Gender and Autism Program: A novel clinical service model for gender-diverse/transgender autistic youth and young adults.

Objective: Situated in Children's National Hospital (CNH)'s Neuropsychology Division, the Gender and Autism Program (GAP) is the first clinical service dedicated to the needs of autistic gender-diverse/transgender youth. This study describes GAP clinical assessment profiles and presents a multi-perspective programmatic review of GAP evaluation services. Method: Seventy-five consecutive gender- and neuropsychologically-informed GAP evaluations were analyzed, including demographics, gender and autism characterization, and primary domains evaluated. Three program-based Delphi studies were conducted and identify: clinician priorities and challenges in providing care, program administrator lessons learned and ongoing barriers, and considerations adapting this model for a rural academic medical center. Results: Nearly two-thirds of referrals were transfeminine. Most youth had existing autism diagnoses; of those undiagnosed, three-quarters were found to be autistic. Five goals of evaluations were identified: Mental health was always assessed, and most evaluations also assessed gender-related needs in the context of autism neurodiversity. Neuropsychological characterization of strengths and challenges informed personalized accommodations to support youth gender-related self-advocacy. Clinicians emphasized frequent youth safety concerns. Administrators emphasized the need for specialized training for working with families. Components for adaptation of the GAP in a rural academic medical center were identified. Conclusions: Since its founding, the GAP has proven a sustainable neuropsychology-based service with consistent referral flow and insurance authorizations. Capturing staff perspectives through rigorous Delphi methods, and addressing the GAP's feasibility and replicability, this study provides a road map for replicating this service. We also highlight GAP training of specialist clinicians, fundamental to addressing the desperate shortage of providers in this field.

Autistic and non-autistic transgender youth are similar in gender development and sexuality phenotypes.

Increasing rhetoric regarding the common intersection of autism and gender diversity has resulted in legislation banning autistic transgender youth from accessing standard of care supports, as well as legislative efforts banning all youth gender care in part justified by the proportional over-occurrence of autism. Yet, no study has investigated whether autistic and non-autistic transgender youth present fundamentally different gender-related phenotypes. To address this gap, we extensively characterized autism, gender diversity, and sexuality among autistic and non-autistic transgender binary youth (N = 66, Mage = 17.17, SDage = 2.12) in order to investigate similarities and/or differences in gender and sexuality phenotypes. Neither autism diagnostic status nor continuous autistic traits were significantly related to any gender or sexuality phenotypes. These findings suggest that the developmental and experiential features of gender diversity are very similar between autistic and non-autistic transgender adolescents. Future research is needed to determine whether the similarity in profiles is maintained over time into adulthood.

The Toronto Adolescent and Youth Cohort Study: Study Design and Early Data Related to Psychosis Spectrum Symptoms, Functioning, and Suicidality.

BACKGROUND: Psychosis spectrum symptoms (PSSs) occur in a sizable percentage of youth and are associated with poorer cognitive performance, poorer functioning, and suicidality (i.e., suicidal thoughts and behaviors). PSSs may occur more frequently in youths already experiencing another mental illness, but the antecedents are not well known. The Toronto Adolescent and Youth (TAY) Cohort Study aims to characterize developmental trajectories in youths with mental illness and understand associations with PSSs, functioning, and suicidality. METHODS: The TAY Cohort Study is a longitudinal cohort study that aims to assess 1500 youths (age 11-24 years) presenting to tertiary care. In this article, we describe the extensive diagnostic and clinical characterization of psychopathology, substance use, functioning, suicidality, and health service utilization in these youths, with follow-up every 6 months over 5 years, including early baseline data. RESULTS: A total of 417 participants were enrolled between May 4, 2021, and February 2, 2023. Participants met diagnostic criteria for an average of 3.5 psychiatric diagnoses, most frequently anxiety and depressive disorders. Forty-nine percent of participants met a pre-established threshold for PSSs and exhibited higher rates of functional impairment, internalizing and externalizing symptoms, and suicidality than participants without PSSs. CONCLUSIONS: Initial findings from the TAY Cohort Study demonstrate the feasibility of extensive clinical phenotyping in youths who are seeking help for mental health problems. PSS prevalence is much higher than in community-based studies. Our early data support the critical need to better understand longitudinal trajectories of clinical youth cohorts in relation to psychosis risk, functioning, and suicidality.

Gender diversity in a Chinese community sample and its associations with autism traits.

Emerging evidence suggests that gender dysphoria or gender diversity (GD) intersects frequently with autism spectrum disorder or autism traits. However, the magnitude and interpretation of this link continue to be debated. Most child studies on this topic were performed in clinical populations, and little is known about the generalizability of this co-occurrence to the broader community, especially to non-Western samples. Also, little is known about whether specific subdomains of autism are more strongly associated with GD. Therefore, we investigated GD and its association with autism traits in a Chinese community sample of 4-12-year-olds (N = 379; 51% birth-assigned girls). Parents provided information about GD characteristics using the standardized Gender Identity Questionnaire for Children and autism traits using the Chinese version of the Autism-Spectrum Quotient-Children. In addition, broader behavioral and emotional challenges were measured by the Behavior Problem Index (BPI) to account for psychological challenges other than autism traits. In this community sample of Chinese children, increased GD was associated with increased autism traits, even after accounting for the BPI. Of the four subscales, the Imagination and Patterns subscales in birth-assigned girls and the Imagination subscale in birth-assigned boys were especially associated with GD. These findings indicate that the association between GD and autism traits generalizes to a nonclinical, non-Western sample. Clinicians and researchers working with clinical as well as community children should thus pay attention to the co-occurrence of GD and autism traits, in and outside the West.

Cognitive and Developmental Profiles Associated with Self-Reported Sexual and Gender Minority Stigmatization Among Binary Transgender Adolescents.

OBJECTIVE: Sexual and gender minority (SGM) stigmatization is a key factor related to transgender adolescent mental health. While previous research has focused on direct associations between stigmatization and mental health, the present study of transgender youth, equitably recruited across the autism spectrum, examines cognitive and developmental factors in relation to the self-report of experienced and perceived SGM stigmatization. METHOD: 65 binary transgender adolescents (43% transfeminine; ages 13-21 years) were intentionally recruited across the spectrum of autism traits from no traits to full criteria autism. Participants completed measures of autism-related social differences, cognitive abilities, and self-reported directly experienced and perceived SGM stigma. Autism-related social differences, cognitive abilities, and age were studied in relation to both SGM stigma factors. RESULTS: Autism-related social differences were negatively associated with level of directly experienced SGM stigma but unassociated with perceived stigma. Greater cognitive ability was positively associated with level of perceived SGM stigma, but unassociated with report of directly experienced stigma. Older age was positively associated with level of perceived SGM stigma. There was a statistical trend toward older age positively associated with level of directly experienced stigma. CONCLUSIONS: The present study identifies candidate cognitive and developmental influences on self-reported SGM stigmatization among transgender adolescents, evenly recruited across the autism spectrum. The factors which may impact the perception and experience of stigmatization have been notably under-explored in the mental health field. The examination of these individual characteristics may allow for more precise predictive models for research with transgender youth, and ultimately, in clinical care.

Common Intersection of Autism and Gender Diversity in Youth: Clinical Perspectives and Practices.

Autism and gender diversity often intersect. Many transgender youth seeking gender-related medical interventions are autistic. Clinicians serving these youth lack an autism-specific evidence base to guide gender care decisions. At present, care decisions are based on extrapolation of care models from transgender youth samples, generally. At this point, there is no evidence to suggest that autistic youth are likely to experience shifts in gender or gender-related medical requests, although this has been insufficiently studied. In this article, cowritten by expert clinicians and autistic gender-diverse collaborators, an overview of clinical care considerations and the current evidence base is provided.

The Intersection of Autism and Transgender and Nonbinary Identities: Community and Academic Dialogue on Research and Advocacy.

Many transgender people are autistic. Community expressions of the autism transgender intersection abound. Some commentators have questioned the proportional overrepresentation of autism among gender-diverse people, suggesting these individuals may not be truly autistic or truly transgender. However, increasing evidence challenges assertions that deny the authenticity of co-occurring autistic and transgender identities. Specifically, research by authors of this article indicates autistic transgender people show neurophenotypes generally consistent with cisgender autistic people and implicit gender phenotypes consistent with nonautistic transgender people. This article features a dialogue between eight leading experts in the field of intersectional autism and gender diversity, including clinicians, researchers, community advocates, and experts who are themselves autistic transgender. Key topics of discussion included: how research findings on autism and gender diversity inform respectful and supportive responses to autistic transgender people; the benefits and harms of increased societal attention toward the autism transgender intersection; and research and advocacy priorities. The expert panel concluded the following: (1) it is important to respect transgender autistic people's wellness and resilience, while also acknowledging the pathologization and stigmatization they face; (2) autistic gender-diverse people are experts of their own identity and should be involved in all aspects of research and clinical care; (3) research is needed to understand the disparities autistic transgender people face; (4) attempts to restrict autistic transgender people's access to gender care are unsupported by existing research; (5) adult gender care may benefit from incorporating universal design principles and neurodiversity-affirming strategies to reduce barriers to care and improve clinician-client communication in treatment delivery and the informed consent process; (6) cross-cultural and cross-societal research will improve best care practices in diverse contexts; (7) research and advocacy must be inclusive across ethnoracial identities, including in leadership and perspectives represented; and (8) a life span developmental framework is needed for adult research in this field.

The Gender-Diversity and Autism Questionnaire: A Community-Developed Clinical, Research, and Self-Advocacy Tool for Autistic Transgender and Gender-Diverse Young Adults.

Background: Autistic transgender people face unique risks in society, including inequities in accessing needed care and related mental health disparities. Given the need for specific and culturally responsive accommodations/supports, the characterization of key experiences, challenges, needs, and resilience factors within this population is imperative. This study developed a structured self-report tool for autistic transgender young adults to communicate their experiences and needs in a report format attuned to common autistic thinking and communication styles. Methods: This cross-nation project developed and refined the Gender-Diversity and Autism Questionnaire through an iterative community-based approach using Delphi panel methodology. This proof-of-principle project defined "expertise" broadly, employing a multi-input expert search approach to balance academic-, community-, and lived experience-based expertise. Results: The expert collaborators (N = 24 respondents) completed a two-round Delphi study, which developed 85 mostly closed-ended items based on 90% consensus. Final item content falls within six topic areas: the experience of identities; the impact of experienced or anticipated discrimination, bias, and violence toward autistic people and transgender people; tasks and experiences of everyday life; gender diversity- or autism-related care needs and history; the experience of others doubting an individual's gender identity and/or autism; and the experience of community and connectedness. The majority of retained items relate to tasks and experiences of everyday life or the impact of experienced or anticipated discrimination, bias, and violence. Conclusions: This study employed a multipronged multimodal search approach to maximize equity in representation of the expert measure development team. The resulting instrument, designed for clinical, research, and self-advocacy applications, has parallel Dutch and English versions and is available for immediate use. Future cross-cultural research with this instrument could help identify contextual risk and resilience factors to better understand and address inequities faced by this large intersectional population.

Why is this an important issue?: Transgender and gender-diverse are words used to describe people whose gender varies from their assigned sex at birth. Many autistic people identify as being transgender/gender-diverse. Autistic gender-diverse/transgender young adults often describe difficulties getting the care they need, which can increase their chances of experiencing stress and mental health challenges. This study created a self-report questionnaire for autistic transgender/gender-diverse young adults to share about their health care, support needs, and broader experiences. What were the results of the study?: A diverse group of experts in the autism and gender diversity co-occurrence, including autistic transgender people, worked together to develop the questionnaire. The researchers found experts by searching the internet and talking to people in the community and research field. The questionnaire is called the Gender-Diversity and Autism Questionnaire and has 85 questions that are grouped into 6 different areas: the experience of identities; the impact of experienced or anticipated discrimination, bias, and violence toward autistic people and transgender people; tasks and experiences of everyday life; gender diversity- or autism-related care needs and history; the experience of others doubting an individual's gender identity and/or autism; and the experience of community and connectedness. The questionnaire has English and Dutch versions so it can be used for research in different countries. What do the authors recommend for future research on this topic?: Researchers are currently using the new questionnaire to compare the experiences and needs of autistic transgender young adults in the Netherlands and the United States. The results may help explain why some outcomes are different between autistic transgender young people in the two countries and how culture and society play a role. How will these findings help autistic adults now or in the future?: We created the questionnaire to be used in different settings, including clinics and in research. The questionnaire gives autistic transgender young adults a structured way to communicate their experiences, needs, challenges, and areas of strength. The answers that an autistic transgender young adult gives on the questionnaire could help other people understand the clinical and community supports that the young adult wants and needs. Future studies may use the questionnaire to understand obstacles that autistic transgender young adults may face.

Body Image in Adolescents with Gender Incongruence and Its Association with Psychological Functioning.

During adolescence, many individuals with gender incongruence (GI) experience distress related to body dissatisfaction. This study aims to describe the body (dis)satisfaction of Dutch adolescents referred for GI and to describe the influence of body image on their psychological functioning. Self-report measures on body satisfaction (Body Image Scale) and psychological functioning (Youth Self-Report) were obtained from 787 adolescents (aged 10-18) who were referred to the Center of Expertise on Gender Dysphoria at the Amsterdam University Medical Centers between 1996 and 2016. First, a general description of body satisfaction in adolescents with GI was developed. Secondly, multiple linear regression analyses were performed to determine the association between body image and psychological functioning, both for total problems and for internalizing and externalizing problems separately. Third, regression analyses are repeated for body area subscales. Adolescents with GI report the greatest dissatisfaction with the genital area, regardless of birth-assigned sex. For all other body areas, there were birth-assigned sex differences in satisfaction. The analyses showed that body satisfaction was significantly related to total psychological problems and both internalizing and externalizing problems. Greater body dissatisfaction is significantly associated with worse psychological functioning in adolescents with GI. Clinicians should monitor the body image of adolescents with GI over time, especially during puberty and medical interventions.

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.

Self-Perception of Transgender Adolescents After Gender-Affirming Treatment: A Follow-Up Study into Young Adulthood.

Purpose: Early medical treatment for transgender adolescents should contribute to healthy psychological development, including the development of positive self-perception. However, at present, there are no longitudinal studies that have examined whether current treatment approaches meet this expectation. Therefore, the aim of this single-arm retrospective study was to examine transgender adolescents' self-perception changes over the course of irreversible medical gender-affirming treatment. Methods: The total study sample consisted of 70 adolescents (49 trans men and 21 trans women). Self-perception was assessed before the start of gender-affirming hormone treatment (mean age = 14.65, standard deviation (SD) = 2.08) and at least 6 months after gender-affirming surgeries (mean age = 20.70, SD = 1.49) by Self-Perception Profile for Adolescents (SPPA). The SPPA is a self-report measure that examines self-perception on seven different domains: Scholastic competence, social acceptance, athletic competence, physical appearance, behavioral conduct, close friendship, and global self-worth. Multilevel modeling (random intercepts model) was conducted to determine the effect of time for all domains of self-perception. Results: It was found that the domains of physical appearance and global self-worth improved significantly over the course of treatment. No domain worsened significantly over the course of treatment. The domains of scholastic competence, social acceptance, athletic competence, and close friendship remained stable over time. Conclusion: This study provides the first suggestive evidence that irreversible gender-affirming treatment for adolescents could contribute to the development of a more positive self-perception.

Childhood Gender Variance and the Autism Spectrum: Evidence of an Association Using a Child Behavior Checklist 10-Item Autism Screener.

Childhood gender variance (GV) is associated with autism spectrum disorder (ASD) diagnosis/traits; however, this association has mainly been investigated in clinical samples. An ASD screening measure based on 10 items from the commonly used Child Behavior Checklist (CBCL) might enable investigation of this association in a wider variety of (non-clinical) populations where the CBCL and a measure of GV are available. We investigated whether GV in 6- to 12-year-olds (N = 1719; 48.8% assigned male at birth) from a community sample showed an association with the CBCL 10-item ASD screener. The Gender Identity Questionnaire for Children measured GV. The CBCL 10-item ASD screener measured ASD traits. The remaining CBCL items provided a measure of children's general emotional and behavioral challenges. Higher GV was associated with higher CBCL ASD screener scores, including when controlling for the remaining CBCL items. The CBCL 10-item ASD screener can be useful for investigating the link between GV and ASD traits in 6- to 12-year-olds. Given that the CBCL is commonly employed, secondary analyses of existing datasets that also included a measure of GV could enable investigation of how widely the association between GV and ASD applies across a variety of populations.

Assessing Medical Decision-Making Competence in Transgender Youth.

BACKGROUND: According to international transgender care guidelines, an important prerequisite for puberty suppression (PS) is transgender adolescents' competence to give informed consent (IC). In society, there is doubt whether transgender adolescents are capable of this, which in some countries has even led to limited access to this intervention. Therefore, this study examined transgender adolescents' medical decision-making competence (MDC) to give IC for starting PS in a structured, replicable way. Additionally, potential associated variables on MDC, such as age, intelligence, sex, psychological functioning, were investigated. METHODS: A cross-sectional semistructured interview study with 74 transgender adolescents (aged 10-18 years; 16 birth-assigned boys, 58 birth-assigned girls) within two Dutch specialized gender-identity clinics was performed. To assess MDC, judgements based on the reference standard (clinical assessment) and the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), a validated semistructured interview, were used. RESULTS: Of the transgender adolescents, 93.2% (reference standard judgements; 69 of 74) and 89.2% (MacCAT-T judgements; 66 of 74) were assessed competent to consent. Intermethod agreement was 87.8% (65 of 74). Interrater agreements of the reference standard and MacCAT-T-based judgements were 89.2% (198 of 222) and 86.5% (192 of 222), respectively. IQ and sex were both significantly related to MacCAT-T total score, whereas age, level of emotional and behavioral challenges, and diagnostic trajectories duration were not. CONCLUSIONS: By using the MacCAT-T and clinicians' assessments, 93.2% and 89.2%, respectively, of the transgender adolescents in this study were assessed competent to consent for starting PS.

Examining the Relation Between Gender Nonconformity and Psychological Well-Being in Children: The Roles of Peers and Parents.

No study to date has simultaneously tested how poor peer relations, generic risk factors, and parental attitudes impact the behavioral and emotional challenges of children who vary in their gender expression. In a community sample, the present study investigated various hypothesized psychosocial and generic risk factors regarding the association between childhood gender nonconformity (GNC) and psychological well-being. Canadian parents/guardians reported on their children aged 6-12 years (N = 1719, 48.8% assigned male at birth) regarding their child's GNC, measured by the Gender Identity Questionnaire for Children; behavioral and emotional challenges, measured by the Child Behavior Checklist (CBCL); and peer relations, measured by the CBCL and Strength and Difficulties Questionnaire. Parent/guardian gender-stereotypical attitudes toward child-rearing were assessed using an adapted version of the Child-Rearing Sex Role Attitude Scale, and attachment between the parent/guardian and child was measured with an adapted version of the Child-Rearing Practices Report. Based on regression analyses, GNC was related to elevated behavioral and emotional challenges, and this association was stronger for those who experienced poor peer relations as well as for those whose parents/guardians endorsed gender-stereotyped attitudes and were less willing to serve as a secure base for the child. Recommendations are provided for ways in which social environments can be altered to improve psychological well-being among gender-nonconforming children.

INSAR Special Interest Group Report: Stakeholder Perspectives on Priorities for Future Research on Autism, Sexuality, and Intimate Relationships.

The number of empirical studies on sexuality and intimate relationships in autistic people has grown over the last years with the increasing awareness that sexuality and intimate relationships are an important part of life and well-being for autistic people. Further, expression and enjoyment of sexuality is a fundamental, basic human right. This paper reports on needs for future research in this area based on the input of autistic adults, researchers, and other stakeholders (e.g., parents and professionals). Utilizing the nominal group technique, 65 individuals participated in eight groups in which they brainstormed on research questions they deemed most important. Responses were categorized into themes and ranked according to importance based on the level of priority attributed by participants. Findings suggest that future research should focus on developing ways to support sexual and relationship well-being and getting a better understanding of sexuality and relationships in autistic people. Also, attention was drawn to the need for studying the influence of stereotypical societal views, and stigma. Finally, the importance of participatory research to include perspectives of autistic people in research and practice was stressed. LAY SUMMARY: Sexuality and romantic relationships are part of daily life for most people, including autistic people. For this study, groups of autistic people, professionals, and autism researchers discussed which research on autism, sexuality, and relationships is needed and can help autistic adolescents and adults. The group discussions revealed that more research is needed on how to support well-being relating to romantic relationships and sexuality in autistic people and how the people around them can contribute to this. Therefore, we also need to learn more about how autistic people of all ages and throughout their lives experience sexuality and relationships. Finally, the need for attention to the role of stereotypical ideas and stigma about autism, sexuality, and relationships was pointed out. Attention to the experiences of autistic people can help professionals, researchers, and policy makers to offer and organize attuned support and do relevant research. Autism Res 2020, 13: 1248-1257. © 2020 The Authors. Autism Research published by International Society for Autism Research published by Wiley Periodicals LLC.

Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers.

PURPOSE: Transgender adolescents are at risk for internalizing and externalizing problems, along with high suicidality rates, and poor peer relations. The present study compared transgender adolescents before and after gender-affirmative care with a sample of nonclinical age-equivalent cisgender adolescents from the general population on psychological well-being and aimed to investigate the possible effect of transgender care involving puberty suppression. METHODS: In this cross-sectional study, emotional and behavioral problems were assessed by the Youth Self-Report in a sample of 272 adolescents referred to a specialized gender identity clinic who did not yet receive any affirmative medical treatment and compared with 178 transgender adolescents receiving affirmative care consisting of puberty suppression and compared with 651 Dutch high school cisgender adolescents from the general population. RESULTS: Before medical treatment, clinic-referred adolescents showed more internalizing problems and reported increased self-harm/suicidality and poorer peer relations compared with their age-equivalent peers. Transgender adolescents receiving puberty suppression had fewer emotional and behavioral problems than the group that had just been referred to transgender care and had similar or fewer problems than their same-age cisgender peers on the Youth Self-Report domains. CONCLUSIONS: Transgender adolescents show poorer psychological well-being before treatment but show similar or better psychological functioning compared with cisgender peers from the general population after the start of specialized transgender care involving puberty suppression.

Re-evaluation of the Dutch approach: are recently referred transgender youth different compared to earlier referrals?

The background of this article is to examine whether consecutively transgender clinic-referred adolescents between 2000 and 2016 differ over time in demographic, psychological, diagnostic, and treatment characteristics. The sample under study consisted of 1072 adolescents (404 assigned males, 668 assigned females, mean age 14.6 years, and range 10.1-18.1 years). The data regarding the demographic, diagnostic, and treatment characteristics were collected from the adolescents' files. Psychological functioning was measured by the Child Behaviour Check List and the Youth Self-Report, intensity of gender dysphoria by the Utrecht Gender Dysphoria Scale. Time trend analyses were performed with 2016 as reference year. Apart from a shift in sex ratio in favour of assigned females, no time trends were observed in demographics and intensity of dysphoria. It was found, however, that the psychological functioning improved somewhat over time (CBCL ß - 0.396, p < 0.001, 95% CI - 0.553 to - 0.240, YSR ß - 0.278, p < 0.001, 95% CI - 0.434 to - 0.122). The percentage of referrals diagnosed with gender dysphoria (mean 84.6%, range 75-97.4%) remained the same. The percentage of diagnosed adolescents that started with affirmative medical treatment (puberty suppression and/or gender-affirming hormones) did not change over time (mean 77.7%; range 53.8-94.9%). These findings suggest that the recently observed exponential increase in referrals might reflect that seeking help for gender dysphoria has become more common rather than that adolescents are referred to gender identity services with lower intensities of gender dysphoria or more psychological difficulties.

Separation anxiety and gender variance in a community sample of children.

In clinical child and retrospective adult samples, childhood gender variance (GV; i.e., cross-gender behaviour) has been associated with separation anxiety (SA; i.e., distress related to separation from attachment figures) in males. This study examined GV and SA in a nonclinical sample of 892 boys and 933 girls aged 6-12 years via parent-reports. Parental factors (i.e., parenting style, parent-child relationship, willingness to serve as an attachment figure, attitudes towards gender stereotypes in children) were examined as potential moderators. GV predicted SA in boys, even when statistically controlling for general psychopathology and demographic variables. Authoritative parenting, closeness in the parent-child relationship, willingness to serve as an attachment figure, and liberal attitudes towards gender stereotypes in children moderated the association between GV and SA in both boys and girls. Thus, SA may be a unique internalizing problem related to GV in boys in nonclinical samples and influenced by a variety of parental factors.