Assessment of Transgender and Gender-Diverse Adolescents: Incorporating the World Professional Association of Transgender Health Standard of Care 8th Edition.

This article provides an overview of the World Professional Association of Transgender Health (WPATH) Standard of Care 8th edition (SOC8) recommendations for adolescents seeking gender-affirming care. SOC8 was the first iteration of the guidelines to employ a Delphi consensus process that required 75% agreement of 120 multidisciplinary international transgender health experts for approval of its recommendations. While the evidence base for adolescent care is evolving, gender-affirming treatment is medically necessary and promotes long-term psychological wellbeing. The guidelines emphasize the importance of an assessment to determine maturity and decision-making capacity for treatments that have long-term body implications.

Expanding upon the relationship between gender-affirming hormone therapy, neural connectivity, mental health, and body image dissatisfaction.

OBJECTIVE: Transgender/non-binary (TNB) youth are at increased risk for anxiety, depression, and suicidality compared to cisgender youth. Gender affirming hormone therapy (GAHT, i.e., testosterone or estrogen) is a standard of care option for TNB youth, and we have recently shown that GAHT (testosterone) in transgender youth assigned a female sex at birth is associated with reductions in internalizing symptomatology. The current analysis explores: 1) whether these benefits are observed in both TNB youth assigned female at birth (TNBAFAB) and TNB youth assigned male at birth (TNBAMAB) and 2) the extent to which body image dissatisfaction and alteration in neural circuitry relate to internalizing symptoms. METHOD: The current study is an expansion of a previous publication from our lab that explored the association between gender-affirming testosterone and internalizing symptomatology. While participants in our previous study consisted of 42 TNBAFAB youth, participants in the current study included adolescent TNBAFAB receiving GAHT (n = 21; GAHT+) and not receiving GAHT (n = 29; GAHT-) as well as adolescent GAHT+ TNBAMAB (n = 15) and GAHT- TNBAMAB (n = 17). Participants reported symptoms of trait and social anxiety, depression, suicidality in the past year, and body image dissatisfaction. Brain activation was measured during a face processing task designed to elicit amygdala activation during functional MRI. RESULTS: GAHT+ TNBAFAB had significantly lower rates of social anxiety, depression, and suicidality compared to GAHT- TNBAFAB. While there were no significant relationships between estrogen and depression and anxiety symptoms, longer duration of estrogen was related to less suicidality. Both testosterone and estrogen administration were related to significantly lower rates of body image dissatisfaction compared to GAHT- youth. No significant differences emerged for BOLD response in the left or right amygdala during the face processing task, however, there was a significant main effect of GAHT on functional connectivity between the right amygdala and the ventromedial prefrontal cortex, such that GAHT+ youth had stronger co-activation between the two regions during the task. Body image dissatisfaction, greater functional connectivity, their interaction effect, and age predicted depression symptomatology and body image dissatisfaction additionally predicted suicidality in the past year. CONCLUSION: The current study suggests that GAHT is associated with fewer short-term internalizing symptoms in TNBAFAB than in TNBAMAB, although internalizing symptoms among TNBAMAB may diminish with longer durations of estrogen treatment. Controlling for age and sex assigned at birth, our findings indicate that less body image dissatisfaction and greater functional connectivity between the amygdala and ventromedial prefrontal cortex were both predictors of fewer levels of internalizing symptoms following GAHT.

Associations Among Gender-Affirming Hormonal Interventions, Social Support, and Transgender Adolescents' Mental Health.

PURPOSE: We aimed to examine the concurrent associations of gender-affirming hormonal interventions (i.e., puberty blockers, testosterone, estrogen), as well as family and friend social support, on transgender and nonbinary (TNB) adolescents' reports of anxiety symptoms, depressive symptoms, nonsuicidal self-injury (NSSI), and suicidality. We hypothesized that gender-affirming hormonal interventions and greater social support would be associated with lower levels of mental health concerns. METHODS: Participants (n = 75; aged 11-18; Mage = 16.39 years) were recruited for this cross-sectional study from a gender-affirming multidisciplinary clinic. Fifty-two percent were receiving gender-affirming hormonal interventions. Surveys assessed anxiety and depressive symptoms, NSSI and suicidality in the past year, and social support from family, friends, and significant others. Hierarchical linear regression models examined associations between gender-affirming hormonal interventions and social support (i.e., family, friend) with mental health while accounting for nonbinary gender identity. RESULTS: Regression models explained 15%-23% of variance in TNB adolescents' mental health outcomes. Gender-affirming hormonal interventions were associated with fewer anxiety symptoms (ß = -0.23; p < .05). Family support was associated with fewer depressive symptoms (ß = -0.33; p = .003) and less NSSI (ß = -0.27; p = .02). Friend support was associated with fewer anxiety symptoms (ß = -0.32; p = .007) and less suicidality (ß = -0.25; p = .03). DISCUSSION: TNB adolescents had better mental health outcomes in the context of receiving gender-affirming hormonal interventions and having greater support from family and friends. Findings highlight the important role of quality family and friend support for TNB mental health. Providers should aim to address both medical and social factors to optimize TNB mental health outcomes.

Exogenous testosterone administration is associated with differential neural response to unfamiliar peer's and own caregiver's voice in transgender adolescents.

Changes in gonadal hormones during puberty are thought to potentiate adolescents' social re-orientation away from caregivers and towards peers. This study investigated the effect of testosterone on neural processing of emotional (vocal) stimuli by unfamiliar peers vs. parents, in transgender boys receiving exogenous testosterone as a gender-affirming hormone (GAH+) or not (GAH-). During fMRI, youth heard angry and happy vocal expressions spoken by their caregiver and an unfamiliar teenager. Youth also self-reported on closeness with friends and parents. Whole-brain analyses (controlling for age) revealed that GAH+ youth showed blunted neural response to caregivers' angry voices-and heightened response to unfamiliar teenage angry voices-in the anterior cingulate cortex. This pattern was reversed in GAH- youth, who also showed greater response to happy unfamiliar teenager vs. happy caregiver voices in this region. Blunted ACC response to angry caregiver voices-a pattern characteristic of GAH+ youth-was associated with greater relative closeness with friends over parents, which could index more "advanced" social re-orientation. Consistent with models of adolescent neurodevelopment, increases in testosterone during adolescence may shift the valuation of caregiver vs. peer emotional cues in a brain region associated with processing affective information.

The Gender Self-Report: A multidimensional gender characterization tool for gender-diverse and cisgender youth and adults.

Gender identity is a core component of human experience, critical to account for in broad health, development, psychosocial research, and clinical practice. Yet, the psychometric characterization of gender has been impeded due to challenges in modeling the myriad gender self-descriptors, statistical power limitations related to multigroup analyses, and equity-related concerns regarding the accessibility of complex gender terminology. Therefore, this initiative employed an iterative multi-community-driven process to develop the Gender Self-Report (GSR), a multidimensional gender characterization tool, accessible to youth and adults, nonautistic and autistic people, and gender-diverse and cisgender individuals. In Study 1, the GSR was administered to 1,654 individuals, sampled through seven diversified recruitments to be representative across age (10-77 years), gender and sexuality diversity (∼33% each gender diverse, cisgender sexual minority, cisgender heterosexual), and autism status (> 33% autistic). A random half-split subsample was subjected to exploratory factor analytics, followed by confirmatory analytics in the full sample. Two stable factors emerged: Nonbinary Gender Diversity and Female-Male Continuum (FMC). FMC was transformed to Binary Gender Diversity based on designated sex at birth to reduce collinearity with designated sex at birth. Differential item functioning by age and autism status was employed to reduce item-response bias. Factors were internally reliable. Study 2 demonstrated the construct, convergent, and ecological validity of GSR factors. Of the 30 hypothesized validation comparisons, 26 were confirmed. The GSR provides a community-developed gender advocacy tool with 30 self-report items that avoid complex gender-related "insider" language and characterize diverse populations across continuous multidimensional binary and nonbinary gender traits. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Care of Gender Diverse Youth with Obesity.

PURPOSE OF REVIEW: The relationships between gender identity, body image, and gender expression are complex, requiring a gender affirming approach to address weight management. This purpose of this review is to describe the essentials to caring for gender diverse youth, as well as the differences and intersections among those with obesity. RECENT FINDINGS: Gender-affirming hormone therapy may lead to abnormal weight gain and increased body mass index, or worsen obesity and exacerbate weight-related complications. Moreover, given the high prevalence of victimization, marginalization, and stigmatization among gender diverse people and youth with obesity, care guidelines and treatment goals should also include reducing the negative impact of social-related complications. Despite the overlap in clinical care and lived experiences that impact the health of gender diverse youth with obesity, there is very little research to help guide clinicians. Careful attention to medical and behavioral comorbidities, barriers to care, and health disparities can inform clinical practice. Future research that specifically addresses nuances to care for gender diverse youth with obesity can help to establish standards of care to address their unmet needs and further support clinicians, patients and their families.

Transgender Youth Executive Functioning: Relationships with Anxiety Symptoms, Autism Spectrum Disorder, and Gender-Affirming Medical Treatment Status.

Executive function (EF) underlies broad health and adaptive outcomes. For transgender youth, navigating gender discernment and gender affirmation demand EF. Yet, factors associated with transgender youth EF are unknown. We investigate hypothesized predictors of EF: over-represented conditions among transgender youth (anxiety and depression symptoms, autism spectrum disorder [ASD]) and gender-affirming care. One-hundred twenty-four transgender 11-21-year-olds participated. Parents/caregivers completed EF and mental health report measures. ASD diagnostics and gender-affirming medication histories were collected. 21 % of non-autistic and 69 % of autistic transgender youth had clinically elevated EF problems. Membership in the gender-affirming hormone treatment group was associated with better EF. ASD, anxiety symptoms, and membership in the long-duration pubertal suppression group were associated with poorer EF. Given the importance of EF skills for multiple outcomes, and the unique and additional EF demands specific to transgender youths' experiences, EF skill monitoring-and when appropriate, supports-should be considered for transgender youth.

Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys.

OBJECTIVE: Many transgender adolescents experience clinically elevated anxiety and depression. Testosterone (T), used as a gender affirming treatment, may reduce symptoms of anxiety and depression. We assessed the effect of gender affirming T treatment on internalizing symptoms, body image dissatisfaction, and activation patterns within the amygdala-prefrontal cortex circuit in transgender adolescent boys. METHOD: Symptoms of generalized anxiety, social anxiety, depression, suicidality and body image dissatisfaction were measured by self-report and brain activation was measured during a face processing task with functional MRI in a group of 19 adolescent transgender boys receiving T treatment and 23 not receiving gonadal hormone treatment (UT). RESULTS: Severity of anxiety and depression was significantly lower in the T treated group relative to the UT group, along with a trend of lower suicidality. The T group also reported less distress with body features and exhibited stronger connectivity within the amygdala-prefrontal cortex circuit compared to the UT group. Finally, group differences on depression and suicidality were directly associated with body image dissatisfaction, and anxiety symptoms were moderated by amygdala-prefrontal cortex connectivity differences between groups. CONCLUSION: T treatment is associated with lower levels of internalizing symptoms among transgender adolescent boys. T is also associated with greater body satisfaction and greater connectivity in a neural circuit associated with anxiety and depression. Satisfaction with body image was found to overlap with the association between T and both depression and suicidality, and amygdala-prefrontal co-activation moderated the role of T on anxiety.

Revisiting the Link: Evidence of the Rates of Autism in Studies of Gender Diverse Individuals.

Turban and van Schalkwyk assert in their Translations article, "'Gender Dysphoria' and Autism Spectrum Disorder: Is the Link Real?" that an over-representation of autism spectrum disorder (ASD) in gender dysphoria is unsupported based on current evidence. Turban and van Schalkwyk discuss 7 of the currently 19 available empirical studies (excluding reviews and case reports) of the over-occurrence of ASD and/or autism traits with gender dysphoria/diversity. They are correct to note that some ASD screeners may lack specificity; that is, a clinical-range total score could indicate non-ASD-related mental health conditions or other developmental difference. However, they do not account for the 7 available studies which specifically report rates of clinical diagnoses of ASD among unselected gender-diverse samples. We suggest also that many of the studies that assess ASD-symptoms in gender-diverse groups are more convincing than suggested by Turban and van Schalkwyk because they employ measures assessing the multi-dimensionality of ASD symptoms and report significant elevations not only for socially-related symptoms but also for the various components of restricted and repetitive behaviors and interests (RRBI) core to ASD. We come together to write this response as gender clinicians and researchers, autism clinicians and researchers, and key stakeholders, including autistic and autistic transgender self-advocates. We work and live with the co-occurrence of autism and gender diversity on a daily basis, and we are concerned that perpetuating misunderstanding about the co-occurrence places individuals at risk.

"They Thought It Was an Obsession": Trajectories and Perspectives of Autistic Transgender and Gender-Diverse Adolescents.

Despite research exploring autism in gender-diverse adolescents, no studies have elicited these individuals' perspectives. In-depth interviews with 22 well-characterized autistic gender-diverse adolescents revealed critical themes, including: recollections of pre-pubertal gender nonconformity; vivid experiences of gender dysphoria; a fear of social gender expression due to perceived animosity toward transgender people; and specific challenges that result from the interplay of gender diversity and neurodiversity. During the ~ 22 month study social gender affirmation increased in six participants and gender dysphoria attenuated in four participants. Given the ethical imperative to understand and prioritize the voiced perspectives and needs of autistic gender minority adolescents as well as the discovery of shared themes and experiences in this population, results should inform clinical research approaches and priorities.

Lesbian, Gay, Bisexual, and Transgender Adolescent Health: An Interprofessional Case Discussion.

INTRODUCTION: Lesbian, gay, bisexual, and transgender (LGBT) adolescents frequently endure considerable adversity as they encounter identity-related stigma. As a result, LGBT adolescents are often at disproportionate risk for experiencing negative social and health outcomes. METHODS: This four-module curriculum allows learners to explore challenges common to the clinical care of LGBT adolescents while also providing exposure to current trends and evidence in LGBT health. Through a combination of reflective exercises, didactic lectures, foundational readings, facilitated case discussion, and debate, the curriculum introduces learners to issues of assessment, treatment, and support as they relate to LGBT youth. The curriculum was written for use with learners in an interprofessional training program representing the disciplines of medicine, nursing, nutrition, social work, and psychology. RESULTS: Four years of evaluation data indicate that the curriculum is particularly useful for exposing learners to the complexities of serving and supporting LGBT youth and identifying personal skills that may require additional development. Learners emerge with greater confidence in identifying local and national LGBT resources. DISCUSSION: Incorporating cultural humility is key to fostering a commitment to lifelong learning and maintaining learners' confidence when working with marginalized populations. Optimal discussion occurs when learners in all disciplines contribute, yet instructors can teach modules separately or modify them when learners from all disciplines are not present. In addition, learners emerge with greater confidence in connecting with outside resources, which assists both referrals for patients and self-directed learning.

Understanding gender variance in children and adolescents.

Gender variance is an umbrella term used to describe gender identity, expression, or behavior that falls outside of culturally defined norms associated with a specific gender. In recent years, growing media coverage has heightened public awareness about gender variance in childhood and adolescence, and an increasing number of referrals to clinics specializing in care for gender-variant youth have been reported in the United States. Gender-variant expression, behavior, and identity may present in childhood and adolescence in a number of ways, and youth with gender variance have unique health needs. For those experiencing gender dysphoria, or distress encountered by the discordance between biological sex and gender identity, puberty is often an exceptionally challenging time. Pediatric primary care providers may be families' first resource for education and support, and they play a critical role in supporting the health of youth with gender variance by screening for psychosocial problems and health risks, referring for gender-specific mental health and medical care, and providing ongoing advocacy and support.

Assessing gender identity concerns in children and adolescents: evaluation, treatments, and outcomes.

Child and adolescent psychiatrists are increasingly evaluating youth who present with gender-nonconforming behaviors and identities. The lack of discipline-specific guidelines has made assessment and treatment of children and adolescents presenting with these concerns more difficult. Several new guidelines have recently been published, and research efforts are advancing to broaden the scope of understanding of gender identity assessment and treatment in children and adolescents. Familiarity with the latest standards of care, recent research advances, and current knowledge gaps is important to help improve clinical competency in treating mental health issues in this population.

The development of a gender identity psychosocial clinic: treatment issues, logistical considerations, interdisciplinary cooperation, and future initiatives.

Few interdisciplinary treatment programs that tend to the needs of youth with gender nonconforming behaviors, expressions, and identities exist in academic medical centers with formal residency training programs. Despite this, the literature provides evidence that these youth have higher rates of poor psychosocial adjustment and suicide attempts. This article explores the logistical considerations involved in developing a specialized interdisciplinary service to these gender minority youth in accordance with the existing treatment guidelines.Demographic data will be presented and treatment issues will be explored. The impact that a specialized interdisciplinary treatment program has on clinical expansion, research development, education and training, and community outreach initiatives is discussed.

Improving medical education about gender-variant youth and transgender adolescents.

Gender minority children and adolescents present to a wide variety of health professionals for gender-related care and other care. However,few professionals may be prepared to meet their needs. Unprepared clinicians risk developing insufficient therapeutic rapport, missing salient information, and inadvertently contributing to risk. In this article the authors outline ways to address these gaps at all training levels to meet the needs of gender minority children and adolescents. They provide practical resources for colleagues interested in expanding education opportunities in their own community. In the end, competency in gender minority health should improve access to care for these youths.