Caring for gender diverse children and adolescents in Italy: A mixed-method investigation of clinicians’ knowledge and approach to clinical practice

Abstract

Introduction:

In today’s Italy, gender diversity has assumed a remarkable resonance and visibility in both scientific and popular literature, which has facilitated the development of studies regarding treatments and support for children and adolescents with gender-related issues.

Aim:

the aim of this study was to conduct a preliminary evaluation of how Italian clinicians (psychologists and pediatricians) perceive gender variant children and adolescents, evaluating their approach to clinical practice.

Methods:

An online questionnaire directed to clinicians regarding their experience with, and perceptions of, gender variant children and adolescents was used for the first part of the research. In the second part of this study, Consensual Qualitative Research (CQR) methodology was applied to semi-structured interviews aimed at investigating clinicians’ approach to clinical practice.

Results:

Professionals reported 374 cases, including 200 children (aged 2–11 years) and 174 adolescents (aged 12–19 years); a total of 10 interviews were conducted with professionals.

Conclusion:

This study highlights the increase of gender variant children and adolescents seen by professionals, but also the poor awareness of Italian professionals about gender diversity and their care, as well as an absence of a network model of intervention.

Keywords

Gender diverse youth transgender youth childhood adolescence transgender care

Introduction

Gender diverse children and adolescents are a heterogeneous group presenting, in most cases, an incongruence between the young person’s perceived gender identity and gender assigned at birth (Almirall & Chronis-Tuscano, 2016; Drescher et al., 2016; Spivey & Edwards-Leeper, 2019). The diagnosis of gender dysphoria (GD) was introduced by the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) for cases in which this incongruence causes significant discomfort, distress, and the necessity of clinical attention. During childhood, the manifestation of non-conforming gender—described as gender variance (GV)—does not necessarily indicate the presence of GD (Ristori & Steensma, 2016). In this article, we will always refer to GV or gender variant individuals, since a GD diagnosis was not an eligibility criterion for our study. Nowadays, studies on the prevalence of GV during development are scarce, and empirical research evidence regarding the clinical management of children and adolescents is lacking (e.g., Drescher & Pula, 2014). Specialized centers exist in many countries; the most active in the last decade have been the VU University Medical Center of Amsterdam, the Gender Clinic of San Francisco, the Gender Identity Development Service (GIDS) of London, and the Child Youth and Family Gender Identity Clinic of Toronto. In the last decade, there has been an exponential increase in referrals to these centers (de Graaf et al., 2018; Wiepjes et al., 2018). It is not clear what caused such increase, but it is fair to suppose that in recent years, thanks to lesbian, gay, bisexual and transgender (LGBT) awareness-raising campaigns, there has been a cultural change in mass media and society that has led to an increase in knowledge about the topic (de Vries & Cohen-Kettenis, 2012). Consequently, these issues have been greatly acknowledged and accepted.

In general, the onset age of the first behavioral manifestations occurs during preschool years (Gülgöz et al., 2019; Nieder et al., 2011; Ristori & Steensma, 2016). Early findings suggested that 70% of pre-pubertal children who experience GV do not continue to display the same issues about gender also during adolescence and adulthood (desisters; Steensma et al., 2013). By contrast, in the transition from adolescence to adulthood, such issues persist in 80% of cases (persisters; de Vries, Steensma, et al., 2011; Drummond et al., 2008). Nevertheless, some authors consider the count of desisters an overestimation due to methodological biases (Ehrensaft, 2012). As such, the percentage of gender diverse children whose gender diversity persists into adolescence and adulthood may be much higher.

There are some specialized centers for children and adolescents with GV in Italy, but the landscape is still confusing and varied, and the assistance and support is rather diversified and complex. There are non-profit organizations, associations, and social cooperatives that mainly focus on providing social support and counseling for youths and their families, as well as centers that belong to the National Health Service which, with an interdisciplinary team, try to offer a multidisciplinary intervention through a tandem work. In addition of being part of health facilities, these centers endorse the guidelines promoted by the National Observatory for the Gender Identity (ONIG – Osservatorio Nazionale sull’Identità di Genere, 2016, 2017), and the Standards of Care for transsexual, transgender, and gender nonconforming people developed by the World Professional Association for Transgender Health (WPATH; SOC 7 WPATH, 2011; see also Fisher et al., 2014; Hembree et al., 2017).

Although in recent years there has been an increase in referrals in Italy, if compared with other services in Western countries, the number of cases seen by Italian specialized centers seems to be limited (Fisher, Ristori, et al., 2017). This may mean that gender diversity in developmental age receives less attention than it deserves. However, despite the apparently low numbers of referrals and centers compared with other countries, the improved diagnostic accuracy and the intensified resonance and media visibility of transgender lives have led to an increase in Italian studies on this topic (Amodeo et al., 2018; Fisher et al., 2013; Giovanardi et al., 2018, 2019; Lingiardi et al., 2017; Ristori et al., 2020; Scandurra et al., 2018; Vitelli et al., 2017; Vitelli & Riccardi, 2010).

The number of cases seen by professionals and the referrals to specialized clinics in Italy, nevertheless, are still low, and there is a lack of updated knowledge about gender issues. The first effort to systematically collect national data regarding the prevalence of transgender individuals and gender affirming surgery in Italy was made by Caldarera and Pfäfflin (2011). However, the numbers were affected by a lack of standardization regarding record procedures and the age of individuals who underwent gender affirming surgery, which regards only adults.

In this context, we thought it would be important and useful to conduct a preliminary evaluation of the presence in Italy of children and adolescents with features ascribable to GV, investigating their age, gender, and other characteristics, and evaluating the response and the type of intervention of clinicians and specialized centers.

Aims

The aim of this study was twofold. First, we wanted to explore the clinical encounter between Italian psychologists and pediatricians and gender variant children and adolescents, investigating the clinicians’ perception and knowledge of GV, their approach to clinical practice, and their interaction with specialized centers. Our second aim was to conduct a deeper analysis of clinicians’ experience in this field.

Methods

This study has been articulated in two different stages. First, we made a preliminary evaluation of the number of cases of children and adolescents (2–19 years) with features that could indicate a gender variant behavior seen by Italian psychologists and pediatricians. We administered to clinicians an online questionnaire aimed to explore the type of care they offered to such young people, as well as to investigate clinicians’ experience and knowledge of GV. Second, we administered an ad hoc interview to some of the clinicians who answered the online questionnaire, to explore more in depth their intervention approach with gender variant youth. These interviews were examined through qualitative analysis.

The study protocol was approved by the institution’s ethics committee. Respondents provided their written informed consent to participate in the study.

Measures

An online ad hoc questionnaire¹ with 20 questions for psychologists and pediatricians was developed for this study. All Italian psychologists’ regional registers were asked to inform their members about the questionnaire. On the other hand, pediatricians were informed about the questionnaire by the Associazione Culturale Pediatri (ACP, Pediatricians’ Cultural Association) via an announcement to all its members. The questionnaire described the main features of GV in children and adolescents and investigated the following items:

Number of cases seen by the professional;

Perceived knowledge about GV;

Perceptions and behaviors relating to gender identity shown by the young person;

If a young person was offered direct care by the professional or referred to a specialized center or to other professionals.

The questionnaire was constructed describing in a non-specialistic and non-pathologizing language the characteristics of GV retrieved from scientific literature on this topic, as well as using and adapting the main criteria of psychiatric diagnoses related to GV. Moreover, as the features of gender variant children and adolescents vary, specific questions were developed to describe children’s (2–11 years) and adolescents’ (12–19 years) behaviors and preferences. To improve the validity and reliability of the questions, we submitted a pilot version of the questionnaire to 15 international and 20 Italian experts of the field, and we prepared the final version following their advices and suggestions.

The questionnaire was uploaded and housed online for 6 months on the website of the Department of Dynamic and Clinical Psychology of Sapienza University of Rome.

In total, 432 clinicians answered to our questionnaire. As our stated aim was to describe the interaction between professionals and gender diverse youth, we retained the questionnaires of the 374 individuals who reported in full detail a case of gender diverse youth and excluded the 58 others. At the end of the questionnaire, we asked who wanted to be interviewed for the second part of research.

With regard to the second step, a semi-structured interview with 11 questions was created. In line with other studies (e.g., Brown et al., 2013; Rood et al., 2017) using the Consensual Qualitative Research (CQR; Hill, 2012) methodology, we developed the interview integrating various elements from phenomenological and grounded theory analyses. The interview was aimed to explore some of the responses professionals gave in the online questionnaire concerning the young people they have seen. This interview included questions about age and gender of young people, clinicians’ interpretation of GV and their opinions regarding GV’s onset, their perceptions about their own degree of knowledge on the topic, and their approach to clinical practice, including questions about referrals to other professionals or specialized centers. Finally, we asked individuals a clinical account about one of their encounters with gender variant youths.

We contacted all the clinicians who gave the consent to be interviewed (10). All interviews were audiotaped and transcribed verbatim, removing any information that could have identified the interviewed.

Participants

First step (questionnaire): 374 professionals in total participated in the study (322 psychologists and 52 pediatricians).

Second step (interviews): Among the professionals who answered the questionnaire, we interviewed three pediatricians and seven psychologists (10 in total).

Procedure

The data for this study were derived from two different sources. In the first phase, the data were analyzed using descriptive statistical methods. In the second phase, 10 interviews were analyzed using the CQR methodology (Hill, 2012).

The CQR methodology is a rigorous and systematic qualitative research approach that aims to investigate the subjective experience of participants. It has been used for a wide range of topics, such as therapeutic processes (Knox & Burkard, 2009), cultural diversity (Kim & Drolet, 2003), and gender diversity (Brown et al., 2013; Rood et al., 2017). This methodology allows for an investigation of general themes (domains) that are present in the interviews and are processed by an interactive discussion with one of the authors. Each domain of the interview is composed of core ideas extracted by each member of the research group. Core ideas capture the essence of what was said in fewer words, given a representative example (Hill et al., 2005). Research team members compared core ideas and arrived at a consensus list of core ideas for each domain. The core ideas were subsequently cross-analyzed to achieve consensus on categories. To check the cross-analysis process and triangulate the data, one auditor reviewed the results for objectivity of data analysis and accuracy of categorization of themes. Moreover, each team member independently examined the central ideas of each domain trying to identify common elements and similarities, and then clustered together similar core ideas into categories. Following this process, the team discussed these preliminary categories until a consensus was reached about what category best represented specific themes across all data. After a list of categories was established for each domain, the research team once again compared the core ideas with the transcripts and placed them into established categories.

Finally, the analysis of the frequencies explained how the individual categories (and subcategories) were representative of the entire sample. To do this, the researchers counted cases that fell into one category and used conventional frequency denominations (Elliott & Timulak, 2005). Frequency labels of general, typical, and variant were used. Following the guidelines suggested by Hill et al. (2005), categories were labeled general when all, or all but one or two of the participants, endorsed the associated core ideas (8–10); typical when half or more than half of the participants (5–7) endorsed the associated core ideas; and variant when at least two participants and up to half of the participants endorsed the associated core ideas (2–4).

Results

Online questionnaire

In total, 374 responses to the online questionnaire were collected from psychologists (322) and pediatricians (52). The described cases involved 200 children and 174 adolescents (see Table 1).

Table 1.

Children and adolescents seen by professionals in the online questionnaire.

Gender assigned at birth	N (%)	Average age
Children assigned F at birth (2–11 years old)	57 (28)	6,7
Children assigned M at birth (2–11 years old)	143 (72)	6,4
Adolescents assigned F at birth (12–19 years old)	79 (47)	15,6
Adolescents assigned M at birth (12–19 years old)	95 (53)	14,8

M: males; F: females.

Professionals were invited to report their perceived knowledge about GV (see Table 2). The average knowledge of GV was rather poor (only a very small portion of psychologists, and no pediatricians, reported having a “very good” knowledge about GV), and 90% of all participants (psychologists and pediatricians) reported an interest to know more about GV.

Table 2.

Professionals’ perceived knowledge about GV.

	No knowledge (%)	Sufficient knowledge (%)	Good knowledge (%)	Very good knowledge (%)	Significance
Psychologists	15	54	26	5	p < .01*
Pediatricians	42	49	9	0	p < .01*

GV: gender variance.

χ² (3, N = 374) = 23.93, p = .000026.

Tables 3 and 4 illustrate the frequencies of observed features ascribable to GV in children and adolescents seen by professionals. In children, such features referred mostly to gender-typed behaviors and preferences about toys/play, whereas in adolescents, such features referred not only to such preferences and behaviors but also to feelings and perceptions concerning body and identity. With regard to comparisons between males and females, no significant differences were found at each age range.

Table 3.

The frequencies of observed features ascribable to GV in children and adolescents seen by professionals.

Features	ChildrenM (2–11 y.o.; %)	ChildrenF (2–11 y.o.; %)	Significance0.5	p value	AdolescentsM (12–19 y.o.; %)	AdolescentsF (12–19 y.o.; %)	Significancep < .05
Preference for games or activities typical of the other gender	76	77	n.s.	.823	64	77	n.s.
Preference for the roles of the other gender in make-believe play or fantasy play	71	75	n.s.	.501	51	58	n.s.
Preference for the typical way of clothing of the other gender	62	57	n.s.	.599	55	45	n.s.
Preference for spending time with peers of the other gender	53	57	n.s.	.545	47	43	n.s.
Affirmation/desire to belong to the other gender or to any other gender	27	37	n.s.	.148	44	44	n.s.
Desire to get rid of primary and/or secondary sex characteristics	9	7	n.s.	.666	40	31	n.s.
Being repulsed by sexual anatomy	6	5	n.s.	.914	28	25	n.s.

GV: gender variance; M: males; F: females; y.o.: years old.

Table 4.

The frequencies of observed features compared between children and adolescents.

Features	Children (N = 200; 2–11 y.o.; %)	Adolescents (N = 174; 12–19 y.o.; %)	Significance (p value)
Preference for games or activities typical of the other gender	76	70	n.s.
Preference for the roles of the other gender in make-believe play or fantasy play	72	54	<.01*
Preference for the typical way of clothing of the other gender	61	50	n.s.
Preference for spending time with peers of the other gender	54	45	n.s.
Affirmation/desire to belong to the other gender or to any other gender	30	44	<.01**
Desire to get rid of primary and/or secondary sex characteristics	8	36	<.01***
Being repulsed by sexual anatomy	6	27	<.01****

M: males; F: females; y.o.: years old.

χ² (1, N = 374) = 12.99, p = .000312.

χ² (1, N = 374) = 8.14, p = .004323.

***

χ² (1, N = 374) = 41.11, p = .00001.

****

χ² (1, N = 374) = 31.57, p = .00001.

The response of professionals to these cases is shown in Table 5. The majority of cases were offered direct care by responders. Of the cases referred to other professionals, the most common were referrals to psychotherapists, whereas referrals to specialized services were rare (less than 10% in all subgroups).

Table 5.

Patients directly cared by professionals or referred to other specialists.

Direct care or referral	Children assigned M (2–11 y.o.; %)	Children assigned F (2–11 y.o.; %)	Adolescents assigned M (12–19 y.o.; %)	Adolescents assigned F (12–19 y.o.; %)
Direct care by the professional	55	66	75	62
Referral to a psychiatrist	15	4	8	14
Referral to a psychotherapist	19	18	10	14
Referral to a specialized center for GV	3	0	8	8

M: males; F: females; y.o.: years old; GV: gender variance.

Interviews with professionals (private practice)

From the analysis of the transcripts made using the CQR methodology (Hill, 2012), nine domains (see extended results in the table in the Supplemental Material) emerged that can be divided in three different areas: (1) Identity and gender: the clinician’s point of view (see Table 6); (2) Family: structure and dynamics (see Table 7); and (3) Approach to practice: positive aspects and critical issues (see Table 8).

Identity and gender: the clinician’s point of view

Table 6.

Domains, subdomains, and categories with frequencies in the “identity and gender: the clinician’s point of view” area.

Domain	Category	Subcategory	Frequency
1. Psychological issues and associated risk factors	Psychological distress	Anxiety	General
		Depression	Variant
		Discomfort related to sexuality	Variant
	Stigma and social and educational discrimination	Rigidity and school closure	General
		Social stigma	Typical
		Bullying	Typical
	Trauma/abuse		Variant
	Self-administration of hormones (iatrogen risk)		Variant
	Self harm/suicide		Variant
2. Clinician’s interpretation of GV	Distress due to the incongruence between physical and mental aspects—primary problem of identity		Typical
	Secondary to other problems	Result of family dynamics	Typical
		Problems related to sexuality	Variant
		Non-acceptance of homosexuality	Variant
		Desire for social revenge	Variant
3. Reflections on identity and gender	Binary vs non-binary paths	Imposition of a binary choice (M or F)	Typical
	Binary vs non-binary paths	Non-binary patterns in society	Variant
	Persistance/desistance	Persisters recognizable from an early age	General
	Persistance/desistance	Desistance after puberty	Variant

M: males; F: females; GV: gender variance.

Table 7.

Domains, subdomains, and categories with frequencies in the “family: structure and dynamics” area.

Domain	Category	Subcategory	Frequency
1. Family situation at the onset of GV	Parental crisis	Parental conflict	Typical
	Parental crisis	Parental separation/divorce	Variant
	Structural problems in the family	Problems related to gender roles in the family	Typical
	Structural problems in the family	Involving parents	Variant
2. Reactions of parents to GV	Concern	Relative to sexual orientation	General
	Concern	Relative to social stigma	General
	Refuse	Refusal of the non-standard identity	Typical
	Refuse	Refusal of requests relating to clothing	Typical
	Sense of guilt or shame	Guilt	Typical
	Sense of guilt or shame	Shame	Variant
	Acceptance	Acceptance after an initial period of refuse	Typical
	Acceptance	Acceptance since the beginning	Typical

GV: gender variance.

Table 8.

Domains, subdomains, and categories with frequencies in the “approach to practice: positive aspects and critical issues” area.

Domain	Category	Subcategory	Frequency
1. Relationship between clinician and the family	Positive	Only with the mother	Typical
	Positive	With both parents	Variant
	Scarce collaboration		Variant
2. Network between clinicians and the specialized centers	No knowledge/no research		General
2. Network between clinicians and the specialized centers	Skepticism		Typical
3. Training on the topic: experiences and needs	Need for adequate training	Difficulty in referring GV youth to other professionals	General
		Need to be updated on the latest developments	General
		Risk of doing harm	Typical
	Experiences carried out	Attendance of specific courses	Variant
	Experiences carried out	Cycle of meetings with experts	Variant
4. Overall evaluation of the care	Positive outcomes		Typical
	Drop-out		Typical
	Uncertainty about medical choices		Variant

GV: gender variance.

Psychological issues and associated risk factors

The reader should keep in mind that all the themes emerged from the interviews are the result of our elaboration—via the CQR methodology—of the respondents’ point of view. Not all clinicians (i.e., pediatricians) have had a psychological training. Thus, their analysis should be by no means intended as a psychological assessment of gender variant individuals. In clinicians’ descriptions, however, we found some indicators of several psychological issues. Clinicians stated that gender variant youth have to deal with a significant amount of distress and that they present high levels of anxiety. The respondents described a phenomenon that we may label as “separation anxiety” in GV children (i.e., difficulty to separate from parents to go to school, or high levels of preoccupation during separation) and as social anxiety in GV adolescents (i.e., fear of being bullied, discomfort in social situations). In both cases, anxiety was directly associated by respondents to the children’s and adolescents’ gender incongruence, and to the fact that they feel different from their peers. It is important, however, to consider such association in the light of the respondents’ perceived knowledge of GV. Research has shown that the relationship between GV and psychological associated conditions is complex and not univocal (e.g., Ristori & Steensma, 2016). The respondents of our study seem to endorse a simplistic and deterministic view, in which children’s and adolescent’s distress is seen as secondary to their gender incongruence. However, as shown by questionnaire results, many respondents declared to have poor knowledge of the topic; thus, most of them could not assess properly the co-occurrence of these phenomena.

Another risk factor is the social stigma experienced at school, related to non-conforming preferences about clothing or regarding toys/play. Often, GV children and adolescents refuse to go to school because they are afraid of being bullied and discriminated by peers. Regarding other risk factors, the transcripts revealed the presence of various traumatic experiences (e.g., rejection, physical and psychological abuse by family members and/or peers); self-administration of hormones, acts of self-harm, and suicide risk were also found. These risk factors and psychological difficulties corroborate other research data about traumatic experiences in GV youth (Bandini et al., 2011; Bockting et al., 2013; Grossman & D’Augelli, 2006; Newcomb et al., 2020) as well as the results of some studies, which have highlighted higher level of internalizing disorders in gender variant young people (de Vries, Doreleijers, et al., 2011; Fisher et al., 2017; Weiselberg et al., 2019).

We first had to work on his difficulties about going to school. He had it for a year, showing discomfort and isolation—Psychologist

He was a boy with very intense psychopathology secondary to GD, characterized by a significant depressive risk—Psychologist

Clinicians’ interpretation of GV

First of all, professionals consider GV as subjective suffering due to the incongruence between the gender experienced and the gender assigned at birth, which is in line with the diagnostic manuals (APA, 2013; World Health Organization [WHO], 2018). There is no agreement whether incongruence is a primary problem of identity or if it is secondary to other problems. In this latter case, the main issues that, according to professionals, can lead to GV are family dynamics, problems related to sexuality, non-acceptance of one’s own homosexuality, and a desire for social revenge.

I think that she had homosexual tendencies and that she tried to hide them dressing as a boy—Pediatrician

Reflections on identity and gender

Two interesting considerations on gender identity emerged from this study. The first is about the male–female binarism. Not all gender variant youth identify as males or females (Rimes et al., 2019; Tellier 2019; Twist & de Graaf, 2019; Weinhardt et al., 2019). In fact, in the case descriptions provided by clinicians, many young people seemed to have a non-binary identity. In the respondents’ opinion, the imposition of a binary choice can be damaging. Most respondents supported the idea of a “watchful waiting” (de Vries & Cohen-Kettenis, 2012), without forcing a gender identification in any direction.

Binarism is something that leads to a very strong identity categorization, and people with GD just need to have the possibility of deciding for themselves who they are—Pediatrician

The second reflection concerns the theme of the persistence or the desistence of GV after puberty. As mentioned in the “Introduction” section, the difference between desisters and persisters is much debated. The results of the original Dutch studies affirming high rates of desisters after puberty (e.g., Drummond et al., 2008; Steensma et al., 2013) have been contrasted by some other studies (e.g., Ehrensaft et al., 2018; Temple Newhook et al., 2018), in which authors have sustained the possibility of recognizing a stable trans identity since childhood. Our respondents seemed to agree about the fact that persisters are recognizable from an early age and that, when a child affirms to experience GV, “desistance” is unusual.

In my opinion, usually if a child arrives asking for help to a professional, he will not change his mind about his gender identity. Maybe he will decide to not undergo surgery and to remain in a gender variant condition, but desister cases are very unusual among those who ask for help—Psychologist

2. Family: structure and dynamics

Family situation at the onset of GV

Some professionals refer that parents who deal with the onset of GD/incongruity in their child sometimes experience a crisis in their relationship as a couple.

These troubles can be temporary, like in the case of conflict related to managing the child’s situation. In a few cases, such conflicts can lead to separation or divorce.

Professionals observe that structural problems can be present in the family of non-conforming youth. The principal issues are related to gender roles and to the general structure and patterns of the family.

Reactions of parents to GV

Clinicians highlighted a wide array of parents’ reactions (see Supplementary Material), the most frequent of which was concern, particularly regarding sexual orientation and social stigma. The concern about social stigma among parents is often linked to the sense of being responsible for what will happen to their children, which in many cases results in guilt or shame related to the social response to their child’s non-conforming gender.

Many parents asked to me if the GD of their son/daughter was in some way related to their parental attachment or behavior, as if they felt responsible—Psychologist

Overall, professionals described two types of parental reactions to the GV of their offspring: refusal or acceptance. Refusal can be general, a total non-acceptance of non-standard identity. Some parents, instead, may refuse their children requests relating to clothes and/or toys/play. Acceptance, on the other hand, includes both an acceptance after an initial period of refusal and an acceptance since the beginning.

Usually, at first parents are reluctant and reject the idea of GD, but after this initial phase they start accepting it. I think that acceptance is related to finding a professional who can offer support to their child and to themselves—Psychologist

3. Approach to practice: positive aspects and critical issues

Relationship between the clinician and the family

As reported by clinicians, a positive relationship between them and the family was uncommon (see table in Supplemental Table). When a positive relationship is present, it is typically with the mothers. More rarely, a positive relationship with both parents was present. For these reasons, in some cases, professionals refer an absence of collaboration and the risk of drop-out of therapy.

Mothers tend to be more acceptant than fathers. This often leads to family issues that increase the stress level of the child/adolescent—Pediatrician

Network between clinicians and specialized centers

Surprisingly, almost all individuals of our study, including professionals working in big cities, had no knowledge of the existence of specialized centers. None of these professionals ever tried to search for a center. Some of the respondents reported being skeptical toward centers, highlighting the absence of a network model of work.

I don’t know if there is a specialized structure around here, but I think that these specialized centers can increase the level of social stigma around this theme—Psychologist

Training on the topic: experiences and needs

All the professionals interviewed highlighted the need for adequate training about GV. A few reported having attended specific courses or seminars with experts.

The lack of knowledge about GV leads to difficulties in offering gender variant youths the proper care as well as to a lack of networking with specialist centers.

As a pediatrician, I really need to know more about this topic. We are the front-line help for parents, and we need to be prepared and trained about this—Pediatrician

Overall evaluation of the care

The last theme regards the overall evaluation of the approach with GV children and adolescents. Half of the clinicians reported being satisfied with the therapy outcomes, while the other half reported a drop-out due to desistence of GV. The respondents reported also feeling uncertain about medical paths, as well as about how to help the child or the adolescent, and what to suggest.

I had many concerns about the correct way to help this child and his family not only in the present but especially regarding the future guidelines to follow—Psychologist

Discussion

Recently, increased attention has been given to gender variant children and adolescents across different countries, both in scientific literature (e.g., Turban & Ehrensaft, 2018) and media (Vrouenraets et al., 2016). In Italy, nevertheless, the situation is still not well known (e.g., National Geographic, 2017). As such, this preliminary investigation aims to outline a description of Italian clinicians’ approach to intervention.

The number of responses to the online questionnaire exceeded our expectations. These data could indicate either that in Italy, the number of children and adolescents seen by professionals is increasing, in line with what is happening in other countries (Aitken et al., 2015; Fuss et al., 2015), or that there is a higher attention toward GV by professionals. However, only an epidemiological study can confirm these hypotheses.

The online questionnaire was not intended to evaluate if the cases described met the DSM-5 criteria; however, the emerged characteristics seem to be in line with DSM-5 descriptions. Clinicians noted no significant differences between assigned males and females; moreover, the most represented features, as in the DSM, are the preferences for games, activities, and roles typical of the other gender, especially for children. On the other hand, clinicians reported that adolescents display a major degree of rejection toward their own sex characteristics and wish to get rid of them. While in describing GV children’s features, clinicians focused their attention mostly on activities and behaviors, in describing GV adolescents they stressed a marked conflict between teenager’s identity and their body.

Several aspects emerged from the interviews. Overall, in line with other studies (Bockting et al., 2013; Hughto et al., 2015), professionals stated that GV children’s and adolescents’ distress was mostly due to social stigma. They also reported that parents fear and worry about their children’s concerns regarding social isolation, being bullied, and receiving direct verbal aggression or indirect harassment through the spreading of rumors or social exclusion. Clinicians also noted that a family crisis is not uncommon when gender non-conformity is displayed by a child and that, sometimes, such crisis ends in separation or divorce. During the interview, clinicians reported that parents often seem to feel guilty about their “role” in the development of GV or ashamed about an open display of gender incongruence. This often leads to a refusal of their children’s identity and, to a certain degree, to transphobia. However, many respondents report eventual acceptance after initial refusal.

The interpretation of GV varies between professionals: some consider it a form of subjective distress due to a structural aspect of identity, persistent in most cases after puberty, others, a secondary result of family dynamics, or an issue connected to homosexuality. The consideration of GV as a form of subjective distress of an individual toward his or her gender is in line with the DSM-5 diagnosis and consistent with recent research (Agana et al., 2019).

Other interpretations, however, reflect certain classic psychodynamic and pathologizing conceptions about gender identity (Coates et al., 1991; Stoller, 1968), highlighting the lack of knowledge about GV among professionals. Indeed, in some interviews, sexuality surprisingly overlaps with gender identity. In addition, GV is described as a “problem with sexuality” and is naively connected to gender role issues in parental figures (mothers not “feminine” enough, fathers displaying a poor degree of “masculinity”).

In some other cases, a more complex view of identity is displayed. Many respondents acknowledged a non-binary view of gender identity, describing the potential stigma of binaristic impositions (school uniforms, use of toilet rooms, and need of gender affirming surgery to change name on documents) for gender diverse individuals.

Notably, the results from the online questionnaire revealed that clinicians’ knowledge about GV is poor, especially among pediatricians. Compared to the other professional group, in fact, pediatricians perceive themselves as having less knowledge about this topic, which is probably due to their different professional background. However, all subsamples of our study reported great interest in learning more about GV. Moreover, an uncertainty about the therapeutic goals often emerged in the interviews. This confirms the need for specific training about GV. The risk is that clinicians may base their interventions on inaccurate conceptions of GV and operate in a situation defined by a lack of network with specialized centers, where everyone does what they “think” is more appropriate. The uncertainty about the psychological support may be reflected by what emerged about the relationship between clinicians and families. Parents’ fears might also be ignited by an uncertainty of goals. This is worrying since establishing an alliance with the family is the first step for every therapeutic work with children and adolescents, especially with gender diverse youth (Di Ceglie, 2014). This underlines the need for adequate, informed, and updated psychological support for the complex needs of gender diverse youth.

The questionnaire also revealed that most children and adolescents are seen directly by individual professionals rather than referred to specialized services or other professionals. Knowing that most professionals have a poor knowledge of GV, this is surprising. Moreover, regarding referrals to other professionals, the most common is the referral to psychotherapists, and not to specialized services. This seems to confirm that specialized centers in Italy still represent a very little-known reality, especially among psychologists. We can hypothesize that access to specialized psychological care for GV children and adolescents is not frequent in Italy for a number of reasons: fear of stigmatization (particularly relevant in the case of GV), underestimation of psychological needs, and poor knowledge about the services. Our study highlighted a scarcity of information among professionals about the existence of specialized centers. This seems to bring to light a lack of networking between professionals and such structures. As a result, GV youths’ parents tend to turn to pediatricians, which in turn tends to refer the child to private practice psychotherapists. These children are referred by professionals mostly through word of mouth and through other colleagues or by schools that report a social discomfort that the child or adolescent is experiencing. Professionals’ practice is not unusually characterized by pathological assumptions about gender diversity and/or lack of accurate/up to date information, as well as by a confusion about goals/direction of therapeutic work with gender diverse children and their families. These findings are in contrast with the best practices for gender diverse youth (American Psychological Association, 2015; Coleman et al., 2012).

In our opinion, the lack of cooperation between specialized services and professionals needs further investigation and represents a challenge for the progression of medical practices and psychological care in Italy.

Limitations of the study

Some limitations warrant mention. First, as already stated, this is only a preliminary study aiming to roughly evaluate the number of cases managed by clinicians in Italy rather than to evaluate the prevalence of GV in our country. Thus, cases could have been double counted (if the same child or adolescent was seen by different professionals who participated in this study). Second, we could not verify the reliability of the answers to the questionnaire. Third, the respondents in this study are by no means representative of the whole professional population of Italian psychologists and pediatricians. Finally, the sample of psychologists and pediatricians is heterogeneous in terms of care offered by clinicians and their professional background—a fact that we have to take in consideration. Moreover, in Italy, pediatricians are usually the first health professionals to see GV children, and frequently, parents consider them a point of reference for their children’s health as a whole, including mental health. Thus, gender variant children may never arrive to an appropriate assessment.

The qualitative approach to the study made it possible to investigate the ways in which clinicians such as psychologists and pediatricians work, as well as to assess their knowledge of GV. However, the considerations explicated in this study come from a relatively small sample of professionals who have had a brief and recent experience with children and adolescents with perceptions of GV.

Conclusion and future directions

This study was a first attempt to evaluate clinicians’ approach to intervention with GD children and adolescents in Italy. As already mentioned, a lack of network between services and professionals emerged. This may result in a difficulty for transgender youth to access proper care, which in turn could lead to negative consequences under many aspects: it may result in an increased distress related to a lack of understanding (e.g., Fisher et al., 2017); it may delay the access to hormonal treatment, which scientific literature proved to be beneficial for both physical and mental health (e.g., Priest, 2019); and it may intensify the isolation GV youth experience, since specialized centers often offer the possibility to attend support groups meetings and work usually in network with schools (e.g., Agana et al., 2019).

Moreover, psychologists and pediatricians should receive proper and specific training on gender issues and on how to best treat GV children and adolescents. In addition, studies regarding the family role in gender issues, as well as regarding the influence of low acceptance among trans youths, should be conducted. In conclusion, a more detailed understanding of the Italian situation in comparison with other countries is needed.

Supplemental Material

Table_in_supp_material – Supplemental material for Caring for gender diverse children and adolescents in Italy: A mixed-method investigation of clinicians’ knowledge and approach to clinical practice

Supplemental material, Table_in_supp_material for Caring for gender diverse children and adolescents in Italy: A mixed-method investigation of clinicians’ knowledge and approach to clinical practice by Alexandro Fortunato, Guido Giovanardi, Marta Mirabella, Domenico Di Ceglie, Anna Maria Speranza, Giorgio Caviglia and Vittorio Lingiardi in Clinical Child Psychology and Psychiatry

Footnotes

Acknowledgements

We would like to thank Dr. Marianna Liotti for her contributions to this work.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Guido Giovanardi was funded by the “V:ALERE plus” project, University of Campania “Luigi Vanvitelli,” Caserta, Italy. The other authors did not receive financial support for the conduct of the research and/or preparation of the article.

ORCID iDs

Alexandro Fortunato

Vittorio Lingiardi

Supplemental material

Supplemental material for this article is available online.

Notes

Author biographies

Alexandro Fortunato, PhD, is a Psychologist, Psychotherapist and Research Fellow in Department of Dynamic and Clinical Psychology, “Sapienza”, University of Rome.

Guido Giovanardi, PhD, is a Psychologist and Research Fellow in Department of Dynamic and Clinical Psychology, “Sapienza”, University of Rome.

Marta Mirabella is a Psychologist and PhD student in Department of Dynamic and Clinical Psychology, “Sapienza”, University of Rome.

Domenico Di Ceglie is a Lifetime honorary consultant child & adolescent Psychiatrist in Gender Identity Development Service, Tavistock and Portman NHS Foundation Trust, London, United Kingdom.

Anna Maria Speranza, PhD, is a Psychologist, Psychotherapist and Full Professor of Developmental Psychopathology in Department of Dynamic and Clinical Psychology, “Sapienza”, University of Rome.

Giorgio Caviglia is a Full Professor of Dynamic Psychology in Department of Psychology in University of Campania, Luigi Vanvitelli, Caserta.

Vittorio Lingiardi is a Psychiatrist, Psychoanalyst and Full Professor of Dynamic Psychology in Department of Dynamic and Clinical Psychology, “Sapienza”, University of Rome.

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