Young Children With Gender Nonconforming Behaviors and Preferences

Etiology Beliefs About Sexual and Gender Minority Youth (EB-SGM): Validation with College Students, Community Adults, and Pediatric Healthcare Providers

Sexual and gender minority (SGM) youth are at risk for adverse health outcomes because of stigma and discrimination exposure. Individuals' beliefs about the biological origin of SGM identity are linked to their negative attitudes and biases against SGM populations, which can also apply to pediatric healthcare providers. The current study outlines validation of the Etiology Beliefs about Sexual and Gender Minority Youth (EB-SGM) scale, a 12-item measure designed to assess adults' beliefs about youths' biological versus environmental SGM etiology. College students (N = 285; study 1), community adults (N = 258; study 2), and pediatric providers (N = 104; study 3) completed the EB-SGM and other self-report measures. Exploratory factor analysis (EFA) in study 1 revealed a three-factor structure: beliefs about gender nonconforming behavior, beliefs about gender identity, and beliefs about sexual attraction/behavior. Confirmatory factor analysis (CFA) in study 2 suggested a bi-factor structure, which was replicated in study 3. The EB-SGM demonstrated adequate concurrent and discriminant validity. We also examined bivariate correlations between etiology beliefs and sociodemographic characteristics across samples. Findings indicate that EB-SGM is a psychometrically sound instrument to measure adults' etiology beliefs. The EB-SGM has the potential to be used as a screening measure to enhance pediatric healthcare providers' SGM training.

Gender non-conformity in childhood and adolescence and mental health through to adulthood: a longitudinal cohort study, 1995-2018

BACKGROUND

Few studies have examined associations between gender non-conformity (GNC) in childhood or adolescence and mental health outcomes later in life. This study examined associations between (1) GNC and mental health over multiple time points in childhood and adolescence, and (2) GNC in childhood and/or adolescence and mental health in adulthood.

METHOD

Second generation participants from the Raine Study, a longitudinal cohort from Perth, Western Australia. Data were collected between 1995 and 2018, comprising seven waves: ages 5 (N = 2236), 8 (N = 2140), 10 (N = 2048), 14 (N = 1864), 17 (N = 1726), 22 (N = 1236) and 27 (N = 1190) years. History of GNC, v. absence of this history, was based on responses to item 110 from the Child Behaviour Checklist (CBCL)/Youth Self Report (YSR) ('wishes to be of opposite sex'). The CBCL/YSR were used to measure internalising and externalising symptoms. Items 18 ('deliberate self-harm [DSH] or attempts suicide') and 91 ('talks/thinks about killing self') were used as measures of suicidal ideation (SI) and DSH. For adults, Depression, Anxiety and Stress Subscales and Kessler Psychological Distress Scale assessed mental health.

RESULTS

Child and adolescent GNC was associated with elevated internalising and externalising behaviours and increased odds of DSH. A history of GNC was also associated with vulnerability for severe psychological distress in adulthood in some symptom scales.

CONCLUSION

GNC over the child and adolescent period is associated with significant emotional and behavioural difficulties, and psychological distress. A history of GNC in childhood and/or adolescence also predicts poorer mental health in adulthood on multiple symptom domains.

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

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

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

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

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

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

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.

Developing Parenting Guidelines to Support Transgender and Gender Diverse Children's Well-being

OBJECTIVES

Parents and caregivers' responses to their child's gender identity or expression play a pivotal role in their mental health. Despite increasing visibility of transgender and gender diverse (TGD) children, few scientific resources exist to advise their parents and caregivers.

METHODS

We used an online Delphi study to generate expert consensus. Expert adult participants (N = 93; 55% cisgender women, 12% cisgender men, 33% gender minority; 83% White race or ethnicity) rated statements describing parenting strategies compiled from a systematic search of community-generated online literature. Participants represented 3 distinct "panels" of expertise: parents and caregivers of a TGD child, TGD persons, and/or professionals working with TGD populations. Statements rated as essential or important by 80% to 100% of each panel were endorsed as a guideline. Three rounds of surveys were used with iterative feedback to develop consensus.

RESULTS

Of 813 total statements, only 125 were endorsed by all 3 panels. Key domains of consensus included: supportive strategies for parents (eg, open communication, listening), behaviors to avoid (eg, pressuring a child into a gender transition), strategies for navigating healthcare and school systems, and common responses for parents (eg, confusion). Areas of disagreement, in which professional and TGD panels concurred but the parent panel did not, included whether to allow gender identity experimentation during childhood, the value of providing access to gender diverse media, and how to avoid misgendering a child.

CONCLUSIONS

These consensus-based guidelines offer a unique and needed resource for parents and caregivers and clinicians and can be used to promote the mental health and well-being of TGD children.

Family-Based Interventions with Transgender and Gender Expansive Youth: Systematic Review and Best Practice Recommendations

Research on transgender and gender expansive (TGE) youth has highlighted the disproportionate and challenging mental health and developmental outcomes faced by these young people. Research also largely suggests that family acceptance of TGE youth's gender identity and expression is crucial to preventing poor psychosocial outcomes in this community. Recently, family-based treatment has become common practice with TGE youth whose families are available for care, but it is unclear whether research provides outcome data for family interventions with TGE youth. This study follows Preferred Systematic Reviews and Meta-Analyses (PRISMA) guidelines to systematically review articles that provide outcome data or clinical recommendations for family-based interventions with TGE youth and their families. No quantitative outcome data for family therapy with TGE youth were found, but numerous articles spanning decades (n=32) provided clinical practice recommendations for family-based interventions with this population. Very few articles provided outcome data for family therapy with sexual minority youth (n=2). Over time, clinical strategies have moved from pathologizing to affirming of TGE youths' gender journey. Common clinical strategies of affirming interventions include (1) providing psychoeducation, (2) allowing space for families to express reactions to their child's gender, (3) emphasizing the protective power of family acceptance, (4) utilizing multiple modalities of support, (5) giving families opportunities for allyship and advocacy, (6) connecting families to TGE community resources, and (7) centering intersectional approaches and concerns. Future research should examine the efficacy of family-based interventions that incorporate these clinical strategies and collect quantitative data to systematically determine their effect on psychosocial outcomes.

Pediatric Research and Health Care for Transgender and Gender Diverse Adolescents and Young Adults: Improving (Biopsychosocial) Health Outcomes

Adolescent and young adult (AYA) transgender health care and research have expanded rapidly in the United States and abroad, but the effects of gender-affirming social, hormonal, or surgical care on overall health remain unclear. Gender diverse identities, also termed nonbinary, have often been neglected in favor of (male/female) binary identities, even in the context of transgender health care and research. No high quality studies have assessed how gender-affirming medical care impact health inequities in transgender and gender diverse (TG/GD) adults, much less in AYAs, despite the fact that that TG/GD adults have higher than average morbidity and mortality across a host of health concerns, from human immunodeficiency virus infection to thromboembolism, and that reported depression with suicidal ideation is >10 times higher in TG/GD adults than in the general population. TG/GD youth have related but different needs from TG/GD adults. TG/GD AYA are embedded in family and schools, where stigma may be difficult to escape; mental health during adolescence has areas of increased risk as well as resilience; and the effects of early hormonal and surgical interventions on long-term health are insufficiently studied. Because of this, an inclusive and proactive approach to addressing the needs of TG/GD AYA by pediatric clinicians, researchers, and educators is particularly crucial. This article focuses on what is known and unknown about clinical practice, research, and education related to TG/GD health. We highlight the role of gender affirmation by clinicians as they care and advocate for TG/GD AYAs; the potential challenges of hormonal treatment for peripubertal youth; and short- and long-term effects on physical and reproductive health of medical or surgical interventions. We also discuss how social context influences knowledge gaps and the health-relevant risks faced by TG/GD AYA. The challenges are formidable, but opportunities await: high priority research questions to explore, educational gaps to be filled, and advocacy that needs the voices of pediatricians to promote policies to facilitate positive health outcomes for TG/GD AYA.

Is Research on Transgender Children What It Seems? Comments on Recent Research on Transgender Children with High Levels of Parental Support

Recent research on transgender children who have had support from their parents for their transitioning has concluded that their mental health is virtually no different than that of nontransgender children. Such research has been extensively cited, over 370 times in the past three years. Most of the hundreds of reviews received the stated results of the studies with little caution. However, the research featured numerous statistical errors and omissions, the implications of which would likely lead neutral observers to conclude that the mental health of transgender children, even when supported by their parents, was poorer than that of the groups of control children. In particular, levels of anxiety as reported by both parents and their transgender children appear to be significantly higher, and the transgender children's reports of self-worth appear to be significantly lower. Although reports regarding depression are not as significantly different, the effect sizes were generally in a similar direction as the other outcomes, being less favorable for the transgender children. Such issues highlight the need for careful examination of statistical research, even when published in highly regarded medical journals. As with other research, findings from the early stages of controversial research may often be premature. Further research is needed to explore factors underlying these results.

Summary

Some scholars have believed that if transgender children were supported by their parents before the children reached puberty, the generally higher rates of mental illness experienced by many transgender persons might be prevented or alleviated. Dr. Kristina Olson of the Department of Psychology at the University of Seattle was the first scholar to have studied groups of transgender children who were being supported by their parents and to have compared them to a control group of children and to siblings of the same transgender children. Her conclusion was that there were minimal, if any, differences in anxiety, depression, and self-worth among the groups of children; her research has since been cited extensively as having found just that. We reanalyzed her raw data and found that, to the contrary, the transgender children, even when supported by their parents, had significantly lower average scores on anxiety and self-worth. Often, a significantly higher percentage of transgender children, compared to controls, featured preclinical or clinical levels of anxiety. Parental support of transgender children may temporarily reduce levels of poor mental health for some transgender children, but it does not appear to eliminate those problems for all transgender children. Our findings should serve as a warning against accepting research at a surface level, which can lead to acceptance of invalid information and pursuit of ineffective interventions.

Trends in Referrals to a Pediatric Transgender Clinic

OBJECTIVES

We characterized referral trends over time at a transgender clinic within an integrated health system in Northern California. We identified the transition-related requests of pediatric transgender and gender-nonconforming patients and evaluated differences in referrals by age group.

METHODS

Medical records were analyzed for all patients <18 years of age in the Kaiser Permanente Northern California health system who were referred to a specialty transgender clinic between February 2015 and June 2018. Trends in treatment demand, demographic data, service requests, and surgical history were abstracted from medical charts and analyzed by using descriptive statistics.

RESULTS

We identified 417 unique transgender and gender-nonconforming pediatric patients. The median age at time of referral was 15 years (range 3-17). Most (62%) identified on the masculine spectrum. Of the 203 patients with available ethnicity data, 68% were non-Hispanic. During the study period, the clinic received a total of 506 referrals with a significant increase over time (P < .001). Most referrals were for requests to start cross-sex hormones and/or blockers (34%), gender-affirming surgery (32%), and mental health (27%). Transition-related requests varied by age group: younger patients sought more mental health services, and older patients sought hormonal and surgical services. Eighty-nine patients underwent gender-affirming surgeries, mostly before age 18 and most frequently mastectomies (77%).

CONCLUSIONS

The increase in referrals supports the need for expanded and accessible health care services for this population. The transition-related care of patients in this large sample varied by age group, underscoring the need for an individualized approach to gender-affirming care.

What about the family in youth gender diversity? A literature review

Background: Previous research has suggested that gender diversity affects everyone in the family, with positive mental health and global outcomes for gender diverse youth reliant on receiving adequate family support and validation. Although the individual mental health, treatment and outcomes for gender diverse youth have received recent research attention, much less is known about a family perspective. Hence, a review of the literature exploring youth gender diversity from a family perspective is warranted. Aims: To systematically identify, appraise and summarize all published literature primarily exploring gender diversity in young people under the age of 18 years, as well as selected literature pertaining to a family understanding. Methods: Six electronic databases (CINAHL, MEDLINE, EMBASE, PsycINFO, SCOPUS, Web of Science) were searched for relevant literature pertaining to youth under the age of 18 years. Results: Research evidence was consistently found to support the beneficial effects of a supportive family system for youth experiencing gender diversity, and a systemic understanding and approach for professionals. Conversely, lack of family support was found to lead to poorer mental health and adverse life outcomes. Few articles explored the experience of siblings under the age of 18 years. Discussion: This literature review is the first to critically evaluate and summarize all published studies which adopted a family understanding of youth gender diversity. The review highlighted a lack of current research and the need for further targeted research, which utilizes a systemic clinical approach to guide support for gender diverse youth and family members.