Controversies About Genesis of Adolescent Gender Dysphoria: A Hypothesis

Aims: Weak evidence exists to justify each extreme position on the controversy between supportive and exploratory psychotherapy for transgender identified youth. These positions differ in presumptions about the mechanisms of formation of a post-pubertal new gender identity. The question remains--which approach maximizes the patients' long-term mental and physical health benefits? Methods: The two forms of psychotherapy's assumptions, content, duration, settings, and purpose are explained. The varied education of psychotherapists and the diversity youth themselves are also presented. This review reminds that patients are in control of their gender identity and gender expressions and that no therapeutic technique for inducing desistance exists. Results: A new hypothesis is generated to include biological contributions (predisposing factors) and psychosocial factors (precipitating and maintaining factors): A new transgender identity is a private, creative, unconscious, intrapsychic, often maladaptive solution to existential pain deriving from intense disappointment with oneself or trauma outside or within the family. The utility of this hypothesis is explained. Conclusions: There is no long-term evidence to support either opposing belief systems. Psychiatric tradition argues that clinicians should remain interested in the mechanisms of symptom formation, including major identity shifts, to ameliorate distress. It is not likely that science will be able to settle the fundamental disagreements.