Perceived Gender Presentation Among Transgender and Gender Diverse Youth: Approaches to Analysis and Associations with Bullying Victimization and Emotional Distress

Prevalence of Eating Disorder Symptoms in Transgender and Gender Diverse Adolescents Presenting for Gender-Affirming Care

PURPOSE

To describe the prevalence of eating disorder symptoms among adolescents seeking gender-affirming care.

METHODS

Cross-sectional study of 660 gender-diverse adolescents who completed the Branched Eating Disorder Test to measure anorexia and bulimia symptoms.

RESULTS

23.9% (95% CI 20.7-27.4) reported both anorexia symptoms, namely overvaluation of weight and fear of (or recurrent interference with) weight gain. 0.9% (95% CI 0.3-2.0) reported all bulimia symptoms, namely overvaluation of weight, recurrent binge eating, and recurrent compensatory behaviors (e.g., weekly purging). For all symptoms, prevalence was higher among i) adolescents assigned female at birth compared to those assigned male at birth, and ii) adolescents who felt unsure about their gender identity compared to those who identified as trans or nonbinary.

DISCUSSION

Clinicians should monitor eating disorder symptoms among adolescents presenting for gender-affirming care, especially among those assigned female at birth or who are unsure about their gender identity.

The Gender Self-Report: A multidimensional gender characterization tool for gender-diverse and cisgender youth and adults

Gender identity is a core component of human experience, critical to account for in broad health, development, psychosocial research, and clinical practice. Yet, the psychometric characterization of gender has been impeded due to challenges in modeling the myriad gender self-descriptors, statistical power limitations related to multigroup analyses, and equity-related concerns regarding the accessibility of complex gender terminology. Therefore, this initiative employed an iterative multi-community-driven process to develop the Gender Self-Report (GSR), a multidimensional gender characterization tool, accessible to youth and adults, nonautistic and autistic people, and gender-diverse and cisgender individuals. In Study 1, the GSR was administered to 1,654 individuals, sampled through seven diversified recruitments to be representative across age (10-77 years), gender and sexuality diversity (∼33% each gender diverse, cisgender sexual minority, cisgender heterosexual), and autism status (> 33% autistic). A random half-split subsample was subjected to exploratory factor analytics, followed by confirmatory analytics in the full sample. Two stable factors emerged: Nonbinary Gender Diversity and Female-Male Continuum (FMC). FMC was transformed to Binary Gender Diversity based on designated sex at birth to reduce collinearity with designated sex at birth. Differential item functioning by age and autism status was employed to reduce item-response bias. Factors were internally reliable. Study 2 demonstrated the construct, convergent, and ecological validity of GSR factors. Of the 30 hypothesized validation comparisons, 26 were confirmed. The GSR provides a community-developed gender advocacy tool with 30 self-report items that avoid complex gender-related "insider" language and characterize diverse populations across continuous multidimensional binary and nonbinary gender traits. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Complex Psychiatric Histories and Transgender and Gender Diverse Youth

Transgender and gender diverse (TGD) individuals face higher rates of stressors driving disproportionate health risks. Although psychiatric conditions are important to consider in the context of greater health-promoting efforts for TGD youth, any mental health concerns may or may not be related to gender identity or associated dysphoria. Nevertheless, it is essential to consider the impact of complex mental health factors on decisional capacity and gender care discussions. Psychiatric care of TGD youth includes stratifying risk factors through a minority stress lens, balancing acute needs with patient and caregiver priorities, and bolstering resilience using affirming care principles.

Assessment of Quality of Life of Transgender and Gender-Diverse Children and Adolescents in Melbourne, Australia, 2017-2020

IMPORTANCE

Transgender and gender-diverse (TGD) children and adolescents may experience not only gender dysphoria but also depression and anxiety, all of which are likely to be associated with reduced quality of life (QOL). Despite this, little is known about QOL in this population.

OBJECTIVES

To identify demographic, social, and clinical characteristics associated with reduced QOL in TGD children and adolescents; compare their QOL with age-matched population-based norms and that of young people with common mental health problems; and evaluate the association between gender dysphoria and QOL.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, baseline data were derived from questionnaires completed in a prospective cohort study (Trans20) of TGD children aged 6 to 12 years and adolescents aged 13 to 17 years first seen at the Royal Children's Hospital Gender Service (Melbourne, Australia) between February 2017 and February 2020.

MAIN OUTCOMES AND MEASURES

The main outcome was QOL, measured using the Child Health Utility 9D instrument (CHU-9D). Data collection included demographic information, social factors (eg, bullying, lack of support, and social transition), and clinical characteristics (eg, gender identity, gender dysphoria, and mental health difficulties). Population norms and CHU-9D data for Australian youths with mental health diagnoses were derived from published literature.

RESULTS

The TGD cohort comprised 525 children and adolescents aged 6 to 17 years (median age, 14 years [IQR, 12-16 years]; 364 [69.33%] presumed female at birth). The mean (SD) CHU-9D score was 0.46 (0.26). Compared with population norms, TGD children (0.58 [0.27] vs 0.81 [0.16]; P < .001) and adolescents (0.41 [0.25] vs 0.80 [0.14]; P < .001) had significantly lower scores. Within the TGD cohort, mean (SD) scores were significantly lower in adolescents (0.41 [0.24] vs 0.62 [0.25]; P < .001), those assigned female at birth (0.43 [0.26] vs 0.55 [0.25]; P < .001), those reporting mental health problems (0.37 [0.23] vs 0.57 [0.25]; P < .001) and physical health problems (0.41 [0.26] vs 0.48 [0.26]; P = .04), and those who were bullied (0.38 [0.24] vs 0.52 [0.25]; P < .001). Gender dysphoria alone was associated with a lower mean (SD) CHU-9D score (0.51 [0.23]) than that in control adolescents with serious mental health conditions such as depression (0.64 [0.26]) and anxiety (0.70 [0.24]) and was an independent factor associated with QOL.

CONCLUSIONS AND RELEVANCE

In this cohort study of TGD children and adolescents in Australia, QOL was worse in this population than in age-matched, population-based peers. Quality of life associated with gender dysphoria was substantially worse than that seen in young people with common mental health conditions. These findings emphasize the risk of poor QOL among TGD young people and the need to better support them.

The moderating effect of physical activity on the relationship between bullying and mental health among sexual and gender minority youth

BACKGROUND

Sexual and gender minority youth frequently experience bullying, which often contributes to higher depressive symptoms and lower self-esteem. Given that physical activity (PA) can mitigate depressive symptoms and improve self-esteem, we examined the moderating effect of PA on the relationship between bullying and mental health among sexual and gender minority youth.

METHODS

Data from the Lesbian, Gay, Bisexual, Transgender, and Queer National Teen Survey (n = 9890) were analyzed. Hierarchical regression analyses examined the influence of history and frequency of being bullied, PA, and the interaction of these variables on depressive symptoms and self-esteem. Simple slopes analyses were used to probe significant interactions.

RESULTS

Results indicated the importance of accounting for bullying history when examining effects of PA on mental health. PA was negatively related to depression (t = -4.18, p < 0.001) and positively related to self-esteem (t = 12.11, p < 0.001). Bullying frequency was positively related to depression (t = 19.35, p < 0.001) and negatively related to self-esteem (t = -12.46, p < 0.001). There was a significant interaction between bullying frequency and PA for depression (t = 4.45, p < 0.001) and self-esteem (t = -4.69, p < 0.001). Post hoc analyses suggested that the positive effects of PA on mental health may be limited to those not bullied because it had a negligible effect on those who were bullied.

CONCLUSION

Results suggest that sexual and gender minority youth exercise interventions aiming to improve mental health should first address bullying history; otherwise, their effectiveness may be limited to those who have been bullied.

Sexuality and Gender Identity Inequities in Substance Use Disorder and Its Treatment among American Indian, Alaska Native, and Native Hawaiian College Students

BACKGROUND

The aim of this study was to investigate inequities in substance use disorder (SUD) diagnosis, opioid misuse, marijuana misuse, SUD treatment utilization, and utilization of university mental health services among sexual and gender minority (SGM) American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students.

METHODS

Data consisting of 8,103 AI/AN/NH students' responses to the American College Health Association's National College Health Assessment survey from fall 2015 through spring 2019 were utilized for this study. Multivariable logistic regression models were used to compare the odds of SUD diagnosis, opioid misuse, and marijuana misuse in SGM AI/AN/NH students to cisgender, heterosexual peers. Unadjusted odds of SUD treatment utilization and utilization of university mental health services were also evaluated.

RESULTS

Compared to cisgender females, transgender (aOR = 4.43, 95% CI = 2.67-7.34) and gender diverse (aOR = 2.86, 95% CI = 1.61-5.07) students had significantly higher odds of SUD diagnosis. Similarly, significantly higher odds of SUD diagnosis were observed among sexual minorities, including gay/lesbian (aOR = 2.95, 95% CI = 1.71-5.09) and bisexual (aOR = 1.97, 95% CI = 1.30-2.99) students compared to heterosexual peers. Sexual minority students had significantly higher odds of utilizing university mental health services (uOR = 2.43, 95% CI = 1.22-4.84) than heterosexual peers. Odds of opioid misuse and marijuana misuse were also significantly increased among sexual minority students.

CONCLUSIONS

AI/AN/NH college students who identify as SGM have higher odds of SUD diagnosis, opioid misuse, and marijuana misuse than their cisgender, heterosexual peers. These findings highlight the need to consider tailored programming for SGM AI/AN/NH students in substance use prevention and intervention efforts in U.S. college settings.

An Analogue Study Investigating Differential Parenting of Gender Conforming and Nonconforming Boys

Gender nonconforming children are at heightened risk for negative parenting interactions. This study investigated possible explanations for differences in parenting behaviors with gender conforming and nonconforming boys. A sample of 201 adults (43% women/57% men; 81% White, 10% Black/African American, 6% Multiracial, 3% Asian, and 1% American Indian or Alaska Native; and 7% Hispanic/Latinx) ranging in age from 20 to 74 years (M = 35.44, SD = 9.76) were presented two vignettes describing a gender conforming and nonconforming boy. Following each vignette, participants provided endorsements of parenting behaviors and reported their concern for that child's future. In addition, participants completed measures assessing their attitudes toward homosexuality and need for closure. Contrary to expectations, there were no significant differences in endorsements of physical discipline or positive parenting for the two boys. Participants did, however, report higher concern for the gender nonconforming boy's future. Individual differences in homonegativity were associated with greater endorsements of physical discipline toward the gender nonconforming boy, after accounting for endorsements of physical discipline toward the gender conforming boy. Further, higher concern for the gender nonconforming boy's future was associated with greater endorsements of physical discipline and lower endorsements of positive parenting, after accounting for endorsements of each behavior for the gender conforming boy as well as concern for their future. Intervention efforts to support the parent-child relationship for gender nonconforming boys may benefit from identifying and responding to both negative attitudes toward homosexuality and addressing motivations to change behavior resulting from concern for their child's future.

Supporting young people to manage gender-related distress using third-wave cognitive behavioural theory, ideas and practice

The Gender Identity Development Service (GIDS) supports gender diverse young people, and their families but currently does not provide weekly psychological therapy as part of its core work. In addition, local Child and Adolescent Mental Health Services (CAMHS), may feel deskilled in providing support for this population. We, a group of three Clinical Psychologists, aim to share some common themes and observations gained from our work in GIDS. We talk about how existing Cognitive Behavioural Therapy (CBT) models can be relevant and helpful for the challenges facing gender diverse young people, without pathologising, or aiming to change a young person's gender identity. An illustrative case study is presented, based on an amalgamation of young people we have worked with highlighting how third-wave cognitive behavioural theory, ideas and practice can be used to support young people to manage gender-related distress. Further reflections on the broader socio-political context, and implications for clinical practice and future research are discussed.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

"Words Aren't Supposed to Hurt, But They Do": Sexual and Gender Minority Youth's Bullying Experiences

Sexual and gender minority youth (SGMY) are more likely to experience bullying and violence compared to the youth who do not identify as SGMY, leading to increased risk of poor mental and physical health outcomes, and poor academic performance. Few studies explore the entire range of bullying experienced by sexual and gender minority youth (SGMY). The purpose of this study was to qualitatively describe the ways in which SGMY experience bullying victimization. We conducted semi-structured interviews with a diverse sample of 20 SGMY aged 14-18 years (median age 16 years) recruited from online social media. The sample included 10 participants who identified as cisgender girls, 4 who identified as cisgender boys, 2 who identified as transgender, and 4 who identified as another gender identity. Ten participants identified as bisexual, six identified as lesbian, and four identified as gay. Findings indicated six common experiences of bullying among the participants: (a) verbal harassment; (b) gender policing; (c) physical violence; (d) sexual harassment; (e) treated as sexual perpetrators and deviants; and (f) and social exclusion. SGMY described how bullying victimization ranged from overt to concealed attitudes and behaviors, and they articulated how several forms of bullying are likely not experienced by heterosexual and cisgender youth. These results support findings from prior qualitative studies and suggest that efforts to address school-based bullying may benefit from a more complete awareness of the range of bullying victimization experienced by SGMY. Development of multi-item scales of bullying that reflect the six common experiences of bullying presented in this study would allow researchers to quantitatively explore the range of bullying behaviors experienced by SGMY, and would aid in the conceptualization and successful implementation of anti-bullying interventions.

Gender Variations, Generational Effects, and Mental Health of Transgender People in Relation to Timing and Status of Gender Identity Milestones

Transgender and gender diverse (TGD) people commonly report the following gender identity milestones: feeling different about their gender than expectations for their sex assigned at birth, identifying as TGD, living in their affirmed gender, and, for some, accessing gender-affirming medical care. We explored the average ages of reaching these milestones and variations across gender groups and generational cohorts. We also examined how gender groups, generational cohorts, and endorsement of reaching each of the milestones related to minority stress variables and mental health. This online study included 695 TGD individuals ages 16-73. Boomers+ and Generation X groups were more likely to identify as trans women compared to the younger generational cohorts, who were more varied in their identities. Trans women had later ages of starting to live in their affirmed gender and receiving gender affirming medical care compared to other gender groups. The Boomers+ cohort reported later ages for the milestones compared to other generational cohorts. And, finally, younger generational cohorts had higher levels of internalized stigma, anxiety, and depression, compared to the older cohorts. Gender congruence emerged as a consistent predictor of mental health in the full sample and within each generational cohort. There are important generational differences across identity milestones, minority stress, and mental health that need exploration in future longitudinal research. In addition, beyond the effects of milestone timing, reporting feelings of congruence with one's gender identity is an important consideration for mental health.

Associations of nonconforming gender expression and gender identity with bullying victimization: an analysis of the 2017 youth risk behavior survey

PURPOSE

Although gender nonconformity (GNC) and transgender identity are both linked to bullying victimization, few studies have examined them with bullying victimization simultaneously. Using a sample of Youth Risk Behavior Survey, we investigated the associations of GNC and transgender identity with bullying victimization within the same study.

METHODS

We analyzed data from the cross-sectional school-based Youth Risk Behavior Survey in 2017 (n = 25,378). The exposures were GNC and transgender identity. The main outcomes were traditional victimization, cyber victimization, and combined victimization. We calculated adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) using Poisson regression models.

RESULTS

There were 22.15% of high school students with GNC, and 1.61% identified themselves as transgender. GNC is associated with traditional (APR,1.45;95%CI, 1.21-1.73), cyber (APR,2.00; 95%CI, 1.66-2.40) and combined victimization (APR,1.61;95%CI, 1.42-1.83) respectively among assigned male at birth (AMAB) students only. Transgender male and female students are both at higher risk of bullying victimization for all the three outcomes than cisgender peers.

CONCLUSIONS

AMAB GNC and transgender identity are associated with a higher risk of bullying victimization. Providing support systems and celebrating gender diversity within and outside schools are important.

Diverse Sexual and Gender Identity, Bullying, and Depression Among Adolescents

Surveillance data indicate youth have many sexual and gender identities that should be included in clinical forms and surveys to document and improve health equity.

Using Family and Ecological Systems Approaches to Conceptualize Family- and Community-Based Experiences of Transgender and/or Nonbinary Youth From the Trans Teen and Family Narratives Project

The current study used family and ecological systems approaches to understand transgender and/or nonbinary (TNB) youths' experiences of their gender identity within family and community contexts. A sample of 33 TNB youth, ages 13-17 years (M = 15.18, SD = 1.24), were recruited from community-based venues in the New England region of the United States to participate in the Trans Teen and Family Narratives Project, a longitudinal community-based mixed methods study. TNB youth in the sample identified as trans girls (n = 12), trans boys (n = 17), and nonbinary (n = 3 assigned female at birth; n = 1 assigned male at birth). Race/ethnicity of the sample was 73% White and 15% mixed race/ethnicity. All participants completed a one-time, in-person semi-structured qualitative interview at baseline about their family and community-based experiences related to their TNB identity. Interviews were audio-recorded and professionally transcribed. Interview transcripts were coded and analyzed using immersion/crystallization and thematic analysis approaches. Eight themes were developed, which correspond to different levels of the ecological systems model: individual-level (identity processes, emotions/coping), family-level (general family experiences, family support), community-level (general community experiences; community support; lesbian, gay, bisexual, transgender, queer (LGBTQ) community), and societal/institutional-level (external forces). Findings emphasize the importance of using family and ecological systems approaches to understanding the family- and community-based experiences of TNB youth and have implications for improving clinical practice with TNB youth and families.

Approach to the Patient: Pharmacological Management of Trans and Gender-Diverse Adolescents

Internationally, increasing numbers of children and adolescents with gender dysphoria are presenting for care. In response, gender-affirming therapeutic interventions that seek to align bodily characteristics with an individual's gender identity are more commonly being used. Depending on a young person's circumstances and goals, hormonal interventions may aim to achieve full pubertal suppression, modulation of endogenous pubertal sex hormone effects, and/or development of secondary sex characteristics congruent with their affirmed gender. This is a relatively novel therapeutic area and, although short-term outcomes are encouraging, longer term data from prospective longitudinal adolescent cohorts are still lacking, which may create clinical and ethical decision-making challenges. Here, we review current treatment options, reported outcomes, and clinical challenges in the pharmacological management of trans and gender-diverse adolescents.

Characterization of a transgender population in Portugal

INTRODUCTION

Gender dysphoria (GD) is a condition in which the individual's gender identity does not correspond to their biological sex, causing significant distress. Biological males who identify as females are referred to as transgender females or as showing male-to-female GD (MtF GD) and biological females who identify as males are referred to as transgender males or as showing female-to-male GD (FtM GD). In our center, there is a multidisciplinary consultation to approach and follow patients with GD.

AIM

We aimed to analyze the characteristics of the individuals who attend this consultation.

METHODS

Retrospective study of individuals attending the Sexual Medicine Group Consultation. Age, comorbidities, symptom onset, and hormonal and surgical treatment were analyzed.

RESULTS

114 patients were diagnosed with GD: 68.4% FtM GD and 31.6% MtF GD. Median age was 30.2±12 years. 63.2% reported symptom onset in childhood: 14.9% between 10 and 18 years, and 4.4% later than 18 years. Median age at treatment initiation was 23.1±7.1 years. Several individuals had concomitant medical conditions, notably smoking (n=37; 32.5%) and depression (n=26; 22.3%). The majority of (92.3% FtM GD and 88.9% MtF GD) were under hormone treatment, and about one-third had undergone some sex reassignment surgery.

DISCUSSION

We found higher prevalence of FtM than MtF, in contrast with most other studies. The reasons for this are not clear. A high percentage of our patients were self-medicated. Other characteristics were similar to those previously reported.

CONCLUSION

Medical requests by individuals with GD are increasing worldwide. To our knowledge, this is the first study to portray a case series in a consultation center dedicated to the diagnosis, treatment and follow-up of individuals with GD in Portugal.

A Waitlist Intervention for Transgender Young People and Psychosocial Outcomes

BACKGROUND

Recent referrals of transgender young people to specialist gender services worldwide have risen exponentially, resulting in wait times of 1-2 years. To manage this demand, we introduced an innovative First Assessment Single-Session Triage (FASST) clinic that provides information and support to young people and their families and triages them onto a secondary waitlist for subsequent multidisciplinary care. Although FASST has been shown to substantially reduce initial wait times, its clinical impact is unknown.

METHODS

FASST was evaluated by analysis of clinical surveys and qualitative interviews. A total of 142 patients were surveyed before and after FASST, and comparison was made to a historical control group of 120 patients who did not receive FASST. In-depth interviews were also held with FASST attendees (n = 14) to explore experiences of FASST, and inductive content analysis was performed.

RESULTS

After FASST, there were improvements in depression (standardized mean difference [SMD] = -0.24; 95% confidence interval [CI]: -0.36 to -0.11; P < .001), anxiety (SMD = -0.14; 95% CI: -0.26 to -0.02; P = .025) and quality of life (SMD = .39; 95% CI: 0.23 to 0.56; P < .001). Compared with historical controls, those attending FASST showed reduced depression (SMD = -0.24; 95% CI: -0.50 to 0.01; P = .065) and anxiety (SMD = -0.31; 95% CI: -0.57 to -0.05; P = .021). FASST attendees qualitatively described an increased sense of agency, which was related to improved outlook, validation, sense of self, and confidence.

CONCLUSIONS

Given burgeoning waitlists of pediatric gender services worldwide, this study suggests FASST may prove a useful model of care elsewhere.

The clinical profile of patients attending a large, Australian pediatric gender service: A 10-year review

Objectives: To better understand the clinical profile of patients attending a large Australian pediatric gender service. Retrospective clinical audit of patients seen at the Royal Children's Hospital Gender Service (RCHGS) over 10 years (2007-16). Setting: The RCHGS: Australia's largest pediatric gender service. Participants: Patients were eligible for inclusion if they had an appointment with the RCHGS between January 2007 - December 2016, and had either a self-reported gender which differed from what was presumed for them at birth or sought guidance regarding gender identity/expression. Main outcome measures: Demographic/developmental history, clinical presentation including information about gender identity/dysphoria, comorbidities, self-harm, suicidal ideation, gender-affirming treatment, psychosocial functioning. Results: 359 patients were first seen during the study period. Assigned females (54%) slightly outnumbered assigned males (46%), and presented at an older age (14.8 vs 12.4 years. Patients predominantly identified as transgender (87.2%) or non-binary (7.2%). Across the cohort, gender diversity was evident from a young age (median age 3), and symptoms of gender dysphoria were noted earlier in assigned males (median age 4) than assigned females (median age 11). Although 81% of patients met eligibility for GD, rates of hormonal treatment were much lower, with 29% of young people ≥10 years of age receiving puberty blocking treatment and 38% of adolescents ≥ 16 years of age receiving gender-affirming hormones (i.e. testosterone or estrogen). Many patients had mental health difficulties and/or neurodevelopment disorders, including major depressive disorder/low mood (51%), self-harm (25%), suicidal ideation (30%) and autism spectrum disorder (16%). Conclusion: This audit illustrates the complex profile and needs of transgender and gender diverse children and adolescents presenting to specialist gender services. Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1939221 .

Measurement tools for gender identity, gender expression, and gender dysphoria in transgender and gender-diverse children and adolescents: a systematic review

Increasing numbers of children and adolescents are being referred to gender services for gender-related concerns. Various instruments are used with these patients in clinical care, but their clinical validity, strengths, and limitations have not been systematically reviewed. In this systematic review, we searched MEDLINE, PubMed, and PsycINFO databases for available tools that assess gender identity, gender expression, or gender dysphoria in transgender and gender-diverse (TGD) children and adolescents. We included studies published before Jan 20, 2020, that used tools to assess gender identity, expression, or dysphoria in TGD individuals younger than 18 years. Data were extracted from eligible studies using a standardised form. We found 39 studies that met the inclusion criteria, from which we identified 24 tools. The nature of tools varied considerably and included direct observation, child and adolescent self-report, and parent-report tools. Many methods have only been used with small samples, include outdated content, and lack evaluation of psychometric properties. In summary, a paucity of studies in this area, along with sparse reporting of psychometric properties, made it difficult to compare the relative use of tools, and current tools have substantial limitations. Future research is required to validate existing measures and create more relevant, culturally appropriate tools.

Mental Health and Psychosocial Risk and Protective Factors Among Black and Latinx Transgender Youth Compared With Peers

IMPORTANCE

Black and Latinx transgender youth experience stigma that may increase their susceptibility to mental health symptoms.

OBJECTIVE

To compare past-year mental health symptoms and psychosocial factors among Black and Latinx transgender youth, White transgender youth, and Black and Latinx cisgender youth.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used data from the 2015-2017 Biennial California Healthy Kids Survey with a weighted sample (N = 45 269) representative of California's secondary school population. The analytic sample (n = 19 780) included Black and Latinx transgender youth, White transgender youth, and Black and Latinx cisgender youth in the 9th and 11th grades. Data analysis was conducted from July 2020 to February 2021.

MAIN OUTCOMES AND MEASURES

Outcomes include past-year depressive symptoms and suicidality. Psychosocial risk factors include school-based victimization, gender-based harassment, sexuality-based harassment, and race-based harassment; protective factors include school connectedness and caring adult relationships.

RESULTS

The analytic sample of 19 780 participants (in 9th grade: weighted percentage, 51% [95% CI, 50% to 52%]; female participants: weighted percentage, 50% [95% CI, 49% to 51%]) included 252 Black and Latinx transgender youth (weighted percentage, 1.3% [95% CI, 1.1% to 1.5%]), 104 White transgender youth (weighted percentage, 0.7% [95% CI, 0.6% to 0.8%]), and 19 424 Black and Latinx cisgender youth (weighted percentage, 98.0% [95% CI, 97.8% to 98.2%]). For Black and Latinx transgender youth, estimated prevalence of depressive symptoms and suicidality were 50% (95% CI, 44% to 57%) and 46% (95% CI, 39% to 52%), respectively. Logistic regression models adjusted for grade, living arrangement, and reported sex indicated that compared with White transgender youth, Black and Latinx transgender youth had similar odds of depressive symptoms (adjusted odds ratio, 0.6; 95% CI, 0.4 to 1.1) and suicidality (adjusted odds ratio, 1.1; 95% CI, 0.6 to 1.8) and similar odds of all forms of harassment (eg, race-based harassment: adjusted odds ratio, 1.5; 95% CI, 0.8 to 2.6). Regression models indicated that compared with White transgender youth, Black and Latinx transgender youth had similar levels of victimization (adjusted linear regression coefficient, 0.5; 95% CI, -0.3 to 1.3) and caring adult relationships (adjusted linear regression coefficient, -0.6; 95% CI, -1.4 to 0.09) but lower levels of school connectedness (adjusted linear regression coefficient, -1.6; 95% CI, -2.9 to -0.4). With similar analyses, compared with Black and Latinx cisgender youth, Black and Latinx transgender youth had higher odds of depressive symptoms (adjusted odds ratio, 2.7; 95% CI, 2.0 to 3.7) and suicidality (adjusted odds ratio, 5.9; 95% CI, 4.3 to 8.0), higher odds and levels of all forms of harassment and victimization (eg, race-based harassment: adjusted odds ratio, 3.2; 95% CI, 2.4 to 4.5), and lower levels of school connectedness (adjusted linear regression coefficient, -2.6; 95% CI -3.3 to -1.8) and caring adult relationships (adjusted linear regression coefficient, -0.9; 95% CI -1.3 to -0.5).

CONCLUSIONS AND RELEVANCE

In this study, Black and Latinx transgender youth had high rates of mental health symptoms, with rates comparable with White transgender youth but higher than Black and Latinx cisgender youth. Their unique pattern of psychosocial risk and protective factors for these mental health symptoms should be factored in clinical preventive services and school-based interventions to support them.

Transgender Identity Is Associated With Bullying Involvement Among Finnish Adolescents

Background

During adolescence, bullying often has a sexual content. Involvement in bullying as a bully, victim or both has been associated with a range of negative health outcomes. Transgender youth appear to face elevated rates of bullying in comparison to their mainstream peers. However, the involvement of transgender youth as perpetrators of bullying remains unclear in the recent literature.

Objective

The aim of this study was to compare involvement in bullying between transgender and mainstream youth and among middle and late adolescents in a general population sample.

Methods

Our study included 139,829 students in total, divided between a comprehensive school and an upper secondary education sample. Associations between gender identity and involvement in bullying were first studied using cross-tabulations with chi-square statistics. Logistic regression was used to study multivariate associations. Gender identity was used as the independent variable, with cisgender as the reference category. Subjection to and perpetration of bullying were entered each in turn as the dependent variable. Demographic factors, family characteristics, internalizing symptoms, externalizing behaviors, and involvement in bullying in the other role were added as confounding factors. Odds ratios (OR) with 95% confidence intervals (95% CI) are given. The limit for statistical significance was set at p < 0.001.

Results

Both experiences of being bullied and perpetrating bullying were more commonly reported by transgender youth than by cisgender youth. Among transgender youth, all involvement in bullying was more commonly reported by non-binary youth than those identifying with the opposite sex. Logistic regression revealed that non-binary identity was most strongly associated with involvement in bullying, followed by opposite sex identity and cisgender identity. Transgender identities were also more strongly associated with perpetration of bullying than subjection to bullying.

Conclusion

Transgender identity, especially non-binary identity, is associated with both being bullied and perpetrating bullying even when a range of variables including internal stress and involvement in bullying in the opposite role are taken into account. This suggests that bullying during adolescence may serve as a mechanism of maintaining heteronormativity.

Case Report: Successful Use of Minoxidil to Promote Facial Hair Growth in an Adolescent Transgender Male

Increasing numbers of trans and gender diverse young people are presenting to health services seeking gender-affirming medical care. While testosterone therapy in transgender males is generally effective in inducing masculinization, some adolescents encounter barriers to accessing such treatment or may not wish to experience all the changes that usually accompany testosterone. Here, we describe the case of a 17 year old trans male who presented with gender dysphoria but was initially unable to start testosterone therapy. Due to a desire for facial hair, he was therefore treated with topical minoxidil, an easily accessible, over-the-counter medication that has been used to treat androgenic alopecia for several decades. In this case, minoxidil was applied regularly to the lower face and, after three months of treatment, he developed obvious pigmented facial hair that was sufficient to help him avoid being misgendered. The only reported side effect was excessive skin dryness. Unexpectedly, despite no direct application to other areas, there was also an increase in pigmented body hair, suggestive of systemic absorption and effect. Given its long-standing use and safety record in the management of alopecia, minoxidil might thus represent a useful treatment option for trans males who desire an increase in facial hair.

High Burden of Mental Health Problems, Substance Use, Violence, and Related Psychosocial Factors in Transgender, Non-Binary, and Gender Diverse Youth and Young Adults

Transgender and gender diverse (TGD) people are disproportionately impacted by various health issues and associated risk factors, but little is known about differences in these outcomes between gender identities within the TGD population. This study characterized the health of a diverse sample of TGD youth and young adults. Data were taken from the baseline visit of two longitudinal studies in the Chicago area, RADAR (N = 1079, M age = 20.8 years) and FAB 400 (N = 488, M age = 19.57 years), which are cohorts of young sexual and gender minorities assigned male at birth (AMAB) and assigned female at birth (AFAB), respectively. There was a combined sample of 214 TGD (128 AFAB, 86 AMAB) individuals across cohorts. We examined differences between gender identities in self-reported health and related psychosocial variables, and compared TGD youth and their cisgender sexual minority peers from their cohort of origin on all variables. Among TGD youth, we found high rates of depression and suicidality (ideation, plan, attempt), violence (trauma, victimization, childhood sexual abuse), and substance use (cigarette, alcohol, illicit drug use). With the exception of depression, transgender women and non-binary AMAB youth reported worse health outcomes than transgender men and non-binary AFAB youth. Non-binary AMAB youth reported the highest rates of certain outcomes, including traumatic experiences and suicidal ideation. TGD youth generally reported worse outcomes than cisgender sexual minority youth; these differences were less pronounced among AFAB youth. Findings point to the diversity of experiences within the TGD population and critical needs for intervention approaches to mitigate health disparities.

Introduction to the Special Section on Clinical Approaches to Adolescents with Gender Dysphoria

Transgender development in adolescents often occurs in the context of diverse psychiatric symptoms or diagnoses preceding, co-occurring with, or following the onset of the atypical gender identity variations. In addition, it tends to upset the prevailing binary gender ideology and, thereby, strain intra-family relationships as well as elicit stigma in other social contexts. The purpose of this Special Section is to describe clinical approaches to assessment and treatment of patients presenting with such challenging combinations of problems, before the background of societal changes that are affecting the traditional binary gender ideology.

Bullying Victimization among LGBTQ Youth: Current and Future Directions

PURPOSE OF REVIEW

This paper examines recent research on bullying victimization among lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth to identify critical issues and advocate for future research priorities.

RECENT FINDINGS

Recent studies have begun to document the importance of bullying in general, and bias-based bullying (rooted in stigma) in particular, on the health and wellbeing of this vulnerable subgroup of adolescents, as well as drivers of disparities. Current research demonstrates the role of multiple identities for and important differences among LGBTQ youth and has begun to identify protective factors for youth who are the targets of bullying.

SUMMARY

Researchers, clinicians, and those working with and on behalf of LGBTQ youth must measure and acknowledge the multiple reasons for which LGBTQ youth are the targets of bullying. Intervention and prevention efforts should focus on improving the supportiveness of the climates within which LGBTQ youth live.