Childhood Gender Diversity and Mental Health: Protocol for the Longitudinal, Observational Gender Journey Project.

BACKGROUND: Prepubertal transgender, nonbinary, and gender-diverse (TGD) children (ie, those asserting gender identity, expressing gender-role behavior outside of culturally defined norms for their sex registered at birth, or both) are presenting in greater numbers to pediatric gender clinics across the United States and abroad. A large subset of TGD children experiences gender dysphoria, that is, distress that arises from the incongruence between gender identity and sex registered at birth. A lack of consensus exists regarding care for prepubertal TGD children due, in part, to a dearth of empirical research on longitudinal developmental trajectories of gender identity, role behavior, and gender dysphoria (when present). OBJECTIVE: The objective of this National Institutes of Health-funded study is to provide evidence to inform clinical care for prepubertal TGD children by establishing a US longitudinal cohort (N=248) of prepubertal TGD children and their caregivers that is followed prospectively at 6-month intervals across 18 months. METHODS: At each timepoint, clinical and behavioral data are collected via web-based visit from child and caregiver reporters. Latent class analysis, among other methods, is used to identify subgroups and longitudinally characterize the gender identity and gender-role behavior of TGD children. These models will define longitudinal patterns of gender identity stability and characterize the relationship between TGD classes and mental and behavioral health outcomes, including the moderating role of social gender transition (when present), on these associations. RESULTS: Baseline data collection (N=248) is complete, and the identification of TGD subgroups based on gender identity and expression using latent class analysis is anticipated in 2024. The completion of all 4 waves of data collection is anticipated in July 2024, coinciding with the start of a no-cost study extension period. We anticipate longitudinal analyses to be completed by winter 2024. CONCLUSIONS: Through a longitudinal observational design, this research involving prepubertal TGD children and their caregivers aims to provide empirical knowledge on gender development in a US sample of TGD children, their mental health symptomology and functioning over time, and how family initiated social gender transition may predict or alleviate mental health symptoms or diagnoses. The research findings have promise for clinicians and families aiming to ensure the best developmental outcome for these children as they develop into adolescents. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55558.

Military Family Physicians' Readiness to Provide Gender-Affirming Care: A Serial Cross-Sectional Study.

PURPOSE: Family physicians are increasingly more likely to encounter transgender and gender-diverse (TGD) patients requesting gender-affirming care. Given the significant health inequities faced by the TGD community, this study aimed to assess changes in military-affiliated clinicians' perspectives toward gender-affirming care over time. METHODS: Using a serial cross-sectional survey design of physicians at the 2016 and 2023 Uniformed Services Academy of Family Physicians conferences, we studied participants' perception of, comfort with, and education on gender-affirming care using Fisher's Exact tests and logistic regression. RESULTS: Response rates were 68% (n = 180) and 69% (n = 386) in 2016 and 2023, respectively. Compared to 2016, clinicians in 2023 were significantly more likely to report receiving relevant education during training, providing care to >1 patient with gender dysphoria, and being able to provide nonjudgmental care. In 2023, 26% reported an unwillingness to prescribe gender-affirming hormones (GAH) to adults due to ethical concerns. In univariable analysis, female-identifying participants were more likely to report willingness to prescribe GAH (OR = 2.6, 95%CI = 1.7-4.1) than male-identifying participants. Willingness to prescribe was also associated with ≥4 h of education (OR = 2.2, 95%CI = 1.1-4.2) compared to those with fewer than 4 h, and those who reported the ability to provide nonjudgmental care compared to those who were neutral (OR = 0.09, 95%CI = 0.04-0.2) or disagreed (OR = 0.11, 95%CI = 0.03-0.39). Female-identifying clinicians were more likely to agree additional training would benefit their practice (OR = 5.3, 95%CI = 3.3-8.5). CONCLUSIONS: Although military-affiliated family physicians endorsed more experience with and willingness to provide nonjudgmental gender-affirming care in 2023 than 2016, profound gaps in patient experience may remain based on the assigned clinician. Additional training opportunities should be available, and clinicians unable to provide gender-affirming care should ensure timely referrals. Future research should explore trends across clinical specialties.

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 (ß = 1.75, p = .005, CI 0.53-2.97, R2 = .04 and ß = 4.20, p < .001, CI 2.99-5.40, R2 = .07, respectively) and Internalizing Problem (ß = 4.43, p < .001, CI 3.13-5.74, R2 = .06 and ß = 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 (ß = 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 (ß = 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.

Puberty suppression in adolescents with gender dysphoria: an emerging issue with multiple implications.

Controversy exists over puberty suppression (PS) in adolescents with gender dysphoria (GD). PS is preferentially achieved with GnRH analogues. By preventing the development of secondary sex characteristics, PS may improve psychological functioning, well-being, quality of life, emotional and behavioral (especially internalizing) problems and depressive symptoms, thus decreasing suicidality. PS can also extend the diagnostic period and give transgender adolescents time to explore their gender identity. GnRHa may also decrease the need for feminization/masculinization surgery. However, 2-year treatment with GnRHa may result in bone mass accrual retardation (decrease in BMD/BMAD z-scores), growth velocity deceleration (decrease in height SDS), increase in fat mass, temporary pause in oocyte/sperm maturation. The most common side effects of GnRHa are hot flashes, mood fluctuations, fatigue and headache. They are usually mild and rarely lead to GnRHa discontinuation. Based on current scientific evidence, PS could be recommended to adolescents who meet the diagnostic criteria of gender incongruence (by DSM-5 and/or ICD-11) and have long-lasting intense GD, which aggravates with puberty onset. Before initiating PS, possible mental issues should be addressed and informed consent (by the adolescent/caregiver) should be given, after counseling on probable reproductive effects of GnRHa. GnRHa can only be started after the adolescent has entered Tanner stage 2. Nevertheless, published studies are inadequate in number, small in size, uncontrolled and relatively short-term, so that it is difficult to draw safe conclusions on efficacy and safety of GnRHa. Large long-term randomized controlled trials are needed to expand knowledge on this controversial issue and elucidate the benefit and risks of PS.

Trans depathologisation and gender identity disorder in Japan: A critical discourse analysis of medical literature, 2010-2022.

Since the depathologisation movement in 2007 to challenge the pathologisation of trans identities in Western psychiatry, significant developments have occurred, including revisions to Standards of Care and diagnostic criteria such as ICD-11's gender incongruence and DSM-5's gender dysphoria, acknowledging gender diversity as an expected part of human development. This paper argues that Japanese medical models reflect global issues but also have unique aspects shaped by cultural and linguistic nuances. Using critical discourse analysis, this paper examines how depathologisation discourses are perceived in the Japanese medical community, focusing on the term seidouitsusei-syogai (gender identity disorder), presenting three ways in which seidouitsusei-syogai is used: psychiatric disorder, syogai/sikkan (impairment/disability/disorder), and diagnostic category. These uses are influenced by legal and social reforms, healthcare access and alignment with international classifications, while the medical profession's authority remains unexamined. Reflecting the structural challenges of diagnostic models in trans medicine, the interpretation of seidouitsusei-syogai differs from the English phrase 'gender identity disorder' due to the specific connotations of syogai in the Japanese context. By examining Japan's approach to depathologisation and medicalisation, this paper enriches the understanding of trans medicine and the impact of depathologisation discourse in Japan.

[The Sorrows of the Old from the Gender of the Young: A Commentary on Korte, A. & Tschuschke, V. (2023). Media's Stranglehold on Storm and Stress ­ The Sorrows of Generation Z about Sex and Gender]. / Die Leiden der Alten am Geschlecht der Jungen.

When Old People Suffer Because of the Sex of the Young: A Commentary on Korte, A. & Tschuschke, V. (2023). The Media's Stranglehold on Sturm und Drang - The Sorrows of Generation Z Regarding Sex and Gender Abstract: In their article "Sturm und Drang im Würgegriff der Medien - Die Leiden der jungen Generation am eigenen Geschlecht" in the Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (volume 51, issue 5), our colleagues Korte and Tschuschke address the question of the extent to which the increase in gender identity deviations among adolescents "also results from upheavals the cultural landscape and, above all, in media technology." The authors look critically at the planned German "Self-Determination Law," the social transition of children and adolescents, the so-called puberty blockade, and hormone therapy in adolescents and justify their preference for a gender-critical over a transaffirmative therapy approach. Although the article introduces some interesting hypotheses from the perspective of cultural studies and philosophy (among others), it may contribute to uncertainty among colleagues in treating trans*people because of its trans-critical tone. This stems from linguistic devices, misleading and erroneous quotations, and incomplete or incorrect descriptions of facts. This contribution therefore takes a critical look at the article by Korte and Tschuschke, using critical linguistic analysis and examining the facts, data, and sources cited by the authors. It encourages our colleagues to engage in a joint, participatory, trans*respectful treatment process with gender-dysphoric children and adolescents while exploring the sizeable intermediate area between "gender-critical" and "transaffirmative" attitudes, which the authors Korte and Tschuschke barely touch on in their article.

Differences in Subjective Transition Outcomes Between Transgender and Gender-Diverse Individuals Who Completed Mandatory Psychiatric Assessment and Those Who Received Gender-Affirmative Medical Treatment in Croatia: A Cross-Sectional Online Survey.

The aim of this study was to evaluate different aspects of transition outcomes in groups of transgender and gender diverse (TGD) people based on their transition status. We divided the 70 TGD participants (19 individuals assigned male at birth and 51 assigned female at birth) into two groups: those who had completed their psychiatric and psychological evaluation (PPE), which is mandatory in Croatia, and those who had undergone gender-affirming medical treatment (GAMT) (both gender-affirming hormone treatment and gender-affirming surgery). The online survey included sociodemographic questions and a custom-designed nine-item scale. The items were specifically designed based on the DSM-5-TR criteria for gender dysphoria to assess subjectively perceived transition outcomes. We conducted a factor analysis of the scale followed by structural equation modeling for confirmation. Chi-squared and Mann-Whitney U tests were used to compare group differences. The following three-factor structure was confirmed: better functioning, reduced body dysphoria, and satisfaction with decision. A positive influence of better functioning on satisfaction with the decision was found. In addition, our results showed that TGD individuals who had undergone GAMT scored higher on better functioning than those who had just completed PPE. Both groups consistently scored high on satisfaction with the decision, with no statistically significant differences between them. Our findings suggest that TGD individuals view gender-affirming medical care as beneficial to their overall functioning.

Association between genital gender-affirming surgery and psychiatric comorbidities in individuals with gender incongruence.

BACKGROUND: Previous studies present mixed evidence on the relationship between psychiatric comorbidities and genital gender-affirming surgery (GGAS) in individuals with gender incongruence (GI). AIM: This research aims to investigate the psychiatric comorbidity rates post-GGAS in the GI population-namely, depressive disorders, anxiety disorders, posttraumatic stress disorders, substance abuse disorder, and suicidality. METHODS: Based on the TriNetX health care database, an international database with >250 million patients, a cross-sectional study was executed comparing psychiatric comorbidity rates among cases of GI with and without GGAS. Individuals were matched for demographic and health-related variables, which included history of cardiovascular disease, diabetes, and obesity. OUTCOMES: The main focus was to establish the rates and changes in psychiatric comorbidities following GGAS. RESULTS: Among individuals with GI, the study identified 4061 with GGAS and 100 097 without. At 1 year post-GGAS, there was a significant decrease in depression (odds ratio [OR], 0.748; 95% CI, 0.672-0.833; P < .0001), anxiety (OR, 0.730; 95% CI, 0.658-0.810; P < .0001), substance use disorder (OR, 0.730; 95% CI, 0.658-0.810; P < .0001), and suicidality (OR, 0.530; 95% CI, 0.425-0.661; P < .0001), and these reductions were maintained or improved on at 5 years, including posttraumatic stress disorder (OR, 0.831; 95% CI, 0.704-0.981; P = .028). CLINICAL IMPLICATIONS: The findings indicate that GGAS may play a crucial role in diminishing psychiatric comorbidities among individuals with GI. STRENGTHS AND LIMITATIONS: This is the largest known study to evaluate the effect of GGAS on psychiatric comorbidities in the GI population, offering robust evidence. The reliance on the precision of CPT and ICD-10 codes for data extraction poses a limitation due to potential coding inaccuracies. CONCLUSION: The evidence suggests a significant association between GGAS and reduced psychiatric comorbidities in individuals with GI.

Getting old in the desired gender: a systematic review on aging diseases in transgender people.

INTRODUCTION: The growing demographic presence of the transgender (TGD) population has sparked an increase in clinical investigations focusing on the impacts of gender-affirming hormone therapy (GAHT) in adults with gender dysphoria. Despite this surge in studies, there remains a significant gap in the literature regarding the health status of older TGD individuals. This review aims to assess prevalent pathological conditions within the TGD population, specifically concentrating on aging-related diseases investigated to date. METHODS: A systematic search across Embase Ovid, Scopus, PubMed, Cochrane Library, and Web of Science databases was conducted to identify articles reporting on the aging process in TGD individuals. Methodological quality was evaluated using Newcastle-Ottawa Scale (NOS) scores. RESULTS: Initial database searches yielded 12,688 studies, which were refined to 18 through elimination of duplicates and title/abstract review. Following a comprehensive appraisal, nine studies were included in the systematic review. These articles, published between 2017 and 2023, involved a total of 5403 participants. The evidence indicates a noteworthy percentage of the TGD population being at risk for cardiovascular diseases, experiencing depression or disability, and demonstrating hesitancy toward major recommended screening programs. CONCLUSIONS: Limited studies on older TGD individuals highlight not only an organic risk of chronic diseases but also a cognitive/psychiatric risk that should not be underestimated. Further research is imperative to deepen our understanding of the pathophysiological mechanisms involved in the health challenges faced by older TGD individuals.

Paediatric gender medicine: Longitudinal studies have not consistently shown improvement in depression or suicidality.

AIM: Systematic literature reviews have found the evidence for hormonal interventions in paediatric-age patients with gender dysphoria is of low certainty. Studies in this field have all been observational, and generally of low quality. Nevertheless, some experts assert that the observational studies in this field have consistently found improvement in mental health, and therefore constitute sufficient evidentiary basis for hormonal interventions. The present review sought to characterise results of the longitudinal clinical research studies that have reported depression and suicidality outcomes. METHODS: The present review collated, from examination of six existing reviews, 14 longitudinal clinical research studies that have specifically investigated depression and/or suicidality outcomes. RESULTS: Significantly positive depression outcomes were reported in six studies, and significantly positive suicidality outcomes in two studies. Outcomes were negative in the largest study. Notably, some studies articulated positive conclusions about hormonal interventions even in the setting of insignificant, small or negative findings. CONCLUSIONS: Analysis of longitudinal clinical research in this field showed inconsistent demonstration of benefit with respect to depression and suicidality. This analysis suggests that, contrary to assertions of some experts and North American professional medical organisations, the impact of hormonal interventions on depression and suicidality in this population is unknown.

What is the Purpose of the Initial Psychiatric Evaluation of Minors with Gender Dysphoria.

The rising incidence of trans youth throughout the world and the new policy of many European countries and 25 US states that psychotherapy should be the first therapeutic response to Gender Dysphoria have made a reexamination of a comprehensive psychiatric evaluation (CPE) urgently relevant. Two conflicting views of the purpose of the CPE exist based on etiologic beliefs and convictions about the best therapeutic approach. This paper provides one clinician's synthesis of the elements, processes, goals, values, benchmarks of CPE and its usual recommendation for psychotherapy. The CPE recommended herein provides cogent hypotheses about the origins of the intrapsychic creation of a trans identity that are to be strengthened, weakened, or supplanted by explanations that emerge from psychotherapy. It also strengthens familial bonds and clarifies the intention to improve the mental health, social function, and autonomy of the minor. The inescapable ethical tensions that surround trans minor health care are discussed. The recommended CPE does not prevent subsequent medical interventions.

A Systematic Review of Gender Dysphoria Measures in Autistic Samples.

This systematic review investigated how studies have measured gender dysphoria (GD) in autistic samples and the impact of using different measures on study results. The literature search identified 339 relevant papers, with 12 of them meeting the inclusion criteria. Results showed that seven different measures of GD characteristics have been used with autistic samples and that the studies consistently reported a greater number of GD characteristics and a greater severity of GD in autistic compared to non-autistic samples. Methodological common practices were found in recruiting participants from clinical settings rather than the general population, having more autistic males than females in the samples, for studies being conducted in Europe, North America, and Oceania, and using single-item measures of GD for samples of autistic children. Issues were identified with study designs and measures of GD, suggesting a need for a more standardized multi-item self-report measure of GD for use in clinical and non-clinical samples across different ages and cultures.

Tran in April: The Analysis of A Transgender Adolescent With Notes on the Metapsychology of Gender Transition.

The aim of this article is twofold: firstly, to describe the seven-year analytic treatment of a TG adolescent (F "April" to M "Tran") and, secondly, based on the clinical observations, to propose a reflection on the intrapsychic events linked to gender transition. We could witness during this analysis that the dissonant anatomical sex, which is at the heart of the gender dysphoria, resists mentalization and consequently its psychological integration. The psychic events of transition, understood here on the model of a mourning process, could denote the various strategies necessary to the TG individual to negotiate the obstacle of mentalization.

Prevalence of Gender-Affirming Surgical Procedures Among Minors and Adults in the US.

This cross-sectional study uses a national dataset to examine the prevalence of gender-affirming surgical procedures among minors and adults in the US.