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Sex ratio and age distribution in the total sample, in children (aged 5-10), and adolescents (aged 11-18).
Source publication
Background
Young transgender or gender nonconforming (TGNC) children and adolescents or those with a gender dysphoria (GD) diagnosis show an increased risk of suicidal and nonsuicidal self-harming thoughts and behaviors (STBs). Data from German-speaking regions on this topic and studies comparing self- and parent-reported STBs have been scarce. The...
Context in source publication
Context 1
... comparison was conducted using the t test. Tests were performed with a 2-sided alpha level of .05. Table 1 summarizes the sociodemographic characteristics of the participants. The analysis sample of adolescents (n = 343, 87%) consisted of 84% AFAB people and 16% AMAB people with a mean age of 15.5 years, and there were no significant age differences between AFAB and AMAB adolescents. ...Similar publications
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The present study aimed to investigate whether differences exist between younger and older presenting adolescents at the Center of Expertise on Gender Dysphoria regarding psychological functioning and autistic traits. A total of 1487 consecutively assessed adolescents between 2000 and 2018 were divided in younger presenters (age ≤ 13.9 years) and o...
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Citations
... Other research focusing on TGD youth found that youth and caregivers presenting to a German gender clinic (N = 393; ages 5-18), often provided different responses in items capturing NSSI and suicidal thoughts and behaviors, with youth self-reporting more NSSI and suicidality than their caregivers had perceived (Hartig et al., 2022). Kuper et al. (2019) found that, in a sample of gender diverse youth presenting to a Southern United States pediatric gender clinic (N = 149), approximately one-third of youth reported clinically significant internalizing symptoms, while parents reported slightly lower rates of these symptoms than youth. ...
... TGD adolescents' self-reported psychological distress on the YSR was consistently higher than what their caregivers reported on the CBCL, thus offering support for Hypothesis 1. One possible reason for this pattern is that TGD adolescents have a tendency toward internalizing symptomatology (Connolly et al., 2016;Hartig et al., 2022;Levitan et al., 2019), potentially as a response to systematic and individualized discrimination as well as other forms of minority stress (Herrmann et al., 2024). Therefore, it is likely that caregivers may not be able to reliably assess the TGD adolescents' mental health or gender-related experiences, which poses a challenge to using caregivers as informants about TGD youth in research. ...
Gender-affirming hormones can be an essential intervention for gender dysphoria in transgender and gender diverse (TGD) adolescents. Caregivers are generally required to provide consent for adolescent medical intervention, but it is not yet well understood whether caregivers share their TGD adolescent’s understanding of their mental health and functioning at the time of hormone readiness assessment and whether any differences in understanding are related to adolescent mental health outcomes. The primary aims of this study were to (a) examine the degree of congruence between TGD adolescents’ self-reported psychosocial functioning and the caregivers’ report of the adolescent’s psychosocial functioning and (b) evaluate if the level of congruence was associated with the adolescent’s self-reported internalizing and externalizing symptomatology. Data were collected from 548 TGD adolescents and their caregivers at the time of hormone readiness assessment using the Youth Self-Report and Child Behavior Checklist. The results indicated moderate to strong correlations between adolescent’s self-report and caregiver report, though adolescents consistently reported experiencing greater symptomatology compared to caregiver perceptions. Hierarchical regressions revealed that greater differences between Youth Self-Report and Child Behavior Checklist Total problems subscale scores were associated with significantly greater adolescent internalizing and externalizing behaviors, after adjusting for various other variables. Findings suggest that caregivers are often not fully aware of the extent of distress experienced by TGD adolescents and that greater discrepancies between adolescent- and caregiver-reported psychosocial functioning at the time of hormone readiness are associated with greater self-reported distress from TGD youth. Implications for clinical care with TGD youth and their caregivers are explored.
... In addition to the "classic" EO developmental trajectories, possibly with a social role change in childhood, less bodyrelated distress until expected puberty, and a relatively higher proportion of individuals assigned male at birth (AMAB), in clinical settings, there seems to be a shifted sex ratio in adolescence in many centers around the world, including our outpatient clinic (84% AFAB vs. 16% AMAB presentations; Hartig et al., 2022;Herrmann et al., 2022;Levitan et al., 2019), with some additional clinical observations from our experience: 1 1) A considerable number of older adolescents report severe and persistent distress about their sex characteristics with previously gender-conforming psychosexual development and puberty without body-related distress. This group often presents with etiologically unclear psychological problems, such as social fears, depressive withdrawal, and self-injurious behaviors. ...
... For example, Kaltiala-Heino et al. (2015) reported at least one preexisting or current mental health disorder in 75% of the youth in their study. In German studies, mostly internalizing problems, such as affective and anxiety disorders, self-injury, and suicidality, are also significantly overrepresented compared to norm populations (Becker et al., 2014;Hartig et al., 2022;Levitan et al., 2019;Sievert et al., 2021), both in childhood and adolescence. Questionnaire assessments, mostly conducted with the CBCL or the YSR (Achenbach, 1991), consistently show levels of psychological problems in the clinical range, regardless of the birth-assigned sex (Bechard et al., 2017;de Graaf et al., 2018;de Vries et al., 2016;Levitan et al., 2019;Zucker et al., 2012). ...
An increasing heterogeneity of clinical presentations and varying levels of psychological problems characterize gender dysphoria (GD) in adolescents. These clinical patterns suggest distinct developmental trajectories. Here, we examine the onset age of GD, i.e., the percentage of early onset (EO) vs. late onset (LO), and its association with internalizing problems in adolescents with GD. The sample consisted of 462 adolescents (11–18 years, Mage = 15.46 years; 392 birth-assigned females, 70 birth-assigned males) who attended the Hamburg Gender Identity Service for Children and Adolescents (Hamburg GIS) in Germany between 2013 and 2021. Onset age was self-reported during clinical interviews and then later scored by clinicians using a DSM-5 rating sheet. When adolescents retrospectively met criteria A and B for childhood-onset GD, they were rated as having an EO. Those who fulfilled neither criteria A nor B in childhood were considered to have a LO. Internalizing problems were assessed using the Youth Self-Report. Overall, 51% (n = 237) of adolescents with GD presented with an EO and 49% (n = 225) reported diagnostic criteria related to a LO. More than half of the sample (58%, n = 266) fell within the clinical range for internalizing problems. Furthermore, LO (as opposed to EO) was significantly associated with reporting more internalizing problems. Our findings emphasize that adolescents with LO represent a particularly vulnerable group whose needs should be considered more closely diagnostically and treatment-wise. A protocol-based approach to the indication of physical interventions may not adequately address current clinical presentations and should be complemented by a differential approach based on individual adolescent development.
... For youth with GD, gender-related distress can amplify ED, making it harder for these adolescents to regulate emotions [13]. Recent literature data support the idea that adolescents who experience gender incongruence later in life probably have fewer opportunities to adapt to such emotional and social burdens, while adolescents with early onset of GD, who had likely developed coping mechanisms precociously, were generally better equipped to manage their distress when they sought gender-affirming treatment [14,15]. The literature on early-and late-onset gender dysphoria (GD) is still limited, with only a few studies addressing the differences between these presentations in terms of clinical outcomes and mental health challenges. ...
... Some of these highlighted that children who exhibited consistent and persistent GD from a young age (before puberty) were generally better adjusted psychologically by the time they reached adolescence [37,38] and were seeking gender-affirming care. In contrast, those whose GD emerged later, during adolescence, often exhibited more severe psychological distress [3], including higher levels of depression, anxiety, and suicidal ideation at the time of seeking care [14,15,37]. However, most of these studies did not directly compare adolescents with GD seeking gender reassignment by distinguishing between GD presentation in childhood or adolescence. ...
Studies have consistently shown that gender-diverse youth experience higher rates of internalizing disorders and self-harm behaviors (SH) compared to their cisgender peers. However, there is limited research on how body investment and emotion regulation influence these symptoms, especially in relation to the age of gender dysphoria (GD) presentation. Objectives: This study aimed to explore the relationship between the timing of GD presentation (early vs. late) and psychological distress in adolescents seeking gender affirmation (GA), specifically focusing on internalizing symptoms, emotion regulation, and body investment. The study also investigated how SH during the year preceding the request for gender affirmation might have impacted these factors. Methods: On a total of 80 adolescents (mean age: 14.88 years) at their first request for GA, participants were divided into two groups: early-presentation GD (EP-GD; mean age: 14.93 years) and late-presentation GD (LP-GD; mean age: 14.83 years). Among the sample, 60% exhibited SH. Internalizing symptoms, emotion regulation, and body investment were assessed using the Youth Self-Report (YSR), the Difficulties in Emotion Regulation Scale (DERS), and the Body Investment Scale (BIS). Results: Results revealed that LP-GD adolescents had significantly higher emotion dysregulation (ED), particularly in the Strategies domain of the DERS (p = 0.040), and more social problems in the YSR (p = 0.047) compared to EP-GD ones. SH were associated with higher internalizing symptoms, including anxiety, withdrawal, and somatic complaints (p < 0.03), as well as increased body dissatisfaction, particularly in the BIS Care and Protection dimensions (p = 0.044; p = 0.034). Conclusions: These findings supported the hypothesis that LP-GD adolescents and youths with a history of SH showed more pronounced emotion regulation difficulties and internalizing symptoms, further emphasizing the need for early intervention programs targeting both GD and co-occurring mental health problems.
... Societal anti-trans stigma, or transphobia, fuels alarmingly high rates of suicidality among transgender and gender diverse (TGD) youth (Austin et al., 2022;Hartig et al., 2022;Jackman et al., 2021;Trevor Project, 2023). Recent research suggests that TGD youth are 2.7-3.5 times more likely to attempt suicide than their cisgender peers (Jackman et al., 2021;Toomey et al., 2018). ...
... The psychological problems and psychiatric comorbidities of minors who are AFAB and AMAB are still debated. Some studies have reported poorer mental health in young individuals who are AFAB, particularly in terms of depression and anxiety [25], self-harm [26], and suicidality [27]. However, other studies have shown the opposite, indicating that individuals who are AMAB might have worse mental health [28, 29]. ...
... In particular, we specifically found evidence that young individuals who were AFAB exhibited more severe mental health issues than those who were AMAB: there were significant differences in terms of suicidality (more suicide attempts, more suicidal ideation), as well as a greater incidence of psychiatric comorbidities, particularly major depressive disorders, and anxiety disorders. These findings align with prior research [25,26] and may offer additional insight into why a greater proportion of individuals who are AFAB seek treatment at gender clinics. On the other hand, fewer studies have reported different results, with AMAB individuals experiencing more mental health problems [28,29]. ...
Context
Clinical data on transgender children and adolescents are scarce, and sample sizes often do not allow for comparisons according to sex assigned at birth. Besides, most gender identity clinics have pointed to a recent switch in favor of an increase in the number of adolescents assigned females at birth (AFAB) over assigned males at birth (AMAB).
Method
We collected data on sociodemographic characteristics, and psychiatric and social vulnerabilities according to sex assigned at birth for all youths who were treated at the French largest gender identity clinic. In addition, management modalities for gender transition were discussed in multidisciplinary concertation meetings.
Results
We collected data from 239 youths [162(68%) AFAB, 74(32%) AMAB, and 3(1%) intersex; mean age = 14.5(± 3.16) years]. The distribution of age at referral was better explained by two clusters (C1: N = 61, mean age = 11.3 years, with more AMAB; C2: N = 175, mean age = 15.9 years with more AFAB). 215(91%) youths had gender incongruence, with 32% reporting it before puberty. School drop-out, suicidality, depression, and anxiety were common and occurred significantly more often in the AFAB group. 178(74%) youths experienced social transition within the family, and 144(61%) at school [mean age = 15.13(± 2.06) years]. The social transition was more frequent in the AFAB group. Twenty-six (11%) youths received puberty blockers [mean age = 13.87(± 2.31) years], and 105(44%) received gender-affirming hormones [mean age = 16.87(± 1.4) years]. AMABs were more likely to take puberty blockers, and there was no difference in the proportion of AMAB and AFAB taking gender-affirming hormones. Surgical requests (mainly torsoplasty) were very rare.
Conclusion
Age at referral should be considered when exploring gender incongruence. During adolescence, we found that gender incongruence has substantial social and psychological effects, particularly on AFAB youths, possibly explaining their higher referral rates to specialized centers, as in other specialized clinics around the world.
... Pudimos observar que las personas AMN presentaron una mayor vulnerabilidad psicológica determinada por autolesiones, ideación suicida e intentos de suicidio. Estas diferencias fueron reportadas previamente en múltiples investigaciones en las que se observó que las personas AMN presentan mayor riesgo de autolesiones, ideas suicidas e intentos de suicidio que las AVN (Arcelus et al., 2015;de Graaf et al., 2022;Fisher et al., 2017;Hartig et al., 2022;Holt, Skagerberg, & Dunsford, 2016;Miranda-Mendizabal et al., 2019;Newcomb et al., 2020;Ream, 2019;Rood, Puckett, Pantalone, & Bradford, 2015;Thoma et al., 2019;Toomey, Syvertsen, & Shramko, 2018). Esta mayor tendencia a riesgo de autolesiones y suicida podría ser explicada en parte por las diferencias biológicas y hormonales y porque a pesar de que las personas AVN suelen tener mayor estigmatización, que se observa por el mayor antecedente de haber sufrido bullying, las personas AMN tendrían mayores dificultades para lidiar con la angustia provocada por su imagen corporal, como fue demostrado previamente (Fisher et al., 2017). ...
Introducción: Las personas transgénero sufren de discriminación y estrés de las minorías y con frecuencia reportan altos índices de vulnerabilidad psicológica. El objetivo de esta investigación fue evaluar la situación psicosocial de las personas trans que consultaron al Servicio de Diversidad y los factores involucrados en el riesgo de suicidalidad. Material y métodos: Se recabaron en forma retrospectiva datos demográficos y de vulnerabilidad psicológica de las historias clínicas de 934 personas trans de las cuales 359 fueron asignados varón al nacer y 575 asignados mujer al nacer. Resultados y conclusiones: Las personas asignadas mujer al nacer consultaron a una edad menor y reportaron una mayor frecuencia de bi/pansexualidad. Resultados: Se reportó un 33,1 % de abuso sexual, 63,3 % de bullying, 40,9 % de autolesiones, 52,7 % de ideación suicida y 25,2 % de intentos de suicidio, siendo las personas asignadas mujer al nacer, las que presentaron la mayor frecuencia de vulnerabilidad psicológica. En el análisis de regresión logística, las variables asociadas a mayor riesgo de autolesiones y suicidalidad fueron: la menor edad, la orientación bi/pansexual, ser asignado mujer al nacer, el antecedente de abusos y bullying. Conclusión: Por todo esto se hace necesario elaborar programas de acompañamiento y prevención del riesgo suicida en esta población.
... However, the study was based on parental and self-reported psychological symptoms and did not include referrals after 2016. Studies have increasingly revealed high levels of psychological difficulties among young people applying for gender-affirming treatment, however they are often limited by small case numbers and are mostly based on self-reported psychological symptoms [11,[18][19][20][21][22][23][24][25]. A Norwegian survey on living conditions found that transgender people report lower quality of life and more discrimination and psychological difficulties than other LHBTIQ-groups [26]. ...
... Our study makes an important contribution to knowledge on the mental health burden by reporting validated psychiatric diagnoses given by psychiatrists or psychologists. Other clinical studies are mostly based on self-or parental reports through screening instruments [11,[18][19][20][21][22][23][24][25]. The reporting of psychiatric diagnoses, as seen in our study, is important as they may capture more severe mental health problems than symptom descriptions from questionnaires. ...
... However, the study was based on parental and self-reported psychological symptoms and did not include referrals after 2016. Studies have increasingly revealed high levels of psychological difficulties among young people applying for gender-affirming treatment, however they are often limited by small case numbers and are mostly based on self-reported psychological symptoms [11,[18][19][20][21][22][23][24][25]. A Norwegian survey on living conditions found that transgender people report lower quality of life and more discrimination and psychological difficulties than other LHBTIQ-groups [26]. ...
... Our study makes an important contribution to knowledge on the mental health burden by reporting validated psychiatric diagnoses given by psychiatrists or psychologists. Other clinical studies are mostly based on self-or parental reports through screening instruments [11,[18][19][20][21][22][23][24][25]. The reporting of psychiatric diagnoses, as seen in our study, is important as they may capture more severe mental health problems than symptom descriptions from questionnaires. ...
Over the last decade, there has been a sharp increase in young people seeking medical treatment for gender dysphoria/gender incongruence (GD/GI). The aims of this study were to calculate yearly population-adjusted numbers of children and adolescents referred to the Norwegian National Center for Gender Incongruence (NCGI) at Oslo University Hospital (OUS) from 2000 to 2022; to describe the demographic characteristics and prevalence of psychiatric diagnoses, self-harm and suicide attempts among the referred from 2000 to 2020; and to investigate time trends. The study used data from the Gender Incongruence Registry for Children and Adolescents (GIRCA) in Norway. All persons under 18 years (n = 1258) referred to the NCGI between 2000 and 2020 were included: 68.4% assigned female gender at birth (AFAB) and 31.6% assigned male gender at birth (AMAB). We found a sharp increase in referrals to the NCGI favouring AFAB over AMAB. Nearly two in three (64.5%) had one or more registered psychiatric diagnoses. Self-harm was registered among 35.5%, and 12.7% had attempted suicide. Registered psychiatric diagnoses were significantly (p ≤ 0.001) more prevalent among AFAB (67.8%) than AMAB (57.4%). The number of registered diagnoses per person decreased significantly over time, with an average reduction of 0.02 diagnoses per person per year. Although there was a downward time trend in registered diagnoses per person, the total mental health burden among children and adolescents with GI emphasizes the need for a holistic approach.
... GD, besides being an inherently distressing experience, can also be understood within the framework of minority stress, associated with experiences of discrimination, exclusion, victimization, and internalized as well as external stigmatization (2,3). It is thus unsurprising that GD is frequently associated with co-occurring mental health conditions such as depression, anxiety, eating disorders, self-harm, and suicidality (4)(5)(6)(7)(8). In order to alleviate GD, TGD persons may seek genderaffirming medical treatment (GAMT) such as hormone therapy or surgery to better align their physical appearance with their gender identity (9). ...
... Age of onset was early childhood and puberty in 169/ 282 (59.9%) and 113/282 (40.1%) individuals, respectively. Outing age to family and/or friends was recorded in 110 patients, with a median age of 13 years (IQR 12-15; range [4][5][6][7][8][9][10][11][12][13][14][15][16][17]. Median age at outing was significantly higher in AMAB (14 years, IQR 14-15) than in AFAB individuals (13 years, IQR 12-15; p= 0.034). ...
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.
... Six studies explored differences in suicide attempts and/or self-harm by age groups, with estimates generally higher in older age categories. 41 75 81 84 97 98 Two studies explored differences in suicide attempts and/or self-harm over time in the referred populations. 35 89 One found no trend over time 35 and the other found a reduction in suicide attempts in 2015 (8.6%) compared with 2012 (13.3%). ...
... 50 96 Five studies explored differences in suicide and/or self-harm ideation by age groups and generally estimates were higher in older age categories. 41 81 84 97 98 Depression and/or anxiety There were 63 (44%) studies from 13 countries reporting data for depression and/or anxiety in the referred population, with data recorded from 1980 to 2021. There were eight studies only reporting data in continuous form (mean and SD) and there were different measures used, so it was not possible to synthesise. ...
Background
Increasing numbers of children/adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. Services and practice guidelines are responding to these changes.
Aim
This systematic review examines the numbers and characteristics of children/adolescents (under 18) referred to specialist gender or endocrinology services.
Methods
Database searches were performed (April 2022), with results assessed independently by two reviewers. Peer-reviewed articles providing at least birth-registered sex or age at referral were included. Demographic, gender-related, mental health, neurodevelopmental conditions and adverse childhood experience data were extracted. A narrative approach to synthesis was used and where appropriate proportions were combined in a meta-analysis.
Results
143 studies from 131 articles across 17 countries were included. There was a twofold to threefold increase in the number of referrals and a steady increase in birth-registered females being referred. There is inconsistent collection and reporting of key data across many of the studies. Approximately 60% of children/adolescents referred to services had made steps to present themselves in their preferred gender. Just under 50% of studies reported data on depression and/or anxiety and under 20% reported data on other mental health issues and neurodevelopmental conditions. Changes in the characteristics of referrals over time were generally not reported.
Conclusions
Services need to capture, assess and respond to the potentially co-occurring complexities of children/adolescents being referred to specialist gender and endocrine services. Agreement on the core characteristics for collection at referral/assessment would help to ensure services are capturing data as well as developing pathways to meet the needs of these children.
PROSPERO registration number
CRD42021289659.
