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Mental Health

Female-to-Male Youth

Gail A. Knudson, MD, MPE, FRCPC

Reprinted from "Men" issue of Visions Journal, 2005, 2 (5), pp. 30-31

Adolescence is a time of excitement, growth and change. An important developmental task in adolescence is separation from parents and creation of attachments to peers and partners. It is also a time for risk-taking activities. Youth who are gender variant and whose sexual orientation is not heterosexual are at greater risk.

This paper will introduce the concept of gender identity disorder (GID) as applied to natal females and well also explore the potential mental health risks for this population, as well as offer treatment strategies and resources available in BC.

Definition of terms

To begin, it is important to include a definition of terms. Bockting and Coleman1 have defined the following terms: gender identity refers to one’s basic conviction of being a man, a woman or another gender, such as transgender; natal or biological sex refers to one’s sex as it appears at birth; sex role refers to characteristics culturally defined as masculine or feminine and commonly known as sex-role stereotypes; and sexual orientation is defined by sexual attraction to others.

The term transgendered is usually applied to individuals whose appearance and behaviours do not conform to the gender roles as ascribed by society for people of a particular sex and includes cross-dressers, transsexuals, drag queens/kings, and male and female impersonators. Transgendered is an umbrella term that encompasses people who are gender variant.

The term transsexual, while fitting under the transgender umbrella, is at the more extreme end of gender variance. A transsexual is a person whose gender identity is opposite to his or her biological sex.2 A natal female who identifies as male is termed a FtM (female to male). There is no explicit term to identify a transsexual who is on hormones and/or has had surgery to facilitate a sex change.

The DSM-IV,3 introduced in 1994, replaced the term transsexualism with gender identity disorder (GID). Individuals with GID have a strong and persistent cross-gender identification and persistent discomfort with their sex, or a sense of inappropriateness in the gender role of that sex, causing clinical distress in social, occupational or other areas of functioning in childhood, adolescence or adulthood.3

FtM: from childhood to adulthood

Few studies have looked at the developmental trajectories of children and youth with gender identity disorder. Even fewer have studied girls. These studies suggest that only a few of children who were followed across time are diagnosed with GID into adolescence and young adulthood.4 Most become attracted to those of the same sex.

Those presenting to gender clinics in their adolescent years, however, have a higher probability of the GID diagnosis remaining.4

Although many researchers believe that gender identity is formed between ages three and five, it appears that another crucial period for shaping gender identity exists in early adolescence. Zucker postulates that gender identity may be somewhat malleable in childhood and gradually consolidates as the person reaches adolescence.4

Whether the cause of GID is biological, psychological or both is still unknown. In any case, efforts should be focused on assessing for risk factors and offering intervention and support. The goal is to strike a balance between expression of their male identity and the safety of the individual.

Risk factors

FtM youth are at greater risk for mental health issues than are non gender-variant youth.5 They may become segregated of their own accord or, more likely, because of stigma. They may be teased, ridiculed, harassed or abused. This may lead to feelings of rejection, shame, loneliness, depression and suicidal ideation. The teen may then withdraw and isolate or act out and become self-destructive with high-risk behaviours.5 Depression is more frequent amongst the gender dysphoric adolescent girls than boys, while harassment/persecution is significantly more common in gender dysphoric adolescent boys than girls.5 in either case, there is an increased risk for substance abuse, self-harm and suicide.5

Intervention and support

There have been no controlled studies thus far on intervention with children or adolescents.4 Most clinicians follow the HBIGDA Standards of Care,6 an evolving set of guidelines representing an international consensus on best practices relating to gender transition. The main point to remember with children is that the vast majority outgrow their felling of gender dysphoria and most likely will be attracted to the same sex.4

In terms of intervention, a team approach is warranted. FtM youth must have support for their transgendered experience from family, school, peers and mental health professionals. Parental support is crucial to positive outcome. Adjustment in school is very important and teachers should model respect of diversity. Many urban schools now have Gay-Straight Alliances that, together with school administration, help prevent hostile environments. Peer support groups such as the Lesbian and Gay Youth Society of BC’s Youthquest and those offered through the BC FTM Network are important to decrease social isolation. Mental health professionals, as well as primary care physicians, have a vital role in monitoring risk factors and offering treatment. Reversible hormone therapy should only be considered after consultation with the members of the care team and parents.6

About the author
Gail is a psychiatric consultant at the BC Centre for Sexual Medicine and Clinical Instructor in the UBC Department of Sexual Medicine
  1. Bockting, W.O. & Coleman, E. (1992). A comprehensive approach to the treatment of gender dysphoria. Journal of Psychology and Human Sexuality, 5(4), 131-155

  2. Cole, C.M. O’Boyle, M., Emory, L.E. et al. (1997). Comorbidity of gender dysphoria and other major psychiatric diagnoses. Archives of Sexual Behavior, 26(1), 13-26.

  3. American Psychiatric Association. (1994). Diagnostic and statistical Manual of Mental Disorders: DSM-IV (4th ed.). Washington, DC:APA.

  4. Zucher, K.J. (in press). Gender identity disorder in children and adolescents. Annual Review of Clinical Psychology.

  5. Di Ceglie, D., Freedman, D., McPherson, S. et al. (2002). Children and adolescents referred to a specialist gender identity development service: Clinical features and demographic characteristics. International Journal of Transgenderism 6(1). Retrieved February 10, 2005, from

  6. Harry Benjamin International Gender Dysphoria Association. (2001). Standards of Care for Gnder Identity Disorders (6th version). Retrieved February 9, 2005, from

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