Treatment trajectories of gender incongruent Austrian youth seeking gender-affirming hormone therapy.

Objective: The aim of this study was to describe the treatment trajectories of Austrian children and adolescents with gender incongruence seeking gender-affirming medical care. Methods: Patients who presented with gender incongruence at the pediatric outpatient clinic for differences in sex development at a large university hospital in Austria from January 2008 to December 2022 were included in a retrospective chart review, and analyzed regarding referral numbers, patient characteristics, treatment trajectories, fertility preservation, and legal gender marker changes. Results: Of 310 eligible patients, 230 (74.2%) were assigned female at birth (AFAB), and 80 (25.8%) were assigned male at birth (AMAB). The number of referrals increased steeply from 2008 to 2018, whereafter it stabilized at around 50 per year. At the time of initial presentation, the median age of patients was 15.6 years (IQR 14.3-16.8). AMAB individuals tended to be younger (median 14.9 years, IQR 13.9-16.8) than AFAB individuals (median 15.8 years, IQR 14.4-16.8; p= 0.012). 207 (66,8%) completed the assessment process and were eligible for gender affirming medical treatment (GAMT). Of those, 89% (186/207) commenced gender affirming hormone therapy in the pediatric outpatient clinic (79/186 received GnRHa monotherapy, 91/186 GnRHa and sex steroids, and 16/186 sex steroid monotherapy). Of the 54 AMAB individuals receiving GAMT, 6 (11.1%) completed fertility preservation prior to therapy initiation. Only 1/132 AFAB adolescents receiving GAMT completed fertility preservation. Chest masculinization surgery was performed in 22 cases (16.7%), and breast augmentation in two cases (3.7%) between the ages of 16 and 18. Changes in legal gender marker were common, with 205 individuals (66.1%) having changed their legal gender marker. Conclusion: This is the first time that treatment trajectories, fertility preservation rates, and changes of legal gender marker have been described in Austrian adolescents with gender incongruence seeking GAMT. The majority received GAMT and changed their legal gender marker, while gender affirming surgery rates were low, and utilization of fertility preservation treatment options was rare.

The Role of Psychiatry for Transgender and Gender Diverse Adults.

ABSTRACT: Since the inclusion of gender identity disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry and the broader medical field have made substantial alterations in their recognition of and respect for transgender and gender diverse (TGD) identities. As this recognition continues to expand, psychiatrists should be aware of both historical harm and current best care practices, especially in light of psychiatric morbidity in TGD populations relative to the general population. This article contextualizes the history of psychiatry's engagement with TGD patients and presents the gender minority stress and resilience model to frame the mental health disparities experienced by TGD people. We envision a role for psychiatry that goes beyond gatekeeping gender-affirming hormone therapy and surgeries. Instead, we should invest in equitable care across the continuum of mental health needs. We provide an overview of existing literature to help characterize psychiatric epidemiology for this population, with the goal of offering guidance on how psychiatrists can deliver responsive and high-quality care for TGD people. Some key areas of proposed clinical improvement include culturally tailoring interventions for substance use disorders, reducing medical trauma in acute psychiatric care settings, and better understanding the interplay of psychopharmacology and gender-affirming hormone therapy.

Genital Tucking Practices in Transgender and Gender Diverse Patients.

Genital tucking (tucking) is the practice of hiding or minimizing the appearance of one's genitals and gonads. We aimed to better understand the prevalence of tucking and its potential effect on behavior and health. An online questionnaire was distributed to adults with a diagnosis of gender dysphoria or gender incongruence (n = 98). The risk of side effects increased with the length of tucking sessions (P = 0.046) with many patients avoiding medical care despite experiencing side effects. Health care providers should empathetically discuss tucking and its potential risks and benefits with transgender and gender diverse patients. Further research is needed to better quantify the potential risks involved with tucking and to assist in developing educational resources.

Mental Health of Youth With Autism Spectrum Disorder and Gender Dysphoria.

BACKGROUND AND OBJECTIVES: Youth with either autism spectrum disorder (ASD) or gender dysphoria (GD) alone have also been shown to be at greater risk for mental health (MH) concerns; however, very little research has considered how cooccurring ASD and GD may exacerbate MH concerns. The purpose of this study was to examine associations between ASD, GD, and MH diagnoses (anxiety, depression, eating disorder, suicidality, and self-harm) among US adolescent populations. METHODS: This is a secondary analysis of a large administrative dataset formed by 8 pediatric health system members of the PEDSnet learning health system network. Analyses included descriptive statistics and adjusted mixed logistic regression models testing for associations between combinations of ASD and GD diagnoses and MH diagnoses as recorded in the patient's electronic medical record. RESULTS: Based on data from 919 898 patients aged 9 to 18 years, adjusted mixed logistic regression indicated significantly greater odds of each MH diagnosis among those with ASD alone, GD alone, and cooccurring ASD/GD diagnoses compared with those with neither diagnosis. Youth with cooccurring ASD/GD were at significantly greater risk of also having anxiety (average predicted probability, 0.75; 95% confidence interval, 0.68-0.81) or depression diagnoses (average predicted probability, 0.33; 95% confidence interval, 0.24-0.43) compared with youth with ASD alone, GD alone, or neither diagnosis. CONCLUSIONS: Youth with cooccurring ASD/GD are more likely to also be diagnosed with MH concerns, particularly anxiety and depression. This study highlights the need to implement developmentally appropriate, gender-affirming MH services and interventions for youth with cooccurring ASD/GD.

Have the psychiatric needs of people seeking gender reassignment changed as their numbers increase? A register study in Finland.

BACKGROUND: The number of people seeking gender reassignment (GR) has increased everywhere and these increases particularly concern adolescents and emerging adults with female sex. It is not known whether the psychiatric needs of this population have changed alongside the demographic changes. METHODS: A register-based follow-up study of individuals who contacted the nationally centralized gender identity services (GIS) in Finland in 1996-2019 (gender dysphoria [GD] group, n = 3665), and 8:1 age and sex-matched population controls (n = 29,292). The year of contacting the GIS was categorized to 5-year intervals (index periods). Psychiatric needs were assessed by specialist-level psychiatric treatment contacts in the Finnish Care Register for Hospital Care in 1994-2019. RESULTS: The GD group had received many times more specialist-level psychiatric treatment both before and after contacting specialized GIS than had their matched controls. A marked increase over time in psychiatric needs was observed. Among the GD group, relative risk for psychiatric needs after contacting GIS increased from 3.3 among those with the first appointment in GIS during 1996-2000 to 4.6 when the first appointment in GIS was in 2016-2019. When index period and psychiatric treatment before contacting GIS were accounted for, GR patients who had and who had not proceeded to medical GR had an equal risk compared to controls of needing subsequent psychiatric treatment. CONCLUSION: Contacting specialized GIS is on the increase and occurs at ever younger ages and with more psychiatric needs. Manifold psychiatric needs persist regardless of medical GR.

National Estimates of Gender-Affirming Surgery in the US.

Importance: While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited. Objective: To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups. Design, Setting, and Participants: This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified. Main Outcome Measures: Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed. Results: A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients. Conclusions and Relevance: Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

The risk of psychosis for transgender individuals: a Dutch national cohort study.

BACKGROUND: The stressful minority position of transgender persons may result in a high risk of psychosis. Conflicting data suggest that the observed risk depends on setting of recruitment. We assessed the relative risk of non-affective psychotic disorder (NAPD) in a large, representative cohort of transgender persons. METHODS: This cohort was composed using: data on legal sex change from the Dutch population registry and data on dispensing of cross-sex hormones (route 1), and a registry of insurance claims from mental health care including persons with a diagnosis of gender identity disorder (DSM-IV) or gender dysphoria (DSM-5) (route 2). They were matched by sex at birth, calendar year and country of birth to controls from the general population. Transgender persons (N = 5564) and controls (N = 27 820), aged 16-60 years at 1 January 2011, were followed until the first insurance claim for NAPD in 2011-2019. RESULTS: The incidence rate ratio (IRR) of NAPD for transgender persons selected exclusively through route 1 (N = 3859, IRR = 2.00, 95%-CI 1.52-2.63) was increased, but significantly lower than the IRRs for those selected exclusively through route 2 (N = 694, IRR = 22.15, 95%-CI 13.91-35.28) and for those found by both routes (N = 1011, IRR = 5.17, 95%-CI 3.57-7.49; p value for differences in IRR < 0.001). CONCLUSIONS: This study supports the social defeat-hypothesis of NAPD. The results also show the presence of a substantial number of transgender persons with severe psychiatric problems who have not (yet) taken steps to gender-affirmative care.

Danish healthcare offer for children and adolescents with gender dysphoria.

The nationwide Danish healthcare service for children and adolescents with gender dysphoria opened in 2016, based on clinical experience from other European countries and early follow-up studies, implying that early medical transition resulted in better physical and psychological outcomes. This review discusses how a rapid increase of referrals, especially among adolescent birth-assigned girls, and other factors such as high rates of psychiatric morbidity and varying developmental trajectories of gender identity have affected international and Danish healthcare in recent years.

Dimensional approach to gender dysphoria in Nigeria: Association with socio-demographic and psycho-sexual variables.

Background: Recent changes across the world with respect to gender transitioning of children and adolescents have generated a bio-psycho-socio-cultural discourse among interest groups. Aim: This study sought to examine gender dysphoric symptoms among adolescents and young persons in an African population, using a dimensional approach. Method: A total of 747 primary/secondary school and university students aged 10-24 years were studied using the 27-item Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA). Participants were divided into early, mid- and late adolescents. The composite and domain scores were calculated using the criteria described by Deogracias, and comparison of the median scores was done using Mann-Whitney U-test and Kruskal-Wallis test as appropriate. Dunnett's post-hoc test was used for pairwise comparisons. Results: The prevalence of self-identified transgender and self-reported non-heterosexuals was 0.9% (95%CI: 0.36-1.92) and 18.6% (15.85-21.59), respectively. The participants as a group scored 4.56 out of a possible 5 on the gender dysphoria scale, indicating less gender dysphoric symptoms in this cohort. However, participants in mid- and late adolescents had significantly lower scores when compared with early adolescents (P = 0.009). Self-reported transgender had significantly lower scores in the social (P = 0.001) and socio-legal (P < 0.001) indicators of the scale. Conclusion: The findings of this study, although, preliminary demonstrated less gender dysphoric symptoms in this cohort of Nigerian adolescents and young adults compared to the Western population. Nevertheless, some degree of GD was noticed, revealing that this condition is existent in our society.

Co-occurring Autism Spectrum Disorder and Gender Dysphoria in Adolescents.

BACKGROUND AND OBJECTIVES: Autism spectrum disorder (ASD) and gender dysphoria (GD) frequently cooccur. However, existing research has primarily used smaller samples, limiting generalizability and the ability to assess further demographic variation. The purpose of this study was to (1) examine the prevalence of cooccurring ASD and GD diagnoses among US adolescents aged 9 to 18 and (2) identify demographic differences in the prevalence of cooccurring ASD and GD diagnoses. METHODS: This secondary analysis used data from the PEDSnet learning health system network of 8 pediatric hospital institutions. Analyses included descriptive statistics and adjusted mixed logistic regression testing for associations between ASD and GD diagnoses and interactions between ASD diagnosis and demographic characteristics in the association with GD diagnosis. RESULTS: Among 919 898 patients, GD diagnosis was more prevalent among youth with an ASD diagnosis compared with youth without an ASD diagnosis (1.1% vs 0.6%), and adjusted regression revealed significantly greater odds of GD diagnosis among youth with an ASD diagnosis (adjusted odds ratio = 3.00, 95% confidence interval: 2.72-3.31). Cooccurring ASD/GD diagnoses were more prevalent among youth whose electronic medical record-reported sex was female and those using private insurance, and less prevalent among youth of color, particularly Black and Asian youth. CONCLUSIONS: Results indicate that youth whose electronic medical record-reported sex was female and those using private insurance are more likely, and youth of color are less likely, to have cooccurring ASD/GD diagnoses. This represents an important step toward building services and supports that reduce disparities in access to care and improve outcomes for youth with cooccurring ASD/GD and their families.

[Care pathways for young transgender people]. / Parcours de soins des jeunes personnes transgenres.

Gender incongruence corresponds to the mismatch between gender identity and gender/sex assigned at birth gender/sex assigned at birth. It can be accompanied by psychological distress. In line with the literature, an increase in consultations for gender incongruence has been observed, especially among young people. Multidisciplinary care should be offered to this population; here we provide an example of healthcare proposed at the university hospital of Nancy.

Gender Dysphoria in Pediatric and Transitional-Aged Youth Hospitalized for Suicidal Behaviors: A Cross-National Inpatient Study.

Objective: Our study aims to demarcate the sociodemographic differences in pediatric patients hospitalized for suicidal behaviors and struggling with gender dysphoria. Additionally, we evaluated the demographic factors and comorbidities that are predictive of gender dysphoria in patients with suicidal behaviors.Methods: We included 319,430 patients (aged 6-24 years) with suicidal behaviors and a primary psychiatric diagnosis (per ICD-10 criteria) of mood disorders (depressive disorders, 75.3%; bipolar disorders, 15.9%; and other mood disorders, 8.8%) from the Nationwide Inpatient Sample (2018-2019). We compared the distributions of categorical variables using the Pearson χ2 test and continuous variables using an independent-samples t test in inpatients without versus with gender dysphoria. We used a logistic regression model to calculate the odds ratio (OR) to assess the demographic and comorbid characteristics of gender dysphoria with suicidal behaviors.Results: The prevalence of codiagnosis of gender dysphoria in inpatients hospitalized for suicidal behaviors was 1.5%. Gender dysphoria was seen in a higher proportion of adolescents (68.2%), females (73.6%), those from high-income families (51.7%), and those from metropolitan counties (88.8%). The prevalent psychiatric comorbidities in inpatients with gender dysphoria included anxiety disorders (63.6%), posttraumatic stress disorder (PTSD; 28.2%), and neurodevelopmental disorders (27.4%). Comorbidities including somatic disorders (OR = 2.30), eating disorders (OR = 1.95), obsessive-compulsive disorder (OR = 1.71), anxiety disorders (OR = 1.59), PTSD (OR = 1.32), and neurodevelopmental disorders (OR = 1.17) increased the likelihood of codiagnoses of gender dysphoria.Conclusions: There exists a high prevalence of psychiatric comorbidities in those with gender dysphoria and hospitalized for suicidal behavior. Our findings call for prompt evaluations of comorbidities of suicidal behaviors among adolescents and youth with gender dysphoria to provide a coordinated approach to suicide prevention, thereby reducing the future risk of poor health outcomes and mortality.

Evolution and trends in referrals to a specialist gender identity unit in Spain over 10 years (2012-2021).

BACKGROUND: International studies have reported an increase in referrals to gender identity units, a shift in the assigned sex ratio of adolescents, a decrease in the age at first visit, and a growing presence of individuals with nonbinary gender identities. AIM: To investigate whether these trends are present in a Spanish sample of individuals referred to a gender identity unit over the last 10 years. METHODS: We conducted a retrospective chart review of 913 consecutive referrals to a gender identity unit between 2012 and 2021 and retrieved information regarding sex assigned at birth, age at first visit, and expressed gender identity. We stratified the patients into 5 age categories: children (<12 years), adolescents (12-17 years), young adults (18-25 years), adults (26-45 years), and older adults (>45 years). The data were analyzed via descriptive and regression analyses. OUTCOMES: Outcomes included the number of annual referrals, age at first visit, assigned sex ratio, and individuals with nonbinary gender identities. RESULTS: The number of referrals increased 10-fold, from 18 in 2012 to 189 in 2021. The rates of increase over time were significantly more pronounced for adolescents and young adults and significantly greater for those assigned female at birth (AFAB). The age of referrals at first visit decreased, and AFAB individuals were, on average, younger than individuals assigned male at birth. The assigned sex ratio favored AFAB patients among adolescents (2.4:1) and young adults (1.75:1). Logistic regression showed that the odds of a new referral being AFAB increased by 9% per calendar year and that adolescent and young adult new referrals were significantly more likely to be AFAB. There were 21 referrals of nonbinary individuals starting in 2017, making up 6.4% of applications in 2021 and 2.9% during the last 5 years. CLINICAL IMPLICATIONS: The evolution and trends observed in this study highlight the need for expanded resources, competent care, and careful reflection about implications for best practice. STRENGTHS AND LIMITATIONS: This investigation involves a large sample of patients and is the first in our country to include people of all ages. However, the findings might not be generalizable to other gender identity units or the broader population of gender-diverse individuals. CONCLUSION: Overall, our findings were consistent with previous international reports. We observed a marked increase in referrals, particularly among AFAB adolescents and young adults, a decreased age at first visit, and a growing presence of nonbinary individuals.

Prevalence and Comorbidity of Gender Dysphoria in Taiwan, 2010-2019.

Gender dysphoria (GD) is a condition in which a person exhibits marked incongruence between their expressed or experienced gender and their sex assigned at birth. The last survey of individuals with GD in Taiwan was conducted approximately 10 years ago. In this study, we investigated the prevalence of GD in Taiwan within the last 10 years as well as comorbidities. A retrospective medical record review was performed for all patients in the database of the Health and Welfare Data Science Center covered by National Health Insurance in Taiwan from January 2010 until December 2019. The study population of persons with GD was defined as individuals who had been diagnosed with transsexualism (transgender or transsexual) or gender identity disorders. Our review found case numbers and prevalence of GD in 2019 were about twice that of patients in 2010 for both assigned males and assigned females at birth. Case numbers for 2010 versus 2019 were 440 versus 867 for assigned males at birth, and 189 versus 386 for assigned females at birth. The 1-year prevalence for 2010 versus 2019 was 3.8/100,000 versus 7.4/100,000 for assigned males at birth, and 1.6/100,000 versus 3.2/100,000 for assigned females at birth. Comorbidities of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and psychosis were more likely in children with GD younger than 12 years of age; comorbid depression was more likely in adolescents and adults with GD. Improvements in social and mental health support should be provided to help address these comorbidities of ADHD, ASD, and depression among individuals with GD.

Validation of Two Measures of Gender Dysphoria/Incongruence in Transgender and Cisgender Populations in China.

This study examined gender dysphoria (GD) in transgender and cisgender populations in China and aimed to provide validity evidence for two dimensional measures of GD. A total of 293 transgender people (170 transmen, 65 transwomen, and 58 non-binary trans people; mean age, 21.3 years) and 538 cisgender people (296 ciswomen and 242 cismen; mean age, 23.5 years) completed the Utrecht Gender Dysphoria Scale (UGDS), the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA), and demographic information online. The UGDS and the GIDYQ-AA had good reliability and validity for the Chinese population. Transgender people reported higher intensity of GD than cisgender people. Cisgender women reported higher intensity of GD than cisgender men. Non-binary transgender people reported lower intensity than binary transgender people. However, transmen reported higher intensity than transwomen for the UGDS but not for the GIDYQ-AA. Transgender people with gender-affirming hormonal treatment experience reported higher intensity of GD than those without treatment. Moreover, transgender people coming out to parents reported higher intensity than those who did not. The cutoff values of the UGDS and the GIDYQ-AA in the original version show high sensitivity for transgender people and specificity for cisgender people. Our findings indicate that the UGDS and the GIDYQ-AA are validated measures of GD in China.

Demographics and gender-related measures in younger and older adolescents presenting to a gender service.

Transgender adolescents may present to gender identity specialty services earlier or later in adolescence. The aim of this study was to examine whether, 'younger' and 'older' presenters could be identified in a large cohort of transgender adolescents and if differences exist between the two groups. The study sample consisted of 1487 adolescents (506 birth-assigned males, 981 birth-assigned females) referred between 2000 and 2018. The distribution of age at intake was evaluated. Demographic, diagnostic, and treatment characteristics, the Recalled Childhood Gender Identity/Gender Role Questionnaire (RCGI) to measure childhood gender nonconformity and the Body Image Scale (BIS) to measure body image were collected. Based on a stem-and-leaf plot and a histogram, two groups were identified: adolescents presenting at ≤ 13.9 years ('younger presenters') and adolescents presenting at 14 years or older ('older presenters'). The sex ratio was more extreme in the group of older presenters favoring birth-assigned females (Χ2(1, N = 1487) = 19.69, p < 0.001). Furthermore, more adolescents from the younger presenting group lived with both biological parents (Χ2(1, N = 1427) = 24.78, p < 0.001), were diagnosed with gender dysphoria and started with medical gender-affirming treatment (Χ2(1, N = 1404) = 4.60, p = 0.032 and Χ2(1, N = 1487) = 29.16, p < 0.001). Younger presenters showed more gender nonconformity in childhood (ß 0.315, p < 0.001, 95% CI 0.224-0.407). Older presenters were more dissatisfied with various aspects of their bodies (p < 0.001). The differences between older and younger presenting adolescents suggest that there may be different developmental pathways in adolescents that lead to seeking gender-affirming medical care and argues for more tailored care.

Healthcare clinician perspectives on the intersection of autism and gender dysphoria.

LAY ABSTRACT: Autistic people are more likely to have a gender identity which does not match their sex assigned at birth. Some people experience distress about their sex and gender not matching, which is called gender dysphoria. Such individuals may wish to attend a gender clinic to access healthcare support for gender dysphoria. Currently, there is limited evidence to help clinicians best support autistic people who need healthcare for gender dysphoria. We wanted to find out what healthcare clinicians think about working with autistic patients with gender dysphoria. We interviewed 16 clinicians who work in healthcare services with adults and young people who are autistic and experience gender dysphoria. We recorded the interviews and carefully analysed the content to find key themes. We found that clinicians worked with patients to try and better understand their experiences of gender dysphoria. Clinicians identified features of autism that they believed were related to gender identity and dysphoria including different thinking styles, social differences, and sensory sensitivities. Clinicians noticed that autistic people spoke about their gender in different ways to non-autistic people. Clinicians tried to adapt their practice to better meet the needs of their autistic patients. These adaptations tended to focus on differences in the assessment process, for example, offering longer or shorter appointments and changing their communication style. We conclude that clinicians were offering an individualised approach to autistic patients experiencing gender dysphoria. However, these clinicians were particularly interested in working with autistic people, and so may not be representative of the wider clinician population. Clinicians working in this area should receive training on autism adaptations and the intersection of autism and gender dysphoria.

Autism Spectrum Disorder and Gender Dysphoria/Incongruence. A systematic Literature Review and Meta-Analysis.

The suggested overlap between autism spectrum disorder (ASD) and gender dysphoria/incongruence (GD/GI) has been much disputed. This review showed a relationship between ASD traits and GD feelings in the general population and a high prevalence of GD/GI in ASD. Our meta-analyses revealed that the pooled estimate of the prevalence of ASD diagnoses in GD/GI people was 11% (p < .001) and the overall effect size of the difference in ASD traits between GD/GI and control people was significant (g = 0.67, p < .001). Heterogeneity was high in both meta-analyses. We demonstrated that the chances that there is not a link between ASD and GD/GI are negligible, yet the size of it needs further investigation.

Prevalence of gender dysphoria and suicidality and self-harm in a national database of paediatric inpatients in the USA: a population-based, serial cross-sectional study.

BACKGROUND: Transgender and non-binary young people experience discrimination that has been linked to suicidal ideation and self-harm, but few studies have examined this association systematically. We aimed to study the association between gender dysphoria-related diagnostic coding and hospital admission for suicidality or self-harm in a large representative pediatric inpatient database from the USA. METHODS: Using the 2016 and 2019 Kids' Inpatient Database (KID), we identified transgender and non-binary young people (aged 6-20 years) with International Classification of Diseases (ICD)-10 codes related to gender dysphoria. We identified suicidal ideation using explicit suicidality ICD-10 codes, and self-harm using 355 self-harm ICD-10 codes. Prevalence of suicidality (primary outcome), self-harm, and the combination of suicidality and self-harm (secondary outcomes) was compared between young people with and without gender dysphoria-related codes. Univariable and multivariable regression was used to test for an association between gender dysphoria and suicidality, self-harm, or suicidality and self-harm combined. FINDINGS: 1 090 544 individuals were included from KID 2016 and 1 026 752 from KID 2019. Gender dysphoria-related diagnoses were prevalent in 161 per 100 000 hospital admissions in KID 2016 and 475 per 100 000 hospital admissions in KID 2019. In KID 2016 and KID 2019, among individuals who were White, privately insured, or from higher median income ZIP code areas, proportionately more had gender dysphoria-related codes. Prevalence of suicidality was greater in individuals with gender dysphoria-related codes than in individuals without gender dysphoria-related codes in KID 2016 (635 [36%] of 1755 individuals with gender dysphoria-related codes vs 55 351 [5%] of 1 088 789 individuals without gender dysphoria-related codes; unadjusted prevalence ratio [PR] 7·19 [95% CI 6·75-7·66]) and KID 2019 (2680 [55%] of 4872 individuals with gender dysphoria-related codes vs 38 831 [4%] of 1 021 880 individuals without gender dysphoria-related codes; unadjusted PR 5·45 [5·30-5·60]). This association persisted in multivariable modelling adjusting for confounders in KID 2016 (adjusted PR 5·02 [95% CI 4·67-5·41]) and KID 2019 (4·14 [4·02-4·28]). Increased unadjusted and adjusted PRs for individuals with gender dysphoria-related codes, relative to those without, were also evident for self-harm and when combining suicidality and self-harm in both the 2016 and 2019 datasets. INTERPRETATION: In a large representative national sample, transgender and non-binary young people with gender dysphoria-related diagnoses were frequently admitted to hospital for suicidality or self-harm. The lower rates of gender-dysphoria-related codes among young people who were non-White, publicly insured, and from low-income households suggest that underlying inequities might shape the identification and management of gender dysphoria. Structural and health-care provider-level interventions are needed to reduce discrimination and expand gender-affirming competencies to prevent adverse outcomes for hospitalised transgender and non-binary young people with gender dysphoria. FUNDING: National Institutes of Health.

Gender dysphoria in twins: a register-based population study.

Both genetic and environmental influences have been proposed to contribute to the variance of gender identity and development of gender dysphoria (GD), but the magnitude of the effect of each component remains unclear. We aimed to examine the prevalence of GD among twins and non-twin siblings of individuals with GD, using data derived from a large register-based population in Sweden over the period 2001-2016. Register data was collected from the Statistics Sweden and the National Board of Health and Welfare. The outcome of interest was defined as at least four diagnoses of GD or at least one diagnosis followed by gender-affirming treatment. A total of 2592 full siblings to GD cases were registered, of which 67 were twins; age at first GD diagnosis for the probands ranged from 11.2 to 64.2 years. No same-sex twins that both presented with GD were identified during the study period. The proportion of different-sex twins both presenting with GD (37%) was higher than that in same-sex twins (0%, Fisher's exact test p-value < 0.001) and in non-twin sibling pairs (0.16%). The present findings suggest that familial factors, mainly confined to shared environmental influences during the intrauterine period, seem to contribute to the development of GD.