Reflections on emerging trends in clinical work with gender diverse children and adolescents

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

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

Mental Health Evaluation of Younger and Older Adolescents Referred to the Center of Expertise on Gender Dysphoria in Amsterdam, The Netherlands

The present study aimed to investigate whether differences exist between younger and older presenting adolescents at the Center of Expertise on Gender Dysphoria regarding psychological functioning and autistic traits. A total of 1487 consecutively assessed adolescents between 2000 and 2018 were divided in younger presenters (age ≤ 13.9 years) and older presenters (age ≥ 14 years). Of younger presenters, 227 (41.1%) were assigned male at birth and 325 (58.9%) assigned female at birth. In older presenters, 279 (29.8%) were assigned male at birth and 656 (70.2%) assigned female at birth. Behavioral and emotional problems were assessed with the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR). For autism traits, the Social Responsiveness Scale (SRS) was used. Compared to younger presenters, on both the CBCL and YSR older presenters had higher Total Problem (β = 1.75, p = .005, CI 0.53-2.97, R2 = .04 and β = 4.20, p < .001, CI 2.99-5.40, R2 = .07, respectively) and Internalizing Problem (β = 4.43, p < .001, CI 3.13-5.74, R2 = .06 and β = 6.69, p < .001, CI 5.31-8.07, R2 = .12, respectively) scores. Regarding autistic traits, a higher mean SRS total score was found in older presenting assigned males at birth (β = 4.55, p = .036, CI 0.30-8.81, R2 = .34). In assigned females at birth, no statistically significant difference between older and younger presenters was found in mean SRS total score (β = 1.19, p = .063, CI - 0.07 to 2.45, R2 = .39). Differences in mental health exist between younger and older presenting adolescents and call for an individualized approach in the clinical care of transgender adolescents.

Demographics and gender-related measures in younger and older adolescents presenting to a gender service

Transgender adolescents may present to gender identity specialty services earlier or later in adolescence. The aim of this study was to examine whether, 'younger' and 'older' presenters could be identified in a large cohort of transgender adolescents and if differences exist between the two groups. The study sample consisted of 1487 adolescents (506 birth-assigned males, 981 birth-assigned females) referred between 2000 and 2018. The distribution of age at intake was evaluated. Demographic, diagnostic, and treatment characteristics, the Recalled Childhood Gender Identity/Gender Role Questionnaire (RCGI) to measure childhood gender nonconformity and the Body Image Scale (BIS) to measure body image were collected. Based on a stem-and-leaf plot and a histogram, two groups were identified: adolescents presenting at ≤ 13.9 years ('younger presenters') and adolescents presenting at 14 years or older ('older presenters'). The sex ratio was more extreme in the group of older presenters favoring birth-assigned females (Χ2(1, N = 1487) = 19.69, p < 0.001). Furthermore, more adolescents from the younger presenting group lived with both biological parents (Χ2(1, N = 1427) = 24.78, p < 0.001), were diagnosed with gender dysphoria and started with medical gender-affirming treatment (Χ2(1, N = 1404) = 4.60, p = 0.032 and Χ2(1, N = 1487) = 29.16, p < 0.001). Younger presenters showed more gender nonconformity in childhood (β 0.315, p < 0.001, 95% CI 0.224-0.407). Older presenters were more dissatisfied with various aspects of their bodies (p < 0.001). The differences between older and younger presenting adolescents suggest that there may be different developmental pathways in adolescents that lead to seeking gender-affirming medical care and argues for more tailored care.

Exploring navigation of gender in a sample of clinically referred young people attending the gender identity development service

BACKGROUND

Gender-diverse young people experience a cisnormative world and are subject to unique minority stressors, which have been found to contribute to adverse mental health. This research aims to understand the social and personal context unique to gender-diverse people that young people navigate prior to attending specialised services.

METHODS

The baseline measure of a newly developed questionnaire, the GIDS Gender Questionnaire (GIDS-GQ), was sent to all young people (or caregivers for those aged under 12) attending the Gender Identity Development Service (GIDS). Eighty-four young people and caregivers completed the questionnaire, with eighty-one included in the final sample (M = 15.77 years, SD = 1.83, range = 9-17; assigned female at birth = 72, assigned male at birth = 9). Questionnaires were emailed to participants via an online survey between one and three appointments with the Service. Data were collected between April 2021 and February 2022.

RESULTS

All young people had initiated a social transition, with 75.3% categorised as fully socially transitioned. More young people reported experiencing transphobic bullying (64.2%) and a lack of acceptance of their gender identity (85.1%) in the past (lifetime) than in the 6 months prior to attending the service (transphobic bullying: 12.3%; non-acceptance: 49.4%). 94.5% of the sample reported disliked body parts, most commonly breasts (80.8%), genitals (37%), and hips (31.5%). Participants most commonly reported a decrease in their mood (61.25%) and most areas of social connectedness.

CONCLUSIONS

The majority of this sample had socially transitioned, were supported in their identification, and had experienced less transphobic bullying and non-acceptance prior to commencing services. However, young people continued to dislike their bodies, and experience low mood and social connectedness. Future research is needed to understand how clinical support can help reduce the impact of these external/distal minority stressors by promoting social connectedness, incorporating such learnings into clinical practice and subsequent policy in clinical work with gender-diverse young people.

Rapid Onset Gender Dysphoria: Parent Reports on 1655 Possible Cases

During the past decade there has been a dramatic increase in adolescents and young adults (AYA) complaining of gender dysphoria. One influential if controversial explanation is that the increase reflects a socially contagious syndrome: Rapid Onset Gender Dysphoria (ROGD). We report results from a survey of parents who contacted the website ParentsofROGDKids.com because they believed their AYA children had ROGD. Results focused on 1655 AYA children whose gender dysphoria reportedly began between ages 11 and 21 years, inclusive. These youths were disproportionately (75%) natal female. Natal males had later onset (by 1.9 years) than females, and they were much less likely to have taken steps toward social gender transition (65.7% for females versus 28.6% for males). Pre-existing mental health issues were common, and youths with these issues were more likely than those without them to have socially and medically transitioned. Parents reported that they had often felt pressured by clinicians to affirm their AYA child's new gender and support their transition. According to the parents, AYA children's mental health deteriorated considerably after social transition. We discuss potential biases of survey responses from this sample and conclude that there is presently no reason to believe that reports of parents who support gender transition are more accurate than those who oppose transition. To resolve controversies regarding ROGD, it is desirable that future research includes data provided by both pro- and anti-transition parents, as well as their gender dysphoric AYA children.

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

BACKGROUND

International studies have reported an increase in referrals to gender identity units, a shift in the assigned sex ratio of adolescents, a decrease in the age at first visit, and a growing presence of individuals with nonbinary gender identities.

AIM

To investigate whether these trends are present in a Spanish sample of individuals referred to a gender identity unit over the last 10 years.

METHODS

We conducted a retrospective chart review of 913 consecutive referrals to a gender identity unit between 2012 and 2021 and retrieved information regarding sex assigned at birth, age at first visit, and expressed gender identity. We stratified the patients into 5 age categories: children (<12 years), adolescents (12-17 years), young adults (18-25 years), adults (26-45 years), and older adults (>45 years). The data were analyzed via descriptive and regression analyses.

OUTCOMES

Outcomes included the number of annual referrals, age at first visit, assigned sex ratio, and individuals with nonbinary gender identities.

RESULTS

The number of referrals increased 10-fold, from 18 in 2012 to 189 in 2021. The rates of increase over time were significantly more pronounced for adolescents and young adults and significantly greater for those assigned female at birth (AFAB). The age of referrals at first visit decreased, and AFAB individuals were, on average, younger than individuals assigned male at birth. The assigned sex ratio favored AFAB patients among adolescents (2.4:1) and young adults (1.75:1). Logistic regression showed that the odds of a new referral being AFAB increased by 9% per calendar year and that adolescent and young adult new referrals were significantly more likely to be AFAB. There were 21 referrals of nonbinary individuals starting in 2017, making up 6.4% of applications in 2021 and 2.9% during the last 5 years.

CLINICAL IMPLICATIONS

The evolution and trends observed in this study highlight the need for expanded resources, competent care, and careful reflection about implications for best practice.

STRENGTHS AND LIMITATIONS

This investigation involves a large sample of patients and is the first in our country to include people of all ages. However, the findings might not be generalizable to other gender identity units or the broader population of gender-diverse individuals.

CONCLUSION

Overall, our findings were consistent with previous international reports. We observed a marked increase in referrals, particularly among AFAB adolescents and young adults, a decreased age at first visit, and a growing presence of nonbinary individuals.

Transgender identity: Development, management and affirmation

In this review, I discuss recent research on transgender identity development, management and affirmation, situating key topics within a social feedback model of transgender identity. This model foregrounds the dynamic interplay between internal and external influences on transgender identity. Furthermore, issues of intersectionality are highlighted throughout and located within broader socio-political contexts. Collectively, research on topics such as gender euphoria, passing, identity affirmation and social transitions, among others, points to the pivotal role of supportive social relationships and social environments in the healthy development and expression of transgender identities. Future work should prioritize longitudinal studies with careful and rigorous assessment of identity-related constructs in order to further examine these and other topics.

Gender Development in Gender Diverse Children

Within "mainstream" developmental science, gender researchers largely study the developmental trajectory of children considered to be "gender-typical", while research housed primarily in psychiatry and clinical psychology often documents the trajectories of gender diverse children. This article aims to bridge the studies of gender diversity and "mainstream" gender development. First, we review literature on the development of four commonly studied subgroups of gender diverse children - children referred to medical clinics because of their gender identity and expression, transgender children, female children with congenital adrenal hyperplasia, and tomboys - highlighting how these gender trajectories do or do not align with modal developmental patterns. We then describe social, cognitive, and biological determinants of gender in light of their implications for understanding diverse gender development. Finally, we note methodological suggestions for future research, with an eye toward better integrating research on gender diversity into "mainstream" gender development research.

Body image and treatment desires at clinical entry in non-binary and genderqueer adults

Background: Gender clinics are experiencing an increase in non-binary and/or genderqueer (NBGQ) individuals applying for gender affirming medical treatment (GAMT). GAMT is a well-established approach in reducing body dissatisfaction in binary transgender (BT) people, but knowledge on GAMT in NBGQ people is limited. Previous research shows that NBGQ individuals report different treatment needs compared to BT individuals. In attempting to address this difference, the current study examines the association between identifying as NBGQ, body dissatisfaction and their underlying motives for GAMT. The main research objectives were to describe the desires and motives for GAMT in NBGQ people and to examine how body dissatisfaction and gender identity relate to one's request for GAMT. Methods: Online self-report questionnaires were administered on 850 adults referred to a gender identity clinic (Mdn age = 23.9 years). Gender identity and desires for GAMT were surveyed at clinical entry. Body satisfaction was assessed with the Body Image Scale (BIS). Multiple linear regressions were used to examine whether BIS scores differed between NBGQ and BT individuals. Chi-square post hoc analyses were used to identify differences in treatment desires and motives between BT and NBGQ individuals. Logistic regressions were conducted to study the association between body image, gender identity and treatment desire. Results: Compared to BT persons (n = 729), NBGQ persons (n = 121) reported less body dissatisfaction, primarily with the genital area. NBGQ persons also preferred fewer GAMT interventions. If a procedure was not desired, NBGQ individuals more often motivated this on the basis of their gender identity, while BT individuals more often cited the risks of the procedure as their primary reason. The study confirms the need for more NBGQ specialized care, as they have a distinct experience of their gender incongruence, physical distress and express specific needs in GAMT.

Endorsement of gender stereotypes in gender diverse and cisgender adolescents and their parents

Previous work has documented adolescents' gender stereotype endorsement, or the extent to which one believes men or women should embody distinct traits. However, understanding of gender stereotype endorsement in gender diverse adolescents-those who identify as transgender, nonbinary, and/or gender nonconforming-is limited. Gender diverse adolescents' experiences with gender raise the question of whether they endorse gender stereotypes with the same frequency as cisgender adolescents. In this study, we investigated three primary research questions: (1) if gender diverse (N = 144) and cisgender (N = 174) adolescents (13-17 years) and their parents (N = 143 parents of gender diverse adolescents, N = 160 parents of cisgender adolescents) endorse gender stereotypes; (2) whether these groups differed from one another in their endorsement of gender stereotypes; and (3) whether parents' gender stereotyping was related to either their adolescents' stereotyping and/or their adolescents' predictions of their parents' stereotyping. We found (1) that participants showed low amounts of stereotyping; (2) there were no significant differences between gender stereotype endorsement in gender diverse and cisgender adolescents (or between their parents), though parents endorsed stereotypes slightly less than adolescents; and (3) there was a small positive association between adolescents' stereotyping and their parents' gender stereotyping. We discuss the limitations of our methods, and the possibility that rates of explicit stereotype endorsement may be changing over time.

Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy

BACKGROUND

Recently, the variability and heterogeneity of gender presentations in transgender youths have gained significant attention worldwide. Alongside this, specialized gender services have reported an increase in referrals of youths reporting non-binary identities. In Italy, studies investigating gender identity and expression in gender non-conforming youths are lacking, as are data regarding the non-binary population.

AIM

The present study aimed at dimensionally exploring how transgender and non-binary Italian adolescents identify and express their gender.

OUTCOMES

Gender expression in trans binary youths and non-binary youths.

METHODS

The Gender Diversity Questionnaire (GDQ; Twist & de Graaf, 2019) was used to investigate gender identity, gender fluidity, and gender expression in a sample of 125 adolescent patients from the Gender Identity Development Service (SAIFIP) in Rome and the Gender Incongruence Unit of the Careggi Hospital in Florence, between April 2019-June 2021.

RESULTS

The majority of participants (74.4%) identified as trans* binary and the remaining (25.6%) participants identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity across time and contexts. Almost all participants rated external appearance as important to their gender expression, yet trans binary participants attributed more importance to the body in this respect. Body discomfort and pubertal stage emerged as the most influential factors in participants' experiences of gender. Participants who were assigned male at birth expressed significantly more desire for puberty blockers, whereas those who were assigned female at birth had a stronger desire to engage in breast/chest surgery. Non-binary participants sought different medical interventions relative to trans binary participants.

CLINICAL IMPLICATIONS

These results may be useful for clinicians working with transgender youths as they provide awareness regarding the features of young people who identify within and outside of binary constructions of gender.

STRENGTHS & LIMITATIONS

This study provides useful data in gaining insight into understanding the variety of experiences and challenges of gender non-conforming youths. However as the sample was recruited from specialized services, it may not represent the entire gender non-conforming population in Italy.

CONCLUSION

The results describe the range of gender identities and expressions among gender non-conforming youths attending gender specialized services in Italy, thereby improving our understanding of the variety of identities experienced and the specific medical needs of both trans binary and non-binary adolescents. Mirabella M, Piras I, Fortunato A, et al. Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy. J Sex Med 2022;19:1035-1048.

Epidemiology of personality disorders in individuals with gender dysphoria

PURPOSE OF REVIEW

Prevalence estimates of personality disorders (PD) in individuals with gender dysphoria (GD) are variable and heterogeneous, as psychiatric comorbidity and long-term follow-up data from gender-diverse samples are still limited. This review aims to assess prevalence rates across age groups and discuss potential reasons for variability in PD prevalence estimates among transgender people.

RECENT FINDINGS

International epidemiological data from several countries indicate that the best available estimates of the prevalence of any PD diagnosis in transgender youth are around 20% for adolescents and tend to increase to nearly 50% in trans-adults. The paucity of available data on personality dysfunction in children and adolescents with GD precluded us from definitive conclusions on the trends of emerging PDs in this population. Estimates of PD prevalence in transgender and gender-diverse people seem to be highly affected by methodological characteristics of the studies with no universally agreed reference standards for this population.

SUMMARY

The review of epidemiological studies on PD among gender-diverse people highlights the need for using more standardized study methodologies to make findings comparable. Nevertheless, international epidemiological data seem to support the link association between the development of PD and GD.

Psychological Functioning in Non-binary Identifying Adolescents and Adults

Gender diverse individuals who do not conform to society's binary gender expectations are more likely to experience difficulties in acceptance and in recognition of gender, compared to binary-identifying transgender people. This may accentuate the feeling that their gender identity is not socially recognized or validated. This study aimed to investigate psychological functioning among gender diverse adolescents and adults who identify beyond the binary gender spectrum. In both study populations, 589 clinically-referred gender diverse adolescents from the UK (n = 438 birth-assigned females and n = 151 birth-assigned males), and 632 clinically-referred gender diverse adults from the Netherlands (n = 278 birth-assigned females and n = 354birth-assigned males), we found that a higher degree of psychological problems was predicted by identifying more strongly with a non-binary identity. For adolescents, more psychological problems were related to having a non-binary gender identity and being assigned female at birth. In the adult population, experiencing psychological difficulties was also significantly related to having a stronger non-binary identity and having a younger age. Clinicians working with gender diverse people should be aware that applicants for physical interventions might have a broader range of gender identities than a binary transgender one, and that people with a non-binary gender identity may, for various reasons, be particularly vulnerable to psychological difficulties.

Gender identity development in children and young people: A systematic review of longitudinal studies

BACKGROUND

Children are presenting in greater numbers to gender clinics around the world. Prospective longitudinal research is important to better understand outcomes and trajectories for these children. This systematic review aims to identify, describe and critically evaluate longitudinal studies in the field.

METHOD

Five electronic databases were systematically searched from January 2000 to February 2020. Peer-reviewed articles assessing gender identity and psychosocial outcomes for children and young people (<18 years) with gender diverse identification were included.

RESULTS

Nine articles from seven longitudinal studies were identified. The majority were assessed as being of moderate quality. Four studies were undertaken in the Netherlands, two in North America and one in the UK. The majority of studies had small samples, with only two studies including more than 100 participants and attrition was moderate to high, due to participants lost to follow-up. Outcomes of interest focused predominantly on gender identity over time and emotional and behavioural functioning.

CONCLUSIONS

Larger scale and higher quality longitudinal research on gender identity development in children is needed. Some externally funded longitudinal studies are currently in progress internationally. Findings from these studies will enhance understanding of outcomes over time in relation to gender identity development in children and young people.

Clinical Outcomes Following Acute Residential Psychiatric Treatment in Transgender and Gender Diverse Adolescents

IMPORTANCE

Transgender and gender diverse (TGD) individuals, who have a gender identity that differs from their sex assigned at birth, are at increased risk of mental health problems, including depression, anxiety, self-injurious behavior, and suicidality, relative to cisgender peers.

OBJECTIVE

To examine mental health outcomes among TGD vs cisgender adolescents in residential treatment.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study's longitudinal design was used to compare groups at treatment entry and discharge, and 1-month postdischarge follow-up. The setting was an adolescent acute residential treatment program for psychiatric disorders. Participants were TGD or cisgender adolescents enrolled in the treatment program. Statistical analysis was performed October 2019 to March 2021.

EXPOSURE

Adolescents participated in a 2-week acute residential treatment program for psychiatric disorders.

MAIN OUTCOMES AND MEASURES

Primary outcomes were depressive (the Center for Epidemiologic Studies Depression Scale [CES-D]) and anxiety (the Multidimensional Anxiety Scale for Children [MASC]) symptoms, and emotional dysregulation (the Difficulties in Emotion Regulation Scale [DERS]), measured at treatment entry and discharge, and postdischarge follow-up. Age of depression onset, suicidality, self-injury, and childhood trauma also were assessed at treatment entry.

RESULTS

Of 200 adolescent participants who completed treatment entry and discharge assessments, the mean (SD) age was 16.2 (1.5) years; 109 reported being assigned female at birth (54.5%), 35 were TGD (17.5%), and 66 (49.3%) completed 1-month follow-up. TGD participants had an earlier mean (SD) age of depression onset (TGD: 10.8 [2.4] years vs cisgender: 11.9 [2.3] years; difference: 1.07 years; 95% CI, 0.14-2.01 years; P = .02), higher mean (SD) suicidality scores (TGD: 44.4 [23.1] vs cisgender: 28.5 [25.4]; difference: 16.0; 95% CI, 6.4-25.5; P = .001), more self-injurious behavior (mean [SD] RBQ-A score for TGD: 3.1 [2.5] vs cisgender: 1.7 [1.9]; difference: 1.42; 95% CI, 0.69-2.21; P = .001) and more childhood trauma (eg, mean [SD] CTQ-SF score for emotional abuse in TGD: 12.7 [5.4] vs cisgender: 9.8 [4.7]; difference: 2.85; 95% CI, 1.06-4.64; P = .002). The TGD group also had higher symptom scores (CES-D mean difference: 7.69; 95% CI, 3.30 to 12.08; P < .001; MASC mean difference: 7.56; 95% CI, 0.46 to 14.66; P = .04; and DERS mean difference: 18.43; 95% CI, 8.39 to 28.47; P < .001). Symptom scores were significantly higher at entry vs discharge (CES-D mean difference, -12.16; 95% CI, -14.50 to -9.80; P < .001; MASC mean difference: -3.79; 95% CI, -6.16 to -1.42; P = .02; and DERS mean difference: -6.37; 95% CI, -10.80 to -1.94; P = .05) and follow-up (CES-D mean difference: -9.69; 95% CI, -13.0 to -6.42; P < .001; MASC mean difference: -6.92; 95% CI, -10.25 to -3.59; P < .001; and DERS mean difference: -12.47; 95% CI, -18.68 to -6.26; P < .001).

CONCLUSIONS AND RELEVANCE

This cohort study found mental health disparities in TGD youth relative to cisgender youth, with worse scores observed across assessment time points. For all participants, primary clinical outcome measures were significantly lower at treatment discharge than at entry, with no significant differences between discharge and 1-month follow-up. Given the substantial degree of mental health disparities reported in TGD individuals, these findings warrant focused clinical attention to optimize treatment outcomes in gender minority populations.

Attachment Patterns in Children and Adolescents With Gender Dysphoria

The current study examines patterns of attachment/self-protective strategies and rates of unresolved loss/trauma in children and adolescents presenting to a multidisciplinary gender service. Fifty-seven children and adolescents (8.42–15.92 years; 24 birth-assigned males and 33 birth-assigned females) presenting with gender dysphoria participated in structured attachment interviews coded using dynamic-maturational model (DMM) discourse analysis. The children with gender dysphoria were compared to age- and sex-matched children from the community (non-clinical group) and a group of school-age children with mixed psychiatric disorders (mixed psychiatric group). Information about adverse childhood experiences (ACEs), mental health diagnoses, and global level of functioning was also collected. In contrast to children in the non-clinical group, who were classified primarily into the normative attachment patterns (A1-2, B1-5, and C1-2) and who had low rates of unresolved loss/trauma, children with gender dysphoria were mostly classified into the high-risk attachment patterns (A3-4, A5-6, C3-4, C5-6, and A/C) (χ² = 52.66; p < 0.001) and had a high rate of unresolved loss/trauma (χ² = 18.64; p < 0.001). Comorbid psychiatric diagnoses (n = 50; 87.7%) and a history of self-harm, suicidal ideation, or symptoms of distress were also common. Global level of functioning was impaired (range 25–95/100; mean = 54.88; SD = 15.40; median = 55.00). There were no differences between children with gender dysphoria and children with mixed psychiatric disorders on attachment patterns (χ² = 2.43; p = 0.30) and rates of unresolved loss and trauma (χ² = 0.70; p = 0.40). Post hoc analyses showed that lower SES, family constellation (a non-traditional family unit), ACEs—including maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence)—increased the likelihood of the child being classified into a high risk attachment pattern. Akin to children with other forms of psychological distress, children with gender dysphoria present in the context of multiple interacting risk factors that include at-risk attachment, unresolved loss/trauma, family conflict and loss of family cohesion, and exposure to multiple ACEs.

Gender Diverse Children and Adolescents in Italy: A Qualitative Study on Specialized Centers' Model of Care and Network

In recent years, Italy, similar to many other countries, has witnessed an increase in children and adolescents presenting gender incongruence. This trend has led to the development and implementation of specialized centers providing care and support for these youths and their families. The present study aimed at investigating the functioning of agencies specialized in working with transgender and gender non-conforming youths in the Italian territory. Professionals in these agencies were interviewed about their perspectives on their agency's functioning, networks with other services, and work with trans* youths and their families. A semi-structured interview was developed and administered to professionals in specialized centers and associations dedicated to trans * youths, and deductive thematic analysis was applied to the transcripts. Eight professionals were interviewed: six working in specialized centers and two working in associations. The qualitative analyses of transcripts revealed four main themes, pertaining to service referrals, assessment protocols and intervention models, psychological support for youths and families, and agency shortcomings. The study explored the functioning of Italian agencies specialized in caring for transgender and gender non-conforming youths, from the perspective of professionals working in these agencies. While several positive aspects of the work emerged, the study highlighted a lack of uniformity across the Italian territory and the need for better networks between agencies and other medical professionals.

Association of Media Coverage of Transgender and Gender Diverse Issues With Rates of Referral of Transgender Children and Adolescents to Specialist Gender Clinics in the UK and Australia

IMPORTANCE

Specialist gender clinics worldwide have witnessed an increase in referrals of transgender and gender diverse (TGD) children and adolescents, but the underlying factors associated with this increase are unknown.

OBJECTIVE

To determine whether increases in TGD young people presenting to specialist gender clinics are associated with related media coverage.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted at 2 publicly funded, pediatric specialist gender services, one located in the UK and the other in Australia. Participants were all children and adolescents aged 0 to 18 years, referred between January 1, 2009, and December 31, 2016, to their respective gender services in the UK and Australia. Data analysis was performed in April 2019.

EXPOSURES

Media coverage of TGD issues.

MAIN OUTCOMES AND MEASURES

Referral rates from each gender service were compared with local TGD-related media coverage during the study period.

RESULTS

Referral data for 5242 TGD young people were obtained (4684 in the UK, of whom 1847 [39.4%] were assigned male at birth and 2837 [60.6%] were assigned female at birth; 558 in Australia, of whom 250 [44.8%] were assigned male at birth and 308 [55.2%] were assigned female at birth), and a total of 2614 news items were identified (UK, 2194; Australia, 420). The annual number of TGD young people referred to both specialist gender clinics was positively correlated with the number of TGD-related local media stories appearing each year (Spearman r = 1.0; P < .001). Moreover, weekly referral rates in both the UK for week 1 (β̂ = 0.16; 95% CI, 0.03-0.29; P = .01) and Australia for week 2 (β̂ = 0.12; 95% CI, 0.04-0.20; P = .003) showed evidence of association with the number of TGD-related media items appearing within the local media. There was no evidence of association between referrals and media items appearing 3 weeks beforehand. Media predominantly focused on TGD issues showed some association with increased referral rates. Specifically, TGD-focused stories showed evidence of association with referral numbers at week 1 (β̂ = 0.16; 95% CI, 0.04-0.28; P = .007) and week 2 (β̂ = 0.23; 95% CI, 0.11-0.35; P < .001) in Australia and with referral numbers at week 1 (β̂ = 0.22; 95% CI, 0.01-0.44; P = .04) in the UK. No evidence of association was found between media peripherally related to TGD issues and referral rates.

CONCLUSIONS AND RELEVANCE

This study found evidence of an association between increasing media coverage of TGD-related topics and increasing numbers of young people presenting to gender clinics. It is possible that media coverage acts as a precipitant for young people to seek treatment at specialist gender services, which is consistent with clinical experiences in which TGD young people commonly identify the media as a helpful source of information and a trigger to seek assistance.

Re-evaluation of the Dutch approach: are recently referred transgender youth different compared to earlier referrals?

The background of this article is to examine whether consecutively transgender clinic-referred adolescents between 2000 and 2016 differ over time in demographic, psychological, diagnostic, and treatment characteristics. The sample under study consisted of 1072 adolescents (404 assigned males, 668 assigned females, mean age 14.6 years, and range 10.1-18.1 years). The data regarding the demographic, diagnostic, and treatment characteristics were collected from the adolescents' files. Psychological functioning was measured by the Child Behaviour Check List and the Youth Self-Report, intensity of gender dysphoria by the Utrecht Gender Dysphoria Scale. Time trend analyses were performed with 2016 as reference year. Apart from a shift in sex ratio in favour of assigned females, no time trends were observed in demographics and intensity of dysphoria. It was found, however, that the psychological functioning improved somewhat over time (CBCL β - 0.396, p < 0.001, 95% CI - 0.553 to - 0.240, YSR β - 0.278, p < 0.001, 95% CI - 0.434 to - 0.122). The percentage of referrals diagnosed with gender dysphoria (mean 84.6%, range 75-97.4%) remained the same. The percentage of diagnosed adolescents that started with affirmative medical treatment (puberty suppression and/or gender-affirming hormones) did not change over time (mean 77.7%; range 53.8-94.9%). These findings suggest that the recently observed exponential increase in referrals might reflect that seeking help for gender dysphoria has become more common rather than that adolescents are referred to gender identity services with lower intensities of gender dysphoria or more psychological difficulties.

Family Discussions of Early Childhood Social Transitions

Objective

An increasing number of children are socially transitioning to live as their identified genders rather than their assigned sexes, yet little empirical work has examined the decision-making process surrounding social transitions. We aimed to understand (1) why parents and their gender nonconforming children do and do not consider social transitions and (2) whether families discuss social transitions both before and after initial social transitions.

Methods

Studies 1 and 2 involved telephone interviews of parents of socially transitioned transgender children (N=60) and gender nonconforming children who were not socially transitioned (N=60), respectively. Study 3 involved an online survey of 266 parents of socially transitioned transgender children.

Results

Parents of socially transitioned transgender children (Study 1) and parents of gender nonconforming children who are not socially transitioned (Study 2) often reported that their children had led the decision to transition or not. Most parents of gender nonconforming children who had not transitioned had discussed transitioning (Study 2) and most parents of socially-transitioned transgender children reported discussing the option of future re-transitions (Study 3).

Conclusions

Parents often report that they and their children are discussing social transitions, a process that children are leading. In contrast to possible concerns about discussing transitions, our results suggest that many families openly discuss the possibility of their children transitioning (or re-transitioning), yet these discussion do not inevitably lead to an imminent transition.

Ethical issues arising in the provision of medical interventions for gender diverse children and adolescents

The care of children and adolescents whose experience of the body is at odds with their gender feelings raises a number of questions that are as much ethical as medical or psychological. In this article I highlight some areas of ethical concern from the point of view of a senior clinician at the nationally commissioned UK Gender Identity Development Service (GIDS). I make the assumption that ethical deliberation is relational and grounded in the natural, social, political and institutional worlds in which the ethical questions arise. I try to show how matters of empirical fact, alongside an appreciation of broad social contexts, and historic and current power relations, provide an essential framework for the ways that ethical choices are framed by key groups of people as they take up different, sometimes opposing, ethical positions. I argue that practising ethically in such a service is not helpfully reduced to a single event, a treatment decision aimed at achieving the morally 'right' outcome, but an extended process in time. In the charged debate surrounding the recognition of these young people's needs, we must do more to promote responsible debate about the scope of sound ethical practice.