Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results

Desire for Gender-Affirming Medical Care Before Age 18 in Transgender and Nonbinary Young Adults

Purpose: We aimed to understand transgender and nonbinary (TNB) young adults' desire to receive gender-affirming medical care (GAMC) before age 18 and identify barriers and facilitators to receiving this care in adolescence. Methods: A cross-sectional survey was administered to TNB young adults presenting for care between ages 18 and 20 in 2023. Descriptive statistics characterized the sample, χ2 tests with post hoc pairwise comparisons identified differences in desire for gender-affirming medications, outness, and parental consent by gender identity and sex assigned at birth, and t-tests evaluated differences in barriers and facilitators to receiving care by outness to parents. Results: A total of 230 TNB respondents had complete data. Nearly all (94.3%) indicated they desired GAMC before age 18. Half (55.7%) of the respondents reported being out about their gender identity to a parent before age 18. Outness, discussing desire for GAMC, and asking for consent to receive GAMC from a parent were significantly more common among participants who identified as men compared to those who identified as women and among those assigned female at birth compared to those assigned male at birth. No such differences emerged when comparing nonbinary individuals to those who identified as men or women. Lack of parental willingness to consent for GAMC was cited as the primary contributor of not having received care in adolescence. Conclusions: Many TNB young adults desire GAMC in adolescence; however, lack of parental support is a key barrier to receiving this care, suggesting a need for more readily available resources for parents to support TNB adolescents.

Variation in Time-to-Gender-Affirming Hormone Therapy in the US Active Duty Service Members

BACKGROUND

Beginning in July 2016, transgender service members in the US military were allowed to receive gender-affirming medical care, if so desired.

OBJECTIVE

This study aimed to evaluate variation in time-to-hormone therapy initiation in active duty Service members after the receipt of a diagnosis indicative of gender dysphoria in the Military Health System.

RESEARCH DESIGN

This retrospective cohort study included data from those enrolled in TRICARE Prime between July 2016 and December 2021 and extracted from the Military Health System Data Repository.

PARTICIPANTS

A population-based sample of US Service members who had an encounter with a relevant International Classification of Diseases 9/10 diagnosis code.

MEASURES

Time-to-gender-affirming hormone initiation after diagnosis receipt.

RESULTS

A total of 2439 Service members were included (Mage 24 y; 62% white, 16% Black; 12% Latine; 65% Junior Enlisted; 37% Army, 29% Navy, 25% Air Force, 7% Marine Corps; 46% first recorded administrative assigned gender marker female). Overall, 41% and 52% initiated gender-affirming hormone therapy within 1 and 3 years of diagnosis, respectively. In the generalized additive model, time-to-gender-affirming hormone initiation was longer for Service members with a first administrative assigned gender marker of male relative to female (P<0.001), and Asian and Pacific Islander (P=0.02) and Black (P=0.047) relative to white Service members. In time-varying interactions, junior enlisted members had longer time-to-initiation, relative to senior enlisted members and junior officers, until about 2-years postinitial diagnosis.

CONCLUSION

The significant variation and documented inequities indicate that institutional data-driven policy modifications are needed to ensure timely access for those desiring care.

Co-design and usability of an interactive web-based fertility decision aid for transgender youth and young adults

OBJECTIVE

To develop a patient- and family-centered Aid For Fertility-Related Medical Decisions (AFFRMED) interactive website targeted for transgender and nonbinary (TNB) youth/young adults and their parents to facilitate shared decision-making about fertility preservation interventions through user-centered participatory design.

METHOD

TNB youth/young adults interested in or currently receiving pubertal suppression or gender-affirming hormone treatment and parents of eligible TNB youth/young adults were recruited to participate in a series of iterative human-centered co-design sessions to develop an initial AFFRMED prototype. Subsequently, TNB youth/young adults and parents of TNB youth/young adults were recruited for usability testing interviews, involving measures of usability (i.e., After Scenario Questionnaire, Net Promotor Score, System Usability Scale).

RESULTS

Twenty-seven participants completed 18 iterative co-design sessions and provided feedback on 10 versions of AFFRMED (16 TNB youth/young adults and 11 parents). Nine TNB youth/young adults and six parents completed individual usability testing interviews. Overall, participants rated AFFRMED highly on measures of acceptability, appropriateness, usability, and satisfaction. However, scores varied by treatment cohort, with TNB youth interested in or currently receiving pubertal suppression treatment reporting the lowest usability scores.

CONCLUSIONS

We co-created a youth- and family-centered fertility decision aid prototype that provides education and decision support in an online, interactive format. Future directions include testing the efficacy of the decision aid in improving fertility and fertility preservation knowledge, decisional self-efficacy, and decision satisfaction.

Association of Pubertal Blockade at Tanner 2/3 With Psychosocial Benefits in Transgender and Gender Diverse Youth at Hormone Readiness Assessment

PURPOSE

Compare psychosocial function at the time of hormone readiness assessment for transgender and gender diverse (TGD) youth who received pubertal blockade to prevent a nonaffirming puberty with those who did not.

METHODS

Retrospective cohort study of psychological assessment data from hormone readiness evaluations conducted at a multispecialty gender clinic. Participants include all TGD youth between the ages of 13 and 17 assessed for hormone readiness between 2017 and 2021.

RESULTS

Our cohort consisted of 438 TGD youth, 40 who were prescribed pubertal blockade at Tanner stage 2 or 3, and 398 who had not. The blocker population was younger, more likely to be assigned male and affirming a female identity, and had a different racial/ethnic identity distribution. Having puberty blocked was associated with significantly lower T-scores on the Youth Self Report for internalizing problems (β = -7.4, p < .001), anxiety problems (β = -4.6, p = .003), depressive problems (β = -6.5, p < .001), stress problems (β = -4.0, p = .01), and total problems (β = -4.9, p = .003). The blocker population was also significantly less likely to report any suicidal thoughts (odds ratio = 0.38, p = .05). With the exception of increased risk of suicidal thoughts, these associations remained significant when adjusted for gender.

DISCUSSION

At the time of hormone readiness evaluation, TGD youth who received pubertal blockade at Tanner 2 or 3 were found to have less anxiety, depression, stress, total problems, internalizing difficulties, and suicidal ideation than TGD peers who had been through more of a nonaffirming puberty.

Psychiatric Diagnoses and Psychotropic Drug Usage in Gender-Affirming Voice Surgery Patients

OBJECTIVES

To describe the burden of psychiatric illness and psychotropic medication usage among the subset of transgender patients who undergo gender-affirming laryngeal surgery and describe some of the most commonly encountered conditions experienced by this population.

METHODS

An Institutional Review Board-approved chart review was conducted for the 18 patients who have undergone gender-affirming laryngeal procedures from August 2019 to June 2022 performed at a single institution. Patient demographic data, treatment details, and psychiatric diagnoses and prescriptions for psychotropic medications were recorded.

RESULTS

Of the 18 patients who underwent gender-affirming laryngeal surgery at this institution, 16 patients underwent these operations as part of a transition from male to female gender, while 2 patients were transitioning from female to male gender. In this cohort, 13 patients were diagnosed with a psychiatric comorbidity (72.2%). Of these patients, 11 were prescribed at least 1 psychotropic medication (61.1%). The most common psychiatric illnesses encountered in these patients were depression, anxiety, and post-traumatic stress disorder. Ten patients were diagnosed with more than 1 psychiatric comorbidity (55.6%). The most commonly prescribed psychotropic drugs were selective serotonin/norepinephrine reuptake inhibitors. Three patients in this cohort had a recorded history of at least one prior suicide attempt.

CONCLUSIONS

Multiple studies have demonstrated increased rates of mental illness in transgender individuals, however, this is the first study to describe the burden of these conditions specifically in the subset of patients who undergo gender-affirming laryngeal surgery.

[Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria]

Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria Abstract: Objective: The suppression of physiological puberty using puberty-blocking pharmacological agents (PB) and prescribing cross-sex hormones (CSH) to minors with gender dysphoria (GD) is a current matter of discussion, and in some cases, PB and CSH are used in clinical practice for this particular population. Two systematic reviews (one on PB, one on CSH treatment) by the British National Institute for Clinical Excellence (NICE) from 2020 indicated no clear clinical benefit of such treatments regarding critical outcome variables. In particular, these two systematic NICE reviews on the use of PB and CSH in minors with GD detected no clear improvements of GD symptoms. Moreover, the overall scientific quality of the available evidence, as discussed within the above-mentioned two NICE reviews, was classified as "very low certainty" regarding modified GRADE criteria. Method: The present systematic review presents an updated literature search on this particular topic (use of PB and CSH in minors with GD) following NICE principles and PICO criteria for all relevant new original research studies published since the release of the two above-mentioned NICE reviews (updated literature search period was July 2020-August 2023). Results: The newly conducted literature search revealed no newly published original studies targeting NICE-defined critical and important outcomes and the related use of PB in minors with GD following PICO criteria. For CSH treatment, we found two new studies that met PICO criteria, but these particular two studies had low participant numbers, yielded no significant additional clear evidence for specific and clearly beneficial effects of CSH in minors with GD, and could be classified as "low certainty" tfollowing modified GRADE criteria. Conclusions: The currently available studies on the use of PB and CSH in minors with GD have significant conceptual and methodological flaws. The available evidence on the use of PB and CSH in minors with GD is very limited and based on only a few studies with small numbers, and these studies have problematic methodology and quality. There also is a lack of adequate and meaningful long-term studies. Current evidence doesn't suggest that GD symptoms and mental health significantly improve when PB or CSH are used in minors with GD. Psychotherapeutic interventions to address and reduce the experienced burden can become relevant in children and adolescents with GD. If the decision to use PB and/or CSH is made on an individual case-by-case basis and after a complete and thorough mental health assessment, potential treatment of possibly co-occurring mental health problems as well as after a thoroughly conducted and carefully executed individual risk-benefit evaluation, doing so as part of clinical studies or research projects, as currently done in England, can be of value in terms of generation of new research data. The electronic supplement (ESM) 1 is an adapted and abreviated English version of this work.

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.

Supporting the Mental Health of Transgender and Gender-Diverse Youth

Increasing numbers of youth are identifying as transgender or gender diverse (TGD), meaning their gender identity or expression do not conform to culturally defined expectations for their designated sex at birth. The mental health needs of TGD youth are diverse, and to effectively address these needs requires knowledgeable general pediatric providers, who often are families' first resource for education and support around gender diversity. To help general pediatric providers work more effectively with TGD youth, we describe the role of mental health providers working with TGD youth and how best to support TGD youth's access to gender-affirming mental health and medical interventions. [Pediatr Ann. 2023;52(12):e456-e461.].

Gender-Affirming Medical Treatments

Individuals with gender dysphoria (as defined by Diagnostic and Statistical Manual of Mental Disorders or DSM-V) experience a marked incongruence between the sex assigned at birth and the experienced gender resulting in significant distress or impairment in social, occupational, or other important areas of functioning. For transgender and gender diverse minors, the Endocrine Society recommends a multidisciplinary approach to gender-affirming medical treatment that involves a physician and a mental health provider, also consistent with the World Professional Association for Transgender Health Standard of Care 8th Edition recommendations. This article will outline the role of medical providers in implementing safe and effective gender-affirming medical treatments in youth.

Hemostatic considerations for gender affirming care

Gender dysphoria or gender incongruence is defined as "persons that are not satisfied with their designated gender" [1]. The awareness and evidence-based treatment options available to this population have grown immensely over the last two decades. Protocols now include an Endocrine Society Clinical Practice Guideline [1] as well as the World Professional Association of Transgender Health Standards of Care (WPATH SOC) [2]. Hematologic manifestations, most notably thrombosis, are one of the most recognized adverse reactions to the hormones used for gender-affirming care. Therefore, hematologists are frequently consulted prior to initiation of hormonal therapy to help guide safe treatment. This review will focus on the scientific evidence related to hemostatic considerations for various gender-affirming therapies and serve as a resource to assist in medical decision-making among providers and patients.

Assessment of Transgender/Gender-Expansive Accessibility in Inpatient Pediatric Mental Health Facilities

Purpose

This study surveyed a national sample of inpatient pediatric behavioral health facilities on policies related to care for transgender and gender-expansive (TGE) youth to assess adherence to best practices.

Methods

Staff/providers at youth inpatient psychiatric facilities were recruited by phone or email. Participants completed an electronic survey on facilities' training policies, staff comfort related to gender diversity, and other policies related to caring for TGE youth.

Results

Of 479 potential participating facilities, 124 surveys were initiated and 59 were completed. Measures to ensure accessibility to TGE patients are present in many facilities surveyed, with most reporting that their facility had nondiscrimination policies in place (86.2%) and required training on working with TGE patients (52.5%). A minority of participants (12.1%) reported that their facility roomed TGE youth based on sex assigned at birth, although only a small portion roomed based on gender identity alone (19.0%). Slightly more than two-thirds stated that their facility had individual restrooms available. Most participants (74.6%) stated that facility staff were comfortable discussing gender diversity in general, although this was less common for other topics related to TGE patient care.

Conclusion

Our survey highlights efforts made by inpatient behavioral health facilities to ensure accessibility of services to TGE youth, although our results showed notable differences across facilities. Given inconsistent federal protections for TGE patients, there remains a need for efforts to ensure that TGE youth are receiving all possible support in these treatment settings, such as accessible restrooms and bedroom assignments, as well as the opportunity to room with peers.

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.

Gender diversity in autistic clients: an ethical perspective

Autonomy and dignity are key ethical principles in psychiatric and psychological codes of ethics. Yet, when working with autistic individuals who are transgender/gender non-conforming (TGNC), non-autistic and cisgender clinicians can unintentionally take away client dignity and autonomy by disbelieving or stigmatizing clients' gender identities. Lack of awareness or discomfort around autism and gender dysphoria can lead clinicians to assumptions and interventions that damage both client rapport and client mental health; discouraging clients from being honest with clinicians about their mental health, and potentially leading to harm. Clinicians must take an intersectional view of their autistic clients' gender identities to reduce stigma and recognize the needs of the whole person. Facilitating access to gender-affirming care is an important part of caring for TGNC clients, including those who are autistic. The authors will discuss the ethical imperative to help autistic clients access gender-affirming care, while discussing common concerns clinicians have when helping autistic clients access this care, as well as the need to believe and support autistic clients when they share their gender identities with clinicians.

Early Access to Testosterone Therapy in Transgender and Gender-Diverse Adults Seeking Masculinization: A Randomized Clinical Trial

Importance

Testosterone treatment is a necessary component of care for some transgender and gender-diverse individuals. Observational studies have reported associations between commencement of gender-affirming hormone therapy and improvements in gender dysphoria and depression, but there is a lack of data from randomized clinical trials.

Objective

To assess the effect of testosterone therapy compared with no treatment on gender dysphoria, depression, and suicidality in transgender and gender-diverse adults seeking masculinization.

Design, Setting, and Participants

A 3-month open-label randomized clinical trial was conducted at endocrinology outpatient clinics and primary care clinics specializing in transgender and gender-diverse health in Melbourne, Australia, from November 1, 2021, to July 22, 2022. Participants included transgender and gender-diverse adults aged 18 to 70 years seeking initiation of testosterone therapy.

Interventions

Immediate initiation of testosterone commencement (intervention group) or no treatment (standard care waiting list of 3 months before commencement). This design ensured no individuals would be waiting longer than the time to standard care.

Main Outcomes and Measures

The primary outcome was gender dysphoria, as measured by the Gender Preoccupation and Stability Questionnaire. Secondary outcomes included the Patient Health Questionnaire-9 (PHQ-9) to assess depression and the Suicidal Ideation Attributes Scale (SIDAS) to assess suicidality. Questionnaires were undertaken at 0 and 3 months. The evaluable cohort was analyzed.

Results

Sixty-four transgender and gender-diverse adults (median [IQR] age, 22.5 [20-27] years) were randomized. Compared with standard care, the intervention group had a decrease in gender dysphoria (mean difference, -7.2 points; 95% CI, -8.3 to -6.1 points; P < .001), a clinically significant decrease in depression (ie, change in score of 5 points on PHQ-9; mean difference, -5.6 points; 95% CI, -6.8 to -4.4 points; P < .001), and a significant decrease in suicidality (mean difference in SIDAS score, -6.5 points; 95% CI, -8.2 to -4.8 points; P < .001). Resolution of suicidality assessed by PHQ-9 item 9 occurred in 11 individuals (52%) with immediate testosterone commencement compared with 1 (5%) receiving standard care (P = .002). Seven individuals reported injection site pain/discomfort and 1 individual reported a transient headache 24 hours following intramuscular administration of testosterone undecanoate. No individual developed polycythemia.

Conclusions and Relevance

In this open-label randomized clinical trial of testosterone therapy in transgender and gender-diverse adults, immediate testosterone compared with no treatment significantly reduced gender dysphoria, depression, and suicidality in transgender and gender-diverse individuals desiring testosterone therapy.

Trial Registration

ANZCTR Identifier: ACTRN1262100016864.

Sexual Orientation and Gender Identity/Expression in Adolescent Research: Two Decades in Review

There is a long history of research among adolescents who are minoritized and marginalized for their sexual orientation and gender identity/expression (SOGIE). However, it remains unclear how we can best conceptualize and assess SOGIE in adolescence, resulting in different subpopulations and findings across studies. Addressing this issue, we present a narrative literature review of the conceptualization and assessment of SOGIE, and provide recommendations for conceptualizing and operationalizing these concepts. Our review indicated that most research with adolescent populations still almost exclusively assesses isolated dimensions of sexuality and gender (e.g., attraction but not identity). We argue that to make research inclusive and equitable, scholars are required to make clear substantiated decisions and be transparent about the SOGIE dimensions and, thus, subpopulations they represent.

Exploring the Impact of Legislation Aiming to Ban Gender-Affirming Care on Pediatric Endocrine Providers: A Mixed-Methods Analysis

Context

Access to gender-affirming medical care is associated with better mental health outcomes in transgender and gender diverse youth. In 2021 and 2022, legislation aiming to ban gender-affirming medical care for youth was proposed in 24 states.

Objective

This study aimed to (1) assess the impact of this legislation on pediatric providers based on legislative status of their state of practice and (2) identify the themes of concerns reported by them.

Methods

A mixed-methods study was conducted via an anonymous survey distributed to pediatric endocrinology providers. Survey responses were stratified based on US state of practice, with attention to whether legislation aiming to ban gender-affirming care had been considered. Data were analyzed both quantitatively and qualitatively.

Results

Of 223 respondents, 125 (56.0%) were currently providing gender-affirming medical care. A total of 103 (45.7%) respondents practiced in a state where legislation aiming to ban gender-affirming care had been proposed and/or passed between January 2021 to June 2022. Practicing in legislation-affected states was associated with negative experiences for providers including (1) institutional pressure that would limit the ability to provide care, (2) threats to personal safety, (3) concerns about legal action being taken against them, (4) concerns about their career, and (5) institutional concerns about engagement with media. Major qualitative themes emerging for providers in legislation-affected states included safety concerns and the impact of laws on medical practice.

Conclusion

This study suggests that legislation aiming to ban health care for transgender youth may decrease access to qualified providers in affected states.

Reproductive and Fertility Knowledge and Attitudes Among Transgender and Gender-Expansive Youth: A Replication and Extension

Purpose

This study sought to replicate and expand a previous pilot investigation of reproductive knowledge, attitudes toward fertility and parenthood, and sources of information on these topics among transgender and gender-expansive (TGE) youth.

Methods

The Yale Pediatric Gender Program (YPGP) Reproductive Knowledge and Experiences Survey (YPGP-RKES) was administered to 70 TGE adolescents receiving care at an interdisciplinary clinic providing gender-affirming health care at an academic medical center. Data gathered included sources of information on reproduction and fertility, concerns about future parenthood and reproduction, and interest in different types of parenthood.

Results

Over a third (39.1%) of participants reported it was important to them to have a child one day, while only a small proportion (23.2%) reported an interest in biological parenthood. A plurality of participants (37.3%) reported at least one concern about future fertility. The number of reproductive concerns did not differ by age or treatment (puberty blockers or gender-affirming hormones vs. no treatment) status. With respect to needs for more information and sources of information, most (56.5%) participants received information about fertility issues before this study, with the most cited source of information being online research.

Conclusions

The current study replicated and extended previous findings on the reproductive attitudes and knowledge of TGE adolescents. Understanding the informational needs and priorities of adolescent TGE patients presenting for medical treatment will allow providers to give more robust patient education. This will, in turn, facilitate patients' ability to provide fully informed consent for treatment that aligns with their fertility and reproductive priorities and goals.

A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people

This systematic review assessed the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning. Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. Evidence for quality of life was inconsistent, with some trends suggesting improvements. There was some evidence of affective changes differing for those on masculinizing versus feminizing hormone therapy. Results for self-mastery effects were ambiguous, with some studies suggesting greater anger expression, particularly among those on masculinizing hormone therapy, but no increase in anger intensity. There were some trends toward positive change in interpersonal functioning. Overall, risk of bias was highly variable between studies. Small samples and lack of adjustment for key confounders limited causal inferences. More high-quality evidence for psychosocial effects of gender-affirming hormone therapy is vital for ensuring health equity for transgender people.

Care of Transgender and Gender-Diverse Children and Adolescents

Children and adolescents may present with transgender or gender diverse (TGD) identity during the course of development. Pediatricians may be the first health care providers to whom TGD identity is revealed. Pediatricians can optimize health care outcomes by promoting a gender-affirming clinical environment, initiating the evaluation for gender incongruence, supporting social transition, and initiating medical interventions. Clinical practice guidelines are available from the World Professional Association for Transgender Health (WPATH, Standards of Care, version 8, 2022) and the Endocrine Society (2017). This article outlines a general approach to providing social and medical affirming care from the pediatrician's office.

Review of current 2SLGBTQIA+ inequities in the Canadian health care system

Gender identity and sexual orientation are determinants of health that can contribute to health inequities. In the 2SLGBTQIA+ community, belonging to a sexual and/or gender minority group leads to a higher risk of negative health outcomes such as depression, anxiety, and cancer, as well as maladaptive behaviors leading to poorer health outcomes such as substance abuse and risky sexual behavior. Empirical evidence suggests that inequities in terms of accessibility to health care, quality of care, inclusivity, and satisfaction of care, are pervasive and entrenched in the health care system. A better understanding of the current Canadian health care context for individuals of the 2SLGBTQIA+ community is imperative to inform public policy and develop sensitive public health interventions to make meaningful headway in reducing inequity. Our search strategy was Canadian-centric and aimed at highlighting the current state of 2SLGBTQIA+ health inequities in Canada. Discrimination, patient care and access to care, education and training of health care professionals, and crucial changes at the systemic and infrastructure levels have been identified as main themes in the literature. Furthermore, we describe health care-related disparities in the 2SLGBTQIA+ community, and present available resources and guidelines that can guide healthcare providers in narrowing the gap in inequities. Herein, the lack of training for both clinical and non-clinical staff has been identified as the most critical issue influencing health care systems. Researchers, educators, and practitioners should invest in health care professional training and future research should evaluate the effectiveness of interventions on staff attitudinal changes toward the 2SLGBTQIA+ community and the impact on patient outcomes.

Age of Realization and Disclosure of Gender Identity Among Transgender Adults

PURPOSE

The "rapid-onset gender dysphoria" (ROGD) hypothesis theorized, based on a parent-report survey, a distinct and more transient form of gender dysphoria in which individuals purportedly come to understand themselves as transgender and/or gender diverse (TGD) suddenly during adolescence. This study evaluated components of ROGD by (1) estimating the prevalence among TGD adults of first realizing one's TGD identity after childhood (i.e., after the onset of puberty), and (2) assessing the median time between realizing one's gender identity and disclosing this to someone else.

METHODS

We conducted a secondary analysis of the 2015 US Transgender Survey, a survey of 27,715 TGD adults in the United States. Participants were asked the age at which they first realized their gender identity was different than societal expectations based on their sex assigned at birth and grouped by "childhood realization" (ages ≤ 10 years) and "later realization" (ages > 10). They were also asked the age at which they first shared their gender identity with another person.

RESULTS

Of 27,497 participants, 40.8% reported "later realization" of TGD identities. Within the "childhood realization" group, the median age of sharing one's gender identity with another person was 20. In this group, the median time between realization of one's gender identity and sharing this with another person was 14 years.

DISCUSSION

A substantial proportion of TGD adults reported realizing their gender identity was different from societal expectations based on their sex assigned at birth during adolescence or later. Several years typically elapsed between participants' TGD identity realization and sharing this with another person. The results of this study do not support the ROGD hypothesis.

Impact of Hormone Treatment on Psychosocial Functioning in Gender-Diverse Young People

Purpose: Few studies have assessed the effects of hormonal treatments such as gonadotropin-releasing hormone agonists (GnRHa) and gender-affirming hormones (GAH) on mental health outcomes in clinically referred gender-diverse young people from a younger age. Where this research has been conducted, findings have been mixed. This study investigated a cohort of young people before treatment, 1 year into GnRHa, and 1 year into GAH treatment to understand psychological and behavioral impacts over time. Methods: Thirty-eight young people (28 assigned female and 10 assigned male) referred to endocrinology, younger than 15 years at/beyond Tanner stage two, who received GnRHa followed by GAH treatment, were assessed in a retrospective analysis study. Young people completed the Youth Self Report (YSR), the Body Image Scale, and the Utrecht Gender Dysphoria Scale, while caregivers completed the Child Behavior Checklist (CBCL) and the Social Responsiveness Scale-2 at all time points. Results: Dissatisfaction with primary sexual characteristics (p = 0.02), gender dysphoria (p = 0.01), and social motivation (p = 0.04) improved significantly over time. Self-harm and suicidality also showed a general decrease. Caregivers reported a significant reduction in internalizing (p = 0.03) behaviors on the CBCL after GnRHa. Other subcategories of the YSR and CBCL were within normal ranges with no significant difference (p > 0.05). Conclusion: These findings demonstrate some improvements in psychological and behavioral outcomes in young people concurrently receiving psychosocial support and hormone treatment. Future research with larger and more diverse samples is warranted to further understand generalizability.

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.

Gender-Affirming Hormone Therapy: Physical and Sociopsychological Effects, Impact and Satisfaction

Background Gender dysphoria treatment includes gender-affirming hormone therapy (GAHT). Studies are still lacking on how to characterize its effects and impact on transgender people's lives more effectively. Aim To study the physical and psychological effects of GAHT on transgender individuals, assess its impact on their lives, and rate their overall satisfaction. Methods Participants (n = 114; ages 18-62 years; median age 24.0 (21.0 - 33.0) years) included transgender adults residing in Portugal who were undergoing or had undergone hormonal therapy for at least one uninterrupted year. Participants completed an original questionnaire. For most items, an ordinal Likert-style scale ranging from 0 (worst result) to 6 (best result) was used. Descriptive statistics and non-parametric tests, including Pearson's chi-squared test, Wilcoxon signed-rank test, and Mann-Whitney U test were used to analyze categorical and continuous variables, with a significance level set at 0.05. Outcomes The outcomes included desired physical changes rating (perception and satisfaction with changes); side effects of GAHT; the sociopsychological impact of GAHT (on self-esteem, body image, psychological wellbeing, social and family relations); overall satisfaction (with treatment results and medical follow-up). Results The changes classified as the most perceptible in those undergoing masculinizing treatment (Group M) were amenorrhea (6 (5.0-6.0) points) and clitoris enlargement (6 (5.0-6.0) points). These were also the ones rated as the most satisfactory (6 (6.0-6.0) points for amenorrhea and 6 (4.0-6.0) points for clitoris enlargement). On those undergoing feminizing therapy (Group F), the alteration voted as the most perceptible was sperm production decrease (6 (2.0-6.0) points), and the ones classified as the most satisfactory were sperm production decrease (6 (4.0-6.0) points) and spontaneous erections decrease (6 (5.0-6.0) points). Side effects were reported by 89.7% of Group M (mood swings were the most common) and 96.3% of Group F (decreased libido was the most frequent). The sociopsychological impact of hormonal treatment was significantly positive in all analyzed variables (p<0.001). Overall satisfaction with treatment results and medical follow-up were rated with 5 points and 4.5 points, respectively. Clinical implications This study provides clinicians with more evidence that GAHT may improve the physical, psychological and social health of transgender people seeking medical transition. Strengths and limitations The strengths of the current study include a high participant count relative to the target population, the acquisition of data on previously unexplored variables, and the significance of being one of the few investigations of its kind conducted in Portugal. However, the study has limitations, including differences in participant characteristics, a small sample size for some variables, potential bias due to the retrospective nature of the study, individualized treatment regimens, and the inclusion of participants from different countries, which limit the generalization of the results. Conclusions This study provides further evidence that GAHT is effective, and that its physical effects are satisfactory while resulting in mostly non-severe nor life-threatening side effects. GAHT is an important therapy in gender dysphoria and has consistent results in improving numerous sociopsychological variables.

Affirming Care for Transgender Patients

Gender identity is a deeply felt internal sense of self, which may correspond (cisgender) or not correspond (transgender) with the person's assigned sex at birth. Transgender, nonbinary, and gender diverse people may choose to affirm their gender in any number of ways including medical gender affirmation. This is a primer on the medical care of transgender individuals which covers an introduction to understanding a common language, history of transgender medical care, creating a welcoming environment, hormone therapy, surgical therapies, fertility considerations, and cancer screening in transgender people.

Prevalence and Determinants of Depressive and Anxiety Symptoms among Transgender People: Results of a Survey

OBJECTIVES

The aim was to investigate the prevalence of probable depression and probable anxiety and to investigate the determinants of depressive symptoms and anxiety symptoms among transgender people.

METHODS

In this "Transgender Survey" (n = 104) we included transgender people who had joined self-help groups to obtain and share information about the gender-affirming surgeries performed at the Division of Plastic, Reconstructive and Aesthetic Surgery at the University Medical Center Hamburg-Eppendorf. Data collection took place between April and October 2022. To measure probable depression, the patient health questionnaire-9 was used. The generalized anxiety disorder-7 was used to quantify probable anxiety.

RESULTS

The prevalence of probable depression was 33.3% and it was 29.6% for probable anxiety. Multiple linear regressions showed that both more depressive symptoms and anxiety symptoms were significantly associated with younger age (β = -0.16, p < 0.01; β = -0.14, p < 0.01), being unemployed (e.g., full-time employed compared to unemployment: β = -3.05, p < 0.05; β = -2.69, p < 0.05), worse self-rated health (β = -3.31, p < 0.001; β = -1.88, p < 0.05), and having at least one chronic disease (β = 3.71, p < 0.01; β = 2.61, p < 0.05).

CONCLUSIONS

Remarkably high prevalence rates were identified among transgender people. Furthermore, risk factors of poor mental health (e.g., unemployment or younger age) were identified-which can help to address transgender people at risk for poor mental health.

Gender-Affirming Care of Transgender and Gender-Diverse Youth: Current Concepts

Increasing numbers of transgender and gender-diverse (TGD) youth, from early puberty through late adolescence, are seeking medical services to bring their physical sex characteristics into alignment with their gender identity-their inner sense of self as male or female or elsewhere on the gender spectrum. Numerous studies, primarily of short- and medium-term duration (up to 6 years), demonstrate the clearly beneficial-even lifesaving-mental health impact of gender-affirming medical care in TGD youth. However, there are significant gaps in knowledge and challenges to such care. Long-term safety and efficacy studies are needed to optimize medical care for TGD youth.

Psychosocial Functioning in Transgender Youth after 2 Years of Hormones

BACKGROUND

Limited prospective outcome data exist regarding transgender and nonbinary youth receiving gender-affirming hormones (GAH; testosterone or estradiol).

METHODS

We characterized the longitudinal course of psychosocial functioning during the 2 years after GAH initiation in a prospective cohort of transgender and nonbinary youth in the United States. Participants were enrolled in a four-site prospective, observational study of physical and psychosocial outcomes. Participants completed the Transgender Congruence Scale, the Beck Depression Inventory-II, the Revised Children's Manifest Anxiety Scale (Second Edition), and the Positive Affect and Life Satisfaction measures from the NIH (National Institutes of Health) Toolbox Emotion Battery at baseline and at 6, 12, 18, and 24 months after GAH initiation. We used latent growth curve modeling to examine individual trajectories of appearance congruence, depression, anxiety, positive affect, and life satisfaction over a period of 2 years. We also examined how initial levels of and rates of change in appearance congruence correlated with those of each psychosocial outcome.

RESULTS

A total of 315 transgender and nonbinary participants 12 to 20 years of age (mean [±SD], 16±1.9) were enrolled in the study. A total of 190 participants (60.3%) were transmasculine (i.e., persons designated female at birth who identify along the masculine spectrum), 185 (58.7%) were non-Latinx or non-Latine White, and 25 (7.9%) had received previous pubertal suppression treatment. During the study period, appearance congruence, positive affect, and life satisfaction increased, and depression and anxiety symptoms decreased. Increases in appearance congruence were associated with concurrent increases in positive affect and life satisfaction and decreases in depression and anxiety symptoms. The most common adverse event was suicidal ideation (in 11 participants [3.5%]); death by suicide occurred in 2 participants.

CONCLUSIONS

In this 2-year study involving transgender and nonbinary youth, GAH improved appearance congruence and psychosocial functioning. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.).

The Effect of Gender-Affirming Hormone Therapy on the Risk of Subclinical Atherosclerosis in the Transgender Population: A Systematic Review

OBJECTIVE

The impact of gender-affirming hormone therapy (GAHT) on cardiovascular (CV) health is still not entirely established. A systematic review was conducted to summarize the evidence on the risk of subclinical atherosclerosis in transgender people receiving GAHT.

METHODS

A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and data were searched in PubMed, LILACS, EMBASE, and Scopus databases for cohort, case-control, and cross-sectional studies or randomized clinical trials, including transgender people receiving GAHT. Transgender men and women before and during/after GAHT for at least 2 months, compared with cisgender men and women or hormonally untreated transgender persons. Studies reporting changes in variables related to endothelial function, arterial stiffness, autonomic function, and blood markers of inflammation/coagulation associated with CV risk were included.

RESULTS

From 159 potentially eligible studies initially identified, 12 were included in the systematic review (8 cross-sectional and 4 cohort studies). Studies of trans men receiving GAHT reported increased carotid thickness, brachial-ankle pulse wave velocity, and decreased vasodilation. Studies of trans women receiving GAHT reported decreased interleukin 6, plasminogen activator inhibitor-1, and tissue plasminogen activator levels and brachial-ankle pulse wave velocity, with variations in flow-mediated dilation and arterial stiffness depending on the type of treatment and route of administration.

CONCLUSIONS

The results suggest that GAHT is associated with an increased risk of subclinical atherosclerosis in transgender men but may have either neutral or beneficial effects in transgender women. The evidence produced is not entirely conclusive, suggesting that additional studies are warranted in the context of primary prevention of CV disease in the transgender population receiving GAHT.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier CRD42022323757.

The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence

It has been a quarter of a century since Dutch clinicians proposed puberty suppression as an intervention for "juvenile transsexuals," which became the international standard for treating gender dysphoria. This paper reviews the history of this intervention and scrutinizes the evidence adduced to support it. The intervention was justified by claims that it was reversible and that it was a tool for diagnosis, but these claims are increasingly implausible. The main evidence for the Dutch protocol came from a longitudinal study of 70 adolescents who had been subjected to puberty suppression followed by cross-sex hormones and surgery. Their outcomes shortly after surgery appeared positive, except for the one patient who died, but these findings rested on a small number of observations and incommensurable measures of gender dysphoria. A replication study conducted in Britain found no improvement. While some effects of puberty suppression have been carefully studied, such as on bone density, others have been ignored, like on sexual functioning.

Gender Dysphoria: Optimizing Healthcare for Transgender and Gender Diverse Youth with a Multidisciplinary Approach

Transgender and gender diverse (TGD) youth and their families are seeking medical and mental health care at increasing rates. As the number of multidisciplinary pediatric gender programs expands, we consider the history and evidence base for gender affirmative care and highlight existing models of care that can flexibly accommodate the diverse needs of TGD youth and their families. Comprehensive multidisciplinary care includes both medical and mental health providers who work collaboratively with TGD youth and their caregivers to assess gender-related support needs and facilitate access to developmentally appropriate medical and mental health interventions. In addition to direct health-care services, multidisciplinary care for TGD youth and their families extends into community training, education, community outreach, nonmedical programming, and advocacy for TGD youth.

Mindfulness Meditation Programs Informed by Transgender Youth

Objectives

This study explores the openness of transgender and gender diverse youth and young adults (TGDY) to mindfulness meditation programs in order to create culturally informed interventions to benefit this population.

Method

Two focus groups were conducted with a total of ten TGDY ages 14-24 years old at a transgender youth health center in a large metropolitan city in the USA. A 10-min guided mindfulness meditation was included for participants to experience and voice reactions to. The State-Trait Anxiety Inventory (STAI) was utilized to measure the quantitative impact of the meditation on participants' anxiety and thematic analysis for the qualitative data.

Results

Reflexive Thematic Analysis on qualitative focus group data revealed the following four themes: Active in Self-care, Silent Meditation Is "Not for Me," Guided Mindfulness Calms and Connects, and Program Ideas for Future. STAI results indicated a statistically significant reduction in anxiety following participation in the group meditation.

Conclusions

Participants were open to mindfulness as an additional method of self-care, and they emphasized future programs should include sensory stimulation, a pressure-free environment accepting of active minds and bodies, and a transgender instructor if possible. Meditation and mindfulness have the potential to be a very powerful healing modality for TGDY in clinical and therapeutic care.

Preregistration

This study is not preregistered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-022-02048-6.

Geographic Distribution of Clinical Care for Transgender and Gender-Diverse Youth

OBJECTIVES

Geographic barriers limit access to clinical care in the United States for transgender and gender-diverse (TGD) youth. Some factors differentiating access to care are variability in state laws/policies, the number of available clinical care programs and mental health providers for TGD youth.

METHODS

We aggregated data from the Human Rights Campaign for pediatric clinical care programs for TGD youth, the Movement Advancement Project for state-by-state assessment of gender identity laws and policies, and Psychology Today for mental health providers for TGD youth by state. Current prevalence rates for TGD youth were applied by state with 2020 Census data. Findings were summarized as a whole and per capita by state, region, and country overall.

RESULTS

The South has the highest number of TGD youth per clinic (36 465-186 377), and the lowest average equality score in gender identity laws and policies (1.96). The Midwest has the highest number of TGD youth per mental health provider (278-1422). The Northeast has the lowest number of TGD youth per clinic (11 094-56 703), the highest average equality score in laws and policies per state (17.75), and the highest average number of TGD youth per mental health providers (87-444).

CONCLUSIONS

Findings support there are barriers to TGD youth care throughout the United States, especially the South and Midwest. Increasing medical and mental health care for TGD youth is likely to improve their health and well-being. Enacting gender identity protective laws/policies would allow for equal treatment and access to care among TGD youth.

Association of Gonadotropin-Releasing Hormone Analogue Use With Subsequent Use of Gender-Affirming Hormones Among Transgender Adolescents

IMPORTANCE

Gonadotropin-releasing hormone analogue (GnRHa) use during puberty improves mental health among transgender and gender-diverse (TGD) adolescents. In previous studies, most (96.5%-98.1%) TGD adolescents who started GnRHa subsequently started gender-affirming hormones (GAH), raising concerns that GnRHa use promotes later use of GAH.

OBJECTIVE

To determine whether GnRHa use among TGD adolescents is associated with increased subsequent GAH use.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective cohort study of administrative records collected between 2009 and 2018. The current analysis was completed in August 2022. Participants were enrolled in the US Military Healthcare System (MHS) with an initial TGD-related encounter occurring between ages 10 and 17 years.

EXPOSURES

GnRHa use.

MAIN OUTCOMES AND MEASURES

Initiation of GAH.

RESULTS

The 434 patients were a mean (SD) of 15.4 (1.6) years old at the time of their first TGD-related encounter; 312 (71.9%) were assigned female at birth, and 300 (69.1%) had an enlisted insurance sponsor. GnRHa use was more common among patients who were assigned male at birth (28 patients [23.0%]) than those assigned female (42 patients [13.5%]), but GAH use was not. Socioeconomic status was not associated with GnRHa or GAH use. Compared with older patients (aged 14-17 years), those who were younger (aged 10-13 years) at the time of the initial TGD-related encounter had a higher rate of GnRHa use (32 patients [57.1%] vs 38 patients [10.1%]) and a longer median time to starting GAH. The median interval from the date of the initial encounter to starting GAH decreased over time, from 2.3 years (95% CI, 1.7-2.8 years) between October 2009 and December 2014 to 0.6 years (95% CI, 0.5-0.6 years) between September 2016 and April 2018. Patients who were prescribed GnRHa had a longer median time to starting GAH (1.8 years; 95% CI, 1.1-2.4 years) than patients who were not (1.0 years; 95% CI, 0.8-1.2 years) and were less likely to start GAH during the 6 years after their first TGD-related encounter (hazard ratio, 0.52; 95% CI, 0.37-0.71). Among 54 younger (aged 10-13 years) patients who were not eligible to start GAH at their first encounter, GnRHa use was associated with a longer median time to starting GAH, but age at the first TGD-related visit was not.

CONCLUSIONS AND RELEVANCE

In this cohort study of TGD adolescents, GnRHa use was not associated with increased subsequent GAH use. These findings suggest that clinicians can offer the benefits of GnRHa treatment without concern for increasing rates of future GAH use.

Factors that drive mental health disparities and promote well-being in transgender and nonbinary people

Transgender (or trans) is an umbrella term for individuals who experience their gender differently from what is associated with the sex they were assigned at birth. Individuals who are nonbinary experience their gender outside binary conceptions of gender. Although research has predominantly focused on negative mental health outcomes for transgender and non-binary (TNB) individuals, an emergent literature has begun to explore protective and health-promoting factors and dimensions of psychological well-being. In this Review, we discuss the sociocultural context for TNB people, beginning with a brief history of TNB identity before highlighting frameworks for understanding the higher prevalence of certain mental health concerns among TNB individuals. Next, we summarize the predictive factors associated with higher rates of depression, anxiety, suicidality, trauma-related concerns, disordered eating behaviours and substance use. We also review TNB coping, resilience and resistance to anti-trans stigma, as well as psychological well-being, flourishing and gender euphoria. Tying these topics together, we discuss affirming interventions for reducing mental health disparities and promoting psychological health in TNB individuals and communities. We conclude by discussing future research directions.

Individuals who are transgender or nonbinary experience a higher prevalence of certain mental health concerns, including depression, anxiety and disordered eating behaviours. In this Review, Tebbe and Budge discuss these disparities along with factors that protect these individuals from negative outcomes and promote well-being.

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.

Transgender and Gender Diverse Patients in Intensive Mood Disorder Treatment: A Comparative Examination of Clinical Presentation and Treatment Outcomes

Individuals who are transgender and gender diverse (TGD) are more likely to suffer from and to seek mental health services for mood disorders. Some literature suggests that TGD individuals, because of pervasive and systemic minority stress, may have more complex clinical presentations (i.e., psychiatric conditions and severity of symptoms) and may benefit from empirically based treatments to a lesser degree than their cisgender peers. However, research has yet to examine individuals who are TGD receiving treatment in specialized, intensive mood disorder treatment despite the propensity for them to be diagnosed with and treated for mood disorders. Using a sample of 1,326 adult patients in intensive mood disorder treatment (3.8% TGD), the clinical presentation and treatment outcomes were compared between patients who are TGD and cisgender. Contrary to previous research, TGD patients were largely similar if not healthier than their cisgender counterparts, including similar depression severity, quality of life, emotion dysregulation, and behavioral activation, and less severe rumination at admission. Despite similar to better reported mental health symptoms, TGD patients were diagnosed with more psychiatric conditions overall, including greater prevalence of social anxiety and neurodevelopmental diagnoses. Those who are TGD did not experience attenuated treatment response as predicted. Findings suggest that patients in intensive mood disorder treatment who are TGD may be more resilient than previously assumed, or supports may have increased to buffer effects of stigma on mental health, and emphasize the need to exercise discretion and sensitivity in diagnostic practices to prevent over-diagnosis and pathologizing of TGD individuals.

Continuation of Gender-affirming Hormones Among Transgender Adolescents and Adults

INTRODUCTION

Concerns about future regret and treatment discontinuation have led to restricted access to gender-affirming medical treatment for transgender and gender-diverse (TGD) minors in some jurisdictions. However, these concerns are merely speculative because few studies have examined gender-affirming hormone continuation rates among TGD individuals.

METHODS

We performed a secondary analysis of 2009 to 2018 medical and pharmacy records from the US Military Healthcare System. We identified TGD patients who were children and spouses of active-duty, retired, or deceased military members using International Classification of Diseases-9/10 codes. We assessed initiation and continuation of gender-affirming hormones using pharmacy records. Kaplan-Meier and Cox proportional hazard analyses estimated continuation rates.

RESULTS

The study sample included 627 transmasculine and 325 transfeminine individuals with an average age of 19.2 ± 5.3 years. The 4-year gender-affirming hormone continuation rate was 70.2% (95% CI, 63.9-76.5). Transfeminine individuals had a higher continuation rate than transmasculine individuals 81.0% (72.0%-90.0%) vs 64.4% (56.0%-72.8%). People who started hormones as minors had higher continuation rate than people who started as adults 74.4% (66.0%-82.8%) vs 64.4% (56.0%-72.8%). Continuation was not associated with household income or family member type. In Cox regression, both transmasculine gender identity (hazard ratio, 2.40; 95% CI, 1.50-3.86) and starting hormones as an adult (hazard ratio, 1.69; 95% CI, 1.14-2.52) were independently associated with increased discontinuation rates.

DISCUSSION

Our results suggest that >70% of TGD individuals who start gender-affirming hormones will continue use beyond 4 years, with higher continuation rates in transfeminine individuals. Patients who start hormones, with their parents' assistance, before age 18 years have higher continuation rates than adults.

Trajectories of transgender adolescents referred for endocrine intervention in England

OBJECTIVES

Some gender-diverse young people (YP) who experience clinically significant gender-related distress choose to pursue endocrine treatment alongside psychotherapeutic support to suppress pubertal development using gonadotropin-releasing hormone analogues (GnRHa), and then to acquire the secondary sex characteristics of their identified gender using gender affirming hormones (GAH). However, little is known about the demographics of transgender adolescents accessing paediatric endocrinology services while under the specialist Gender Identity Development Service (GIDS) in England.

DESIGN

Demographics of referrals from the GIDS to affiliated endocrinology clinics to start GnRHa or GAH between 2017 and 2019 (cohort 1), with further analysis of a subgroup of this cohort referred in 2017-2018 (cohort 2) were assessed.

RESULTS

668 adolescents (227 assigned male at birth (AMAB) and 441 assigned female at birth (AFAB)) were referred to endocrinology from 2017 to 2019. The mean age of first GIDS appointment for cohort 1 was 14.2 (±2.1) years and mean age of referral to endocrinology postassessment was 15.4 (±1.6) years. Further detailed analysis of the trajectories was conducted in 439 YP in cohort 2 (154 AMAB; 285 AFAB). The most common pathway included a referral to access GnRHa (98.1%), followed by GAH when eligible (42%), and onward referral to adult services when appropriate (64%). The majority (54%) of all adolescents in cohort 2 had a pending or completed referral to adult services.

CONCLUSIONS

This study highlights the trajectories adolescents may take when seeking endocrine treatments in child and adolescent clinical services and may be useful for guiding decisions for gender-diverse YP and planning service provision.

Policy attitudes toward adolescents transitioning gender

Anti-transgender policies and state legislative initiatives that focus on school bathroom use and hormone use have emerged in recent years. These policies are generally written by and voted on by cisgender people, and as such, it is crucial to understand influences on nonaffirming attitudes toward policies that can impact trans youth. The present study aimed to extend research on transphobic attitudes in general to attitudes toward policies that impact youth undergoing transition. Latent variable covariances and structural equation modeling were used to test the relations between transphobia, genderism, homophobia, need for closure, sexual orientation, social dominance orientation, attitudes toward sexual minorities, beliefs about gender roles, aggression, religious fundamentalism, and contact with sexual and gender minority individuals, as they are related to attitudes toward hormone use and bathroom use for trans youth. Analyses of data from a sample of 248 cisgender adults indicated that genderism and transphobia was associated with attitudes toward gender-affirming hormone use and bathroom use for trans youth; need for closure was associated with gender-affirming attitudes toward bathroom use, but was not associated with hormone use. Sexual orientation was linked to attitudes toward gender-affirming policies, such that nonheterosexual participants had more affirming attitudes toward trans youths' bathroom use, but not hormone use. Implications for future research, advocacy efforts to promote rights for trans youth, and clinical work with trans youth and/or parents/guardians of trans youth are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Ensuring Care for Transgender Adolescents Who Need It: Response to 'Reconsidering Informed Consent for Trans-Identified Children, Adolescents and Young Adults'

Adolescent transgender care is increasingly surrounded by controversies and criticism. One of these concerns expressed in a review article by Levine et al. entitled 'Reconsidering Informed Consent for Trans-Identified Children, Adolescents and Young Adults' is the limited evidence base, especially of the Dutch studies which provided the first and mostly cited basis for medical intervention at a young age. This Response is written by the first author of two of those studies that showed effectiveness of the approach that included puberty blockers. The author rebuts several of the concerns that Levine et al.have regarding these Dutch studies, among which are the limited statistical improvements of psychological measures, the use of the Utrecht Gender Dysphoria and the selection of participants. The author further refers to several shorter term longitudinal follow up studies that have been published, which are not mentioned by Levine et al.. They also show improvement or stable psychological functioning and relief of gender incongruence. Finally, a careful evaluation and informed consent provision has always been recommended in all editions of the WPATH's Standards of Care and are also part of the 8th version as well as the Endocrine Society guidelines. The author agrees therefore with Levine et al. that clinicians in transgender care should follow these international guidelines and provide such an assessment in order to ensure that medical interventions are appropriately provided for those transgender adolescents who need them.

Experiences of Puberty and Puberty Blockers: Insights From Trans Children, Trans Adolescents, and Their Parents

This research explored experiences of transgender children and their families approaching and into adolescence, understanding experiences relating to puberty and puberty blocking medication. Data were drawn from 30 parents of 30 trans children and adolescents who at time of interview, were an average age of 11 years old. Parental interviewees were 90% white, 93% female, 100% cis, 60% heterosexual. Additional data were drawn from 10 trans children and adolescents, average age 12 years old. Interviews were held remotely, with families from across the UK. Rich qualitative interviews, averaging 2 hours for parents, and 25 minutes for children, covered aspects of family life, healthcare, and education. This article examined a sub-set of data on trans children and adolescents’ experiences of puberty, and of accessing, or trying to access, puberty blockers. Research received ethical approval from the author’s university. Data were analyzed through inductive reflexive thematic analysis. Three major themes are presented, relating to pre-pubertal anxiety; difficulties accessing blockers; and, for a minority who were on blockers, experiences of relief and frustration. The research has significant relevance for families, for healthcare professionals and policymakers, and for all seeking to protect trans adolescent mental health and well-being.

Review on the Transgender Literature: Where Are We Now and a Step beyond the Current Practice?

The transgender concept is described as a clinically significant distress due to the incongruity between the experienced gender and assigned gender. A transgender person carries a gender identity that is different from their assigned sex at birth. Transgender people may be binary: male to female (transgender women) or female to male (transgender men) or genderqueer (non-binary, fluid or variable gender expression). The binary concept has been described in transgender population, where the term transwomen is used to describe people assigned male at birth (AMAB) who are recognized as females during gender transition; with the term transmen where they are assigned female at birth (AFAB) and are then recognized as males in gender transition. According to the DSM-5 classification, gender dysphoria is described when a transgender person develops clinically relevant bio-psychosocial suffering. Currently, the transgender population has gained massive public awareness through social media and gained a considerable level of attention globally. Several studies on transgender populations from different parts of the world have shown real discrimination and stigma towards transgender people, which sometimes acts as a barrier to the provision of the required care for them. Lack of access to the required information, legal issues, lack of solutions to fertility problems, financial constraints, and psychological and emotional obstacles, together with risk of sexually transmitted infections, including human immunodeficiency virus (HIV), all make the life of a transgender person more complicated. Testosterone therapy is a hormone-based therapy for transgender men that provides a body image tallying with the favored gender identification, whereas estrogen and androgen-suppressing agents are used in transgender females to produce changes compatible with their required gender identity. Gender affirmation surgery is a broad term, under which the genital reconstruction is described as a major component. Psychological conditions such as depression, substance abuse, suicidal deaths, and sexually transmitted infections, particularly among males having sex with males, are reported at a significantly higher rate among transgender populations. Cardiovascular morbidity is higher among this population, and continuous medical surveillance is warranted. Medical care provision to transgender populations should be handled with great care, while attending to the unmet needs of this population, as this care should extend beyond routine hormonal therapy and gender reassignment surgery.

Attitudes in the U.S. Toward Hormonal and/or Surgical Interventions for Adolescents Experiencing Gender Dysphoria

In order to align with their inner sense of gender identity, adolescents suffering from gender dysphoria are increasingly being treated with cross-sex hormones and irreversible surgeries to alter their bodies. The present study is the first to examine attitudes about these recently emergent medical practices in a national population. We used data from the 2018 Post-Midterm Election Study, a survey representative of adults in the USA ages 20 to 65 years (N = 5285), to examine the social factors associated with approval or disapproval of hormonal and/or surgical interventions for adolescents seeking medical treatment for gender dysphoria. Higher fertility, race/ethnicity (in this case, black), sex (male), and heterosexual self-identity were each robustly associated with disapproval. Nested regression models revealed that a range of religion measures were statistically significant (toward disapproval). However, all but evangelical self-identification were no longer significant after accounting for support for abortion rights, the spectrum of political self-identification, and voting behavior. These findings, prompted by a high percentage of variance explained, led us to consider perspectives on medical transitions for adolescents as fitting the "culture war" framework, largely polarized between a "progressive" worldview of bodily autonomy and an "orthodox" worldview of bodily integrity.

Self-Perception of Transgender Adolescents after Gender-Affirming Treatment: A Follow-Up Study into Young Adulthood

Purpose: Early medical treatment for transgender adolescents should contribute to healthy psychological development, including the development of positive self-perception. However, at present, there are no longitudinal studies that have examined whether current treatment approaches meet this expectation. Therefore, the aim of this single-arm retrospective study was to examine transgender adolescents' self-perception changes over the course of irreversible medical gender-affirming treatment. Method: The total study sample consisted of 70 adolescents (49 trans men and 21 trans women). Self-perception was assessed before the start of gender-affirming hormone treatment (mean age = 14.65, standard deviation (SD) = 2.08) and at least 6 months after gender-affirming surgeries (mean age = 20.70, SD = 1.49) by Self-Perception Profile for Adolescents (SPPA). The SPPA is a self-report measure that examines self-perception on seven different domains: Scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct, close friendship, and global self-worth. Multilevel modeling (random intercepts model) was conducted to determine the effect of time for all domains of self-perception. Results: It was found that the domains of physical appearance and global self-worth improved significantly over the course of treatment. No domain worsened significantly over the course of treatment. The domains of scholastic competence, social acceptance, athletic competence, and close friendship remained stable over time. Conclusion: This study provides the first suggestive evidence that irreversible gender-affirming treatment for adolescents could contribute to the development of a more positive self-perception.

Association of Gender-Affirming Hormone Therapy With Depression, Thoughts of Suicide, and Attempted Suicide Among Transgender and Nonbinary Youth

PURPOSE

There are no large-scale studies examining mental health among transgender and nonbinary youth who receive gender-affirming hormone therapy (GAHT). The purpose of this study is to examine associations among access to GAHT with depression, thoughts of suicide, and attempted suicide among a large sample of transgender and nonbinary youth.

METHODS

Data were collected as part of a 2020 survey of 34,759 lesbian, gay, bisexual, transgender, queer, and questioning youth aged 13-24, including 11,914 transgender or nonbinary youth. Adjusted logistic regression assessed whether receipt of GAHT was associated with lower levels of depression, thoughts of suicide, and attempted suicide among those who wanted to receive GAHT.

RESULTS

Half of transgender and nonbinary youth said they were not using GAHT but would like to, 36% were not interested in receiving GAHT, and 14% were receiving GAHT. Parent support for their child's gender identity had a strong relationship with receipt of GAHT, with nearly 80% of those who received GAHT reporting they had at least one parent who supported their gender identity. Use of GAHT was associated with lower odds of recent depression (adjusted odds ratio [aOR] = .73, p < .001) and seriously considering suicide (aOR = .74, p < .001) compared to those who wanted GAHT but did not receive it. For youth under age 18, GAHT was associated with lower odds of recent depression (aOR = .61, p < .01) and of a past-year suicide attempt (aOR = .62, p < .05).

CONCLUSIONS

Findings support a relationship between access to GAHT and lower rates of depression and suicidality among transgender and nonbinary youth.

Providing Gender-Affirmative Care During the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic Era: Experiences and Perspectives from Pediatric Endocrinologists in the United States

Transgender and gender diverse (TGD) youth are at risk of worsened health disparities during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Health care delivery by pediatric endocrinologists, including rapid implementation of telemedicine services, during the pandemic has not been documented. The Pediatric Endocrine Society's Transgender Health Special Interest Group met virtually to survey practice patterns during the SARS-CoV-2 pandemic. The majority of pediatric endocrinologists continued to provide most aspects of medical transition; however, we also identified several barriers to care. Overall, the survey results demonstrated that telemedicine can be utilized as an effective way to provide gender-affirming medical care to TGD youth.