ESCAP statement on the care for children and adolescents with gender dysphoria: an urgent need for safeguarding clinical, scientific, and ethical standards

According to the DSM-5-TR [1] gender dysphoria refers to “…the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender”, requiring also the presence of “…clinically significant distress or impairment in social, school, or other important areas of functioning”; the DSM-5-TR lists gender dysphoria among mental disorders. In contrast, the latest ICD-11 [2] describes gender incongruence as a condition “…characterized by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex”. In order to avoid the stigma connected to mental disordes and the “double stigmatisation” of this historically highly stigmatised population, the ICD-11 decided to remove the gender identity-related diagnoses from the section on mental disorders and include it in the section “Conditions Related to Sexual Health” [3]. As such, gender dysphoria is not a mental health disorder according to WHO definitions, but psychiatrists and other mental health professionals may be asked to be involved to address co-occurring mental health problems [4]. Even though not all people with gender incongruence experience distress or dysfunction, the condition can be accompanied by significant suffering and have a major psychosocial impact on the individual and the family, sometimes requiring medical and psychosocial interventions. Consequently, one of the major reasons for the decision to leave gender dysphoria diagnosis as a mental disorder in DSM-5-TR, was to enable funding for the provision of any medical and mental health treatments needed [3]. A proportion of people experiencing gender dysphoria (from here the term that calls for psychosocial and medical care will refer also to the more neutral term “gender incongruence” if not stated otherwise) pursue social, legal, and medical changes affirming their subjectively experienced gender. These may include presenting with the desired gender in their personal environments (e.g., family, friends, workplace, school, …) by using different names and pronouns—referred to as social transition. It may also include formal changes of their name and/or gender on documents—referred to as legal transition. Finally, medical transition can be achieved by prescription of cross-sex hormones (estrogens or testosterone, depending on subjects’ biological characteristics) and/or gender-reassigning surgical procedures including genital (gynecological, urological) and other (mastectomy, plastic surgery, and ear, nose, and throat surgery procedures) [5, 6]. …