Gender Dysphoria and Suicidal Ideation: Clinical Observations from a Psychiatric Emergency Service

Abstract

Adolescent gender dysphoria is increasingly common. There has been documentation of the association of gender dysphoria with numerous other psychiatric conditions as well as attempted and completed suicide. The literature is unsettled on specific risk factors for self-harm within this population. Though there are published recommendations, there appears to be a need for additional clinical evidence for the determination of the safest and most effective treatment strategies for adolescent gender dysphoria. This clinical observation describes the unique case of an adolescent with gender dysphoria, severe body dysmorphia, and suicidal ideation who presented for emergency psychiatric evaluation. Gender-affirming hormone therapy had been administered to this patient at the age of 13, well earlier than published guidelines, though it was discontinued after a short course due to persistent gender uncertainty and distress. This case provides an opportunity to consider the complexity of adolescent gender dysphoria, including the unique individual features that affect the risk for self-harm and how treatment history may be related. With an increasing prevalence of gender dysphoria in this population, it is essential that every provider who cares for adolescents be well informed and prepared to recognize and respond to these risks.

Dilemas éticos relacionados con la supresión de la pubertad

“…Posteriormente, la misma paciente expresa su deseo de suspender el tratamiento por no lograr mejorar su angustia. En ambos casos llegó a la idea de suicidio (26). Otros autores mencionan que en muchos casos que han sido tratados médicamente, puede persistir la idea de suicidio (18).…”

“…Desde un punto de vista ético hay controversia entre quienes consideran éticamente ilícito el cambio de identidad sexual y quienes lo consideran moralmente adecuado. Dentro de quienes apoyan el cambio de género, existen también controversias en cuanto a la indicación y eficacia de la supresión de la pubertad en la infancia (26,32,36). Los posibles efectos adversos a nivel físico (32), el cuestionamiento en cuanto a su presunta reversibilidad, las posibles consecuencias psicológicas que podría acarrear esta terapia, sumados a la escasa evidencia científica en torno a la eficacia (36), seguridad y riesgos que presenta (26), hacen que el profesional de la salud que debe aconsejar al paciente y su familia, realmente se cuestione si no existe otra alternativa terapéutica que permita alcanzar una adecuada salud psicosocial sin los dilemas que trae consigo esta terapia.…”

Gender Dysphoria and Its Non-Surgical and Surgical Treatments

“…Studies also show that individuals who received gender-affirming treatment at younger ages had less suicidal ideation than those who received treatment later. 34 While it is most common for gender dysphoria to present in early teenage years, it is not uncommon for individuals to present in early adulthood. Almost 25-30% of patients with gender dysphoria present after the age of 18.…”

“…Treatment decreases suicidality among individuals with gender dysphoria and leads to improved quality of life. 10 Treatment options include psychosocial therapy, medical treatment for underlying depression and/or anxiety, hormonal treatment, and more than a dozen possible surgical procedures. More invasive treatments are associated with more severe adverse effects.…”

“…There is also a decreased rate of suicidality among patients who receive appropriate gender affirmation treatment. 10 Treatment starts with hormone therapy. Patients who have received hormone therapy for a year may qualify to undergo gender confirmation surgery.…”