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Objectives: Our first aim was to examine baseline differences in body dissatisfaction, depression, and anxiety symptoms by gender, age, and Tanner (ie, pubertal) stage. Our second aim was to test for changes in youth symptoms over the first year of receiving gender-affirming hormone therapy. Our third aim was to examine potential differences in change over time by demographic and treatment characteristics. Youth experiences of suicidal ideation, suicide attempt, and nonsuicidal self-injury (NSSI) are also reported. Methods: Participants (n = 148; ages 9-18 years; mean age 14.9 years) were receiving gender-affirming hormone therapy at a multidisciplinary program in Dallas, Texas (n = 25 puberty suppression only; n = 123 feminizing or masculinizing hormone therapy). Participants completed surveys assessing body dissatisfaction (Body Image Scale), depression (Quick Inventory of Depressive Symptoms), and anxiety (Screen for Child Anxiety Related Emotional Disorders) at initial presentation to the clinic and at follow-up. Clinicians completed the Quick Inventory of Depressive Symptoms and collected information on youth experiences of suicidal ideation, suicide attempt, and NSSI. Results: Affirmed males reported greater depression and anxiety at baseline, but these differences were small (P < .01). Youth reported large improvements in body dissatisfaction (P < .001), small to moderate improvements in self-report of depressive symptoms (P < .001), and small improvements in total anxiety symptoms (P < .01). No demographic or treatment-related characteristics were associated with change over time. Lifetime and follow-up rates were 81% and 39% for suicidal ideation, 16% and 4% for suicide attempt, and 52% and 18% for NSSI, respectively. Conclusions: Results provide further evidence of the critical role of gender-affirming hormone therapy in reducing body dissatisfaction. Modest initial improvements in mental health were also evident.
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Body Dissatisfaction and Mental Health
Outcomes of Youth on
Gender-Afrming Hormone Therapy
Laura E. Kuper, PhD,a,b Sunita Stewart, PhD,a,b Stephanie Preston, MD,bMay Lau, MD, MPH,a,b Ximena Lopez, MDa,b
abstractOBJECTIVES: Our rst aim was to examine baseline differences in body dissatisfaction, depression,
and anxiety symptoms by gender, age, and Tanner (ie, pubertal) stage. Our second aim was to
test for changes in youth symptoms over the rst year of receiving gender-afrming hormone
therapy. Our third aim was to examine potential differences in change over time by
demographic and treatment characteristics. Youth experiences of suicidal ideation, suicide
attempt, and nonsuicidal self-injury (NSSI) are also reported.
METHODS: Participants (n= 148; ages 918 years; mean age 14.9 years) were receiving gender-
afrming hormone therapy at a multidisciplinary program in Dallas, Texas (n= 25 puberty
suppression only; n= 123 feminizing or masculinizing hormone therapy). Participants
completed surveys assessing body dissatisfaction (Body Image Scale), depression (Quick
Inventory of Depressive Symptoms), and anxiety (Screen for Child Anxiety Related Emotional
Disorders) at initial presentation to the clinic and at follow-up. Clinicians completed the Quick
Inventory of Depressive Symptoms and collected information on youth experiences of suicidal
ideation, suicide attempt, and NSSI.
RESULTS: Afrmed males reported greater depression and anxiety at baseline, but these
differences were small (P,.01). Youth reported large improvements in body dissatisfaction
(P,.001), small to moderate improvements in self-report of depressive symptoms (P,
.001), and small improvements in total anxiety symptoms (P,.01). No demographic or
treatment-related characteristics were associated with change over time. Lifetime and follow-
up rates were 81% and 39% for suicidal ideation, 16% and 4% for suicide attempt, and 52%
and 18% for NSSI, respectively.
CONCLUSIONS: Results provide further evidence of the critical role of gender-afrming hormone
therapy in reducing body dissatisfaction. Modest initial improvements in mental health were
also evident.
WHATS KNOWN ON THIS SUBJECT: Guidelines exist for providing gender-
afrming hormone therapy (ie, puberty suppression and masculinizing or
feminizing hormone therapy) to transgender youth; however, little research
has been conducted on the impact of treatment on body dissatisfaction and
mental health and factors that may inuence this impact.
WHAT THIS STUDY ADDS: One year of receiving gender-afrming hormone
therapy resulted in large reductions in youth body dissatisfaction and
modest improvements in mental health. No demographic or treatment-
related factors were associated with change over time.
To cite: Kuper LE, Stewart S, Preston S, et al. Body
Dissatisfaction and Mental Health Outcomes of Youth on
Gender-Afrming Hormone Therapy. Pediatrics. 2020;
145(4):e20193006
aChildrens Health Systems of Texas, Dallas, Texas; and bUniversity of Texas Southwestern Medical Center, Dallas,
Texas
Dr Kuper oversaw data collection, conducted data analysis, and drafted the manuscript; Drs
Stewart, Lau, and Lopez conceptualized and designed the study and provided feedback on
manuscript drafts; Dr Preston assisted with drafting the manuscript; and all authors contributed to
the development of study aims, approved the nal manuscript as submitted, and agree to be
accountable for all aspects of the work .
DOI: https://doi.org/10.1542/peds.2019-3006
Accepted for publication Dec 6, 2019
Address correspondence to Laura E. Kuper, PhD, Department of Endocrinology, Childrens Health
Systems of Texas, 1935 Medical District Dr, Mail Code F4.05, Dallas, TX 75235. E-mail: laura.kuper@
childrens.com
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Two inuential longitudinal studies
from the Netherlands have helped
establish guidelines for providing
gender-afrming hormone therapy
(ie, puberty suppression and
masculinizing or feminizing hormone
therapy) to transgender youth with
gender dysphoria.
1,2
De Vries et al
3
conducted a prospective study with
70 youth who received puberty
suppression (ie, medication to stop
the progression of puberty). After
2 years, internalizing, externalizing,
and depressive symptoms improved
along with global functioning, but
there was no improvement in body
dissatisfaction or anxiety symptoms.
A subset of the same cohort (n= 55)
was reassessed after masculinizing or
feminizing hormone therapy and
gender-afrming surgery
(vaginoplasty or mastectomy and
hysterectomy), at which point there
was a sustained improvement in
global functioning and most measures
of mental health. Gender dysphoria
and body dissatisfaction also
improved, and self-reported quality of
life was similar to the Dutch
population.
4
However, patients were
not evaluated after masculinizing or
feminizing hormone therapy alone.
In the only other longitudinal study
of youth, participants seen in
a gender clinic in the United
Kingdom (n= 35) demonstrated
improvement in clinician assessment
of psychosocial functioning after
12 months of receiving puberty
suppression.
5
Only 1 cross-sectional
study has included a subset of
transgender youth (n= 82 of 202). In
comparison with those who had not
started treatment, individuals who
received both puberty suppression
and/or masculinizing or feminizing
hormone therapy as well as surgery
had more favorable body image but
not those who received puberty
suppression and/or masculinizing or
feminizing hormone therapy only.
6
Within this study, youth and adults
as well as those receiving puberty
suppression and/or masculinizing or
feminizing hormone therapy were
combined.
The benets of gender-afrming
treatment are better described in
adults. A recent review of 5
longitudinal and 2 cross-sectional
studies found that receipt of
masculinizing or feminizing hormone
therapy alone was associated with
improved depression in 5 of 7
studies, improved anxiety in 2 of 2
studies, and better quality of life in 3
of 3 studies.
7
Two studies also found
lower rates of body uneasiness in
adults who received masculinizing or
feminizing hormone therapy alone
(ie, dissatisfaction with body parts
and negative body-related
experiences, such as avoidance and
self-monitoring).
8,9
Understanding the impact of gender-
afrming hormone therapy on the
mental health of transgender youth is
critical given the health disparities
documented in this population.
Within samples of transgender youth
presenting for gender-afrming
hormone therapy, estimates of
clinically signicant depressive
symptoms or diagnoses have
averaged in the range of 30% to
60%,
1013
and estimates of clinically
signicant anxiety symptoms or
diagnoses have averaged in the range
of 20% to 30%.
11,1416
Lifetime
history of suicidal ideation (average
range 30%50%),
10,11,16
suicide
attempt (average range
15%30%),
10,11,13
and nonsuicidal
self-injury (NSSI) (average range
20%40%)
12,13,16
also appear
common.
There is also some evidence that rates
of mental health concerns may vary
by gender, but no clear pattern has
emerged.
11,14,15,17
Two studies have
found higher levels of body
dissatisfaction among afrmed
females (ie, individuals assigned male
at birth who identify as female) in
comparison with afrmed males (ie,
individuals assigned female at birth
who identify as male).
6,18
Changes
associated with puberty, as reected
in age and/or Tanner stage (ie, stage
of puberty), may exacerbate body
dissatisfaction and mental health
concerns. Fewer studies have
examined differences by age;
however, one study found greater
symptoms of depression but not
anxiety among older adolescents,
16
and one study found higher levels of
body dissatisfaction.
4
None have
specically examined the impact of
Tanner stage.
Our rst aim in this study was to
explore how transgender youth
baseline body dissatisfaction,
depression, and anxiety symptoms
vary on the basis of their gender, age
at initial assessment, and Tanner
stage at rst medical visit. Consistent
with our earlier article examining
differences in mental health
functioning using the Child Behavior
Checklist and Youth Self-Report,
14
we
hypothesized that afrmed males will
report greater symptoms of
depression and anxiety. We also
hypothesized that older age and
greater Tanner stage will be
associated with higher ratings of body
dissatisfaction and more symptoms of
depression and anxiety.
Our second aim was to examine how
transgender youth body
dissatisfaction, depression, and
anxiety symptoms change over the
rst year of receiving gender-
afrming hormone therapy. We
anticipated improvements in each of
these domains but did not have any
a priori hypotheses regarding which
domains would demonstrate the
greatest improvements.
Our third aim was to explore how any
changes over time vary by afrmed
gender, Tanner stage, age, type of
treatment, months on masculinizing
or feminizing hormone therapy,
mental health treatment received, and
whether chest (ie, top) surgery was
also obtained (among those assigned
female at birth). We hypothesized
that older age, greater Tanner stage,
2 KUPER et al
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receipt of puberty suppression only,
fewer months on masculinizing or
feminizing hormone therapy, and lack
of chest surgery will be associated
with fewer changes over time. Lastly,
for descriptive purposes, we report
information on lifetime and follow-up
rates of suicidal ideation, suicide
attempts, NSSI, and mental health
treatment.
METHODS
Participants and Procedure
Participants are youth who received
gender-afrming hormone therapy
with a multidisciplinary program in
Dallas, Texas. Before initiating care,
participants and their families
participated in an initial assessment
with the programs psychologist,
psychiatrist, and/or clinical therapist
after parents completed a phone
intake survey and provided a referral
letter from a licensed therapist or
counselor documenting the presence
of gender dysphoria (this letter is no
longer required). Approximately 34%
of families did not follow-up after the
phone intake. Initial assessments
occurred between August 2014 and
March 2018, with most occurring in
2017 (41%) or 2016 (37%). At home
before this visit, participants
completed self-report measures of
depression, anxiety, and body
dissatisfaction. During the visit,
clinicians also completed a report of
depressive symptoms and collected
information regarding lifetime and
recent suicidal ideation, suicide
attempts, and NSSI as well as current
participation in therapy and support
groups and use of psychiatric
medication(s).
After the assessment, participants
were discussed by the
multidisciplinary team of providers
from psychology, social work,
pediatric endocrinology, pediatric and
adolescent gynecology, and
adolescent medicine. The Endocrine
Society Clinical Practice Guidelines
2
guided the initiation of hormone
therapy. Chest surgery was not
performed within the program, but
participants were provided with
referrals when requested.
Approximately 1 year after this initial
assessment (range: 1118 months),
all patients were asked to participate
in a yearly reassessment visit.
Participants were readministered
self-report measures, and clinicians
again completed a report of
depressive symptoms and
documented information about
suicidal ideation, suicide attempts,
NSSI, and mental health treatment.
Survey and clinician data were
entered into a research database for
analysis along with demographic and
treatment-related information (ie,
Tanner stage at rst medical visit,
treatment start and end dates, and
chest surgery date extracted from
physiciansnotes). All participants
provided consent, or assent with
parent consent, to allow this
information to be used for research.
The study was approved by the
institutional review board at the
University of Texas Southwestern
Medical Center.
Measures
Participants were asked to self-report
their gender identity (all ages) and
sexual orientation (age 12 and older).
These responses were recorded
verbatim by the clinician and entered
into the research database. Gender
identities were coded into the
following categories: (1) male, boy, or
man; (2) male spectrum (eg, trans
masculineor masculine
nonbinary); (3) female, girl, or
woman; (4) female spectrum (eg,
mostly female, slightly nonbinary);
and (5) nonbinary (eg, agenderor
part girl, part boy).
To assess body dissatisfaction,
participants aged 12 years and older
rated their degree of dissatisfaction
with 29 areas of the body using the
Body Image Scale (BIS).
19
Participants of all ages completed the
Screen for Child Anxiety Related
Emotional Disorders (SCARED),
which produces a total score as well
as subscale scores for panic-related,
social, separation-related,
generalized, and school
avoidancerelated anxiety
symptoms,
20
as well as the Quick
Inventory of Depressive Symptoms
(QIDS)
21
to measure symptoms of
depression that reect the Diagnostic
and Statistical Manual of Mental
Disorders, Fifth Edition criteria for
major depressive disorder.
22
The
QIDS produces a total score that can
also be grouped into clinical
categories: not elevated (05), mild
(610), moderate (1115), and severe
(1627). Clinicians also completed
the clinician version of the QIDS.
When the percentage of missing
values for each total score and
subscale score was #15%, missing
values were imputed by using the
mean of nonmissing values.
Analyses
To examine baseline differences in
depression (QIDS self and clinician),
anxiety (SCARED), and body
dissatisfaction (BIS), bivariate
correlation coefcients were rst
examined by using Pearsons r for
age, Spearmansrfor Tanner stage,
and point biserial for gender.
Variables with signicant correlations
were then simultaneously entered
into a linear regression for each
outcome, and Cohensf
2
was
calculated as a measure of effect
size (0.1 = small, 0.25 = moderate,
and 0.4 = large).
23
To examine change over time, QIDS
(self and clinician), SCARED, and BIS
scores were rst tested for normality
by using the Kolmogorov-Smirnov
test. Changes in normally distributed
variables were examined by using
paired ttests, and the Wilcoxon rank
test was used when the Kolmogorov-
Smirnov value was signicant.
Cohensdwas used as a measure of
effect size (0.2 = small, 0.5 =
moderate, and 0.8 = large).
23
Changes
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in clinical groupings on the QIDS
were also examined by using the
Wilcoxon rank test. For both baseline
and longitudinal analyses, we planned
to rst examine the SCARED total
score then test for differences in
subscale scores only if this change
was signicant.
To test for associations between
change scores and demographic and
treatment characteristics, change
scores were calculated by subtracting
baseline scores from follow-up scores
for variables that exhibited
a signicant change over time.
Bivariate correlation coefcients were
then examined by using Pearsonsr
for age and months on feminizing or
masculinizing hormone therapy,
Spearmansrfor Tanner stage and
therapy frequency, and point biserial
for gender, treatment type,
psychiatric medication use, support
group participation, and chest
surgery receipt (for those assigned
female at birth). We planned to
include any variables with signicant
correlations in a linear regression.
P,.01 was signicant for all
statistical tests to help account for the
overall number of tests. Condence
intervals (CIs) are reported at the
95% level.
RESULTS
Figure 1 presents a ow diagram of
participants who were due for
follow-up ($18 months since initial
assessment), participants with
follow-up data, and the reasons why
follow-up data were not available or
excluded. The mean number of
months between initial assessment
and reassessments was 14.9 (SD
2.1). Table 1 presents demographic
information on participants. At the
initial assessment, patients ranged
in age from 9 to 18 years (mean
15.4; SD 2.0). All but 1 participant
met Diagnostic and Statistical
Manual of Mental Disorders, Fifth
Edition criteria for gender
dysphoria. This participant
subsequently met criteria at
a follow-up visit and was started on
treatment. Participants who started
puberty suppression only did so at
a mean age of 13.7 years (range
9.814.9; SD 1.5), and participants
started feminizing or masculinizing
hormone therapy at a mean age of
16.2 years (range 13.218.6; SD
1.2). For participants who were on
masculinizing or feminizing hormone
therapy, the mean length of time
receiving treatment before follow-up
was 10.9 months (range 118; SD
3.3). During the follow-up period, 2
participants stopped puberty
suppression without starting
masculinizing or feminizing hormone
therapy, and no participants stopped
masculinizing or feminizing hormone
therapy. Fifteen afrmed males
obtained chest surgery at an average
age of 17.1 years (range 15.218.7;
SD 1.2) and at an average of
9.2 months from baseline (range
3.016.0; SD 3.3).
Table 2 presents means, SDs, and
ranges for QIDS, SCARED, and BIS
scores at initial assessment and
follow-up for the full sample as well
as by gender and treatment type. At
baseline, afrmed males had greater
clinician-reported depressive
symptoms (CI 23.76 to 20.81), self-
reported depressive symptoms (CI
24.46 to 20.79), total anxiety
symptoms (CI 214.94 to 23.99),
panic symptoms (CI 25.88 to 21.78),
and school avoidance symptoms (CI
21.81, to 20.36) in comparison with
afrmed females. However, Cohensf
2
effect sizes were all in the small
range (0.07, 0.06, 0.09, 0.10, and 0.07,
respectively). No differences were
found by age or Tanner stage.
Within the full sample, a signicant
decrease in body dissatisfaction (CI
FIGURE 1
Flow diagram.
4 KUPER et al
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14.74 to 21.90), self-reported
depressive symptoms (CI 1.24 to
2.97), and total anxiety symptoms (CI
1.05 to 6.70) was observed during the
follow-up period. Decreases in
generalized, separation, and school-
related anxiety symptoms were
signicant at the P,.05 level but not
the P,.01 level. No change in
clinician report of depressive
symptoms was found. Cohensdeffect
sizes were large for change in BIS
scores (1.04), small to moderate for
change in QIDS self-report scores
(0.44), and small for change in
SCARED total scores (0.27). Table 3
reports the percentage of the sample
that fell into each clinical category on
the QIDS at initial assessment and
follow-up. A signicant change was
also found in self-reported depressive
symptom categories (P,.001) but
not clinician-reported categories. No
correlations were found between
change scores and demographic and
treatment-related characteristics.
Although change scores were
generally higher for participants who
received chest surgery, no
correlations were signicant.
Table 4 presents descriptive data on
mental health treatment, and Table 5
presents data on suicidal ideation,
suicide attempt, and NSSI. During the
follow-up period, the distribution of
therapy frequency was as follows:
none (16%), less than every 3 months
(15%), every 2 to 3 months (12%),
monthly (22%), every other week
(21%), and weekly (14%). Of those
who experienced suicidal ideation
during the follow-up period, 94% had
a lifetime history. These gures were
67% for suicide attempt and 87%
for NSSI.
DISCUSSION
Youth reported large improvements
in body dissatisfaction during the 1-
year follow-up period. The amount of
improvement was not related to
treatment type. These ndings are
consistent with a handful of studies
that have documented improvements
in body dissatisfaction within
samples of adults receiving
feminizing or masculinizing hormone
therapy
8,9
but contrast with the 2
existing studies of youth. Within the
longitudinal cohort from Amsterdam,
puberty suppression alone was not
associated with improvements in
body dissatisfaction,
3
and within
a cross-sectional study with a mixed
sample of youth and adults, puberty
suppression and/or feminizing or
masculinizing hormone therapy was
not associated with more favorable
body image.
6
In contrast to the
Amsterdam sample, youth in the
current study were younger when
starting puberty suppression (age:
mean 12.5 and range 9.814.9 versus
mean 13.7 and range 11.117.0).
Age, puberty stage, length of time
receiving feminizing or masculinizing
hormone therapy, and receipt of chest
surgery were also not associated with
amount of improvement. However,
the sample size of participants
receiving puberty suppression only
and chest surgery were small, and
variations in months on feminizing or
masculinizing hormone therapy may
not have been meaningful enough in
the relatively short follow-up period.
TABLE 1 Participant Demographics
n(%)
Gender identity
Male, boy, or guy 81 (55)
Male spectrum 9 (6)
Female, girl, or woman 52 (35)
Female spectrum 2 (1)
Something else
a
3 (2)
Assigned sex
Male 55 (37)
Female 94 (63)
Sexual orientation
b
Pansexual 25 (20)
Straight 24 (19)
Bisexual 15 (12)
Gay 12 (10)
Unsure 12 (10)
No label 11 (9)
Asexual 10 (8)
Something else 10 (8)
Lesbian 6 (5)
Race
White 137 (95)
African American 3 (2)
Multiracial 3 (2)
American Indian 1 (1)
Ethnicity
Hispanic 24 (17)
Non-Hispanic 120 (83)
Tanner stage
I 3 (2)
II 6 (4)
III 5 (4)
IV 32 (23)
V 94 (67)
Treatment type
c
Puberty suppression only 25 (17)
Masculinizing or femininizing therapy only 93 (63)
Both treatments 30 (20)
a
Excluded from gender analyses.
b
Age 12 and older.
c
Masculinizing or feminizing therapy only and both treatments were collapsed for analysis by treatment type.
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TABLE 2 Body Dissatisfaction, Depression, and Anxiety Symptoms at Baseline and Follow-up
nRange
a
Baseline, Mean (SD) Follow-up,
Mean (SD)
Body dissatisfaction (BIS) 0116
Full sample
b
96 69.9 (15.6) 51.7 (18.4)
Afrmed males 66 71.1 (13.4) 52.9 (16.8)
Afrmed females 30 67.5 (19.5) 49.0 (21.6)
Puberty suppression 10 64.1 (18.2) 53.8 (20.1)
Feminine or masculine hormone therapy 86 70.7 (15.2) 51.4 (18.3)
Depressive symptoms (QIDS), self report
c
027
Full sample
b
118 9.4 (5.2) 7.3 (4.6)
Afrmed males 76 10.4 (5.0) 7.5 (4.5)
Afrmed females 40 7.5 (4.9) 6.6 (4.4)
Puberty suppression 13 8.2 (6.1) 7.0 (5.6)
Feminine or masculine hormone therapy 105 9.6 (5.0) 7.4 (4.5)
Depressive symptoms (QIDS), clinician report
c
027
Full sample 125 5.8 (4.2) 5.9 (3.9)
Afrmed males 78 6.7 (4.4) 6.2 (4.1)
Afrmed females 45 4.2 (3.2) 5.4 (3.4)
Puberty suppression 19 5.3 (4.9) 5.5 (4.8)
Feminine or masculine hormone therapy 106 5.9 (4.1) 6.0 (3.8)
Anxiety symptoms (SCARED), total score
c
082
Full sample
d
102 32.4 (16.3) 28.6 (16.1)
Afrmed males 65 35.4 (16.5) 29.8 (15.5)
Afrmed females 33 26.4 (14.2) 24.3 (15.4)
Puberty suppression 22 31.8 (16.6) 29.3 (17.1)
Feminine or masculine hormone therapy 80 32.6 (16.3) 28.4 (15.9)
Panic symptoms (SCARED)
c
026
Full sample 104 8.2 (6.3) 7.1 (6.3)
Afrmed males 66 9.3 (6.5) 7.9 (6.5)
Afrmed females 34 5.7 (4.9) 5.1 (4.9)
Puberty suppression 22 8.7 (6.5) 7.2 (5.7)
Feminine or masculine hormone therapy 82 8.1 (6.3) 7.1 (6.5)
Generalized anxiety symptoms (SCARED) 018
Full sample 104 9.7 (5.1) 8.7 (5.1)
Afrmed males 66 10.4 (5.0) 9.0 (5.1)
Afrmed females 34 8.6 (5.1) 8.0 (5.1)
Puberty suppression 22 8.5 (5.2) 8.2 (5.4)
Feminine or masculine hormone therapy 82 10.0 (5.1) 8.8 (5.0)
Social anxiety symptoms (SCARED) 014
Full sample 104 8.0 (4.1) 7.6 (4.3)
Afrmed males 66 8.5 (4.0) 7.8 (4.1)
Afrmed females 34 7.1 (3.9) 6.8 (4.4)
Puberty suppression 22 6.3 (3.6) 7.3 (4.7)
Feminine or masculine hormone therapy 82 8.5 (4.1) 7.7 (4.2)
Separation anxiety symptoms (SCARED)
e
016
Full sample 103 4.0 (3.4) 3.3 (2.7)
Afrmed males 65 4.2 (3.4) 3.4 (2.6)
Afrmed females 34 3.4 (3.3) 2.7 (2.3)
Puberty suppression 22 5.8 (4.0) 4.2 (3.1)
Feminine or masculine hormone therapy 81 3.5 (3.0) 3.1 (2.5)
School avoidance symptoms (SCARED)
c
08
Full sample 102 2.6 (2.2) 2.0 (2.1)
Afrmed males 65 2.9 (2.3) 2.0 (2.3)
Afrmed females 33 1.8 (1.7) 1.9 (2.1)
Puberty suppression 22 2.6 (2.7) 2.4 (2.4)
Feminine or masculine hormone therapy 80 2.6 (2.1) 2.0 (2.0)
a
Absolute range.
b
Signicant change from initial assessment to follow-up (P,.001).
c
Signicant difference in baseline scores by gender (P,.01).
d
Signicant change from initial assessment to follow-up (P,.01).
e
Signicant difference in baseline scores by age (P,.01).
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Most participants (90%) were also in
advanced stages of puberty (Tanner
stage IV or V) when presenting for
care. Limitations associated with
collecting data within a busy clinical
setting with multiple providers also
resulted in missing data. Nonetheless,
results suggest that youth receiving
gender-afrming hormone therapy
experience meaningful short-term
improvements in body dissatisfaction,
and no participants discontinued
feminizing or masculinizing hormone
therapy. These results provide
additional support for the
incorporation of these treatments
into the standards of care for
transgender youth experiencing
gender dysphoria.
1,2
Youth also reported modest
improvements in mental health
functioning during the follow-up
period. These results are consistent
with the existing longitudinal studies
of youth.
35
Several factors may help
explain why improvements were not
greater than what was observed.
Although physical changes associated
with feminizing or masculinizing
hormone therapy often start within
the rst 3 months, changes continue
over the course of several years.
Furthermore, environmental
stressors associated with ones
transgender status may not improve
after hormone therapy and could
potentially worsen should they
increase the youths visibility as
a transgender person. Research has
consistently documented higher rates
of bullying among transgender youth
in comparison with nontransgender
youth.
24,25
Within the current study,
rates of school avoidancerelated
anxiety did not improve over the
follow-up period.
The larger political context is also
important to consider. Within Texas,
where the current study was
conducted, a well-publicized
bathroom billwas introduced during
the study period that prohibited
transgender people from using
a restroom that was different from the
sex on their birth certicate, although
the bill ultimately failed to pass.
26
As
a whole, the mental health functioning
of youth from the present clinic as well
as youth from a handful of other US-
and European-based clinics appears
poorer than the mental health
functioning of youth from the
Amsterdam clinic.
11,14,17
Previous
studies have attributed this difference
to Amsterdams social and political
climate, which is known to be more
supportive of the lesbian, gay, bisexual,
and transgender population.
17
Consistent with our study
examining baseline differences in
mental health functioning as
measured by the Child Behavior
Checklist and Youth Self-Report,
14
afrmed males reported greater
symptoms of depression and several
forms of anxiety in comparison with
afrmed females. However, the effect
size of these differences was smaller
within the current study in
comparison with the former.
Differences in measurement
approach may help explain the
mixed ndings regarding gender
differences in mental health
functioning across youth
clinics.
11,15,17
Although some
research suggests that nonclinic
samples of afrmed male youth
report more experiences of
bullying,
24
afrmed females are
thought to experience greater stigma
regarding expression of femininity.
Consistent with the current sample,
the sex ratio of youth presenting to
clinics also appears to be shifting
from more afrmed females to more
afrmed males presenting for care.
27
Although causes of this shift are
largely unknown, they may be
associated with other shifts in
clinical presentations (eg, mental
health and psychosocial
functioning).
CONCLUSIONS
The current study is the largest
longitudinal study of youth receiving
gender-afrming hormone therapy to
date and documents important
improvements in body dissatisfaction
over the rst year of treatment.
Continued longitudinal study of this
TABLE 3 Depressive Symptoms (QIDS) Scoring Ranges
Range Self-Report
a
Clinician Report
Baseline, N(%) Follow-up, N(%) Baseline,
N(%)
Follow-
up,
N(%)
Not elevated 05 33 (25) 51 (40) 73 (53) 67 (49)
Mild 610 46 (35) 48 (37) 44 (32) 49 (36)
Moderate 1115 29 (22) 22 (17) 15 (11) 16 (12)
Severe 1627 24 (18) 8 (6) 5 (4) 4 (3)
a
Signicant change from initial assessment to follow-up (P,.001).
TABLE 4 Mental Health Treatment
At Initial
Assessment, n(%)
Follow-up
Period, n(%)
Psychiatric medication 67 (47) 80 (61)
Therapist or counselor 144 (97) 114 (84)
Support group
a
60 (43) 45 (35)
a
Participation by parents and/or youth (eg, transgender family support organization; lesbia n, gay, bisexual, and
transgender youth center; or school-based Gay-Straight Alliance).
PEDIATRICS Volume 145, number 4, April 2020 7
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population will increase the elds
understanding of the benets of
gender-afrming hormone therapy
and assist providers in better
anticipating needs. Follow-up periods
of several years or more will help
document the full impact of the
physical changes with feminizing or
masculinizing hormone therapy, and
larger sample sizes will improve the
ability to examine the specic impacts
of treatment type and chest surgery.
Greater consideration of
intersectionality and sociocultural
context will further strengthen these
efforts.
ACKNOWLEDGMENT
Rong Huang, MS, provided
consultation on the data analysis.
ABBREVIATIONS
BIS: Body Image Scale
CI: condence interval
NSSI: nonsuicidal self-injury
QIDS: Quick Inventory of
Depressive Symptoms
SCARED: Screen for Child Anxiety
Related Emotional
Disorders
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to this article to disclose.
FUNDING: Research reported in this publication was supported by Childrens Health. The content is solely the responsibility of the authors and does not necessarily
represent the ofcial views of Childrens Health. The Research Electronic Data Capture database was funded by the Clinical and Translational Science Awards
program National Insitutes of Health grant UL1-RR024982 awarded to the UT Southwestern Center For Translational Medicine.
POTENTIAL CONFLICT OF INTEREST: Dr Lopez has participated as a member of an advisory board for Endo International; the other authors have indicated they have
no potential conicts of interest to disclose.
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2020;145;Pediatrics
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Body Dissatisfaction and Mental Health Outcomes of Youth on
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... 5 TGE youth are at a substantially increased risk of being diagnosed with a variety of mental health conditions, [6][7][8][9] and research has shown gender-affirming hormone therapy is associated with a decrease in depression, suicidal ideation, and symptoms of gender dysphoria, as well as an improvement in subjective quality of life and well-being in young TGE patients. 6,7,[10][11][12][13] A recent study of a wider age range (18-44 years) of TGE individuals found that gender-affirming surgical procedures result in lower psychological distress and suicidal ideation in recipients compared with individuals without access to such procedures. 14 Gender-affirming hormone therapies are potentially associated with increased risk of infertility, due to decreased sperm production in patients assigned male at birth 15,16 and decreased ovulation in patients assigned female at birth, 17,18 although the degree of infertility and reversibility following discontinuation of hormones remains unclear. ...
... Participants were on average 16 years of age (M = 16.17 years; SD = 2.00, range [13][14][15][16][17][18][19][20][21][22]. Most patients identified as transmasculine (59.4%), white (69.6%), and non-Hispanic (85.5%). ...
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Abstract Purpose: This study sought to replicate and expand a previous pilot investigation of reproductive knowledge, attitudes toward fertility and parenthood, and sources of information on these topics among transgender and gender-expansive (TGE) youth. Methods: The Yale Pediatric Gender Program (YPGP) Reproductive Knowledge and Experiences Survey (YPGP-RKES) was administered to 70 TGE adolescents receiving care at an interdisciplinary clinic providing gender-affirming health care at an academic medical center. Data gathered included sources of information on reproduction and fertility, concerns about future parenthood and reproduction, and interest in different types of parenthood. Results: Over a third (39.1%) of participants reported it was important to them to have a child one day, while only a small proportion (23.2%) reported an interest in biological parenthood. A plurality of participants (37.3%) reported at least one concern about future fertility. The number of reproductive concerns did not differ by age or treatment (puberty blockers or gender-affirming hormones vs. no treatment) status. With respect to needs for more information and sources of information, most (56.5%) participants received information about fertility issues before this study, with the most cited source of information being online research. Conclusions: The current study replicated and extended previous findings on the reproductive attitudes and knowledge of TGE adolescents. Understanding the informational needs and priorities of adolescent TGE patients presenting for medical treatment will allow providers to give more robust patient education. This will, in turn, facilitate patients' ability to provide fully informed consent for treatment that aligns with their fertility and reproductive priorities and goals.
... Previous research has used the QIDS in TGD samples (e.g., Kuper et al., 2020), however psychometric data was not provided. In the current study, internal consistency was adequate (ɑ = .67). ...
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Individuals who are transgender and gender diverse (TGD) are more likely to suffer from and to seek mental health services for mood disorders. Some literature suggests that TGD individuals, because of pervasive and systemic minority stress, may have more complex clinical presentations (i.e., psychiatric conditions and severity of symptoms) and may benefit from empirically based treatments to a lesser degree than their cisgender peers. However, research has yet to examine individuals who are TGD receiving treatment in specialized, intensive mood disorder treatment despite the propensity for them to be diagnosed with and treated for mood disorders. Using a sample of 1,326 adult patients in intensive mood disorder treatment (3.8% TGD), the clinical presentation and treatment outcomes were compared between patients who are TGD and cisgender. Contrary to previous research, TGD patients were largely similar if not healthier than their cisgender counterparts, including similar depression, quality of life, emotion dysregulation, and behavioral activation, and less severe rumination at admission. Despite similar to better reported mental health symptoms, TGD patients were diagnosed with more psychiatric conditions overall, including greater prevalence of social anxiety and neurodevelopmental diagnoses. Those who are TGD did not experience attenuated treatment response as predicted. Findings suggest that patients in intensive mood disorder treatment who are TGD may be more resilient than previously assumed, or supports may have increased to buffer effects of stigma on mental health, and emphasize the need to exercise discretion and sensitivity in diagnostic practices to prevent over-diagnosis and pathologizing of TGD individuals.
... 39 Moreover, in a previous study, transgender adults who received GAHT were found to have more manageable distress symptoms and decreased body dissatisfaction than those who have not yet undergone hormone therapy. 41 In our study, more than half were GAHT-naïve, and not being on GAHT is associated with a higher prevalence rate of desiring surgery in the crude bivariable analysis. However, upon adjusting with other predictors, the association turned out to be non-significant. ...
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Adolescents seeking professional help with their gender identity development often present with psychological difficulties. Existing literature on psychological functioning of gender diverse young people is limited and mostly bound to national chart reviews. This study examined the prevalence of psychological functioning and peer relationship problems in adolescents across four European specialist gender services (The Netherlands, Belgium, the UK, and Switzerland), using the Child Behavioural Checklist (CBCL) and the Youth Self-Report (YSR). Differences in psychological functioning and peer relationships were found in gender diverse adolescents across Europe. Overall, emotional and behavioural problems and peer relationship problems were most prevalent in adolescents from the UK, followed by Switzerland and Belgium. The least behavioural and emotional problems and peer relationship problems were reported by adolescents from The Netherlands. Across the four clinics, a similar pattern of gender differences was found. Birth-assigned girls showed more behavioural problems and externalising problems in the clinical range, as reported by their parents. According to self-report, internalising problems in the clinical range were more prevalent in adolescent birth-assigned boys. More research is needed to gain a better understanding of the difference in clinical presentations in gender diverse adolescents and to investigate what contextual factors that may contribute to this.
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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 higher frequency of suicide attempts in TG youth with a desire for weight change, and more female-to-male youth reported a history of suicide attempts and self-harm behaviors than male-to-female youth. Findings indicate that this population is at a high risk for psychiatric comorbidities and life-threatening behaviors.
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The number of adolescents referred to specialized gender identity clinics for gender dysphoria appears to be increasing and there also appears to be a corresponding shift in the sex ratio, from one favoring natal males to one favoring natal females. We conducted two quantitative studies to ascertain whether there has been a recent inversion of the sex ratio of adolescents referred for gender dysphoria. The sex ratio of adolescents from two specialized gender identity clinics was examined as a function of two cohort periods (2006-2013 vs. prior years). Study 1 was conducted on patients from a clinic in Toronto, and Study 2 was conducted on patients from a clinic in Amsterdam. Across both clinics, the total sample size was 748. In both clinics, there was a significant change in the sex ratio of referred adolescents between the two cohort periods: between 2006 and 2013, the sex ratio favored natal females, but in the prior years, the sex ratio favored natal males. In Study 1 from Toronto, there was no corresponding change in the sex ratio of 6,592 adolescents referred for other clinical problems. Sociological and sociocultural explanations are offered to account for this recent inversion in the sex ratio of adolescents with gender dysphoria. Aitken M, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A, Spegg C, Wasserman L, Ames M, Fitzsimmons CL, Leef JH, Lishak V, Reim E, Takagi A, Vinik J, Wreford J, Cohen-Kettenis PT, de Vries ALC, Kreukels BPC, and Zucker KJ. Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. J Sex Med **;**:**-**. © 2015 International Society for Sexual Medicine.
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Purpose: Gender dysphoria (GD) is associated with clinically significant distress and impairment in social, scholastic, and other important areas of functioning, especially when early onset is reported. The aim of the present study is to assess the psychopathological features associated with GD in adolescence, comparing a group of gender dysphoric adolescents (GDs) with a group of non-referred adolescents (NRs), in terms of body uneasiness, suicide risk, psychological functioning, and intensity of GD. Methods: A sample of 46 adolescents with GD and 46 age-matched NRs was evaluated (mean ± SD age = 16.00 ± 1.49 and 16.59 ± 1.11 respectively, p > 0.05). Subjects were asked to complete the Body Uneasiness Test (BUT) to explore body uneasiness, the Youth Self Report (YSR) to measure psychological functioning, the Multi-Attitude Suicide Tendency Scale (MAST) for suicide risk, and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) for GD assessment. Results: Adolescents with GD reported significantly higher levels of body uneasiness (BUT-GSI, F = 380.13, p < 0.0001), as well as a worse psychological functioning (YSR, F = 13.06 and p < 0.0001 for "total problem scale" and F = 12.53, p = 0.001 for "internalizing" scale) as compared to NRs. When YSR subscales were considered, GDs showed significantly higher scores in the "withdrawal/depression", "anxiety/depression", and "social problems" (all p < 0.0001). In addition, GDs showed significantly higher levels in the "attraction to death" and "repulsion by life" scales and lower scores in the "attraction to life" scale (all p < 0.0001). Finally, GIDYQ-AA score was significantly lower (meaning a higher level of gender dysphoria symptoms) in GDs vs. NRs (p < 0.0001). Conclusions: GD adolescents reported significantly higher body dissatisfaction and suicidal risk compared to NRs. In addition, results confirmed a significant impairment in social psychological functioning in adolescents with GD.