A European Network for the Investigation of Gender Incongruence in adolescents

BACKGROUND

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

AIM

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

METHODS

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

OUTCOMES

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

RESULTS

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

CLINICAL IMPLICATIONS

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

STRENGTHS AND LIMITATIONS

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

CONCLUSION

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

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.

Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol

BACKGROUND

Twenty years ago, the Dutch Protocol-consisting of a gonadotropin-releasing hormone agonist (GnRHa) to halt puberty and subsequent gender-affirming hormones (GAHs)-was implemented to treat adolescents with gender dysphoria.

AIM

To study trends in trajectories in children and adolescents who were referred for evaluation of gender dysphoria and/or treated following the Dutch Protocol.

METHODS

The current study is based on a retrospective cohort of 1766 children and adolescents in the Amsterdam Cohort of Gender Dysphoria.

OUTCOMES

Outcomes included trends in number of intakes, ratio of assigned sex at birth, age at intake, age at start of GnRHa and GAH, puberty stage at start of GnRHa, proportions of adolescents starting and stopping GnRHa, reasons for refraining from GnRHa, and proportions of people undergoing gender-affirming surgery.

RESULTS

A steep increase in referrals was observed over the years. A change in the AMAB:AFAB ratio (assigned male at birth to assigned female at birth) was seen over time, tipping the balance toward AFAB. Age at intake and at start of GnRHa has increased over time. Of possibly eligible adolescents who had their first visit before age 10 years, nearly half started GnRHa vs around two-thirds who had their first visit at or after age 10 years. The proportion starting GnRHa rose only for those first visiting before age 10. Puberty stage at start of GnRHa fluctuated over time. Absence of gender dysphoria diagnosis was the main reason for not starting GnRHa. Very few stopped GnRHa (1.4%), mostly because of remission of gender dysphoria. Age at start of GAH has increased mainly in the most recent years. When a change in law was made in July 2014 no longer requiring gonadectomy to change legal sex, percentages of people undergoing gonadectomy decreased in AMAB and AFAB.

CLINICAL IMPLICATIONS

A substantial number of adolescents did not start medical treatment. In the ones who did, risk for retransitioning was very low, providing ongoing support for medical interventions in comprehensively assessed gender diverse adolescents.

STRENGTHS AND LIMITATIONS

Important topics on transgender health care for children and adolescents were studied in a large cohort over an unprecedented time span, limited by the retrospective design.

CONCLUSION

Trajectories in diagnostic evaluation and medical treatment in children and adolescents referred for gender dysphoria are diverse. Initiating medical treatment and need for surgical procedures depends on not only personal characteristics but societal and legal factors as well.

The barriers and needs of transgender men in pregnancy and childbirth: A qualitative interview study

OBJECTIVE

Transgender and gender diverse individuals are individuals whose gender identity differs from their sex assigned at birth. The discordance between gender identity and sex assignment may cause significant psychological distress: gender dysphoria. Transgender individuals may choose to undergo gender-affirming hormone treatment or surgery, but some decide to (temporarily) refrain from surgery and gender affirming hormone treatment and hence retain the possibility to become pregnant. Pregnancy may enhance feelings of gender dysphoria and isolation. To improve perinatal care for transgender individuals and their health care providers, we conducted interviews to explore the needs and barriers of transgender men in family planning, pregnancy, childbirth, puerperium and perinatal care.

DESIGN

In this qualitative study five in-depth semi-structured interviews were conducted with Dutch transgender men who had given birth while identifying on the transmasculine spectrum. The interviews were conducted online through a video remote-conferencing software program (n=4) or live (n=1). Interviews were transcribed verbatim. An inductive approach was used to find patterns and collect data from the participants' narratives and constant comparative method was adapted in analysing the interviews.

MEASUREMENTS AND FINDINGS

The experiences of transgender men regarding the preconception period, pregnancy and puerperium and with perinatal care varied widely. Though all participants expressed overall positive experiences, their narratives emphasized they had to overcome substantial hurdles pursuing pregnancy. For instance the necessity to prioritise becoming pregnant over gender transitioning, lack of support by healthcare providers and increased gender dysphoria and isolation during pregnancy KEY CONCLUSIONS: Since pregnancy in transgender men enhances feelings of gender dysphoria, transgender men comprise a vulnerable group in perinatal care. Health care providers are perceived as feeling unaccustomed for the care of transgender patients, as they are perceived to often lack the right tools and knowledge to provide adequate care. Our findings help strengthen the foundation of insight in the needs and hurdles of transgender men pursuing pregnancy and therefore may guide health care providers to provide equitable perinatal care, and emphasize the necessity of patient-centred gender-inclusive perinatal care. A guideline including the option for consultation of an expertise center is advised to facilitate patient-centered gender-inclusive perinatal care.

Body Image in Adolescents with Gender Incongruence and Its Association with Psychological Functioning

During adolescence, many individuals with gender incongruence (GI) experience distress related to body dissatisfaction. This study aims to describe the body (dis)satisfaction of Dutch adolescents referred for GI and to describe the influence of body image on their psychological functioning. Self-report measures on body satisfaction (Body Image Scale) and psychological functioning (Youth Self-Report) were obtained from 787 adolescents (aged 10-18) who were referred to the Center of Expertise on Gender Dysphoria at the Amsterdam University Medical Centers between 1996 and 2016. First, a general description of body satisfaction in adolescents with GI was developed. Secondly, multiple linear regression analyses were performed to determine the association between body image and psychological functioning, both for total problems and for internalizing and externalizing problems separately. Third, regression analyses are repeated for body area subscales. Adolescents with GI report the greatest dissatisfaction with the genital area, regardless of birth-assigned sex. For all other body areas, there were birth-assigned sex differences in satisfaction. The analyses showed that body satisfaction was significantly related to total psychological problems and both internalizing and externalizing problems. Greater body dissatisfaction is significantly associated with worse psychological functioning in adolescents with GI. Clinicians should monitor the body image of adolescents with GI over time, especially during puberty and medical interventions.

Mastectomy is a safe procedure in transgender men with a history of breast reduction

Little is known about the safety and surgical outcomes of mastectomy after breast reduction in the trans male population. Several concerns have been voiced that performing mastectomy with prior breast reduction surgery, increases the risk for complications and revision surgery. All transgender men with a history of breast reduction, who underwent a mastectomy at our center between 01-1990 and 01-2021 were identified from our hospital registry. A retrospective chart study was conducted recording surgical characteristics, surgical complications, revision surgery, and clinical follow-up. A total of 1362 subcutaneous mastectomies were performed between 01-1990 and 01-2021. A total of 36 (2.6%) individuals were included (35 bilateral and 1 unilateral breast reduction). The mean age at mastectomy was 37 ± 10 years, and the median time between breast reduction and mastectomy was 6.3 years (range 1.0-31.1). Most individuals underwent a Wise-pattern breast reduction (91%) and a double incision mastectomy with free nipple grafts (86%). Following mastectomy, one acute reoperation was performed because of hemorrhage (3%). Partial pedicled nipple necrosis was seen in 7% and (partial) non-take of nipple grafts in 4%. Scar revisions were performed in 9%, dogear corrections in 20%, and both nipple corrections, and contour corrections in 6%. When comparing the outcomes in literature for surgical complications, scar revision, contour correction or nipple areolar complex revision, no clear disadvantage seems to be present when performing mastectomy after breast reduction. Mastectomy is a safe procedure in transgender men with a history of breast reduction.

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.

Differences in self-perception and social gender status in children with gender incongruence

Background: Gender incongruent children report lower self-perception compared to the norm population. This study explored differences in self-perception between children living in their gender role assigned at birth and children living in their experienced gender role.Method: The self-perception questionnaire was administered to 312 children referred to the Center of Expertise on Gender Dysphoria 'Amsterdam UMC'. Social transition status was determined by parental interviews. 2 (social transition) by 2 (sex assigned at birth) ANCOVA's were conducted.Results: Children living in their assigned gender role reported comparable self-perception to children living in their experienced gender role. Birth assigned girls living in their assigned gender role reported poorer self-perception on 'athletic competence', compared to girls living in their experienced gender role. Birth assigned boys living in their assigned gender role reported poorer on 'scholastic competence' and 'behavioral conduct' compared to boys living in their experienced gender role.Conclusions: Social transition did not show to affect self-perception. Self-perception was poorer for birth assigned boys living in their experienced gender role. For birth assigned girls this was reversed. Future studies should give more insight in the role of social transitions in relation to child development and focus on other aspects related to self-perception.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Comparison of surgical outcomes and urinary functioning after phalloplasty with versus without urethral lengthening in transgender men

Background: Phalloplasty in transgender men is performed with or without Urethral Lengthening (UL). To create clear expectations in the choice of UL, an overview and comparison of outcomes is useful. Aims: To provide and compare surgical outcomes and urinary functioning after phalloplasty with versus without UL in transgender men. Methods: A single-center, retrospective chart review was conducted among transgender men who underwent phalloplasty with or without UL between 01-2013 and 10-2020. Primary outcomes were differences in complication and reoperation rates. Secondary outcomes were end-stages of voiding at last follow-up and differences in voiding analyses pre- and postoperatively. Results: Of 136 men, 91 (67%) underwent phalloplasty with, and 45 (33%) without UL. Wound infection (31 vs. 16%, p = 0.06) and partial flap loss (35 vs. 13%, p = 0.008) were predominately seen after UL. In the UL group, 43% urethral fistulas and 60% urethral strictures were observed, relative to one man without UL who had a urethral fistula (both p < 0.001). Meatal or perineal orifice stenosis was seen in 29% with versus 11% without UL (p = 0.02). Reoperation was needed in 81% with versus 27% without UL (p < 0.001). At follow-up, 80/91 (88%) after UL reached end-stage of voiding, with 60/80 (75%) able to void while standing and 20/80 (25%) having a definitive urethrostomy. The remaining 11/91 (12%) men were awaiting further treatment for urological complications. The men able to void while standing had a median of one reoperation (range 0-6), and a significant decrease in maximum flow rate on postoperative uroflowmetry (21.4 vs. 29.8 mL/s, p < 0.001). After phalloplasty without UL, all men had a definitive perineostomy without changes in voiding analyses. Discussion: The choice for or against UL during phalloplasty has become more relevant over the years. This comparison of surgical outcomes and urinary functioning can be useful in the shared decision-making process to come to the most suitable choice of phalloplasty.

Self-Perception of Transgender Adolescents after Gender-Affirming Treatment: A Follow-Up Study into Young Adulthood

Purpose: Early medical treatment for transgender adolescents should contribute to healthy psychological development, including the development of positive self-perception. However, at present, there are no longitudinal studies that have examined whether current treatment approaches meet this expectation. Therefore, the aim of this single-arm retrospective study was to examine transgender adolescents' self-perception changes over the course of irreversible medical gender-affirming treatment. Method: The total study sample consisted of 70 adolescents (49 trans men and 21 trans women). Self-perception was assessed before the start of gender-affirming hormone treatment (mean age = 14.65, standard deviation (SD) = 2.08) and at least 6 months after gender-affirming surgeries (mean age = 20.70, SD = 1.49) by Self-Perception Profile for Adolescents (SPPA). The SPPA is a self-report measure that examines self-perception on seven different domains: Scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct, close friendship, and global self-worth. Multilevel modeling (random intercepts model) was conducted to determine the effect of time for all domains of self-perception. Results: It was found that the domains of physical appearance and global self-worth improved significantly over the course of treatment. No domain worsened significantly over the course of treatment. The domains of scholastic competence, social acceptance, athletic competence, and close friendship remained stable over time. Conclusion: This study provides the first suggestive evidence that irreversible gender-affirming treatment for adolescents could contribute to the development of a more positive self-perception.

Talking About Sexuality With Youth: A Taboo in Psychiatry?

BACKGROUND

Young people who have psychiatric problems are more likely than their peers to endure difficulties during their sexual and gender identity development.

AIM

This study aims to examine the communication between mental health care providers and their patients about the topics of relations, sexuality and gender identity, including a description of professionals' attitudes toward these topics and the factors that contribute to and inhibit communication.

METHODS

Study participants (n = 242, response rate = 31%) were a representative sample of a large multicenter cohort of 768 mental health care professionals (eg, medical doctors, psychiatrists, psychologists, group counselors, parent counselors) of 7 institutions and 5 solo practices in the Netherlands, who completed a survey on communication about sexuality and gender identity with their young patients (age 12-21 years).

OUTCOMES

Sexuality and gender identity are infrequently discussed by mental health care providers with their young patients or their patients' parents.

RESULTS

Of the study sample, 99.5 % valued sexuality as an important topic to discuss with their patients. However, only 17.1% of the professionals reported that they discussed sexuality-related issues with the majority (>75%) of their patients (adolescents: 19.9%, parents: 14.4%) Additionally, only 2.3 % of the participants discussed gender nonconformity regularly with patients. Information about sexual side effects of prescribed medication was infrequently (20.3%) provided: antidepressants (40.0%), antipsychotics (34.0%), benzodiazepines (5.1%) and stimulants (2.4%). The most frequently cited reasons for not discussing these topics were a lack of awareness, own feelings of discomfort, and the patients' supposed feelings of shame. There was no gender differences observed.

CLINICAL IMPLICATIONS

Recommendations for professionals include to be aware of these topics, initiating age-appropriate conversation and use inclusive language.

STRENGTHS AND LIMITATIONS

The present study included a diverse and representative group of mental health care professionals. Frequency of sexual communication was based on self-report, which brings a risk of bias.

CONCLUSION

Despite a recognized need to engage in age-appropriate communication about sexuality and gender identity in youth mental health care, mental health providers seem to remain hesitant to discuss such topics. Bungener SL, Post L, Berends I, et al. Talking About Sexuality With Youth: A Taboo in Psychiatry?. J Sex Med 2022;19:421-429.

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.

Longitudinal Outcomes of Gender Identity in Children (LOGIC): study protocol for a retrospective analysis of the characteristics and outcomes of children referred to specialist gender services in the UK and the Netherlands

INTRODUCTION

Specialist gender services for children and young people (CYP) worldwide have experienced a significant increase in referrals in recent years. As rates of referrals increase, it is important to understand the characteristics and profile of CYP attending these services in order to inform treatment pathways and to ensure optimal outcomes.

METHODS AND ANALYSIS

A retrospective observational study of clinical health records from specialist gender services for CYP in the UK and the Netherlands. The retrospective analysis will examine routinely collected clinical and outcome measures data including demographic, clinical, gender identity-related and healthcare resource use information. Data will be reported for each service and also compared between services. This study forms part of a wider programme of research investigating outcomes of gender identity in children (the Longitudinal Outcomes of Gender Identity in Children study).

ETHICS AND DISSEMINATION

The proposed study has been approved by the Health Research Authority and London-Hampstead Research Ethics Committee as application 19/LO/0181. The study findings will be published in peer-reviewed journals and presented at both conferences and stakeholder events.

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.

Surgical and demographic trends in genital gender-affirming surgery in transgender women: 40 years of experience in Amsterdam

This was a single-centre, retrospective study of transgender women undergoing genital gender-affirming surgery. A chart study was conducted, recording individual demographics, all genital surgical procedures, and surgical techniques. Procedure incidence, techniques employed, and demographic variations over the years were analysed.

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.

Gender-affirmation surgery and bariatric surgery in transgender individuals in The Netherlands: Considerations, surgical techniques and outcomes

INTRODUCTION

The number of transgender individuals seeking medical and surgical care has increased over the last years. Within the transgender population overweight and obesity is more frequently observed when compared to the general population. Little is known on the prevalence of bariatric surgery in the transgender population and the effects on the surgical gender transition path of the individual transgender with overweight or obesity.

MATERIAL AND METHODS

All transgender individuals who underwent gender-affirming surgery (GAS) between 1980 and 2020 were retrospectively identified from our hospital registry. Those with a history of bariatric surgery were selected. A retrospective chart study was conducted, recording gender identity, bariatric surgery specifications, gender surgery specifications, complications, reoperations and clinical follow-up time.

RESULTS

A total of 15 transgender individuals (11 transgender men, 4 transgender women) who underwent bariatric surgery were identified. All individuals underwent bariatric surgery before any GAS procedure, except for one transgender man. At the first GAS procedure, all individuals experienced significant weight loss when compared to their weight at bariatric surgery (mean 13.1 ± 3.8 BMI points lost for transgender men, mean BMI points lost 14.3 ± 2.8 for transgender women, p < 0.01). Obesity was still frequently prevalent in transgender men after bariatric surgery. All included transgender men underwent mastectomy via the double incision with free nipple grafting technique. Only one transgender man underwent genital GAS. All transgender women underwent penile-inversion vaginoplasty, one in combination with prosthesis-based augmentation mammoplasty.

CONCLUSION

Surgical gender transition is possible after massive weight loss after bariatric surgery. Specific surgical subtechniques will be more prevalent in this population.

Reliability and Clinical Utility of Gender Identity-Related Diagnoses: Comparisons Between the ICD-11, ICD-10, DSM-IV, and DSM-5

Purpose: The World Health Organization general assembly approved the 11th revision of the International Classification of Diseases (ICD) in 2019 which will be implemented in 2022. Gender identity-related diagnoses were substantially reconceptualized and removed from the mental health chapter so that the distress criterion is no longer a prerequisite. The present study examined reliability and clinical utility of gender identity-related diagnoses of the ICD-11 in comparison with the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5, ICD-10, and DSM-IV. Methods: Sixty-four health care providers assessed six videos of two children, two adolescents, and two adults referred for gender incongruence. Each provider rated one pair of videos with three of the four classification systems (ICD-11, DSM-5, ICD-10, and DSM-IV-TR). This resulted in 72 ratings for the adolescent and adult diagnoses and 59 ratings for the children's diagnoses. Results: Interrater agreement rates for each instrument ranged from 65% to 79% for the adolescence/adulthood diagnoses and from 67% to 94% for the childhood diagnoses and were comparable regardless of the system used. Only agreement rates for ICD-11 were significantly better than those for DSM-5 for both age categories. Clinicians evaluated all four systems as convenient and easy to use. Conclusion: In conclusion, both classification systems (DSM and ICD) and both editions (DSM-IV and DSM-5 and ICD-10 and ICD-11) of gender identity-related diagnoses seem reliable and convenient for clinical use.

Proportion of people identified as transgender and non-binary gender in Brazil

Studies estimate that gender-diverse persons represent 0.1 to 2% of populations investigated, but no such assessment was performed in Latin America. In a representative sample of Brazil's adult population (n = 6000), we investigated participants' sociodemographic characteristics and possible associations between these and current gender identity, categorized as cisgender, transgender or non-binary gender. We also investigated transgender individuals' distress associated with gender-related body characteristics. As main results, we found that transgender individuals represented 0.69% (CI95% = 0.48-0.90) of the sample, whereas non-binary persons were 1.19% (CI95% = 0.92-1.47). These percentages were not different among Brazil's 5 geographic regions. Preliminary analyses showed that transgender individuals were on average younger (32.8 ± 14.2 years, CI95% = 28.5-37.1), compared to cisgender (42.2 ± 15.9, CI95% = 42.5-42.8) and non-binary (42.1 ± 16.5 years, CI95% = 38.3-46.5) groups. Non-binary persons are less likely to be in a relationship compared to cisgender individuals (OR = 0.57, CI95% = 0.35-0.93). In the transgender group, 85% of transgender men and 50% of transgender women reported distress due to gender-related body characteristics. Our main findings draw attention that gender-diverse Brazilian individuals represent around 2% of the country's adult population (almost 3 million people), and are homogeneously located throughout the country, reiterating the urgency of public health policies for these individuals in the five Brazilian sub-regions.

Sexual Experiences of Young Transgender Persons During and After Gender-Affirmative Treatment

OBJECTIVES

Early gender-affirmative treatment (GAT) of adolescents may consist of puberty suppression, use of affirming hormones, and gender-affirmative surgeries. This treatment can potentially influence sexual development. In the current study, we describe sexual and romantic development during and after treatment.

METHODS

The participants were 113 transgender adolescents treated with puberty suppression, affirmative hormones, and affirmative surgery who were assessed as young adults (38 transwomen and 75 transmen; mean age 20.79 years, SD 1.36) during and after their GAT. A questionnaire on sexual experiences, romantic experiences, and subjective sexual experiences was administered and compared to the experiences of a same-aged sample from a Dutch general population study (N = 4020).

RESULTS

One year post surgery, young transgender adults reported a significant increase in experiences with all types of sexual activities: masturbation increased from 56.4% to 81.7%, petting while undressed increased from 57.1% to 78.7%, and sexual intercourse increased from 16.2% to 37.6% post surgery compared to presurgery. Young transmen and transwomen were almost equally experienced. In comparison with the general population, young transgender adults were less experienced with all types of sexual activities.

CONCLUSIONS

Early GAT (including puberty suppression, affirmative hormones, and surgeries) may provide young transgender adults with the opportunity to increase their romantic and sexual experiences.

Timing of Puberty Suppression and Surgical Options for Transgender Youth

OBJECTIVES

Puberty suppression (PS) is a cornerstone of treatment in youth experiencing gender dysphoria. In this study, we aim to inform prescribing professionals on the long-term effects of PS treatment on the development of sex characteristics and surgical implications.

METHODS

Participants received PS according to the Endocrine Society guideline at Tanner 2 or higher. Data were collected from adolescents who received PS between 2006 and 2013 and from untreated transgender controls. Data collection pre- and post-PS and before surgery included physical examination and surgical information.

RESULTS

In total, 300 individuals (184 transgender men and 116 transgender women) were included. Of these, 43 individuals started PS treatment at Tanner 2/3, 157 at Tanner 4/5, and 100 used no PS (controls). Breast development was significantly less in transgender men who started PS at Tanner 2/3 compared with those who started at Tanner 4/5 and controls. Mastectomy was more frequently omitted or less invasive after PS. In transgender women, the mean penile length was significantly shorter in the PS groups compared with controls (by 4.8 cm [Tanner 2/3] and 2.1 cm [Tanner 4/5]). As a result, the likelihood of undergoing intestinal vaginoplasty was increased (odds ratio = 84 [Tanner 2/3]; odds ratio = 9.8 [Tanner 4/5]).

CONCLUSIONS

PS reduces the development of sex characteristics in transgender adolescents. As a result, transgender men may not need to undergo mastectomy, whereas transgender women may require an alternative to penile inversion vaginoplasty. These surgical implications should inform decision-making when initiating PS.

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.

Orchiectomy in transgender individuals: A motivation analysis and report of surgical outcomes

Background: Different surgical procedures are available for transgender women wishing to undergo genital gender-affirming surgery. Aim: To assess preoperative motivations, the frequency of orchiectomy procedures, and postoperative outcomes of orchiectomy in transgender individuals. Methods: All transgender individuals who underwent orchiectomy in the period between January 2012 and January 2020 at our institution were retrospectively identified. A chart study was conducted, recording motivations, demographics, perioperative characteristics and surgical outcomes. The frequency of orchiectomy and vaginoplasty procedures during the study period were determined and compared. Results: During the study period, an increase of performed orchiectomy procedures was observed. The orchiectomy/vaginoplasty ratio was 0.01-0.07 in the period 2012-2018 and 0.24 in 2019. A total of 43 transgender individuals were retrospectively identified. Sixteen (37%) initially wished to undergo a vaginoplasty, but did not meet institutional requirements (nonsmoker, BMI < 30kg/m²) or were not eligible for vaginoplasty surgery because of interfering somatic or mental health issues. Fourteen (33%) individuals who underwent orchiectomy regarded it as a preceding step to a future vaginoplasty procedure. Out of these fourteen, one person is now on the waiting list for vaginoplasty surgery. Thirteen (30%) others did not report a desire to pursue vaginoplasty in the future. This was mostly motivated by the absence of genital dysphoria or motivations related to their gender identity, with a desire to discontinue anti-testosterone treatment. The postoperative course was uncomplicated in 39 (91%) individuals. Conclusion: In the Netherlands, especially in the last year, the frequency of orchiectomy procedures has increased. Reasons that people chose to undergo this procedure include: not being eligible for a vaginoplasty procedure, seeing it as a preceding step to a possible future vaginoplasty or other identity-related motivations (i.e., non-binary gender identification or absence of genital dysphoria).

Self-perception of transgender clinic referred gender diverse children and adolescents

Transgender children and adolescents show high rates of co-occurring psychopathology, which might be related to low self-confidence. Earlier research showed that compared to the norm population, transgender clinic-referred children have lower self-perception on two domains: physical appearance and global self-worth. This study aimed to compare self-perception in a sample of transgender clinic-referred children and adolescents with their standardization samples and to examine differences between these two groups. To measure self-esteem, the Self-Perception Profile for Children was administered to 305 referred children (162 assigned males at birth (AMABs) and 143 assigned females at birth (AFABs), mean age = 9.05 ( SD, 1.47), range = 5.9-13.00 years), and the Self-Perception Profile for Adolescents was administered to 369 referred adolescents (118 AMABs and 251 AFABs, mean age = 15.27 ( SD, 1.80), range = 10.73-18.03 years). To measure the severity of gender dysphoria, the parents of the children completed the Gender Identity Questionnaire and the adolescents completed the Utrecht Gender Dysphoria Scale. Referred children and adolescents had a significantly lower self-concept compared to the normative population, whereby referred adolescents felt less competent compared to referred children. Compared to their peers, childhood referred AFABs perceived themselves even better on scholastic and athletic competence and social acceptance. With regard to gender differences, referred AFABs generally showed a better self-perception compared to referred AMABs. The lower self-perception of transgender clinic-referred children and adolescents compared to same age peers deserves clinical attention and interventions aimed at, for example, improving social and physical self-worth.

Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London (2000-2017)

INTRODUCTION

The prevalence of gender dysphoria in children is not known; however, there are some data on the sex ratio of children referred to specialized gender identity clinics.

AIM

We sought to examine the sex ratio of children, and some associated factors (age at referral and year of referral), referred to the Gender Identity Development Service in the United Kingdom, the largest such clinic in the world.

METHODS

The sex ratio of children (N = 1,215) referred to the Gender Identity Development Service between 2000-2017 was examined, along with year of referral, age-related patterns, and age at referral.

MAIN OUTCOME MEASURE

Sex ratio of birth-assigned boys vs birth-assigned girls.

RESULTS

The sex ratio significantly favored birth-assigned boys over birth-assigned girls (1.27:1), but there were also age and year of referral effects. The sex ratio favored birth-assigned boys at younger ages (3-9 years), but favored birth-assigned girls at older ages (10-12 years). The percentage of referred birth-assigned boys significantly decreased when 2 cohorts were compared (2000-2006 vs 2007-2017). On average, birth-assigned boys were referred at a younger age than birth-assigned girls.

CLINICAL IMPLICATIONS

The evidence for a change in the sex ratio of children referred for gender dysphoria, particularly in recent years, matches a similar change in the sex ratio of adolescents referred for gender dysphoria. The reasons for this remain understudied.

STRENGTH & LIMITATIONS

The United Kingdom data showed both similarities and differences when compared to data from 2 other gender identity clinics for children (Toronto, Ontario, Canada, and Amsterdam, The Netherlands). Such data need to be studied in more gender identity clinics for children, perhaps with the establishment of an international registry.

CONCLUSION

Further study of the correlates of the sex ratio for children referred for gender dysphoria will be useful in clinical care and management. de Graaf NM, Carmichael P, Steensma TD, et al. Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London (2000-2017). J Sex Med 2018;15:1381-1383.

The Genderqueer Identity (GQI) Scale: Measurement and validation of four distinct subscales with trans and LGBQ clinical and community samples in two countries

Background: Non-binary gender measurement has grown out of a need for accurate representation in scholarship and public health services available to a diverse gender population. Aims: The Genderqueer Identity Scale (GQI) was developed to allow for a multidimensional assessment of genderqueer identity, including non-binary identity, socially constructed versus essentialist gender, theoretical awareness of gender concepts, and gender fluidity. The GQI was designed to assess gender identity across a full spectrum of gender, at any age after mid-adolescence, and at various stages of gender identity development, including prior to, during, and after a gender transition, where applicable. Two of the GQI subscales focus on intrapersonal processes, while two focus on interpersonal processes. Methods: The measure was piloted and refined across four distinct samples: a U.S. university based LGBT sample, consecutive clinical referrals at the Center of Expertise on Gender Dysphoria in Amsterdam, the Netherlands, a Dutch LGB community sample, and an online survey forum (LGBTQ). Results: The first exploratory factor analysis identified minor potential adjustments, which were refined and retested. Researchers evaluated and cross-validated the hypothesized factor structure and determined that the three factor GQI subscales and the unidimensional Gender Fluidity measure yielded internally consistent and valid scores among transgender individuals seeking clinical treatment and LGB individuals within a community setting. The exploratory and confirmatory factor analyses provide evidence of good reliability, construct validity, and internal consistency of all four subscales. Discussion: The subscales were appropriate across a spectrum of gender identities and can be taken in the same form over time and across gender transition statuses, making them suitable for clinical evaluation and community based longitudinal research with trans-identified or gender nonconforming persons. The development of the GQI fills critical gaps in gender-related measurement including the ability to assess multiple dimensions of gender identity, and to assess gender identity across time.

Psychological symptoms and body image in individuals with gender dysphoria: A comparison between Iranian and Dutch clinics

Background: Few studies have compared the psychological functioning of individuals with gender dysphoria in Western and non-Western cultures. To our knowledge, this is the first study comparing the mental health of transgender individuals from an Islamic and non-Islamic country (Iran and the Netherlands). Methods: In this study, the psychological functioning and body image of 163 individuals with gender dysphoria (100 transgender women (75 in the Netherlands, 25 in Iran) and 63 transgender men (45 in the Netherlands, 18 in Iran) in two clinics located in Iran (N = 43) and the Netherlands (N = 120) was evaluated using the SCL-90 and the Body Image Scale (BIS). Also, none of these individuals had yet received hormonal therapy and/or surgery in their clinics. Results: Dutch participants (M = 31.56, SD = 12.26) were older than Iranian participants (M = 25.21, SD = 3.04). Dutch transwomen were less often androphilic (sexually attracted to men) than Iranian transwomen, and Iranian trans people were more often bisexual than the Dutch trans people. Significantly more Dutch transgender people were married (we had no information about the gender of the spouse), and indicated to have more contact with their families than the participants in Iran. The participants from Iran had significantly more psychological complaints than the Dutch participants. Compared to participants in Iran, participants in the Netherlands were more dissatisfied with their secondary sexual characteristics and neutral body characteristics, but there was no significant difference between the countries in terms of satisfaction with primary sex characteristics. Conclusions: Although transgender people in many countries face social and mental health problems, this study suggests that socio-cultural factors may increase the likelihood of psychopathology.

How Should Physicians Help Gender-Transitioning Adolescents Consider Potential Iatrogenic Harms of Hormone Therapy?

Counseling and treatment of transgender youth can be challenging for mental health practitioners, as increased availability of gender-affirming treatments in recent years raises ethical and clinical questions. Is a gender identity diagnosis helpful? What is the right time to treat, and should the adolescent's age matter in decision making? In this article, we discuss these questions in light of a case in which an adolescent wishes to pursue hormone therapy. Our analysis focuses on the importance of balanced decision making when counseling and treating adolescents with nonconforming gender identities. We argue that clinicians' communicating appropriate expectations about the effectiveness and limitations of hormone therapy and the risks of psychological and physical iatrogenic effects is critical.

Do sex differences in CEOAEs and 2D:4D ratios reflect androgen exposure? A study in women with complete androgen insensitivity syndrome

Background

Studies investigating the influence of perinatal hormone exposure on sexually differentiated traits would greatly benefit from biomarkers of these early hormone actions. Click-evoked otoacoustic emissions show sex differences that are thought to reflect differences in early androgen exposure. Women with complete androgen insensitivity syndrome (CAIS), who lack androgen action in the presence of XY-chromosomes, enabled us to study the effect of complete androgen inaction. The main goal was to investigate a possible link between click-evoked otoacoustic emissions and effective androgen exposure and, thus, whether this can be used as a biomarker. In addition, we aimed to replicate the only previous 2nd vs 4th digit-ratio study in women with CAIS, because despite the widely expressed criticisms of the validity of this measure as a biomarker for prenatal androgen exposure, it still is used for this purpose.

Methods

Click-evoked otoacoustic emissions and digit ratios from women with CAIS were compared to those from control men and women.

Results

The typical sex differences in click-evoked otoacoustic emissions and digit ratios were replicated in the control groups. Women with CAIS showed a tendency towards feminine, i.e., larger, click-evoked otoacoustic emission amplitudes in the right ear, and a significant female-typical, i.e., larger, digit ratio in the right hand. Although these results are consistent with androgen-dependent development of male-typical click-evoked otoacoustic emission amplitude and 2nd to 4th digit ratios, the within-group variability of these two measures was not reduced in women with CAIS compared with control women.

Conclusions

In line with previous studies, our findings in CAIS women suggest that additional, non-androgenic, factors mediate male-typical sexual differentiation of digit ratios and click-evoked otoacoustic emissions. Consequently, use of these measures in adults as retrospective markers of early androgen exposure is not recommended.

Sexual and Romantic Experiences of Transgender Youth Before Gender-Affirmative Treatment

OBJECTIVE

In various Western countries early medical gender-affirmative treatment has become increasingly available for transgender adolescents. Research conducted before the start of medical gender-affirming treatment has focused on psychological and social functioning, and knowledge about the sexual health of this specific young group is lacking.

METHODS

Gender identity clinics referred 137 adolescents: 60 transgirls (birth-assigned boys, mean age 14.11 years, SD 2.21) and 77 transboys (birth assigned girls, mean age 15.14 years, SD 2.09; P = .05). A questionnaire on sexual experiences (kissing, petting while undressed, sexual intercourse), romantic experiences (falling in love, romantic relationships), sexual orientation, negative sexual experiences, and sexual satisfaction was administered. Experiences of the transgender adolescents were compared with data for same-aged youth of a Dutch general population study (N = 8520).

RESULTS

Of the transgender adolescents, 77% had fallen in love, 50% had had a romantic relationship, 26% had experienced petting while undressed, and 5% had had sexual intercourse. Transboys had more sexual experience than transgirls. In comparison with the general population, transgender adolescents were both sexually and romantically less experienced.

CONCLUSIONS

Despite challenges, transgender adolescent are sexually active, although to a lesser extent than their peers from the general population.

Gender Incongruence of Childhood: Clinical Utility and Stakeholder Agreement with the World Health Organization's Proposed ICD-11 Criteria

The World Health Organization (WHO) is revising the tenth version of the International Classification of Diseases and Related Health Problems (ICD-10). This includes a reconceptualization of the definition and positioning of Gender Incongruence of Childhood (GIC). This study aimed to: 1) collect the views of transgender individuals and professionals regarding the retention of the diagnosis; 2) see if the proposed GIC criteria were acceptable to transgender individuals and health care providers; 3) compare results between two countries with two different healthcare systems to see if these differences influence opinions regarding the GIC diagnosis; and 4) determine whether healthcare providers from high-income countries feel that the proposed criteria are clinically useful and easy to use. A total of 628 participants were included in the study: 284 from the Netherlands (NL; 45.2%), 8 from Flanders (Belgium; 1.3%), and 336 (53.5%) from the United Kingdom (UK). Most participants were transgender people (or their partners/relatives; TG) (n = 522), 89 participants were healthcare providers (HCPs) and 17 were both HCP and TG individuals. Participants completed an online survey developed for this study. Overall, the majority response from transgender participants (42.9%) was that if the diagnosis would be removed from the mental health chapter it should also be removed from the ICD-11 completely, while 33.6% thought it should remain in the ICD-11. Participants were generally satisfied with other aspects of the proposed ICD-11 GIC diagnosis: most TG participants (58.4%) thought the term Gender Identity Disorder should change, and most thought Gender Incongruence was an improvement (63.0%). Furthermore, most participants (76.1%) did not consider GIC to be a psychiatric disorder and placement in a separate chapter dealing with Gender and Sexual Health (the majority response in the NL and selected by 37.5% of the TG participants overall) or as a Z-code (the majority response in the UK and selected by 26.7% of the TG participants overall) would be preferable. In the UK, the majority response (35.8%) was that narrowing the GIC diagnosis was an improvement, while the NL majority response (49.5%) was that this was not an improvement. Although generally the results from HCPs were in line with the results from TG participants some differences were found. This study suggests that, although in an ideal world a diagnosis is not welcomed, several participants felt the diagnosis should not be removed. This is likely due to concerns about restricting access to reimbursed healthcare. The choice for positioning of a diagnosis of GIC within the ICD-11 was as a separate chapter dealing with symptoms and/or disorders regarding sexual and gender health. This was the overall first choice for NL participants and second choice for UK participants, after the use of a Z-code. The difference reflects that in the UK, Z-codes carry no negative implications for reimbursement of treatment costs. These findings highlight the challenges faced by the WHO in their attempt to integrate research findings from different countries, with different cultures and healthcare systems in their quest to create a manual that is globally applicable.

Gender dysphoria in childhood

Gender dysphoria (GD) in childhood is a complex phenomenon characterized by clinically significant distress due to the incongruence between assigned gender at birth and experienced gender. The clinical presentation of children who present with gender identity issues can be highly variable; the psychosexual development and future psychosexual outcome can be unclear, and consensus about the best clinical practice is currently under debate. In this paper a clinical picture is provided of children who are referred to gender identity clinics. The clinical criteria are described including what is known about the prevalence of childhood GD. In addition, an overview is presented of the literature on the psychological functioning of children with GD, the current knowledge on the psychosexual development and factors associated with the persistence of GD, and explanatory models for psychopathology in children with GD together with other co-existing problems that are characteristic for children referred for their gender. In light of this, currently used treatment and counselling approaches are summarized and discussed, including the integration of the literature detailed above.

Gender Incongruence of Adolescence and Adulthood: Acceptability and Clinical Utility of the World Health Organization's Proposed ICD-11 Criteria

The World Health Organization (WHO) is currently updating the tenth version of their diagnostic tool, the International Classification of Diseases (ICD, WHO, 1992). Changes have been proposed for the diagnosis of Transsexualism (ICD-10) with regard to terminology, placement and content. The aim of this study was to gather the opinions of transgender individuals (and their relatives/partners) and clinicians in the Netherlands, Flanders (Belgium) and the United Kingdom regarding the proposed changes and the clinical applicability and utility of the ICD-11 criteria of 'Gender Incongruence of Adolescence and Adulthood' (GIAA). A total of 628 participants were included in the study: 284 from the Netherlands (45.2%), 8 from Flanders (Belgium) (1.3%), and 336 (53.5%) from the UK. Most participants were transgender people (or their partners/relatives) (n = 522), 89 participants were healthcare providers (HCPs) and 17 were both healthcare providers and (partners/relatives of) transgender people. Participants completed an online survey developed for this study. Most participants were in favor of the proposed diagnostic term of 'Gender Incongruence' and thought that this was an improvement on the ICD-10 diagnostic term of 'Transsexualism'. Placement in a separate chapter dealing with Sexual- and Gender-related Health or as a Z-code was preferred by many and only a small number of participants stated that this diagnosis should be excluded from the ICD-11. In the UK, most transgender participants thought there should be a diagnosis related to being trans. However, if it were to be removed from the chapter on "psychiatric disorders", many transgender respondents indicated that they would prefer it to be removed from the ICD in its entirety. There were no large differences between the responses of the transgender participants (or their partners and relatives) and HCPs. HCPs were generally positive about the GIAA diagnosis; most thought the diagnosis was clearly defined and easy to use in their practice or work. The duration of gender incongruence (several months) was seen by many as too short and required a clearer definition. If the new diagnostic term of GIAA is retained, it should not be stigmatizing to individuals. Moving this diagnosis away from the mental and behavioral chapter was generally supported. Access to healthcare was one area where retaining a diagnosis seemed to be of benefit.

Poor peer relations predict parent- and self-reported behavioral and emotional problems of adolescents with gender dysphoria: a cross-national, cross-clinic comparative analysis

This study is the third in a series to examine behavioral and emotional problems in children and adolescents with gender dysphoria in a comparative analysis between two clinics in Toronto, Ontario, Canada and Amsterdam, the Netherlands. In the present study, we report Child Behavior Checklist (CBCL) and Youth Self-Report (YSR) data on adolescents assessed in the Toronto clinic (n = 177) and the Amsterdam clinic (n = 139). On the CBCL and the YSR, we found that the percentage of adolescents with clinical range behavioral and emotional problems was higher when compared to the non-referred standardization samples but similar to the referred adolescents. On both the CBCL and the YSR, the Toronto adolescents had a significantly higher Total Problem score than the Amsterdam adolescents. Like our earlier studies of CBCL data of children and Teacher's Report Form data of children and adolescents, a measure of poor peer relations was the strongest predictor of CBCL and YSR behavioral and emotional problems in gender dysphoric adolescents.

Body Satisfaction and Physical Appearance in Gender Dysphoria

Gender dysphoria (GD) is often accompanied by dissatisfaction with physical appearance and body image problems. The aim of this study was to compare body satisfaction with perceived appearance by others in various GD subgroups. Data collection was part of the European Network for the Investigation of Gender Incongruence. Between 2007 and 2012, 660 adults who fulfilled the criteria of the DSM-IV gender identity disorder diagnosis (1.31:1 male-to-female [MtF]:female-to-male [FtM] ratio) were included into the study. Data were collected before the start of clinical gender-confirming interventions. Sexual orientation was measured via a semi-structured interview whereas onset age was based on clinician report. Body satisfaction was assessed using the Body Image Scale. Congruence of appearance with the experienced gender was measured by means of a clinician rating. Overall, FtMs had a more positive body image than MtFs. Besides genital dissatisfaction, problem areas for MtFs included posture, face, and hair, whereas FtMs were mainly dissatisfied with hip and chest regions. Clinicians evaluated the physical appearance to be more congruent with the experienced gender in FtMs than in MtFs. Within the MtF group, those with early onset GD and an androphilic sexual orientation had appearances more in line with their gender identity. In conclusion, body image problems in GD go beyond sex characteristics only. An incongruent physical appearance may result in more difficult psychological adaptation and in more exposure to discrimination and stigmatization.

Partial Treatment Requests and Underlying Motives of Applicants for Gender Affirming Interventions

INTRODUCTION

Historically, only individuals with a cross-gender identity who wanted to receive a full treatment, were eligible for "complete sex reassignment" consisting of feminizing/masculinizing hormone treatment and several surgical interventions including genital surgery (full treatment). Currently, it is unclear what motives underlie a request for hormones only or surgery only or a combination of hormones and surgery (e.g., a mastectomy), but no genital surgery (partial treatment).

AIMS

The aims of this study were (i) to describe treatment requests of applicants at a specialized gender identity clinic in the Netherlands; and (ii) to explore the motives underlying a partial treatment request, including the role of (non-binary) gender identity.

METHODS

Information was collected on all 386 adults who applied for treatment at the Center of Expertise on Gender Dysphoria of the VU University Medical Center in Amsterdam, the Netherlands, in the year 2013. Treatment requests were available for 360 individuals: 233 natal men (64.7%) and 127 natal women (35.3%). Treatment requests were systematically collected during assessment. Individuals were classified as either desiring a full or partial treatment. The motives behind a partial treatment request were collected and categorized as well.

RESULTS

The majority of applicants at our gender identity clinic requested full treatment. Among those who requested partial treatment, the most reported underlying motive was surgical risks/outcomes. Only a small number of applicants requested partial treatment to bring their body into alignment with their non-binary gender identity.

CONCLUSION

It becomes clear that partial treatment is requested by a substantial number of applicants. This emphasizes the need for gender identity clinics to provide information about the medical possibilities and limitations, and careful introduction and evaluation of non-standard treatment options.

Young adult psychological outcome after puberty suppression and gender reassignment

BACKGROUND

In recent years, puberty suppression by means of gonadotropin-releasing hormone analogs has become accepted in clinical management of adolescents who have gender dysphoria (GD). The current study is the first longer-term longitudinal evaluation of the effectiveness of this approach.

METHODS

A total of 55 young transgender adults (22 transwomen and 33 transmen) who had received puberty suppression during adolescence were assessed 3 times: before the start of puberty suppression (mean age, 13.6 years), when cross-sex hormones were introduced (mean age, 16.7 years), and at least 1 year after gender reassignment surgery (mean age, 20.7 years). Psychological functioning (GD, body image, global functioning, depression, anxiety, emotional and behavioral problems) and objective (social and educational/professional functioning) and subjective (quality of life, satisfaction with life and happiness) well-being were investigated.

RESULTS

After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. Well-being was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being.

CONCLUSIONS

A clinical protocol of a multidisciplinary team with mental health professionals, physicians, and surgeons, including puberty suppression, followed by cross-sex hormones and gender reassignment surgery, provides gender dysphoric youth who seek gender reassignment from early puberty on, the opportunity to develop into well-functioning young adults.