Baseline characteristics of gender dysphoric youth

Characteristics of children and adolescents referred to specialist gender services: a systematic review

BACKGROUND

Increasing numbers of children/adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. Services and practice guidelines are responding to these changes.

AIM

This systematic review examines the numbers and characteristics of children/adolescents (under 18) referred to specialist gender or endocrinology services.

METHODS

Database searches were performed (April 2022), with results assessed independently by two reviewers. Peer-reviewed articles providing at least birth-registered sex or age at referral were included. Demographic, gender-related, mental health, neurodevelopmental conditions and adverse childhood experience data were extracted. A narrative approach to synthesis was used and where appropriate proportions were combined in a meta-analysis.

RESULTS

143 studies from 131 articles across 17 countries were included. There was a twofold to threefold increase in the number of referrals and a steady increase in birth-registered females being referred. There is inconsistent collection and reporting of key data across many of the studies. Approximately 60% of children/adolescents referred to services had made steps to present themselves in their preferred gender. Just under 50% of studies reported data on depression and/or anxiety and under 20% reported data on other mental health issues and neurodevelopmental conditions. Changes in the characteristics of referrals over time were generally not reported.

CONCLUSIONS

Services need to capture, assess and respond to the potentially co-occurring complexities of children/adolescents being referred to specialist gender and endocrine services. Agreement on the core characteristics for collection at referral/assessment would help to ensure services are capturing data as well as developing pathways to meet the needs of these children.PROSPERO registration number CRD42021289659.

Gender diversity is correlated with dimensional neurodivergent traits but not categorical neurodevelopmental diagnoses in children

BACKGROUND

Gender clinic and single-item questionnaire-based data report increased co-occurrence of gender diversity and neurodevelopmental conditions. The nuances of these associations are under-studied. We used a transdiagnostic approach, combining categorical and dimensional characterization of neurodiversity, to further the understanding of its associations with gender diversity in identity and expression in children.

METHODS

Data from 291 children (Autism N = 104, ADHD N = 104, Autism + ADHD N = 17, neurotypical N = 66) aged 4-12 years enrolled in the Province of Ontario Neurodevelopmental Network were analyzed. Gender diversity was measured multi-dimensionally using a well-validated parent-report instrument, the Gender Identity Questionnaire for Children (GIQC). We used gamma regression models to determine the significant correlates of gender diversity among age, puberty, sex-assigned-at-birth, categorical neurodevelopmental diagnoses, and dimensional neurodivergent traits (using the Social Communication Questionnaire and the Strengths and Weaknesses of ADHD Symptoms and Normal Behavior Rating Scales). Internalizing and externalizing problems were included as covariates.

RESULTS

Neither a categorical diagnosis of autism nor ADHD significantly correlated with current GIQC-derived scores. Instead, higher early-childhood dimensional autistic social-communication traits correlated with higher current overall gender incongruence (as defined by GIQC-14 score). This correlation was potentially moderated by sex-assigned-at-birth: greater early-childhood autistic social-communication traits were associated with higher current overall gender incongruence in assigned-males-at-birth, but not assigned-females-at-birth. For fine-grained gender diversity domains, greater autistic restricted-repetitive behavior traits were associated with greater diversity in gender identity across sexes-assigned-at-birth; greater autistic social-communication traits were associated with lower stereotypical male expression across sexes-assigned-at-birth.

CONCLUSIONS

Dimensional autistic traits, rather than ADHD traits or categorical neurodevelopmental diagnoses, were associated with gender diversity domains across neurodivergent and neurotypical children. The association between early-childhood autistic social-communication traits and overall current gender diversity was most evident in assigned-males-at-birth. Nuanced interrelationships between neurodivergence and gender diversity should be better understood to clarify developmental links and to offer tailored support for neurodivergent and gender-diverse populations.

Somatic Health and Psychosocial Background Among Finnish Adolescents with Gender Dysphoria Seeking Hormonal Interventions

Purpose

Although the number of young adults suffering from gender dysphoria (GD) is increasing, reports focusing on their somatic health remain scarce. We studied the somatic health, pubertal development, psychosocial background, and interest regarding gender-affirming surgical treatment of Finnish adolescents seeking gender-affirming hormonal treatment (GAHT).

Methods

In this retrospective register study at an adolescent gynecology clinic in Helsinki University Hospital, Finland we included 124 adolescents diagnosed with GD and referred to GAHT between January 1, 2011 and December 31, 2018. This cohort covered two thirds of all Finnish adolescents referred to GAHT during the follow-up. Data on the general adolescent population were obtained from the Finnish School Health Promotion (SHP) study of year 2017.

Results

Most adolescents were assigned female at birth. Sex ratio increased from 1.2 in 2012 to 5.2 in 2017. One-third of the patients were overweight or obese (body mass index [BMI] >25 kg/m2). Other somatic comorbidities were rare. Interest toward reconstructive genital surgery was more common among male-to-female than female-to-male patients (80% vs. 22%, respectively, p<0.001). Depression (29%) and anxiety (19%) were common psychiatric comorbidities. Parental divorce rate (57%) was higher than in the general adolescent population in Finland (23%, p<0.001).

Conclusion

Finnish adolescents diagnosed with GD-seeking GAHT have good somatic health, but a higher proportion of overweight, depression, and anxiety than the general adolescent population. Prospective follow-up of this cohort will provide an opportunity to evaluate the somatic and psychosocial outcomes and quality of life during GAHT.

The Continued Impact of the COVID-19 Pandemic on Pediatric Obesity: A Commentary on the Return to a Healthy New "Normal"

Two years into this pandemic, mental health symptoms are more prevalent in children and adolescents, routine wellness visits have decreased, individuals and families are experiencing increased stress, and food and nutrition insecurity are on the rise. Pediatric overweight and obesity are yet another health condition that has been impacted by the pandemic. The current commentary aims to (a) summarize a variety of factors contributing to worsening obesity and healthy lifestyle choices in youth throughout the pandemic and to (b) provide recommendations for healthcare providers on navigating this challenge. Specific health behaviors, such as increased sedentary behavior, decreased physical activity, a change to families' home-food environments, and an increase in sleep dysregulation have contributed to increased weight gain in children and adolescents. As uncertainty continues with the advent of various COVID-19 variants, it remains important to consider how the pandemic has impacted pediatric overweight and obesity.

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.

Growth, growth potential, and influences on adult height in the transgender and gender-diverse population

The sexually dimorphic trait of height is one aspect of the experience of transgender and gender‐diverse (TGD) individuals that may influence their gender dysphoria and satisfaction with their transition. In this article, we have reviewed the current knowledge of the factors that contribute to one's final adult height and how it might be affected in TGD youth who have not experienced their gonadal puberty in the setting of receiving gonadotropin‐releasing hormone analog (GnRHa) and gender‐affirming hormonal treatment. Additional research is needed to characterize the influence of growth and final adult height on the lived experience of TGD youth and adults and how to best assess their growth, predict their final adult height, and how medical transition can be potentially modified to help them meet their goals.

Non-HIV chronic disease burden among transgender populations globally: A systematic review and narrative synthesis

Chronic disease is a growing concern for research, policy and clinical care. While the global burden of HIV for transgender populations has been comprehensively covered in recent systematic reviews, the same is not true for the burden of other chronic disease. The objective of this study was to review the literature on non-HIV chronic disease burden for transgender populations worldwide. A systematic review was conducted of Medline, Embase, CINAHL, PsycINFO and LGBT Life bibliographic databases for peer-reviewed scientific studies with non-HIV chronic disease prevalence data for transgender populations published any date up to February 15, 2019 without restriction on country or study design. A total of 93 studies and 665 datapoints were included in this review, comprising 48 distinct chronic disease outcomes in seven groups (cancer, cerebro/cardiovascular conditions, chronic liver and kidney disease, mental health and substance use conditions, metabolic and endocrine disorders, musculoskeletal and brain disorders, respiratory conditions, and unspecified and other conditions). The empirical literature on chronic disease among global transgender populations focuses on mental health morbidity, demonstrating an evidence gap on chronic physical health morbidity, particularly beyond that of sexual health. This review identified important gaps including in age-related conditions, inflammation-related disease and studies designed explicitly to investigate chronic disease burden among transgender populations. There is a need for high quality evidence in this area, including longitudinal population-based studies with appropriate comparison groups, and consistent measurement of both transgender status and chronic conditions.