Evidence for an Altered Sex Ratio in Clinic‐Referred Adolescents with Gender Dysphoria

Estimating Transgender and Gender-Diverse Youth Populations in Health Systems and Survey Data

OBJECTIVES

To identify and examine demographic variation in estimates of gender-diverse youth (GDY) populations from the PEDSnet learning health system network and the Youth Risk Behavior Survey (YRBS).

METHODS

The PEDSnet sample included 14- to 17-years-old patients who had ≥2 encounters at a member institution before March 2022, with at least 1 encounter in the previous 18 months. The YRBS sample included pooled data from 14- to 17-year-old in-school youth from the 2017, 2019, and 2021 survey years. Adjusted logistic regression models tested for associations between demographic characteristics and gender dysphoria (GD) diagnosis (PEDSnet) or self-reported transgender identity (YRBS).

RESULTS

The PEDSnet sample included 392 348 patients and the YRBS sample included 270 177 youth. A total of 3453 (0.9%) patients in PEDSnet had a GD diagnosis and 5262 (1.9%) youth in YRBS self-identified as transgender. In PEDSnet, adjusted logistic regression indicated significantly lower likelihood of GD diagnosis among patients whose electronic medical record-reported sex was male and among patients who identified as Asian, Black/African American, and Hispanic/Latino/a/x/e. In contrast, in the YRBS sample, only youth whose sex was male had a lower likelihood of transgender identity.

CONCLUSIONS

GDY are underrepresented in health system data, particularly those whose electronic medical record-reported sex is male, and Asian, Black/African American, and Hispanic/Latino/a/x/e youth. Collecting more accurate gender identity information in health systems and surveys may help better understand the health-related needs and experiences of GDY and support the development of targeted interventions to promote more equitable care provision.

Global prevalence of major depressive disorder in LGBTQ+ samples: A systematic review and meta-analysis of epidemiological studies

BACKGROUND

LGBTQ+ populations have been reported to have higher rates of depression compared with their heterosexual peers. Such data provided us the impetus to conduct a meta-analysis on the worldwide prevalence of major depressive disorder (MDD) in LGBTQ+ populations and moderating factors that contributed to differences in prevalence estimates between studies.

METHODS

A systematic literature search was performed in major international (PubMed, PsycINFO, Web of Science, EMBASE) and Chinese (Chinese Nation Knowledge Infrastructure (CNKI) and WANFANG) databases from dates of inception to 10 December 2021.

RESULTS

48 articles comprising 4,618,787 individuals were included in the meta-analysis. The overall prevalence of MDD was 32.2 % (95%CI: 30.8-33.6 %, I2 = 99.6 %, τ2 = 0.284). MDD prevalence was higher in the LGBTQ+ samples from the United States than other countries, though the difference was not significant in moderator analyses. Moderator analyses indicated point and lifetime prevalence of MDD were significantly higher than estimates based on the past year (Q = 6.270, p = 0.043). Furthermore, studies that relied on convenience sampling had a higher prevalence of MDD than those based on other sampling methods (Q = 8.159, p = 0.017). In meta-regression analyses, mean age (B = 0.03, z = 9.54, p < 0.001) and study quality assessment score (B = 0.24, z = 67.64, p < 0.001) were positively associated with pooled prevalence of MDD while year of study (B = -0.08, z = -72.55, p < 0.001) and sample size (B = -1.46, z = -37.83, p < 0.001) were negatively associated with pooled prevalence of MDD in LGBTQ+ samples.

CONCLUSIONS

MDD is common among in LGBTQ+ individuals. Considering the negative consequences MDD has on daily life and well-being, appropriate prevention and treatment measures should be provided to vulnerable members of these populations. The findings of this meta-analysis could facilitate identifying at-risk subgroups, developing relevant health policy for LGBTQ+ individuals and allocating health resources from an intersectionality perspective.

Doing and undoing transgender health care: The ordering of 'gender dysphoria' in clinical practice

A formal Gender Dysphoria classification- as outlined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders- is a prerequisite for the reimbursement of both gender-affirming medical care and transgender mental health care in the Netherlands. Gender Dysphoria and its conceptual precursors have always been moving targets: moving due to research, policy, care practices and activism both within and outside of medicine. This raises the question of what Gender Dysphoria is exactly. To elucidate this question, we turn to the people who use the concept in clinical practice to come to a diagnosis and treatment indication: mental health professionals working in gender-affirming medical care and transgender mental health care. Using a material semiotics approach, we reflect upon how Gender Dysphoria is done in clinical practice. Based on an analysis of seventeen practice-based interviews with clinicians as well as an examination of clinical guidelines and texts, we describe four modes in which Gender Dysphoria is ordered. These modes of ordering illustrate that Gender Dysphoria is not one, but multiple. We illustrate how in the mode of isolating, Gender Dysphoria is something which is carefully isolated from mental disorders, while in the modes doing the future and narrating, Gender Dysphoria is done as a continuous and predictable object of care. Such orderings of Gender Dysphoria potentially conflict with a fourth mode of ordering: the doing of diversity in transgender health care. The study's findings provide empirical insights into how transgender health care is currently done in The Netherlands and provide a foundation on which ethical debates on what good transgender health care should entail.

Development of Gender Non-Contentedness During Adolescence and Early Adulthood

Adolescence is an important period for the development of gender identity. We studied the development of gender non-contentedness, i.e., unhappiness with being the gender aligned with one's sex, from early adolescence to young adulthood, and its association with self-concept, behavioral and emotional problems, and adult sexual orientation. Participants were 2772 adolescents (53% male) from the Tracking Adolescents' Individual Lives Survey population and clinical cohort. Data from six waves were included (ages 11-26). Gender non-contentedness was assessed with the item "I wish to be of the opposite sex" from the Youth and Adult Self-Report at all six waves. Behavioral and emotional problems were measured by total scores of these scales at all six waves. Self-concept was assessed at age 11 using the Global Self-Worth and Physical Appearance subscales of the Self-Perception Profile for Children. Sexual orientation was assessed at age 22 by self-report. In early adolescence, 11% of participants reported gender non-contentedness. The prevalence decreased with age and was 4% at the last follow-up (around age 26). Three developmental trajectories of gender non-contentedness were identified: no gender non-contentedness (78%), decreasing gender non-contentedness (19%), and increasing gender non-contentedness (2%). Individuals with an increasing gender non-contentedness more often were female and both an increasing and decreasing trajectory were associated with a lower global self-worth, more behavioral and emotional problems, and a non-heterosexual sexual orientation. Gender non-contentedness, while being relatively common during early adolescence, in general decreases with age and appears to be associated with a poorer self-concept and mental health throughout development.

Gender services for children and adolescents across the EU-15+ countries: an online survey

BACKGROUND

Over the last 10-15 years, there has been an increase in the number of children and adolescents referred to gender services, particularly among adolescent birth-registered females. This population shows a higher prevalence of co-occurring mental health difficulties and neurodevelopmental conditions. Some countries have recently restricted access to medical treatments in recognition of the uncertain evidence base.

AIM

To understand the current provision of gender services for children and adolescents across the EU-15+ countries that have comparable high-income healthcare systems, to inform service development in the UK.

METHODS

An e-survey of paediatric gender services was conducted between September 2022 and April 2023. It covered service structure, care pathways, interventions and data collection. Data were described and compared to identify similarities and differences among participating services.

RESULTS

15 services in eight countries (Australia, Belgium, Denmark, Norway, Northern Ireland, The Netherlands, Spain and Finland) responded. While a multidisciplinary team was present in all services, its composition and organisation varied. Clinical practice was informed by international guidelines, with four countries following their own national guidelines. Differences were observed in referral criteria, care pathways for prepubertal children and those with co-occurring conditions. Eligibility criteria for medical interventions also varied. Psychosocial support and interventions were limited, and outcome data collection was scarce.

CONCLUSIONS

This survey revealed both similarities and key variations in the clinical practice of paediatric gender services across eight different countries. The study emphasises the need for service development that both considers the management of co-occurring conditions and embeds routine data collection in practice.

Demographics of referrals to a specialist gender identity service in the UK between 2017 and 2020

Trends in clinical referrals to specialist gender services historically comprised more assigned male at birth young people. In the last decade, this has shifted in adolescent samples to more assigned female young people. An updated review of the current patterns of referrals is important to better understand the potential changing needs of clinically referred gender-diverse children and adolescents. We assessed the demographics of referrals to the Gender Identity Development Service (GIDS) and their attendance patterns from 2017 to 2020. During this period, 9555 referrals were received in total, most were in adolescence (n = 7901, 82.7%), and more assigned female (age range = 1-18 years; M = 14.05; SD = 2.5) were referred than assigned male young people overall (n = 6823, 71.4%). A larger proportion of assigned female adolescents (assigned female: n = 5835, 62.3%, assigned male: n = 1897, 20.3%) and assigned female children (n = 988, 10.6%, assigned male: n = 640, 6.8%) were referred. For 2%, sex assigned at birth was unrecorded, 83.4% were White British and 36.6% had an unidentified ethnicity. Only 4% did not attend a first appointment, indicating the need for care from this specialist service. With more young people presenting to gender services, understanding the demographics of young people seeking gender care is vital for service provision. Future research should explore how to increase access to gender care for ethnic minorities, and how to support those accessing services.

Family Discordance in Gender Identification Is Not Associated with Increased Depression and Anxiety Among Trans Youth

Purpose: We examined the relationship between parent- and child-reported gender identity of the youth with internalizing symptoms in transgender and gender-diverse (TGD) youth. In addition, we investigated differences in sex assigned at birth ratios and pubertal development stages in TGD and cisgender youth. Methods: We analyzed longitudinal data from the Adolescent Brain Cognitive Development study (ABCD), corresponding to baseline and 1st-to-3rd-year follow-up interviews (n = 6030 to n = 9743, age range [9-13]). Sociodemographic variables, self- and parent-reported gender identity, and clinical measures were collected. Results: TGD youth showed higher levels of internalizing symptoms compared with cisgender youth. However, this was not worsened by discordance in gender identification between TGD youth and parents. Over the 3-year follow-up period, the proportion of TGD participants increased from 0.8% (95% confidence interval (CI) [0.6-1.0]) at baseline to 1.4% (95% CI [1.1-1.7]) at the 3rd-year follow-up (χ2 = 10.476, df = 1, false discovery rate (FDR)-adjusted p = 0.00256), particularly among those assigned female at birth (AFAB) in relation to people assigned male at birth (AMAB) (AMAB:AFAB at baseline: 1:1.9 vs. AMAB:AFAB at 3rd-year follow-up: 1:4.7, χ2 = 40.357, df = 1, FDR-adjusted p < 0.0001). Conclusions: TGD youth in ABCD reported higher internalizing symptoms than cisgender youth, although this was not affected by parental discordance in gender identification. A substantial increase over time in TGD children AFAB was documented. More research is needed to understand the clinical implications of these preliminary results, for which the longitudinal design of ABCD will be crucial.

White matter microstructure in transmasculine and cisgender adolescents: A multiparametric and multivariate study

Adolescence is a sensitive developmental period for neural sex/gender differentiation. The present study used multiparametric mapping to better characterize adolescent white matter (WM) microstructure. WM microstructure was investigated using diffusion tensor indices (fractional anisotropy; mean, radial, and axial diffusivity [AD]) and quantitative T1 relaxometry (T1) in hormone therapy naïve adolescent cisgender girls, cisgender boys, and transgender boys (i.e., assigned female at birth and diagnosed with gender dysphoria). Diffusion indices were first analyzed for group differences using tract-based spatial statistics, which revealed a group difference in AD. Thus, two multiparametric and multivariate analyses assessed AD in conjunction with T1 relaxation time, and with respect to developmental proxy variables (i.e., age, serum estradiol, pubertal development, sexual attraction) thought to be relevant to adolescent brain development. The multivariate analyses showed a shared pattern between AD and T1 such that higher AD was associated with longer T1, and AD and T1 strongly related to all five developmental variables in cisgender boys (10 significant correlations, r range: 0.21-0.73). There were fewer significant correlations between the brain and developmental variables in cisgender girls (three correlations, r range: -0.54-0.54) and transgender boys (two correlations, r range: -0.59-0.77). Specifically, AD related to direction of sexual attraction (i.e., gynephilia, androphilia) in all groups, and T1 related to estradiol inversely in cisgender boys compared with transgender boys. These brain patterns may be indicative of less myelination and tissue density in cisgender boys, which corroborates other reports of protracted WM development in cisgender boys. Further, these findings highlight the importance of considering developmental trajectory when assessing the subtleties of neural structure associated with variations in sex, gender, and sexual attraction.

European Academy of Paediatrics statement on the clinical management of children and adolescents with gender dysphoria

Gender issues have become a polarised and political subject in modern paediatrics and indeed, in broader society. These include the management of infants with disorders of sex development and transgender sports participation, but especially recently regarding the management of gender dysphoria. The European Academy of Paediatrics (EAP) acknowledges that there are deeply held beliefs about this issue based on conscience and social norms. Several European countries, led by the UK, have recently reviewed the management of gender dysphoria in children and young people. Recognising the need for far more research into treatments such as pubertal suppression and cross-sex hormones in children and young people, we review the current ethical and legal dilemmas facing children with gender dysphoria, their families and the clinical teams caring for them. We suggest an approach that maintains the child's right to an open future whilst acknowledging that the individual child is the crucial person affected by decisions made and must receive appropriate support in decision-making and care for any associated mental health or psychological issues. Noting that national approaches to this vary and are in flux, the EAP advocates a child-centred individual rights-based analytical approach.

Psychological Symptoms and Service Utilization in Prepubertal and Pubertal Transgender and Gender-Diverse Patients

STUDY OBJECTIVE

To describe the demographic characteristics and psychological symptoms of gender-diverse patients and to compare symptoms between prepubertal and pubertal subgroups METHODS: This was a retrospective chart review of all gender-diverse patients seen by at least 1 provider at the Nemours Gender Wellness Program from March 2015 to December 2020. The extracted data included demographic and psychosocial characteristics at baseline and 1-year follow-up visits. Pubertal status was determined by Tanner staging by a pediatric endocrinologist or gynecologist. Descriptive statistics were used to compare these variables between prepubertal and pubertal subgroups.

RESULTS

Our sample included 177 individuals at baseline and 96 subjects at the 1-year follow-up visit. Most patients were White (83.0%), non-Hispanic (92.0%), transgender male (72.9%), and pubertal (90.4%). Compared with prepubertal patients, at the baseline visit, pubertal patients had significantly higher rates of current (68.1% vs 17.6%, P < .001) and lifetime (80.0% vs 23.5%, P < .001) depressive symptoms, current anxiety symptoms (70.0% vs 41.2%, P = .01), lifetime suicide attempts (12.5% vs 0%, P < .001), and a formal diagnosis of an eating disorder (5.0% vs 0%, P < .001). Symptoms did not change significantly over time from baseline to the 1-year follow-up visit.

CONCLUSION

We found elevated rates of psychological symptoms and diagnoses in gender-diverse youth, with higher rates in pubertal compared with prepubertal patients. By elucidating how the psychosocial characteristics of gender-diverse children and adolescents differ based on pubertal status, these data can be used to improve current outreach and treatment strategies for transgender pediatric patients.

Legislation, medicine, and politics: care for gender diverse youth

PURPOSE OF REVIEW

A recent increase in legislation in the United States prohibiting gender-affirming care (GAC) for transgender youth follows a wave of its politicization despite support from all pertinent mainstream medical associations. This review describes the standards of GAC for transgender youth, the origins of legislation prohibiting this care, a review of current legislation in the United States and a discussion on the impact on patients, providers, and the medical field.

RECENT FINDINGS

A critical evaluation of historical parallels and current organizations supporting this legislation reveals it stems not from concerns within the medical field but from political and religious interests. This intrusion sets a dangerous precedent, undermining evidence-based medicine, providers' ability to practice according to standards of care, and patients' and guardians' autonomy and medical decision-making. This wave of antitrans rhetoric and legislation has resulted in threats to health providers and hospitals, 'moral distress" in providers, and migration of providers and patients from hostile states.

SUMMARY

Similar to antiabortion legislation, these legislative efforts will likely result in negative health outcomes and worsening disparities. The medical community must confront these forces directly through an understanding of the political and structural forces at play and adopting strategies to leverage collective power.

Gender Diversity Among Youth Attending an Intensive Interdisciplinary Pain Treatment Program

Transgender and gender diverse (TGD) youth with chronic pain may be at unique risk for psychological distress and associated functional impairment, yet research on the intersection of chronic pain and gender identity is lacking. In a retrospective chart review of 491 participants admitted to a pediatric intensive interdisciplinary pain treatment (IIPT) program in the midwestern United States over an approximately 4-year period, 6.11% were TGD. TGD participants who completed the IIPT program reported significant and large improvements in anxiety, depression, pain catastrophizing, and functional ability. At baseline, TGD participants presented as more emotionally distressed and functionally impaired compared to age-matched, cisgender peers. When accounting for baseline scores, TGD participants who completed the IIPT program reported similar scores to cisgender peers at discharge, yet TGD youth were significantly less likely than cisgender peers to complete the IIPT program. Future directions and implications for clinical practice are discussed.

Demographic Differences in Gender Dysphoria Diagnosis and Access to Gender-Affirming Care Among Adolescents

Purpose: The goal of this article was to identify demographic differences in receipt of gender dysphoria (GD) diagnosis and access to gender-affirming care (GAC) among adolescents whose gender identity and/or pronouns differed from their sex assigned at birth. Methods: Data were from 2444 patients who were 13-17 years old and had a documented gender identity and/or pronouns that differed from their sex assigned at birth in the electronic health record. Adjusted logistic regression models explored associations between demographic characteristics (sex assigned at birth, gender identity, race and ethnicity, language, insurance type, rural status) and presence of GD diagnosis and having accessed GAC. Results: The average predicted probability (Pr) of having received a GD diagnosis was 0.62 (95% confidence interval [CI] = 0.60-0.63) and of having accessed GAC was 0.48 (95% CI = 0.46-0.50). Various significant demographic differences emerged. Notably, Black/African American youth were the least likely to have received a GD diagnosis (Pr = 0.43, 95% CI = 0.33-0.54) and accessed GAC (Pr = 0.32, 95% CI = 0.22-0.43). Although there were no significant differences in GD diagnosis by insurance type, youth using Medicaid, other government insurance, or self-pay/charity care were less likely to have accessed GAC compared with youth using commercial/private insurance. Conclusion: Results indicate significant differences in both receipt of GD diagnosis and accessing GAC by various demographic characteristics, particularly among Black/African American youth. Identification of these differences provides an opportunity to further understand potential barriers and promote more equitable access to GAC among adolescents who desire this care.

Characteristics of the pediatric population with gender incongruence attending specialized care in Cali, Colombia: an observational, descriptive and retrospective study

BACKGROUND

Gender incongruence can often manifest itself from early childhood [Olson KR, Gülgöz S. Child Dev Perspect. 2018;12:93-7. https://doi.org/10.1111/cdep.12268 ] with a significant psychological impact, altering social and school dynamics without the appropriate care.[Tordoff DM, et al. JAMA Netw Open. 2022;5(2): e220978. https://doi.org/10.1001/jamanetworkopen.2022.0978 ] Early identification and gender-affirming care are essential to reduce adverse mental health outcomes, such as depression and self-harm [Tordoff DM, et al. JAMA Netw Open. 2022;5(2): e220978. https://doi.org/10.1001/jamanetworkopen.2022.0978 ]..This study aims to analyze characteristics and to estimate relative frequencies of gender incongruence in a population of children and adolescents receiving gender-affirming care at a high-complexity university hospital located in the third largest city in Colombia.

METHODS

This was a retrospective descriptive study of patients under 18 with gender incongruence that received gender-affirming care between January 2018 and June 2022 at Fundacion Valle del Lili in Cali, Colombia. Sociodemographic and clinical characteristics of 43 patients were assessed, as well as the relative frequencies of gender incongruence. Data analysis was performed with the statistical package STATA®. To determine significant differences between the characteristics of the patients who participated in the study, the Mann‒Whitney U test was performed for numerical variables with non-parametric distribution, while either Pearson's Chi-2 test or Fisher's exact test was performed for categorical variables.

RESULTS

For every ten individuals assigned female at birth, who manifested gender incongruence, there were eight assigned male at birth. The median age of onset of gender incongruence was ten years (IQR: 5-13 years), and the median time elapsed between the reported onset of gender incongruence and the first consultation with a multidisciplinary gender-affirming team was three years (IQR: 1-10 years). The frequency of transgender identity was notable in participants with ages between 15 and 17 years. Depressive symptoms, anxiety, and psychotropic drug use were significantly higher in individuals assigned female at birth. Among 25 individuals assigned female at birth who participated in this study, 60% self-recognized as transgender men.18 individuals assigned male at birth, 67% self-recognized as transgender women. The most frequent treatment was a referral to mental health services (46.51%).

CONCLUSION

Based on the cohort of our study, we can conclude that patients consult for gender-affirming treatment 3 years after the onset of gender incongruence. Anxiety and depression were higher in individuals assigned female at birth. Additionally, they presented at a later stage of sexual maturation, reducing the possibility of using puberty blockers.

Binary and Non-binary Gender Identities, Internalizing Problems, and Treatment Wishes Among Adolescents Referred to a Gender Identity Clinic in Germany

Clinical research on transgender and gender-nonconforming (TGNC) adolescents has focused on binary individuals or often not differentiated among gender identities. Recent studies suggest that a considerable proportion of TGNC adolescents identify as non-binary and that these youth report more internalizing problems as well as different transition-related medical treatment wishes than binary adolescents. However, the results are inconclusive, and data for the German-speaking area are lacking. Therefore, the present study aimed to assess the percentage of binary and non-binary gender identities in a German sample of clinically referred TGNC adolescents and examine associations of gender identity with internalizing problems and transition-related medical treatment wishes. The sample consisted of 369 adolescents (11-18 years, Mage = 15.43; 305 birth-assigned female, 64 birth-assigned male) who attended the Hamburg Gender Identity Service for children and adolescents (Hamburg GIS) between 2013 and 2019. Gender identity and treatment wishes were assessed using study-specific items and internalizing problems using the Youth Self-Report. In total, 90% (n = 332) of the sample identified as binary and 10% (n = 37) as non-binary. Having a non-binary gender identity was significantly associated with more internalizing problems and with wishing for no transition-related medical treatment or only puberty-suppressing hormones. The results underscore that non-binary adolescents represent a specifically vulnerable subgroup within TGNC adolescents with unique mental health needs and treatment wishes. Future research should differentiate among various gender identities. In clinical practice, it is crucial to create an inclusive space for non-binary youth and provide mental health care if needed.

Detransition and Desistance Among Previously Trans-Identified Young Adults

Persons who have renounced a prior transgender identification, often after some degree of social and medical transition, are increasingly visible. We recruited 78 US individuals ages 18-33 years who previously identified as transgender and had stopped identifying as transgender at least six months prior. On average, participants first identified as transgender at 17.1 years of age and had done so for 5.4 years at the time of their participation. Most (83%) participants had taken several steps toward social transition and 68% had taken at least one medical step. By retrospective reports, fewer than 17% of participants met DSM-5 diagnostic criteria for Gender Dysphoria in Childhood. In contrast, 53% of participants believed that "rapid-onset gender dysphoria" applied to them. Participants reported a high rate of psychiatric diagnoses, with many of these prior to trans-identification. Most participants (N = 71, 91%) were natal females. Females (43%) were more likely than males (0%) to be exclusively homosexual. Participants reported that their psychological health had improved dramatically since detransition/desistance, with marked decreases in self-harm and gender dysphoria and marked increases in flourishing. The most common reason given for initial trans-identification was confusing mental health issues or reactions to trauma for gender dysphoria. Reasons for detransition were more likely to reflect internal changes (e.g., the participants' own thought processes) than external pressures (e.g., pressure from family). Results suggest that, for some transgender individuals, detransition is both possible and beneficial.

Self-Reported Sexual Behavior of Transgender Youth

INTRODUCTION

Research indicates transgender/gender diverse (TGD) youth are more likely to engage in sexual behavior, have more sexual partners, and initiate sexual behavior earlier than their cisgender peers. However, no gender-inclusive self-report survey questionnaires (i.e., those that do not assume the gender of sexual partners or body parts used for sex) exist to assess sexual behavior of TGD youth. The current study illustrates a questionnaire with nuanced wording to more accurately portray the sexual behavior of TGD youth presenting for gender-affirming medical care compared to national adolescent norms.

METHODS

Retrospective chart review of 323 youth, ages 13-18, presenting to a pediatric gender clinic between 2015-2021. Youth self-reported their gender identity (i.e., masculine, feminine, gender queer, questioning/unsure), sexual behaviors, and partners via a REDCAP survey.

RESULTS

Rates of dating among TGD youth were significantly lower than national norms (33.7% v 68.3%; X2=172.644, p< 0.0001), as was sexual behavior (14.9% vs. 39.5% X2=80.419, p< 0.0001). Rates of self-reported involuntary sexual activity among TGD youth did not differ significantly from national norms (7.1% vs. 6.9%, ns). Body parts used for sex, the number of sexual partners, and the gender identity of sexual partners are reported.

DISCUSSION

Results suggest that rates of dating and sexual behavior among TGD youth are significantly lower than national norms, supporting a need for screening of sexual health among TGD youth utilizing gender-inclusive measures. A standardized gender-inclusive questionnaire of sexual behavior is needed to improve data accuracy and help develop inclusive programs to address the sexual health needs of TGD youth.

An Examination of Power in a Triadic Model of Parent-Child-Pediatrician Relationships Related to Early Childhood Gender Development

In this paper, the authors introduce the Triadic Model of Pediatric Care, an innovative conceptual framework for pediatric practice with transgender and gender diverse children. The Triadic Model of Pediatric Care consists of three experts-pediatricians, primary caregiver(s), and children-who each possess unique insights, knowledge, and decision-making power. This model guides pediatricians to provide gender-affirming care that acknowledges children as experts of their own experience and worthy of bodily autonomy, while also working to ensure primary caregiver(s) have the information and support necessary to provide a safe and nurturing developmental environment for their child. The authors provide a recommendation for how the Triadic Model of Pediatric Care might be applied in a pediatric healthcare setting and conclude with a summary of the model's implications, limitations, and future directions.

Demographics and gender-related measures in younger and older adolescents presenting to a gender service

Transgender adolescents may present to gender identity specialty services earlier or later in adolescence. The aim of this study was to examine whether, 'younger' and 'older' presenters could be identified in a large cohort of transgender adolescents and if differences exist between the two groups. The study sample consisted of 1487 adolescents (506 birth-assigned males, 981 birth-assigned females) referred between 2000 and 2018. The distribution of age at intake was evaluated. Demographic, diagnostic, and treatment characteristics, the Recalled Childhood Gender Identity/Gender Role Questionnaire (RCGI) to measure childhood gender nonconformity and the Body Image Scale (BIS) to measure body image were collected. Based on a stem-and-leaf plot and a histogram, two groups were identified: adolescents presenting at ≤ 13.9 years ('younger presenters') and adolescents presenting at 14 years or older ('older presenters'). The sex ratio was more extreme in the group of older presenters favoring birth-assigned females (Χ2(1, N = 1487) = 19.69, p < 0.001). Furthermore, more adolescents from the younger presenting group lived with both biological parents (Χ2(1, N = 1427) = 24.78, p < 0.001), were diagnosed with gender dysphoria and started with medical gender-affirming treatment (Χ2(1, N = 1404) = 4.60, p = 0.032 and Χ2(1, N = 1487) = 29.16, p < 0.001). Younger presenters showed more gender nonconformity in childhood (β 0.315, p < 0.001, 95% CI 0.224-0.407). Older presenters were more dissatisfied with various aspects of their bodies (p < 0.001). The differences between older and younger presenting adolescents suggest that there may be different developmental pathways in adolescents that lead to seeking gender-affirming medical care and argues for more tailored care.

A New Flight from Womanhood? The Importance of Working Through Experiences Related to Exposure to Pornographic Content in Girls Affected by Gender Dysphoria

Parallel to the advent of social media and the easy access to online pornographic content there is a sharp increase in adolescent females expressing gender dysphoria worldwide. This paper argues that treatment of gender dysphoria in female adolescents must include explicit exploration into their use and exchange of pornographic content, as well as possible online or offline contacts with adults. Possible avenues of how pornographic content may increase the shame and fear of becoming a woman include the acquisition of misogynistic sexual scripts based on false assumptions on sexuality including the normalization of the violation of females as pleasurable for them, peer influence among female friendship groups, the susceptibility of our medical systems to "mass hysteria" phenomena, easier access of adults with sexually abusive intentions to youth through social media, sexual abuse and victim blaming on females, as well as the influence of pornography on mentalization capacities. As the influence of pornography on gender dysphoria in girls is understudied, this paper provides questions for qualitative and quantitative research, case studies and history taking. Especially the lack of an adequate other during exposure may aggravate false assumptions on gender roles and gender inequality seen in mainstream pornography. Girls affected by autism might be at higher risk because of their reduced mentalization capacities. Working through experiences associated with pornographic content and sexually abusive experiences may correct false beliefs about gender inequality and therefore might alleviate gender dysphoria.

Une approche d'affirmation pour les soins aux jeunes transgenres et de diverses identités de genre

Un nombre croissant de jeunes s'identifient comme transgenres ou de diverses identités de genre. De nombreux pédiatres et dispensateurs de soins de première ligne accueilleront cette population dans leur pratique, dans le cadre de soins liés au genre ou de soins de santé généraux. Le présent document de principes se veut une ressource pour orienter les pédiatres et les dispensateurs de soins de première ligne à adopter une approche d'affirmation pour la prestation des soins réguliers à tous les jeunes. De plus, il contient de l'information visant à aider les dispensateurs à répondre aux demandes de conseils des jeunes transgenres et de diverses identités de genre et de leur famille au sujet des possibilités de transition médicale et d'orientation vers des services spécialisés s'ils le désirent et le jugent pertinent. Enfin, on anticipe que la demande de soins d'affirmation de genre continue d'augmenter, et certains dispensateurs de soins peuvent souhaiter acquérir les connaissances et les habiletés nécessaires pour amorcer les inhibiteurs d'hormones et les hormones d'affirmation de genre chez les adolescents. Le présent document ne contient pas de directives cliniques, mais de l'information fondamentale au sujet des divers éléments possibles des soins d'affirmation de genre, tout en reconnaissant que les besoins et les objectifs d'adolescents particuliers n'incluent pas automatiquement de telles interventions. D'autres ressources permettant d'acquérir les compétences nécessaires pour offrir des interventions d'affirmation de genre sont également proposées.

An affirming approach to caring for transgender and gender-diverse youth

Increasing numbers of youth identify as transgender or gender-diverse (TGD). Many paediatricians and primary care providers (PCPs) will encounter this population in their practice, either for gender-related care or general health needs. This statement is intended as a resource to guide paediatricians and PCPs in implementing an affirming approach to routine health care provision for all youth. Furthermore, it presents information to assist providers in responding to requests for counselling from TGD youth and their families around potential options for medical transition, and in making referrals to specialized services, if desired and relevant. Finally, as demand for gender-affirming care is anticipated to continue to increase, some health care providers (HCPs) may wish to develop the knowledge and skills required to initiate adolescents on hormone-blocking agents and gender-affirming hormones. This document is not intended to be a clinical practice guideline, but will provide foundational information regarding these potential components of gender-affirming care, recognizing that the needs and goals of individual adolescents may or may not include such interventions. Additional resources relevant to developing the expertise required to provide gender-affirming interventions will also be identified.

Testosterone Restores Body Composition, Bone Mass, and Bone Strength Following Early Puberty Suppression in a Mouse Model Mimicking the Clinical Strategy in Trans Boys

Transgender youth increasingly present at pediatric gender services. Some of them receive long-term puberty suppression with gonadotropin-releasing hormone analogues (GnRHa) before starting gender-affirming hormones (GAH). The impact of GnRHa use started in early puberty on bone composition and bone mass accrual is unexplored. It is furthermore unclear whether subsequent GAH fully restore GnRHa effects and whether the timing of GAH introduction matters. To answer these questions, we developed a mouse model mimicking the clinical strategy applied in trans boys. Prepubertal 4-week-old female mice were treated with GnRHa alone or with GnRHa supplemented with testosterone (T) from 6 weeks (early puberty) or 8 weeks (late puberty) onward. Outcomes were analyzed at 16 weeks and compared with untreated mice of both sexes. GnRHa markedly increased total body fat mass, decreased lean body mass, and had a modest negative impact on grip strength. Both early and late T administration shaped body composition to adult male levels, whereas grip strength was restored to female values. GnRHa-treated animals showed lower trabecular bone volume and reduced cortical bone mass and strength. These changes were reversed by T to female levels (cortical bone mass and strength) irrespective of the time of administration or even fully up to adult male control values (trabecular parameters) in case of earlier T start. The lower bone mass in GnRHa-treated mice was associated with increased bone marrow adiposity, also reversed by T. In conclusion, prolonged GnRHa use started in prepubertal female mice modifies body composition toward more fat and less lean mass and impairs bone mass acquisition and strength. Subsequent T administration counteracts GnRHa impact on these parameters, shaping body composition and trabecular parameters to male values while restoring cortical bone architecture and strength up to female but not male control levels. These findings could help guide clinical strategies in transgender care. © 2023 American Society for Bone and Mineral Research (ASBMR).

Unmet Needs of Pediatricians in Transgender-Specific Care: Results of a Short-Term Training

INTRODUCTION

The aim of this study was to evaluate (i) the knowledge about different dimensions of sexual identity in a group of family pediatricians and (ii) the efficacy of a training program to improve knowledge and reduce genderism and heteronormativity.

METHODS

A pre-post-follow-up study was conducted with 96 Italian pediatricians (48 men and 48 women) who participated in a 6-h training program and divided into 2 sections. The first section was theoretical and focused on the conceptual foundations of sexual identity, the depathologizing approach to gender diversity, and the role of pediatricians as the first contacts of children's or adolescents' family. The second part was experiential and included the presentation of a clinical case and the activation of a group reflection on the management of gender-diverse youth. Knowledge about sexual identity, genderism, and heteronormativity was measured.

RESULTS

Pre-training questionnaires revealed that the mean score of knowledge about sexual identity was 7.13 ± 3.21. One-way within-subject ANOVA revealed significant effects from pre- to post-training and from pre- to follow-up assessment but not from post-training to follow-up assessment, suggesting that significant changes in the knowledge about sexual identity (F = 39.75, p < 0.001), in personal biases related to genderism (F = 7.46, p < 0.01), and in heteronormative attitudes (F = 44.99, p < 0.001) and behaviors (F = 79.29, p < 0.001) were achieved through the training and maintained at follow-up.

CONCLUSION

These findings indicate the importance of training pediatricians to work with gender-diverse youth and provide them with the best clinical interventions.

[Media's Stranglehold on Storm and Stress - The Sorrows of Generation Z about Sex and Gender]

Media's Stranglehold on Storm and Stress - The Sorrows of Generation Z about Sex and Gender Abstract: The feeling of not belonging to one's birth sex is not new; one can trace this phenomenon back even to ancient mythology. Although it has always been rare, there has recently been a sharp increase in gender identity deviations among adolescents. This text addresses this problem by asking to what extent this development also results from upheavals in the cultural landscape and, above all, in media technology. Do they cause young people to believe they are in the "wrong gender" and, in extreme cases, to strive for transition? We present the most salient cornerstones of the planned German self-determination law (Self-ID), most of which, however, are unlikely to do justice to the underlying problem. The text concludes by describing several unanswered questions concerning this matter and by attempting to propose first answers. The advantages of a gender-exploratory over the trans affirmative therapy approach are summarized.

Respecting the free will, authenticity and autonomy of transgender youth

Transgender and gender diverse (TGD) youth are currently being targeted by global anti-trans legislation that would prevent their access to gender-affirming care even by healthcare providers willing to deliver it and who understand the importance of this support. It has been suggested in some studies that transness in young people is a result of peer contagion. As such their free will, authenticity and autonomy could be brought into question when accessing gender-affirming care. It is important to explore the relevance of these concepts concerning the provision of gender-affirming care to TGD youth by nurses and other healthcare professionals. Nurses should challenge the notion held by some that these young people are not capable of knowing themselves or the level of treatment they require. They can do this by practising gender-affirming care determined by aspirational ethical values of beneficence, non-maleficence, autonomy and justice.

A PRISMA systematic review of adolescent gender dysphoria literature: 3) treatment

It is unclear whether the literature on adolescent gender dysphoria (GD) provides evidence to inform clinical decision making adequately. In the final of a series of three papers, we sought to review published evidence systematically regarding the types of treatment being implemented among adolescents with GD, the age when different treatment types are instigated, and any outcomes measured within adolescence. Having searched PROSPERO and the Cochrane library for existing systematic reviews (and finding none at that time), we searched Ovid Medline 1946 -October week 4 2020, Embase 1947-present (updated daily), CINAHL 1983-2020, and PsycInfo 1914-2020. The final search was carried out on 2nd November 2020 using a core strategy including search terms for 'adolescence' and 'gender dysphoria' which was adapted according to the structure of each database. Papers were excluded if they did not clearly report on clinically-likely gender dysphoria, if they were focused on adult populations, if they did not include original data (epidemiological, clinical, or survey) on adolescents (aged at least 12 and under 18 years), or if they were not peer-reviewed journal publications. From 6202 potentially relevant articles (post deduplication), 19 papers from 6 countries representing between 835 and 1354 participants were included in our final sample. All studies were observational cohort studies, usually using retrospective record review (14); all were published in the previous 11 years (median 2018). There was significant overlap of study samples (accounted for in our quantitative synthesis). All papers were rated by two reviewers using the Crowe Critical Appraisal Tool v1·4 (CCAT). The CCAT quality ratings ranged from 71% to 95%, with a mean of 82%. Puberty suppression (PS) was generally induced with Gonadotropin Releasing Hormone analogues (GnRHa), and at a pooled mean age of 14.5 (±1.0) years. Cross Sex Hormone (CSH) therapy was initiated at a pooled mean of 16.2 (±1.0) years. Twenty-five participants from 2 samples were reported to have received surgical intervention (24 mastectomy, one vaginoplasty). Most changes to health parameters were inconclusive, except an observed decrease in bone density z-scores with puberty suppression, which then increased with hormone treatment. There may also be a risk for increased obesity. Some improvements were observed in global functioning and depressive symptoms once treatment was started. The most common side effects observed were acne, fatigue, changes in appetite, headaches, and mood swings. Adolescents presenting for GD intervention were usually offered puberty suppression or cross-sex hormones, but rarely surgical intervention. Reporting centres broadly followed established international guidance regarding age of treatment and treatments used. The evidence base for the outcomes of gender dysphoria treatment in adolescents is lacking. It is impossible from the included data to draw definitive conclusions regarding the safety of treatment. There remain areas of concern, particularly changes to bone density caused by puberty suppression, which may not be fully resolved with hormone treatment.

Co-occurring Autism Spectrum Disorder and Gender Dysphoria in Adolescents

BACKGROUND AND OBJECTIVES

Autism spectrum disorder (ASD) and gender dysphoria (GD) frequently cooccur. However, existing research has primarily used smaller samples, limiting generalizability and the ability to assess further demographic variation. The purpose of this study was to (1) examine the prevalence of cooccurring ASD and GD diagnoses among US adolescents aged 9 to 18 and (2) identify demographic differences in the prevalence of cooccurring ASD and GD diagnoses.

METHODS

This secondary analysis used data from the PEDSnet learning health system network of 8 pediatric hospital institutions. Analyses included descriptive statistics and adjusted mixed logistic regression testing for associations between ASD and GD diagnoses and interactions between ASD diagnosis and demographic characteristics in the association with GD diagnosis.

RESULTS

Among 919 898 patients, GD diagnosis was more prevalent among youth with an ASD diagnosis compared with youth without an ASD diagnosis (1.1% vs 0.6%), and adjusted regression revealed significantly greater odds of GD diagnosis among youth with an ASD diagnosis (adjusted odds ratio = 3.00, 95% confidence interval: 2.72-3.31). Cooccurring ASD/GD diagnoses were more prevalent among youth whose electronic medical record-reported sex was female and those using private insurance, and less prevalent among youth of color, particularly Black and Asian youth.

CONCLUSIONS

Results indicate that youth whose electronic medical record-reported sex was female and those using private insurance are more likely, and youth of color are less likely, to have cooccurring ASD/GD diagnoses. This represents an important step toward building services and supports that reduce disparities in access to care and improve outcomes for youth with cooccurring ASD/GD and their families.

Dimensional approach to gender dysphoria in Nigeria: Association with socio-demographic and psycho-sexual variables

Background

Recent changes across the world with respect to gender transitioning of children and adolescents have generated a bio-psycho-socio-cultural discourse among interest groups.

Aim

This study sought to examine gender dysphoric symptoms among adolescents and young persons in an African population, using a dimensional approach.

Method

A total of 747 primary/secondary school and university students aged 10-24 years were studied using the 27-item Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA). Participants were divided into early, mid- and late adolescents. The composite and domain scores were calculated using the criteria described by Deogracias, and comparison of the median scores was done using Mann-Whitney U-test and Kruskal-Wallis test as appropriate. Dunnett's post-hoc test was used for pairwise comparisons.

Results

The prevalence of self-identified transgender and self-reported non-heterosexuals was 0.9% (95%CI: 0.36-1.92) and 18.6% (15.85-21.59), respectively. The participants as a group scored 4.56 out of a possible 5 on the gender dysphoria scale, indicating less gender dysphoric symptoms in this cohort. However, participants in mid- and late adolescents had significantly lower scores when compared with early adolescents (P = 0.009). Self-reported transgender had significantly lower scores in the social (P = 0.001) and socio-legal (P < 0.001) indicators of the scale.

Conclusion

The findings of this study, although, preliminary demonstrated less gender dysphoric symptoms in this cohort of Nigerian adolescents and young adults compared to the Western population. Nevertheless, some degree of GD was noticed, revealing that this condition is existent in our society.

Exploring Gender Diversity in Transgender and Non-Binary Adults Accessing a Specialized Service in Italy

In Italy, studies investigating gender identity and expression in gender non-conforming adults are lacking, as well as data regarding the non-binary population. The present study aimed at dimensionally exploring how transgender and non-binary Italian adults identify and express their gender. The Gender Diversity Questionnaire (GDQ) was administered to a sample of 112 adult subjects aged 18-60 years accessing a gender-specialized service in Rome. The majority of the participants were aged 18-24 years (53.6%), whereas fewer subjects were aged 25-35 years (32%) and 35 years and older (14.3%). Most participants (83.9%) identified themselves as trans binary, while the remaining (16.1%) identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity over time and across contexts. Younger subjects recognized the use of chosen names, pronouns, and clothes as important for their gender expression, whereas older subjects attributed more importance to physical appearance and emotions. Differences regarding gender-affirmative interventions emerged between non-binary and transbinary participants. Findings evidence that gender non-conforming adults accessing gender-specialized services have unique needs and features, thus it is essential to shed light on this population by providing greater visibility and recognition.

The Participation of Trans Women in Competitive Fencing and Implications on Fairness: A Physiological Perspective Narrative Review

Debate has surrounded whether the participation of trans women in female sporting categories is fair, specifically the retained male physiological advantage due to increased testosterone compared to cisgender females. Recently, individual sporting organisations have been investigating and assessing policies regarding trans women athlete participation in female categories, resulting in several banning participation. This review aims to discuss the scientific evidence and provide appropriate guidance for the inclusion of trans women in elite competitive female fencing categories. Fencing is an intermittent sport, where competitions can span 1 to 3 days. The lunge is the most common movement used to attack opponents, where a successful hit relies on the speed of the action. Male puberty induced increased circulating testosterone promotes a greater stature, cardiovascular function, muscle mass, and strength compared to cisgender females, culminating in a ~12-40% sport performance advantage. Elite cisgender male fencers perform significantly higher, ~17-30%, jump heights and leg power measures compared to elite cisgender female fencers, resulting in faster lunges. Trans women receiving androgen-suppression therapy for 12 months showed significant reductions in strength, lean body mass, and muscle surface area, but even after 36 months, the measurements of these three indices remained above those for cisgender females. Previous male muscle mass and strength can be retained through continuation of resistance training. The literature reviewed shows that there is a retained physiological advantage for trans women who have undergone male puberty when participating in the elite competitive female fencing category. A proposed solution of an open or third gender category for elite fencing competition promotes fair competition, while allowing trans women to compete in their chosen sport.

Iatrogenic Harm in Gender Medicine

Although transition regret and detransition are often dismissed as rare, the increasing number of young detransitioners who have come forward in recent years to publicly share their experiences suggests that there are cracks in the gender-affirmation model of care that can no longer be ignored. In this commentary, I argue that the medical community must find ways to have more open discussions and commit to research and clinical collaboration so that regret and detransition really are vanishingly rare outcomes. Moving forward, we must recognize detransitioners as survivors of iatrogenic harm and provide them with the personalized medicine and supports they require.

Transition Regret and Detransition: Meanings and Uncertainties

Gender transition is undertaken to improve the well-being of people suffering from gender dysphoria. However, some have argued that the evidence supporting medical interventions for gender transition (e.g., hormonal therapies and surgery) is weak and inconclusive, and an increasing number of people have come forward recently to share their experiences of transition regret and detransition. In this essay, I discuss emerging clinical and research issues related to transition regret and detransition with the aim of arming clinicians with the latest information so they can support patients navigating the challenges of regret and detransition. I begin by describing recent changes in the epidemiology of gender dysphoria, conceptualization of transgender identification, and models of care. I then discuss the potential impact of these changes on regret and detransition; the prevalence of desistance, regret, and detransition; reasons for detransition; and medical and mental healthcare needs of detransitioners. Although recent data have shed light on a complex range of experiences that lead people to detransition, research remains very much in its infancy. Little is known about the medical and mental healthcare needs of these patients, and there is currently no guidance on best practices for clinicians involved in their care. Moreover, the term detransition can hold a wide array of possible meanings for transgender-identifying people, detransitioners, and researchers, leading to inconsistences in its usage. Moving forward, minimizing harm will require conducting robust research, challenging fundamental assumptions, scrutinizing of practice patterns, and embracing debate.

The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes

BACKGROUND

According to the minority stress theory, stigma affects the health of marginalized populations. Previous stigma research has focused on the health effects of individual and interpersonal stigma, paying less attention to structural factors. Laws on legal gender recognition affect the lives of transgender individuals in unique ways. The fact that these laws and population attitudes vary greatly between European countries, offer a unique opportunity to study the role of structural stigma in the lives of transgender individuals. Little is known about how transgender specific structural stigma relates to individual health determinants. Consequently, the aim of this study was to explore the association between structural stigma and access to gender affirming care, gender identity disclosure in health care, and experiences of discrimination in health care across 28 European countries.

METHODS

By using multilevel regression, we combined data on health seeking behavior, transgender identity disclosure to health care providers, and experiences of discrimination in health care from 6,771 transgender individuals participating in the 2012 European Union Lesbian, Gay, Bisexual and Transgender survey with a structural stigma measure, consisting of population attitudes towards transgender individuals as well as national legislation on gender recognition. Reasons to refrain from seeking care and discrimination in health care were assessed by categorizing countries as low or high in structural stigma and using Chi-square statistics.

RESULTS

Country-level structural stigma was negatively associated experiences of seeking gender affirming care and positively associated with concealment of being transgender to health care providers. Identity concealment was associated with a lower likelihood of exposure to discrimination in the health care setting across countries regardless of their level of structural stigma. The most prevalent reasons to forgo gender affirming care were shared between low and high structural stigma country groups and centered around fear.

CONCLUSION

The results highlight the importance of changing stigmatizing legislation and population attitudes to promote access to gender affirming care as well as openness of being transgender towards providers. Measures to decrease discrimination in the health care setting are warranted in high as well as in low structural stigma countries.

The autism spectrum among transgender youth: default mode functional connectivity

The common intersection of autism and transgender identities has been described in clinical and community contexts. This study investigates autism-related neurophenotypes among transgender youth. Forty-five transgender youth, evenly balanced across non-autistic, slightly subclinically autistic, and full-criteria autistic subgroupings, completed resting-state functional magnetic resonance imaging to examine functional connectivity. Results confirmed hypothesized default mode network (DMN) hub hyperconnectivity with visual and motor networks in autism, partially replicating previous studies comparing cisgender autistic and non-autistic adolescents. The slightly subclinically autistic group differed from both non-autistic and full-criteria autistic groups in DMN hub connectivity to ventral attention and sensorimotor networks, falling between non-autistic and full-criteria autistic groups. Autism traits showed a similar pattern to autism-related group analytics, and also related to hyperconnectivity between DMN hub and dorsal attention network. Internalizing, gender dysphoria, and gender minority-related stigma did not show connectivity differences. Connectivity differences within DMN followed previously reported patterns by designated sex at birth (i.e. female birth designation showing greater within-DMN connectivity). Overall, findings suggest behavioral diagnostics and autism traits in transgender youth correspond to observable differences in DMN hub connectivity. Further, this study reveals novel neurophenotypic characteristics associated with slightly subthreshold autism, highlighting the importance of research attention to this group.

Social Introversion Personality Trait as Predictor of Internalizing Symptoms in Female Adolescents with Gender Dysphoria

The personality trait of social introversion refers to the individual inclination toward the inner/outer world. Moreover, adolescents who experience Gender Dysphoria (GD) can be involved in relationship conflicts with family, peers, and friends and experience stigmatization and rejection from society. This leads higher distress in females which are more sensitive to this kind of feelings. This leads in them frequently developing a negative sense of well-being and low self-esteem which increases their risk of internalizing symptoms. So, the aims of this study were: (1) to investigate the presence of significant differences in Social Introversion (SI) dimensions between an assigned-female at birth (AFAB) GD group and a cisgender female group both diagnosed with a depressive disorder, (2) to verify whether the two clinical groups may be characterized by different profiles of internalizing symptoms, (3) to investigate if the SI dimensions could promote the internalizing symptomatology. Our results confirmed the presence of significantly higher score in GD sample for MMPI-SI scale and subscales and showed no significant difference in depressive profiles. Lastly, SI could promote internalizing symptomatology in AFAB underlying a link between SI and depression in this condition which should be further investigated.

Exploring gender dysphoria and related outcomes in a prospective cohort study: protocol for the Swedish Gender Dysphoria Study (SKDS)

INTRODUCTION

There has been a drastic increase in the reported number of people seeking help for gender dysphoria in many countries over the last two decades. Yet, our knowledge of gender dysphoria and related outcomes is restricted due to the lack of high-quality studies employing comprehensive approaches. This longitudinal study aims to enhance our knowledge of gender dysphoria; different aspects will be scrutinised, focusing primarily on the psychosocial and mental health outcomes, prognostic markers and, secondarily, on the underlying mechanisms for its origin.

METHODS AND ANALYSIS

The Swedish Gender Dysphoria Study is an ongoing multicentre longitudinal cohort study with 501 registered participants with gender dysphoria who are 15 years old or older. Participants at different phases of their clinical evaluation process can enter the study, and the expected follow-up duration is three years. The study also includes a comparison group of 458 age- and county-matched individuals without gender dysphoria. Data on the core outcomes of the study, which are gender incongruence and experienced gender dysphoria, body satisfaction and satisfaction with gender-affirming treatments, as well as other relevant outcomes, including mental health, social functioning and life satisfaction, are collected via web surveys. Two different research visits, before and after starting on gender-affirming hormonal treatment (if applicable), are planned to collect respective biological and cognitive measures. Data analysis will be performed using appropriate biostatistical methods. A power analysis showed that the current sample size is big enough to analyse continuous and categorical outcomes, and participant recruitment will continue until December 2022.

ETHICS AND DISSEMINATION

The ethical permission for this study was obtained from the Local Ethical Review Board in Uppsala, Sweden. Results of the study will be presented at national and international conferences and published in peer-reviewed journals. Dissemination will also be implemented through the Swedish Gender Dysphoria Study network in Sweden.

Prevalence and Comorbidity of Gender Dysphoria in Taiwan, 2010-2019

Gender dysphoria (GD) is a condition in which a person exhibits marked incongruence between their expressed or experienced gender and their sex assigned at birth. The last survey of individuals with GD in Taiwan was conducted approximately 10 years ago. In this study, we investigated the prevalence of GD in Taiwan within the last 10 years as well as comorbidities. A retrospective medical record review was performed for all patients in the database of the Health and Welfare Data Science Center covered by National Health Insurance in Taiwan from January 2010 until December 2019. The study population of persons with GD was defined as individuals who had been diagnosed with transsexualism (transgender or transsexual) or gender identity disorders. Our review found case numbers and prevalence of GD in 2019 were about twice that of patients in 2010 for both assigned males and assigned females at birth. Case numbers for 2010 versus 2019 were 440 versus 867 for assigned males at birth, and 189 versus 386 for assigned females at birth. The 1-year prevalence for 2010 versus 2019 was 3.8/100,000 versus 7.4/100,000 for assigned males at birth, and 1.6/100,000 versus 3.2/100,000 for assigned females at birth. Comorbidities of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and psychosis were more likely in children with GD younger than 12 years of age; comorbid depression was more likely in adolescents and adults with GD. Improvements in social and mental health support should be provided to help address these comorbidities of ADHD, ASD, and depression among individuals with GD.

Is Social Gender Transition Associated with Mental Health Status in Children and Adolescents with Gender Dysphoria?

Social gender transition is an increasingly accepted intervention for gender variant children and adolescents. To date, there is scant literature comparing the mental health of children and adolescents diagnosed with gender dysphoria who have socially transitioned versus those who are still living in their birth-assigned gender. We examined the mental health of children and adolescents referred to the Gender Identity Development Service (GIDS), a specialist clinic in London, UK, who had socially transitioned (i.e., were living in their affirmed gender and/or had changed their name) versus those who had not socially transitioned. Referrals to the GIDS were aged 4-17 years. We assessed mental health correlates of living in one's affirmed gender among 288 children and adolescents (208 birth-assigned female; 210 socially transitioned) and of name change in 357 children and adolescents (253 birth-assigned female; 214 name change). The presence or absence of mood and anxiety difficulties and past suicide attempts were clinician rated. Living in role and name change were more prevalent in birth-assigned females versus birth-assigned males. Overall, there were no significant effects of social transition or name change on mental health status. These findings identify the need for more research to understand how social transition influences mental health, including longitudinal studies that allow for more confident inferences to be made regarding the relationship between social transition and mental health in young people with gender dysphoria.

Chest Wall Contouring in Transgender Men: A 20-Year Experience from a National Center

Several western countries have experienced a drastic increase of referrals to specialist gender services of transgender and gender-diverse people. Chest wall contouring is an important element in treatment of gender dysphoria. National data concerning this group have yet to be investigated. The aim of this study was to examine and evaluate the techniques and surgical outcome of chest wall contouring from the last 20 years from a single center in Norway.

Methods

This study is a retrospective review of all female-to-male patients who underwent chest wall contouring surgery at Oslo University Hospital between 2000 and 2020. Statistical analysis with comparison of techniques and evaluation of development over time was examined.

Results

In total, 333 patients underwent bilateral chest wall contouring, 209 (62.8%) with inframammary incision with free nipple graft (IM), and 124 (37.2%) with periareolar technique (PA). In 20 years, the average age decreased from 31 (19-68) to 24.9 years (17-61). Average body mass index was significantly lower in the PA-group than in the IM-group. Complication rate was 20.7%, with postoperative bleeding being the most frequent (9.6%). Revision surgery was required in 24.9% of the cases; periareolar technique required significantly more procedures.

Conclusions

The number of patients referred and operated on has increased drastically over a 20-year period. When comparing the techniques, the outcome concerning complications and revisions is at an acceptable level. Postoperative bleeding and revision surgery occur more often with the periareolar technique. There remains a knowledge gap concerning quality of life and satisfaction after surgery within this patient group.

Rapid Onset Gender Dysphoria: Parent Reports on 1655 Possible Cases

During the past decade there has been a dramatic increase in adolescents and young adults (AYA) complaining of gender dysphoria. One influential if controversial explanation is that the increase reflects a socially contagious syndrome: Rapid Onset Gender Dysphoria (ROGD). We report results from a survey of parents who contacted the website ParentsofROGDKids.com because they believed their AYA children had ROGD. Results focused on 1655 AYA children whose gender dysphoria reportedly began between ages 11 and 21 years, inclusive. These youths were disproportionately (75%) natal female. Natal males had later onset (by 1.9 years) than females, and they were much less likely to have taken steps toward social gender transition (65.7% for females versus 28.6% for males). Pre-existing mental health issues were common, and youths with these issues were more likely than those without them to have socially and medically transitioned. Parents reported that they had often felt pressured by clinicians to affirm their AYA child's new gender and support their transition. According to the parents, AYA children's mental health deteriorated considerably after social transition. We discuss potential biases of survey responses from this sample and conclude that there is presently no reason to believe that reports of parents who support gender transition are more accurate than those who oppose transition. To resolve controversies regarding ROGD, it is desirable that future research includes data provided by both pro- and anti-transition parents, as well as their gender dysphoric AYA children.

Gender Dysphoria in Young People: A Model of Chronic Stress

BACKGROUND

Gender dysphoria (GD) refers to the distress that may accompany gender incongruence, often heightened at the onset of puberty, with the development of secondary sex characteristics. Children and adolescents may be especially vulnerable to severe stressors, including GD, with potentially irreversible effects if these exposures occur during critical periods of development and brain maturation.

SUMMARY

We describe the evidence for GD as a chronic stressor, drawing parallels to other established models of stress, activating both innate psychological and biological stress responses. As well as being an inherently distressing experience, a person who experiences GD may also experience minority stress. Minority stress has been demonstrated in young people who experience GD with higher rates of social rejection and internalized stigma and shame. The biological stress response in young people with GD is illustrated through the activation of the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and pro-inflammatory response. The number of young people who report experiencing GD has increased exponentially worldwide in the past decade, demanding a change in the clinic infrastructure. Paediatric endocrinologists and specialists in mental health work together to both support psychosocial well-being and offer individualized treatment to align the phenotype with gender identity with the aim of alleviating the distress of GD. Medical interventions may include puberty suppression and gender-affirming hormones. Ongoing monitoring is required prior to initiation and during treatment to ensure that the goals of treatment are being achieved.

In Addition to Stigma: Cognitive and Autism-Related Predictors of Mental Health in Transgender Adolescents

OBJECTIVE

Autism spectrum disorder (ASD) is significantly over-represented among transgender adolescents. Independently, ASD and gender diversity are associated with increased mental health risks. Yet, mental health in autistic-transgender adolescents is poorly understood. This study investigates mental health in the largest matched sample to date of autistic-transgender, non-autistic (allistic) transgender, and autistic-cisgender adolescents diagnosed using gold-standard ASD diagnostic procedures. In accordance with advancing understanding of sex/gender-related autism phenotypes, slightly subthreshold autistic diagnostic presentations (common in autistic girls/women) are modeled.

METHOD

This study includes 93 adolescents aged 13-21, evenly divided between autistic-transgender, autistic-cisgender, and allistic-transgender groups; 13 transgender adolescents were at the margin of ASD diagnosis and included within a larger "broad-ASD" grouping. Psychological and neuropsychological evaluation included assessment of mental health, IQ, LGBT stigma, ASD-related social symptoms, executive functioning (EF), and EF-related barriers to achieving gender-related needs.

RESULTS

Autistic-transgender adolescents experienced significantly greater internalizing symptoms compared to allistic-transgender and autistic-cisgender groups. In addition to stigma-related associations with mental health, ASD-related cognitive/neurodevelopmental factors (i.e., poorer EF and greater social symptoms) were associated with worse mental health: specifically, social symptoms and EF gender barriers with greater internalizing and EF problems and EF gender barriers with greater suicidality. Comparing across all ASD and gender-related groups, female gender identity was associated with greater suicidality.

CONCLUSIONS

Parsing the heterogeneity of mental health risks among transgender youth is critical for developing targeted assessments and interventions. This study identifies ASD diagnosis, ASD phenotypic characteristics, and EF-related gender barriers as potential risks for poorer mental health in transgender adolescents.

Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol

BACKGROUND

Twenty years ago, the Dutch Protocol-consisting of a gonadotropin-releasing hormone agonist (GnRHa) to halt puberty and subsequent gender-affirming hormones (GAHs)-was implemented to treat adolescents with gender dysphoria.

AIM

To study trends in trajectories in children and adolescents who were referred for evaluation of gender dysphoria and/or treated following the Dutch Protocol.

METHODS

The current study is based on a retrospective cohort of 1766 children and adolescents in the Amsterdam Cohort of Gender Dysphoria.

OUTCOMES

Outcomes included trends in number of intakes, ratio of assigned sex at birth, age at intake, age at start of GnRHa and GAH, puberty stage at start of GnRHa, proportions of adolescents starting and stopping GnRHa, reasons for refraining from GnRHa, and proportions of people undergoing gender-affirming surgery.

RESULTS

A steep increase in referrals was observed over the years. A change in the AMAB:AFAB ratio (assigned male at birth to assigned female at birth) was seen over time, tipping the balance toward AFAB. Age at intake and at start of GnRHa has increased over time. Of possibly eligible adolescents who had their first visit before age 10 years, nearly half started GnRHa vs around two-thirds who had their first visit at or after age 10 years. The proportion starting GnRHa rose only for those first visiting before age 10. Puberty stage at start of GnRHa fluctuated over time. Absence of gender dysphoria diagnosis was the main reason for not starting GnRHa. Very few stopped GnRHa (1.4%), mostly because of remission of gender dysphoria. Age at start of GAH has increased mainly in the most recent years. When a change in law was made in July 2014 no longer requiring gonadectomy to change legal sex, percentages of people undergoing gonadectomy decreased in AMAB and AFAB.

CLINICAL IMPLICATIONS

A substantial number of adolescents did not start medical treatment. In the ones who did, risk for retransitioning was very low, providing ongoing support for medical interventions in comprehensively assessed gender diverse adolescents.

STRENGTHS AND LIMITATIONS

Important topics on transgender health care for children and adolescents were studied in a large cohort over an unprecedented time span, limited by the retrospective design.

CONCLUSION

Trajectories in diagnostic evaluation and medical treatment in children and adolescents referred for gender dysphoria are diverse. Initiating medical treatment and need for surgical procedures depends on not only personal characteristics but societal and legal factors as well.

Evolution and trends in referrals to a specialist gender identity unit in Spain over 10 years (2012-2021)

BACKGROUND

International studies have reported an increase in referrals to gender identity units, a shift in the assigned sex ratio of adolescents, a decrease in the age at first visit, and a growing presence of individuals with nonbinary gender identities.

AIM

To investigate whether these trends are present in a Spanish sample of individuals referred to a gender identity unit over the last 10 years.

METHODS

We conducted a retrospective chart review of 913 consecutive referrals to a gender identity unit between 2012 and 2021 and retrieved information regarding sex assigned at birth, age at first visit, and expressed gender identity. We stratified the patients into 5 age categories: children (<12 years), adolescents (12-17 years), young adults (18-25 years), adults (26-45 years), and older adults (>45 years). The data were analyzed via descriptive and regression analyses.

OUTCOMES

Outcomes included the number of annual referrals, age at first visit, assigned sex ratio, and individuals with nonbinary gender identities.

RESULTS

The number of referrals increased 10-fold, from 18 in 2012 to 189 in 2021. The rates of increase over time were significantly more pronounced for adolescents and young adults and significantly greater for those assigned female at birth (AFAB). The age of referrals at first visit decreased, and AFAB individuals were, on average, younger than individuals assigned male at birth. The assigned sex ratio favored AFAB patients among adolescents (2.4:1) and young adults (1.75:1). Logistic regression showed that the odds of a new referral being AFAB increased by 9% per calendar year and that adolescent and young adult new referrals were significantly more likely to be AFAB. There were 21 referrals of nonbinary individuals starting in 2017, making up 6.4% of applications in 2021 and 2.9% during the last 5 years.

CLINICAL IMPLICATIONS

The evolution and trends observed in this study highlight the need for expanded resources, competent care, and careful reflection about implications for best practice.

STRENGTHS AND LIMITATIONS

This investigation involves a large sample of patients and is the first in our country to include people of all ages. However, the findings might not be generalizable to other gender identity units or the broader population of gender-diverse individuals.

CONCLUSION

Overall, our findings were consistent with previous international reports. We observed a marked increase in referrals, particularly among AFAB adolescents and young adults, a decreased age at first visit, and a growing presence of nonbinary individuals.

Developmental Pathway Choices of Young People Presenting to a Gender Service with Gender Distress: A Prospective Follow-Up Study

This prospective case-cohort study examines the developmental pathway choices of 79 young people (13.25-23.75 years old; 33 biological males and 46 biological females) referred to a tertiary care hospital's Department of Psychological Medicine (December 2013-November 2018, at ages 8.42-15.92 years) for diagnostic assessment for gender dysphoria (GD) and for potential gender-affirming medical interventions. All of the young people had attended a screening medical assessment (including puberty staging) by paediatricians. The Psychological Medicine assessment (individual and family) yielded a formal DSM-5 diagnosis of GD in 66 of the young people. Of the 13 not meeting DSM-5 criteria, two obtained a GD diagnosis at a later time. This yielded 68 young people (68/79; 86.1%) with formal diagnoses of GD who were potentially eligible for gender-affirming medical interventions and 11 young people (11/79; 13.9%) who were not. Follow-up took place between November 2022 and January 2023. Within the GD subgroup (n = 68) (with two lost to follow-up), six had desisted (desistance rate of 9.1%; 6/66), and 60 had persisted on a GD (transgender) pathway (persistence rate of 90.9%; 60/66). Within the cohort as a whole (with two lost to follow-up), the overall persistence rate was 77.9% (60/77), and overall desistance rate for gender-related distress was 22.1% (17/77). Ongoing mental health concerns were reported by 44/50 (88.0%), and educational/occupational outcomes varied widely. The study highlights the importance of careful screening, comprehensive biopsychosocial (including family) assessment, and holistic therapeutic support. Even in highly screened samples of children and adolescents seeking a GD diagnosis and gender-affirming medical care, outcome pathways follow a diverse range of possibilities.

Transgender identity is associated with severe suicidal ideation among Finnish adolescents

OBJECTIVES

Emerging evidence reveals disparities in suicidal behaviour and ideation exist between transgender and cisgender youth. It has been hypothesized that certain gender minority specific risk factors, such as experiences of victimization, could partially explain the mental health disparities between transgender and cisgender youth. We set out to explore whether transgender identity is associated with severe suicidal ideation among Finnish adolescents and whether the possible association persist when a range of covariates is controlled for.

METHODS

The study included 1,425 pupils (mean age (SD) = 15.59 (0.41)) who participated in the study during a school lesson. Logistic regression was used to study associations between transgender identity and severe suicidal ideation.

RESULTS

Four models, each adding more covariates, were created. The final model revealed a statistically significant association between transgender identity and severe suicidal ideation, even though the association grew weaker as more covariates were added and controlled for.

CONCLUSIONS

The results indicate that transgender identity is associated with severe suicidal ideation even after prominent covariates or risk factors of suicidal behaviour and ideation have been taken into account.