From Gender Variance to Gender Dysphoria The research presented in this thesis was financially supported by Afdeling Medische Psychologie en Medisch Maatschappelijk werk Fonds Wetenschappelijk Onderzoek Seksualiteit (FWOS) Ferring B.V. Copyright © 2013 T.D. Steensma Cover design and layout by Suzanne Bakkum Printed by Ridderprint ISBN: 978-90-5335-670-8 nur: 773 All rights reserved. No parts of this thesis may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronical, mechanical, photocopying, recording, or otherwise, without the permission of the author and the publisher holding the copyright of the published articles. VRIJE UNIVERSITEIT From Gender Variance to Gender Dysphoria: Psychosexual development of gender atypical children and adolescents ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. L.M. Bouter, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de Faculteit der Geneeskunde op vrijdag 3 mei 2013 om 11.45 uur in de aula van de universiteit, De Boelelaan 1105 door Thomas Dirk Steensma geboren te Obdam promotor: copromotor: prof.dr. P.T. Cohen-Kettenis dr. B.P.C. Kreukels For my beloved parents, Dirk & Anna One tough fighter, Feye And a bright little star in heaven, Sam Content Chapter 1 General Introduction Chapter 2 Gender Identity Development in Adolescence 19 Chapter 3 The Utrecht Gender Dysphoria Scale: A Validation Study 41 Gender Variance in Childhood and Sexual Orientation in Adulthood: A Prospective Study 57 Desisting and Persisting Gender Dysphoria after Childhood: A Qualitative Follow-up Study 75 Factors Associated with Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-up Study 97 Chapter 7 Gender Transitioning before Puberty? 117 Chapter 8 Behavioral and Emotional Problems on the Teacher’s Report Form: A Cross-National, Cross-Clinic Comparative Analysis of Gender Dysphoric Children and Adolescents 121 Chapter 9 Summary and General Discussion 141 Chapter 10 Nederlandse Samenvatting 159 Chapter 4 Chapter 5 Chapter 6 9 References 177 Curriculum Vitae 197 List of Publications 199 Dankwoord 203