The Holistic Management of Children with Gender Identity Development Issues<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t![\"\"](\"https:\/\/medicine.nus.edu.sg\/cbme\/wp-content\/uploads\/sites\/14\/2025\/04\/Ethinar-EDM-1042-x-527-px.png\")
\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\t\n\t\t\n\t\t\t\n\t\t\t\t- <\/span>Home<\/span><\/a><\/li><\/ul>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t
\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\tDate: Friday 16 May 2025<\/p>\n
Time: 3.00 to 5.00pm (SGT)<\/p>\n
Mode: Online via Zoom<\/p><\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\tThank you for joining us at the Ethinar<\/span><\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t![\"\"](\"https:\/\/medicine.nus.edu.sg\/cbme\/wp-content\/uploads\/sites\/14\/2025\/06\/Ethinar-Photo-May-2025.png\")
\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\tVideo from the Ethinar<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t<\/div>\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\tQ&A questions and Responses<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\t\tClick<\/a> to view the Q&A document<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ1. How young is the youngest that you have seen with features of gender dysphoria?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> Based on our child guidance clinic\u2019s (CGC) recent retrospective study of 107 patients over a 5-year period from 2017-2021, 71 (67%) first experienced gender-related issues before they turned 13 years old. The median age for the onset of these issues was 11 years. The average age at which participants sought help for their GD concerns was 15.6 years.
A\/Prof Oh Jean Yin:<\/strong> The youngest I have seen is 12 years old. Note that the Adolescent Medicine service sees kids in the adolescent age group mainly.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ2. Do you see young children (all speakers) who want to have sex change due to incongruence with their gender identity\/orientation? Or that caregivers insist on sex change as they sympathise with child\/adolescent?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> In Child Guidance Clinic, we have not seen young children (referring to children age 6 – 12 years old) who want sex change or that their caregivers insist on sex change. As elucidated in the talk, there are a lot of diagnostic challenges, ethical considerations and health implications when considering medical transitioning in young children with GD.
A\/Prof Oh Jean Yin:<\/strong> No, the service has not seen this trend.<\/p>\n<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ3: The Healthcare Services Act 2021 has added gender reassignment surgery into the list of surgical procedures requiring ethical approval, similar procedures include separation of conjoint twins and organ transplantation. What should the guiding principles be in reviewing such cases for ethical approval, in contrast with organ transplants\/separation of conjoint twins?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Chan Mei Yoke:<\/strong> The guiding principles are not that different and make use of frameworks like the 4 Principles of Beauchamp and Childress to identify which principles are involved and which are in conflict; the Jonson 4-box method to find out what information is important and what is missing; and the ABC toolkit to help with consistent decision-making. There are of course other frameworks out there that can be used as well. Every case is different and ultimately, we have to balance the pros and cons of all ethically reasonable options, taking into account individual and societal factors.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ4: How common is gender dysphoria in children\/adolescent locally vs elsewhere? compared with adults?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> Based on a local 2024 retrospective study of 107 patients diagnosed with GD in a tertiary child psychiatric clinic, the incidence rate of GD in Singapore residents aged 6 -19 yrs old has increased from 2.17 per 10,000 population in 2017 to 5.85 per 10,000 population in 2021. The prevalence (2017\u20132021) of GD in the study was 1:5434 (0.019%).
<\/p>\n\nWestern studies estimate the prevalence of GD to range from 0.002% to 0.7%, while Asian studies report a range from 0.0015% to 0.92%. These studies are predominantly on adult populations.<\/p>\n<\/div><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ5: Gender dysphoria is now almost synonymous with transgenderism. However, the literal interpretation of gender dysphoria relates to the anxiety and distress experienced by a person with gender identity incongruence. Can a person with gender identity incongruence NOT have dysphoria if they do not suffer anxiety, distress etc from it?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> Not all individuals with transgenderism or gender incongruence would experience anxiety, depressive symptoms or emotional distress. Without distress or impairment to academic, occupational or social functioning, it would categorically not be considered as an illness. Hence the term transgenderism has been removed from DSM-5 and replaced by gender dysphoria which connotes a disorder that should be approached from a bio-psychosocial and medical perspective.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ6: Does co-morbidity include ADHD? Noted that it is not listed here<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> The link between GD and ADHD is not strong and there is no known underlying mechanism for the association between the two. However, we have seen children presenting first as having ADHD and a few years later when they become adolescents express having GD experiences.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ7: From a psychiatric assessment perspective, can we assume that upon establishing mental capacity in the absence of other psychiatric illness be considered the same as condoning\/approving gender-related treatment such as hormonal treatment, gonadectomy (oophorectomy, orchidectomy) or even gender reassignment surgery?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> Having the mental capacity does not connote a straight path to medical transitioning including surgical gender reassignment. The medical indication must be clear and strong before such a recommendation is made. Local age of consent for surgical procedure must be met as well. In adolescents, it is recommended that the consent of two parents be obtained for hormonal treatment if medically indicated and if the patient is under 21 years of age.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ8: How do healthcare providers - doctors, psychologists, counsellors, MSWs - provide for transition of care for patients with GD? Will it be better for a doctor to refer a child presenting with possible GD direclty to a doctor \/ healthcare resources who can continue care of this child into adulthood?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> A multidisciplinary approach to assessment and management is an essential part of the biopsychosocial approach a doctor should take in all his\/her patients with GD. Typically in a mental health clinic, a young person with GD would be referred to a psychologist to explore his\/her gender identity, to assess coping skills\/styles and to manage any emotional distress arising from unhelpful or negative thought processes or beliefs. Parents and caregivers can be referred to a medical social worker for assessment of parental attitudes and their belief systems, how they could support their child during the medical review process and whether they need any support of their own. The medical review process could take years and if necessary, a handover should be conducted from the child mental health team to the adult team.
A\/Prof Oh Jean Yin:<\/strong> Agree that the approach is to ensure all biopsychosocial health aspects is considered. The medical review is to understand if there are any physical health conditions e.g. ambiguous genitalia\/ disorders of sex development (DSD), and to assess the pubertal and growth development and nutritional status. A multidisciplinary team who provides developmentally appropriate management should be involved in the care of a patient with GD and their family with the consideration of transitioning to adult care when the young person (and family) is ready.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ9: Would you agree that sexual and gender identity consolidation is still developing during adolescence, and that making decisions regarding gender reassignment or hormonal treatment during this stage may be premature? Given the relatively high percentage of individuals of individuals who eventually desist, what considerations might clinicians take into consideration when contemplating a delay in such interventions which are mostly irreversible?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> Agree. Experience tells us that young patients can and do change their mind with the passage of time, after being provided with more information and more time to think about their situations or gender experiences. Any medical interventions come with significant risks, and it is paramount that patients and their caregivers fully understand the implications of going through the medical treatment and procedures, and whether if they could live with the side effects or if they were to be dissatisfied with the treatment outcomes. Clinicians must be guided by scientific evidence of any medical treatments and procedures. Given the paucity of long-term outcome studies on hormonal treatment in young children, certain treatments are not recommended, for example the use of pubertal blockers for pre-pubertal children with GD.
A\/Prof Oh Jean Yin:<\/strong> This is the approach that we take with many medical conditions in needing to balance the risks with the benefits of treatment. Even with conditions like severe obesity in adolescents, where there is evidence that Bariatric Surgery is effective in managing the chronic condition \u2013 clinicians should be guided by recommendations based on more robust long-term studies which in recent years show significant treatment effectiveness of sleeve gastrectomy in improving metabolic outcomes in young people. And for this surgical intervention which is mostly irreversible, we need to help the adolescent and their family in their consideration of options which are right for them, in the best interest of their biopsychosocial health.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ10: To Singapore-based panelist: Is it true that hormonal treatments (as opposed to psychological and psychiatric intervention) for gender dysphoria in Singapore are not government subsidised and that patients have to self-fund?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Chan Mei Yoke:<\/strong> At this point in time, that is true.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ11: What are the actual\/potential implications of the recent executive and court orders regarding recognition of biological sexes in the US and UK have on medical care?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Oh Jean Yin:<\/strong> We can\u2019t comment on other countries\u2019 legal framework. For adolescents, we just need to be aware of what material they may be exposed to on social media and help them to understand context and encourage perspective taking.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t
\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t- <\/span>Home<\/span><\/a><\/li><\/ul>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t
\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\tDate: Friday 16 May 2025<\/p>\n
Time: 3.00 to 5.00pm (SGT)<\/p>\n
Mode: Online via Zoom<\/p><\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t
\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\tThank you for joining us at the Ethinar<\/span><\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t
\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\tVideo from the Ethinar<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t
\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t<\/div>\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\tQ&A questions and Responses<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t
\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\t\tClick<\/a> to view the Q&A document<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t
\n\t\t\t\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\n\t\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ1. How young is the youngest that you have seen with features of gender dysphoria?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> Based on our child guidance clinic\u2019s (CGC) recent retrospective study of 107 patients over a 5-year period from 2017-2021, 71 (67%) first experienced gender-related issues before they turned 13 years old. The median age for the onset of these issues was 11 years. The average age at which participants sought help for their GD concerns was 15.6 years.
A\/Prof Oh Jean Yin:<\/strong> The youngest I have seen is 12 years old. Note that the Adolescent Medicine service sees kids in the adolescent age group mainly.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ2. Do you see young children (all speakers) who want to have sex change due to incongruence with their gender identity\/orientation? Or that caregivers insist on sex change as they sympathise with child\/adolescent?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> In Child Guidance Clinic, we have not seen young children (referring to children age 6 – 12 years old) who want sex change or that their caregivers insist on sex change. As elucidated in the talk, there are a lot of diagnostic challenges, ethical considerations and health implications when considering medical transitioning in young children with GD.
A\/Prof Oh Jean Yin:<\/strong> No, the service has not seen this trend.<\/p>\n<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ3: The Healthcare Services Act 2021 has added gender reassignment surgery into the list of surgical procedures requiring ethical approval, similar procedures include separation of conjoint twins and organ transplantation. What should the guiding principles be in reviewing such cases for ethical approval, in contrast with organ transplants\/separation of conjoint twins?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Chan Mei Yoke:<\/strong> The guiding principles are not that different and make use of frameworks like the 4 Principles of Beauchamp and Childress to identify which principles are involved and which are in conflict; the Jonson 4-box method to find out what information is important and what is missing; and the ABC toolkit to help with consistent decision-making. There are of course other frameworks out there that can be used as well. Every case is different and ultimately, we have to balance the pros and cons of all ethically reasonable options, taking into account individual and societal factors.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ4: How common is gender dysphoria in children\/adolescent locally vs elsewhere? compared with adults?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> Based on a local 2024 retrospective study of 107 patients diagnosed with GD in a tertiary child psychiatric clinic, the incidence rate of GD in Singapore residents aged 6 -19 yrs old has increased from 2.17 per 10,000 population in 2017 to 5.85 per 10,000 population in 2021. The prevalence (2017\u20132021) of GD in the study was 1:5434 (0.019%).
<\/p>\n\nWestern studies estimate the prevalence of GD to range from 0.002% to 0.7%, while Asian studies report a range from 0.0015% to 0.92%. These studies are predominantly on adult populations.<\/p>\n<\/div><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ5: Gender dysphoria is now almost synonymous with transgenderism. However, the literal interpretation of gender dysphoria relates to the anxiety and distress experienced by a person with gender identity incongruence. Can a person with gender identity incongruence NOT have dysphoria if they do not suffer anxiety, distress etc from it?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> Not all individuals with transgenderism or gender incongruence would experience anxiety, depressive symptoms or emotional distress. Without distress or impairment to academic, occupational or social functioning, it would categorically not be considered as an illness. Hence the term transgenderism has been removed from DSM-5 and replaced by gender dysphoria which connotes a disorder that should be approached from a bio-psychosocial and medical perspective.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ6: Does co-morbidity include ADHD? Noted that it is not listed here<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> The link between GD and ADHD is not strong and there is no known underlying mechanism for the association between the two. However, we have seen children presenting first as having ADHD and a few years later when they become adolescents express having GD experiences.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ7: From a psychiatric assessment perspective, can we assume that upon establishing mental capacity in the absence of other psychiatric illness be considered the same as condoning\/approving gender-related treatment such as hormonal treatment, gonadectomy (oophorectomy, orchidectomy) or even gender reassignment surgery?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> Having the mental capacity does not connote a straight path to medical transitioning including surgical gender reassignment. The medical indication must be clear and strong before such a recommendation is made. Local age of consent for surgical procedure must be met as well. In adolescents, it is recommended that the consent of two parents be obtained for hormonal treatment if medically indicated and if the patient is under 21 years of age.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ8: How do healthcare providers - doctors, psychologists, counsellors, MSWs - provide for transition of care for patients with GD? Will it be better for a doctor to refer a child presenting with possible GD direclty to a doctor \/ healthcare resources who can continue care of this child into adulthood?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> A multidisciplinary approach to assessment and management is an essential part of the biopsychosocial approach a doctor should take in all his\/her patients with GD. Typically in a mental health clinic, a young person with GD would be referred to a psychologist to explore his\/her gender identity, to assess coping skills\/styles and to manage any emotional distress arising from unhelpful or negative thought processes or beliefs. Parents and caregivers can be referred to a medical social worker for assessment of parental attitudes and their belief systems, how they could support their child during the medical review process and whether they need any support of their own. The medical review process could take years and if necessary, a handover should be conducted from the child mental health team to the adult team.
A\/Prof Oh Jean Yin:<\/strong> Agree that the approach is to ensure all biopsychosocial health aspects is considered. The medical review is to understand if there are any physical health conditions e.g. ambiguous genitalia\/ disorders of sex development (DSD), and to assess the pubertal and growth development and nutritional status. A multidisciplinary team who provides developmentally appropriate management should be involved in the care of a patient with GD and their family with the consideration of transitioning to adult care when the young person (and family) is ready.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ9: Would you agree that sexual and gender identity consolidation is still developing during adolescence, and that making decisions regarding gender reassignment or hormonal treatment during this stage may be premature? Given the relatively high percentage of individuals of individuals who eventually desist, what considerations might clinicians take into consideration when contemplating a delay in such interventions which are mostly irreversible?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Ong Say How:<\/strong> Agree. Experience tells us that young patients can and do change their mind with the passage of time, after being provided with more information and more time to think about their situations or gender experiences. Any medical interventions come with significant risks, and it is paramount that patients and their caregivers fully understand the implications of going through the medical treatment and procedures, and whether if they could live with the side effects or if they were to be dissatisfied with the treatment outcomes. Clinicians must be guided by scientific evidence of any medical treatments and procedures. Given the paucity of long-term outcome studies on hormonal treatment in young children, certain treatments are not recommended, for example the use of pubertal blockers for pre-pubertal children with GD.
A\/Prof Oh Jean Yin:<\/strong> This is the approach that we take with many medical conditions in needing to balance the risks with the benefits of treatment. Even with conditions like severe obesity in adolescents, where there is evidence that Bariatric Surgery is effective in managing the chronic condition \u2013 clinicians should be guided by recommendations based on more robust long-term studies which in recent years show significant treatment effectiveness of sleeve gastrectomy in improving metabolic outcomes in young people. And for this surgical intervention which is mostly irreversible, we need to help the adolescent and their family in their consideration of options which are right for them, in the best interest of their biopsychosocial health.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ10: To Singapore-based panelist: Is it true that hormonal treatments (as opposed to psychological and psychiatric intervention) for gender dysphoria in Singapore are not government subsidised and that patients have to self-fund?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Chan Mei Yoke:<\/strong> At this point in time, that is true.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t<\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\tQ11: What are the actual\/potential implications of the recent executive and court orders regarding recognition of biological sexes in the US and UK have on medical care?<\/a>\n\t\t\t\t\t<\/div>\n\t\t\t\t\tA\/Prof Oh Jean Yin:<\/strong> We can\u2019t comment on other countries\u2019 legal framework. For adolescents, we just need to be aware of what material they may be exposed to on social media and help them to understand context and encourage perspective taking.<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t