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

Population-adjusted numbers, demographics and mental health among children and adolescents referred to the Norwegian National Center for Gender Incongruence over two decades

Over the last decade, there has been a sharp increase in young people seeking medical treatment for gender dysphoria/gender incongruence (GD/GI). The aims of this study were to calculate yearly population-adjusted numbers of children and adolescents referred to the Norwegian National Center for Gender Incongruence (NCGI) at Oslo University Hospital (OUS) from 2000 to 2022; to describe the demographic characteristics and prevalence of psychiatric diagnoses, self-harm and suicide attempts among the referred from 2000 to 2020; and to investigate time trends. The study used data from the Gender Incongruence Registry for Children and Adolescents (GIRCA) in Norway. All persons under 18 years (n = 1258) referred to the NCGI between 2000 and 2020 were included: 68.4% assigned female gender at birth (AFAB) and 31.6% assigned male gender at birth (AMAB). We found a sharp increase in referrals to the NCGI favouring AFAB over AMAB. Nearly two in three (64.5%) had one or more registered psychiatric diagnoses. Self-harm was registered among 35.5%, and 12.7% had attempted suicide. Registered psychiatric diagnoses were significantly (p ≤ 0.001) more prevalent among AFAB (67.8%) than AMAB (57.4%). The number of registered diagnoses per person decreased significantly over time, with an average reduction of 0.02 diagnoses per person per year. Although there was a downward time trend in registered diagnoses per person, the total mental health burden among children and adolescents with GI emphasizes the need for a holistic approach.

Referrals For Gender-Affirming Hormone Treatment in Croatia's National Network for Transgender Healthcare

A network of healthcare professionals specializing in transgender care was established in Croatia in 2011, and legal advancements were subsequently made in 2014. Both achievements made gender transition more transparent and thus more attainable in Croatia. This observational study was conducted to assess the number of transgender individuals initiating gender-affirming hormone treatment (GAHT) in Croatia and describes trends in age and sex assigned at birth. Between 2011 and 2022, a total of 111 transgender individuals initiated GAHT. Within the cohort, 52 were assigned male at birth (AMAB) and 59 were assigned female at birth (AFAB). The overall annual incidence rate of transgender individuals initiating GAHT was 0.52 per 100,000 age-adjusted individuals. There was a statistically significant increase (p < 0.01) in transgender individuals commencing GAHT before the COVID-19 pandemic. Furthermore, a rising trend toward masculinizing rather than feminizing treatment was identified (p < 0.05), particularly among younger transgender individuals. The COVID-19 pandemic disrupted these trends in 2020, except for the trend of initiating therapy at a younger age (p < 0.01). The annual incidence and age distribution trends of transgender individuals initiating GAHT in Croatia closely mirrored those in other European countries, with a higher prevalence of individuals assigned female at birth. The study underscores a significant rise in the number of individuals initiating gender-affirming hormone treatment, emphasizing the need for proper legal regulation and healthcare system response.

Treatment trajectories of gender incongruent Austrian youth seeking gender-affirming hormone therapy

Objective

The aim of this study was to describe the treatment trajectories of Austrian children and adolescents with gender incongruence seeking gender-affirming medical care.

Methods

Patients who presented with gender incongruence at the pediatric outpatient clinic for differences in sex development at a large university hospital in Austria from January 2008 to December 2022 were included in a retrospective chart review, and analyzed regarding referral numbers, patient characteristics, treatment trajectories, fertility preservation, and legal gender marker changes.

Results

Of 310 eligible patients, 230 (74.2%) were assigned female at birth (AFAB), and 80 (25.8%) were assigned male at birth (AMAB). The number of referrals increased steeply from 2008 to 2018, whereafter it stabilized at around 50 per year. At the time of initial presentation, the median age of patients was 15.6 years (IQR 14.3-16.8). AMAB individuals tended to be younger (median 14.9 years, IQR 13.9-16.8) than AFAB individuals (median 15.8 years, IQR 14.4-16.8; p= 0.012). 207 (66,8%) completed the assessment process and were eligible for gender affirming medical treatment (GAMT). Of those, 89% (186/207) commenced gender affirming hormone therapy in the pediatric outpatient clinic (79/186 received GnRHa monotherapy, 91/186 GnRHa and sex steroids, and 16/186 sex steroid monotherapy). Of the 54 AMAB individuals receiving GAMT, 6 (11.1%) completed fertility preservation prior to therapy initiation. Only 1/132 AFAB adolescents receiving GAMT completed fertility preservation. Chest masculinization surgery was performed in 22 cases (16.7%), and breast augmentation in two cases (3.7%) between the ages of 16 and 18. Changes in legal gender marker were common, with 205 individuals (66.1%) having changed their legal gender marker.

Conclusion

This is the first time that treatment trajectories, fertility preservation rates, and changes of legal gender marker have been described in Austrian adolescents with gender incongruence seeking GAMT. The majority received GAMT and changed their legal gender marker, while gender affirming surgery rates were low, and utilization of fertility preservation treatment options was rare.

Gender-affirming hormone treatment: friend or foe? Long-term follow-up of 755 transgender people

PURPOSE

Gender-affirming hormone treatment (GAHT) is one of the main demands of transgender and gender diverse (TGD) people, who are usually categorised as transgender assigned-male-at birth (AMAB) and assigned-female-at birth (AFAB). The aim of the study is to investigate the long-term therapeutic management of GAHT, considering hormonal targets, treatment adjustments and GAHT safety.

METHODS

A retrospective, longitudinal, observational, multicentre clinical study was carried out. Transgender people, both AMAB and AFAB, were recruited from two Endocrinology Units in Italy (Turin and Modena) between 2005 and 2022. Each subject was managed with specific and personalized follow-up depending on the clinical practice of the Centre. All clinical data routinely collected were extracted, including anthropometric and biochemical parameters, lifestyle habits, GAHT regime, and cardiovascular events.

RESULTS

Three-hundred and two transgender AFAB and 453 transgender AMAB were included. Similar follow-up duration (p = 0.974) and visits' number (p = 0.384) were detected between groups. The transgender AFAB group reached therapeutic goals in less time (p = 0.002), fewer visits (p = 0.006) and fewer adjustments of GAHT scheme (p = 0.024). Accordingly, transgender AFAB showed a higher adherence to medical prescriptions compared to transgender AMAB people (p < 0.001). No significantly increased rate of cardiovascular events was detected in both groups.

CONCLUSION

Our real-world clinical study shows that transgender AFAB achieve hormone target earlier and more frequently in comparison to transgender AMAB individuals. Therefore, transgender AMAB people may require more frequent check-ups in order to tailor feminizing GAHT and increase therapeutic adherence.

Adolescent gender dysphoria management: position paper from the Italian Academy of Pediatrics, the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, the Italian Society of Adolescent Medicine and the Italian Society of Child and Adolescent Neuropsychiatry

BACKGROUND

In response to the imperative need for standardized support for adolescent Gender Dysphoria (GD), the Italian Academy of Pediatrics, in collaboration with the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, Italian Society of Adolescent Medicine and Italian Society of Child and Adolescent Neuropsychiatry is drafting a position paper. The purpose of this paper is to convey the author's opinion on the topic, offering foundational information on potential aspects of gender-affirming care and emphasizing the care and protection of children and adolescents with GD.

MAIN BODY

Recognizing that adolescents may choose interventions based on their unique needs and goals and understanding that every individual within this group has a distinct trajectory, it is crucial to ensure that each one is welcomed and supported. The approach to managing individuals with GD is a multi-stage process involving a multidisciplinary team throughout all phases. Decisions regarding treatment should be reached collaboratively by healthcare professionals and the family, while considering the unique needs and circumstances of the individual and be guided by scientific evidence rather than biases or ideologies. Politicians and high court judges should address discrimination based on gender identity in legislation and support service development that aligns with the needs of young people. It is essential to establish accredited multidisciplinary centers equipped with the requisite skills and experience to effectively manage adolescents with GD, thereby ensuring the delivery of high-quality care.

CONCLUSION

Maintaining an evidence-based approach is essential to safeguard the well-being of transgender and gender diverse adolescents.

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

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

Executive summary: Quality standards of care units for people with sexual and gender diversity

Comprehensive biopsychosocial care for people with gender incongruence (ICD 11) who are transgender (trans) or gender diverse is a complex process in which the quality of the medical transition can only be guaranteed after a multidisciplinary approach, through teams that integrate professionals with training and experience not only in medicine but also in diversity and gender identity. Based on this, the Gonad, Identity and Sexual Differentiation working group of the Spanish Society of Endocrinology and Nutrition (GT-GIDSEEN) has established minimum care requirements that aim to guarantee adequate health care for these people by professionals. A position paper has been produced and is available at https://www.seen.es/portal/documentos/estandares-calidad-gidseen-2024.

A European Network for the Investigation of Gender Incongruence in adolescents

BACKGROUND

Knowledge regarding the effects and side effects of gender-affirming hormone therapy (GAHT) in adults is rapidly growing, partly through international research networks such as the European Network for the Investigation of Gender Incongruence (ENIGI). However, data on the effects of puberty suppression (PS) and GAHT in transgender and gender diverse (TGD) youth are limited, although these data are of crucial importance, given the controversies surrounding this treatment.

AIM

We sought to present a detailed overview of the design of the ENIGI Adolescents study protocol, including the first baseline data.

METHODS

The ENIGI Adolescents study is an ongoing multicenter prospective cohort study. This study protocol was developed by 3 European centers that provide endocrine care for TGD adolescents and were already part of the ENIGI collaboration: Amsterdam, Ghent, and Florence.

OUTCOMES

Study outcomes include physical effects and side effects, laboratory parameters, bone mineral density, anthropometric characteristics, attitudes toward fertility and fertility preservation, and psychological well-being, which are measured in the study participants during PS and GAHT, up to 3 years after the start of GAHT.

RESULTS

Between November 2021 and May 2023, 172 TGD adolescents were included in the ENIGI Adolescents protocol, of whom 51 were assigned male at birth (AMAB) and 121 were assigned female at birth (AFAB); 3 AFAB participants reported a nonbinary gender identification. A total of 76 participants were included at the start of PS, at a median (IQR) age of 13.7 (12.9-16.5) years in AMAB and 13.5 (12.4-16.1) years in AFAB individuals. The remaining 96 participants were included at start of GAHT, at a median (IQR) age of 15.9 (15.1-17.4) years in AFAB and 16.0 (15.1-16.8) years in AMAB individuals. At the time of this report the study was open for inclusion and follow-up measurements were ongoing.

CLINICAL IMPLICATIONS

In response to the rising demand for gender-affirming treatment among TGD youth, this ongoing study is fulfilling the need for prospective data on the effects and safety of PS and GAHT, thus providing a foundation for evidence-based healthcare decisions.

STRENGTHS AND LIMITATIONS

This study has a strong multicenter, prospective design that allows for systematic data collection. The use of clinical and self-reported data offers a broad range of outcomes to evaluate. Nevertheless, the burden of additional measurements and questionnaires may lead to withdrawal or lower response rates. Few participants with a non-binary gender identity have been included.

CONCLUSION

With the ENIGI Adolescents study we aim to create a comprehensive dataset that we can use for a wide range of studies to address current controversies and uncertainties and to improve healthcare for TGD adolescents.

Autistic Characteristics in a Nationally Representative Clinical Sample of Adolescents Seeking Medical Gender-Affirming Treatment in Norway

PURPOSE

Several studies have reported on the intersection of autism and gender incongruence (GI) in clinical populations. This study aims to investigate autistic characteristics and registered autism spectrum diagnoses (ASD) in a clinical cohort of 83 adolescents referred to the National Gender Team for Children and Adolescents in Norway during 2020.

METHODS

Parents completed the Social Responsiveness Scale (SRS). Background information and registered psychiatric diagnoses were extracted from patient files.

RESULTS

The results showed that 25% of the participants scored within the clinical range on the SRS: 27.4% of adolescents who were assigned female at birth (AFAB) and 19.0% of adolescents who were assigned male at birth (AMAB). AFAB had significantly higher scores on SRS Total Scale and the Social Motivation and Autistic Mannerisms subscales compared to the female norm group. AMAB had higher scores on the Social Motivation subscale and lower scores on the Social Awareness subscale, compared to the male norm population. Information from patient files revealed that 67.5% had one or more registered psychiatric diagnosis. 9.6% had received an ASD diagnosis, all AFAB. 18.1% had received an attention deficit hyperactivity disorder (ADHD) diagnosis. The most common psychiatric diagnoses were depression (25.3%) and anxiety disorders (18.1%). Further, 44.6% had a history of self-harm, and 15.7% had a history of a suicide attempt.

CONCLUSION

The results showed an overrepresentation of ASD diagnoses and autistic characteristics measured by SRS for AFAB. There was an overrepresentation of psychiatric diagnoses for both the AFAB and the AMAB group in this study sample. Implications for treatment and future research are discussed.

Patterns of gender identity data within electronic health record databases can be used as a tool for identifying and estimating the prevalence of gender-expansive people

Objective

Electronic health records (EHRs) within the United States increasingly include sexual orientation and gender identity (SOGI) fields. We assess how well SOGI fields, along with International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) codes and medication records, identify gender-expansive patients.

Materials and Methods

The study used a data set of all patients that had in-person inpatient or outpatient encounters at an academic medical center in a rural state between December 1, 2018 and February 17, 2022. Chart review was performed for all patients meeting at least one of the following criteria: differences between legal sex, sex assigned at birth, and gender identity (excluding blank fields) in the EHR SOGI fields; ICD-10 codes related to gender dysphoria or unspecified endocrine disorder; prescription for estradiol or testosterone suggesting use of gender-affirming hormones.

Results

Out of 123 441 total unique patients with in-person encounters, we identified a total of 2236 patients identifying as gender-expansive, with 1506 taking gender-affirming hormones. SOGI field differences or ICD-10 codes related to gender dysphoria or both were found in 2219 of 2236 (99.2%) patients who identify as gender-expansive, and 1500 of 1506 (99.6%) taking gender-affirming hormones. For the gender-expansive population, assigned female at birth was more common in the 12-29 year age range, while assigned male at birth was more common for those 40 years and older.

Conclusions

SOGI fields and ICD-10 codes identify a high percentage of gender-expansive patients at an academic medical center.