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Identity Integration in Adolescents With Features of Gender Dysphoria Compared to Adolescents in General Population

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  • Psychiatric University Clinics (UPK) Basel / Switzerland

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Adolescence is an important period for identity formation and identity consolidation is one of the main developmental tasks. Gender identity is an essential aspect of identity but so far little is known about its development. Neither has the identity development of adolescents with features of gender dysphoria (GD) been extensively studied so far. However, adolescents with features of GD have been shown to present extensive psychiatric psychopathology and could therefore be assumed also to have more problems with identity development. We set out to compare the identity integration of adolescents with features of GD (n = 215; 186 natal females, 29 natal males) and adolescents from general population (n = 400; 244 females, 154 males and 2 who did not report their sex) using a culture-adapted Finnish version of an assessment tool for adolescents and young adults on identity in terms of personality functioning, the Assessment of Identity Development in Adolescence (AIDA). AIDA is a 58-item self-report questionnaire enabling dimensional differentiation between healthy and impaired identity development. The continuous AIDA total score (sum score) and its subscales were analyzed using MANOVA, and dichotomized T-scores differentiating identity development in impaired and healthy range using cross-tabulations with chi-square statistics. Adolescents with features of GD showed identity development similar to adolescents in general population. The slight differences seen in AIDA scores were in favor of the GD group. The proportion scoring to identity impairment was lowest among gender-referred adolescents assigned males at birth. Identity integration of the gender-referred adolescents was further compared to that of 77 adolescents in specialist level psychiatric outpatient treatment (67 females, 10 males). The adolescent psychiatric outpatients scored much higher toward impaired identity on all AIDA scales than did the adolescents with features of GD. These results suggest that features of GD are not associated with problems in identity development in adolescents at large. Adolescents with features of GD may have been required to process their identity more, thereby advancing further in their identity consolidation process than young people on average.
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ORIGINAL RESEARCH
published: 09 June 2022
doi: 10.3389/fpsyt.2022.848282
Frontiers in Psychiatry | www.frontiersin.org 1June 2022 | Volume 13 | Article 848282
Edited by:
Megan Klabunde,
University of Essex, United Kingdom
Reviewed by:
Martin Fuchs,
Innsbruck Medical University, Austria
Kenneth Zucker,
University of Toronto, Canada
¸Senol Turan,
Istanbul University Cerrahpa ¸sa, Turkey
*Correspondence:
Milla Karvonen
mikarv.research@gmail.com
Specialty section:
This article was submitted to
Child and Adolescent Psychiatry,
a section of the journal
Frontiers in Psychiatry
Received: 04 January 2022
Accepted: 16 May 2022
Published: 09 June 2022
Citation:
Karvonen M, Goth K, Eloranta SJ and
Kaltiala R (2022) Identity Integration in
Adolescents With Features of Gender
Dysphoria Compared to Adolescents
in General Population.
Front. Psychiatry 13:848282.
doi: 10.3389/fpsyt.2022.848282
Identity Integration in Adolescents
With Features of Gender Dysphoria
Compared to Adolescents in General
Population
Milla Karvonen 1
*, Kirstin Goth 2, Sami J. Eloranta 3and Riittakerttu Kaltiala 1, 4,5
1Department of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland, 2Department of Child and Adolescent
Psychiatry, Psychiatric University Clinics (UPK) Basel, Basel, Switzerland, 3Faculty of Social Sciences, Tampere University,
Tampere, Finland, 4Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland, 5Vanha Vaasa
Hospital, Vaasa, Finland
Adolescence is an important period for identity formation and identity consolidation
is one of the main developmental tasks. Gender identity is an essential aspect of
identity but so far little is known about its development. Neither has the identity
development of adolescents with features of gender dysphoria (GD) been extensively
studied so far. However, adolescents with features of GD have been shown to
present extensive psychiatric psychopathology and could therefore be assumed also
to have more problems with identity development. We set out to compare the identity
integration of adolescents with features of GD (n=215; 186 natal females, 29 natal
males) and adolescents from general population (n=400; 244 females, 154 males
and 2 who did not report their sex) using a culture-adapted Finnish version of an
assessment tool for adolescents and young adults on identity in terms of personality
functioning, the Assessment of Identity Development in Adolescence (AIDA). AIDA is a
58-item self-report questionnaire enabling dimensional differentiation between healthy
and impaired identity development. The continuous AIDA total score (sum score) and
its subscales were analyzed using MANOVA, and dichotomized T-scores differentiating
identity development in impaired and healthy range using cross-tabulations with chi-
square statistics. Adolescents with features of GD showed identity development similar
to adolescents in general population. The slight differences seen in AIDA scores were
in favor of the GD group. The proportion scoring to identity impairment was lowest
among gender-referred adolescents assigned males at birth. Identity integration of the
gender-referred adolescents was further compared to that of 77 adolescents in specialist
level psychiatric outpatient treatment (67 females, 10 males). The adolescent psychiatric
outpatients scored much higher toward impaired identity on all AIDA scales than did
the adolescents with features of GD. These results suggest that features of GD are not
associated with problems in identity development in adolescents at large. Adolescents
with features of GD may have been required to process their identity more, thereby
advancing further in their identity consolidation process than young people on average.
Keywords: gender dysphoria, identity development, gender identity, personality disorder, adolescence
Karvonen et al. Identity Development in GD Adolescents
INTRODUCTION
Identity and its favorable and unfavorable development play
an essential role in both psychoanalytic/psychodynamic and
socio-cognitive theories on the human mind. Identity is a
broad concept encompassing both intrapsychic and interpersonal
aspects and could therefore be roughly defined as a “unity of
being” (1) or a “balance or interaction between that considered to
be self and that considered to be other” (2). In general, identity
can be said to allow one to move through life with a sense of
continuity and purpose toward expressing one’s goals and values.
According to many socio-cognitive theories, identity can be
divided into two higher order domains “I” and “ME”, where
the former emphasizes continuity, stable core, and emotional
access, and the latter coherence, integrated whole, and cognitive
access (1).
Within the psychodynamic tradition, Erikson (3) saw identity
as a constant developmental process of ego growth. According to
him, identity provides a sense of continuity within an individual
and in contact with others (self-sameness) and also a means to
differentiate between oneself and others (uniqueness), thereby
enabling the individual to act independently from others. In
this identity formation process, adolescence is a particularly
important transitional period because the identifications of
childhood are summed up, processed, and gradually replaced by
a new form of identity. Additionally, the identities that form
later in life are based on this adolescent identity to such an
extent that they are perceptible as its variations (4). Hence,
identity consolidation can be seen as a result of successful
adolescent development.
Identity consolidation then involves, for example,
experiencing oneself as consistent over time and situations,
having stable values, long-term goals, and commitments
[e.g., (5)]. Marcia et al. (6) elaborated on Erikson’s concepts
and developed a model including three identity statuses in
addition to the achieved identity (that involved commitment
after exploration): foreclosure, moratorium, and diffusion. In
foreclosure, role and value commitments are made without
exploration or struggle. Moratorium is a transitional phase and
identity issues are put on hold due to occupational or other role
commitments, which nevertheless signifies an active search for
identity. Identity diffusion is more pathological and involves
no commitments despite or without exploration, and can be
seen, for example, in reoccurring changes in careers, values, and
ideologies (5,6). Identity diffusion can also be seen as a lack of
integration of the concept of self and significant others [e.g., (7)].
The developmental process would ideally advance from
initial childhood foreclosure or diffusion through moratorium to
eventual identity achievement, which is challenged and reformed
in connection with different life events (3,8). However, it has
been reported that large proportions of late adolescents and
young adults do not complete the identity formation process, but
nevertheless among those undergoing identity status transitions
in late adolescence and young adulthood, progressive change is
more than twice as likely than regressive change (9).
Identity can also be regarded as a core construct of personality
(10). Hence, identity development can be seen as essential to
personality development, with disturbances therein representing
disturbances in personality development. Identity diffusion is
considered to be one of the core elements of borderline
personality organization (1,7), and in the Diagnostic and
Statistical Manual (DSM-5) (11), identity is classified as a central
diagnostic criterion for personality disorders. In many countries,
however, personality disorders are not diagnosed in adolescents.
The life-span approach that promotes the diagnosing of children
and adolescents and early intervention is gaining ground and is
implemented in the new ICD-11 classification system (12) once
it comes into effect.
Gender identity is one of the subareas of identity and refers
to the person’s own inner sense of their gender, which is distinct
from the sex assigned to them at birth, which is based on their
biological characteristics. This inner sense of gender does not
necessarily align with the sex assigned at birth or the traditional
expectations associated with it (13). Gender dysphoria (GD)
refers to the distress experienced in relation to one’s sex assigned
at birth and the sex-discordant gender identity.
The process of gender identity consolidation is not known,
but there are various theoretical perspectives on gender identity
formation that view it as multi-dimensional, multi-determined,
and open to change over time (2). For example, according
to Bussey’s model (14), aspects of individual, behavioral, and
environmental level interact to co-create gender identity and
likewise affect the change in gender identity over time. In this
model, developmental change in gender identity is considered to
be ongoing and continuous (14).
Gender identity in adolescence is nevertheless considered so
stable that to relieve GD, international guidelines recommend
interventions that modify physical sexual characteristics [e.g.,
(15)]. So far little research has been presented on GD in
the context of identity development at large, or identity
development among adolescents displaying GD. Adolescents
with features of GD have been shown to present with excessive
psychopathology (1618) [along with, for example, excessive
involvement in bullying (19)], and psychiatric disorders have
been suggested to be associated with delayed or impaired
identity development in general (20). Therefore, it could be
assumed that they would also have problems in identity
development, psychopathology either making them vulnerable
to or representing impairment of identity development. Further
research into the identity development of these adolescents
would serve to determine their treatment needs as a group and
thus help their treatment planning.
A recent Austrian study compared the presence of identity
diffusion in adolescents with GD to population youth measured
with the “Assessment of Identity Development in Adolescence”
[AIDA; (21)]. AIDA is a self-report inventory to assess identity in
terms of personality functioning and was specifically developed
for adolescents and young adults (12–18 years old) to enable
a dimensional differentiation between healthy and impaired
identity development. Impaired identity development is assumed
to be associated with a high risk of a current personality disorder,
especially borderline personality disorder. Although identity
diffusion was found in slightly over a third of the adolescents with
GD, the overall results of this study suggested no pathological
Frontiers in Psychiatry | www.frontiersin.org 2June 2022 | Volume 13 | Article 848282
Karvonen et al. Identity Development in GD Adolescents
identity development for this group compared to same-aged
population norms (21).
The tools used for the assessment of gender identity
development are generally relatively one-dimensional, based
on narrow concepts and do not yield information on identity
development as a whole [for a recent assessment of the
gender identity tools see (22)]. The assessment of overall
identity development provides more reliable indications for
proper individual treatment paths. AIDA is based on a broad
and well-grounded theoretical framework and can offer an
indicative building block in the detection of disturbances in
identity development (1). It is not known whether the overall
identity development of adolescents experiencing features of GD
differs from the overall identity development of adolescents not
experiencing these features. It seems probable that due to the
significant psychopathology, adolescents with features of GD
could also have more problems in their identity development, but
on the other hand, they may have been required to process their
identity more, which would yield them more favorable results
than average.
The aim of this study was to assess the identity development
of adolescents seeking treatment in a gender identity clinic due to
GD and compare it to the identity development of adolescents in
general population using the AIDA assessment tool. We set out
to answer the following research questions:
1. Does the identity development of adolescents with features of
GD requiring clinical assessment differ from that of same-aged
adolescents in general population?
2. For how many of the adolescents with features of GD
requiring clinical assessment are problems in identity
development reaching levels indicating impairment in
personality development?
3. How does the identity development of adolescents with
features of GD requiring clinical assessment differ from that
of adolescents requiring specialist level psychiatric care?
MATERIALS AND METHODS
This is a cross-sectional case-control study comparing 215
adolescents referred to a nationally centralized gender identity
unit due to seeking gender affirming therapy and 400 population
adolescents from four different schools participating in a study
intended to collect data on three psychometric instruments
recently translated into Finnish (23).
The data collection concerning the gender-referred
adolescents comprised a retrospective chart review among
adolescents with whom at least the initial assessments and
interviews had been completed by the time of data collection
in 2020. In Finland, mental health assessment of adolescents
seeking medical gender affirming therapy is centralized to two
university hospitals. A multi-disciplinary team comprising an
adolescent psychiatrist, a psychologist, a social worker, and a
psychiatric nurse carry out the assessments. The assessment of
adolescents with features of GD takes place in an outpatient
setting and comprises at minimum a review of their earlier
medical and social welfare files and an initial assessment
interview with the young person and their guardian(s). The
AIDA is administered during the first visit and is the first
structured measure used in the assessment process. Further
assessments may not follow if more urgent treatment needs
related to severe psychiatric disorders are evident at this stage;
in such cases the young person is referred to appropriate care. If
the gender identity assessment is continued, further free format
and structured interviews and assessments are carried out,
including the assessment of developmental history, adolescent
development and personality, and specific gender identity related
measures are also applied [see for example (18,24)]. Gender
affirming hormonal interventions can be initiated if there are
no contraindications, such as severe psychiatric disorders that
warrant treatment more urgently, and the young person has
adequate caregiver support. Surgical treatments are possible after
coming of age.
The gender-referred sample of the present study were 215
adolescents consecutively admitted to the gender identity unit for
minors in Tampere University Hospital between 2016 and 2019.
Of the gender-referred group, 15% were assigned males at birth,
and 85% were assigned females at birth. Their mean (sd) age was
16.2 (1.3) years.
The participants from general population were 400 high
school students from four different schools in three different
cities in Finland. They responded anonymously using an
Internet-based form during regular school hours in the spring
term of 2019. Their parents received an electronic information
letter before the students were recruited to participate, but
active parental consent was not required. The students were
informed by their teachers about the study and the voluntariness
of participating. Students who did not want to participate were
instructed to submit an empty form. Completed forms were
taken as a consent to participate. The population adolescents had
a mean (sd) age of 16.2 (1.5) years and 38.8% were males and
61.2% females; two students did not report their sex.
A clinical psychiatric comparison sample comprised 77
adolescents who were in specialist level outpatient adolescent
psychiatric treatment in the Department of Adolescent
Psychiatry in Tampere University Hospital between December
2020 and December 2022, were at least 15 years of age
and consented to participate in a study project assessing
suitability of selected psychometric instruments for a later
psychotherapy outcome study. Consenting, otherwise unselected
adolescent psychiatric outpatients filled anonymously in a set of
psychometric instruments, including AIDA, and indicated their
age and sex. Other background information was not collected.
The adolescent psychiatric outpatient sample had a mean (sd)
age of 16.6 (1.0) years, and 87% (67/77) were females. It is known
that more than half of the outpatients in the study clinic have
a primary diagnosis in the categories of severe mood disorders
(F30–39) and anxiety disorders (F40–49) (25).
The register based clinical data collection was duly approved
by the Ethics Committee of Tampere University Hospital, and
the population study received ethics approval from Tampere
University Ethics Committee.
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Karvonen et al. Identity Development in GD Adolescents
Measures
The “Assessment of Identity Development in Adolescence”
(AIDA) is a self-report questionnaire enabling a dimensional
differentiation between healthy and impaired identity
development that is considered central in personality disorders,
especially in borderline personality disorder (26). A detailed
presentation of AIDAs theoretical underpinnings can be found
at (27). AIDA contains 58 items with a 5-step answering format
(0 =no to 4 =yes). All items are added up to obtain the total
score representing Identity Diffusion. For descriptive purposes,
the total score can be divided into two dimensions, Discontinuity
and Incoherence. The continuity/discontinuity dimension has
three subdimensions: consolidating perspectives and attributes
(9 items; e.g., “I could list a few things that I can do very well.”),
consolidating relationships and roles (11 items; e.g., “I feel
like I’m a valuable member of my family.”), and consolidating
emotional self-experience (7 items; e.g., “Sometimes I have
strong feelings without knowing where they come from.”). The
coherence/incoherence dimension also has three subdimensions:
consistency in self-concepts (11 items; e.g., “I often feel lost,
as if I had no clear inner self.”), autonomy and ego strength
(12 items; e.g., “If I am criticized or others see me failing, I feel
really worthless and devastated.”), and integrating cognitive
self-experience (8 items; e.g., “I am confused about what kind
of person I really am.”). This reflects the theoretical origins
and complexity of the concept. All scores are coded toward
pathology, that is, higher scores indicate pathology. Goth and
Schmeck (26) reported very good scale reliabilities (0.94 for total
score, 0.86 and 0.92 for main dimensions, and from 0.76 to 0.86
for subdimensions) for the original AIDA in German. Jung et al.
(20) have demonstrated that AIDA can differentiate adolescents
with personality disorder from the general population and also
from adolescents with other types of psychiatric problems.
Scores clearly above the average (T-scores above 60) denote
probable risk for a current (borderline) personality disorder and
an in-depth clinical investigation (e.g., with a clinical interview)
is therefore recommended.
The culture-adapted version AIDA Finnish (28) was developed
by the last author and her associates at the Universities of
Tampere and Helsinki, Finland, in cooperation with the original
authors. The original items were translated into Finnish with
respect to cultural compatibility and were empirically tested
in a pilot test with 77 adolescents. Based on the results, 10
items were slightly reformulated for the main test version
without changing the targeted identity-related content in order
to improve comprehensibility and reliability. The main test was
performed in a combined sample of 400 adolescents from four
schools and 129 adolescent psychiatric patients. The full sample
consisted of 32.2% boys and 67.8% girls in the age range 12–21
years (mean =16.2, SD =1.4). To test the clinical validity of
the Finnish version of AIDA, the sample was enlarged with 33
suicidal patients with diagnoses from the internalizing spectrum
(20 with major depressive disorder). The AIDA Finnish scale
reliabilities were good with Cronbach’s alpha 0.96 on total, 0.90
and 0.95 on primary and 0.75–0.89 on subscale level. Exploratory
factor analysis supported a one-factor solution speaking for a
joint factor of “identity pathology”. The AIDA Finnish total
score on Identity Diffusion differed at a highly significant level
of p=0.000 and with a large effect size of Cohen’s d=
1.4 standard deviations between the adolescents of the school
population (mean =75.7, SD =38.4) and the subsample of the
33 suicidal patients (mean =126.0, SD =30.7), mostly diagnosed
with major depression based on K_SADS interview and a
clinical classification conference after a thorough psychosocial
evaluation of the young person and their family. This matches
the results on clinical validity of the original Swiss-German AIDA
version in patient groups with diagnoses from the internalizing
spectrum (20).
In using self-report instruments, some information is always
lost due to participants skipping individual questions or items
of scales. AIDA Total score can be calculated if the number
of missing items in the whole scale remains below 10%, and
there is a maximum of 2 missing items per subscale. As per
this rule, AIDA Total score and Discontinuity and Incoherence
scores were successfully calculated for all participants in both
population and clinical samples.
Statistical Analyses
The data were analyzed using one-way multivariate analysis
of variance (MANOVA) with SPSS 27. MANOVA is used
to determine whether there are any differences between
independent groups on more than one continuous dependent
variable. Mean values of AIDA Total score and Discontinuity
and Incoherence dimensions as well as of their respective
subdimensions were compared between population males,
population females, gender-referred adolescents assigned males
at birth and gender-referred adolescents assigned females at
birth. Within each sample, comparisons were made between
sexes, and the gender-referred adolescents were also compared
with population adolescents of the same and the opposite sex.
Statistical differences between groups were assessed using Wilk’s
lambda, and effect sizes using partial eta squared (η2p). Statistical
significance of differences in pairwise comparisons was analyzed
using Tukey’s post-hoc test, and due to multiple comparisons, cut-
off for statistical significance was, using Bonferroni correction,
set at p<0.006. Next, we compared the proportions of general
population males, general population females, and gender-
referred adolescents assigned males and females at birth whose
AIDA T-scores exceeded 60, which suggests impaired identity
development, using cross-tabulations with chi-square statistics.
Finally, AIDA Total score and Discontinuity and Incoherence
dimensions as well as their respective subdimensions were
compared between the gender-referred group and the general
adolescent psychiatric outpatient sample.
RESULTS
Overall, there were statistically significant differences between the
four groups on Identity diffusion and its subscales [F(24,1740.8) =
7.467, Wilks’ Lambda =0.753, p<0.001]. AIDA Total score
(=Identity diffusion), Discontinuity and Incoherence dimension
and their subdimension scores are given in Table 1 for general
population males, general population females, gender-referred
Frontiers in Psychiatry | www.frontiersin.org 4June 2022 | Volume 13 | Article 848282
Karvonen et al. Identity Development in GD Adolescents
TABLE 1 | AIDA total score, Discontinuity and Incoherence scale as well as their subscale scores by sex among population and gender-referred samples of Finnish
adolescents [mean (sd)].
Population boys
n=154
Population girls
n=244
Gender-referred
natal boys
n=29
Gender-referred
natal girls
n=184
Mean sd Mean sd Mean sd Mean sd F(3;607)p1Partial eta
squared2
AIDA total score identity
diffusiona
68.07 40.46 80.56 36.21 63.54 29.39 69.66 32.47 5.730 0.001 0.028
Discontinuityb32.15 16.61 35.43 16.25 30.64 13.83 34.22 14.33 1.851 0.137 0.009
Consolid. perspectivesc13.18 6.045 13.95 5.85 11.17 5.58 12.51 5.36 3.451 0.016 0.017
Consolid. relationshipsd10.47 7.70 10.69 6.39 12.36 5.79 13.32 5.66 7.454 <0.001 0.036
Consolid. emot.
self-experiencee
8.49 6.64 10.80 6.37 7.10 5.48 8.40 6.04 7.875 <0.001 0.037
Incoherencef35.93 26.23 45.13 21.43 32.90 17.67 35.44 19.77 9.516 <0.001 0.045
Consistency in selfg13.68 9.50 16.24 8.86 13.33 8.45 13.29 7.80 5.067 0.002 0.024
Autonomyh13.51 10.73 18.33 8.73 11.17 7.52 13.47 8.88 14.933 <0.001 0.069
Cogn self-experi8.75 7.18 10.56 5.85 8.38 4.74 8.68 5.25 4.821 (3,607) 0.003 0.023
1p-values in this column indicate that overall, there are statistically significant differences between the groups on the dimension of the line; detailed findings of pairwise comparisons are
explained in the text. P-values statistically significant after Bonferroni correction are highlighted in bold.
2Effect size η2p >0.01 small, >0.06 medium, >0.14 large.
aItems per scale 58, range 0–232.
bItems per scale 27, range 0–108.
cItems per scale 9, range 0–36.
dItems per scale 11, range 0–44.
eItems per scale 7, range 0–28.
fItems per scale 31, range 0–124.
gItems per scale 11, range 0–44.
hItems per scale 12, range 0–48.
iItems per scale 8, range 0–32.
assigned males at birth, and gender-referred assigned females
at birth.
The females in the population sample scored significantly
higher than the population males on AIDA Identity Diffusion (p
=0.004), Discontinuity subdimension emotional self-experience
(p=0.002), primary dimension Incoherence (p<0.001) and
its subdimension autonomy and ego strength (p<0.001). No
significant differences between sexes were seen on any dimension
or subdimension scores within the gender-referred group.
Gender-referred adolescents assigned males at birth did not
differ statistically significantly from either general population
males or females on AIDA Total score and its primary
dimensions. Regarding subscales, they displayed a lower score
on the autonomy and ego strength subscale of the primary
dimension Incoherence than general population females (p
=0.001).
Gender-referred adolescents assigned females at birth did
not differ from either population males or females on
AIDA Total score and its primary dimension Discontinuity.
They differed from general population females—but not from
males—in displaying a lower score on primary dimension
Incoherence (p<0.001). Regarding subdimensions, gender-
referred adolescents assigned females at birth differed from
population females by displaying a higher score on the
Discontinuity subdimension consolidating relationships and
roles (p<0.001) and lower scores on the Discontinuity
subdimension consolidating emotional self-experience (p=
0.001) and on the Incoherence subdimensions consistency in self-
concepts (p=0.003) and autonomy and ego strength (p<0.001),
and borderline lower on the subdimension integrating cognitive
self-experience (p=0.007). They showed mostly subdimension
scores comparable to those of general population males,
differing only by scoring higher on discontinuity subdimension
consolidating relationships and roles (p<0.001; Table 1).
Proportions of Population and
Gender-Referred Adolescents Displaying
Identity Pathology
In the general population sample, 14.2% of the scores reached a
range suggesting impairment in identity development (T-score
>60) on AIDA total scale Identity Diffusion, whereas in the GD
sample, the corresponding proportion was 9.8% (p=0.07).
Among the general population adolescents, 15.8%, and in
the GD group, 14.0%, of the scores reached a range suggesting
impaired development on primary dimension Discontinuity (p=
0.32), and 15.0 and 9.3%, respectively, on Incoherence (p=0.03).
The proportions reaching impaired range among males and
females in the general population and birth-assigned males
and females in the gender-referred sample are shown in
Table 2. Pairwise comparisons between the groups revealed
that the difference in proportions of those reaching impaired
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Karvonen et al. Identity Development in GD Adolescents
TABLE 2 | The proportion of those adolescents in each population/gender-referred group scoring within the pathological range (T-scores >60) in Identity diffusion,
Discontinuity and Incoherence [% (n/N)].
Population males Population females Gender-referred
assigned males at birth
Gender-referred
assigned females at birth
p
Identity diffusion 11.0 (17/155) 16.4 (40/244) 3.4 (1/29)a10.8 (20/185) 0.1
Discontinuity 13.5 (21/155) 17.2 (42/244) 6.9 (2/29) 15.1 (28/185) 0.5
Incoherence 11.0 (17/155) 17.6 (43/244) 3.4 (1/29)b10.3 (19/185) 0.03
aDifference to population females statistically significant at level p =0.05.
bDifference to population females statistically significant at level p =0.03.
TABLE 3 | AIDA total score, Discontinuity and Incoherence scale as well as their subscale scores among gender-referred and adolescent psychiatric outpatient samples
of Finnish adolescents [mean (sd)].
Gender-referred
n=215
Outpatients
n=77
Mean sd Mean sd F(1;287)pPartial eta squared1
AIDA total score identity diffusiona69.0 32.3 121.5 39.8 130.591 <0.001 0.314
Discontinuityb33.8 14.5 54.2 17.6 96.729 <0.001 0.253
Consolid. perspectivesc12.5 5.4 18.6 6.4 64.315 <0.001 0.184
Consolid. relationshipsd13.2 5.8 18.0 7.6 33.021 <0.001 0.104
Consolid. emot. self-experiencee8.2 6.0 17.6 6.6 125.314 <0.001 0.305
Incoherencef35.1 19.7 67.8 23.7 136.040 <0.001 0.323
Consistency in selfg13.3 7.9 24.0 10.5 84.440 <0.001 0.229
Autonomyh13.1 8.7 26.9 8.8 137.168 <0.001 0.325
Cogn self-experi8.6 5.2 16.7 6.8 109.796 <0.001 0.278
1Effect size η2p >0.01 small, >0.06 medium, >0.14 large.
aItems per scale 58, range 0–232.
bItems per scale 27, range 0–108.
cItems per scale 9, range 0–36.
dItems per scale 11, range 0–44.
eItems per scale 7, range 0–28.
fItems per scale 31, range 0–124.
gItems per scale 11, range 0–44.
hItems per scale 12, range 0–48.
iItems per scale 8, range 0–32.
range in Identity diffusion was statistically significant only
between gender-referred adolescents assigned males at birth
and general population females (p=0.05). For Discontinuity,
none of the pairwise comparisons revealed statistically significant
differences between the groups. For Incoherence, a statistically
significant difference was in pairwise comparisons again seen
only between gender-referred adolescents assigned males at birth
vs. population females (p=0.03).
Identity Development in Gender-Referred
Adolescents Compared to Clinical Sample
of Adolescent Psychiatric Patients
There were statistically significant differences between the
gender-referred and the general adolescent psychiatric outpatient
samples on Identity diffusion and its subscales [F(8,278) =20.299,
Wilks’ Lambda =0.631, p<0.001, η2p =0.37]. The gender-
referred adolescents scored lower, indicating more favorable
identity development, than the adolescent psychiatric outpatients
on all AIDA scores (Table 3). Due to the very small number
of males in the outpatient sample, this analysis could not be
stratified by sex, but post-hoc analysis among only adolescents
with female sex confirmed the systematic differences between the
groups, all statistically significant at level p<0.001.
DISCUSSION
Finnish adolescents with features of GD in our study showed
no marked pathological identity development as a group, which
concurs with the results of the only study on the subject so far,
conducted on Austrian youth [i.e., (21)]. The adolescents with
features of GD did not differ from the population adolescents of
either the same or the opposite sex regarding AIDA total score
Identity integration and AIDA primary dimension Discontinuity.
As to the primary dimension Incoherence, a difference in
favor of gender-referred adolescents assigned females at birth
in relation to population females was observed. Differences
in subscale scores, when present, mostly suggested favorable
development in the gender-referred adolescents in relation to
Frontiers in Psychiatry | www.frontiersin.org 6June 2022 | Volume 13 | Article 848282
Karvonen et al. Identity Development in GD Adolescents
population at large. Among the compared groups, the proportion
scoring to identity impairment was lowest among gender-
referred adolescents assigned males at birth.
The identity development of adolescents with features of
GD has not yet been extensively studied and focusing on
identity consolidation/identity diffusion at large is the unique
contribution of the present study. Earlier research on identity in
adolescents with features of GD has almost exclusively focused
on the aspect of gender identity, ignoring the larger context of
identity development at large.
In the only comparable study, by Haid-Stecher et al.
(21), Austrian gender-referred adolescents scored to population
norms on AIDA total score, primary dimensions and almost
all their subdimensions. Our findings are slightly in favor of
the gender-referred adolescents who on several scales displayed
lower scores than their peers in population. The scores of the
gender-referred adolescents in the present study also appear
systematically lower, and thus more favorable, than the scores of
the sample in the Austrian study (21). Adolescents presenting
in gender identity services may differ between countries (29)
for many reasons, such as differences in service systems and
pathways to care as well as in societal acceptance of diversity.
Fewer of the adolescents with features of GD scored within
the impaired range of Identity Diffusion compared to the young
people in general population. This differs from the findings of
Haid-Stecher et al. (21), where Identity Diffusion appeared likely
in one third of the transgender adolescents, clearly exceeding
the proportion in their population sample and also in our
sample of gender-referred adolescents. Our finding suggests that
for the vast majority of Finnish adolescents with features of
GD, gender concerns are not associated with impaired identity
development at large and, thus, do not indicate disturbances in
their personality functioning.
There were no differences in the identity development
between sexes among the adolescents with features of GD,
whereas within the general population group females scored
significantly higher than males on most comparisons (including
total Identity Diffusion and primary dimension Incoherence).
Higher scores suggest higher levels of impairment in general,
however, the scores of the females did not reach levels anywhere
near to identity pathology. It should be kept in mind that the
clinical group of suicidal adolescents scored a mean 126.0 in
AIDA total score (28).
It may be of interest to compare the scores of the adolescents
with features of GD with those of the gender opposite to their
birth-assigned sex in general population, and vice versa. In our
study, the scores of the birth-assigned males with features of GD
did not differ significantly from those of the population males
or females (except for one subdimension in comparison to the
population females). Meanwhile, the birth-assigned females in
the gender-referred group differed on one primary dimension
and some subdimensions from the general population females
but not from the males. Hence, the identity development of
the gender-referred females was slightly more mature than that
of the population females and did not differ significantly from
that of the population males. Additionally, analyses comparing
proportions scoring to impaired range of identity development
suggested least problems among gender-referred adolescents
assigned males at birth.
This study suggests that the identity development trajectory
may be slightly different among the adolescents with features of
GD compared to that of adolescents on average, but in a positive
way. The adolescents with features of GD may have been required
to process their identity more and may thus have benefited from
their possible identity crisis deriving from the experience of GD.
This seems to be the case especially among the birth-assigned
males with features of GD in our study, who seem to have
been able to consolidate their identity most successfully, perhaps
against many environmental odds, since feminine behavior in
boys may be less readily tolerated than masculine behavior in girls
(30,31).
Excessive psychopathology has been reported in adolescents
with GD (1618), and severe psychopathology has been
connected to poorer identity development (20). However,
in our sample of gender-referred adolescents, identity
development appeared normative and differed positively
from the identity development of an adolescent psychiatric
outpatient sample. However, more research is warranted on
the role of psychopathology in identity integration among
gender-referred samples.
Limitations
Our study included 215 adolescents with features of GD,
which yields quite a representative sample of this group in
Finland. However, the number of birth-assigned males in the
GD group was relatively low (n=29), thus, further research
with larger samples of birth-assigned males with GD is needed.
The possibility should also be considered that those adolescents
with features of GD who may simultaneously be suffering from
more severe psychiatric comorbidities may not even have been
referred to gender identity assessment and thus are not included
in our sample. Additionally, the gender-referred adolescents
in our sample were at the initial stage of the gender identity
assessment process and were not (at least yet) diagnosed with
Gender Dysphoria/ Transsexualism or receiving any gender
affirming treatment.
Certain caution is warranted in interpreting the meaning of
the finding of the slightly more favorable identity development
in the gender-referred group as compared to the population one.
Demographic and psychological variables, such as socioeconomic
status and IQ, could differ between the groups and actually
account for differences in identity development (32). Future
research needs to proceed to exploring identity development
taking into account such factors.
In addition to comparing identity development between
gender-referred adolescents and same-aged peers in the general
population, we were able to make comparisons between gender-
referred adolescents and a sample of adolescents in specialist
level psychiatric outpatient treatment. The gender-referred
differed clearly from this clinical group, with the adolescent
psychiatric outpatients displaying systematically significantly
more impairment. Thus, gender-referred adolescents did not
display general identity pathology as compared to population
adolescents, and their identity development clearly differed from
Frontiers in Psychiatry | www.frontiersin.org 7June 2022 | Volume 13 | Article 848282
Karvonen et al. Identity Development in GD Adolescents
that of clinical adolescent psychiatric patients, the latter showing
systematically more impairment. Future studies should further
pursue to compare the identity development of gender-referred
adolescents to different samples, also taking into account the
possible psychopathology of the gender-referred adolescents. In
the present data, no such background information was available.
This is a limitation of the present study and warrants attention
in future studies. It is known that adolescents presenting for
gender identity assessment in the study clinic commonly present
with severe psychiatric disorders and also differ from general
population regarding sociodemographics, for example by living
less commonly with both parents (18).
AIDA has been shown to have excellent clinical validity in
detecting personality disorders, especially borderline personality
disorder, and this has been shown in several languages (20,
26). Unfortunately, there was no Finnish borderline personality
disorder sample to similarly test this clinical validity because
diagnosing personality disorders before the age of 18 is not
recommended in the ICD-10 (33), which is the diagnostic
classification in use in Finland. However, the Finnish version
is equivalent in all other result patterns to the original version
of AIDA and has been developed step-by-step in cooperation
with the original authors to ensure equivalence in the content.
Moreover, a sample of Finnish suicidal adolescent psychiatric
patients showed clearly elevated levels of impaired identity
development. Persistent suicidality in adolescents may suggest
borderline personality development (34), and, thus, findings
among suicidal patients suggest that AIDA Finland likely
differentiates personality pathology similarly to the original
German version. Finnish version of the AIDA is, however,
relatively recent, and research on its associations with dimensions
of psychopathology in the general population is pending.
As concerns self-report materials at large, we cannot
rule out attempts to present oneself overtly favorably or
to exaggerate one’s problems. Some of the gender-referred
adolescents may have attempted to avoid discussion of possible
mental health related needs, in hope of so prompting access to
medical interventions. However, impression management when
responding to AIDA is difficult as the underlying construct of
identity development is complex and, therefore, it is not that easy
to clearly understand the pathological reference of the full item
set and manipulate the full result.
Different identity theories may use the same terminology
to refer to different concepts and phenomena. In the work
of Erikson, Marcia, and Kroger (3,9), identity diffusion is an
identity status characterized by lack of identity commitments and
active identity work. In AIDA, the concept of identity diffusion
refers, in line with Kernberg’s theory of personality disorders,
to a pathological identity development deemed a psychiatric
syndrome underlying all severe personality disorders. Borderline
personality organization in particular is characterized by identity
diffusion manifesting in a non-integrated concept of the self and
significant others (7,20). In both these theoretical approaches,
identity diffusion may manifest in a lack of commitment in a
variety of life domains.
CONCLUSION
In our study, the clinically referred adolescents with features
of GD displayed similar or slightly more favorable identity
development than did the Finnish young people in general.
Adolescent birth-assigned males with features of GD presented
with least impairment in their identity development. This does
not suggest that transgender identification with feelings of GD
would represent problems in identity development at large.
The gender-referred adolescents with features of GD may have
been required to process their identity more and, thus, may
have benefited from the possible identity crisis related to GD.
The potential progress in the identity development of these
adolescents could be seen as their strength and taken into account
when working with these adolescents, whether they progress
further in their gender-affirming treatments or not.
DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included
in the article/supplementary material, further inquiries can be
directed to the corresponding author.
ETHICS STATEMENT
The studies involving human participants were reviewed and
approved by Ethics Committee of Tampere University Hospital
and Tampere University. Written informed consent from the
participants’ legal guardian/next of kin was not required to
participate in this study in accordance with the national
legislation and the institutional requirements.
AUTHOR CONTRIBUTIONS
RK analyzed the data. MK was responsible for drafting and
revising the manuscript. All authors contributed to the design
of the work, acquisition and interpretation of the data, revising
the manuscript, and approving its submission to Frontiers
in Psychiatry.
FUNDING
This study has received financial support from Tampere
University Hospital Research Grants (9X012 and 9AA022).
REFERENCES
1. Goth K, Foelsch P, Schlüter-Müller S, Birkhölzer M, Jung E, Pick
O, et al. Assessment of identity development and identity diffusion
in adolescence - theoretical basis and psychometric properties of the
self-report questionnaire AIDA. Child Adolesc Psychiatry Ment Health. (2012)
6:27. doi: 10.1186/1753-2000-6-27
2. Ferrer-Wreder L, Kroger J. Identity in Adolescence: The Balance Between Self
and Other. London: Routledge (2020).
3. Erikson EH. Identity: Youth and Crisis. Oxford: Norton and Co. (1968).
Frontiers in Psychiatry | www.frontiersin.org 8June 2022 | Volume 13 | Article 848282
Karvonen et al. Identity Development in GD Adolescents
4. Marcia JE. Ego identity and personality disorders. J Pers Disord. (2006)
20:577–96. doi: 10.1521/pedi.2006.20.6.577
5. Westen D, Betan E, Defife JA. Identity disturbance in adolescence: associations
with borderline personality disorder. Dev Psychopathol. (2011) 23:305–
13. doi: 10.1017/S0954579410000817
6. Marcia JE, Waterman AS, Matteson DR, Archer SL, Orlofsky JL. Ego Identity:
A Handbook for Psychosocial Research. New York, NY: Springer-Verlag (1993).
7. Kernberg OF. Identity: recent findings and clinical implications. Psychoanal
Q. (2006) 75:969–1004. doi: 10.1002/j.2167-4086.2006.tb00065.x
8. Stephen J, Fraser E, Marcia JE. Moratorium–achievement (Mama) cycles
in lifespan identity development: value orientations and reasoning system
correlates. J Adolesc. (1992) 15:283–300. doi: 10.1016/0140-1971(92)90031-Y
9. Kroger J, Martinussen M, Marcia JE. Identity status change during
adolescence and young adulthood: a meta-analysis. J Adolesc. (2010) 33:683–
98. doi: 10.1016/j.adolescence.2009.11.002
10. Marcia JE. Identity in adolescence. In: Adelson J, editor. Handbook of
Adolescent Psychology. New York, NY: Wiley (1980). p. 159–87.
11. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, 5th Edition. Washington, DC: American Psychiatric
Association (2013).
12. World Health Organisation. International Statistical Classification of Diseases
and Related Health Problems, 11th Revision (ICD-11). Geneva: WHO (2018).
13. Goldhammer H, Crall C, Keuroghlian AS. Distinguishing and addressing
gender minority stress and borderline personality symptoms. Harv
Rev Psychiatry. (2019) 27:317–25. doi: 10.1097/HRP.00000000000
00234
14. Bussey K. Gender identity development. In: Schwartz SJ, Luyckx K, Vignoles
VL, editors. Handbook of Identity Theory and Research. (2011). p. 603–628.
15. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman
J, et al. Standards of care for the health of transsexual, transgender, and
gender-nonconforming people, version 7. Int J Transgend. (2012) 13:165–
232. doi: 10.1080/15532739.2011.700873
16. Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender dysphoria in
adolescence: current perspectives. Adolesc Health Med Ther. (2018) 9:31–
41. doi: 10.2147/AHMT.S135432
17. Kozlowska K, McClure G, Chudleigh C, Maguire AM, Gessler D,
Scher S, et al. Australian children and adolescents with gender
dysphoria: Clinical presentations and challenges experienced by a
multidisciplinary team and gender service. Human Systems. (2021)
1:70–95. doi: 10.1177/26344041211010777
18. Kaltiala-Heino R, Sumia M, Työläjärvi M, Lindberg N. Two years of gender
identity service for minors: overrepresentation of natal girls with severe
problems in adolescent development. Child Adolesc Psychiatry Ment Health.
(2015) 9:9. doi: 10.1186/s13034-015-0042-y
19. Heino E, Ellonen N, Kaltiala R. Transgender identity is associated with
involvement in bullying among Finnish adolescents. Front Psychol. (2021)
11:612424. doi: 10.3389/fpsyg.2020.612424
20. Jung E, Pick O, Schlüter-Müller S, Schmeck K, Goth K. Identity development
in adolescents with mental problems. Child Adolesc Psychiatry Ment Health.
(2013) 7:26. doi: 10.1186/1753-2000-7-26
21. Haid-Stecher N, Fuchs M, Ortner N, Sevecke K. TransIdentität – Die
Entwicklung der Identität bei transidenten Jugendlichen. Prax Kinderpsychol
Kinderpsychiatr. (2020) 69:541–53. doi: 10.13109/prkk.2020.69.6.541
22. Bloom TM, Nguyen TP, Lami F, Pace CC, Poulakis Z, Telfer M,
et al. Measurement tools for gender identity, gender expression, and
gender dysphoria in transgender and gender-diverse children and
adolescents: a systematic review. Lancet Child Adolesc Health. (2021)
5:582–88. doi: 10.1016/S2352-4642(21)00098-5
23. Eloranta SJ, Kaltiala R, Lindberg N, Kaivosoja M, Peltonen K. Validating
measurement tools for mentalization, emotion regulation difficulties and
identity diffusion among Finnish adolescents. Nord Psychol. (2020) 1–23.
doi: 10.1080/19012276.2020.1863852
24. Kaltiala R, Heino E, Työläjärvi M, Suomalainen L. Adolescent
development and psychosocial functioning after starting cross-sex
hormones for gender dysphoria. Nord. J. Psychiatry. (2019) 74:3,
213–219. doi: 10.1080/08039488.2019.1691260
25. Reinsalo P, Kaltiala R. Onko nuorisopsykiatrian poliklinikan potilaskunta
muuttunut lähetemäärien kasvaessa? Lääkärilehti. (2019) 36:19569.
26. Goth K, Schmeck K. AIDA (Assessment of Identity Development in
Adolescence) German Version: A Self-Report Questionnaire for Measuring
Identity Development in Adolescence - Short Manual. Offenbach: Academic-
Tests (2018).
27. Sharp C, Vanwoerden S, Odom A, Foelsch P. Culture-adapted version
English USA of the Self-Report Questionnaire AIDA (Assessment of Identity
Development in Adolescence; Authors Goth and Schmeck) - Short Manual.
Houston, TX: University of Houston (2018). Available online at: https://
academic-tests.com/aida/AIDA_Model_English.pdf (accessed December 30,
2021).
28. Kaltiala R, Lindberg N. Culture-adapted Finnish version of the self-report
questionnaire AIDA (Assessment of Identity Development in Adolescence;
authors Goth & Schmeck) – Short manual. Offenbach: Academic-Tests
[Finnish] (2022).
29. de Graaf N, Cohen-Kettenis P, Carmichael P. deVries ALC, Dhondt K,
Laridaen J, et al. Psychological functioning in adolescents referred to
specialist gender identity clinics across Europe: a clinical comparison
study between four clinics. Eur Child Adolesc Psychiatry. (2018) 27:909–
19. doi: 10.1007/s00787-017-1098-4
30. Sandnabba NK, Ahlberg J. Parents’ attitudes and expectations
about children’s cross-gender behavior. Sex Roles. (1999) 40:249–
63. doi: 10.1023/A:1018851005631
31. Ristori J, Steensma T. Gender dysphoria in childhood. Int Rev Psychiatry.
(2016) 28:13–20. doi: 10.3109/09540261.2015.1115754
32. Garber J, Hollon SD. What can specificity designs say about
causality in psychopathology research? Psychol Bull. (1991)
110:129–36. doi: 10.1037/0033-2909.110.1.129
33. World Health Organization. ICD-10: International Statistical Classification
of Diseases and Related Health Problems: 10th Revision, 2nd ed. Geneva:
WHO (2004).
34. Yen S, Weinstock LM, Andover MS, Sheets ES, Selby EA, Spirito A.
Prospective predictors of adolescent suicidality: 6-month post-hospitalization
follow-up. Psychol Med. (2013) 43:983–93. doi: 10.1017/S0033291712001912
Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
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Copyright © 2022 Karvonen, Goth, Eloranta and Kaltiala. This is an open-access
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Frontiers in Psychiatry | www.frontiersin.org 9June 2022 | Volume 13 | Article 848282
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Increasing numbers of children and adolescents are being referred to gender services for gender-related concerns. Various instruments are used with these patients in clinical care, but their clinical validity, strengths, and limitations have not been systematically reviewed. In this systematic review, we searched MEDLINE, PubMed, and PsycINFO databases for available tools that assess gender identity, gender expression, or gender dysphoria in transgender and gender-diverse (TGD) children and adolescents. We included studies published before Jan 20, 2020, that used tools to assess gender identity, expression, or dysphoria in TGD individuals younger than 18 years. Data were extracted from eligible studies using a standardised form. We found 39 studies that met the inclusion criteria, from which we identified 24 tools. The nature of tools varied considerably and included direct observation, child and adolescent self-report, and parent-report tools. Many methods have only been used with small samples, include outdated content, and lack evaluation of psychometric properties. In summary, a paucity of studies in this area, along with sparse reporting of psychometric properties, made it difficult to compare the relative use of tools, and current tools have substantial limitations. Future research is required to validate existing measures and create more relevant, culturally appropriate tools.
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Identity development is one of the most important developmental tasks of adolescence. Adolescents whose gender identity does not correspond to the gender assigned at birth (trangender people) are also faced with this challenge, as are cis-gender adolescents of the same age. This study is the first to examine the personality function of identity in transgender adolescents. Based on the self report of a population of 69 adolescents from the outpatient unit for gender dysphoria the extent of identity diffusion measured by AIDA (Assessment of Identity Development in Adolescence) was compared with the values of the normative sample consisting of German-speaking pupils. Both the overall construct of identity diffusion and the areas of continuity and coherence showed average values in the examined young people, which speaks against pathological identity development. Nevertheless, identity diffusion was found in over a third (36 %). Most notably the aspect of stabilising relationships and roles was above average, which suggests that positive role identification from the areas of culture, family and body-self is present to a lesser extent than in the norm sample. The identity-stabilizing feeling of social anchoring appears to be impaired in the young transidents studied.
Article
Purpose: To assess how adolescent development progresses and psychiatric symptoms develop among transsexual adolescents after starting cross-sex hormone treatment. Materials and methods: Retrospective chart review among 52 adolescents who came into gender identity assessment before age 18, were diagnosed with transsexualism and started hormonal gender reassignment. The subjects were followed over the so-called real-life phase of gender reassignment. Results: Those who did well in terms of psychiatric symptoms and functioning before cross-sex hormones mainly did well during real-life. Those who had psychiatric treatment needs or problems in school, peer relationships and managing everyday matters outside of home continued to have problems during real-life. Conclusion: Medical gender reassignment is not enough to improve functioning and relieve psychiatric comorbidities among adolescents with gender dysphoria. Appropriate interventions are warranted for psychiatric comorbidities and problems in adolescent development.
Article
As transgender and gender-diverse people are gaining increased visibility in clinical settings, clinicians are requesting better guidance on providing affirming care to improve the mental health and well-being of these patients. In particular, more direction is needed on whether, when, and how to diagnose and treat borderline personality disorder among gender minorities, partially in response to beliefs among some mental health clinicians that a gender minority identity may be a manifestation of identity diffusion. In this Perspectives article, we argue that gender minority identity, even when fluid, is rarely a sign of identity diffusion. By taking a careful history of a patient's gender identity development, the clinician can clarify and gain more conviction regarding the presence of a patient's gender minority identity. Moreover, multiple stigma-related stressors experienced by gender minorities may produce symptoms and behaviors that can mimic or be consistent with certain diagnostic criteria for borderline personality disorder. We therefore conclude with recommendations for adopting a gender-affirming framework to treat borderline personality symptoms when present among gender minority patients, with implications for future research and practice.