Psychosocial Functioning in Transgender Youth after 2 Years of Hormones.

BACKGROUND: Limited prospective outcome data exist regarding transgender and nonbinary youth receiving gender-affirming hormones (GAH; testosterone or estradiol). METHODS: We characterized the longitudinal course of psychosocial functioning during the 2 years after GAH initiation in a prospective cohort of transgender and nonbinary youth in the United States. Participants were enrolled in a four-site prospective, observational study of physical and psychosocial outcomes. Participants completed the Transgender Congruence Scale, the Beck Depression Inventory-II, the Revised Children's Manifest Anxiety Scale (Second Edition), and the Positive Affect and Life Satisfaction measures from the NIH (National Institutes of Health) Toolbox Emotion Battery at baseline and at 6, 12, 18, and 24 months after GAH initiation. We used latent growth curve modeling to examine individual trajectories of appearance congruence, depression, anxiety, positive affect, and life satisfaction over a period of 2 years. We also examined how initial levels of and rates of change in appearance congruence correlated with those of each psychosocial outcome. RESULTS: A total of 315 transgender and nonbinary participants 12 to 20 years of age (mean [±SD], 16±1.9) were enrolled in the study. A total of 190 participants (60.3%) were transmasculine (i.e., persons designated female at birth who identify along the masculine spectrum), 185 (58.7%) were non-Latinx or non-Latine White, and 25 (7.9%) had received previous pubertal suppression treatment. During the study period, appearance congruence, positive affect, and life satisfaction increased, and depression and anxiety symptoms decreased. Increases in appearance congruence were associated with concurrent increases in positive affect and life satisfaction and decreases in depression and anxiety symptoms. The most common adverse event was suicidal ideation (in 11 participants [3.5%]); death by suicide occurred in 2 participants. CONCLUSIONS: In this 2-year study involving transgender and nonbinary youth, GAH improved appearance congruence and psychosocial functioning. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.).

Research Review: Gender identity in youth: treatment paradigms and controversies.

BACKGROUND: Pediatric gender identity has gained increased attention over the past several years in the popular media, political arena, and medical literature. This article reviews terminology in this evolving field, traditional models of gender identity development and their limitations, epidemiology and natural history of cross-gender identification among children and adolescents, co-occurring conditions and behaviors, research into the biological and psychosocial determinants of cross-gender identification, and research into the options regarding and benefits of clinical approaches to gender incongruent youth. METHODS: Based on a critical review of the extant literature, both theoretical and empirical, that addresses the issue of pediatric gender identity, the authors synthesized what is presently known and what is in need of further research in order to elucidate the developmental trajectory and clinical needs of gender diverse youth. RESULTS: The field of pediatric gender identity has evolved substantially over the past several years. New research suggests that cross-gender identification is prevalent (approximately 1% of youth). These youth suffer disproportionately high rates of anxiety, depression, and suicidality. Although research into the etiology of cross-gender identification is limited, emerging data have shown that affirmative treatment protocols may improve the high rates of mental health difficulties seen among these patients. CONCLUSIONS: The field of pediatric gender identity has evolved dramatically. Emerging data suggest that these patients' high rates of anxiety, depression, and suicidality appear to be improved with affirmative protocols, although future longitudinal data are needed.

Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents.

Evidence indicates an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD). The clinical assessment and treatment of adolescents with this co-occurrence is often complex, related to the developmental aspects of ASD. There are no guidelines for clinical care when ASD and GD co-occur; however, there are clinicians and researchers experienced in this co-occurrence. This study develops initial clinical consensus guidelines for the assessment and care of adolescents with co-occurring ASD and GD, from the best clinical practices of current experts in the field. Expert participants were identified through a comprehensive international search process and invited to participate in a two-stage Delphi procedure to form clinical consensus statements. The Delphi Method is a well-studied research methodology for obtaining consensus among experts to define appropriate clinical care. Of 30 potential experts identified, 22 met criteria as expert in co-occurring ASD and GD youth and participated. Textual data divided into the following data nodes: guidelines for assessment; guidelines for treatment; six primary clinical/psychosocial challenges: social functioning, medical treatments and medical safety, risk of victimization/safety, school, and transition to adulthood issues (i.e., employment and romantic relationships). With a cutoff of 75% consensus for inclusion, identified experts produced a set of initial guidelines for clinical care. Primary themes include the importance of assessment for GD in ASD, and vice versa, as well as an extended diagnostic period, often with overlap/blurring of treatment and assessment.

Listening and Learning from Gender-Nonconforming Children.

The twenty-first century brings to our clinical doorsteps increasing numbers of children exploring and questioning their gender identities and expressions. This paper begins with a reassessment of the psychoanalytic thinking about gender and then outlines a clinical and developmental model of gender adapted from D. W. Winnicott's concepts of true self, false self, and individual creativity. The underlying premise is that gender nonconformity, when the core psychological issue, is not a sign of pathology but rather a reflection of healthy variations on gender possibilities. Working from that premise, composite clinical material from the author's practice as a psychoanalytic gender specialist is presented of a gender-nonconforming child transitioning from female to male, to demonstrate the psychoanalytic tools applied, including listening, mirroring, play, and interpretation, with the goal of facilitating a child's authentic gender self. Emphasis is placed on learning from the patient, working collaboratively with the family and social environments, and remaining suspended in a state of ambiguity and not-knowing as the child explores and solidifies a True Gender Self.

Biopsychosocial Assessments for Pubertal Suppression to Treat Adolescent Gender Dysphoria.

Transgender and gender diverse (TGD) adolescents are those whose gender identity is incongruent with societal expectations based on their sex assigned at birth.1 Some TGD adolescents may meet criteria for gender dysphoria, which requires at least 6 months of psychological distress related to gender incongruence.1 Such adolescents may seek pubertal suppression with a gonadotropin-releasing hormone agonist (GnRHa).1 GnRHa temporarily and reversibly suppress endogenous puberty, allowing adolescents to engage with care without puberty-related psychological distress.2 Most patients treated with GnRHa proceed to treatment with gender-affirming hormones (eg, estrogen or testosterone to induce puberty that aligns with their gender identity), whereas a small number choose to stop GnRHa treatment, allowing endogenous puberty to proceed.2 Longitudinal cohort and cross-sectional studies link GnRHa treatment to improved mental health outcomes, when provided in accordance with clinical guidelines.2.

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.

Development of a family-level intervention for families with transgender and/or nonbinary youth: Lessons and recommendations.

Family support plays an important role in promoting resilience and health among transgender and/or nonbinary youth (TNBY), but family members often experience barriers to supporting their TNBY, including minority-adjacent stress stemming from exposure to structural stigma and antitransgender legislation. TNBY and their families need effective family-level interventions developed using community-based participatory research (CBPR), which integrates community members (e.g., TNBY, family members, service providers for families with TNBY) into the intervention development process to ensure the resulting intervention is relevant and useful. Informed by findings from the Trans Teen and Family Narratives Project, we used CBPR to develop the Trans Teen and Family Narratives Conversation Toolkit, a family-level intervention designed to educate families about TNBY and facilitate conversations about gender. The toolkit was developed across 1.5 years (June 2019 to January 2021) using four integrated phases: (1) content development: digital storytelling workshop with TNBY; (2) content review: digital storyteller interviews and user focus groups; (3) content development: study team content synthesis and website development; and (4) content review: website review by TNBY, family members, and mental health providers, and intervention refinement. This article outlines the intervention development process, describes strategies employed to navigate challenges encountered along the way, and shares key learnings to inform future CBPR intervention development efforts. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Perspective on equitable translational studies and clinical support for an unbiased inclusion of the LGBTQIA2S+community.

Research regarding the mental health of the Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, 2 Spirit (LGBTQIA2S+) community has been historically biased by individual and structural homophobia, biphobia, and transphobia, resulting in research that does not represent the best quality science. Furthermore, much of this research does not serve the best interests or priorities of LGBTQIA2S + communities, despite significant mental health disparities and great need for quality mental health research and treatments in these populations. Here, we will highlight how bias has resulted in missed opportunities for advancing understanding of mental health within LGBTQIA2S + communities. We cite up-to-date research on mental health disparities facing the LGBTQIA2S + community and targeted treatment strategies, as well as guidance from health care professionals. Importantly, research is discussed from both preclinical and clinical perspectives, providing common language and research priorities from a translational perspective. Given the rising tide of anti-transgender sentiment among certain political factions, we further emphasize and discuss the impact of historical and present day ciscentrism and structural transphobia in transgender mental health research, from both clinical and translational perspectives, with suggestions for future directions to improve the quality of this field. Finally, we address current best practices for treatment of mental health issues in this community. This approach provides an opportunity to dispel myths regarding the LGBTQIA2S + community as well as inform the scientific community of best practices to work with this community in an equitable manner. Thus, our approach ties preclinical and clinical research within the LGBTQIA2S + community.

High Internalized Transphobia and Low Gender Identity Pride Are Associated With Depression Symptoms Among Transgender and Gender-Diverse Youth.

PURPOSE: Prior studies have identified a significant relationship between internalized transphobia and poor mental health among transgender and gender-diverse (TGD) adults; however, this relationship has not been extensively examined among youth. Further, little research has sought to explore protective factors, such as identity pride, and their influence on this relationship. We examined the association between internalized transphobia and depression and anxiety symptoms among TGD youth and explored the moderating role of gender identity pride on these associations. METHODS: Participants were 315 TGD youth ages 12-20 years (mean = 16; standard deviation = 1.89) seeking gender-affirming hormone treatment at one of four major pediatric hospitals across the United States. At the time of enrollment, participants were naïve to gender-affirming hormone treatment. Participants self-reported mental health, internalized transphobia, and identity pride. Multiple regression models were used with depression and anxiety symptoms as outcomes and age, designated sex at birth, and perceived parental support included as covariates. RESULTS: Greater internalized transphobia was associated with greater depressive symptoms, and gender identity pride moderated this relationship, such that greater gender identity pride was associated with fewer depressive symptoms. Greater internalized transphobia was significantly associated with greater anxiety symptoms; no moderation effect was observed for this relationship. DISCUSSION: Gender identity pride influenced mental health symptoms for youth experiencing internalized transphobia and represents a potential key protective factor. These results support efforts to further develop, test, and implement clinical inventions to bolster identity pride for TGD youth.

Mental Health and Gender Affirmation of Black and Latine Transgender/Nonbinary Youth Compared to White Peers Prior to Hormone Initiation.

PURPOSE: To compare baseline mental health symptoms and gender affirmation between Black/Latine versus White transgender/nonbinary youth (BLTY vs. WTY) and examine relationships between gender affirmation and mental health symptoms, and whether associations differed by race/ethnicity subgroup. METHODS: Baseline data were analyzed from the gender-affirming hormone cohort of the Trans Youth Care United States Study-a 4-clinic site, observational study. Mental health symptoms assessed included depression, suicidality, and anxiety. Gender affirmation measures included the parental acceptance subscale from the perceived Parental Attitudes of Gender Expansiveness Scale-Youth Report; non-affirmation, internalized transphobia, and community connectedness subscales from the Gender Minority Stress and Resilience Measure-Adolescent; and self-reported living full time in affirmed gender. Fisher exact tests and independent sample t tests compared mental health symptoms and gender affirmation between subgroups. Logistic regression analyses evaluated associations between gender affirmation and mental health symptoms. Interaction analyses assessed differences in associations between subgroups. RESULTS: The sample (mean age 16 years, range 12-20 years) included 92 BLTY (35%) and 170 WTY (65%). Subgroups had comparable prevalence of depression and anxiety symptoms. WTY had higher prevalence of lifetime suicidality (73% vs. 59%; p = .02). There were no differences in gender affirmation. Among the whole sample, higher parental acceptance decreased odds of depression symptoms. Not living in affirmed gender increased odds of depression symptoms. Higher non-affirmation and internalized transphobia increased odds of depression and anxiety symptoms and suicidality. Associations did not vary by subgroup. DISCUSSION: BLTY and WTY had comparable mental health symptoms. For both subgroups, gender affirmation decreased odds of those symptoms.

The 2016 United States presidential election's impact on families with transgender adolescents in New England.

During and after the 2016 United States (U.S.) presidential election, discriminatory policies and stigmatizing rhetoric have been increasingly directed toward the transgender community at state and national levels. Transgender and/or nonbinary (TNB) adolescents, already at elevated risk for poorer health relative to their cisgender (nontransgender) peers, may have been adversely impacted by the shifting sociopolitical climate. This secondary analysis used qualitative data from the Trans Teen and Family Narratives Project to investigate how perceived shifts in the sociopolitical climate following the 2016 election affected families with TNB adolescents in the New England region of the U.S. (states of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont). Data included two waves of semistructured interviews conducted with TNB adolescents and their caregivers and siblings (N = 20 families, 60 family members). Two coders analyzed transcripts using a thematic analysis approach. Emergent themes included: contemporary life for trans people in America (e.g., being discriminated against and dehumanized), perceptions of the national sociopolitical climate (e.g., anger toward political figures), forms of resistance and advocacy (e.g., confronting misinformation), and factors amplifying or buffering effects of the sociopolitical climate (e.g., the formation of alliances or coalitions within the family). Findings indicate the 2016 election spurred the redefinition of communication boundaries within, and outside, the immediate family, particularly regarding online communication and social media. TNB adolescents and their families anxiously anticipated changes in the sociopolitical climate and their foreseen impact on TNB adolescents' rights and safety. Implications for family therapy, intervention design, and policy reform are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

COVID-19 and Transgender and Gender Expansive Children and Youth.

The coronavirus disease 2019 pandemic has put strains on transgender and gender expansive (TGE) children and youth, with increased rates of anxiety and depression, lower access to medical and mental health services, and greater exposure to unaccepting home environments. At the same time, for some of these young people, particularly those with supportive living situations, sheltering in place and online schooling has afforded them the opportunity to freely explore and consolidate their gender, protected from the strains of socially induced anxieties, and anticipated or experienced negative, hostile messages from their surrounding environment (ie, school or public meeting places). Culling from emerging data on the psychosocial effects of the pandemic on TGE children and youth, an argument is made for an understanding of these young people's experiences as both stress-inducing and resilience-building, each existing in dialectic tension with the other. Providers are called on to hold both in mind to fortify the biopsychosocial well-being of transgender and gender expansive children and youth. [Pediatr Ann. 2021;50(9):e366-e370.].

Take the T out, put the T in: Gender-affirming hormones in youth.

BACKGROUND: An increasing number of adolescents are seeking gender care at clinics and hospital programs, and requesting gender-affirming hormonal treatment. The interventions can either include suppression of testosterone and introduction of estrogen, or suppression of estrogen and introduction of testosterone. AIMS: This review article focuses on the psychosocial experiences of youth who have completed their endogenous puberty and are now requesting one of these two forms of gender-affirming hormonal treatment. We investigate the comparative profiles of these two subgroups of transgender/gender-expansive youth. MATERIALS AND METHODS: Review of research data, established standards of care and practice guidelines, and clinical observations. RESULTS: Differences and similarities are noted and discussed in several realms: gender-related experiences prior to receiving hormonal treatment; the relationship between the physical changes and psychological experiences that accompany the introduction of testosterone or suppression of testosterone with replacement with estrogen; the intrapersonal and interpersonal implications of the treatment; considerations of fertility preservation for future family building; the role of the family in the decision-making process prior to starting a course of hormone therapy; and the capacity of youth to make informed decisions about these partially irreversible medical interventions. DISCUSSION: Medical providers who offer gender-affirming hormonal care to youth should work with the family and allied professionals to assure that the youth's gender health is enhanced, barriers to care are removed, and mental health risks are reduced, whether the T is coming out or going in. CONCLUSION: The cohort of youth who come to medical providers after completing puberty, and request gender-affirming hormones in the form of increases or reductions in T have a great deal in common, and also extensive variation among them.

Psychosocial Characteristics of Transgender Youth Seeking Gender-Affirming Medical Treatment: Baseline Findings From the Trans Youth Care Study.

PURPOSE: This study aimed to characterize two developmental cohorts of transgender and nonbinary youth enrolled in the Trans Youth Care Network Study and describe their gender identity-related milestones and baseline mental health and psychosocial functioning. METHODS: Trans Youth Care participants were recruited from four pediatric academic medical centers in the U.S. before initiating medical treatment for gender dysphoria either with gonadotropin-releasing hormone agonists (GnRHa) or gender-affirming hormones (GAH). GnRHa cohort data were collected from youth and a parent; GAH cohort data were collected from youth only. RESULTS: A total of 95 youth were enrolled in the GnRHa cohort. Mean age was 11.22 years (standard deviation = 1.46), and the majority were white (52.6%) and designated male at birth (51.6%). Elevated depression symptoms were endorsed by 28.6% of GnRHa cohort youth, and 22.1% endorsed clinically significant anxiety. Approximately one fourth (23.6%) endorsed lifetime suicidal ideation, with 7.9% reporting a past suicide attempt. A total of 316 youth were enrolled in the GAH cohort. The mean age was 16.0 years (standard deviation = 1.88), and the majority were white (62%) and designated female at birth (64.9%). Elevated depression symptoms were endorsed by 51.3% of the GAH cohort, and 57.3% endorsed clinically significant anxiety. Two-thirds (66.6%) endorsed lifetime suicidal ideation, with 24.6% reporting a past suicide attempt. Life satisfaction was lower among both cohorts compared with population-based norms. CONCLUSIONS: GnRHa cohort youth appear to be functioning better from a psychosocial standpoint than GAH cohort youth, pointing to possible benefits of accessing gender-affirming treatment earlier in life.

Impact of Early Medical Treatment for Transgender Youth: Protocol for the Longitudinal, Observational Trans Youth Care Study.

BACKGROUND: Transgender children and adolescents (ie, those who experience incongruence between assigned sex at birth and internal gender identity) are poorly understood and an understudied population in the United States. Since 2008, medical care for transgender youth has generally followed guidelines developed by professional consensus, given the paucity of empirical research, particularly in the US setting. OBJECTIVE: The objective of this research was to provide evidence-based data to inform clinical care for transgender youth. The study aims (1) to evaluate the impact of gonadotropin-releasing hormone agonists administered for puberty suppression on mental health, psychological well-being, and metabolic and physiologic parameters including bone health in a cohort of children and adolescents (Tanner stages 2-4) with gender dysphoria, comparing baseline and follow-up assessments, and (2) to determine the impact of gender-affirming hormones (eg, estradiol and testosterone) administered for phenotypic gender transition on mental health, psychological well-being, and metabolic and physiologic parameters in a cohort of adolescents with gender dysphoria, comparing baseline and follow-up assessments. METHODS: The study uses a longitudinal observational design to examine the outcomes of existing medical treatment protocols for gender dysphoria in two distinct cohorts: youth initiating puberty suppression and youth pursuing a phenotypic gender transition. Data on routine anthropometric and physiologic parameters are collected through chart abstraction, questionnaires, and research interviews in the 24-month study period. Audio computer-assisted self-interview and individual interview survey instruments are used to collect demographic, mental health, psychosocial, and behavioral data from parents and youth in the blocker cohort and only from youth in the gender-affirming hormone cohort at baseline and 6, 12, 18, and 24 months. RESULTS: Participant recruitment commenced in July 2016, and enrollment was completed in September 2018. A total of 90 participants were enrolled in the blocker cohort and 301 participants were enrolled in the gender-affirming hormone cohort. Findings based on baseline data are expected to be submitted for publication in 2019. CONCLUSIONS: This longitudinal, observational study is collecting critical data on the existing models of care for transgender youth that have been used in clinical settings for close to a decade, although with limited empirical research to support them. This research is a direct response to the Institute of Medicine report calling for such studies as well as the needs of clinicians and patients. Results from this study have the potential to significantly impact the medical and mental health services provided to transgender youth by making available rigorous scientific evidence on the impact and safety of early treatment based on the sexual development stage. Ultimately, we aim to understand if early medical intervention reduces the health disparities well known to disproportionately affect transgender individuals across their lifespan. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/14434.

Creating the Trans Youth Research Network: A Collaborative Research Endeavor.

Purpose: This article outlines the process of establishing the Trans Youth Care Research Network, composed of four academic clinics providing care for transgender and gender-diverse (TGD) youth. The Network was formed to design and implement research studies to better understand physiologic and psychosocial outcomes of gender-affirming medical care among TGD youth. Methods: Formed in response to both the Institute of Medicine's report recommendation for an increase of data concerning sexual and gender minority populations and a transgender-specific NIH program announcement, The Center for Transyouth Health and Development at Children's Hospital Los Angeles, the Gender Management Service at Boston Children's Hospital, the Child and Adolescent Gender Center Clinic at Benioff Children's Hospital in San Francisco, and the Gender and Sex Development Program at Lurie Children's Hospital of Chicago established a collaborative research network that subsequently designed a longitudinal observational study of TGD youth undergoing medical interventions to address gender dysphoria. Results: Two cohorts, youth starting puberty blockers and youth starting gender-affirming hormones, are participating. Psychosocial measures that span multiple domains of mental and behavioral health are collected from youth and parents. Physiologic data are abstracted from patient's charts. Baseline and follow-up data of this large cohort will be disseminated through conferences, abstracts, posters, and articles. Conclusion: Since initiation of funding in 2015, a total of 497 participants have been enrolled in TYC across the four sites; gonadotropin releasing hormone analogs (GnRHa) cohort youth (n=93), GnRHa cohort parents (n=93), and gender affirming hormone cohort youth (n=311). As the network moves toward data dissemination, its lessons learned have helped strengthen the current study, as well as inform future endeavors in this field.

When baby makes three or four or more: attachment, individuation, and identity in assisted-conception families.

Using examples from clinical work with parents and children in assisted-conception families, this chapter explores the anxieties, conflicts, and psychological defenses of parents as they intersect with the developmental tasks and emotional experiences of the children. Coining the term "birth other" to refer to the outside party in conception--donor, surrogate, or gestational carrier the resurfacing of early primal scenes and oedipal dramas on the part of parents is connected to psychological strategies and defenses, particularly denial, to ward off anxieties generated by introducing an outside party into the most intimate arena of family life--conception of a child. The parental negotiation of conflicts is then associated to three developmental tasks for the child: confronting one's sense of uniqueness; establishing a sense of belonging; forging an identity based on assisted-conception origins. Lastly, developmental facilitators are outlined to enhance success in each of these tasks respectively: age-appropriate narratives of the child's origins; family reveries (shared fantasies about the birth others and their position in the family); a child's family romances that include the birth other. The intent of this discourse is to sensitize clinicians to the psychological issues in their work with children and parents faced with internal or interpersonal challenges when baby was conceived with the help of an outside party.

Just Molly and me, and donor makes three: lesbian motherhood in the age of assisted reproductive technology.

The psychological experiences of lesbian mothers, both coupled and single, are compared and contrasted with heterosexual and gay parents who use assisted reproductive technology, focusing on issues of parental desire, fertility, babies conceived from science rather than sex, presence of an outside party in conception, genetic asymmetry, social anxieties, legal protections, disclosure, and gender. The psychological meaning of the donor or surrogate as "extra" and "missing" piece of the family, along with the interactive effects of homophobia and "reproductive technophobia" are considered. Lesbian families are recognized to be constructing a new narrative of a bio-social family as they define and live their experience.

Double Helix Rainbow Kids.

Double Helix Rainbow Kids is a letter to the editor in conjunction with the forthcoming issue on autism and gender that discusses the intersection between autism and gender expansiveness, calling on extant research, clinical observations at the UCSF Benioff Children's Hospital Child and Adolescent Gender Center and other clinics, as well as personal narratives. It alerts the reader to the importance of giving full attention to the gender stress or gender dysphoria that often accompanies autism spectrum in children, making constitutional-psychological-social links between neurodiversity and gender diversity.