Suicidality, Self-Harm, and Body Dissatisfaction in Transgender Adolescents and Emerging Adults with Gender Dysphoria

Testing body-related components of objectification theory: A meta-analysis of the relations between body shame, self-objectification, and body dissatisfaction

Objectification theory has been instrumental in better understanding risk for eating disorders, depression, and sexual dysfunction, with self-objectification and body shame as serial mediators leading to these outcomes. Although originally proposed to explain these mental health outcomes in heterosexual women, researchers have extended objectification theory to individuals of various ages, racial identities, and sexual and gender identities. We conducted a systematic literature review of empirical peer-reviewed published research examining the relationship between the constructs of self-objectification, body dissatisfaction, and body shame in adult, youth, and LGBTQ+ samples. Our search yielded 5200 results, of which 318 met inclusion criteria. Of the papers included in this review, 26 reported correlations with sexual and gender diverse samples, 43 reported correlations with youth samples, and 249 reported correlations with samples of general adults (non-sexual or gender minorities). The meta-analyses yielded significant, moderate, positive correlations between body dissatisfaction and self-objectification, and between body shame and self-objectification, for each of the sub-samples. The majority of samples were predominantly White and cisgender female, suggesting the need for additional research examining these constructs among racial and gender minority populations. Overall, the results of this review highlight the unique contributions of body shame and body dissatisfaction to self-objectifying behaviors, and identify the moderating role of race and gender in these interrelations.

Gender diversity among adolescents with obesity in a weight management programme

Gender dysphoria (GD) and obesity share commonalities, including associations with mental health comorbidities, disordered eating, body dissatisfaction and may intensify with physical and developmental changes during adolescence. While associations of obesity and gender diversity have been identified, rates of gender diversity among adolescents with obesity remain unclear. The aim was to examine gender diversity among adolescents with obesity in a weight management programme. A single-centre cross-sectional questionnaire study was conducted. Eligible adolescents received the Gender Identity/GD Questionnaire for Adolescents and Adults (GIDYQ-AA), a validated instrument measuring gender diversity and GD. Gender identities, sexual orientations, questionnaire scores, and frequency of GD (GIDYQ-AA score <3) were determined. The relationship of GIDYQ-AA scores and BMI Z-score (BMIz) was assessed. Of 72 consenting youth, 29 assigned females (AF) and 17 assigned males (AM) completed GIDYQ-AA and demographic questions. Seventeen (59%) AF reported non-heterosexual orientations, and 6 (21%) reported non-cisgender identities. One (6%) AM reported non-cisgender identity. Two (4%) AF individuals had GD based on GIDYQ-AA scores. GIDYQ-AA scores did not correlate with BMIz. In conclusion, adolescents with obesity, particularly AF with non-heterosexual orientation, reported high rates of non-cisgender identity and GD. Routine screening for gender-related concerns in weight management settings may be warranted.

The effects of gender-affirming hormone therapy and mastectomy on psychopathology, body image, and quality of life in adults with gender dysphoria who were assigned female at birth

PURPOSE

Individuals with gender dysphoria (GD) may request hormone therapy and various surgical operations to change their physical characteristics. The present study aimed to investigate the effects of two treatments, mastectomy and gender-affirming hormone therapy (GAHT), on adults with GD who were assigned female at birth (GD AFAB).

METHODS

In this cross-sectional study, we gathered data from a total of 269 individuals in three groups: (a) untreated group (n = 121), (b) GAHT group (n = 84) who had been receiving treatment for at least 6 months, and (c) GAHT-MAST group (n = 64) who had been using GAHT for at least 6 months and had undergone mastectomy at least 3 months prior. All participants were asked to complete the Symptom Checklist-90-Revised (SCL-90-R), the Body Uneasiness Test (BUT), and the World Health Organization's Quality of Life Questionnaire- Brief Form, Turkish Version (WHOQOL-BREF-Tr).

RESULTS

We found that individuals in the untreated group had higher psychopathological symptoms and body uneasiness scores, and lower quality of life scores compared to both GAHT and GAHT-MAST groups. There was no difference in psychopathology between the GAHT-MAST group and the GAHT group, but body uneasiness scores were lower, and quality of life scores were higher in the GAHT-MAST group.

CONCLUSION

Our study suggests that individuals receiving GAHT improved mental health, body satisfaction, and overall quality of life. Combining mastectomy with GAHT may further enhance these benefits.

Development of a gender-affirming care protocol in eating disorder treatment settings

Transgender and gender-expansive (TGE) individuals suffer from eating disorders (EDs) at disproportionate rates relative to their gender-conforming counterparts. While literature on EDs in TGE populations is growing and evolving, best practice guidelines are scant. A framework for providing gender-affirming care (GAC) in an ED treatment setting was developed by integrating findings from a focused literature review and insights from leading experts. Following synchronous and asynchronous training, the protocol was implemented in a virtual ED treatment setting with a national reach serving patients ages 6-24 years. This paper offers a summary of best practices and approaches for providing GAC in ED treatment settings. The use of GAC practices has the potential to address underlying issues and inequities in treatment delivery and outcomes. We encourage ED treatment providers to consider the adoption/adaptation of GAC best practices to more effectively meet the needs of TGE patients. More research is needed to better understand the influence of individual and collective GAC practices on specific ED treatment outcomes.

Embodying loving kindness: Examining self-compassionate writing tasks and body satisfaction among transgender and non-binary people

Using an experimental posttest-only control group design, the purpose of this study was to examine the effects of self-compassionate writing exercises on transgender and non-binary participants' body satisfaction, gender identity pride, and internalized transphobia. A total of 238 transgender people participated in this study (Mage = 28.27, SD = 8.12). Participants were randomly assigned to a self-compassionate writing task focusing on their gender identity, a self-compassionate writing task focusing on their body image as a transgender person (i.e., gendered body image), and a control condition, which required them to write about a neutral day in their lives. Results demonstrated that those in the gendered body image self-compassionate condition reported higher state-level effects of body satisfaction following the intervention than those in the control condition. No significant effects were observed for condition on state-level gender identity pride or internalized transphobia. Results also demonstrated that non-binary participants reported higher levels of gender identity pride than trans femme participants. Exploratory post-hoc analyses revealed that gender identity pride moderated the effect of condition on body satisfaction. Compared to those in the control condition, participants in the gendered body self-compassionate condition with moderate and high levels of gender identity pride reported higher levels of body satisfaction. Results demonstrate potential beneficial effects of brief self-compassionate writing exercises on transgender peoples' body satisfaction.

Risk and protective factors for self-harm thoughts and behaviours in transgender and gender diverse people: A systematic review

Background

Self-harm (any self-injury or -poisoning regardless of intent) is highly prevalent in transgender and gender diverse (TGD) populations. It is strongly associated with various adverse health and wellbeing outcomes, including suicide. Despite increased risk, TGD individuals' unique self-harm pathways are not well understood. Following PRISMA guidelines we conducted the first systematic review of risk and protective factors for self-harm in TGD people to identify targets for prevention and intervention.

Methods

We searched five electronic databases (PubMed, PsychInfo, Scopus, MEDLINE, and Web of Science) published from database inception to November 2023 for primary and secondary studies of risk and/or protective factors for self-harm thoughts and behaviours in TGD people. Data was extracted and study quality assessed using Newcastle-Ottawa Scales.

Findings

Overall, 78 studies published between 2007 and 2023 from 16 countries (N = 322,144) were eligible for inclusion. Narrative analysis identified six key risk factors for self-harm in TGD people (aged 7-98years) were identified. These are younger age, being assigned female at birth, illicit drug and alcohol use, sexual and physical assault, gender minority stressors (especially discrimination and victimisation), and depression or depressive symptomology. Three important protective factors were identified: social support, connectedness, and school safety. Other possible unique TGD protective factors against self-harm included: chosen name use, gender-identity concordant documentation, and protective state policies. Some evidence of publication bias regarding sample size, non-responders, and confounding variables was identified.

Interpretation

This systematic review indicates TGD people may experience a unique self-harm pathway. Importantly, the risk and protective factors we identified provide meaningful targets for intervention. TGD youth and those assigned female at birth are at increased risk. Encouraging TGD people to utilise and foster existing support networks, family/parent and peer support groups, and creating safe, supportive school environments may be critical for self-harm and suicide prevention strategies. Efforts to reduce drug and alcohol use and experiences of gender-based victimisation and discrimination are recommended to reduce self-harm in this high-risk group. Addressing depressive symptoms may reduce gender dysphoria and self-harm. The new evidence presented in this systematic review also indicates TGD people may experience unique pathways to self-harm related to the lack of social acceptance of their gender identity. However, robust longitudinal research which examines gender-specific factors is now necessary to establish this pathway.

Effect of gender identity on the association between gender dysphoria and suicidality via appearance anxiety among transgender and gender-diverse young people: moderated mediation study

BACKGROUND

Gender dysphoria is associated with suicidality among transgender and gender-diverse (TGD) people. Gender dysphoria also results in a stress on appearance.

AIMS

The objectives of this study were to examine: (a) whether appearance anxiety mediates the effect of gender dysphoria on suicidality; and (b) whether gender identity moderates the mediating effect of appearance anxiety.

METHOD

A total of 117 769 college and university students were recruited in this cross-sectional study from Jilin Province, China. After screening based on participants' gender identity, 2352 TGD young people (aged from 15 to 25 years) were divided into three subgroups: female to male (FTM), male to female (MTF) and non-binary. Self-report inventories measured gender dysphoria, suicidality and appearance anxiety. A structural equation model was run to examine the relationships among TGD gender identity, gender dysphoria, appearance anxiety and suicidality.

RESULTS

Among TGD young people, gender dysphoria was significantly positively associated with suicidality (β = 0.15, 95% CI = 0.11-0.18, P < 0.001). Appearance anxiety partially mediated the association between gender dysphoria and suicidality (β = 0.07, 95% CI = 0.05-0.08, P < 0.001). Gender identity moderated the mediating effects: compared with individuals with FTM identity, among those with MTF and non-binary identities, gender dysphoria showed stronger positive effects on appearance anxiety, and appearance anxiety showed greater effects in mediating the association between gender dysphoria and suicidality.

CONCLUSIONS

Among TGD young people, gender dysphoria is significantly associated with suicidality via appearance anxiety, with gender identity moderating the mediating effects. Diverse treatments should consider the heterogeneity of TGD subgroups, with the aim of limiting the tendency of gender dysphoria to trigger appearance anxiety, thus further buffering against the risk of suicide.

Risk of suicide attempt with gender diversity and neurodiversity

There is growing concern about psychiatric illness co-occurring with gender-diversity and neurodiversity, including risk of suicidal behavior. We carried out systematic reviews of research literature pertaining to suicide attempt rates in association with gender- and neurodiversity, with meta-analysis of findings. Rates of suicidal acts ranked: gender-diverse versus controls (20.1% vs. 1.90%; highly significant) > autism spectrum disorder (4.51% vs. 1.00%; highly significant) > attention deficit-hyperactivity disorder (7.52% vs. 4.09%; not significant). Attempt rates also were greater among controls who included sexual minorities (5.35% vs. 1.41%). The rate among male-to-female transgender subjects (29.1%) was slightly lower than in female-to-male subjects (30.7%), who also were encountered 24.3% more often. In sum, suicidal risk was much greater with gender-diversity than neurodiversity. Suicide attempts rate was somewhat greater among female-to-male transgender subjects. Available information was insufficient to test whether suicidal risk would be even greater among persons with both gender- and neurodiversity.

Physical and psychosocial challenges of people with gender dysphoria: a content analysis study

BACKGROUND

The mismatch between the gender experienced by a person and the gender attributed to him/her leads to gender dysphoria. It seems that people's perception of gender dysphoria is affected by individual, cultural, and sociological factors and these factors affect different aspects of their biological, psychological, and social health. To this end, this qualitative study aimed to identify the physical, psychological, and social challenges of people with gender dysphoria referring to the Department of forensic medicine in Iran.

METHODS

This qualitative study was conducted using conventional content analysis on 9 individuals who were selected through purposive sampling. A total of 16 interviews were conducted with 9 participants. Each interview lasted 60-90 min. The participants' gender dysphoria was confirmed by the Department of forensic medicine. The data were collected through face-to-face semi-structured interviews with the participants.

RESULTS

The data revealed 3 main categories and 10 subcategories. The main categories were living in agony, confusion, and social concerns. The subcategories were annoying physical characteristics, mental suffering, disturbing sexual changes, concerns about public reaction, helplessness, surrender, the final solution, retreating to isolation, stressful family conditions, and lack of public recognition.

CONCLUSION

The findings showed that people with gender dysphoria suffer from some problems including living in agony, confusion, and social concerns. Each of these problems is associated with several challenges. It seems that most of the challenges faced by people with gender dysphoria are caused by unawareness of their conditions by the family and the public, which in turn is caused by the failure of related organizations and experts in this field to provide adequate information about the conditions of these people. Thus, the findings of the present study can have some implications for resolving the challenges faced by people with gender dysphoria.

Emerging Evidence: A Systematic Literature Review of Disordered Eating Among Transgender and Nonbinary Youth

PURPOSE

This systematic literature review explores the evidence base related to the diagnosis and clinical management of eating disorders among transgender and gender nonbinary (TGNB) youth. Through an exploration of the literature, this review highlights key considerations for providers working with this population, including the complex relationship between body image and gender, the assessment of subthreshold eating disorder symptoms, the impact of gender-affirming care on eating disorder treatment outcomes, and available evidence-based metrics, with attention to factors impacting treatment, including family support, psychiatric comorbidities, and community safety.

METHODS

We conducted a search of the databases PubMed and Ovid MEDLINE for articles pertaining to eating disorders and TGNB youth, with forward citation chaining conducted via Google Scholar to provide a review of recent publications. Twenty-six articles published from 2017 to 2022 met the criteria for full-text review.

RESULTS

The selected articles primarily explored data from the United States and varied widely in methodology, including a systematic literature review (n = 1), narrative literature reviews (n = 3), case series (n = 4), case studies (n = 2), cross-sectional population surveys (n = 7), cross-sectional patient surveys (n = 3), other cross-sectional studies (n = 3), retrospective chart reviews (n = 2), and a retrospective longitudinal cohort study (n = 1). Most commonly, researchers sampled patients within the setting of gender clinics. Researchers used a range of validated measures in clinical settings, with the Eating Disorder Examination Questionnaire most frequently reported. The literature highlights several considerations unique to transgender populations, including the complex relationship between gender dysphoria, body dissatisfaction, disordered eating behavior, and gender-affirming care.

DISCUSSION

In clinical settings with TGNB youth, providers may consider implementing validated screening measures to assess for eating disorders. Future research should emphasize a nuanced understanding of the heterogeneity among TGNB patient populations and the impact of gender identity on treatment of eating disorders.

Transgender body image: Weight dissatisfaction, objectification & identity - Complex interplay explored via matched group

In the context of body image and mental health, transgender individuals face distinctive challenges stemming from the complexities of their gender identity journey, societal expectations, and body norms. However, the existing line of research on this topic remains limited. This study explores the complex relationship in transgender individuals between body objectification, body weight dissatisfaction, and eating concerns. A sample of 154 individuals (77 transgenders paired with 77 cisgenders) was recruited via LGBTQ+ groups' mailing lists. Participants completed various questionnaires assessing body image, eating psychopathology, depression, and body objectification. Propensity score matching was performed with different variables: age, current BMI, years of education, current self-identified gender, and sexual orientation. The results revealed that transgender individuals experienced higher levels of body objectification, body weight dissatisfaction, and eating concerns compared to their cisgender counterparts. Additionally, age emerged as a protective factor, as older transgender individuals demonstrated improved body acceptance and self-esteem. Logistic regression analyzes indicated that bulimic behaviors, depressive symptoms, and appearance control beliefs were specific factors significantly associated with being transgender. Our findings highlight the unique challenges faced by transgender individuals in navigating their gender identity and body image, underscoring the importance of targeted interventions and support systems.

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.

Mental Health of Youth With Autism Spectrum Disorder and Gender Dysphoria

BACKGROUND AND OBJECTIVES

Youth with either autism spectrum disorder (ASD) or gender dysphoria (GD) alone have also been shown to be at greater risk for mental health (MH) concerns; however, very little research has considered how cooccurring ASD and GD may exacerbate MH concerns. The purpose of this study was to examine associations between ASD, GD, and MH diagnoses (anxiety, depression, eating disorder, suicidality, and self-harm) among US adolescent populations.

METHODS

This is a secondary analysis of a large administrative dataset formed by 8 pediatric health system members of the PEDSnet learning health system network. Analyses included descriptive statistics and adjusted mixed logistic regression models testing for associations between combinations of ASD and GD diagnoses and MH diagnoses as recorded in the patient's electronic medical record.

RESULTS

Based on data from 919 898 patients aged 9 to 18 years, adjusted mixed logistic regression indicated significantly greater odds of each MH diagnosis among those with ASD alone, GD alone, and cooccurring ASD/GD diagnoses compared with those with neither diagnosis. Youth with cooccurring ASD/GD were at significantly greater risk of also having anxiety (average predicted probability, 0.75; 95% confidence interval, 0.68-0.81) or depression diagnoses (average predicted probability, 0.33; 95% confidence interval, 0.24-0.43) compared with youth with ASD alone, GD alone, or neither diagnosis.

CONCLUSIONS

Youth with cooccurring ASD/GD are more likely to also be diagnosed with MH concerns, particularly anxiety and depression. This study highlights the need to implement developmentally appropriate, gender-affirming MH services and interventions for youth with cooccurring ASD/GD.

Gender-Affirming Surgery in Adolescents and Young Adults: A Review of Ethical and Surgical Considerations

BACKGROUND

The number of transgender adolescents seeking gender-affirming surgery (GAS) in increasing. Surgical care of the adolescent transgender patient is associated with several unique technical, legal, and ethical factors. The authors present a review of the current literature on gender-affirming surgery for individuals under the age of legal majority and propose directions for future research.

METHODS

A scoping review of recent literature was performed to assess evidence on gender-affirming surgery in individuals under the age of legal majority. Articles were included that examined either ethical or technical factors unique to pediatric GAS. Study characteristics and conclusions were analyzed in conjunction with expert opinion.

RESULTS

Twelve articles were identified that met inclusion criteria. Ten of these articles discussed ethical challenges in adolescent GAS, seven discussed legal challenges, and five discussed technical challenges. Ethical discussions focused on the principles of beneficence, nonmaleficence, and autonomy. Legal discussions centered on informed consent and insurance coverage. Technical discussions focused on the effects of puberty blockade on natal tissue.

CONCLUSIONS

Surgical care of the adolescent transgender patient involves important ethical, legal, and technical considerations that must be addressed by the clinical team. As the population of individuals seeking GAS after puberty blockade increases, future research is needed describing functional and psychosocial outcomes in these individuals.

A scoping review of research literature on eating and body image for transgender and nonbinary youth

BACKGROUND

Transgender and nonbinary (TGNB) adolescents and young adults are underrepresented in the literature on eating disorders and body image-related problems, despite increased mental health disparities and emerging research showing high associations between gender dysphoria, body image, and eating disorders among TGNB youth.

AIMS

The scoping review was designed to critically examine the research on TGNB adolescents and young adults who experience eating and body image related problems as well as clinical studies on treatment approaches and effectiveness.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this scoping review. The electronic databases of MEDLINE and PsychInfo were used for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for transgender minor children, adolescents, or young adult samples (18 to 25 years old) and address differences in eating/body-related problems by age. The relevant data was extracted and narratively summarized.

RESULTS

49 studies were identified, data extracted, and analyzed. Increased prevalence of eating disorders and body image problems were identified for TGNB youth. Body-gender congruence through gender affirming social and medical interventions (e.g., hormone therapy) were noted as significant for alleviating body image problems and facilitating eating disorder treatment. Family and social factors were not well understood in the literature and a need for increased study of TGNB youth from varied racial/ethnic, neurodiverse, and within specific identities (e.g., nonbinary) and families and cultural contexts is still needed.

CONCLUSIONS

Future research should consider the use of developmental and family theories for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, more studies are needed with those from minoritized racial and ethnic groups, neurodiversity, and varied gender identities (e.g., nonbinary and gender queer) for identifying important differences.

A systematic review on gender dysphoria in adolescents and young adults: focus on suicidal and self-harming ideation and behaviours

INTRODUCTION

Gender dysphoria (GD) is characterized by the incongruence between one's experienced and expressed gender and assigned-sex-at-birth; it is associated with clinically significant distress. In recent years, the number of young patients diagnosed with GD has increased considerably. Recent studies reported that GD adolescents present behavioural and emotional problems and internalizing problems. Furthermore, this population shows a prevalence of psychiatric symptoms, like depression and anxiety. Several studies showed high rates of suicidal and non-suicidal self-injurious thoughts and behaviour in GD adolescents. To increase understanding of overall mental health status and potential risks of young people with GD, this systematic review focused on risk of suicide and self-harm gestures.

METHODS

We followed the PRISMA 2020 statement, collecting empirical studies from four electronic databases, i.e., PubMed, Scopus, PsycINFO, and Web of Science.

RESULTS

Twenty-one studies on GD and gender nonconforming identity, suicidality, and self-harm in adolescents and young adults met inclusion criteria. Results showed that GD adolescents have more suicidal ideation, life-threatening behaviour, self-injurious thoughts or self-harm than their cisgender peers. Assessment methods were heterogeneous.

CONCLUSION

A standardised assessment is needed. Understanding the mental health status of transgender young people could help develop and provide effective clinical pathways and interventions.

A Longitudinal Study on Disordered Eating in Transgender and Nonbinary Adolescents

OBJECTIVE

We longitudinally explored frequency of disordered eating among transgender and nonbinary (TGNB) adolescents and explored trends by gender identity and gender-affirming care.

METHODS

Participants completed an abbreviated version of the Eating Disorder Examination Questionnaire (EDE-Q) at baseline, 3, 6, and 12 months after establishing care in a gender clinic. We analyzed descriptive statistics and multivariate linear regression analyses.

RESULTS

Of the 91 TGNB adolescent participants, 61% were transmasculine, 30% transfeminine, and 7% nonbinary/gender-fluid. Among TGNB adolescents, disordered eating thoughts/behaviors were frequently endorsed with 26% of participants engaging in any occurrence of binge eating, 27% limiting the amount of food they ate, and 30% excluding foods from their diet. Forty percent of participants reported any occurrence of at least 1 disordered eating behavior and 17% at least 3 behaviors. Abbreviated EDE-Q responses did not differ significantly by sex assigned at birth, gender identity, gender-affirming medications, or time spent receiving gender-affirming care. There was a significant effect of age (P value = .003) on abbreviated EDE-Q scores.

CONCLUSIONS

There were no significant changes in disordered eating after initiating gender-affirming medical care, possibly due to the limited study time frame of 12 months. Given the high prevalence of disordered eating behaviors, clinicians should consider screening all TGNB adolescents for disordered eating thoughts/behaviors throughout gender-affirming care. Future longitudinal research should recruit larger samples with a diverse range of gender identities and survey disordered eating thoughts/behaviors at least one year after starting gender-affirming medications.

Suicidal behavior across a broad range of psychiatric disorders

Suicide is a leading cause of death worldwide. In 2020, some 12.2 million Americans seriously contemplated suicide, 3.2 million planned suicide attempts, and 1.2 million attempted suicide. Traditionally, the approach to treating suicidal behavior (SB) has been to treat the "underlying" psychiatric disorder. However, the number of diagnoses associated with SB is considerable. We could find no studies describing the range of disorders reported to be comorbid with SB. This narrative review summarizes literature documenting the occurrence of SB across the lifespan and the full range of psychiatric diagnoses, not only BPD and those that comprise MDE, It also describes the relevance of these observations to clinical practice, research, and nosology. The literature searches contained the terms "suicid*" and each individual psychiatric diagnosis and identified 587 studies. We did not include case reports, case series, studies only addressing suicidal ideation or non-suicidal self-injury (NSSI), studies on self-harm, not distinguishing between SB and NSSI and studies that did not include any individuals that met criteria for a specific DSM-5 diagnosis (n = 366). We found that SB (suicide and/or suicide attempt) was reported to be associated with 72 out of 145 diagnoses, although data quality varied. Thus, SB is not exclusively germane to Major Depressive Episode (MDE) and Borderline Personality Disorder (BPD), the only conditions for which it is a diagnostic criterion. That SB co-occurs with so many diagnoses reinforces the need to assess current and past SB regardless of diagnosis, and supports the addition of charting codes to the DSM-5 to indicate current or past SB. It also comports with new data that specific genes are associated with SB independent of psychiatric diagnoses, and suggests that SB should be managed with specific suicide prevention interventions in addition to treatments indicated for co-occurring diagnoses. SB diagnostic codes would help researchers and clinicians document and measure SB's trajectory and response to treatment over time, and, ultimately, help develop secondary and tertiary prevention strategies. As a separate diagnosis, SB would preclude situations in which a potentially life-threatening behavior is not accounted for by a diagnosis, a problem that is particularly salient when no mental disorder is present, as is sometimes the case.

Models of Gender Dysphoria Using Social Media Data for Use in Technology-Delivered Interventions: Machine Learning and Natural Language Processing Validation Study

BACKGROUND

The optimal treatment for gender dysphoria is medical intervention, but many transgender and nonbinary people face significant treatment barriers when seeking help for gender dysphoria. When untreated, gender dysphoria is associated with depression, anxiety, suicidality, and substance misuse. Technology-delivered interventions for transgender and nonbinary people can be used discretely, safely, and flexibly, thereby reducing treatment barriers and increasing access to psychological interventions to manage distress that accompanies gender dysphoria. Technology-delivered interventions are beginning to incorporate machine learning (ML) and natural language processing (NLP) to automate intervention components and tailor intervention content. A critical step in using ML and NLP in technology-delivered interventions is demonstrating how accurately these methods model clinical constructs.

OBJECTIVE

This study aimed to determine the preliminary effectiveness of modeling gender dysphoria with ML and NLP, using transgender and nonbinary people's social media data.

METHODS

Overall, 6 ML models and 949 NLP-generated independent variables were used to model gender dysphoria from the text data of 1573 Reddit (Reddit Inc) posts created on transgender- and nonbinary-specific web-based forums. After developing a codebook grounded in clinical science, a research team of clinicians and students experienced in working with transgender and nonbinary clients used qualitative content analysis to determine whether gender dysphoria was present in each Reddit post (ie, the dependent variable). NLP (eg, n-grams, Linguistic Inquiry and Word Count, word embedding, sentiment, and transfer learning) was used to transform the linguistic content of each post into predictors for ML algorithms. A k-fold cross-validation was performed. Hyperparameters were tuned with random search. Feature selection was performed to demonstrate the relative importance of each NLP-generated independent variable in predicting gender dysphoria. Misclassified posts were analyzed to improve future modeling of gender dysphoria.

RESULTS

Results indicated that a supervised ML algorithm (ie, optimized extreme gradient boosting [XGBoost]) modeled gender dysphoria with a high degree of accuracy (0.84), precision (0.83), and speed (1.23 seconds). Of the NLP-generated independent variables, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) clinical keywords (eg, dysphoria and disorder) were most predictive of gender dysphoria. Misclassifications of gender dysphoria were common in posts that expressed uncertainty, featured a stressful experience unrelated to gender dysphoria, were incorrectly coded, expressed insufficient linguistic markers of gender dysphoria, described past experiences of gender dysphoria, showed evidence of identity exploration, expressed aspects of human sexuality unrelated to gender dysphoria, described socially based gender dysphoria, expressed strong affective or cognitive reactions unrelated to gender dysphoria, or discussed body image.

CONCLUSIONS

Findings suggest that ML- and NLP-based models of gender dysphoria have significant potential to be integrated into technology-delivered interventions. The results contribute to the growing evidence on the importance of incorporating ML and NLP designs in clinical science, especially when studying marginalized populations.

The Impact of Stressful Life Events on Suicidal Ideation in Gender Dysphoria: A Moderator Effect of Perceived Social Support

Factors associated with suicidal ideation in the gender dysphoria population are not completely understood. This high-risk population is more likely to suffer stressful events such as assault or employment discrimination. This study aimed to determine the association of stressful events and social support on suicidal ideation in gender dysphoria and to analyze the moderator effect of social support in relation to stressful events and suicidal ideation. A cross-sectional design was used in a clinical sample attending a public gender identity unit in Spain that consisted of 204 individuals (51.7% birth-assigned males and 48.3% birth-assigned females), aged between 13 and 59 (M = 27.95 years, SD = 9.58). A Structured Clinical Interview, a list of 16 stressful events, and a functional social support questionnaire (Duke-UNC-11) were used during the initial visits to the unit. The data were collected between 2011 and 2012. A total of 50.1% of the sample have had suicidal ideation. The following stressful events were associated with suicidal ideation: homelessness, eviction from home, and having suffered from physical or verbal aggression. Also, there was an inverse relation between perceived social support and suicidal ideation. There was a statistically significant interaction between a specific stressful event (eviction) and perceived social support. The study suggests that the promotion of safer environments could be related to lower suicidal ideation and that networks that provide social support could buffer the association between specific stressful events and suicidal ideation.

Systematic review: Psychological/psychosocial interventions for the families of gender diverse youth under 18 years old

BACKGROUND

The aim of this paper is the systematic review of psychological/psychosocial interventions for gender diverse youth under 18 years of age and their families, based on the published protocol: PROSPERO 2020 CRD42020163995.

METHODS

A search strategy was developed using key terms. An electronic literature search was completed using the following data bases (OVID MEDLINE; EBSCO CINAHL; ProQuest MEDLINE; OVID PsycINFO). Only studies published in English between 2001-2021 were included. This review is based on PRISMA guidance. Studies meeting inclusion criteria were quality appraised using the Mixed Methods Assessment Tool (MMAT).

RESULTS

8405 studies were independently screened. Four studies met the inclusion criteria for the study. Parents of transgender youth attended between one and 11 psychological/psychosocial group interventions. Parents reported reduced isolation and increased knowledge, which enabled them to advocate for their young person`s needs. Psychological/psychosocial group interventions were creating challenges in terms of group processes, with some parents dominating interactions. Psychological/psychosocial group interventions were positive for parents, but no outcomes were collected for transgender young people.

CONCLUSION

More research is required to understand the role of group facilitators, the optimal group size and the number of psychological/psychosocial intervention sessions required.

Understanding the Complex Relationship Between One's Body, Eating, Exercise, and Gender-Affirming Medical Care Among Transgender and Nonbinary Adolescents and Young Adults

Purpose

Gender dysphoria has been linked to body dissatisfaction, which can affect an individual's eating and exercise habits and increase their risk for disordered eating. The prevalence of eating disorders among transgender and nonbinary (TGNB) adolescents and young adults (AYA) ranges from 5% to 18% and studies have found a higher risk of disordered eating among these AYA in comparison to their cisgender peers. However, there is minimal research on why TGNB AYA are at higher risk. The aim of this study is to understand unique factors that define a TGNB AYA's relationship between their body and food, how this relationship may be affected by gender-affirming medical care, and how these relationships may contribute to disordered eating.

Methods

A total of 23 TGNB AYA were recruited from a multidisciplinary gender-affirming clinic to participate in semistructured interviews. Transcripts were analyzed using Braun and Clarke's theory of thematic analysis (2006).

Results

The average age of participants was 16.9 years. Forty-four percent of participants identified as having a transfeminine gender identity, 39% transmasculine, and 17% nonbinary/gender fluid. Five themes emerged regarding TGNB participants' relationship to food and exercise: gender dysphoria and control over one's body, societal expectations of gender, mental health and safety concerns, emotional and physical changes with gender-affirming medical care, and recommended resources for TGNB AYA.

Conclusion

By understanding these unique factors, clinicians can provide targeted and sensitive care when screening and managing disordered eating among TGNB AYA.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Internalized transphobia predicts worse longitudinal trend of body uneasiness in transgender persons treated with gender affirming hormone therapy: a 1-year follow-up study

BACKGROUND

Given the relationship between interiorized stigma and body image, it could be hypothesized that high levels of internalized transphobia (IT) might predict higher levels of body uneasiness in subjects with gender dysphoria (GD) and worse improvement of body image after gender affirming hormone therapy (GAHT).

AIM

We sought to evaluate the relationship between IT and body uneasiness in subjects with GD and the role of IT in moderating the improvement of body image after GAHT.

METHODS

In total, 200 individuals with GD performed the baseline assessment; 99 were re-evaluated 12 months after starting GAHT. At baseline participants were evaluated through a face-to-face interview and filled self-administered questionnaires to evaluate GD (Utrecht Gender Dysphoria Scale [UGDS]), IT attitudes (Attitudes Toward Transgendered Individuals [ATTI] Scale), body uneasiness (Body Uneasiness Test, part A [BUT-A]), and general psychopathology (Symptom Checklist 90-Revised [SCL 90-R]). The same questionnaires, except ATTI, were readministered at follow-ups.

OUTCOMES

Outcomes were based on measures of the associations between IT and baseline characteristics of the sample, the longitudinal trends of GD, body uneasiness, and general psychopathology; and IT as a moderator of the longitudinal trend of body uneasiness.

RESULTS

At baseline, IT correlated with lower level of education, higher GD, and more severe body uneasiness. Longitudinal analyses showed significant improvements in GD, body uneasiness, and general psychopathology during GAHT. Moderation analysis confirmed that participants with more transphobic attitudes showed less improvement after GAHT with regard to body uneasiness (bTime*ATTI = -.002, P = .040). The Johnson-Neyman technique revealed that no significant improvement in body uneasiness was found for participants with ATTI scores lower than 71.14.

CLINICAL IMPLICATIONS

The presence of IT should be investigated in subjects with GD who require gender affirming treatments to provide specific interventions aimed at targeting this dimension.

STRENGTHS AND LIMITATIONS

Strengths of this study include the mixed cross-sectional and longitudinal design and the dimensional evaluation of the investigated constructs. Limitations include the small sample size and the limited follow-up. Furthermore, the effects of gender affirming surgery were not evaluated.

CONCLUSION

The association of IT with both baseline body uneasinessand the longitudinal course of this dimension highlighted the clinical significance of body uneasiness and the importance of making continuous efforts to improve education and information to fight societal stigmas.

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.

Adolescent gender diversity: sociodemographic correlates and mental health outcomes in the general population

BACKGROUND

Gender diversity in young adolescents is understudied outside of referral clinics. We investigated gender diversity in an urban, ethnically diverse sample of adolescents from the general population and examined predictors and associated mental health outcomes.

METHODS

The study was embedded in Generation R, a population-based cohort of children born between 2002 and 2006 in Rotterdam, the Netherlands (n = 5727). At ages 9-11 and 13-15 years, adolescents and/or their parents responded to two questions addressing children's contentedness with their assigned gender, whether they (a) 'wished to be the opposite sex' and (b) 'would rather be treated as someone from the opposite sex'. We defined 'gender-variant experience' when either the parent or child responded with 'somewhat or sometimes true' or 'very or often true'. Mental health was assessed at 13-15 years, using the Achenbach System of Empirically Based Assessment.

RESULTS

Less than 1% of the parents reported that their child had gender-variant experience, with poor stability between 9-11 and 13-15 years. In contrast, 4% of children reported gender-variant experience at 13-15 years. Adolescents who were assigned female at birth reported more gender-variant experience than those assigned male. Parents with low/medium educational levels reported more gender-variant experience in their children than those with higher education. There were positive associations between gender-variant experience and symptoms of anxiety, depression, somatic complaints, rule-breaking, and aggressive behavior as well as attention, social, and thought problems. Similar associations were observed for autistic traits, independent of other mental difficulties. These associations did not differ by assigned sex at birth.

CONCLUSIONS

Within this population-based study, adolescents assigned females were more likely to have gender-variant experience than males. Our data suggest that parents may not be aware of gender diversity feelings in their adolescents. Associations between gender diversity and mental health symptoms were present in adolescents.

Inter-Network Brain Functional Connectivity in Adolescents Assigned Female at Birth Who Experience Gender Dysphoria

Gender dysphoria (GD) is characterized by distress due to an incongruence between experienced gender and sex assigned at birth. Brain functional connectivity in adolescents who experience GD may be associated with experienced gender (vs. assigned sex) and/or brain networks implicated in own-body perception. Furthermore, sexual orientation may be related to brain functional organization given commonalities in developmental mechanisms proposed to underpin GD and same-sex attractions. Here, we applied group independent component analysis to resting-state functional magnetic resonance imaging (rs-fMRI) BOLD timeseries data to estimate inter-network (i.e., between independent components) timeseries correlations, representing functional connectivity, in 17 GD adolescents assigned female at birth (AFAB) not receiving gender-affirming hormone therapy, 17 cisgender girls, and 15 cisgender boys (ages 12-17 years). Sexual orientation was represented by degree of androphilia-gynephilia and sexual attractions strength. Multivariate partial least squares analyses found that functional connectivity differed among cisgender boys, cisgender girls, and GD AFAB, with the largest difference between cisgender boys and GD AFAB. Regarding sexual orientation and age, the brain's intrinsic functional organization of GD AFAB was both similar to and different from cisgender girls, and both differed from cisgender boys. The pattern of group differences and the networks involved aligned with the hypothesis that brain functional organization is different among GD AFAB (vs. cisgender) adolescents, and certain aspects of this organization relate to brain areas implicated in own-body perception and self-referential thinking. Overall, brain functional organization of GD AFAB was generally more similar to that of cisgender girls than cisgender boys.

Gender Dysphoria Publication Trends: A Bibliometric Analysis between 1900 and 2018

Objective Research on gender dysphoria (GD) has been growing over the last decades with increasing interest in understanding and characterizing the causal relationships between psychological, genetics, hormonal, and sociocultural factors. Changes and acceptance of this condition as non-pathologic have led to significant changes in general perspective and its management over time. Our objective is to carry out a bibliometric analysis to know the publication trends and quality of evidence related to gender dysphoria.

Methods A systematic search and critical review of the literature was carried out between January 1900 and December 2018 to perform a bibliometric analysis. Research was done in the following databases: OVID, PubMed, EMBASE, Scopus, Web of Science and Google Scholar. The medical subject headings (MeSh) terms used were: gender dysphoria; and surgery and psychology. The results were plotted using the VOSviewer version 1.6.8. Statistical analyses were performed with the IBM SPSS, Version 25.0.

Results A total of 1,239 manuscripts were identified, out of which 1,041 were selected. The average number of cited times per year per manuscript is 1.84 (interquartile range [IQR] 0-2.33). The average impact index was 47.8 (IQR 20-111.6). The median of total citations per manuscript was 3 (IQR 0-33.1), and the highest number of citations per manuscript was 484. Most publications focus on the psychological aspects of GD, and there is a significant amount of manuscripts related to social and anthropological issues. Most articles have a low level of scientific evidence.

Conclusion There is a great amount of published literature on GD; however, there is a significant level of disagreement in many respects on this topic. Regarding surgical gender-affirmation, there is a lack of information supported by high level of evidence to uphold the emerging expansion of medical practices.

Autism Spectrum Disorder and Gender Dysphoria/Incongruence. A systematic Literature Review and Meta-Analysis

The suggested overlap between autism spectrum disorder (ASD) and gender dysphoria/incongruence (GD/GI) has been much disputed. This review showed a relationship between ASD traits and GD feelings in the general population and a high prevalence of GD/GI in ASD. Our meta-analyses revealed that the pooled estimate of the prevalence of ASD diagnoses in GD/GI people was 11% (p < .001) and the overall effect size of the difference in ASD traits between GD/GI and control people was significant (g = 0.67, p < .001). Heterogeneity was high in both meta-analyses. We demonstrated that the chances that there is not a link between ASD and GD/GI are negligible, yet the size of it needs further investigation.

The relationship between realization of transgender identity and transition processes with nonsuicidal self-injury in transgender populations

We hypothesized that transgender and nonbinary (TNB) individuals who reported a longer period of time from realizing they were TNB to beginning their transition will have a longer history of nonsuicidal self-injury (NSSI) and that participants who report higher levels of body investment, fewer years from realization of TNB identity to transition, and more years since NSSI will report lower levels of current anxiety, stress, and depression. We conducted a secondary data analysis of a dataset collected online, which included 217 participants. We conducted multiple regressions to explore the hypotheses. Results revealed that TNB people who had a longer time between realizing their gender identity and beginning a transition had a longer history of NSSI. Exploratory analyses were also conducted to help understand the relationship between NSSI, transition, and body investment on mental health outcomes. Providers are cautioned that the presence of NSSI should not necessarily be a contraindication to transition.

Effects of sex hormones on brain GABA and glutamate levels in a cis- and transgender cohort

Sex hormones affect the GABAergic and glutamatergic neurotransmitter system as demonstrated in animal studies. However, human research has mostly been correlational in nature. Here, we aimed at substantiating causal interpretations of the interaction between sex hormones and neurotransmitter function by using magnetic resonance spectroscopy imaging (MRSI) to study the effect of gender-affirming hormone treatment (GHT) in transgender individuals. Fifteen trans men (TM) with a DSM-5 diagnosis of gender dysphoria, undergoing GHT, and 15 age-matched cisgender women (CW), receiving no therapy, underwent MRSI before and after at least 12 weeks. Additionally, sex differences in neurotransmitter levels were evaluated in an independent sample of 80 cisgender men and 79 cisgender women. Mean GABA+ (combination of GABA and macromolecules) and Glx (combination of glutamate and glutamine) ratios to total creatine (GABA+/tCr, Glx/tCr) were calculated in five predefined regions-of-interest (hippocampus, insula, pallidum, putamen and thalamus). Linear mixed models analysis revealed a significant measurement by gender identity effect (p_corr. = 0.048) for GABA+/tCr ratios in the hippocampus, with the TM cohort showing decreased GABA+/tCr levels after GHT compared to CW. Moreover, analysis of covariance showed a significant sex difference in insula GABA+/tCr ratios (p_corr. = 0.049), indicating elevated GABA levels in cisgender women compared to cisgender men. Our study demonstrates GHT treatment-induced GABA+/tCr reductions in the hippocampus, indicating hormone receptor activation on GABAergic cells and testosterone-induced neuroplastic processes within the hippocampus. Moreover, elevated GABA levels in the female compared to the male insula highlight the importance of including sex as factor in future MRS studies. DATA AVAILABILITY STATEMENT: Due to data protection laws processed data is available from the authors upon reasonable request. Please contact rupert.lanzenberger@meduniwien.ac.at with any questions or requests.

Level of behavioral health integration and suicide risk screening results in pediatric ambulatory subspecialty care

OBJECTIVE

This study aimed to characterize suicide risk screening results for youth in pediatric ambulatory subspecialty clinics.

METHOD

The Ask Suicide-Screening Questions was administered to patients ages 9-24 years in 12 subspecialty clinics to assess suicide risk, determined by suicide ideation/behavior. The SAMSHA-HRSA standard framework for integrated health was used to categorize each clinic's level of behavioral health integration.

RESULTS

6365 patients completed 7440 suicide risk screens; 6.2% of patients screened positive at their initial screen and 4.1% at subsequent annual screens. There was no dose-response pattern between increasing level of integration and decreasing likelihood of a positive suicide screen. Youth identifying as gender expansive were 3.1 times (95% CI [2.0, 4.9]) more likely to screen positive as compared to cisgender youth, adjusted for age, gender, race/ethnicity, screen type, year, and clinic integration level.

CONCLUSION

Results surrounding disparities in suicide risk based on gender identity underscore the importance of further investigating how to optimally identify and manage high-risk, often understudied youth at suicide risk.

Self-Compassion Moderates the Association Between Body Dissatisfaction and Suicidal Ideation in Adolescents: A Cross-Sectional Study

Identifying risk and protective factors for suicidal ideation during adolescence is essential for suicide prevention. One potential risk factor is body dissatisfaction which appears to peak during adolescence. The present study investigated the self-compassion buffering effects in the relationship between body dissatisfaction and suicidal ideation. A convenience sample comprising 580 adolescents (mean age 16.35 years; SD = .87; range 14-18 years) was recruited from public schools. The results indicated a strong positive association between body dissatisfaction and suicidal ideation (Cohen's f 2 = .25). The association was significantly moderated by the self-compassion (β =  - .16, SE = .04, p = .01, t  = 2.4.34, .95% CI [- .16, - .01]). Structural equation modeling analysis showed that the lack of self-kindness was associated with a moderate suicidal ideation level (Cohen's f 2 = .14). Also, higher levels of self-judgment predicted suicidal ideation with a moderate to large effect size (Cohen's f 2 = .28). The findings suggest that therapeutic programs designed to develop self-compassion should be implemented to reduce the risk of suicidal ideation among adolescents with body dissatisfaction. The findings empirically show that a higher degree of self-judgment is strongly associated with suicidal thoughts among adolescents, which must be systematically addressed in clinical studies on suicidal risk.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11469-021-00727-4.

Potential immunological effects of gender-affirming hormone therapy in transgender people - an unexplored area of research

There are well-described sex-based differences in how the immune system operates. In particular, cisgender (cis) females have a more easily activated immune system; associated with an increased prevalence of autoimmune diseases and adverse events following vaccinations. Conversely, cis males have a higher threshold for immune activation, and are more prone to certain infectious diseases, such as coronavirus disease (COVID-19). Oestrogen and testosterone have immune-modulatory properties, and it is likely that these contribute to the sexual dimorphism of the immune system. There are also important immune-related genes located on the X chromosome, such as toll-like receptor (TLR) 7/8; and the mosaic bi-allelic expression of such genes may contribute to the state of immune hyperactivation in cis females. The scientific literature strongly suggests that sex-based differences in the functioning of the immune system are related to both X-linked genes and immune modulation by sex hormones. However, it is currently not clear how this impacts transgender (trans) people receiving gender-affirming hormonal therapy. Moreover, it is estimated that in Australia, at least 2.3% of adolescents identify as trans and/or gender diverse, and referrals to specialist gender-affirming care are increasing each year. Despite the improving social awareness of trans people, they remain chronically underrepresented in the scientific literature. In addition, a small number of case studies describe new onset autoimmune disorders in adult trans females following oestrogen use. However, there is currently minimal long-term research with an immunological focus on trans people. Therefore, to ensure the positive health outcomes of trans people, it is crucial that the role of sex hormones in immune modulation is investigated further.

Healthcare Experiences of Gender Diverse Youth Across Clinical Settings

We explored gender diverse youth's experiences seeking and receiving gender-affirming care in various health system locations. Results provide evidence for system-, clinic-, and provider-level improvements to promote the development of affirming environments and to improve health outcomes for gender diverse youth.

Suicidality in clinic-referred transgender adolescents

Gender and sexually diverse adolescents have been reported to be at an elevated risk for suicidal thoughts and behaviors. For transgender adolescents, there has been variation in source of ascertainment and how suicidality was measured, including the time-frame (e.g., past 6 months, lifetime). In studies of clinic-referred samples of transgender adolescents, none utilized any type of comparison or control group. The present study examined suicidality in transgender adolescents (M age, 15.99 years) seen at specialty clinics in Toronto, Canada, Amsterdam, the Netherlands, and London, UK (total N = 2771). Suicidality was measured using two items from the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR). The CBCL/YSR referred and non-referred standardization samples from both the U.S. and the Netherlands were used for comparative purposes. Multiple linear regression analyses showed that there was significant between-clinic variation in suicidality on both the CBCL and the YSR; in addition, suicidality was consistently higher among birth-assigned females and strongly associated with degree of general behavioral and emotional problems. Compared to the U.S. and Dutch CBCL/YSR standardization samples, the relative risk of suicidality was somewhat higher than referred adolescents but substantially higher than non-referred adolescents. The results were discussed in relation to both gender identity specific and more general risk factors for suicidality.

High court should not restrict access to puberty blockers for minors

Gender dysphoria (GD) is a clinically significant incongruence between expressed gender and assigned gender, with rapidly growing prevalence among children. The UK High Court recently conducted a judicial review regarding the service provision at a youth-focussed gender identity clinic in Tavistock. The high court adjudged it 'highly unlikely' that under-13s, and 'doubtful' that 14-15 years old, can be competent to consent to puberty blocker therapy for GD. They based their reasoning on the limited evidence regarding efficacy, the likelihood of progressing to cross-sex hormone therapy and the 'life-changing consequences' of puberty blockers. In this article, I offer two concurrent arguments to dispute their reasoning. First, I argue that minors can be competent to consent to puberty blockers for GD, because the decision to undergo puberty blocker therapy is no more complex or far-reaching than other medical decisions that we accept a child should be able to make. Second, I argue that-irrespective of competence-such legal restriction for all children fundamentally contradicts the central ethical tenet of child healthcare: best interests. For these two reasons, the high court should not restrict access to puberty blockers for competent GD children.

Improving Mental Health Among Transgender Adolescents: Implementing Mindful Self-Compassion for Teens

The purpose of this study was to investigate the feasibility, acceptability, and preliminary outcomes of an online self-compassion intervention for transgender adolescents, with the aim of improving mental health. Participants identified as transgender or gender expansive, were between the ages of 13 and 17, and lived in the U.S. or Canada. The empirically-based self-compassion program, Mindful Self-Compassion for Teens (formerly Making Friends with Yourself) was implemented in eight 1.5 hour sessions on the Zoom platform by two trained instructors. Surveys were administered pre-, post-intervention, and at 3 months follow-up, and qualitative data were collected through end-of-program interviews and open-ended questions on the post-survey. All protocols were approved by the university IRB. Quantitative data analysis included repeated measures ANOVAs, and qualitative data were analyzed via both inductive and deductive methods. Results indicated that all but one psychosocial measure significantly improved from pre- to post-intervention, which then significantly improved at 3-month follow-up; most other improvements were maintained at follow-up. Four themes emerged from the qualitative data: virtual safe space; connection to body; personal growth; and recommended course changes and are discussed. Results suggest that self-compassion interventions can be incorporated into therapy programs to support and improve mental health for transgender adolescents.

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.

Gender Dysphoria and Chronic Pain in Youth

Chronic pain in youth with gender dysphoria (GD) is poorly understood. The aim of our study was to review the clinical presentation of 8 youth with GD in a multidisciplinary chronic pain clinic. A single center retrospective chart review was conducted to obtain information on demographics, clinical care, previous diagnoses, and validated clinical measures. We present the trajectory of pain in this population with treatment of GD. Recognition and treatment of GD in youth with pain may improve pain outcomes.

Reconnecting to Internal Sensation and Experiences: A Pilot Feasibility Study of an Online Intervention to Improve Interoception and Reduce Suicidal Ideation

Risk factors that are strongly associated with suicide and are amenable to intervention are in need of discovery. This three-study investigation demonstrates that an intervention designed to improve interoception-one potential suicide risk factor-may reduce suicide-related outcomes. Study 1 included 136 undergraduate participants and found that relative to a control condition, participating in a progressive muscle relaxation exercise was associated with reduced implicit identification with suicide through greater body trust, which is one domain of interoception that is consistently linked to suicide-related outcomes. Study 2 included 97 MTurk participants and found that relative to a control condition, participating in a body functionality writing exercise was associated with greater awareness of the body as a whole. Study 3 was a pilot study of a four-session online intervention designed to increase interoception. Study 3 included a sample of 22 clinical participants who completed pre- and postintervention assessments. Participants rated the intervention as highly acceptable and moderately effective. Moreover, the intervention was associated with improvements in interoception and reductions in suicidal ideation, general psychological symptoms, and disordered-eating symptoms. Overall, these findings indicate that our online interoceptive awareness training is acceptable and may be associated with improvements in clinical outcomes. Randomized controlled trials are needed to explore whether the intervention's purported mechanism-improved interoception-leads to changes in clinical outcomes.

Lifetime prevalence of suicidal ideation and suicidal behaviors in gender non-conforming youths: a meta-analysis

Gender identity represents a topic of growing interest in mental health research. People with non-conforming gender identity are prone to suffer from stigmatization and bullying and often present psychiatric issues, which may in turn lead to a high prevalence of suicidal ideation and behaviors. The present meta-analysis aimed to estimate the prevalence of suicidal ideation and suicidal behaviors in gender non-conforming children, adolescents and young adults. A systematic search was performed in Web of Science and PsycINFO from inception to December 2018. We selected cross-sectional and cohort studies including youths (up to 25 years) with a diagnosis confirmed by a clinician according to international classifications, or after a direct interview with a peer. A random-effects meta-analysis was computed for the following outcomes: non-suicidal self-injury (NSSI), suicidal ideation and suicide attempts. Overall, we found a mean prevalence of NSSI of 28.2% (9 studies, 3057 participants, 95% CI 14.8-47.1). A similar prevalence (28%) was found for suicidal ideation (6 studies, 2249 participants, 95% CI 15-46.3), while the prevalence of suicide attempts was 14.8% (5 studies, 1039 participants, 95% CI 7.8-26.3). Subgroup analyses revealed no significant differences according to biological sex. Given the prevalence of suicidal behaviors in gender non-conforming youths, it appears desirable to implement therapeutic and support strategies for this population. Moreover, educational interventions directed to parents, teachers, mental health professionals and general community should be promoted to struggle against stigma and social isolation, factors that may contribute to increasing the risk of suicidal behaviors.

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.

Mental health correlates and potential childhood predictors for the wish to be of the opposite sex in young autistic adults

LAY ABSTRACT

Autistic people/people with autism spectrum disorder are more likely to experience gender dysphoria. However, the possible longitudinal predictors and underlying mechanisms of this co-occurrence are unclear. To fill this knowledge gap, we assessed 88 people with autism spectrum disorder and 42 typically developing individuals at their average ages of 13.0 (baseline, childhood/adolescence) and 20.2 years old (follow-up, adulthood). At follow-up, their endorsement on the item "I wish I was the opposite sex" was used to evaluate gender dysphoric symptoms. We compared mental health symptoms between adults with and without this item endorsement at the follow-up assessment. We explored parent-reported family and autism characteristics-related predictors in childhood/adolescence to this item endorsement in adulthood. We found that more autistic adults reported the wish to be of the opposite sex than did typically developing individuals. Autistic adults who endorsed this item experienced more mental health challenges, more school bullying and cyberbullying, more suicidal ideation, and worse quality of life. Moreover, parent-reported lower family support and more stereotyped/repetitive behaviors during childhood/adolescence predicted the self-reported wish to be of the opposite sex in adulthood in autistic individuals. More attention and support should be provided to autistic people regarding gender development and related mental health and quality of life impact, especially during the transition period to young adulthood.

Sex Matters: A Multivariate Pattern Analysis of Sex- and Gender-Related Neuroanatomical Differences in Cis- and Transgender Individuals Using Structural Magnetic Resonance Imaging

Univariate analyses of structural neuroimaging data have produced heterogeneous results regarding anatomical sex- and gender-related differences. The current study aimed at delineating and cross-validating brain volumetric surrogates of sex and gender by comparing the structural magnetic resonance imaging data of cis- and transgender subjects using multivariate pattern analysis. Gray matter (GM) tissue maps of 29 transgender men, 23 transgender women, 35 cisgender women, and 34 cisgender men were created using voxel-based morphometry and analyzed using support vector classification. Generalizability of the models was estimated using repeated nested cross-validation. For external validation, significant models were applied to hormone-treated transgender subjects (n = 32) and individuals diagnosed with depression (n = 27). Sex was identified with a balanced accuracy (BAC) of 82.6% (false discovery rate [pFDR] < 0.001) in cisgender, but only with 67.5% (pFDR = 0.04) in transgender participants indicating differences in the neuroanatomical patterns associated with sex in transgender despite the major effect of sex on GM volume irrespective of the self-identification as a woman or man. Gender identity and gender incongruence could not be reliably identified (all pFDR > 0.05). The neuroanatomical signature of sex in cisgender did not interact with depressive features (BAC = 74.7%) but was affected by hormone therapy when applied in transgender women (P < 0.001).

Take the T out, put the T in: Gender-affirming hormones in youth

BACKGROUND

An increasing number of adolescents are seeking gender care at clinics and hospital programs, and requesting gender-affirming hormonal treatment. The interventions can either include suppression of testosterone and introduction of estrogen, or suppression of estrogen and introduction of testosterone.

AIMS

This review article focuses on the psychosocial experiences of youth who have completed their endogenous puberty and are now requesting one of these two forms of gender-affirming hormonal treatment. We investigate the comparative profiles of these two subgroups of transgender/gender-expansive youth.

MATERIALS AND METHODS

Review of research data, established standards of care and practice guidelines, and clinical observations.

RESULTS

Differences and similarities are noted and discussed in several realms: gender-related experiences prior to receiving hormonal treatment; the relationship between the physical changes and psychological experiences that accompany the introduction of testosterone or suppression of testosterone with replacement with estrogen; the intrapersonal and interpersonal implications of the treatment; considerations of fertility preservation for future family building; the role of the family in the decision-making process prior to starting a course of hormone therapy; and the capacity of youth to make informed decisions about these partially irreversible medical interventions.

DISCUSSION

Medical providers who offer gender-affirming hormonal care to youth should work with the family and allied professionals to assure that the youth's gender health is enhanced, barriers to care are removed, and mental health risks are reduced, whether the T is coming out or going in.

CONCLUSION

The cohort of youth who come to medical providers after completing puberty, and request gender-affirming hormones in the form of increases or reductions in T have a great deal in common, and also extensive variation among them.

Ten years of experience in counseling gender diverse youth in Flanders, Belgium. A clinical overview

Research on gender variant children and adolescents has stirred debate on the increased amount of referrals, the sex ratio in referrals, the impact of trans care on their psychological well-being, and the amount of children/adolescents who stop treatment. This retrospective study includes the number of referrals, first contacts at the outpatient clinic and the amount of drop-outs between January 1^st 2007 to December 31^st 2016 from the sole Belgian Pediatric Gender clinic. Emotional and behavioral problems, measured by the Child Behavioral Checklist (CBCL) and the Youth Self-Report (YSR), were screened. The adolescents who ceased the counseling, were contacted for follow-up. We included 235 adolescents, referred to the clinic, and 177 (of 235) who had a first physical appointment with a psychologist. Almost one in four (24.5%) on the YSR and more than half (54.8%) on the CBCL fall within the clinical range on the total problem score. On the YSR, 40.4% reported having suicide thoughts and 32.1% reported self-harm behavior and/or at least one suicide attempt, all in the last six months. Five adolescents committed suicide. According to parents, more difficulties with peers predicts more emotional and behavioral problems (F(5, 36) = 3.539, p = 0.011). In this study group, 29 adolescents ceased the counseling, whereof 7 could be traced back in the adult gender clinic after 2016. Results are indicative of the need for mental support for trans youth and their families and moreover, highlight the need for longitudinal follow-up studies.