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(Copyright © William Byne et al. 2018; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)., (Copyright © William Byne et al. 2020; Published by Mary Ann Liebert, Inc.)

Regardless of their area of specialization, adult psychiatrists are likely to encounter gender-variant patients; however, medical school curricula and psychiatric residency training programs devote little attention to their care. This article aims to assist adult psychiatrists who are not gender specialists in the delivery of respectful, clinically competent, and culturally attuned care to gender-variant patients, including those who identify as transgender or transsexual or meet criteria for the diagnosis of Gender Dysphoria (GD) as defined by The Diagnostic and Statistical Manual of Mental Disorders (5th edition). The article will also be helpful for other mental health professionals. The following areas are addressed: evolution of diagnostic nosology, epidemiology, gender development, and mental health assessment, differential diagnosis, treatment, and referral for gender-affirming somatic treatments of adults with GD., Competing Interests: No author has any conflict of interest to report.

Evidence indicates an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD). The clinical assessment and treatment of adolescents with this co-occurrence is often complex, related to the developmental aspects of ASD. There are no guidelines for clinical care when ASD and GD co-occur; however, there are clinicians and researchers experienced in this co-occurrence. This study develops initial clinical consensus guidelines for the assessment and care of adolescents with co-occurring ASD and GD, from the best clinical practices of current experts in the field. Expert participants were identified through a comprehensive international search process and invited to participate in a two-stage Delphi procedure to form clinical consensus statements. The Delphi Method is a well-studied research methodology for obtaining consensus among experts to define appropriate clinical care. Of 30 potential experts identified, 22 met criteria as expert in co-occurring ASD and GD youth and participated. Textual data divided into the following data nodes: guidelines for assessment; guidelines for treatment; six primary clinical/psychosocial challenges: social functioning, medical treatments and medical safety, risk of victimization/safety, school, and transition to adulthood issues (i.e., employment and romantic relationships). With a cutoff of 75% consensus for inclusion, identified experts produced a set of initial guidelines for clinical care. Primary themes include the importance of assessment for GD in ASD, and vice versa, as well as an extended diagnostic period, often with overlap/blurring of treatment and assessment.

Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA's position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.

An expanding number of mental health professionals evaluate, advocate for, treat, and refer gender variant children and transgender youth.Official recognition of these persons and their needs as well as support for improvement and change come from several different national surveys and professional policy and accreditation organizations. Being informed about these and other available resources can help with patient advocacy. The author provides a reading list for youth and families, definitions of terms, a history of youth gender variance, history and policies of professional organizations, and recent reports and initiatives. An appendix with a patient's first-hand story is included.

Objective: There are no published placebo-controlled studies of any agent in the treatment of acute mania in children or adolescents. This is the first placebo-controlled study of lithium's efficacy in the treatment of acute mania in adolescents., Method: In this discontinuation study, participants received open treatment with lithium at therapeutic serum levels (mean 0.99 mEq/L) for at least 4 weeks. Responders were randomly assigned to continue or discontinue lithium during a 2-week double-blind, placebo-controlled phase. This study had 80% power to detect a 40% difference in exacerbation rates between groups (10% on lithium versus 50% on placebo)., Results: Twenty-three of 40 protocol participants (57.5%) experienced a clinically significant symptom exacerbation during the 2-week double-blind phase. However, the slightly lower exacerbation rate in the group maintained on lithium (10/19 or 52.6%) versus the group switched to placebo (13/21 or 61.9%) did not reach statistical significance., Conclusions: This study does not support a large effect for lithium continuation treatment of adolescents with acute mania, mostly due to the unexpectedly high rate of exacerbations in the group that continued on lithium. Further studies are warranted to clarify whether acute mania in adolescents is lithium responsive.

Objective: Although increased evidence of disproportionate psychosocial risk and other health problems encountered by lesbian, gay male, and bisexual (LGB) youths has emerged, no study has described how the topic of homosexuality is addressed within child and adolescent residency psychiatry training., Method: Residency training directors in U.S. child and adolescent psychiatry programs were asked questions about instruction on the topic of homosexuality and the care of LGB patients, the department's view of whether homosexuality represents a pathological condition, the director's awareness of LGB colleagues and residents, and the director's opinion of LGB residents' disclosure of their homosexuality to their patients and patients' families. Asking similar questions facilitated a comparison of survey results with those of an earlier study of general psychiatry training directors., Results: The reported departmental attitudes about whether homosexuality represents a pathological condition were essentially equivalent in general and child programs. Child and adolescent training directors were, however, less likely to have a favorable view of disclosure of sexual orientation to patients, less likely to know LGB residents or faculty, and less likely to report LGB residents an asset to their departments., Conclusions: The prediction that the majority of child and adolescent training programs would reflect a heightened awareness of the vulnerability of LGB youths was not confirmed.

One hundred 5- to 12-year-old boys referred for outpatient psychiatric evaluation were assessed for cross-gender behavior using the Child Behavior and Attitude Questionnaire (CBAQ) and the Child Game Participation Questionnaire (CGPQ), and for possible associated psychopathology using the Child Behavior Checklist (CBCL) and clinical psychiatric (DSM-III) diagnoses. On the two feminine scales of the CBAQ and CGPQ, 30 to 50% scored within defined clinical ranges. High feminine scale scorers did not have higher Total CBCL scores than lower feminine scale scorers, and scores on the feminine scales correlated minimally with scores on the CBCL broad and narrow-band behavior problem scales, except for a significant positive correlation with the Delinquent subscale. No particular clinical psychiatric diagnoses were significantly associated with high feminine scorers: however, high feminine behavior scorers tended to have more conduct problems and mixed adjustment disorders and less anxious and depressive psychopathology. Clinicians were not alert to the degree of cross-gender behavior found, perhaps due to the concomitant externalizing psychopathology and masculine behavior in these same patients.