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The sexual orientation of the natal males and females over the age of 12 years for whom data were available (N = 97, 71 natal females and 26 natal males). 

The sexual orientation of the natal males and females over the age of 12 years for whom data were available (N = 97, 71 natal females and 26 natal males). 

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This article presents the findings from a cross-sectional study on demographic variables and associated difficulties in 218 children and adolescents (Mean age = 14 years, SD = 3.08, range = 5-17 years), with features of gender dysphoria, referred to the Gender Identity Development Service (GIDS) in London during a 1-year period (1 January 2012-31 D...

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Prevalence of suicide attempts, self-injurious behaviors, and associated psychosocial factors were examined in a clinical sample of transgender (TG) adolescents and emerging adults (n = 96). Twenty-seven (30.3%) TG youth reported a history of at least one suicide attempt and 40 (41.8%) reported a history of self-injurious behaviors. There was a hig...
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Objective: We aimed to examine the autistic traits and executive functions that may require clinical attention in children and adolescents with gender dysphoria (GD). Method: The study sample consisted of 25 patients with GD, and 50 controls (aged 5-17 years). The instruments were Social Responsiveness Scale (SRS), and the Behavior Rating Inventory...
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The current literature shows growing evidence of a link between gender dysphoria (GD) and autism spectrum disorder (ASD). This study reviews the available clinical and empirical data. A systematic search of the literature was conducted using the following databases: PubMed, Web of Science, PsycINFO and Scopus; utilizing different combinations of th...

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... YP are supported in exploring their gender identity alongside the complexities that may make up their lives. [12][13][14][15][16][17][18] In relation to physical treatment, the service uises a model of care that facilitates the use of GnRHa only after extensive psychosocial assessment and after the first signs of puberty, and GAH available around age 16 years, and only after approximately 1 year of GnRHa treatment. Referrals to adult gender identity clinics (GICs) are made at around age 18 years. ...
Article
Objectives Some gender-diverse young people (YP) who experience clinically significant gender-related distress choose to pursue endocrine treatment alongside psychotherapeutic support to suppress pubertal development using gonadotropin-releasing hormone analogues (GnRHa), and then to acquire the secondary sex characteristics of their identified gender using gender affirming hormones (GAH). However, little is known about the demographics of transgender adolescents accessing paediatric endocrinology services while under the specialist Gender Identity Development Service (GIDS) in England. Design Demographics of referrals from the GIDS to affiliated endocrinology clinics to start GnRHa or GAH between 2017 and 2019 (cohort 1), with further analysis of a subgroup of this cohort referred in 2017–2018 (cohort 2) were assessed. Results 668 adolescents (227 assigned male at birth (AMAB) and 441 assigned female at birth (AFAB)) were referred to endocrinology from 2017 to 2019. The mean age of first GIDS appointment for cohort 1 was 14.2 (±2.1) years and mean age of referral to endocrinology postassessment was 15.4 (±1.6) years. Further detailed analysis of the trajectories was conducted in 439 YP in cohort 2 (154 AMAB; 285 AFAB). The most common pathway included a referral to access GnRHa (98.1%), followed by GAH when eligible (42%), and onward referral to adult services when appropriate (64%). The majority (54%) of all adolescents in cohort 2 had a pending or completed referral to adult services. Conclusions This study highlights the trajectories adolescents may take when seeking endocrine treatments in child and adolescent clinical services and may be useful for guiding decisions for gender-diverse YP and planning service provision.
... Accumulating research indicates that children and adolescents with co-occurring autism spectrum disorders (ASD) and gender variance (GV) are identified at higher rates than would be expected by chance (de Vries, Noens, Cohen-Kettenis, van Berckelaer-Onnes, & Dorelihers, 2010;Skagerberg, Di Ceglie, & Carmichael, 2015;Janssen, Huang, & Duncan, 2016;Shumer, Reisner, Edwards-Leeper, & Tishelman, 2016;van der Miesen, Hurley, Bal, & de Vries, 2018). Studies investigating rates of clinical ASD diagnosis in youth referred for gender-related treatment suggest a co-occurence rate of 6.3 to 13.3% (de Vries et al., 2010;Holt, Skagerberg, & Dunsford, 2016;Nahata, Quinn, Caltabellotta, & Tischelman, 2017;Shumer et al., 2016). However, recognition of this comorbidity is fairly recent and, as such, research with this population is in its infancy ...
... Nearly half the study sample (47.4%) had a history of significant bullying, as noted elsewhere (e.g. Holt et al., 2016). Whilst unclear whether this was transphobic in nature, research indicates that experience of macro-aggression and social rejection likely contribute to poor mental health in gender diverse young people (Chodzen et al., 2019;Delozier et al., 2020). ...
... The impact of distress and nature of accompanying mental health concerns have been researched extensively among gender clinic cohorts. UK clinic data indicate co-occurring low mood in 42% and self-harming thoughts and behaviours in 39% (Holt et al., 2016;Skagerberg et al., 2013). Similar mental health difficulties have been reported in Dutch (in 32.4%, predominance of internalizing disorders; de Vries et al., 2011), Finnish (64% depression, 53% suicidal/self-harming behaviours; Kaltiala-Heino et al., 2015) and American clinic populations (Olson et al., 2015;Khatchadourian et al., 2014). ...
... Similar mental health difficulties have been reported in Dutch (in 32.4%, predominance of internalizing disorders; de Vries et al., 2011), Finnish (64% depression, 53% suicidal/self-harming behaviours; Kaltiala-Heino et al., 2015) and American clinic populations (Olson et al., 2015;Khatchadourian et al., 2014). Children <12 years are more likely to present with externalising behaviours such as conduct disorder (Holt et al., 2016), replicating the current study findings. Children aged 6-12 years described as gender non-conforming in a Canadian community sample were also more likely to display externalising mental health concerns (van der Miesen et al., 2018). ...
The present research used linked surveillance systems (British Paediatric Surveillance Unit; and the Child and Adolescent Psychiatry Surveillance System) over a 19 month period (1 November 2011–31 May 2013) to notify of young people (4–15.9 years) presenting to secondary care (paediatrics or child and adolescent mental health services) or specialist gender services with features of gender dysphoria (GD). A questionnaire about socio-demographic, mental health, and GD features was completed. Presence of GD was then assessed by experts in the field using then-current criteria (DSM-IV-TR). Incidence across the British Isles was 0.41–12.23 per 100,000. 230 confirmed cases of GD were noted; the majority were white (94%), aged ≥12 years (75.3%), and were assigned female at birth (57.8%). Assigned males presented most commonly in pre-adolescence (63.2%), and assigned females in adolescence (64.7%). Median age-of-onset of experiencing GD was 9.5 years (IQR 5-12); the majority reported long-standing features (2–5 years in 36.1%, ≥5 years in 26.5%). Only 82.5% attended mainstream school. Bullying was reported in 47.4%, previous self-harm in 35.2%, neurodiversity in 16%, and 51.5% had ≥1 mental health condition. These findings suggest GD is rare within this age group but that monitoring wellbeing and ensuring support for co-occurring difficulties is vital.
... Present notions of cis-and binary gender identification are rooted in Western society, and likely contribute to social stigma, prejudice, and bullying in gender diverse people. These experiences have been linked to associated difficulties such as high levels of distress, anxiety, depression, low mood, and self-harm in some gender diverse young people (de Vries et al., 2011;Di Ceglie et al., 2002;Holt et al. 2016;Skagerberg, Davidson & Carmichael, 2013). Indeed, the theory of intersectionality (Crenshaw, 1990) suggests that our socially constructed identities implicate our experiences of oppression, discrimination, privilege or power. ...
Objectives: Gender service utilisation according to ethnicity is largely under-researched. The present research looked at demographics and service user-engagement according to ethnicity of young people accessing a gender service for children. Method: A total of 2063 (M = 14.19 years, SD = 2.59, assigned male = 556, 1495 assigned female = 1495, no-specification=12) referrals were included in the analysis. Self-defined ethnicity in financial years (FY) 2016-2017, 2018-2019, and referrer-defined ethnicity in FY 2020-2021 were compared between years, to the national UK-population, and child and adolescent mental health service (CAMHS) averages. Numbers of offered, attended and non-attended appointments were compared across the White and the ethnic minority population (EMP). Results: Across years 93.35% young people identified as White (higher than the CAMHS and national population averages); 6.65% as EMP. Service utilisation was similar in FY 2016-2017. In FY 2018-2019, the EMP subgroup was offered and attended more appointments compared to the White subgroup, 'did not attended' average was similar. Conclusions: The majority of young people self-identified with a White ethnic-background. Service engagement was comparable between the EMP and White ethnicity subgroups in 2016-2017, while the EMP group was offered and attended more appointments in 2018-2019. Due to the low EMP group numbers, findings need to be interpreted with caution.
... Hendricks and Testa (2012) presented an adaptation of Meyer's Minority Stress Model to the TGD community. When looking at childhood and adolescence, alarming levels of psychological suffering and mental health issues are observed in gender-referred population (Holt et al., 2016). The most frequently reported difficulties are depression, anxiety, eating disorders, non-suicidal self-injury (NSSI), suicidal ideation and suicide attempts (de Graaf et al., 2018;Diemer et al., 2015). ...
Gender diverse children (here defined as minors under 18) face greater risk for depression, anxiety and suicidality than their cisgender peers. This situation calls for research on protective factors of mental health in this population, and on appropriate therapeutic and supportive interventions. This systematic review aimed at (1) examining literature on the role of attachment, mentalization and reflective functioning in protecting mental health of gender diverse children and identifying the mental health outcomes that have been assessed; and (2) outlining interventions based on attachment, mentalization and reflective functioning that have been proposed. The work was conducted according to the PRISMA guidelines. Fifty-one studies were identified and 9 met the inclusion criteria. Results indicate that, besides a general protective role for mental health, attachment, mentalization and reflective functioning moderate and mediate, through different pathways, (1) the association between gender diversity and emotional/behavioural problems; and (2) the negative effects of minority stress. Mentalization seems to be an individual resilience factor; the capacity of the caregiver to serve as a secure base and validate the internal experience of incongruence of the child promote a healthy psychological development. Three levels of action for interventions were identified: individual, family and community.
... W fińskim badaniu z tego samego roku [36] wskazano, że 53% pacjentów niezgodnych płciowo dokonywało samookaleczeń, a w badaniu Holt i wsp. [46] u 13,3% pacjentów w wieku 5-17 lat odnotowano próby samobójcze, a u 38,5% samookaleczanie. Nieco niższy odsetek samookaleczających się (13,1%) podali Chen i wsp. ...
... [42], a Arcelus i wsp. [47] zaobserwowali takie zachowania u 46,3% osób, z tym że przeciętny wiek pacjentów był wyższy niż w badaniu Holt (19 lat) [46]. Próby suicydalne podejmowało 18,8% transpłciowych kobiet [43]. ...
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Gender incongruence according to the ICD-11, compiled by the World Health Organization in 2019, is a sense of inconsistency between experienced and assigned gender that does not have to be associated with discomfort or suffering. However, the aspect of suffering is emphasized in the understanding of the diagnostic unit of gender dysphoria according to the DSM-5 of the American Psychiatric Association. People with gender incongruence are exposed to misunderstanding, persecution and stigmatization, often related to experienced minority stress. The aim of this study was to analyze the available literature in terms of the relationship between gender dysphoria and some mental disorders and minority stress, and to draw attention to the suffering of these people in the context of social confrontation with the phenomenon of gender transposition. The unfavorable image of a person with gender dysphoria created by some media, persecution and, as a result, bans on gender reassignment in some countries mean that a steady increase in mental disorders in these patients can be expected. The main psychiatric problems in people with gender dysphoria, accompanied by minority stress for most of their lives so far, concern the coexistence of depressive and anxiety disorders, self-destructive behaviors and the tendency to addiction. An important aspect of the functioning of people with gender dysphoria are also difficulties in taking up and maintaining employment, fear of losing income due to attempting to live in accordance with the perceived gender. The authors of the presented review wanted to emphasize the importance of minority stress in the lives of these people and the need for social education and a change in the approach to the concept of "employee, " excluding the record gender from it, which-according to the authors-could help people with gender incompatibility in their working life by reducing minority stress.
... These include, among others, minority stress, societal inequities, and barriers to healthcare, e.g., due to long waiting lists for transgender-specific healthcare, lack of physicians' knowledge, or discrimination in healthcare encounters (Braun, Garcia-Grossman, Quinones-Rivera, & Deutsch, 2017;Koehler, Strauss, Briken, Szuecs, & Nieder, 2021;Lo & Horton, 2016). In line with this, gender diversity in the general population has been associated with adolescent psychopathology (Burke, 2020;Potter et al., 2020) and young individuals with gender incongruence show elevated rates of diverse mental health problems and psychiatric comorbidity, especially before the start of treatment (Aitken, VanderLaan, Wasserman, Stojanovski, & Zucker, 2016;de Vries, Doreleijers, Steensma, & Cohen-Kettenis, 2011;Griffin et al., 2020;Holt, Skagerberg, & Dunsford, 2016;Kaltiala-Heino, Sumia, Työläjärvi, & Lindberg, 2015). ...
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Background Increasing numbers of adolescents seek help for gender-identity questions. Consequently, requests for medical treatments, such as puberty suppression, are growing. However, studies investigating the neurobiological substrate of gender incongruence (when birth-assigned sex and gender identity do not align) are scarce, and knowledge about the effects of puberty suppression on the developing brain of transgender youth is limited. Methods Here we cross-sectionally investigated sex and gender differences in regional fractional anisotropy (FA) as measured by diffusion MR imaging, and the impact of puberty on alterations in the white-matter organization of 35 treatment-naive prepubertal children and 41 adolescents with gender incongruence, receiving puberty suppression. The transgender groups were compared with 79 age-matched, treatment-naive cisgender (when sex and gender align) peers. Results We found that transgender adolescents had lower FA in the bilateral inferior fronto-occipital fasciculus (IFOF), forceps major and corpus callosum than cisgender peers. In addition, average FA values of the right IFOF correlated negatively with adolescents' cumulative dosage of puberty suppressants received. Of note, prepubertal children also showed significant FA group differences in, again, the right IFOF and left cortico-spinal tract, but with the reverse pattern (transgender > cisgender) than was seen in adolescents. Conclusions Importantly, our results of lower FA (indexing less longitudinal organization, fiber coherence, and myelination) in the IFOF of gender-incongruent adolescents replicate prior findings in transgender adults, suggesting a salient neural correlate of gender incongruence. Findings highlight the complexity with which (pubertal) sex hormones impact white-matter development and add important insight into the neurobiological substrate associated with gender incongruence.
... This is significant given the elevated rates of mental health problems in both autistic people (Lai et al., 2019) and in transgender people (Nobili et al., 2018) compared to the general population. Furthermore, there is evidence of an increased rate of autism in adults and young people accessing gender clinics internationally, ranging from 5% to 26% (Cheung et al., 2018;de Vries et al., 2010;Holt et al., 2016;Kaltiala-Heino et al., 2015;Pasterski et al., 2014). ...
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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.
... The group of gender-referred children was 15 times more likely to talk or think about suicide and 32 times more likely to engage in suicide attempts/self-harm than the nonreferred group. Among pubescent adolescent populations with GD, the prevalence of STBs is higher than that in prepubescent children, and there seem to be gender differences (Becker et al., 2014;Holt et al., 2016;Skagerberg et al., 2013). When examining transgender adolescents aged 10-17 years old, AFAB people were 144 times more likely to self-harm than a reference group of male youth. ...
... De Graaf et al., (2020) found that STBs were more frequently reported by AFAB adolescents than by AMAB adolescents. Additionally, some studies have found evidence for more suicidal and nonsuicidal actions in AFAB individuals and more suicidal ideation in AMAB individuals (Holt et al., 2016;Ream, 2019;Skagerberg et al., 2013;Toomey et al., 2018). In contrast, the results of Fisher et al. (2017) and Newcomb et al. (2020) showed that young AFAB individuals were more likely to think about suicide, while young AMAB individuals, in contrast, were more likely to carry out self-harming actions. ...
... The present results on STBs reported by caregivers/parents of children aged 5-11 years old (6% reported self-harming or suicide attempts, and 16% reported suicidal ideation/thoughts on the CBCL) are in line with a similar study assessing children with GD conducted by Aitken et al. (2016), who reported approximately 7% and 19%, respectively, for Canadian children aged 6-12 years old. Holt et al. (2016) underscored these outcomes in another clinical study from the UK by showing that approximately 15% of their assessed children aged 5-11 years old engaged in suicidal thoughts, 2.5% in suicide attempts and 15% in self-harm. Note. ...
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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 study aims were therefore to examine: (a) frequencies of self- and parent-reported STBs in a German clinical sample of children and adolescents with GD and (b) differences between age and gender groups, as well as between self- and parent-reports. Methods Two items from the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR) were used to assess self- and parent-reported STBs in a sample of 343 adolescents and 49 children who presented to the Hamburg Gender Identity Service (Hamburg GIS) between 2013 and 2019. Seventy-eight percent of the analysis sample was assigned female at birth (AFAB), and 22% were assigned male at birth (AMAB). Results Parents reported STBs on the CBCL for 16% and 6% of the cases in childhood and for 20% and 29% of the adolescent cases, respectively. STBs were self-reported by 38% and 45% of the adolescents who could report on the YSR. STBs were higher among adolescents than among children and in self-reports (YSR) compared to parent reports (CBCL). AFAB adolescents reported higher degrees of STBs than AMAB adolescents. Conclusions Children and adolescents with GD are a high-risk population for STBs, especially pubescent and AFAB individuals. Mental health professionals should screen early for STBs to prevent possible suicidal ideation-to-action transitions.
... For many professionals who treat developmental gender dysphoria, the decision to administer GnRH analogues is based on the fear of a possible increased risk of suicide in untreated adolescents. In the literature, there is a greater risk of suicidal ideation and attempts among young transsexuals [31,[33][34][35]. Studies investigating suicidal risk factors in transgender and gender non-conforming youth (TGNC) have identified gender dysphoria, parental physical and verbal abuse, and body image concerns as predictors [36]. ...
... Gender dysphoria implies a strong inconsistency between assigned sex and experienced gender, with a rejection of one's sexual attributes leading to clinically significant suffering and impaired individual functioning in daily life [4]. This condition is also associated with problems of a psychological and psychiatric nature, such as depression and anxiety [70]; suicide ideas and attempts [18,31,35]; an intense dissatisfaction with one's body image [71,72]. ...
... The anguish can be so intense that it leads to suicidal ideas and attempts. Suicidal behaviors are more frequent in the transgender population than in the rest of the population [31,[33][34][35]. Unfavorable outcomes of surgical gender reassignment in adults appear to be associated with late treatment rather than early intervention [41]. ...
Chapter
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Gender identity does not always develop in line with biological sex. Gender dysphoria at young age implies a strong incongruence between gender identity and the assigned sex; the rejection of one\'s sexual attributes and the desire to belong to the opposite sex; and a significant clinical suffering or impaired individual functioning in life spheres. The purpose of this chapter is a narrative review of the literature available on puberty suppression therapy through GnRH analogues. Biological puberty provides intense suffering to the adolescent with gender dysphoria who does not recognize himself in his own body. These drugs suppress the production of endogenous gametes and sex hormones. Although the effects of therapy are reversible, and biological development resumes spontaneously once the medication is stopped, the administration of GnRH analogues at a young age has fueled a scientific debate on the matter of the ethics of pharmacological intervention with minors. In conclusion, the studies considered show that GnRH analogues do not have long-term harmful effects on the body; prevent the negative psychosocial consequences associated with gender dysphoria in adolescence (suicidal ideation and attempts, self-medication, prostitution, self-harm); improve the psychological functioning of young transsexuals; and are diagnostic tools that allow adolescents to buy time to explore their gender identities.