Approach to children and adolescents with gender dysphoria

The definition of gender dysphoria (GD) includes the experience of a body that is incongruent with gender identity. The prevalence of GD is not as yet known, but the current proposed numbers are likely underestimated. Prevalence studies are complicated by several confounding factors and results may be misleading. (5)(7). On the basis of strong evidence from retrospective studies of relevant populations, clinicians should be especially vigilant in identifying GD in patients who are peripubertal because the onset of puberty heightens the risk of depression, anxiety, selfdestructive choices, and suicide. (8)(13). On the basis of strong evidence, "reparative psychotherapy" is both unsuccessful and psychologically deleterious. (15)(16)(17) (18) On the basis of expert consensus, the "gender affirmative model" is more accepted. (19). On the basis of strong evidence, adolescents treated with a protocol of pubertal suppression followed by hormone replacement therapy during adolescence and gender reassignment surgery in adulthood have improved psychological outcomes and quality of lives compared with age-matched adults from the general population. (10)(29). A large national transgender survey revealed that 41% of adult respondents had attempting suicide. On the basis of strong evidence, youth who are validated in their transgender identity by supportive family and social environments have much more favorable psychological outcomes. (11) The primary care clinician has a unique role and responsibility to identify patients with possible GD and provide anticipatory guidance, counseling, and family support. Primary health care clinicians can provide the impetus and means to greatly improve the lifelong psychological well-being of their patients with GD and potentially save lives. (9)(11)(13)(30).