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How Early in Life do Transgender Adults Begin to Experience Gender Dysphoria? Why This Matters for Patients, Providers, and for Our Healthcare System

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Introduction The age at which transgender women (TW) and men (TM) first experience gender dysphoria (GD) has not been reported in a U.S. population of adults seeking genital gender-affirming surgery (gGAS). Because gender is an innate part of identity, we hypothesized that untreated GD would be a part of individuals’ earliest memories. Understanding GD onset can help guide providers with when and how to focus care to patients not yet identified as “transgender Aim (i) Determine the age at which transgender adults seeking gGAS first experience GD (ii) Determine the number of life-years that transgender adults spend living with untreated GD Methods During initial consultation for gGAS, we asked patients the earliest age at which they experienced GD and the age at which they had their earliest episodic memory. We also queried history of anxiety, depression, and suicide attempt. Main Outcome Measures Patients self-reported their earliest recollections of experiencing GD, earliest memories in general, and history of anxiety, depression, and suicide attempt. Results Data from 155 TW (mean age 41.3; SD 16.3) and 55 TM (mean age 35.4; SD 10.8) were collected. Most patients (TM: 78%; TW: 73%) reported experiencing GD for the first time between ages 3 and 7 years. For TM the mean age of onset was 6.17 years; for TW it was 6.71 years. A total of 81% of TW and 80% of TM described their first recollection of GD as one of their earliest memories. Mean years of persistent GD before the start of gender transition were 22.9 (TM) and 27.1 (TW). Rates of depression, anxiety, and suicide ideation decreased following gender transition. Conclusion Our findings suggest that GD typically manifests in early childhood and persists untreated for many years before individuals commence gender transition. Diagnosis and early management during childhood and adolescence can improve quality of life and survival. Zaliznyak M, Yuan N, Bresee C, et al. How Early in Life do Transgender Adults Begin to Experience Gender Dysphoria? Why This Matters for Patients, Providers, and for Our Healthcare System. Sex Med 2021;XX:XXXXXX.
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ORIGINAL RESEARCH
TRANSGENDER HEALTH
How Early in Life do Transgender Adults Begin to Experience Gender
Dysphoria? Why This Matters for Patients, Providers, and for Our
Healthcare System
Michael Zaliznyak, BA,
1
Nance Yuan, MD,
2,3
Catherine Bresee, MS,
4
Andrew Freedman, MD,
2
and
Maurice M. Garcia, MD, MAS
2,3,5,6
ABSTRACT
Introduction: The age at which transgender women (TW) and men (TM) rst experience gender dysphoria
(GD) has not been reported in a U.S. population of adults seeking genital gender-afrming surgery (gGAS).
Because gender is an innate part of identity, we hypothesized that untreated GD would be a part of individuals
earliest memories. Understanding GD onset can help guide providers with when and how to focus care to patients
not yet identied as transgender
Aim: (i) Determine the age at which transgender adults seeking gGAS rst experience GD
(ii) Determine the number of life-years that transgender adults spend living with untreated GD
Methods: During initial consultation for gGAS, we asked patients the earliest age at which they experienced GD
and the age at which they had their earliest episodic memory. We also queried history of anxiety, depression, and
suicide attempt.
Main Outcome Measures: Patients self-reported their earliest recollections of experiencing GD, earliest memo-
ries in general, and history of anxiety, depression, and suicide attempt.
Results: Data from 155 TW (mean age 41.3; SD 16.3) and 55 TM (mean age 35.4; SD 10.8) were collected.
Most patients (TM: 78%; TW: 73%) reported experiencing GD for the rst time between ages 3 and 7 years.
For TM the mean age of onset was 6.17 years; for TW it was 6.71 years. A total of 81% of TW and 80% of TM
described their rst recollection of GD as one of their earliest memories. Mean years of persistent GD before the
start of gender transition were 22.9 (TM) and 27.1 (TW). Rates of depression, anxiety, and suicide ideation
decreased following gender transition.
Conclusion: Our ndings suggest that GD typically manifests in early childhood and persists untreated for many
years before individuals commence gender transition. Diagnosis and early management during childhood and
adolescence can improve quality of life and survival. Zaliznyak M, Yuan N, Bresee C, et al. How Early in Life
do Transgender Adults Begin to Experience Gender Dysphoria? Why This Matters for Patients, Providers,
and for Our Healthcare System. Sex Med 2021;9:100448.
Copyright © 2021 The Authors. Published by Elsevier Inc. on behalf of the International Society for Sexual
Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).
KEY WORDS: Transgender; Gender Dysphoria; Gender Afrming Hormone Therapy (GAHT); Gender
Afrming Surgery (GAS); Sex Reassignment Surgery (SRS)
Received May 14, 2021. Accepted September 17, 2021.
1
Saint Louis University School of Medicine, St. Louis, MO, USA;
2
Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA;
3
Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai
Medical Center, Los Angeles, CA, USA;
4
Biostatistics & Bioinformatics Core, Cedars-Sinai Samuel Oschin Compre-
hensive Cancer Center, Los Angeles, CA, USA;
5
Department of Urology, University of California San Francisco, San Fran-
cisco, CA, USA;
6
Department of Anatomy, University of California San Francisco, San Fran-
cisco, CA, USA
Copyright © 2021 The Authors. Published by Elsevier Inc. on behalf of the
International Society for Sexual Medicine. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
https://doi.org/10.1016/j.esxm.2021.100448
Sex Med 2021;9:100448 1
SEXUAL MEDICINE
INTRODUCTION
Gender dysphoria (GD)refers to psychological anguish due
to incongruence between an individuals gender assigned at birth
and perceived gender identity.
1
As public awareness and societal
acceptance of GD increase, the transgender population is
expected to continue to grow. In 2016, the Williams Institute
estimated the US transgender population to be 1.4 million adults
(0.6% of the total population), representing a 100% growth
from 15 years earlier.
2
Social stigma surrounding transgender
identication likely makes these statistics an underestimate of the
true transgender population.
Though robust studies are limited, the prevalence of GD in
childhood and adolescence is believed to range from 0.5-1.3%
3
and varies in severity. Studies have shown that childhood GD
persists into adulthood in 1027% of cases.
4-6
Persistent GD
carries with it serious comorbidities.
7,8
A 2015 national survey
on transgender individuals
9
found that 39% of transgender
adults experienced serious psychological distress, compared with
only 5% of the US population. 40% of transgender adults had
attempted suicide at least once in their lives, nearly nine times
the overall U.S. suicide rate of 4.6%; and 1.4% of transgender
adults reported living with HIV, nearly 5 times the HIV-positive
rate of 0.3% in the overall U.S. population. Rates of depression
and anxiety are also higher among transgender adults. Studies
evaluating mental health disparities of transgender adults have
found that 4465% of transgender adults reported suffering
from depression
10-12
and 3548% reported suffering from anxi-
ety
12,13
, compared with the U.S. population average for depres-
sion and anxiety of 7% and 18%, respectively
14
.
With improved availability of transgender youth health clin-
ics
15
, rates of children/adolescents referred for care will likely
increase. This highlights the importance of understanding how
early GD arises within individuals
16
. Most of our patients refer-
ring for genital gender afrming surgery (gGAS) report know-
ingthat their gender identities did not match their bodies, and
have had GD for most oftheir entire life,”“starting in child-
hood.This suggests that many transgender individuals may live
with GD prior to seeking care. Our study aimed to answer the
following questions: What is the age at which transgender adults
seeking gGAS rst experience GD, and how many life-years do
transgender adults spend living with untreated GD? Prior studies
have examined the age of onset of persistent GD and have shown
that many patients report gender dysphoriaduring early ado-
lescence.
17-21
However, the mean earliest age at which adult
transgender women (TW) (assigned male sex at birth; AMAB)
and men (TM) (assigned female sex at birth; AFAB) rst experi-
ence GD has not been reported in a United States population of
adults seeking gGAS. Data on the length of time transgender
people might live with GD and its associated morbidities helps
direct patient care and resources. With improved understanding
of the typical age of onset of GD, family members, care
providers, and teachers can better support young individuals that
may have GD. As with other challenging human conditions,
early detection of GD, accompanied by early intervention and
support, may reduce morbidity and lead to improvements in
patient health, quality of life, and survival.
METHODS
Data Collection
The Cedars-Sinai Medical Center Institutional Review Board
reviewed and approved this study (IRB #00055933). We per-
formed a retrospective review of consecutive patients that pre-
sented to our institution for gGAS consultation between
September 2016 and November 2018. Only patients who were
presenting for gGAS consultation were included in this study.
Patients who were not presenting for gGAS were excluded from
this study. All participants were previously diagnosed with GD
(per DSM 5 criteria) by 2 mental-health specialists. All patients
in this study had both socially transitioned (living full-time as
their identied gender) and had undergone gender-afrming
hormone therapy (GAHT) for at least a year.
For each patient, the following variables were recorded: gen-
der identity, earliest age at which persistent GD was experienced,
age at time of earliest episodic memory, age at start of GAHT,
age at start of social transition, past and present mental-health
therapy history, past and current suicide ideation and suicide
attempts (if any), medical history, surgical history, and other
demographic information. We also recorded patientsstatements
indicating that the experience of GD was among their earliest
memories: for example, we recorded statements such as I have
known all my life,and for as long as I can remember.All data
were self-reported by patients and analyzed exactly as stated by
patients, without modication or adjustment.
Statistical Analysis
Pearson correlation coefcients were computed to test correla-
tions between variables. Age at earliest memory of GD or rst
memory, as well as years between rst GD and gender transition,
were tested with linear regression modeling to covary for both
age and gender. Data are presented as means +/- standard devia-
tions (SD). Differences were considered signicant where 2-
tailed P-values were <.05. All analysis were performed using SAS
v9.4 software by SAS Institute Inc. (Cary, NC, USA).
RESULTS
Demographics of the patients in our study are shown in
Table 1. A total of 155 transgender women (TW) and 55 trans-
gender men (TM) were included.
2Zaliznyak et al
Sex Med 2021;9:100448
Transgender Men
Gender dysphoria history: Of the 55 TM patients included in
our study, 41 (75%) reported feeling GD for the rst time by
age 7, and 53 (96%) reported rst experiencing GD by age 13
(Table 2). A total of 80% of patients reported that feelings of
GD were among their earliest childhood memories. TM reported
remembering their earliest memories at a mean age of 4.70 years.
Meanwhile, mean age of GD onset was 6.17 years, with a mode
and median of 5 years. The mean number of years that these
patients lived with GD prior to beginning gender afrming tran-
sition (either surgery, GAHT, or social transition) was
22.90 years. Two of these patients (4%) reported living over fty
years with GD before attempting any gender transition (Table 2).
Mental-health history: Of the 55 TM patients in our study
(Table 1), over 90% of patients reported a history of depression,
anxiety, or both; 29 (53%) reported currently suffering from
either depression, anxiety or a combination of both. Ten (18%)
patients indicated a history of one or more suicide attempts
(Table 1). Mean number of lifetime suicide attempts was 1.90
(range: 15). Of patients with suicide attempts, only one (10%)
reported continued suicidal ideation after initiating either GAHT
or social transition. No patients had further suicide attempts after
starting transition.
Transgender Women Results
Gender dysphoria history: Of 155 TW patients, 112 (72%)
reported feeling GD for the rst time by age 7 (Table 2). Eighty-
one percent reported that feelings of GD were among their earli-
est childhood memories. Patients reported that their earliest epi-
sodic memories occurred at a mean age of 4.53 years. The mean
age of the rst onset of GD was 6.71 years, with a mode and
median of 5. The mean number of years that these patients lived
with GD prior to beginning gender-afrming transition (either
surgery, GAHT, or social transition) was 27.14 years (Table 2).
Eighteen (12%) patients reported living over 50 years with GD
before attempting any form of transition.
Mental health history: Of 155 TW patients, over 90%
reported a history of depression, anxiety, or both, with 72 (46%)
Table 1. Demographic data, sexual orientation details, and mental
health comorbidities of patient subjects (n)
Transgender men Transgender women
Age (years) at consultation for
surgery n = 55 %ofn n = 155 %ofn
Age (y) 16, and 17-20 0 (0%) 8(5%)
20-29 19 (35%) 38 (25%)
30-39 13 (24%) 29 (19%)
40-49 15 (27%) 22 (14%)
50-59 6 (11%) 30 (19%)
60+ 2 (4%) 28 (18%)
Mean (SD) 35.4 (10.8) 41.3 (16.3)
Race n = 55 %ofn n = 155 %ofn
White (Non-Hispanic) 26 (47%) 84 (54%)
Hispanic 10 (18%) 30 (19%)
Black or African American 7 (13%) 12 (8%)
Asian or Pacific Islander 4 (7%) 19 (12%)
Not Disclosed 8 (15%) 10 (6%)
Sex of sexual partners n = 52 %ofn n = 153 %ofn
Men 6 (12%) 71 (46%)
Women 38 (73%) 50 (33%)
Both 8 (15%) 32 (21%)
Mental Health Comorbidities n = 55 %ofn n = 155 %ofn
Depression 7 (13%) 17 (11%)
Anxiety 5 (9%) 10 (6%)
Both 17 (31%) 45 (29%)
Neither 26 (47%) 83 (54%)
Reported History of Suicide
Attempt?
n=48 %ofn n = 149 %ofn
Yes 10 (21%) 45 (30%)
No 38 (79%) 104 (70%)
Mean # of Suicide Attempts
(SD)
1.9 (1.3) 1.8 (1.7)
Range 1-5 1-10
Reported Current Feelings of
Suicide Ideation?
n=48 %ofn n = 149 %ofn
Yes 1 (2%) 12 (8%)
No 47 (98%) 137 (92%)
Medical HIV Comorbidities,
No. of patients
n=55 %ofn n = 155 %ofn
HIV + 0 (0%) 11 (7%)
HIV - 55 (100%) 144 (93%)
Table 2. Earliest age of first memory of gender dysphoria among
patient subjects (n) in our study
Transgender men Transgender women
Mean age (y) at time of
earliest memory
# of patients n = 30 # of patients n = 101
4.7 (2.3) 4.5 (2.0)
Mean age (y) at first gender
dysphoria (GD)
# of patients n = 52 # of patients n = 155
6.2 (3.1) 6.7 (3.6)
Age (y) at first memory of
GD, clustered by age group
n=52 %ofn n = 155 %ofn
Age 2-4 16 (30%) 38 (25%)
5-7 25 (48%) 74 (48%)
8-10 4 (8%) 19 (12%)
11-13 5 (10%) 17 (11%)
13+ (max age: 24 years) 2 (4%) 7(5%)
Reported their earliest
memory of GD as amongst
their earliest
life-memories
n=30 %ofn n = 101 %ofn
Yes 24 (80%) 82 (81%)
No 6 (20%) 19 (19%)
Number of years patients
lived with GD prior to
commencing gender
transition (nonsurgical)
n=50 %ofn n = 150 %ofn
<10 7 (14%) 20 (13%)
10-19 17 (34%) 40 (27%)
20-29 13 (26%) 33 (22%)
30-39 6 (12%) 23 (15%)
40-49 5 (10%) 16 (11%)
50+ 2 (4%) 18 (12%)
Mean: 22.9 (12.6) 27.1 (16.4)
Range: 358 1-68
Gender Dysphoria 3
Sex Med 2021;9:100448
reporting current depression, anxiety or both. History of one or
more suicide attempts was found in 45 (30%) patients (Table 1).
The mean number of suicide attempts was 1.81 (range: 16).
Of patients with prior suicide attempts, 12 (27%) reported con-
tinued suicide ideation following commencement of GAHT or
social transition, but there were no further suicide attempts after
transition. Eleven patients (7%) indicated being HIV+ during
their primary visitation (Table 3).
Generational Analysis. There was no signicant association
between current age and age of earliest recollection of GD (r=-
0.044, P= .527), suggesting no generational effectbetween
older and younger subjects with regards to age of GD onset.
(Table 3). Patients that were 40 years and older had an average
age of GD onset at 6.4 +/- 3.4 years, which was similar to
patients under 40 years old, who had an average age of GD onset
at 6.8 +/- 3.6 (P= .182) years.
However, there was a signicant generational effect with the
number of years from GD onset to the start of gender transition
(Table 1;Figure 1).: when compared to patients younger than
40 years old, older patients above age 40 reported living over
twice as many years with GD before starting gender transition (P
<.001).
The TM in this study was signicantly younger than the TW.
Nonetheless, no signicant differences were observed between
genders when comparing age of GD onset, age at reported rst
memory, or the number of years between GD onset and start of
gender transition (Table 3) and no signicant interaction of age
with gender was observed.
DISCUSSION
Age of Earliest Childhood Memories and Age of GD
Onset
This study aimed to identify, among a large sample of TM
and TW, the age at which adult patients recall their rst experi-
ence of GD. We were motivated to investigate the age of GD
onset, as our patients have consistently reported knowingthat
they are transgender, and have experienced the discomfort of
GD, most oftheir entire life.As most adultsearliest complex
(episodic) memories are from ages,
22-25
we also asked our
patients the ages at which they had their earliest complex memo-
ries. By comparing the earliest age of episodic memory and mean
age of GD onset, we sought to estimate the proportion of our
adult patients lives that had been spent with GD and that were
subject to recallable memories. This study nds that GD has, on
average, an early onset and is experienced prior to age 7 by the
majority of TM and TW. Birth sex, age at start of gender transi-
tion, sexual orientation, and age at time of gGAS consultation
were not independent predictors of the age of GD onset (Table 2,
Table 4). Both TM and TW reported a gap of about 2 years
between their earliest memories and the age of GD onset.
Our data aligns well with studies from the eld of memory
research, where Oliver Sacks and others have found that for most
Table 3. Generational and gender differences related to reported age of earliest recollection of gender dysphoria, and, age of first memory
Under 40 40 and older P-value
(n = 109) (n = 101)
Age at earliest memory of GD 6.8 (3.6) 6.4 (3.4) 0.182
Age at reported first memory 4.4 (1.9) 4.8 (2.2) 0.356
Years from earliest memory of GD to undergoing
gender transition (GAHT or social transition)
16.0 (7.0) 37.0 (15.1) <0.001
Transgender Men Transgender Women P-value
(n = 55) (n = 155)
Age at earliest memory of GD 6.2 (3.1) 6.7 (3.6) .245
Age at reported first memory 4.7 (2.3) 4.5 (2.0) .653
Years from earliest memory of GD to undergoing
gender transition (GAHT or social transition)
22.9 (12.6) 27.1 (16.4) .706
Figure 1. Average number of years from earliest memory of gen-
der dysphoria to start of gender transition 338 x 190 mm (300 x
300 DPI).
4Zaliznyak et al
Sex Med 2021;9:100448
adults, episodic memories from the rst 13 years of life cannot
be recalled and that memories from ages 3 to 7 are low in number
and quality.
24-26
The average age of an adults earliest recallable
memories is age 3.5.
22,23
Our data also aligns with gender identity
research, which has found that most children understand gender
permanence (ie, xed identity as a girlor boy) between 5 and
7 years of age.
27
Most of our patients rst experienced GD at this
age when children naturally grasp the concept of gender. Our nd-
ings suggest that those who experience GD tend to experience it
close to their entire (recallable) life. Interestingly, despite the
approximately two-year gap between earliest memory and earliest
experience of GD, nearly identical proportions of TM (80%) and
TW (81%) in our study described feelings of GD as among their
earliest memories,highlighting the impact of GD on their lives.
Impact of GD on Mental Health
Our ndings conrm that, for nearly all patients in our series,
GD affected childhood and adolescence as much as adulthood.
While we did not assess the severity of GD experienced by these
patients as children, several studies have reported that untreated
GD in childhood has adverse mental and physical health effects,
as it does in adulthood.
28-31
Although gender incongruence does
not persist for most children that experience it,
32
it should be
noted that, for the minority of children whose GD persists into
adulthood, lack of awareness of the childs experience and symp-
toms of GD increases the risk that GD will continue untreated
throughout early childhood and early adulthood, increasing the
risk to delay an adequate support and referral to specialized gen-
der clinics. Given the well-dened morbidity of untreated GD,
its cumulative morbidity can clearly be signicant.
The transgender adult patients in this study showed elevated
incidences of depression, anxiety, and suicidality in comparison
with national averages. These ndings corroborate numerous
studies showing that transgender individuals are at greater risk of
mental-health conditions compared to the general population.
33-
35
Suicidality in our patients was assessed not only before and
after gGAS, but throughout gender transition preceding surgery
(ie, after social transition and after commencing GAHT). Our
data shows a considerable decrease in suicidal ideation following
commencement of gender-afrming treatment (Table 1). Poor
mental health often stems from discrimination and rejection
from individualsfamilies and communities.
36,37
Support and
education of youth with early GD have been shown to signi-
cantly improve development and quality of life: gender-dysphoric
children that are supported in their transition by their families
have normative levels of depression and decreased or minimal
elevations in anxiety.
38
Given the high prevalence of suicidality,
depression, and anxiety among transgender communities, it fol-
lows that proper measures should be taken to address the under-
lying conditionuntreated GD.
Association of GD With HIV Positivity
In our cohort, 7% of TW patients were HIV-positive
(Table 1). This is considerably higher than the national average
of 0.3%
9
. Psychological conditions of depression and anxiety are
linked to elevated HIV risk, particularly among young TW.
39
Fear of being outed may cause gender dysphoric youths to hide
their conditions from family members, primary care physicians,
and social workers, thus creating a barrier to proper healthcare
and treatment.
40
The earlier that children are identied as being
gender dysphoric, the earlier that preventative measures can be
implemented to reduce psychological comorbidities that contrib-
ute to unsafe sexual practices. Currently, health services available
to transgender youth are relatively limited as compared to adult
services.
41
Greater efforts should be made to make youth services
more available nationwide.
Years of Untreated GD Before Gender Transition
This study highlights how transgender adults tend to live many
years with untreated GD before starting any form of gender-afrm-
ing transition (social, hormonal, or surgical). When we consider
that life-years of any untreated condition are a robust predictor for
morbidity and decreased quality of life,
42
the number of life-years
associated with GD and its associated morbidities is striking and
serves as a compelling reason for intervention. Many studies have
conrmed that gender-afrming treatments lead to signicantly
improved quality of life and mental health.
7,8,21,43,44
Relevance to Healthcare Access and Public Policy
When we compared the ages at which patients rst experi-
enced GD, we found no signicant difference between younger
Table 4. Sexual orientation differences related to reported age of earliest recollection of gender dysphoria, and, age of first memory. Data
presented as means (SD)
Transgender men Transgender women
Preferred Gender of Sexual Partners Men Women Both Men Women Both
(n = 6) (n = 38) (n = 8) (n = 71) (n = 50) (n = 32)
Age at presentation 39.7 (8.9) 36.5 (11.4) 29.0 (7.3) 39.0 (15.5) 45.0 (16.7) 41.8 (16.6)
Age at earliest memory of GD 9.8 (3.3) 5.2 (2.3) 8.0 (3.8) 6.6 (3.5) 6.8 (3.8) 6.3 (2.9)
Years from earliest memory of GD to
undergoing gender transition (GAHT
or social transition)
17.0 (5.1) 25.6 (13.4) 15.6 (8.2) 21.7 (12.7) 34.3 (17.3) 29.6 (17.2)
Gender Dysphoria 5
Sex Med 2021;9:100448
patients (<age 40) and older patients (>age 40) (Table 3).
However, we did nd that older patients waited a signicantly
longer time before starting gender transition (ie, with social tran-
sition or GAHT) (Table 3;Figure 1). This generational trend
suggests that, with increased societal acceptance of transgender
people and increased access to transgender-related health services,
patients have been starting gender transition (including surgery)
earlier in life. Nonetheless, transgender youth and adults still face
considerable barriers to healthcare access. Studies have shown
that compared to cis-gender lesbian, gay, or bisexual patients,
transgender adults were more likely to be uninsured, experience
discrimination in healthcare settings, and postpone care due to
discrimination.
45
Despite the 2014 announcement that federal
Medicare will cover gGAS for patients who meet WPATH
Standards of Care guidelines (V. 7, 2011)
43,46
many U.S. states
continue to deny coverage for gender-afrming related care
under their State Medicaid Insurance plans.
47
As healthcare reforms and societal acceptance for transgender
individuals continue to improve, it is increasingly important that
the public has access to healthcare professionals who, at mini-
mum, can interact effectively with transgender youth, and who
ideally are properly trained to address fully the needs of this
growing population. A 2010 study of 464 physicians and resi-
dents at a United States medical school found that most physi-
cians did not believe they had proper training to address issues
surrounding sexual orientation and gender identity among pedi-
atric patients.
48
Additionally, if an adolescent stated that he or
she was not sexually active, 41% of physicians in this study
reported that they would not ask additional sexual health-related
questions; the majority of physicians also reported that they
would not ask patients about sexual orientation or gender iden-
tity if an adolescent presented with depression, suicidal thoughts,
or had attempted suicide.
48
The well-documented possibility of childhood GD persisting
into adulthood
4-6
highlights the need to educate medical and
childcare providers in child/gender development and transgen-
der-health needs. Domains that merit attention include sensitiv-
ity to questions about gender identity from children and
adolescents, understanding of how children may express struggles
with gender incongruence (eg, anxiety, depression and self-
harm), and skills to constructively invite discussion with chil-
dren/adolescents to better ascertain their needs.
Lastly, it should be noted that the results of this study demon-
strate that TM and TW suffer from the morbidities commonly
associated with GD nearly equally. In our work, for example,
both genders reported similar rates of depression and anxiety.
Ages of GD onset were similar between both genders, and
patients of both genders reported that their experiences with GD
were their earliest memories. Both genders reported similar rates
of suicidality and decreases in suicidal ideation following treat-
ment. The commonality of these ndings across both genders
supports both the importance and value of early access to care to
transgender youth.
LIMITATIONS
Potential limitations of this study include a possible lack
of generalizability. As this study only included patients pre-
senting for gGAS, our ndings might not be representative
of transgender people who do not seek gGAS. Another
potential limitation of this study is that patients were not
queried as to the severity of their GD during early childhood.
Therefore, the full morbidity of GD experienced during
childhood was not studied directly. Finally, although we
gathered data on patientshistory of mental-health comorbid-
ities, we did not gather information on timing of these
respective diagnoses and thus we are unable to denitively
link these conditions to the diagnoses of GD.
CONCLUSION
Our ndings suggest that GD rst manifests in early child-
hood for the majority of adult transgender patients and that GD
is a part of patientsearliest memories, spanning the majority of
patientsrecallable lives. Patients often spend many years living
with untreated GD, which is associated with depression, anxiety,
suicidality, and HIV. GD is a condition of childhood as much as
adulthood. Access to gender-transition-related care is warranted
and signicantly improves quality of life.
Our ndings are not meant to advocate for the early treat-
ment of all children who report GD, but rather to highlight that,
for the subset of children with GD that persists into adulthood,
untreated GD can cause a signicant impact on quality of life.
Children may hide GD from their parents and healthcare pro-
viders, so providers treating children and adolescents should be
sensitive both to patients who openly report GD, as well as to
those that display other potential signs of GD such as anxiety,
depression, and self-harm. Early intervention to help youth navi-
gate their gender identities and gender transitions will likely
reduce morbidity and improve quality of life.
Corresponding Author: Maurice M. Garcia, MD, MAS, Divi-
sion of Urology, Cedars-Sinai Medical Center, 8635 West 3rd
Street, Suite 1070, Los Angeles, CA 90048, USA; E-mail:
maurice.garcia@csmc.edu
Conict of Interest: The authors report no conicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Conceptualization, M.Z., N.Y., C.B., A.F., M.M.G.; Methodol-
ogy, M.Z., N.Y., C.B., A.F., M.M.G.; Formal Analysis, M.Z.,
N.Y., C.B., A.F., M.M.G.; Investigation, M.Z., N.Y., C.B., A.
F., M.M.G.; Resources, M.Z., N.Y., C.B., A.F., M.M.G.; Data
Curation, M.Z., N.Y., C.B., A.F., M.M.G.; Writing Original
Draft, M.Z., N.Y., C.B., A.F., M.M.G.; Writing Review &
Editing, M.Z., N.Y., C.B., A.F., M.M.G.; Project Administra-
tion, M.Z., N.Y., C.B., A.F., M.M.G.
6Zaliznyak et al
Sex Med 2021;9:100448
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8Zaliznyak et al
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Purpose: The purpose of the study was to determine the frequency of specific health concerns identified by transgender and gender nonconforming patients and their parents at initial clinic visit. Methods: Checklists were developed in an iterative process and distributed to both patients and parents at their initial visit to a transgender clinic. Retrospective chart review and secondary data analyses were performed to determine the number of items endorsed, frequency with which each item was endorsed, and provider domain of each item endorsed: physician, social work, or both physician and social work. Results: Checklists were collected from 118 patients and 103 parents. Patients endorsed a mean of 8.4 concerns (range 0-22) and parents 7.9 concerns (range 0-20). The most commonly endorsed patient concerns included use of gender-affirming hormones, steps for transition, gender-affirming surgery, restroom/dressing room use, and legal issues. Common parent concerns included general resources, child safety at school, acute mental health concerns, restroom/dressing room use, and steps for transition. Of the concerns endorsed by patients, 44% were in the social work domain, 37% in the physician domain, and 19% in both the social work and physician domain. Of the concerns endorsed by parents, 40% were in the social work domain, 31% in the physician domain, and 29% in the social work and physician domain. Conclusions: Although patients and parents had similar numbers of concerns, they primarily focused on different topics. Youth were more interested in hormones and transition, while parents were more interested with transition and acceptance. Many concerns for both patients and parents fell within the social work domain.
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Purpose: This study documented the prevalence of mental health problems among transgender youth in Canada and made comparisons with population-based studies. This study also compared gender identity subgroups and age subgroups (14-18 and 19-25). Methods: A nonprobability sample of 923 transgender youth from Canada completed an online survey. Participants were recruited through community organizations, health care settings, social media, and researchers' networks. Mental health measures were drawn from the British Columbia Adolescent Health Survey and the Canadian Community Health Survey. Results: Transgender youth had a higher risk of reporting psychological distress, self-harm, major depressive episodes, and suicide. For example, 65% of transgender 14- to 18-year olds seriously considered suicide in the past year compared with 13% in the British Columbia Adolescent Health Survey, and only a quarter of participants reported their mental health was good or excellent. Transgender boys/men and nonbinary youth were most likely to report self-harm and overall mental health remained stable across age subgroups. Conclusions: Although a notable minority of transgender youth did not report negative health outcomes, this study shows the mental health disparities faced by transgender youth in Canada are considerable.