Dynamic Gender Presentations: Understanding Transition and "De-Transition" Among Transgender Youth

The following clinical scenarios are composite cases that illustrate clinically important phenomena based on several patients. Jamie is a 19-year-old who was assigned a female gender at birth and had a history of major depressive disorder in remission. She presented to her primary care physician, psychiatrist, and psychotherapist reporting dysphoria related to gender and requesting gender-affirming hormone therapy. Jamie had symptoms for at least 6 months consistent with DSM-5 criteria for gender dysphoria. After full clinical assessment by her therapist, psychiatrist, and primary care physician, her integrated care team initiated gender-affirming hormone therapy and provided close follow-up from her mental health providers. For 13 months, Jamie was treated with testosterone, changed her pronouns to he/him/his, and began wearing traditionally masculine clothing. Throughout this period, she remained engaged in regular care with her psychotherapist, who was experienced in providing gender-affirming care. Eventually, Jamie informed her care team that after the trial of testosterone and much reflection, she had come to understand her identity as a queer woman and wished to discontinue hormone therapy. Jamie reported being pleased about the hormone therapy trial, because this allowed her to clarify her gender identity. She did not regret her social affirmation or any physical changes that occurred during this process, such as fat redistribution and minor facial hair growth, in the context of otherwise being healthy. Lupita is a 23-year-old who was assigned a male gender at birth and had a history of major depressive disorder and panic disorder. At 18 years of age, after a comprehensive evaluation, she initiated gender-affirming hormone therapy with her primary care provider, changed her name to "Lupita," changed her pronouns to she/her/hers, and started wearing more traditionally feminine clothing. That following year, she started attending college and faced continual gender-based harassment from other students as a result of her gender-nonconforming physical appearance. Her college health services were not affirming of her gender and referred to her repeatedly by her birth name and with he-series pronouns. Lupita became demoralized and after 5 months decided to de-transition. She became progressively more depressed and attempted suicide in her sophomore year. Then she transferred colleges, found gender-affirming clinical providers, and resumed estradiol and spironolactone (an antiandrogen) therapy and her social affirmation through name, pronouns, and style of dress. Her mood improved dramatically and she was able to graduate from college. Lupita now presents seeking breast augmentation surgery.