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Young people with features of gender dysphoria: Demographics and associated difficulties

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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 December 2012). Data were extracted from patient files (i.e. referral letters, clinical notes and clinician reports). The most commonly reported associated difficulties were bullying, low mood/depression and self-harming. There was a gender difference on some of the associated difficulties with reports of self-harm being significantly more common in the natal females and autism spectrum conditions being significantly more common in the natal males. The findings also showed that many of the difficulties increased with age. Findings regarding demographic variables, gender dysphoria, sexual orientation and family features are reported, and limitations and implications of the cross-sectional study are discussed. In conclusion, young people with gender dysphoria often present with a wide range of associated difficulties which clinicians need to take into account, and our article highlights the often complex presentations of these young people. © The Author(s) 2014.
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Psychiatry
Clinical Child Psychology and
http://ccp.sagepub.com/content/early/2014/11/26/1359104514558431
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DOI: 10.1177/1359104514558431
published online 26 November 2014Clin Child Psychol Psychiatry
Vicky Holt, Elin Skagerberg and Michael Dunsford
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Young people with features of gender dysphoria: Demographics and associated
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DOI: 10.1177/1359104514558431
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Young people with features of
gender dysphoria: Demographics
and associated difficulties
Vicky Holt, Elin Skagerberg and Michael
Dunsford
The Tavistock and Portman NHS Foundation Trust, UK
Abstract
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 December 2012). Data
were extracted from patient files (i.e. referral letters, clinical notes and clinician reports). The
most commonly reported associated difficulties were bullying, low mood/depression and self-
harming. There was a gender difference on some of the associated difficulties with reports of
self-harm being significantly more common in the natal females and autism spectrum conditions
being significantly more common in the natal males. The findings also showed that many of the
difficulties increased with age. Findings regarding demographic variables, gender dysphoria, sexual
orientation and family features are reported, and limitations and implications of the cross-sectional
study are discussed. In conclusion, young people with gender dysphoria often present with a wide
range of associated difficulties which clinicians need to take into account, and our article highlights
the often complex presentations of these young people.
Keywords
Gender dysphoria, associated difficulties, demographics, bullying, self-harm
Introduction
Gender dysphoria
Children and adolescents with gender dysphoria (GD) experience ‘a marked incongruence between
their experienced/expressed gender and assigned gender’ (American Psychiatric Association,
2013). GD, in itself, often results in profound distress to the individual, namely an intense, often
unbearable feeling of being ‘in the wrong body’. This often causes the young people to struggle in
a number of different areas in their lives. The distress and feeling of being in the wrong body often
Corresponding author:
Vicky Holt, The Tavistock and Portman NHS Foundation Trust, 120 Belsize Lane, London NW3 5BA, UK.
Email: vholt@tavi-port.nhs.uk
558431CCP0010.1177/1359104514558431Clinical Child Psychology and PsychiatryHolt et al.
research-article2014
Article
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2 Clinical Child Psychology and Psychiatry
increases at the onset of puberty due to an intensification of feelings of incongruence between self-
perception and the body (e.g. Steensma, Biemond, De Boer, & Cohen-Kettenis, 2011). The con-
stant conflicting relationship with their natal gender and the often unbearable pubertal changes
often result in young people with GD withdrawing socially and feeling depressed and low in self-
esteem. At times this results in self-harm and/or suicidal feelings (e.g. Skagerberg, Parkinson, &
Carmichael, 2013).
Associated difficulties
An audit by Di Ceglie, Freedman, McPherson, and Richardson (2002), looking at 124 young gen-
der dysphoric people in the United Kingdom, showed that more than half of the young people
experienced relationship difficulties with peers and/or parents/carers and that 42% experienced
depression. Several other papers confirm that children and adolescents with GD often present with
a number of associated difficulties. De Vries, Doreleijers, Steensma, and Cohen-Kettenis (2011)
looked at psychiatric comorbidity in 105 gender dysphoric adolescents in Holland and found that
10% of the young people suffered with social phobia, 21% with anxiety disorders, 12.4% with
mood disorders and 11.4% with disruptive disorders. Skagerberg, Davidson, and Carmichael
(2013) examined externalising (e.g. ‘acting out’) and internalising (e.g. withdrawn, depressed)
behaviours in a sample of 141 gender dysphoric adolescents who had attended an assessment of
4–6 sessions at the Gender Identity Development Service (GIDS). They found that overall the
adolescents showed significantly higher levels of internalising than externalising behaviours.
Moreover, the natal males presented with significantly more internalising behaviours than the natal
females, thus, scoring more in line with their perceived rather than natal gender.
Several other studies have looked at internalising and externalising behaviours in children and
adolescents with GD. Zucker and Bradley (1995) examined parent reports (Child Behaviour
Checklist (CBCL)) of 161 boys with GD between the age of 4 and 11 years and 90 male siblings.
They found that the boys with GD had significantly more behavioural problems compared to their
male siblings and that they also had significantly more internalising than externalising behaviours.
Also, Steensma et al. (2014) looked at behavioural and emotional difficulties and peer relations
using the Teacher’s Report Form in a sample of 728 young people referred to gender identity clin-
ics in the Netherlands and Canada. They found that internalising behaviours were more common
than externalising behaviours and that the children were better functioning than the adolescents,
thus highlighting the increased distress around the onset of puberty. In line with the findings by
Skagerberg, Davidson, and Carmichael (2013), the natal males showed more internalising behav-
iours than the natal females. Furthermore, more emotional and behavioural difficulties were found
in Canada than in the Netherlands, and this was found to be partly attributable to poorer peer
relations.
The incongruence between self-perception and the body is not likely to be the sole contributing
factor to the distress often experienced in this group of young people. Young people with GD fre-
quently suffer with discrimination and prejudice which can itself result in fear, distress and other
associated difficulties (Grant et al., 2011). Zucker et al. (2012), for example, found that the major-
ity of the gender dysphoric youth in their study had difficulties with peer relations, and Cohen-
Kettenis, Owen, Kaijser, Bradley, and Zucker (2003) examined demographic characteristics, social
competence and behavioural difficulties in 488 children referred to gender identity clinics in
Toronto and Utrecht and found that poor peer relations were the strongest predictor of behavioural
difficulties.
Whereas some of the aforementioned associated difficulties are likely to be linked to the GD
itself, other associated difficulties are likely to be related to the effects of the discrimination and
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Holt et al. 3
prejudice often experienced in young people with GD. Therefore, gaining a better understanding
of what the associated difficulties are, and being able to work with young people and their families
by trying to help ameliorate some of these difficulties alongside the GD, will be of benefit. A good
understanding of the associated difficulties is also important in the assessment, formulation and
clinical management, taking into account the complexities and specific needs of these young
people.
The present study
This cross-sectional study intended to provide an overview of demographic characteristics and
associated difficulties in young gender dysphoric people. It follows on from a 2002 audit by Di
Ceglie et al. conducted at the same gender identity service in London and includes a larger sample
and a different focus. We wanted to get a snapshot of the lives of gender dysphoric young people
and the challenges they face, and so we examined a number of different variables from the age of
first gender dysphoric feelings and sexual orientation to associated difficulties such as self-harm,
suicidality, low mood/depression, psychosis and eating difficulties. We also recorded family
makeup, looking specifically at divorce rates, siblings, living arrangements and other familial dif-
ficulties. We thought it might be helpful to have a greater understanding of the sexual orientation
of the young people referred as well as school attendance and bullying. By being more aware of the
range of difficulties young people with GD experience, clinicians can provide them with better and
more appropriate support and care.
Method
Participants
The participants were 218 children and adolescents (Mean age at referral = 14 years, standard devi-
ation (SD) = 3.08, range = 5–17 years) with features of GD attending the GIDS in London. A total
of 37.2% of the young people referred were natal males (Mean age at referral = 13.15 years,
SD = 3.76) and 62.8% were natal females (Mean age at referral = 14.51 years, SD = 2.47).
Information regarding ethnicity was not available for 18.8% (N = 41) of the young people. The
ethnicity of the remaining 177 young people was 88.7% White British, 2.2% Black Caribbean,
2.2% any other mixed background, 2.2% any other White background, 1.1% mixed Black
Caribbean and White, 0.6% mixed Black, 0.6% Asian-Pakistani, 0.6% Asian-Indian, 0.6% Asian-
Chinese, 0.6% mixed White and Asian and 0.6% White Irish.
The GIDS is a national highly specialist gender service covering the United Kingdom, as part
of the National Health Service (NHS). Many of the young people attending the service frequently
present with a number of associated difficulties. The GIDS is a multidisciplinary service consisting
of child and adolescent psychotherapists, child and adolescent psychiatrists, clinical psychologists,
social workers, researchers and trainees.
Data collected
Data were collected for all new referrals to the GIDS in London during a 1-year period (1 January
2012–31 December 2012). The age inclusion criterion was 0–18 years. During this period, 303
children and adolescents were referred to the GIDS. A total of 85 cases were excluded from the
study due to being children who received counselling in relation to having a transsexual parent (as
the children themselves were not gender dysphoric), cases that were referred to the GIDS Leeds
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4 Clinical Child Psychology and Psychiatry
base (i.e. our second centre in Leeds) which the researchers therefore did not have easy access to
or cases that did not result in a first appointment. So data were collected from a total of 218 cases.
The data collected comprised 25 variables: the natal gender, the age of the young person at the
time of the referral, ethnicity, whether they were in education, whether they were living in their
chosen gender, whether they preferred to be referred to by a name different from the name given to
them at birth, sexual orientation, age of first gender dysphoric feelings, family variables (e.g. who
the young people lived with, number of biological siblings, parental depression and alcohol use,
domestic violence, migration) and associated difficulties. The associated difficulties included non-
suicidal self-harm, suicidal ideation, suicide attempts, autism spectrum conditions (ASCs), atten-
tion deficit hyperactivity disorder (ADHD), symptoms of anxiety, psychosis, eating difficulties,
bullying and abuse (i.e. physical, psychological/emotional, sexual abuse and neglect). We were
interested in the challenges that young people face before coming to the service, and so the data
were ascertained from referral letters but also from clinical notes and clinician reports mentioning
any information about the young people before they attended the GIDS. All data were anonymised
in order to ensure the confidentiality of the individuals.
Procedure
The research was carried out by the GIDS consultant child and adolescent psychiatrist, GIDS
research psychologist and GIDS assistant psychologist. Once a list of patients who were referred
to the GIDS between January 2012 and January 2013 had been made and the 85 cases had been
removed (see the above section on data collected), the referral letters and GIDS clinician notes/
reports from each of the 218 remaining case files were systematically read by one of the three
GIDS members. Any reference to associated difficulties prior to attendance at the service, or other
information collected, was recorded on an excel spreadsheet. Data were only recorded when it was
clearly stated in the file. After completion, the data were transferred to SPSS and analysed by the
research psychologist. The research was then written up jointly by the consultant child and adoles-
cent psychiatrist, the research psychologist and the assistant psychologist.
Results
GD and sexual orientation
Information regarding the age of the first gender dysphoric feelings was not available for 4.6% of
the cases (N = 10). For the remaining 208 people, 42.7% reported having their first gender dys-
phoric feelings between 0 and 6 years of age, 34.9% between 7 and 12 years of age and 17.9%
between 13 and 18 years of age. Statistically, no significant difference was found regarding the age
of first gender dysphoric feelings between the genders (χ2(2) = 4.97, p > .05, see Table 1 for more
information).
Overall, 47.8% of the young people preferred to be referred to by a different name from their
birth name, and this percentage differed significantly between the genders (χ2(1) = 41.76, p < .001)
with 67.2% of the natal females and 20.8% of the natal males preferring to be referred to by a name
different to that given to them at birth. Data regarding whether the young people were living in
their chosen gender was not available for 6.4% of the cases (N = 14). For the remaining 205 people,
54.6% were living in their chosen gender full-time, 9.8% part-time and 35.6% were not living in
their chosen gender. A chi-square test revealed that there was a significant difference in the fre-
quency of natal males and natal females living in their chosen gender (full-time or part-time) with
the natal females more often living in their chosen gender than the natal males (χ2(1) = 18.73,
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Holt et al. 5
p < .001). If we separate the percentages by those who live in their chosen gender full-time and
part-time, we find that 69.2% of the natal females were living in their chosen gender full-time
and 6.2% part-time whereas 29.3% of the natal males were living in their chosen gender full-time
and 16% part-time. It is, however, important to remember that the natal males in this study were,
on average, slightly younger (Mean age at referral = 13.15 years, SD = 3.76) than the natal females
(Mean age at referral = 14.51 years, SD = 2.47) and this may have influenced the results.
Information regarding sexual orientation was available for 56.7% (N = 97) of the young people
12 years of age and above (see Table 2 for more details).
Family: features and composition
The mean number of biological siblings was 1.39 (SD = 1.31, range = 0–8). A total of 58.3% of the
young people had parents who had separated, and domestic violence was indicated in 9.2% of the
cases. Maternal depression was indicated in 19.3% of the cases (4.1% post natal) and paternal
depression in 5% of the cases. Parental alcohol/drug abuse was indicated in 7.3% of the cases.
Table 3 shows the living arrangements at the time of referral for all 218 participants.
Associated difficulties
Overall, the three most common associated difficulties were bullying (47%), low mood/depression
(42%) and self-harming (39%). Table 4 shows the percentage of associated difficulties for the natal
males and females separately. For the natal females, self-harm and bullying were the two most
common difficulties whereas for the natal males it was bullying and low mood/depression. Chi-
square tests showed that reports of actual self-harm (χ2(1) = 8.65, p < .01) were significantly more
common in the natal females than the natal males. This finding supports those by Skagerberg,
Parkinson, and Carmichael (2013) looking at self-harming thoughts and behaviours in young peo-
ple with GD. ASC diagnoses and queries were found to be significantly more common in the natal
males (χ2(1) = 7.33, p < .01). No significant difference was found between the genders in terms of
Table 1. The percentage of natal females (N = 129) and males (N = 79) having their first gender dysphoric
feelings between ages 0–6, 7–12 and 13–18 years.
Age of first gender
dysphoric feelings
Natal males Natal females
0–6 years 54.4% (N = 43) 38.3% (N = 50)
7–12 years 29.1% (N = 23) 41.1% (N = 53)
13–18 years 16.5% (N = 13) 20.2% (N = 26)
Table 2. 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).
Sexual orientation Natal males Natal females
Attracted to females 19.2% (N = 5) 67.6% (N = 48)
Attracted to males 42.3% (N = 11) 8.5% (N = 6)
Bisexual 38.5% (N = 10) 21.1% (N = 15)
Asexual 0% (N = 0) 2.8% (N = 2)
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6 Clinical Child Psychology and Psychiatry
Table 3. The living arrangements at the time of referral for all participants (N = 218).
Living with Percentage N
Both biological parents 36.7% 80
Mother 31.2% 68
Mother and step father 11.9% 26
Foster care 4.1% 9
Father 3.2% 7
Father and step mother 3.2% 7
Alternated between separated parents 1.8% 4
Independently 1.8% 3
Grandparents 1.4% 3
Adoptive parents 0.9% 2
Partner’s family 0.9% 2
Boarding school 0.5% 1
Aunt 0.5% 1
Supported accommodation 0.5% 1
Children’s home 0.5% 1
Mother and grandparents 0.5% 1
Unknown 0.9% 2
reports on suicidal ideation, suicide attempts, low mood/depression, abuse, ADHD, anxiety, psy-
chosis, eating difficulties and bullying.
Table 5 shows that, overall, many of the associated difficulties increased with age. Chi-squared
tests showed that there was a significant relationship between age and self-harm (χ2(1) = 12.18,
p < .001), suicidal ideation (χ2(1) = 9.1, p < .01), suicidal attempts (χ2(1) = 5.17, p < .05), low mood/
depression (χ2(1) = 24.61, p < .001) and eating difficulties (χ2(1) = 7.75, p < .01). There was no sig-
nificant relationship between age and bullying, ASC, ADHD, symptoms of anxiety, psychosis and
abuse (all ps > .05). If we look at, for example, self-harm we can see that there were reports of self-
harm in 14.6% of the 5- to 11-year-olds and 44.1% of the 12- to 18-year-olds. Similarly, 7.3% of
Table 4. The percentage of associated difficulties in natal males and females (N = 218, 137 natal females
and 81 natal males).
Associated difficulties Natal males Natal females
Self-harm 25.9% (n = 21) (+ thoughts in 4.9%) 46% (N = 63) (+ thoughts in 3.6%)
Suicidal ideation 38.3% (N = 31) 32.8% (N = 45)
Suicidal attempts 12.3% (N = 10) 13.9% (N = 19)
Low mood/depression 45.7% (N = 37) 39.4% (N = 54)
ASC 18.5% (N = 15) (+ query in 7.4%) 10.2% (N = 14) (+ query in 1.5%)
ADHD 12.3% (N = 10) 5.8% (N = 8)
Symptoms of anxiety 21.0% (N = 17) 23.4% (N = 32)
Psychosis 3.7% (N = 3) 5.8% (N = 8)
Eating difficulties 12.3% (N = 10) 13.9% (N = 19)
Bullying 49.4% (N = 40) 45.3% (N = 62)
Abuse 11.1% (N = 9) 21.2% (N = 29)
ASC: autism spectrum conditions; ADHD: attention deficit hyperactivity disorder.
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Holt et al. 7
the 5- to 11-year-olds reported feeling low in mood whereas 49.7% of the 12- to 18-year-olds
reported feeling low in mood. These findings highlight that puberty is often a time of increased
distress for young people with GD.
Discussion
Most common associated difficulties and comparisons with previous studies
The findings from this cross-sectional study showed that, overall, the three most common associ-
ated difficulties were: bullying (47%), low mood/depression (42%) and self-harming (39%). If we
compare these findings to those of Di Ceglie et al. (2002), we find that the percentage of young
people who were depressed/low in mood was the same (42%) whereas the percentage of young
people who were harassed/bullied was lower in their study (33%) as was the number of young
people who were involved in self-injurious behaviours (18%). The percentage of people who were
involved in self-harming in the current study was higher than in a study by Skagerberg, Parkinson,
and Carmichael (2013) where, overall, 24% of the children and adolescents with GD were reported
to self-harm. It is possible that the higher percentage of young people self-harming in the current
study compared to those in earlier studies simply reflect trends in the general population (see
Muehlenkamp, Claes, Havertape, & Plener, 2012).
Comparisons between natal females and natal males
Our findings showed that there was a significant difference in the occurrence of self-harming and
ASC in the natal males and natal females with self-harming being indicated more often in the natal
females and ASC being indicated more often in the natal males. The higher occurrence of self-
harm in the natal females in this study concurs with, for example, Skagerberg, Parkinson, and
Carmichael (2013) who looked at self-harming thoughts and behaviours in 125 gender dysphoric
children and adolescents, and with Fox and Hawton (2004) and recent figures from the Health &
Social Care Information Centre (2013) in the United Kingdom looking at self-harming in adoles-
cents in the general population. The higher occurrence of ASC in the natal males accords with a
study by De Vries et al. (2011) looking at ASC in children and adolescents referred to the Gender
Identity Clinic in Amsterdam. However, whereas they found an incidence of ASC in 7.8% of their
Table 5. The percentage of young people with associated difficulties in the different age categories.
Associated difficulties 5–11 years (N = 41) 12–18 years (N = 177)
Self-harm 14.6% (+ thoughts in 4.9%) 44.1% (+ thoughts in 4%)
Suicidal ideation 14.6% 39.5%
Suicidal attempts 2.4% 15.8%
Low mood/depression 7.3% 49.7%
ASC 12.2% (+ query in 4.9%) 13.6% (+ query in 3.4%)
ADHD 14.6% 6.8%
Symptoms of anxiety 17.1% 23.7%
Psychosis 2.4% 5.7%
Eating difficulties 0% 16.4%
Bullying 36.6% 49.2%
Abuse 9.8% 19.2%
ASC: autism spectrum conditions; ADHD: attention deficit hyperactivity disorder.
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8 Clinical Child Psychology and Psychiatry
sample of 204 children and adolescents, in the current study we found that ASC was indicated in
13.3% of the young people. It is important to note, though, that the Dutch team used the Diagnostic
Interview for Social and Communication Disorders (DISCO) to assess ASC, while the young peo-
ple in our sample may not all have been formerly diagnosed.
Interestingly, natal females presented to our services more frequently than natal males; this shift
opposes historical trends where more natal males were referred. Also, significantly more natal
females than natal males were living in their chosen gender and/or were referred to by a name
different from that given to them at birth. It is important for clinicians to be aware of the gender
difference on some of the associated difficulties as well as the difference between natal males and
females in terms of living in their chosen gender and changing their name. Natal males and females
may, thus, need to be thought about separately and may require different interventions. As already
mentioned in the results, however, it is important to remember that the natal males in this study
were, on average, 1 year younger than the natal females and this may have influenced the results.
Distress around puberty
Our findings showed that puberty seemed to be a time of increased distress for many of the gender
dysphoric young people. A total of 14.6% of the 5- to 11-year-olds and 39.5% of the 12- to 18-year-
olds reported feeling suicidal. Similar patterns emerged for low mood/depression and self-harm.
This finding accords with the literature on gender dysphoric young people (e.g. Di Ceglie et al.,
2002; Skagerberg, Parkinson, & Carmichael, 2013) and on the general population (e.g. ‘Truth
Hurts’, 2006), which suggests an average age of onset of 12 years for distress associated with
pubertal changes.
Sexuality
Many of the natal females and natal males described being attracted to the opposite sex (to the
gender they identified as). This information is useful as it further informs our understanding of
young people’s sexual identity. Negotiating ones sexual orientation is an important developmental
task for all adolescents and may be more complex for young people with GD and professionals
must, thus, be sensitive to the sexual identity of their patients.
Clinical implications
The findings highlight the importance for clinicians to be mindful of the associated difficulties
linked to GD and to consider what factors are important in increasing these young people’s strength
and resilience (see Grossman, D’Augelli, & Frank, 2011). Clinically young people may present
with GD but also with a number of other psychological difficulties, and one difficulty may precipi-
tate another. High levels of bullying, harassment and abuse were reported and so all services must
ensure that any child protection concerns are responded to urgently. GD in a heteronormative soci-
ety undoubtedly predisposes a young person to a number of other difficulties ranging from social
isolation, stigma and shame to psychological issues such as depression, anxiety, self-harm and
eating disorders.
Our findings stress the need for services to work collaboratively in order to support a young
person with GD. General Practitioners, Child and Adolescent Mental Health Services (CAMHS),
education and specialist services each have important roles in ensuring that young people with GD
are provided with support in a number of areas of their lives. It is, for example, evident that there
are high levels of deliberate self-harm and suicidal ideation which require frequent and ongoing
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Holt et al. 9
support from CAMHS alongside the input from specialist gender services in order to alleviate the
distress. Clinicians therefore need to be particularly aware of signs of low mood and depression
and regularly screen for suicidal ideation and self-harming. This is especially important around
puberty which is often an extremely distressing time for young people with GD.
It is also important for the families to receive support, and a young person may require a number
of different interventions ranging from psychological support and/or medication for mental health
difficulties such as depression, school intervention to help reduce bullying and support regarding
which toilet or changing area to use. This may be alongside a young person being referred for the
hypothalamic blocker in order for the pubertal process to be halted in a reversible manner, allowing
the young person more time and space to explore their gender identity without the often devastat-
ing effects of puberty.
Links with ASC
Our findings show that a significant proportion of cases also have some social and communication
difficulties and are on the autistic spectrum. These young people may require support from more
specialist services, and an understanding of how this may relate to their gender identity is impor-
tant. For example, some young people with a comorbid diagnosis of GD and an ASC may hold
more rigid views of what it is to be male or female. Helping them to explore gender in a less stereo-
typical way may alleviate some of their distress and may deconstruct the gender binary. Conversely,
their perhaps more rigid views and more black and white style of thinking may make their gender
identity less fluid and more fixed (Di Ceglie, 2009; Di Ceglie, Skagerberg, Baron-Cohen, &
Auyeung, 2014).
Future research
More research is undoubtedly needed into links with associated difficulties. In some cases, for
example when a young person with GD is significantly depressed, it is important that the depres-
sion is understood and treated alongside the management of the GD. Undoubtedly, GD can lead to
low mood, but conversely depression can lead to doubts about ones identity in general, and clini-
cians need to take all of this information into account when working with children and adolescents
with GD and ensure that individualised multidisciplinary support is provided. Moreover, as this
cross-sectional study was done at the initial point of referral, it would be useful to follow it up once
the young people have received psychological and/or physical intervention (such as hormone
blockers and cross-sex hormones) to help us understand what factors might lead to amelioration of
the difficulties. Further research is also required to better understand which difficulties are a result
of the GD itself and which are a result of social shaming and stigmatisation of these young people
by society.
Limitations
This study has several limitations. First, the figures presented are likely to be an underestimate as
they were based on referral letters and clinician notes/reports. The referrers and clinicians may not
have asked about demographic variables and associated difficulties and/or may not have included
the information in their letters, notes or reports. Thus, if there was no mention of, for example, self-
harm, then it was assumed that the young person did not engage in this behaviour. It is perhaps
especially likely that more ‘internalising’ behaviours, such as low mood and anxiety, were under-
reported. Second, letters from referrers were sometimes very brief, and even though the GIDS has
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10 Clinical Child Psychology and Psychiatry
a standard referral form enquiring about many of the variables in this study, not all referrers had
completed this form. Finally, numbers were sometimes low, such as in the 5–11 age group, and
further research with a larger sample is needed in order for generalisations to be made from these
findings.
Conclusion
Young people with GD frequently present with associated difficulties. This cross-sectional study
has shown that some of the most common difficulties are bullying, self-harm and low mood/
depression. The findings presented are important as they will inform the management and under-
standing of young people with GD and they highlight the importance for clinicians to regularly
screen for associated difficulties in this group of young people and for them to keep in mind their
often complex presentations.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit
sectors.
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Author biographies
Vicky Holt is a Consultant Child and Adolescent Psychiatrist working at the Gender identity Development
Service, a specialist national commissioning service. She has worked in this area for a number of years and is
a member of the WPATH child and adolescent committee.
Elin Skagerberg is a Research Psychologist in the Gender Identity Development Service at the Tavistock and
Portman NHS Foundation Trust. She has worked in this service since 2009 and has previsouly completed a
Ph.D. in Psychology at the University of Sussex. She has published a number of articles on gender dysphoria
as well as eyewitness testimony.
Michael Dunsford is an Assistant Psychologist/ Research Assistant in the Gender Identity Development
Service at the Tavistock and Portman NHS Foundation Trust. He joined this role shortly after graduating from
the University of Birmingham in 2012, where he studied Psychology, and is currently also taking a Master’s
degree in Political Research.
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... 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.
... 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 ...
... 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.
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