Is Social Gender Transition Associated with Mental Health Status in Children and Adolescents with Gender Dysphoria?

Social gender transition is an increasingly accepted intervention for gender variant children and adolescents. To date, there is scant literature comparing the mental health of children and adolescents diagnosed with gender dysphoria who have socially transitioned versus those who are still living in their birth-assigned gender. We examined the mental health of children and adolescents referred to the Gender Identity Development Service (GIDS), a specialist clinic in London, UK, who had socially transitioned (i.e., were living in their affirmed gender and/or had changed their name) versus those who had not socially transitioned. Referrals to the GIDS were aged 4-17 years. We assessed mental health correlates of living in one's affirmed gender among 288 children and adolescents (208 birth-assigned female; 210 socially transitioned) and of name change in 357 children and adolescents (253 birth-assigned female; 214 name change). The presence or absence of mood and anxiety difficulties and past suicide attempts were clinician rated. Living in role and name change were more prevalent in birth-assigned females versus birth-assigned males. Overall, there were no significant effects of social transition or name change on mental health status. These findings identify the need for more research to understand how social transition influences mental health, including longitudinal studies that allow for more confident inferences to be made regarding the relationship between social transition and mental health in young people with gender dysphoria.

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.

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.

Time trends in referrals to child and adolescent gender identity services: a study in four Nordic countries and in the UK.

Purpose: To explore whether the increase observed in referrals to child and adolescent gender identity services (GIDSs) has been similar in four Nordic countries and in the UK.Materials and methods: Numbers of referrals per year in 2011-2017 were obtained from all GIDS in Denmark, Finland, Norway, Sweden and the UK and related to population aged <18.Results: A similar pattern of increase in referral rates was observed across countries, resulting in comparable population adjusted rates in 2017. In children, male:female birth sex ratio was even; in adolescents, a preponderance of females (birth sex) was observed, particularly in Finland.Conclusions: The demand for GIDSs has evolved similarly across Nordic countries and the UK. The reasons for the increase are not known but increased awareness of gender identity issues, service availability, destigmatization as well as social and media influences may play a role.

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.

Psychological functioning in adolescents referred to specialist gender identity clinics across Europe: a clinical comparison study between four clinics.

Adolescents seeking professional help with their gender identity development often present with psychological difficulties. Existing literature on psychological functioning of gender diverse young people is limited and mostly bound to national chart reviews. This study examined the prevalence of psychological functioning and peer relationship problems in adolescents across four European specialist gender services (The Netherlands, Belgium, the UK, and Switzerland), using the Child Behavioural Checklist (CBCL) and the Youth Self-Report (YSR). Differences in psychological functioning and peer relationships were found in gender diverse adolescents across Europe. Overall, emotional and behavioural problems and peer relationship problems were most prevalent in adolescents from the UK, followed by Switzerland and Belgium. The least behavioural and emotional problems and peer relationship problems were reported by adolescents from The Netherlands. Across the four clinics, a similar pattern of gender differences was found. Birth-assigned girls showed more behavioural problems and externalising problems in the clinical range, as reported by their parents. According to self-report, internalising problems in the clinical range were more prevalent in adolescent birth-assigned boys. More research is needed to gain a better understanding of the difference in clinical presentations in gender diverse adolescents and to investigate what contextual factors that may contribute to this.

Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria.

INTRODUCTION: Puberty suppression by gonadotropin-releasing hormone analogs (GnRHa) is prescribed to relieve the distress associated with pubertal development in adolescents with gender dysphoria (GD) and thereby to provide space for further exploration. However, there are limited longitudinal studies on puberty suppression outcome in GD. Also, studies on the effects of psychological support on its own on GD adolescents' well-being have not been reported. AIM: This study aimed to assess GD adolescents' global functioning after psychological support and puberty suppression. METHODS: Two hundred one GD adolescents were included in this study. In a longitudinal design we evaluated adolescents' global functioning every 6 months from the first visit. MAIN OUTCOME MEASURES: All adolescents completed the Utrecht Gender Dysphoria Scale (UGDS), a self-report measure of GD-related discomfort. We used the Children's Global Assessment Scale (CGAS) to assess the psychosocial functioning of adolescents. RESULTS: At baseline, GD adolescents showed poor functioning with a CGAS mean score of 57.7 ± 12.3. GD adolescents' global functioning improved significantly after 6 months of psychological support (CGAS mean score: 60.7 ± 12.5; P < 0.001). Moreover, GD adolescents receiving also puberty suppression had significantly better psychosocial functioning after 12 months of GnRHa (67.4 ± 13.9) compared with when they had received only psychological support (60.9 ± 12.2, P = 0.001). CONCLUSION: Psychological support and puberty suppression were both associated with an improved global psychosocial functioning in GD adolescents. Both these interventions may be considered effective in the clinical management of psychosocial functioning difficulties in GD adolescents.

Demographics of referrals to a specialist gender identity service in the UK between 2017 and 2020.

Trends in clinical referrals to specialist gender services historically comprised more assigned male at birth young people. In the last decade, this has shifted in adolescent samples to more assigned female young people. An updated review of the current patterns of referrals is important to better understand the potential changing needs of clinically referred gender-diverse children and adolescents. We assessed the demographics of referrals to the Gender Identity Development Service (GIDS) and their attendance patterns from 2017 to 2020. During this period, 9555 referrals were received in total, most were in adolescence (n = 7901, 82.7%), and more assigned female (age range = 1-18 years; M = 14.05; SD = 2.5) were referred than assigned male young people overall (n = 6823, 71.4%). A larger proportion of assigned female adolescents (assigned female: n = 5835, 62.3%, assigned male: n = 1897, 20.3%) and assigned female children (n = 988, 10.6%, assigned male: n = 640, 6.8%) were referred. For 2%, sex assigned at birth was unrecorded, 83.4% were White British and 36.6% had an unidentified ethnicity. Only 4% did not attend a first appointment, indicating the need for care from this specialist service. With more young people presenting to gender services, understanding the demographics of young people seeking gender care is vital for service provision. Future research should explore how to increase access to gender care for ethnic minorities, and how to support those accessing services.

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

BACKGROUND: Gender-diverse young people experience a cisnormative world and are subject to unique minority stressors, which have been found to contribute to adverse mental health. This research aims to understand the social and personal context unique to gender-diverse people that young people navigate prior to attending specialised services. METHODS: The baseline measure of a newly developed questionnaire, the GIDS Gender Questionnaire (GIDS-GQ), was sent to all young people (or caregivers for those aged under 12) attending the Gender Identity Development Service (GIDS). Eighty-four young people and caregivers completed the questionnaire, with eighty-one included in the final sample (M = 15.77 years, SD = 1.83, range = 9-17; assigned female at birth = 72, assigned male at birth = 9). Questionnaires were emailed to participants via an online survey between one and three appointments with the Service. Data were collected between April 2021 and February 2022. RESULTS: All young people had initiated a social transition, with 75.3% categorised as fully socially transitioned. More young people reported experiencing transphobic bullying (64.2%) and a lack of acceptance of their gender identity (85.1%) in the past (lifetime) than in the 6 months prior to attending the service (transphobic bullying: 12.3%; non-acceptance: 49.4%). 94.5% of the sample reported disliked body parts, most commonly breasts (80.8%), genitals (37%), and hips (31.5%). Participants most commonly reported a decrease in their mood (61.25%) and most areas of social connectedness. CONCLUSIONS: The majority of this sample had socially transitioned, were supported in their identification, and had experienced less transphobic bullying and non-acceptance prior to commencing services. However, young people continued to dislike their bodies, and experience low mood and social connectedness. Future research is needed to understand how clinical support can help reduce the impact of these external/distal minority stressors by promoting social connectedness, incorporating such learnings into clinical practice and subsequent policy in clinical work with gender-diverse young people.

Impact of Hormone Treatment on Psychosocial Functioning in Gender-Diverse Young People.

Purpose: Few studies have assessed the effects of hormonal treatments such as gonadotropin-releasing hormone agonists (GnRHa) and gender-affirming hormones (GAH) on mental health outcomes in clinically referred gender-diverse young people from a younger age. Where this research has been conducted, findings have been mixed. This study investigated a cohort of young people before treatment, 1 year into GnRHa, and 1 year into GAH treatment to understand psychological and behavioral impacts over time. Methods: Thirty-eight young people (28 assigned female and 10 assigned male) referred to endocrinology, younger than 15 years at/beyond Tanner stage two, who received GnRHa followed by GAH treatment, were assessed in a retrospective analysis study. Young people completed the Youth Self Report (YSR), the Body Image Scale, and the Utrecht Gender Dysphoria Scale, while caregivers completed the Child Behavior Checklist (CBCL) and the Social Responsiveness Scale-2 at all time points. Results: Dissatisfaction with primary sexual characteristics (p = 0.02), gender dysphoria (p = 0.01), and social motivation (p = 0.04) improved significantly over time. Self-harm and suicidality also showed a general decrease. Caregivers reported a significant reduction in internalizing (p = 0.03) behaviors on the CBCL after GnRHa. Other subcategories of the YSR and CBCL were within normal ranges with no significant difference (p > 0.05). Conclusion: These findings demonstrate some improvements in psychological and behavioral outcomes in young people concurrently receiving psychosocial support and hormone treatment. Future research with larger and more diverse samples is warranted to further understand generalizability.

Urological and Gynaecological Considerations for the Use of Gonadotropin-releasing Hormone Analogues in Transgender and Nonbinary Adolescents: A Narrative Review.

CONTEXT: Gonadotropin-releasing hormone analogues (GnRHAs) delay the progression of puberty in transgender and nonbinary (TGNB) adolescents and reduce the impact of dysphoria due to ongoing physical development. The intervention remains contentious despite growing evidence to support this practice. OBJECTIVE: To stimulate discussion on this topical issue in the urological and gynaecological community given potential ramifications for future fertility, physical development, and options for gender affirmation surgery (GAS). EVIDENCE ACQUISITION: We conducted searches of the MEDLINE (from 1946) and Embase (from 1974) databases for the benefits and potential challenges of hormone blockade in TGNB adolescents on February 1, 2022. Evidence with a primary focus on clinical issues of interest to urologists and gynaecologists was objectively synthesised and reported. EVIDENCE SYNTHESIS: The onset of puberty represents a period of distress for TGNB adolescents as secondary sexual characteristics develop. GnRHAs are prescribed to inhibit sex hormone production, but the decision to treat should be balanced against the known (and unknown) adverse effects. Fertility preservation is more likely to be successful if GnRHA treatment is delayed for as long as possible. Some adolescents may decide to stop GnRHA use to harvest spermatozoa or oocytes before starting gender-affirming hormone treatment. Transfeminine individuals should consider that options for genital GAS may become more limited, as vaginoplasty with penile skin inversion requires an adequate stretched penile length. Transmasculine individuals may no longer require chest reconstruction for breast development. CONCLUSIONS: Offers of GnRHA treatment to TGNB adolescents should be balanced by careful preparation and counselling. Urologists and gynaecologists can complement the expertise of specialist psychosocial and adolescent endocrinology teams, and should be involved early in and throughout the treatment pathway to maximise future functional and surgical outcomes. PATIENT SUMMARY: Puberty blockers for transgender and nonbinary adolescents have benefits, but timing is important to preserve fertility and surgical options.

Trajectories of transgender adolescents referred for endocrine intervention in England.

OBJECTIVES: Some gender-diverse young people (YP) who experience clinically significant gender-related distress choose to pursue endocrine treatment alongside psychotherapeutic support to suppress pubertal development using gonadotropin-releasing hormone analogues (GnRHa), and then to acquire the secondary sex characteristics of their identified gender using gender affirming hormones (GAH). However, little is known about the demographics of transgender adolescents accessing paediatric endocrinology services while under the specialist Gender Identity Development Service (GIDS) in England. DESIGN: Demographics of referrals from the GIDS to affiliated endocrinology clinics to start GnRHa or GAH between 2017 and 2019 (cohort 1), with further analysis of a subgroup of this cohort referred in 2017-2018 (cohort 2) were assessed. RESULTS: 668 adolescents (227 assigned male at birth (AMAB) and 441 assigned female at birth (AFAB)) were referred to endocrinology from 2017 to 2019. The mean age of first GIDS appointment for cohort 1 was 14.2 (±2.1) years and mean age of referral to endocrinology postassessment was 15.4 (±1.6) years. Further detailed analysis of the trajectories was conducted in 439 YP in cohort 2 (154 AMAB; 285 AFAB). The most common pathway included a referral to access GnRHa (98.1%), followed by GAH when eligible (42%), and onward referral to adult services when appropriate (64%). The majority (54%) of all adolescents in cohort 2 had a pending or completed referral to adult services. CONCLUSIONS: This study highlights the trajectories adolescents may take when seeking endocrine treatments in child and adolescent clinical services and may be useful for guiding decisions for gender-diverse YP and planning service provision.

Key socio-demographic characteristics of children and adolescents with gender dysphoria: A British Isles surveillance study.

The present research used linked surveillance systems (British Paediatric Surveillance Unit; and the Child and Adolescent Psychiatry Surveillance System) over a 19 month period (1 November 2011-31 May 2013) to notify of young people (4-15.9 years) presenting to secondary care (paediatrics or child and adolescent mental health services) or specialist gender services with features of gender dysphoria (GD). A questionnaire about socio-demographic, mental health, and GD features was completed. Presence of GD was then assessed by experts in the field using then-current criteria (DSM-IV-TR). Incidence across the British Isles was 0.41-12.23 per 100,000. 230 confirmed cases of GD were noted; the majority were white (94%), aged ≥12 years (75.3%), and were assigned female at birth (57.8%). Assigned males presented most commonly in pre-adolescence (63.2%), and assigned females in adolescence (64.7%). Median age-of-onset of experiencing GD was 9.5 years (IQR 5-12); the majority reported long-standing features (2-5 years in 36.1%, ≥5 years in 26.5%). Only 82.5% attended mainstream school. Bullying was reported in 47.4%, previous self-harm in 35.2%, neurodiversity in 16%, and 51.5% had ≥1 mental health condition. These findings suggest GD is rare within this age group but that monitoring wellbeing and ensuring support for co-occurring difficulties is vital.

Shifts in demographics and mental health co-morbidities among gender dysphoric youth referred to a specialist gender dysphoria service.

Past research has identified shifts in the demographics and co-occurring mental health issues of youth referred to certain gender dysphoria services. The present study examined shifts in demographics (age, sex and social transition status), social adversity (bullying experiences and abuse) and psychological functioning (mood, anxiety, suicidality and autism spectrum disorder) at time of referral (of both children and adolescents) to the Gender Identity Development Service, London between the years of 2012 and 2015. Patients were 782 children and adolescents (M = 13.94, SD = 2.94, range 4-17; 63.8% assigned female at birth). Little change in sex ratio or age was observed between these two time points. However, we observed greater rates of depression and anxiety of birth-assigned females (but not birth-assigned males) in the more recent cohort, at the same time that reported social adversity (bullying and abuse) was falling. Also, of interest, the proportion of young people who had partially or fully socially transitioned prior to contact with the service had increased overtime. We discuss potential factors driving these shifts and their implications for supporting recent cohorts of gender diverse young people.

Discharge outcome analysis of 1089 transgender young people referred to paediatric endocrine clinics in England 2008-2021.

INTRODUCTION: The destination of transgender and gender variant young people referred by the National Health Service (NHS) Gender Identity Development Service (GIDS) to, and discharged from the two English paediatric endocrine liaison clinics is not known. METHODS: 1151 young people referred after full assessment by the GIDS; 827 to University College London Hospital since 2008; 324 to Leeds Children's Hospital since 2013. Discharge categorisation was by agreed criteria. Eleven emigrated and 51 self-discharged. 1089 had known outcomes. RESULTS: 999/1089 (91.7%) continued identifying as gender variant. 867/999 (86.8%) were discharged to adult gender identity clinics (GICs). 166/867 (19.1%) of these were <16 years and 701/867 (80.9%) ≥16 years at initial endocrine referral. No sex differences were seen. 38/999 (3.8%) opted for non-NHS services.90/1089 ceased identifying as gender variant. In 32/1089 (2.9%), this was subsequent to their first clinic appointment.58/1089 (5.3%) stopped treatment either with the gonadotropin releasing hormone analogue (GnRHa) or gender-affirming hormones (GAH) and reverted to their birth gender: <16 years (20/217; 9.2%); ≥16 years (38/872; 4.4%).Subdividing further, 16/217 (7.4%) <16 years ceased GnRHa and 4/217 (1.8%) after GAH. Of those ≥16 years, 33/872 (3.8%) ceased GnRHa and 5/872 (0.6%) GAH. CONCLUSIONS: At discharge, 91.7% continued as transgender or gender variant, 86.8% sought ongoing care through NHS GICs. 2.9% ceased identifying as transgender after an initial consultation prior to any endocrine intervention and 5.3% stopped treatment either with GnRHa or GAH, a higher proportion in the <16 year compared with the ≥16 year groups.

A Single-Center, Observational Study of 607 Children and Young People Presenting With Differences of Sex Development (DSD).

Context: Differences of sex development (DSD) represent a wide range of conditions presenting at different ages to various health professionals. Establishing a diagnosis, supporting the family, and developing a management plan are important. Objective: We aimed to better understand the presentation and prevalence of pediatric DSD. Methods: A retrospective, observational cohort study was undertaken in a single tertiary pediatric center of all children and young people (CYP) referred to a DSD multidisciplinary team over 25 years (1995-2019). In total, 607 CYP (520 regional referrals) were included. Data were analyzed for diagnosis, sex-assignment, age and mode of presentation, additional phenotypic features, mortality, and approximate point prevalence. Results: Among the 3 major DSD categories, sex chromosome DSD was diagnosed in 11.2% (68/607) (most commonly 45,X/46,XY mosaicism), 46,XY DSD in 61.1% (371/607) (multiple diagnoses often with associated features), while 46,XX DSD occurred in 27.7% (168/607) (often 21-hydroxylase deficiency). Most children (80.1%) presented as neonates, usually with atypical genitalia, adrenal insufficiency, undescended testes or hernias. Those presenting later had diverse features. Rarely, the diagnosis was made antenatally (3.8%, n = 23) or following incidental karyotyping/family history (n = 14). Mortality was surprisingly high in 46,XY children, usually due to complex associated features (46,XY girls, 8.3%; 46,XY boys, 2.7%). The approximate point prevalence of neonatal referrals for investigation of DSD was 1 in 6347 births, and 1 in 5101 overall throughout childhood. Conclusion: DSD represent a diverse range of conditions that can present at different ages. Pathways for expert diagnosis and management are important to optimize care.

Longitudinal Outcomes of Gender Identity in Children (LOGIC): protocol for a prospective longitudinal cohort study of children referred to the UK gender identity development service.

INTRODUCTION: Gender identity development services (GIDS) worldwide have seen a significant increase in referrals in recent years. Many of these referrals consist of children and young people (CYP) who experience gender-related distress. This study aims to improve understanding of outcomes of CYP referred to the UK GIDS, specifically regarding gender identity, mental health, physical health and quality of life. The impact of factors such as co-occurring autism and early social transition on outcomes over time will be explored. METHODS AND ANALYSIS: This is a prospective cohort study of CYP aged 3-14 years when referred to the UK GIDS. Eligible participants will be ≤14 years at the time their referral was accepted and will be on the waitlist for the service when baseline measures are completed. Children aged under 12 years will complete the measures in an interview format with a researcher, while young people aged 12 years and over and their parents/caregivers will complete online or paper-based questionnaires. Participants will complete follow-up measures 12 months and 24 months later. The final sample size is expected to be approximately 500. Logistic regression models will be used to explore associations between prespecified explanatory variables and gender dysphoria. Appropriate regression models will also be used to investigate explanatory variables for other outcomes. Subgroup analyses based on birth-assigned gender, age at referral and co-occurring autistic traits will be explored. ETHICS AND DISSEMINATION: The study has been approved by the Health Research Authority and London - Hampstead Research Ethics Committee (reference: 19/LO/0857). The study findings will be published in peer-reviewed journals and presented at both conferences and stakeholder events. Findings will be used to inform clinical practice.

Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK.

BACKGROUND: In adolescents with severe and persistent gender dysphoria (GD), gonadotropin releasing hormone analogues (GnRHa) are used from early/middle puberty with the aim of delaying irreversible and unwanted pubertal body changes. Evidence of outcomes of pubertal suppression in GD is limited. METHODS: We undertook an uncontrolled prospective observational study of GnRHa as monotherapy in 44 12-15 year olds with persistent and severe GD. Prespecified analyses were limited to key outcomes: bone mineral content (BMC) and bone mineral density (BMD); Child Behaviour CheckList (CBCL) total t-score; Youth Self-Report (YSR) total t-score; CBCL and YSR self-harm indices; at 12, 24 and 36 months. Semistructured interviews were conducted on GnRHa. RESULTS: 44 patients had data at 12 months follow-up, 24 at 24 months and 14 at 36 months. All had normal karyotype and endocrinology consistent with birth-registered sex. All achieved suppression of gonadotropins by 6 months. At the end of the study one ceased GnRHa and 43 (98%) elected to start cross-sex hormones. There was no change from baseline in spine BMD at 12 months nor in hip BMD at 24 and 36 months, but at 24 months lumbar spine BMC and BMD were higher than at baseline (BMC +6.0 (95% CI: 4.0, 7.9); BMD +0.05 (0.03, 0.07)). There were no changes from baseline to 12 or 24 months in CBCL or YSR total t-scores or for CBCL or YSR self-harm indices, nor for CBCL total t-score or self-harm index at 36 months. Most participants reported positive or a mixture of positive and negative life changes on GnRHa. Anticipated adverse events were common. CONCLUSIONS: Overall patient experience of changes on GnRHa treatment was positive. We identified no changes in psychological function. Changes in BMD were consistent with suppression of growth. Larger and longer-term prospective studies using a range of designs are needed to more fully quantify the benefits and harms of pubertal suppression in GD.

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.