opposite sex (heterosexuality), to the same sex (homosexuality), or to both sexes (bisexuality).
Gender identity, gender role and sexual orientation are connected, but remain distinct concepts. They can intertwine in complex ways, but each has its own autonomy. In some cases, a person’s gender identity may be different and distant from the sex they were assigned at birth. When this happens, we speak of gender variance or gender non-conformity. For example, some boys and girls may prefer clothes, games or activities that do not correspond to the gender stereotypes associated with their birth sex. This behaviour, which can be referred to as gender incongruence or gender variance, does not necessarily indicate discomfort: many of these children are serene and accept the sex they were identified with at birth.
The situation is different for those who experience gender dysphoria. It is not just a matter of a different preference, but of a profound difficulty in feeling comfortable with one’s body or with the gender role that society associates with one’s sex.
I, instead of Sandro, used to feel like Sofia. In my head, in my heart, I knew my name was Sofia, I knew I had Sofia’s face and Sofia’s body. I was living Sandro’s life, but I was Sofia.
In 2013, the term ‘gender dysphoria’ replaced the previous definition of ‘gender identity disorder’. This change was important because it shifted the focus from considering this condition as an ‘illness’ to focusing on the psychological suffering that the person experiences. The word dysphoria, in fact, comes from the Greek and means ‘hard to bear’, highlighting the suffering that can result from this incongruence.
If we quote the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 TR), ‘gender dysphoria is characterised by a strong and persistent identification with the opposite sex; people consider themselves victims of some sort of “biological accident” that has imprisoned them in a body that is incompatible with the gender identity they subjectively experience.’
Gender dysphoria in childhood: how widespread is it?
According to the data available in Italy, the life-time prevalence of gender dysphoria (DG) is estimated at approximately 1 case per 12,000 for males wishing to become female (MtF, ‘Male to Female’) and 1 per 30,000 for females wishing to become male (FtM, ‘Female to Male’).
There are no formal studies on the epidemiology of DG during childhood, but some research suggests an estimated prevalence of 2-3%. However, these numbers may be underestimated due to the difficulty of detecting all cases. Among adolescents, data from clinical groups indicate a prevalence of between 1 in 7,400 and 1 in 100,000 for males and between 1 in 30,400 and 1 in 400,000 for females. It is important to emphasise that these figures only reflect
people who have been referred to specialised centres, so they hardly represent the general reality.
Characteristics of gender dysphoria in childhood and adolescence
Developmental gender dysphoria manifests itself with some peculiar characteristics that can be summarised as follows:
- children claim to be of the opposite sex;
- they prefer to wear clothes associated with the opposite sex;
- they choose games in which they can play a role of the opposite sex;
- they show a strong preference for games and activities associated with the opposite sex;
- they express a desire to be of the opposite sex;
- they develop negative emotions towards their genitals;
- they reject games and activities associated with their own gender.
These signs may already appear at an early age, even around 2-3 years, when boys and girls begin to explore the concept of gender. However, these manifestations are not always continuous: for instance, dysphoria may emerge between the ages of 3 and 5, disappear for a period and reappear during adolescence. This discontinuity makes it difficult to make a definite diagnosis during childhood, as the course may vary from one individual to the next.
People assigned female at birth but with male gender identity (FtM, Female-to-Male) tend to constitute a more homogeneous group. From childhood, they often express a strong male identity, prefer games typically
associated with males, and experience great discomfort with body changes during puberty, such as menarche, the arrival of the first menstrual cycle. In addition, they may show attraction to persons of the same sex (e.g., women).
Persons assigned male at birth but with a female identity (MtF, Male-to-Female), on the other hand, represent a more heterogeneous group. In general, two main subgroups can be distinguished:
1. Primary MtF: manifest gender dysphoria from childhood and are usually attracted to people of the genotypically opposite sex (males who identify as females attracted to males).
2. Secondary MtF: they develop dysphoria only after puberty. They sometimes report fetishism related to cross-dressing, and their sexual orientation is more variable.
However, in clinical practice, many individuals do not fit neatly into these two models. For instance, those with early gender dysphoria may have sexual orientations that are not exclusively homosexual. In general, MTFs with precocious dysphoria often prefer traditionally feminine activities, play with female playmates and manifest strong discomfort with their bodies, which may be accompanied by difficulties in social and emotional relationships.
One of the most complex aspects of childhood DG concerns its evolution over time. Prospective studies show that in the majority of cases dysphoria disappears during the transition from childhood to adolescence: only 12%27% of children diagnosed with DG continue to manifest it
beyond puberty. However, when dysphoria persists beyond this stage, it is very rare that it is overcome.
For this reason, the period between the ages of 10 and 13 is considered crucial for understanding the evolution of dysphoria and assessing the support needed. During this phase, discussions with specialised figures, such as psychologists with expertise in gender identity, can be crucial.
Gender dysphoria in different age groups
Gender dysphoria in childhood manifests itself differently in different age groups and is influenced by physical, emotional and social factors. Understanding how this condition evolves throughout life is essential to offer adequate support to those affected.
Childhood
At prepubertal age, boys and girls with gender dysphoria may show a strong and persistent sense of identification with a gender different from the one assigned at birth. This results in behaviour, preferences and desires that defy traditional gender expectations.
• Girls assigned as female at birth: these girls may feel strongly male, refuse to be identified as female and declare that they will become men when they grow up. They prefer male clothes and hairstyles, identify with male playmates and show little interest in activities or toys associated with the female gender, such as dolls or female role-play. They often prefer physical games or contact sports. Some may refuse to urinate sitting down or express a desire to have a penis, expressing discomfort at the idea of developing breasts or menstruating.
• Children assigned as boys at birth: these children may identify deeply as girls and declare their desire to become women. They prefer feminine clothes, sometimes created with improvised objects such as towels or scarves to simulate long hair or skirts. They show interest in stereotypically feminine games and activities, such as playing house or drawing, and may impersonate female roles in make-believe games. Female characters, real or fantasy, arouse great fascination, and dolls such as Barbie often become their favourite toys. They often avoid more physical or typically masculine games, such as those with cars or trucks, and may express strong discomfort with their genitals, wishing they had female ones.
At this stage, parents may notice persistent behaviour that leads to a request for support from specialists. More and more boys and girls with gender dysphoria arrive at the clinics having already made a social transition, i.e. adopting clothing, names and roles in line with the gender they have experienced. Finally, it should be emphasised that according to the data released by the Italian Society of Paediatrics (SIP) in the article by Ferrara and colleagues (2021), between 60% and 88% of boys and girls with gender dysphoria during childhood see these feelings diminish or disappear by puberty, with a percentage evolving towards a homosexual orientation rather than a persistence in gender dysphoria.
Puberty
With the onset of puberty, between the ages of 9 and 13 for those assigned female at birth and between the ages of 11 and 14 for those assigned male at birth, concerns about physical changes become more pronounced.
Secondary sexual characteristics, such as breast growth or voice mutation, can generate intense discomfort, even though they are still in an early stage of development. Adolescents often experience the idea of impending physical changes, such as the arrival of menstruation or the growth of facial hair, with anxiety, feeling that they are at odds with their experienced gender.
Adolescence and adulthood
In adolescents and adults, gender dysphoria manifests itself as a strong discomfort with primary (genital) or secondary (such as breasts, beard, or hips) sexual characteristics that do not correspond to the experienced gender. Many wish to change them through medical or surgical interventions to align them with their perceived gender identity.
At this stage, the discrepancy between perceived gender and social role often becomes a source of distress. Individuals may adopt clothing, behaviours and attitudes of the gender they identify with, but experience with discomfort having to be perceived or treated according to the gender assigned at birth.
Gender dysphoria in childhood and associated neuropsychiatric disorders
Boys and girls with gender dysphoria are more at risk of developing psychiatric disorders than boys and girls of the same age with significantly higher prevalence rates for anxiety, depression and suicidal ideation. Recent studies indicate that up to 70% of adolescents with gender
dysphoria experience depressive symptoms and 50-60% suffer from anxiety disorders. Furthermore, rates of suicidal ideation can exceed 80%, with suicide attempts reported in 40-50% of cases in some clinical samples
Below are some of the main neuropsychiatric conditions associated with gender dysphoria.
Anxiety disorders and depression
Anxiety and depression are among the most common psychological disorders among boys with gender dysphoria. Distress due to the discrepancy between gender identity and biological sex can cause severe emotional stress. Difficulty adjusting to gender norms, combined with fear of bullying and discrimination, can increase the risk of developing anxiety and depression. A study by Turanovic et al. (2022) found that transgender youth (both male and female) have higher rates of depressive and anxiety symptoms than their cisgender peers, and this distress is amplified in non-inclusive family and social contexts.
Gender dysphoria can also lead to social isolation, as boys often do not feel accepted by their peers or family. This isolation, in the sense of the boy’s tendency to limit contact with his peers as much as possible, can further exacerbate emotional distress, leading to more severe symptoms of depression. Another study by Budge et al. (2013) found that transgender adolescents show an increased risk of developing psychological disorders such as depression, due to social exclusion and difficulties integrating into family, social and school environments.
Autism and gender dysphoria
Several studies have suggested that there is comorbidity between gender dysphoria and autism spectrum disorders (ASD). According to Van der Miesen and colleagues (2016), children and adolescents with autism are significantly more likely to exhibit gender dysphoria than the general population. Although not all people with ASD manifest gender dysphoria, the researchers speculate that difficulties with social communication and rigidity in thinking may make it more difficult for these individuals to understand gender norms or adapt to social expectations about them.
In addition, boys and girls with ASD may have greater difficulty expressing or understanding gender-related emotions. This may contribute to greater confusion or frustration, with an increased risk of gender dysphoria. However, research in this field is still developing and requires further investigation to better clarify the relationship between these two disorders.
Behavioural disorders
Behavioural disorders, such as aggression, irritability or rejection of authority, are another possible manifestation in girls and boys with gender dysphoria. These behaviours are often a response to psychological distress and frustration related to the difficulty of adapting to social expectations regarding gender.
A study by Simons et al. (2013) showed that boys and girls with gender dysphoria often have difficulty conforming to gender norms imposed by the family, school and society in general. This conflict can result in manifestations of oppositional or aggressive behaviour, which
can be misinterpreted as simple behavioural problems. However, the underlying cause may be deep emotional distress related to gender dysphoria.
School and social adaptation problems
Another relevant aspect in the life of a boy or girl with gender dysphoria concerns difficulties in school and social adaptation. Studies have documented how peer rejection and stigmatisation are common experiences for transgender youth, with significant impacts on their psychological well-being. According to research by Toomey et al. (2018), transgender youth who experience discrimination at school and in the social context are more likely to exhibit sleep disturbances, agitated states, traumatic experiences with an increased risk of suicidal thoughts and acts.
Diagnosis in developmental age
The diagnosis of gender dysphoria in childhood is a complex and delicate process that requires the involvement of a multidisciplinary team. This team must be composed of highly qualified professionals, including neuropsychiatrists and psychologists with solid experience in psychopathology, particularly in children and adolescents. It is essential that these specialists are able to recognise and treat not only gender dysphoria, but also other psychological problems that may emerge during childhood and adolescence, such as anxiety disorders or depression. Furthermore, they must possess the ability to distinguish between disorders that might co-exist with gender dysphoria, such as autism spectrum disorders, and the condition itself. Another essential aspect is that pro-
fessionals have expertise in psychotherapy or counselling, so that they can accompany the child or adolescent and their family throughout the diagnostic and therapeutic process.
The diagnostic process is not based on a single visit or on a superficial assessment, but requires an accurate diagnostic assessment in the initial phase, followed by longterm monitoring that can observe the evolution of symptoms over time and take into account changes in the boy or girl’s family, social and school context. Professionals should also gather information about the family history, any traumas experienced by the child or adolescent, and the family’s approach to gender dysphoria. This helps to create a more complete picture of the young patient, which is not limited to assessing symptoms, but also includes psychological and social aspects that may influence his or her experience.
To ensure that the diagnosis is accurate and based on recognised scientific criteria, professionals must refer to the DSM-5 TR (Diagnostic and Statistical Manual of Mental Disorders), which establishes specific criteria for gender dysphoria. According to the DSM-5 TR, symptoms must be present for a prolonged period, at least six months, and must relate to a persistent incongruence between the child’s or adolescent’s perceived gender and the gender assigned at birth. This perceived incongruence must be associated with significant emotional distress leading to a major limitation of functioning in various life contexts (e.g. school, social, family).
However, the diagnostic criteria alone are not sufficient for a complete diagnosis, and must be supplemented with a comprehensive clinical assessment that also takes into account the child or adolescent’s temperament and psychological development.
A particularly important moment in the diagnostic phase is the restitution, i.e. the moment when the clinician provides the adolescent and his or her family with information about the diagnosis made, but also about the treatment options available, the medical and psychological implications of the treatments, and how these may affect the adolescent’s or girl’s life course. The adolescent, in particular, has the right to be informed about possible treatments, not only to better understand his or her clinical picture, but also to actively participate in the decision-making process. This type of communication helps to reduce the uncertainty and sense of frustration that can arise at a time of great confusion and change.
Finally, it is important to emphasise that the diagnosis of gender dysphoria does not only concern the individual, but also involves the family, which plays a key role in the support process. Professionals must be prepared to face the emotional difficulties that the family may experience, such as fear, confusion or misunderstanding, and offer them appropriate support. The whole process must be guided by competence and the ability to build a good therapeutic alliance with the whole family, to ensure that the child or adolescent receives treatment that not only meets their psychological needs, but also respects their identity and worldview.
In summary, the diagnosis of developmental GD is a complex process that requires an accurate assessment and an integrated approach. It is only through a qualified team and constant attention to the child’s or adolescent’s evolution, combined with empathic support for the family, that treatment can be guaranteed to meet the real needs of girls and boys, respecting their identity and psychological well-being.
Sources
American Psychiatric Association (2023), Diagnostic and statistical manual of mental disorders: DSM-5-TR, Washington, DC, APA. Trad. it., G. Nicolò e E. Pompili (a cura di), DSM-5-TR. Manuale diagnostico e statistico dei disturbi mentali – TR, Milano, Raffaello Cortina, 2023.
Budge S.L., Adelson J.L. e Howard K.A. (2013), Anxiety and depression in transgender individuals: the roles of transition status, loss, social support, and coping, «Journal of Consulting and Clinical Psychology», vol. 81, n. 3, p. 545, doi: 10.1037/a0031774.
Ferrara P., Di Sipio Morgia C. e Sacco R. (2021), Disforia di Genere: quello che il pediatra deve sapere, «Pediatria», n. 10-11, p. 8.
Rigobello L. e Gamba F. (a cura di) (2022), Disforia di genere in età evolutiva: Sostenere la ricerca dell’identità di genere nell’infanzia e nell’adolescenza , Milano, FrancoAngeli.
Toomey R.B., Syvertsen A.K. e Shramko M. (2018), Transgender adolescent suicide behavior, «Pediatrics», vol. 142, n. 4, e20174218. doi: 10.1542/peds.2017-4218.
Turanovic J. J. (2022), Exposure to violence and victimization: Reflections on 25 years of research from the National Longitudinal Study of Adolescent to Adult Health, «Journal of Adolescent Health», vol. 71, n. 6, pp. S14-S23, doi: 10.1016/j.jadohealth.2022.05.018.
Van der Miesen A.I., Hurley H., Bal A.M. e de Vries A.L. (2018), Prevalence of the wish to be of the opposite gender in adolescents and adults with autism spectrum disorder, «Archives of Sexual Behavior», vol. 47, pp. 2307-2317, doi: 10.1007/s10508-018-1234-2.
Five-step practical guide
STEP 1. Gender dysphoria: what it is
Each of us has a unique gender identity that can only be defined by the person himself. Gender identity represents what a person feels inside: he or she may feel male, female, a bit of both or neither.
Gender dysphoria is characterised by a strong identification with the opposite sex and the feeling of being imprisoned in a body that is incompatible with one’s gender identity. The term ‘gender dysphoria’ was introduced in 2013 in place of ‘gender identity disorder’ precisely to emphasise the severe psychological suffering experienced by those who experience this situation.
In children and, especially, adolescents who suffer from gender dysphoria, anxiety, depression and suicidal ideation may be present, with depressive symptoms in 70% of cases and rates of suicidal ideation that can exceed 80%. Among the neurodevelopmental disorders in which GD
most frequently manifests itself is autism spectrum disorder. Rigidity in thinking and difficulties in social communication can affect adaptation to gender norms. Finally, school and social adjustment difficulties are common in children and adolescents with GD, with a high risk of school rejection and social withdrawal. This is usually aggravated by the risk of bullying and victimisation by peers to which these children are exposed.
STEP 2. Gender dysphoria in different age groups
Gender dysphoria is a complex condition that expresses itself in different ways depending on age and the physical, emotional and social changes that characterise each stage of life
Childhood
In boys and girls, gender dysphoria manifests itself mainly through the rejection of traditional gender roles and a strong preference for behaviour, games and clothing typical of the opposite sex. For example:
• In (male) children, identification with the female gender may emerge from an interest in games or activities usually associated with girls, such as dolls, role-playing with female figures, or the desire to wear female clothing. These children may also avoid physical or competitive activities considered ‘masculine’ and, in some cases, express a desire to be a girl;
• The opposite can happen in girls: they prefer typically male games and behaviour, rejecting the clothing and social roles associated with the female gender. Often these girls wear
sporty or masculine clothes and desire short hair, as well as preferring physical or sporty games that involve competition and physical contact.
In both cases, children may manifest a strong desire to belong to the other gender, expressing phrases such as: ‘When I grow up, I will be a girl’ or ‘I will be a boy’. In some cases, they may also reject or despise their sexual characteristics, such as penises in boys or breasts in girls, and desire physical characteristics of the other gender.
Puberty
With the onset of puberty, physical changes are often a major source of discomfort for boys with gender dysphoria. For example:
• In boys, the onset of secondary sexual characteristics such as the growth of facial hair or voice changes can trigger a feeling of detachment from their body, perceived as ‘foreign’ to the gender with which they identify;
• In girls, breast augmentation or the onset of menstruation can be experienced as signs of unwanted femininity, increasing discomfort and the desire to change one’s body.
During this phase, the sense of disconnection between the changing body and the perceived gender identity can cause anxiety, depression and loneliness.
Adolescence and adulthood
During adolescence, gender dysphoria can become more intense and greatly affect daily life. Teenagers expe -
riencing dysphoria may experience an increasing desire to transition, which may include:
- incessant requests to their parents for medical or surgical interventions to modify their body to align it with their perceived gender, such as resorting to hormone treatments or surgeries to remove or modify secondary sexual characteristics;
- social isolation: difficulty relating to peers and the risk of rejection or discrimination may lead to an increasing sense of loneliness, which may be followed by serious impairments in the teenager’s functioning, such as dropping out of school.
At this stage, the conflicting relationship with a body that is perceived to be unable to express the perceived gender and the risk of social discrimination may foster the onset of serious emotional problems, including depression and anxiety. Some boys may develop addictions to substances to cope with emotional pain or have suicidal thoughts.
STEP 3. Advice for parents
Many parents of adolescents or pre-adolescents with gender dysphoria find themselves disoriented and do not know where to turn. The professional response in these cases is often inadequate: many experts promote immediate transition without considering therapeutic alternatives. The science on transition outcomes in boys is still insufficient, and the tendency to promote transition in adolescence is
not supported by solid evidence. Here is some advice for parents.
1. Listening and open dialogue:
• It is essential to listen to your child without judging, maintaining an open and non-confrontational attitude.
• Ask open and delicate questions, for example: «What makes you think that you are a male?» , to allow the boy to explore his own thoughts and feelings. Creating a safe and listening space is crucial to understanding the underlying motivations and facilitating sound thinking.
2. Support your son or daughter, not his/her self-diagnosis:
• Show love and support for who he/she is, without immediately confirming his/her gender identity or consenting to the transition. If the boy/girl is young or the gender identity is recent, it may be helpful not to follow his/her belief immediately.
• In some cases, refusing to confirm self-diagnosis can lead children to lose interest in the transition path, without damaging the family relationship.
3. Avoid emotional blackmail:
• Teens can manipulate the situation to get consent for transition, exploiting your fear for their safety and happiness. It is essential to maintain a balanced attitude, without giving in to their attempt at emotional control.
• It is important to be a stable source of love and support, without reacting with anxiety and fear and avoid falling into conflict situations or child-parent power games.
4. Establish clear and consistent boundaries:
• You have the right to set reasonable limits for your child’s long-term safety and well-being. For example, it may be useful to establish a ban on attending male or female bathrooms in inappropriate settings, or having unlimited
access to the Internet, as well as haggling with them the request to use binder.
• These boundaries must be clear, consistent and not obsessive. It is important for you to monitor your behavior without being too strict, keeping a balanced position.
5. Focus on neutral aspects:
• To reduce tension on the gender issue, you can focus on neutral activities such as hobbies, sports, friendships and other experiences that do not relate to gender identity. This helps the teenager to explore their identity in a more balanced way, reducing pressure on the gender theme.
6. Maintaining family cohesion:
• It is crucial that you both align on the plan to be followed, avoiding conflicts or disagreements that could further confuse your child. Consistency in family decisions is crucial to their well-being.
• In case of disagreements, couple therapy can be useful, but you should choose a therapist who respects your decisions and visions on the path of your child.
STEP 4. What teachers can do
Teachers play an essential role in supporting adolescents with GD, going beyond the simple transmission of knowledge. They are often among the first adults of reference for boys and girls and can positively influence their school experience, making it inclusive and without suffering. In order to adequately support these students, it is crucial that teachers are well prepared, understanding the DG and distinguishing it from other issues such as sexual orientation. Training must address the specific needs of ado -
lescents in transition and how to create an inclusive school environment that respects gender identity. Teachers should use the name and pronouns chosen by the student, avoid intrusive questions and respect their gender identity. They should also educate other students about gender diversity to prevent misunderstandings and bullying. They should also offer emotional support, listen without judging and refer the student to psychological services when necessary, while maintaining privacy.
STEP 5. Who is the appropriate person to contact?
It’s crucial to seek out qualified professionals who can provide psychological, medical, and educational support when a minor experiences gender dysphoria. A multidisciplinary approach is therefore the basis. The main reference figures for the treatment of gender dysphoria in minors include:
1. Psychologists and psychotherapists: professionals who can help the adolescent to explore his or her gender identity in a safe and supportive way. The therapeutic approach may include psychological support to deal with emotional distress and daily difficulties related to dysphoria.
2. Child neuropsychiatrist: the neuropsychiatrist will be able to assess the presence and extent of associated emotional or psychological disorders, such as anxiety or depression. Finally, in some cases, the neuropsychiatrist may be involved in managing any hormonal treatments or other medical interventions.
3. Centres specialised in gender dysphoria and gender identity: there are medical centres and clinics specialising
in the support of children with gender dysphoria. These centres offer psychological, psychiatric support and, if necessary, medical interventions such as the initiation of hormone therapy (for example, with puberty blockers) after a thorough assessment.
Pediatric endocrinologists: in some cases, if they decide to explore hormonal treatment, the endocrinologist (the one who deals with the endocrine system) may be involved in assessing whether there are indications for the use of puberty blockers or other hormonal therapies.
5. Associations and support groups: organizations such as parents’ groups, transgender rights groups or psychological support groups provide resources, advice and a safe environment for families and children.
6. General practitioners: the paediatrician or family doctor may be the first point of contact, directing the family to appropriate specialists.