Gender dysphoria in childhood

Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future

In this essay, we consider the clinical and ethical implications of puberty blockers for pediatric gender dysphoria through the lens of "the child's right to an open future," which refers to rights that children do not have the capacity to exercise as minors, but that must be protected, so they can exercise them in the future as autonomous adults. We contrast the open future principle with the beliefs underpinning the gender affirming care model and discuss implications for consent. We evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment. In discussing these issues, we include relevant empirical evidence and raise questions for clinicians and researchers. We conclude that treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle.

Trajectories of Gender Identity and Depressive Symptoms in Youths

Importance

Concerns about the mental health of youths going through gender identity transitions have received increased attention. There is a need for empirical evidence to understand how transitions in self-reported gender identity are associated with mental health.

Objective

To examine whether and how often youths changed self-reported gender identities in a longitudinal sample of sexual and gender minority (SGM) youths, and whether trajectories of gender identity were associated with depressive symptoms.

Design, Setting, and Participants

This cohort study used data from 4 waves (every 9 months) of a longitudinal community-based study collected in 2 large cities in the US (1 in the Northeast and 1 in the Southwest) between November 2011 and June 2015. Eligible participants included youths who self-identified as SGM from community-based agencies and college groups for SGM youths. Data analysis occurred from September 2022 to June 2023.

Exposure

Gender identity trajectories and gender identity variability.

Main Outcomes and Measures

The Beck Depression Inventory for Youth (BDI-Y) assessed depressive symptoms. Gender identity variability was measured as the number of times participants' gender identity changed. Hierarchical linear models investigated gender identity trajectories and whether gender identity variability was associated with depressive symptoms over time.

Results

Among the 366 SGM youths included in the study (mean [SD] age, 18.61 [1.71] years; 181 [49.4%] assigned male at birth and 185 [50.6%] assigned female at birth), 4 gender identity trajectory groups were identified: (1) cisgender across all waves (274 participants ), (2) transgender or gender diverse (TGD) across all waves (32 participants), (3) initially cisgender but TGD by wave 4 (ie, cisgender to TGD [28 participants]), and (4) initially TGD but cisgender by wave 4 (ie, TGD to cisgender [32 participants]). One in 5 youths (18.3%) reported a different gender identity over a period of approximately 3.5 years; 28 youths varied gender identity more than twice. The cisgender to TGD group reported higher levels of depression compared with the cisgender group at baseline (Β = 4.66; SE = 2.10; P = .03), but there was no statistical difference once exposure to lesbian, gay, bisexual, and transgender violence was taken into account (Β = 3.31; SE = 2.36; P = .16). Gender identity variability was not associated with within-person change in depressive symptoms (Β = 0.23; SE = 0.74; P = .75) or the level of depressive symptoms (Β = 2.43; SE = 2.51; P = .33).

Conclusions

These findings suggest that gender identity can evolve among SGM youths across time and that changes in gender identity are not associated with changes in depressive symptoms. Further longitudinal work should explore gender identity variability and adolescent and adult health.

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.

Mental health outcomes and suicidality in hospitalized transgender adolescents: A propensity score-matched Cross-sectional analysis of the National inpatient sample 2016-2018

Transgender adolescents have unique mental health needs. This demographic has increased rates of mood disorders, anxiety, and depression compared to their cisgender peers. Large-scale studies focused on mental health outcomes, including suicidality, in the transgender adolescent population remain unknown. This study tries to fill these gaps in the literature. Data for this study was taken from the National Inpatient Sample 2016-2018. Transgender adolescents were identified using the ICD-10 codes related to transsexualism diagnoses. These individuals were compared to adolescents without transsexualism diagnoses. To mitigate imbalances in baseline characteristics, we utilized a 1:2 nearest neighbor propensity score matching with a caliper width of 0.0001, considering variables such as age, year of hospitalization, and psychiatric disorders. Following propensity score matching, the study cohort comprised 2635 transgender and 5270 non-transgender adolescents (Mean age 15.2 years). The transgender group demonstrated a notably higher prevalence of mood disorders (91%) and anxiety disorders (65%). Furthermore, the prevalence of suicidal ideation was significantly higher in the transgender group (52.4% vs. 39.2%, p < 0.001). However, there was no significant difference in the prevalence of suicide attempts between the groups. After controlling for psychiatric comorbidities, age, and gender, the odds ratio for the composite outcome of suicidal ideation or attempt was 1.99 (95% CI 1.58-2.12, p < 0.001). Our study identifies elevated mood and anxiety disorders and suicidality rates in hospitalized transgender adolescents compared to cisgender peers. Mood disorders notably amplify the risk of suicidal attempts. These findings urgently call for targeted mental health interventions and policy changes to serve this vulnerable population in healthcare settings better.

A Pilot Study on the Effect of Peer Support on Quality of Life of Adolescents with Autism Spectrum Disorder and Gender Dysphoria

Gender dysphoria (GD) and Autism Spectrum Disorder (ASD) co-occur relatively often, but there is no evidence-based treatment for this specific group. Therefore, we examined the effects of a group intervention for adolescents with ASD and GD in a pilot study with a pre-post-test design. The adolescents completed questionnaires on quality of life, self-esteem, gender dysphoric feelings, and social responsiveness. Results show that participating in this peer support group seems to increase aspects of quality of life, i.e., increased parent-reported psychological well-being and decreased psychological complaints. Even though more research is needed, these results indicate that peer support is an invaluable part of treatment for adolescents with ASD and GD.

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.

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 role of the pediatrician in the management of the child and adolescent with gender dysphoria

Gender dysphoria is a clinical condition characterized by significant distress due to the discordance between biological sex and gender identity. Currently, gender dysphoria is also found more frequently in children and adolescents, thanks to greater social sensibleness and new therapeutic possibilities. In fact, it is estimated that the prevalence of gender dysphoria in pediatric age is between 0.5% and 2% based on the statistics of the various countries. Therefore, the pediatrician cannot fail to update himself on these issues and above all should be the reference figure in the management of these patients. Even if the patient must be directed to a referral center and be followed up by a multidisciplinary team, the treating pediatrician will care to coordinate the clinical and therapeutic framework. The aim of the present report is therefore to integrate literature data with our clinical experience to propose a new clinical approach in which the pediatrician should be the reference in the care of these patients, directing them towards the best therapeutic approach and staying in contact with the specialists of the referral center.

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.

Toward a Standard of Medical Care: Why Medical Professionals Can Refuse to Prescribe Puberty Blockers

That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient's well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical care must not cause dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria.

Gendered Differences in Experiences of Bullying and Mental Health Among Transgender and Cisgender Youth

Even though previous studies have shown that transgender youth have poorer mental health and more experiences of being bullied than their cisgender counterparts, and that bullying associates with poorer mental health, knowledge on such associations in different gender identity groups is scarce. This study investigated how mental health problems and experiences of being bullied appear across different gender identity groups, and how bullying is associated with mental health among the groups in question. Data from the Finnish School Health Promotion 2021 study (n = 152,880, mean age 16.2 years (standard deviation 1.22)) was used and categorized into four gender identity groups: cisgender girls (n = 76,521), cisgender boys (n = 69,735), transfeminine youth (n = 1317), and transmasculine youth (n = 5307). Transgender youth experienced more bullying and reported poorer mental health than cisgender youth. While transfeminine youth faced the most bullying, transmasculine youth had the most mental health symptoms. In each group, bullying associated with poorer mental health. Compared to cisgender boys without bullying experiences, odds of poorer mental health were dozens-fold among transmasculine youth with weekly bullying experiences. In addition, compared to cisgender boys with bullying experiences, odds of poorer mental health were greater among all other gender identity groups with bullying experiences, and among transmasculine youth in particular (e.g., odds ratio of generalized anxiety = 8.36 (95% confidence interval, 6.59-10.6)). Bullying is associated with poorer mental health in all youth, but transgender youth, and especially transmasculine youth, may be in an even more vulnerable position for its implications. This suggests that there is a need for improving effective measures to decrease bullying in schools and to improve wellbeing of transgender youth.

The Myth of "Reliable Research" in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies-and research that has followed

Two Dutch studies formed the foundation and the best available evidence for the practice of youth medical gender transition. We demonstrate that this work is methodologically flawed and should have never been used in medical settings as justification to scale this "innovative clinical practice." Three methodological biases undermine the research: (1) subject selection assured that only the most successful cases were included in the results; (2) the finding that "resolution of gender dysphoria" was due to the reversal of the questionnaire employed; (3) concomitant psychotherapy made it impossible to separate the effects of this intervention from those of hormones and surgery. We discuss the significant risk of harm that the Dutch research exposed, as well as the lack of applicability of the Dutch protocol to the currently escalating incidence of adolescent-onset, non-binary, psychiatrically challenged youth, who are preponderantly natal females. "Spin" problems-the tendency to present weak or negative results as certain and positive-continue to plague reports that originate from clinics that are actively administering hormonal and surgical interventions to youth. It is time for gender medicine to pay attention to the published objective systematic reviews and to the outcome uncertainties and definable potential harms to these vulnerable youth.

Etiology of gender incongruence and its levels of evidence: A scoping review protocol

INTRODUCTION

Gender Incongruence refers to the discordance between biological sex and gender identity. Although it is possible to find literature reviews about the etiology of Gender Incongruence, almost all of these correspond to non-systematic narrative reviews, so they do not make explicit the methodology used in the collection and analysis of sources, even less its levels of evidence. In order to remedy this, we will conduct a scoping review to answer the question: what are the factors associated with gender incongruence and what level of evidence is there for each factor in the scientific literature?

METHODS AND ANALYSIS

We will conduct a scoping review according to the methodology specified in the JBI Manual for Evidence Synthesis (Chapter 11) and the PRISMA extension for scoping reviews (PRISMA-ScR). Four databases will be reviewed to identify papers that match our search criteria, followed by a screening of titles and abstracts, the complete reading of those articles that have not been excluded, and the coding of these using the data extraction instrument developed for this research (see S1 Appendix). Data extracted will be analyzed in terms of frequency counts of factors, types of factors and levels of evidence for each factor. Results will be presented in tabular or diagrammatic forms supported by a narrative summary.

FINDINGS

The present review will help to map the factors associated with incongruence between biological sex and gender identity, specifying their levels of evidence. This evidence-based knowledge will be useful for clinicians evaluating gender incongruence, especially given that international guidelines recommend careful assessment of factors that may interfere with the clarity of gender identity development and decision making.

Gender Felt Pressure, Affective Domains, and Mental Health Outcomes among Transgender and Gender Diverse (TGD) Children and Adolescents: A Systematic Review with Developmental and Clinical Implications

Although capable of mobilizing significant resilience factors to face stigma and discrimination, transgender and gender diverse (TGD) children and adolescents tend to suffer from more adverse mental health outcomes compared to their cisgender counterparts. The minority stressors that this population faces are mainly due to the gender-based pressure to conform to their assigned gender. This systematic review was aimed at assessing the potential mental health issues that affect the TGD population. The literature search was conducted in three databases; namely, Scopus, PubMed, and Web of Science, based on the PRISMA guidelines. The 33 articles included in the systematic review pointed out how TGD children and adolescents experience high levels of anxiety and depression, as well as other emotional and behavioral problems, such as eating disorders and substance use. Resilience factors have been also pointed out, which aid this population in facing these negative mental health outcomes. The literature review highlighted that, on the one hand, TGD individuals appear to exhibit high levels of resilience; nonetheless, health disparities exist for TGD individuals compared with the general population, which are mainly attributable to the societal gender pressure to conform to their assigned gender. Considerations for research and clinical practice are provided.

Gender dysphoria in adolescents with Ehlers-Danlos syndrome

Objectives

Ehlers-Danlos Syndrome represents a family of heritable connective tissue disorders that include joint hypermobility, tissue fragility, and skin hyperextensibility. Ehlers-Danlos Syndrome presents with clinical sequela across multiple body systems that require multidisciplinary care. Little is known about adolescents with Ehlers-Danlos Syndrome who are transgender and gender diverse. To date, there have been no reports of transgender and gender diverse youth in pediatric patients with Ehlers-Danlos Syndrome. The objective of this study was to characterize transgender and gender diverse adolescents with Ehlers-Danlos Syndrome seen in a pediatric multidisciplinary specialty clinic.

Methods

A retrospective chart review was performed and it was found that 28 patients were seen in the Ehlers-Danlos Syndrome multidisciplinary clinic were reported being transgender and gender diverse. Chart review included analysis of all documents in the electronic medical record, including demographic data, gender identity, chosen pronouns, specialty care previously received for Ehlers-Danlos Syndrome, symptoms and conditions related to it, and medications.

Results

Of the 166 total adolescents seen in the pediatric multidisciplinary Ehlers-Danlos Syndrome clinic during the study period, 17% reported gender dysphoria. The average age at Ehlers-Danlos Syndrome diagnosis was 13.5 years (range 8-17 years). Most (61%) reported their gender identity as transgender, followed by nonbinary (14%). Most had preferred male (he/him) pronouns (47%), followed by nonbinary (they/them) pronouns (39%). The vast majority reported fatigue (75%), musculoskeletal issues (96%), psychiatric issues (86%), cardiac issues (71%), gastrointestinal issues (68%), and neurologic issues (79%).

Conclusions

Here we report the first cohort of transgender and gender diverse adolescents in the Ehlers-Danlos syndrome population and show an association between the two. This report increases awareness for providers who care for patients with Ehlers-Danlos Syndrome. As care for those with Ehlers-Danlos Syndrome is often complex and multidisciplinary, providers should adopt practices of gender-affirming medical care that contribute to improved care and outcomes.

Some Limitations of "Challenges in the Care of Transgender and Gender-Diverse Youth: An Endocrinologist's View"

There is significant disagreement about how to support trans-identified or gender-dysphoric young people. Different experts and expert bodies make strikingly different recommendations based upon the same (limited) evidence. The US-originating "gender-affirmative" model emphasizes social transition and medical intervention, while some other countries, in response to evidence reviews of medical intervention outcomes, have adopted psychological interventions as the first line of treatment. A proposed model of gender-affirming care, comprising only medical intervention for "eligible" youth, is described in Rosenthal (2021). Determining eligibility for these medical interventions is challenging and engenders considerable disagreement among experts, neither of which is mentioned. The review also claims without support that medical interventions have been shown to clearly benefit mental health, and leaves out significant risks and less invasive alternatives. The unreliability of outcome studies and the corresponding uncertainties as to how gender dysphoria develops and responds to treatment are also unreported.

Editorial Perspective: Medical body modification in youth with gender dysphoria or body dysmorphic disorder - is current practice coherent and evidence-based?

In recent decades, there has been a steady increase in the number of people, including adolescents, undergoing medical body modification (MBM) to alter their physically healthy bodies in invasive and nearly irreversible ways through medical treatment (e.g. surgery). While MBM is often recommended for youth with persisting gender dysphoria (GD), in body dysmorphic disorder (BDD) it has been considered contraindicated. Here, we outline the current controversies surrounding MBM practice and recommendations in adolescents with GD versus those with BDD in order to better understand under what circumstances we may or may not support adolescents who want to change their bodies medically and often irreversibly. We compare the two disorders in terms of the overlap and uniqueness of their behavioural and psychological features. In doing so, we discuss limitations of the existing (often low-quality) evidence for and against MBM in young patients. We conclude that the currently available evidence is too preliminary and far from conclusive to make any robust recommendations in terms of benefits and harms of MBM in youth with persisting GD or BDD. However, we strongly recommend further urgent scientific discussions and systematic research efforts into more robust evaluations and the identification of more precise psychological characteristics that may serve as decision criteria for or against MBM - particularly in those adolescents who did not respond to non-MBM, that is, psychiatric/psychological treatment and psychosocial support, if available at all. This will greatly benefit youth healthcare professionals in their challenging clinical practice of making decisions regarding MBM today and in the future.

The nature of co-morbid psychopathology in adolescents with gender dysphoria

Gender-referred adolescents (GR) have been reported to present with considerable psychiatric symptomatology compared to their age-peers. There is, however, little research on how they compare to adolescents referred due to mental health problems (MHR). We set out to compare psychopathology in adolescents referred to our specialized gender identity unit (n = 84) and adolescents referred to a general adolescent psychiatric clinic (n = 293) in a university hospital setting in Finland. Of the GR adolescents, 40.9% had not received any psychiatric diagnosis during adolescence. Eating disorders were less common in the GR than in the MHR group, but otherwise the prevalences of disorders did not differ statistically significantly. At the symptom level, the GR adolescents displayed significantly more suicidal ideation and talk and less alcohol abuse and eating disorder symptoms than did the MHR adolescents, but otherwise their symptom profiles were comparable. Additionally, the GR adolescents had significantly fewer total externalizing symptoms than did the MHR adolescents. Adolescents seeking gender affirming treatments present with psychiatric symptoms and disorders comparable to those seen among adolescent psychiatric patients. Medical gender affirming care may not be a sufficient intervention for treating psychiatric comorbidities of adolescents with gender dysphoria.

Double-Edged Sisterhoods: Transgender Identity, Peer Groups and the Commercial Sexual Exploitation of Transgender Girls

One of the existing gaps in the literature on the commercial sexual exploitation (CSE) of children is on transgender (trans) girls. Most of the available literature is heavily skewed toward experiences of cisgender girls. However, there is an undeniable need to understand the experiences of trans children given their unique experiences and vulnerabilities to CSE related to their identity. This article is a case study on the complex interaction between trans identity, peer influence, and other micro, meso, and macro factors that have predisposed trans girls to CSE. The paper is based on interviews with six trans girls, complemented by interviews with four social workers, research notes, and a review of related literature. Data was analyzed thematically. Based on the findings, peer groups provide critical support to trans girls, particularly, in terms of trans identity formation, gender transition information, security and protection, and other forms of support. Ironically, they play the contradictory role of priming and initiating them to CSE. Various structural and personal factors have compounded these and predisposed them to victimization. An interplay of macro (societal), meso (interpersonal), and micro (individual) factors have come into play in the commercial sexual exploitation of these trans girls.

Differences in self-perception and social gender status in children with gender incongruence

Background: Gender incongruent children report lower self-perception compared to the norm population. This study explored differences in self-perception between children living in their gender role assigned at birth and children living in their experienced gender role.Method: The self-perception questionnaire was administered to 312 children referred to the Center of Expertise on Gender Dysphoria 'Amsterdam UMC'. Social transition status was determined by parental interviews. 2 (social transition) by 2 (sex assigned at birth) ANCOVA's were conducted.Results: Children living in their assigned gender role reported comparable self-perception to children living in their experienced gender role. Birth assigned girls living in their assigned gender role reported poorer self-perception on 'athletic competence', compared to girls living in their experienced gender role. Birth assigned boys living in their assigned gender role reported poorer on 'scholastic competence' and 'behavioral conduct' compared to boys living in their experienced gender role.Conclusions: Social transition did not show to affect self-perception. Self-perception was poorer for birth assigned boys living in their experienced gender role. For birth assigned girls this was reversed. Future studies should give more insight in the role of social transitions in relation to child development and focus on other aspects related to self-perception.

Key socio-demographic characteristics of children and adolescents with gender dysphoria: A British Isles surveillance study

The present research used linked surveillance systems (British Paediatric Surveillance Unit; and the Child and Adolescent Psychiatry Surveillance System) over a 19 month period (1 November 2011-31 May 2013) to notify of young people (4-15.9 years) presenting to secondary care (paediatrics or child and adolescent mental health services) or specialist gender services with features of gender dysphoria (GD). A questionnaire about socio-demographic, mental health, and GD features was completed. Presence of GD was then assessed by experts in the field using then-current criteria (DSM-IV-TR). Incidence across the British Isles was 0.41-12.23 per 100,000. 230 confirmed cases of GD were noted; the majority were white (94%), aged ≥12 years (75.3%), and were assigned female at birth (57.8%). Assigned males presented most commonly in pre-adolescence (63.2%), and assigned females in adolescence (64.7%). Median age-of-onset of experiencing GD was 9.5 years (IQR 5-12); the majority reported long-standing features (2-5 years in 36.1%, ≥5 years in 26.5%). Only 82.5% attended mainstream school. Bullying was reported in 47.4%, previous self-harm in 35.2%, neurodiversity in 16%, and 51.5% had ≥1 mental health condition. These findings suggest GD is rare within this age group but that monitoring wellbeing and ensuring support for co-occurring difficulties is vital.

Gender Dysphoria and Its Non-Surgical and Surgical Treatments

Gender dysphoria is defined by severe or persistent distress associated with an incongruence between one's gender identity and biological sex. It is estimated that 1.4 million Americans and 25 million people worldwide identify as transgender and that 0.6% of Americans experience gender dysphoria. The pathophysiology of gender dysphoria is multifactorial and incompletely understood. Genetics, androgen exposure, neuroanatomy, brain connectivity, history of trauma, parents with psychological disorders, and being raised by less than two parents are associated with gender dysphoria. Gender dysphoria most frequently presents in early teenage years but can present earlier or later. Anxiety and depression are the two most common comorbid diagnoses and may be the reason for presentation to medical care. Diagnosis is established through history and or validated questionnaires. Treatment includes psychosocial therapy, pharmacotherapy for underlying depression and/or anxiety, hormonal therapy, non-genital and/or genital feminization or masculinization operations. The frequency and severity of treatment related morbidity increases progressively as treatments go from conservative to more invasive. Gender dysphoria and its treatment is individualized and not completely understood.

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.

Aspects of Gender and Sexuality in Relation to Experiences of Subjection to Sexual Harassment among Adolescents in General Population

Subjection to sexual harassment (SH) has been reported more commonly by girls than by boys, by sexual and gender minority youth more than by mainstream youth, and by sexually active youth more than by those not yet experienced in romantic and erotic encounters. However, the research so far has not addressed these correlates simultaneously. This study aimed to explore independent associations between experiencing SH and these aspects of sex, gender and sexuality-considering all of them concurrently. A cross sectional survey with data from Finland was used, with an analyzable sample of 71,964 adolescents aged 14 to 16-years- of age, collected in 2017. The data were analysed using cross-tabulations with chi-square statistics and logistic regression analyses. The types of SH studied were gender harassment, unwelcome sexual attention, and sexual coercion. Girls, sexual and gender minority youth, and youth engaging in romantic and erotic encounters had experienced all three types of SH more commonly than boys, mainstream youth and those not sexually active. Associations between minority status and experiences of sexual harassment were stronger among boys, and being sexually active had stronger associations with subjection to sexual harassment in girls. The findings appear to support the assumption that sexual harassment serves both as a means of perpetuating heteronormativity and the sexual double standard.

Defining Desistance: Exploring Desistance in Transgender and Gender Expansive Youth Through Systematic Literature Review

Background

Desistance is a concept that has been poorly defined in the literature, yet greatly impacts the arguments for and against providing gender-affirming care for transgender and gender expansive (TGE) youth. This literature review aims to provide an overview of the literature on desistance and how desistance is defined.

Methods

A systematically guided literature review was conducted on March 27, 2020, using CINAHL, Embase, LGBT Life, Medline, PsychINFO, and Web of Science to identify English language peer-reviewed studies, editorials, and theses that discuss desistance concerning TGE pre-pubertal youth for a minimum of three paragraphs. Articles were divided based on methodology and quantitative data were quality assessed and congregated. Definitions of desistance were compiled and analyzed using constant comparative method.

Results

One qualitative study, 2 case studies, 5 quantitative studies, 5 ethical discussions, and 22 editorials were assessed. Quantitative studies were all poor quality, with 83% of 251 participants reported as desisting. Thirty definitions of desistance were found, with four overarching trends: desistance as the disappearance of gender dysphoria (GD) after puberty, a change in gender identity from TGE to cisgender, the disappearance of distress, and the disappearance of the desire for medical intervention.

Conclusions

This review demonstrates the dearth of high-quality hypothesis-driven research that currently exists and suggests that desistance should no longer be used in clinical work or research. This transition can help future research move away from attempting to predict gender outcomes and instead focus on helping reduce distress from GD in TGE children.

Is It Autism? A Critical Commentary on the Co-Occurrence of Gender Dysphoria and Autism Spectrum Disorder

An increasing amount of literature revealed a link between GD and ASD. Both GD and ASD are complex and heterogeneous conditions characterized by a large variety of presentations. Studies have reported that individuals with GD tend to have higher prevalence rates of autistic traits in comparison to the general population. The purpose of this commentary is to provide, through the description of a clinical case, our reading and a possible interpretation of the correlation of these two conditions in light of the several methodological limitations found in literature. We hypothesize that the traits often classified as autistic could be more accurately related to the distress and discomfort evoked by GD. The autistic traits of individuals with GD as forms of psychological defenses and coping mechanisms aimed at dealing with socio-relational and identity problems are discussed.

Informed Consent or Scare Tactics? A Response to Levine et al.'s "Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults"

This responds to "Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults" by Levine et al., part of a small but growing, critical response to contemporary treatments of gender dysphoric/incongruent (GD/GI) children and adolescents. This author, while disagreeing with Levine et al. and other critics, hopes that with dialogue, research and engagement with the wider world, needs of all children, adolescents and young adults-those who have GD/GI and those who may not-will be best served. Critics of gender affirming treatments cite growing numbers of cases, "low level of evidence" supporting treatment, irreversible side effects and expressing regrets as reasons to oppose gender affirmative treatments. Although sharing similar concerns, the author does not conclude treatments should not be offered when appropriate. The critics' alternative reads as "just talk to the young people and find out what is really bothering them." Lacking empirical evidence for that approach does not appear to trouble them.Levine et al.'s caricature of informed consent, which this author parodies, would dissuade anyone from treatment. Their approach does not appear to be written for purposes of engaging frontline clinicians with the aim of improving treatment. Instead, they read as appeals to third parties unfamiliar with the clinical presentations of these children-parents, caretakers courts, legislatures, state health departments and national health care systems-to discourage treatments from proceeding. This impression is further buttressed by a declaration of financial support from The Society for Empirical-Based Gender Medicine, a small group of outliers from mainstream clinicians treating minors with GD/GI who present as "truth-speaking" experts regarding "facts" being ignored, elided over or perhaps even covered up by the mainstream.The author concludes by noting that clinicians who advocate for delaying treatment to GD/GI minors who need and may benefit from it to "protect" those who "aren't really" transgender is an ethically troubling issue. In other words, "first, do no harm" is a sword that cuts two ways.

A PRISMA systematic review of adolescent gender dysphoria literature: 2) mental health

It is unclear whether the literature on adolescent gender dysphoria (GD) provides sufficient evidence to inform clinical decision making adequately. In the second of a series of three papers, we sought to review published evidence systematically regarding the extent and nature of mental health problems recorded in adolescents presenting for clinical intervention for GD. Having searched PROSPERO and the Cochrane library for existing systematic reviews (and finding none), 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 the 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), 32 papers from 11 countries representing between 3000 and 4000 participants were included in our final sample. Most studies were observational cohort studies, usually using retrospective record review (21). A few compared cohorts to normative or population datasets; most (27) were published in the past 5 years. 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 45% to 96%, with a mean of 81%. More than a third of the included studies emerged from two treatment centres: there was considerable sample overlap and it is unclear how representative these are of the adolescent GD community more broadly. Adolescents presenting for GD intervention experience a high rate of mental health problems, but study findings were diverse. Researchers and clinicians need to work together to improve the quality of assessment and research, not least in making studies more inclusive and ensuring long-term follow-up regardless of treatment uptake. Whole population studies using administrative datasets reporting on GD / gender non-conformity may be necessary, along with inter-disciplinary research evaluating the lived experience of adolescents with GD.

Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults

In less than a decade, the western world has witnessed an unprecedented rise in the numbers of children and adolescents seeking gender transition. Despite the precedent of years of gender-affirmative care, the social, medical and surgical interventions are still based on very low-quality evidence. The many risks of these interventions, including medicalizing a temporary adolescent identity, have come into a clearer focus through an awareness of detransitioners. The risks of gender-affirmative care are ethically managed through a properly conducted informed consent process. Its elements-deliberate sharing of the hoped-for benefits, known risks and long-term outcomes, and alternative treatments-must be delivered in a manner that promotes comprehension. The process is limited by: erroneous professional assumptions; poor quality of the initial evaluations; and inaccurate and incomplete information shared with patients and their parents. We discuss data on suicide and present the limitations of the Dutch studies that have been the basis for interventions. Beliefs about gender-affirmative care need to be separated from the established facts. A proper informed consent process can both prepare parents and patients for the difficult choices that they must make and can ease professionals' ethical tensions. Even when properly accomplished, however, some clinical circumstances exist that remain quite uncertain.

Care for Transgender Young People

Clinicians of all disciplines, including pediatric endocrinologists, are likely to encounter transgender and gender-diverse (TGD) young people in their practice regardless of whether they specialize in gender-affirming medical care. Because of this, it is important to be aware of the ways in which medical professionals can affirm these individuals. Although gender-affirming therapy should always include affirmation including proper use of names and pronouns, the transition journey will look different for each patient. The gender-affirming care of TGD young people may include both medical and nonmedical interventions (e.g., social transition). Therapies utilized for medical gender transition such as gonadotropin-releasing hormone agonists and/or gender-affirming hormones have implications for growth, bone health, cardiovascular health, and fertility, although these impacts are not yet completely understood. This review provides an overview of the care of transgender young people as well as a summary of what is known about the outcomes of these therapies. Clinicians should advise TGD young people and their families of the known and unknown risks and work together with patients to decide upon a treatment and follow-up regimen that aligns with their individual gender affirmation and health goals.

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

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

Identity Integration in Adolescents With Features of Gender Dysphoria Compared to Adolescents in General Population

Adolescence is an important period for identity formation and identity consolidation is one of the main developmental tasks. Gender identity is an essential aspect of identity but so far little is known about its development. Neither has the identity development of adolescents with features of gender dysphoria (GD) been extensively studied so far. However, adolescents with features of GD have been shown to present extensive psychiatric psychopathology and could therefore be assumed also to have more problems with identity development. We set out to compare the identity integration of adolescents with features of GD (n = 215; 186 natal females, 29 natal males) and adolescents from general population (n = 400; 244 females, 154 males and 2 who did not report their sex) using a culture-adapted Finnish version of an assessment tool for adolescents and young adults on identity in terms of personality functioning, the Assessment of Identity Development in Adolescence (AIDA). AIDA is a 58-item self-report questionnaire enabling dimensional differentiation between healthy and impaired identity development. The continuous AIDA total score (sum score) and its subscales were analyzed using MANOVA, and dichotomized T-scores differentiating identity development in impaired and healthy range using cross-tabulations with chi-square statistics. Adolescents with features of GD showed identity development similar to adolescents in general population. The slight differences seen in AIDA scores were in favor of the GD group. The proportion scoring to identity impairment was lowest among gender-referred adolescents assigned males at birth. Identity integration of the gender-referred adolescents was further compared to that of 77 adolescents in specialist level psychiatric outpatient treatment (67 females, 10 males). The adolescent psychiatric outpatients scored much higher toward impaired identity on all AIDA scales than did the adolescents with features of GD. These results suggest that features of GD are not associated with problems in identity development in adolescents at large. Adolescents with features of GD may have been required to process their identity more, thereby advancing further in their identity consolidation process than young people on average.

Gender Dysphoria in children and young people: The implications for clinical staff of the Bell V's Tavistock Judicial Review and Appeal Ruling

In the past few years, there has been a very significant rise in the number of children and young people seeking treatment for gender dysphoria This area is the subject of much discussion, as evidenced in a recent court case in the UK which examined competence and capacity of young people to consent to potentially irreversible interventions. Clinicians involved in gaining consent to puberty blockers for gender dysphoric young people, must understand the evidence in this area and be aware of the heavy burden of accountability placed upon them.

Trapped in the Wrong Body? Transgender Identity Claims, Body-Self Dualism, and the False Promise of Gender Reassignment Therapy

In this article, I explore difficult and sensitive questions regarding the nature of transgender identity claims and the appropriate medical treatment for those suffering from gender dysphoria. I first analyze conceptions of transgender identity, highlighting the prominence of the wrong-body narrative and its dualist presuppositions. I then briefly argue that dualism is false because our bodily identity (including our body's biological organization for sexual reproduction as male or female) is essential and intrinsic to our overall personal identity and explain why a sound, nondualist anthropology implies that gender identity cannot be entirely divorced from sexual identity. Finally, I make the case that arguments in favor of hormonal and surgical treatments for gender dysphoria rest on this mistaken dualist anthropology, and that these treatments therefore give false hope to those suffering from gender dysphoria, while causing irreversible bodily harm and diverting attention from underlying psychological problems that often need to be addressed. I also briefly discuss how these philosophical claims relate to empirical studies on the outcomes of hormonal and surgical treatments for gender dysphoria and to testimonies of transgender individuals who regret having undergone these treatments.

Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners

The study's purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.

Freedom to think: the need for thorough assessment and treatment of gender dysphoric children

Referrals (particularly natal female) to gender identity clinics have increased significantly in recent years. Understanding the reasons for this increase, and how to respond, is hampered by a politically charged debate regarding gender identity. This article starts with a discussion of the so-called 'affirmative approach' to gender dysphoria and considers the implications of the Memorandum of Understanding on conversion therapy. I then say something about the relationship between gender dysphoria and the developmental problems that are characteristic of adolescence. Finally, I outline what changes to the current approach are needed to do our best to ensure these patients receive the appropriate treatment.

Sex, gender and gender identity: a re-evaluation of the evidence

In the past decade there has been a rapid increase in gender diversity, particularly in children and young people, with referrals to specialist gender clinics rising. In this article, the evolving terminology around transgender health is considered and the role of psychiatry is explored now that this condition is no longer classified as a mental illness. The concept of conversion therapy with reference to alternative gender identities is examined critically and with reference to psychiatry's historical relationship with conversion therapy for homosexuality. The authors consider the uncertainties that clinicians face when dealing with something that is no longer a disorder nor a mental condition and yet for which medical interventions are frequently sought and in which mental health comorbidities are common.

Defensive Functioning of Individuals Diagnosed With Gender Dysphoria at the Beginning of Their Hormonal Treatment

Defense mechanisms are relevant indicators of psychological functioning and vulnerability to psychopathology. Their evaluation can unveil individuals' unconscious strategies for mediating reactions to emotional conflict and external stressors. At the beginning of their journey toward gender reassignment, individuals diagnosed with gender dysphoria (GD) may experience conflict and stressful experiences that trigger a wide range of defense mechanisms. Mature defenses may strengthen these individuals as they travel along this important path, while neurotic and immature defenses may exacerbate their body dissatisfaction (BD) and hinder their processing of change. Only a few studies have investigated self-reported defensive functioning in transgender people, finding a higher frequency of maladaptive defense mechanisms relative to controls. The present study was the first to apply an in-depth clinician-rated tool to assess the entire hierarchy of defense mechanisms within a sample of transgender people. Defensive functioning and personality organization were assessed in 36 individuals diagnosed with GD (14 trans women, 22 trans men, mean age 23.47 years), using the Defense Mechanisms Rating Scales (Perry, 1990) and the Shedler-Westen Assessment Procedure-200 (Shedler et al., 2014). Body uneasiness was assessed using the Body Uneasiness Test (BUT; Cuzzolaro et al., 2006). The findings showed that defensive functioning correlated positively with healthy personality functioning and negatively with BD. Compared to cisgender controls, participants with GD who presented greater defensive functioning were found to be more immature and to demonstrate significant differences in many levels of functioning. The clinical implications of the results suggest that psychological interventions aimed at improving defensive functioning in individuals with GD will be important in helping them manage the challenges posed by their gender transition.

Psychiatry, psychotherapy and the criminalisation of 'conversion therapy' in Australia

OBJECTIVE

To examine laws in three Australian jurisdictions that prohibit therapy to change or suppress a person's sexual orientation or gender identity.

CONCLUSIONS

The laws in Victoria and the ACT provide inadequate protection for clinically appropriate psychiatric practice and may deprive patients of mental health care.

Body image in children with gender incongruence

BACKGROUND

In the DSM-5 diagnosis of childhood Gender Dysphoria, two of the eight criteria focus on body satisfaction of the child. Nevertheless, this subject is understudied. This study aims to describe the body image of children with gender incongruence (GI) in relation to birth assigned sex and the intensity of GI.

METHOD

Self-report and parent-report measures on body satisfaction and gender incongruence were obtained from 207 children (<12 years) who were referred to the Center of Expertise on Gender Dysphoria at the Amsterdam University Medical Centers, location VUmc, between 2010 and 2016. First, a general description of body satisfaction in children who took part in this study is provided. Secondly, body image of birth assigned boys and girls are compared using chi-square tests and univariate ANCOVA's. Thirdly, the association between intensity of GI and body image is examined using multiple linear regression analyses.

RESULTS

Of the 207 children with GI, 50% reported dissatisfaction with their gender-specific characteristics. Overall, children were less dissatisfied with their neutral body characteristics. Birth assigned girls report greater dissatisfaction with their body characteristics than birth assigned boys. Intensity of GI was significantly related to satisfaction with gender specific body characteristics where a greater intensity of GI relates to more body dissatisfaction.

CONCLUSION

Mental health practitioners should be aware of the diversity in body dissatisfaction in this group. Furthermore, evaluation of body image should be an important topic in the counseling of these children. Future research should focus on the relation of body dissatisfaction and the development of gender incongruent feelings in children with GI.