The Complexities of Treatment Planning for Transgender Youth with Co-Occurring Severe Mental Illness: A Literature Review and Case Study

  • Aron JanssenEmail author
  • Samantha Busa
  • Jeremy Wernick
Special Section: Transgender Identities Emerging During Adolescence


Gender variance and dysphoria are present across all classes, ethnicities, and experiences, including among those with severe and chronic mental illness. In these, our most vulnerable populations, adequate assessment and treatment of gender dysphoria often is overlooked despite evidence that appropriate treatment of gender dysphoria leads to improvement in psychological functioning (Smith, van Goozen, Kuiper, & Cohen-Kettenis, 2005). The World Professional Association for Transgender Health recommend in their Standards of Care that somatic and surgical treatments for gender dysphoria should be made available to those with medical or mental illness with the caveat that “[the illness] must be reasonably well-controlled (2011).” In this article, we will utilize case-based material to elucidate the challenges of treating gender dysphoria in the context of complex mental illness such as bipolar disorder, schizophrenia, and sexual trauma, and the pitfalls of defining “well-controlled” for the sake of treatment.


Transgender youth Consent Gender dysphoria Mental health 



  1. Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., & Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: A respondent driven sampling study in Ontario, Canada. BMC Public Health, 15, 525. Scholar
  2. Bouris, A., Guilamo-Ramos, V., Pickard, A., Shiu, C., Loosier, P. S., Dittus, P., … Waldmiller, J. M. (2010). A systematic review of parental influences on the health and well-being of lesbian, gay, and bisexual youth: Time for a new public health research and practice agenda. Journal of Primary Prevention, 31(5–6), 273–309. Scholar
  3. Byne, W., Bradley, S. J., Coleman, E., Eyler, A. E., Green, R., Menvielle, E. J., & Tompkins, D. A. (2012). Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of Sexual Behavior, 41(4), 759–796. Scholar
  4. Cavanaugh, T., Hopwood, R., & Lambert, C. (2016). Informed consent in the medical care of transgender and gender-nonconforming patients. AMA Journal of Ethics, 18(11), 1147–1155.CrossRefGoogle Scholar
  5. Cohen-Kettenis, P. T., Schagen, S. E. E., Steensma, T. D., de Vries, A. L. C., & Delemarre-van de Waal, H. A. (2011). Puberty suppression in a gender-dysphoric adolescent: A 22-year follow-up. Archives of Sexual Behavior, 40, 843–847. Scholar
  6. Coker, T. R., Austin, S. B., & Schuster, M. A. (2010). The health and health care of lesbian, gay, and bisexual adolescents. Annual Review of Public Health, 31, 457–477. Scholar
  7. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2011). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. International Journal of Transgenderism, 13(4), 165–232. Scholar
  8. Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. Journal of Sexual Medicine, 12(11), 2206–2214. Scholar
  9. D’Augelli, A. R., Grossman, A. H., & Starks, M. T. (2006). Childhood gender atypicality, victimization, and PTSD among lesbian, gay, and bisexual youth. Journal of Interpersonal Violence, 21(11), 1462–1482.CrossRefGoogle Scholar
  10. Darby-Mullins, P., & Murdock, T. B. (2007). The influence of family environment factors on self-acceptance and emotional adjustment among gay, lesbian, and bisexual adolescents. Journal of GLBT Family Studies, 3(1), 75–91. Scholar
  11. Davey, A., Bouman, W. P., Arcelus, J., & Meyer, C. (2014). Social support and psychological well-being in gender dysphoria: A comparison of patients with matched controls. Journal of Sexual Medicine, 11(12), 2976–2985. Scholar
  12. de Vries, A. L., Doreleijers, T. A., Steensma, T. D., & Cohen-Kettenis, P. T. (2011). Psychiatric comorbidity in gender dysphoric adolescents. Journal of Child Psychology and Psychiatry, 52(11), 1195–1202. Scholar
  13. de Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696–704. Scholar
  14. de Vries, A. L., Noens, I. L., Cohen-Kettenis, P. T., van Berckelaer-Onnes, I. A., & Doreleijers, T. A. (2010). Autism spectrum disorders in gender dysphoric children and adolescents. Journal of Autism and Developmental Disorders, 40(8), 930–936. Scholar
  15. Drescher, J., & Byne, W. (2012). Gender dysphoric/gender variant (GD/GV) children and adolescents: summarizing what we know and what we have yet to learn. Journal of Homosexuality, 59(3), 501–510. Scholar
  16. Durwood, L., McLaughlin, K. A., & Olson, K. R. (2017). Mental health and self-worth in socially transitioned transgender youth. Journal of the American Academy of Child & Adolescent Psychiatrys, 56(2), 116–123 e112.
  17. Espelage, D., Aragon, S., & Birkett, M. (2008). Homophobic teasing, psychological outcomes, and sexual orientation among high school students: What influence do parents and schools have? School Psychology Review, 37(2), 202–216.Google Scholar
  18. Friedman, M. S., Koeske, G. F., Silvestre, A. J., Korr, W. S., & Sites, E. W. (2006). The impact of gender-role nonconforming behavior, bullying, and social support on suicidality among gay male youth. Journal of Adolescent Health, 38(5), 621–623. Scholar
  19. Fuss, J., Auer, M. K., & Briken, P. (2015). Gender dysphoria in children and adolescents: A review of recent research. Current Opinion in Psychiatry, 28(6), 430–434. Scholar
  20. Gijs, L., van der Putten-Bierman, E., & De Cuypere, G. (2014). Psychiatric comorbidity in adults with gender identity problems. In B. P. C. Kreukels, T. D. Steensma, & A. L. C. de Vries (Eds.), Gender dysphoria and disorders of sex development: Progress in care and knowledge (pp. 255–276)). New York, NY: Springer.CrossRefGoogle Scholar
  21. Giordano, S. (2008). Lives in a chiaroscuro. Should we suspend the puberty of children with gender identity disorder? Journal of Medical Ethics, 34(8), 580–584. Scholar
  22. Giordano, S. (2014). Medical treatment for children with gender dysphoria: Conceptual and ethical issues. In B. P. C. Kreukels, T. D. Steensma, & A. L. C. de Vries (Eds.), Gender dysphoria and disorders of sex development: Progress in care and knowledge (pp. 205–230). New York, NY: Springer. Scholar
  23. Holt, V., Skagerberg, E., & Dunsford, M. (2016). Young people with features of gender dysphoria: Demographics and associated difficulties. Clinical Child Psychology and Psychiatry, 21(1), 108–118. Scholar
  24. Jacobs, L. A., Rachlin, K., Erickson-Schroth, L., & Janssen, A. (2014). Gender dysphoria and co-occurring autism spectrum disorders: Review, case examples, and treatment considerations. LGBT Health, 1(4), 277–282. Scholar
  25. Janssen, A. (2018). Gender dysphoria and autism spectrum disorders. In A. Janssen & S. Leibowitz (Eds.), Affirmative mental health care for transgender and gender diverse youth (pp. 123–125). New York, NY: Springer.
  26. Janssen, A., Huang, H., & Duncan, C. (2016). Gender variance among youth with autism spectrum disorders: A retrospective chart review. Transgender Health, 1(1), 63–68. Scholar
  27. Kaltiala-Heino, R., Sumia, M., Tyolajarvi, M., & Lindberg, N. (2015). Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health, 9, 9. Scholar
  28. Levine, S. B. (2017). Ethical concerns about emerging treatment paradigms for gender dysphoria. Journal of Sex and Marital Therapy, 44(1), 29–44. Scholar
  29. May, T., Pang, K., & Williams, K. J. (2016). Gender variance in children and adolescents with autism spectrum disorder from the National Database for Autism Research. International Journal of Transgenderism, 18(1), 7–15. Scholar
  30. Mustanski, B. S., Garofalo, R., & Emerson, E. M. (2010). Mental health disorders, psychological distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths. American Journal of Public Health, 100(12), 2426–2432. Scholar
  31. Reisner, S. L., Vetters, R., Leclerc, M., Zaslow, S., Wolfrum, S., Shumer, D., & Mimiaga, M. J. (2015). Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study. Journal of Adolescent Health, 56(3), 274–279. Scholar
  32. Romero, K., & Reingold, R. (2013). Advancing adolescent capacity to consent to transgender-related health care in Colombia and the USA. Reproductive Health Matters, 21(41), 186–195. Scholar
  33. Russell, S. T., Ryan, C., Toomey, R. B., Diaz, R. M., & Sanchez, J. (2011). Lesbian, gay, bisexual, and transgender school victimization: Implication for young adult health and adjustment. Journal of School Health, 81, 223–230.CrossRefGoogle Scholar
  34. Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123(1), 346–352. Scholar
  35. Simon, L., Zsolt, U., Fogd, D., & Czobor, P. (2011). Dysfunctional core beliefs, perceived parenting behavior and psychopathology in gender identity disorder: A comparison of male-to-female, female-to-male transsexual and nontranssexual control subjects. Journal of Behavior Therapy and Experimental Psychiatry, 42(1), 38–45. Scholar
  36. Skagerberg, E., Parkinson, R., & Carmichael, P. (2013). Self-harming thoughts and behaviors in a group of children and adolescents with gender dysphoria. International Journal of Transgenderism, 14(2), 86–92. Scholar
  37. Smith, Y. L. S., van Goozen, S. H. M., Kuiper, A. J., & Cohen-Kettenis, P. T. (2005). Sex reassignment: Outcomes and predictors of treatment for adolescent and adult transsexuals. Psychological Medicine, 35(1), 89–99. Scholar
  38. Stanton, B., Cole, M., Galbraith, J., Xiaoming, L., Pendleton, S., Cottrel, L., … Kaljee, L. (2004). Randomize trial of a parent intervention: Parents can make a difference in long-term adolescent risk behaviors, perceptions, and knowledge. Archive of Pediatric and Adolescent Medicine, 158, 947–955.CrossRefGoogle Scholar
  39. Strang, J. F., Kenworthy, L., Dominska, A., Sokoloff, J., Kenealy, L. E., Berl, M., … Wallace, G. L. (2014). Increased gender variance in autism spectrum disorders and attention deficit hyperactivity disorder. Archives of Sexual Behavior, 43(8), 1525–1533. Scholar
  40. Strang, J. F., Meagher, H., Kenworthy, L., de Vries, A. L., Menvielle, E., Leibowitz, S., … Anthony, L. G. (2016). Initial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents. Journal of Clinical Child and Adolescent Psychology, 47(1), 105–115. Scholar
  41. VanderLaan, D. P., Postema, L., Wood, H., Singh, D., Fantus, S., Hyun, J., … Zucker, K. J. (2015). Do children with gender dysphoria have intense/obsessional interests? Journal of Sex Research, 52(2), 213–219. Scholar
  42. Wallien, M. S., Swaab, H., & Cohen-Kettenis, P. T. (2007). Psychiatric comorbidity among children with gender identity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(10), 1307–1314. Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Child Study Center, Department of Child and Adolescent PsychiatryNYU Langone Medical CenterNew YorkUSA

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