Is Social Gender Transition Associated with Mental Health Status in Children and Adolescents with Gender Dysphoria?

Abstract

Social gender transition is an increasingly accepted intervention for gender variant children and adolescents. To date, there is scant literature comparing the mental health of children and adolescents diagnosed with gender dysphoria who have socially transitioned versus those who are still living in their birth-assigned gender. We examined the mental health of children and adolescents referred to the Gender Identity Development Service (GIDS), a specialist clinic in London, UK, who had socially transitioned (i.e., were living in their affirmed gender and/or had changed their name) versus those who had not socially transitioned. Referrals to the GIDS were aged 4–17 years. We assessed mental health correlates of living in one’s affirmed gender among 288 children and adolescents (208 birth-assigned female; 210 socially transitioned) and of name change in 357 children and adolescents (253 birth-assigned female; 214 name change). The presence or absence of mood and anxiety difficulties and past suicide attempts were clinician rated. Living in role and name change were more prevalent in birth-assigned females versus birth-assigned males. Overall, there were no significant effects of social transition or name change on mental health status. These findings identify the need for more research to understand how social transition influences mental health, including longitudinal studies that allow for more confident inferences to be made regarding the relationship between social transition and mental health in young people with gender dysphoria.

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Archives of Sexual Behavior (2023) 52:1045–1060
https://doi.org/10.1007/s10508-023-02588-5
ORIGINAL PAPER
Is Social Gender Transition Associated withMental Health Status
inChildren andAdolescents withGender Dysphoria?
JamesS.Morandini1 · AidanKelly2· NastasjaM.deGraaf3· PiaMalouf4· EvanGuerin5· IlanDar‑Nimrod1·
PollyCarmichael2
Received: 10 June 2019 / Revised: 11 March 2023 / Accepted: 13 March 2023 / Published online: 4 April 2023
© The Author(s) 2023
Abstract
Social gender transition is an increasingly accepted intervention for gender variant children and adolescents. To date, there is
scant literature comparing the mental health of children and adolescents diagnosed with gender dysphoria who have socially
transitioned versus those who are still living in their birth-assigned gender. We examined the mental health of children and
adolescents referred to the Gender Identity Development Service (GIDS), a specialist clinic in London, UK, who had socially
transitioned (i.e., were living in their affirmed gender and/or had changed their name) versus those who had not socially
transitioned. Referrals to the GIDS were aged 4–17years. We assessed mental health correlates of living in one’s affirmed
gender among 288 children and adolescents (208 birth-assigned female; 210 socially transitioned) and of name change in 357
children and adolescents (253 birth-assigned female; 214 name change). The presence or absence of mood and anxiety dif-
ficulties and past suicide attempts were clinician rated. Living in role and name change were more prevalent in birth-assigned
females versus birth-assigned males. Overall, there were no significant effects of social transition or name change on mental
health status. These findings identify the need for more research to understand how social transition influences mental health,
including longitudinal studies that allow for more confident inferences to be made regarding the relationship between social
transition and mental health in young people with gender dysphoria.
Keywords Gender dysphoria· Social gender transition· Depression· Anxiety· Pediatric
Introduction
There are many unanswered questions regarding how best to
support children and adolescents who experience gender dys-
phoria, a term used to describe persistent distress related to
one’s biological sex/sex characteristics and/or birth-assigned
gender (Zucker etal., 2016). One such question is—at what
age and under what conditions do children and adolescents
who experience gender dysphoria benefit from social gender
transition (i.e., living in their affirmed gender rather than their
gender assigned at birth, which may involve changing their
physical gender markers such as hair and clothing as well as
their name and gender pronouns)?1 Answering this question
is of particular urgency, given that children and adolescents
who experience gender dysphoria or are otherwise gender
variant demonstrate a higher prevalence of mental health
difficulties than their cisgender peers (Becerra-Culqui etal.,
* James S. Morandini
james.morandini@sydney.edu.au
1 School ofPsychology, The University ofSydney, Sydney,
NSW2006, Australia
2 Gender Service Organization, Kelly Psychology, London, UK
3 Center ofExpertise onGender Dyphoria, VU University
Medical Center, Amsterdam, TheNetherlands
4 King Street Psychology Clinic, Newtown, Australia
5 School ofBehavioural andHealth Sciences, Australian
Catholic University, Sydney, Australia
1 In principle, social gender transition may refer to either a binary
social gender transition (in which a person changes gender markers
and appearance to live in the gender role “opposite” to that assigned
at birth) or non-binary gender transition (in which case the person may
aim to defy binary gender-roles in their pronouns and appearance in
some instances) (Breslow etal., 2021; Matsuno & Budge, 2017). In the
present context, we are confining our discussion to binary social gender
transition (birth-assigned males socially transitioning to live as girls
and vice versa), which to this point is the more studied phenomenon in
paediatric gender services and which may be more likely to be associ-
ated with a desire for medical transition (at least among adults) (Bres-
low etal., 2021). We acknowledge the importance of future research
examining non-binary social transition in paediatric populations.
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1046 Archives of Sexual Behavior (2023) 52:1045–1060
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2018). A recent systematic review of psychiatric comorbidi-
ties among prepubertal children diagnosed with gender dys-
phoria (aged 12 and under) (Frew etal., 2021) demonstrated
that up to 21% met criteria for an anxiety disorder, almost
half had a significant psychiatric history, and around 10%
had attempted suicide. A systematic review of adolescents
experiencing gender dysphoria (aged 12–18) (Thompson
etal., 2022) demonstrated that comorbid mental health issues
were present in 22–78%. Specifically, the prevalence of mood
disorders ranged from 30 to 78%, anxiety disorders from 21
to 63%, and suicidal ideation from 12 to 74%. Given that
social gender transition is theorized to ameliorate mental
health issues in gender dysphoric young people (Ehrensaft,
2016), further empirical examination of this intervention is
warranted.
Before moving forward, it is important to clarify termi-
nology. Young people who experience gender dysphoria are
variously referred to as “gender variant” (Riley etal., 2011;
Wong etal., 2019), “transgender” (Durwood etal., 2017;
Olson etal., 2016), “cross-gender identified” (Kuvalanka
etal., 2017), and “gender dysphoric” (Wallien & Cohen-
Kettenis, 2008)—although these respective terms can imply
important sample differences in some instances.2 In the pre-
sent study, we use the term gender variant to capture the
diversity of presentations (and stages of gender identity
development and symptom severity) among children and
adolescents referred to specialist gender dysphoria services.
Disagreement over when social gender transition is indi-
cated is what most differentiates competing models of care for
gender dysphoric young people (de Vries & Cohen-Kettenis,
2012; Ehrensaft etal., 2018; Steensma & Cohen-Kettenis,
2018; Zucker, 2018). Perhaps the most widely endorsed
model of care, the affirmative model, takes a non-pathologiz-
ing stance toward gender variance in young people and views
a “myriad of healthy [non-cisgender] gender outcomes” as
possible (Ehrensaft, 2016). This approach prioritizes follow-
ing the child’s lead and accepting and facilitating expression
of the child’s “true-gendered-self” (i.e., the child’s authentic
gender identity and expression) (Ehrensaft, 2016). A guiding
concern underpinning this approach is the need to protect the
child from harm associated with being raised in the wrong
gender. Indeed, cultural and familial pressures to conform to
cisgender identities, gender roles, and expression are thought
to cause considerable harm as they require a gender variant
child to suppress their authentic self and emulate socially
expected gender roles (the “false gendered self”). Ehrensaft
etal. (2018) contend that the construction of a false gendered
self is a key contributor of psychiatric morbidity, including
suicidality, observed in gender variant populations.
Others have suggested that clinicians and parents should,
where possible, delay social gender transition (Steensma
etal., 2013). This is based on evidence that gender dysphoria
(and cross-gender identities) frequently desist in prepubertal
children (Drummond etal., 2008; Singh etal., 2021; Zucker,
2018) and that premature social gender transition may fore-
close the child’s gender identity development, increasing
the likelihood that gender dysphoria will persist (possibly
necessitating medical transition in adolescence onward). This
approach has been referred to as “watchful waiting” (de Vries
& Cohen-Kettenis, 2012).
There are an increasing number of prepubertal children
pursuing social transition prior to attending specialist gender
services. For example, the Amsterdam Gender Identity Clinic
reported that, before the year 2000, 1.7% of children who
attended the clinic were completely socially transitioned at
first presentation, while between 2000 and 2004, 3.3% had
completed social transitioning at first presentation (Steensma
& Cohen-Kettenis, 2011). Reflecting a more dramatic and
recent shift, the proportion of birth-assigned males who had
socially transitioned prior to contact with the Tavistock Gen-
der Identity Development Service in London, increased from
19.8% in 2012 to 47.2% in 2015 (Morandini etal., 2022). This
shift toward social transition being more common prior to
contact with gender services may reflect increasing cultural
acceptance of transgender identities as viable and healthy
outcomes for children and adolescents (Brunskell-Evans &
Moore, 2019; Ehrensaft, 2016) and, therefore, greater com-
fort of parents in independently facilitating a child’s social
gender transition.
Existing research on the mental health correlates of social
gender transition utilizes diverse methodologies and focuses
on somewhat distinct populations. Tracking this research
chronologically—the first notable study was Kuvalanka
etal.’s (2017) qualitative study of five parents of transgen-
der girls (birth-assigned males) between the ages of 8 and 11.
Kuvalanka etal. found that according to parents, social tran-
sition appeared to reduce distress and increase self-esteem
and self-confidence among their children. Other reports from
clinicians and parents following early childhood social transi-
tion have echoed similar findings, reporting improved mood
in children and enhanced peer and caregiver relationships
2 Some clinically relevant differences can exist between these popu-
lations. For instance, “transgender children and adolescents” typi-
cally refers to individuals who have socially and perhaps medically
transitioned to live as their affirmed gender (e.g., Olson etal., 2016).
Cross-gender identified and gender dysphoric children and adoles-
cents, on the other hand, has been used to describe those experiencing
clinically significant gender concerns, but who may or may not have
socially transitioned to live in their affirmed gender (Wallien & Cohen-
Kettenis, 2008). Finally, gender variant, perhaps the loosest grouping,
has been used to refer to children and adolescents who exhibit gender
non-conforming behaviors and/or identities, which may or may not
be causing clinically significant distress or impairment (Riley etal.,
2011). Given children and adolescents who are transgender, experi-
ence gender dysphoria, and/or are markedly gender non-conforming in
behavior or identity, are a heterogeneous group, it can be difficult to
generalize findings across samples.
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1047Archives of Sexual Behavior (2023) 52:1045–1060
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(Wong & Drake, 2017), as well as being viewed as protec-
tive for the child’s happiness and well-being (Horton, 2022).
Several quantitative studies now exist examining cor-
relates of social gender transition. Kuvalanka etal. (2017)
examined the well-being of 45 children (aged 6–12years) in
the community (volunteered by parents) who were supported
in their gender identity. Kuvalanka etal. compared children
with “cross-gender identities” (i.e., those that identified as
trans girls or trans boys) and those who were gender non-
conforming or had uncertain gender identities (labeled as
having “non-cross-gender identities”) to normed data on the
Child Behavior Checklist (CBCL). Cross-gender identified
children demonstrated functioning in the normal range on all
three measured indices (internalizing problems, externalizing
problems, and total problems). On the other hand, those with
non-cross-gender-identities were in the borderline clinical
or clinical range on the same indices. When the two groups
of gender diverse children were compared, those who were
cross-gender identified demonstrated superior outcomes on
internalizing problems and total problems, suggesting binary
transition may be protective against mental health difficulties
in gender diverse populations—and that socially transitioned
children can demonstrate psychological well-being compa-
rable to cisgender controls.
The most widely cited quantitative studies assessing men-
tal health in social gender transitioned are those by Durwood
etal. (2017) and Olson etal. (2016). These studies, using
the Patient Reported Outcomes Measurement Information
System (PROMIS), compared mental health among com-
munity convenience samples of American and Canadian
prepubescent children who had fully socially transitioned
with cisgender siblings and matched controls. The first study
(Olson etal., 2016), which was based on parent reports of 73
(51 birth-assigned males) socially transitioned transgender
children (3- to 12-years-old), found levels of depression and
anxiety in this group was largely comparable with matched
controls and siblings/peers, although trans-children were
found to have slightly elevated rates of anxiety compared
with national population averages. Additionally, Olson etal.
compared their study’s findings (of socially transitioned
children) to previous clinical samples of children reporting
gender dysphoria, which included transgender children and
those that had not yet transitioned or that may have identi-
fied as non-binary. Olson etal. found lower internalizing of
symptoms in their sample of socially transitioned children,
concluding that social transitioning may reduce mental health
difficulties in gender variant youngsters.
The second study was based on parent and self-report
reports of 116 socially transitioned transgender young peo-
ple (68 birth-assigned males) (Durwood etal., 2017). This
study found that among 9- to 14-year-old transgender young
people, depression did not differ from matched-control or
sibling peers, but that transgender young people, again,
demonstrated slightly elevated anxiety. Additionally, among
6- to 14-year-old transgender young people, self-worth did
not differ from cisgender matched controls or cisgender sib-
lings. Collectively, these findings have been interpreted to
suggest that affirming a gender variant child/adolescents’
gender identity via social transition will reduce psychological
difficulties often observed within gender variant populations
(de Graaf etal., 2018; de Vries etal., 2016; Ehrensaft etal.,
2018). The Olson etal. (2016), Durwood etal. (2017), and
Kuvalanka etal. (2017) studies suggest that social transition
can be associated with normative mental health outcomes
among young people with gender dysphoria, a group who
have been shown to experience poorer psychological well-
being on the whole (Tankersley etal., 2021; Thompson etal.,
2022).
Other recent studies, however, have failed to find supe-
rior well-being in socially transitioned young people. Wong
etal. (2019) compared published CBCL data (van der Miesen
etal., 2018) on 162 cisgender children (aged 6–12years) who
had levels of gender variance similar to children referred to
specialist gender clinics, with published data on 104 chil-
dren who had undertaken social gender transition (Kuvalanka
etal., 2017; Olson etal., 2016). A statistical bootstrapping
approach was utilized to control for birth-assigned sex, age,
and degree of gender variance when comparing CBCL scores
between cisgender gender variant children and socially tran-
sitioned gender variant children. Cisgender gender variant
children and socially transitioned children demonstrated
broadly equivalent levels of internalizing problems—and
only a minority of each sample demonstrated clinical or
borderline clinical scores on internalizing problems. This
latter finding suggests that Olson etal.’s (2016) finding of
broadly comparable mental health status between social gen-
der transitioned children and normative samples might not
be entirely surprising.
Finally, a study by Sievert etal. (2021) more directly
examined whether social gender transition was related to
improved psychological functioning in 54 gender variant
children who had received a gender dysphoria diagnosis
(aged 5– to 11-years). Social transition was assessed in a
graded manner from 1 (no social transition and living in
birth-assigned gender) to 4 (complete social transition in all
life areas). After controlling for gender assigned at birth,
age, socioeconomic status, poor peer relations, and general
family functioning, social transition status did not predict
psychological functioning as measured by the CBCL.
The existing literature has shown mixed evidence for a
relationship between social gender transition and psycho-
logical functioning (positive effects in some studies and
null effects in others). It should be noted, however, that the
existing literature is limited in a number of respects. Past
studies have failed to examine how the mental health conse-
quences of social transition may be moderated by a range of
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1048 Archives of Sexual Behavior (2023) 52:1045–1060
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individual factors, such as birth-assigned gender and pre- ver-
sus post-pubertal age. This may be partly due to the relatively
small samples (N’s = 45–162) utilized in past studies, which
precluded such analyses. Except for Durwood etal. (2017)
(who included 6- to 14-year-olds), existing studies have
been conducted in children aged 12years of age or under.
Given the recent preponderance of gender dysphoria first
becoming apparent in adolescence (Aitken etal., 2015; de
Graaf etal., 2018), examining the mental health correlates of
social gender transition in early, mid, and late adolescence is
increasingly clinically important as well. Next, past studies
examining correlates of social transition have utilized self-
report and parent-report measures (typically the CBCL) in
assessing mental health. No studies to date have included rat-
ings of mental health status by trained mental health profes-
sionals. Apart from Sievert etal. (2021), existing studies have
not compared the mental health outcomes of children and
adolescents diagnosed with gender dysphoria based on their
social transition status, i.e., comparing socially transitioned
versus non-socially transitioned gender dysphoric children
and adolescents in terms of their mental health. Existing
studies have compared transgender participants with their
cisgender siblings or with normative data based on cisgender
populations (Durwood etal., 2017; Olson etal., 2016), with
gender variant cisgender individuals (Wong etal., 2019) or
with non-binary children (Kuvalanka etal., 2017). Given that
some commentators contend that transgender children and
adolescents differ in kind to their gender variant cisgender
peers (Temple Newhook etal., 2018), comparing correlates
of social gender transition status among a population of chil-
dren and adolescents all diagnosed with gender dysphoria
provides a more direct test of proposed benefits of social
gender transition. Failing to ensure that both socially tran-
sitioned and non-socially transitioned referrals to a gender
service were nevertheless still experiencing gender dyspho-
ria could possibly confound findings. For example, patients
living in their birth-assigned gender may be found to have
superior well-being because they were less likely to be gen-
der dysphoric to begin with and, therefore, less distressed
(not because avoidance of social transition leads to superior
outcomes).
The Present Study
There are scarce data comparing the mental health of gen-
der dysphoric children and adolescents who have socially
transitioned with those who have not (and who are living
in their gender assigned at birth). The present study sought
to contribute to this literature by undertaking this compari-
son in a cohort of children and adolescents who had pre-
sented for assessment at a specialist gender identity clinic
in the UK. We aimed to extend on past studies in a number
of ways, including: (1) utilizing a larger sample of socially
transitioned children and adolescents; (2) examining whether
associations between mental health and social transition were
moderated by birth-assigned gender and developmental stage
(by including patients from early childhood through to late
adolescence); and (3) utilizing clinician ratings of mental
health based on a comprehensive mental health assess-
ment—potentially reducing risk of social desirability bias
and complementing past studies of this type that have relied
exclusively on parent or self-report data. Our study examines
correlates of social gender transition on mood and anxiety
disorders, given these disorders appear to be prevalent psy-
chiatric comorbidities among gender variant youth (Frew
etal., 2021; Thompson etal., 2022). We also examined the
link between social gender transition and suicide attempts,
given increased prevalence of this behavior in gender variant
versus cisgender young people (Biggs, 2022), and the theo-
rized link between transition status and suicidality (Ehrensaft
etal., 2018).
Method
Subjects
Patients were drawn from 774 children and adolescents (M
age = 14.37years, SD = 2.47, range 4–17) referred to The
Gender Identity Development Service (GIDS) in London
over a 5-year period (from January 2012 to December 2016),
and for whom the Associated Difficulties form was com-
pleted. The majority of these patients were rated as wishing
to live in a binary gender opposite to their birth-assigned
gender (93%), with a small minority rated as desiring to live
as non-binary (7%). Most were White British (75.4%), with
a small representation of other ethnic groups. To our knowl-
edge, none of the patients referred had commenced any form
of medical transition (including hormone blockers) prior to
first being seen at GIDS. There was a considerable amount of
data missing on critical variables, as depicted in Fig.1 (i.e.,
flowchart outlining exclusion of cases due to missing data on
variables of interest). Missing data were due to clinicians fail-
ing to complete the associated difficulties form at assessment
or clients dropping out prior to assessments being completed.
To be included in the primary analysis, cases required
a diagnosis of gender dysphoria, as well as birth-assigned
gender and age to be recorded. A negative gender dyspho-
ria diagnosis was recorded for n = 155 patients and n = 149
patients did not have gender dysphoria status recorded on
their files. Reasons for the former were not recorded but likely
include clinicians’ failing to complete the form or patient
drop-out prior to gender dysphoria diagnosis being made. In
addition, at least one transition variable (living in role and/or
name change) needed to be recorded. Considerably more data
were missing on the living in birth-assigned gender versus
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1049Archives of Sexual Behavior (2023) 52:1045–1060
1 3
living in affirmed gender variable—than the name change
variable (i.e., n = 69 additional cases) (again, see Fig.1). A
small amount of data were missing on mental health vari-
ables (no more than four cases were missing on either mood,
anxiety, or suicide attempts). For ease of reporting sample
characteristics, only cases for which data on all three mental
health indices were recorded were included in the primary
analysis or in secondary analysis completed in supplementary
materials.
The final sample for analysis of living in birth-assigned
gender versus affirmed gender role status consisted of 288
children and adolescents, of whom 72% were birth-assigned
female and 73% had undertaken a partial or full social gender
transition (208 birth-assigned female; 210 socially transi-
tioned). All patients with living in birth-assigned gender ver-
sus affirmed gender role data also had corresponding name
change data. The final sample for analysis of name change
status consisted of 357 children and adolescents, of whom
71% were birth-assigned female and 60% had changed their
name (253 birth-assigned female; 214 name change).
Procedure andMeasures
Upon first contact with the GIDS, patients and their fami-
lies undertook in-depth psychological assessment of gen-
der dysphoria, comorbid psychiatric disorders, and relevant
psychosocial stressors. These assessments involved a mini-
mum of three one-hour assessments with two mental health
clinicians (psychiatrists, clinical psychologists, or registered
psychotherapists). Assessment sessions involved both child/
adolescent patients and their families, assessed individually
and together as a family. At the end of the assessment period,
the associated difficulties form was completed by both men-
tal health clinicians. Clinicians conferred with one another
to ensure agreement on diagnoses. When disagreement in
opinion was present—clinicians discussed the matter (or
assessed further) until agreement could be made. Referral
letters and clinician reports referencing mental health func-
tioning prior to contact with the GIDS were also taken into
account in making these judgments (e.g., an autism spec-
trum disorder [ASD] diagnosis could be gleaned via letters in
many instances). The associated difficulties form involved 29
questions relevant to demographics, psychosocial stressors,
and DSM-5 diagnoses. These questions are outlined in detail
in a past study from our service using this data (Holt etal.,
2016). The full list of variables in the Associated Difficulties
form is reported in Supplementary Materials. In the present
study, we examined data on 10 variables from the Associ-
ated Difficulties Form: birth-assigned gender, ethnicity, age
at time of referral, age of first gender dysphoria symptoms,
social transition (no, partly, yes), name change (no, partly,
yes), the presence of current mood or anxiety disorders at
time of assessment, and past suicide attempts.
The key variables of social transition, “living in birth-
assigned gender versus affirmed gender role” and “name
change,” were originally rated in three categories: “no” (i.e.,
Fig. 1 Flowchart outlining progressive exclusion of cases due to
missing data and depicting final sample size for regression models
examining name change status on mood, anxiety, and suicide attempt,
and living in role status on mood, anxiety, and suicide attempt. Left-
hand sample size reflects cases where a positive gender dysphoria
(GD) was recorded (primary analyses reported in the manuscript
were conducted upon this sample). Right hand size represents total
cases, inclusive of patients with a positive gender dysphoria diagnosis
recorded (n = 470), a negative gender dysphoria diagnosis recorded
(n = 155), or for which information on gender dysphoria status was
absent (n = 149). Analyses reported in supplementary materials are
based on total cases
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1050 Archives of Sexual Behavior (2023) 52:1045–1060
1 3
no social transition/name change), “partly” (i.e., partial social
transition/name change), or “yes” (i.e., full social transi-
tioned/name change”) (consistent with how social transition
was assessed by Steensma etal., [2013]). Because very few
respondents were rated as partially socially transitioned or as
partially using a new name, this was not a viable cell for anal-
ysis. We, therefore, combined partially and fully transitioned
patients into a single group, creating dichotomous variables
for both living in role and name change (0 = No transition
or No name change, 1 = Any social transition or Any name
change). This dichotomization is consistent with how these
variables were treated by Steensma etal. (2013). See Table1
for a breakdown of social transition/name change, partial
social transition/partial name change, and no social tran-
sition/no name change in the gender dysphoria confirmed
sample and for total cases. Mood difficulties reflected a
full diagnosis of a DSM-5 depressive disorder (e.g., major
depressive disorder or persistent depressive disorder). Anxi-
ety difficulties reflected a full diagnosis of a DSM-5 anxiety
disorder (e.g., social anxiety disorder, panic disorder, gen-
eralized anxiety disorder). Suicide attempts reflected any
suicide attempt occurring in the client’s past. All data were
anonymized in order to ensure the confidentiality of patients.
Data Analytic Plan
In addition to the variables “living in one’s affirmed gender
role” and “name change,” a third social gender transition
variable was computed (“social transition composite”) which
was the sum of “living in one’s affirmed gender role” and
“name change” resulting in a score from 0 (neither “living
in one’s affirmed gender role” nor “name change”) to 2 (both
“living in one’s affirmed gender role” and “name change”).
Age was treated as a continuous variable. Mood and anxiety
difficulties were rated as present or absent, as was history of
a suicide attempt.
We planned to use binomial logistic regression to exam-
ine whether the association between living in role, name
change, and a composite of living in role and name change,
and dependent variables (mood, anxiety, or suicide attempt)
were moderated by age and birth-assigned gender. We exam-
ined interactions between age and birth-assigned gender, and
the social transition variables as past theoretical and empiri-
cal research identify different pathways to gender dysphoria
and different comorbidities associated with gender dyspho-
ria, based on age at referral and birth-assigned gender (Aitken
etal., 2015; Lawrence, 2010).
For each dependent variable, regression models took the
same form. In Step 1, we examined the main effect of “liv-
ing in role” or “name change,” “birth-assigned gender,” and
“age” on the dependent variable of interest. In Step 2 (which
was only interpreted if the Chi-square change for Step 2 was
significant), we added interactions between Birth-assigned
gender × Age, Birth-assigned gender × Living in Role/Name
Change/Composite, and Living in Role/Name Change/Com-
posite × Age. In Step 3, we added the three-way interac-
tion between Birth-assigned gender × Age × Living in Role/
Name Change/Composite (again, Step 3 was only interpreted
if the Chi-square change for Step 3 was significant). Whereas
analysis reported here is for those patients who had a positive
gender dysphoria diagnosis—we also completed identical
analysis on the full sample of referrals to the GIDS (with
or without a positive diagnosis of gender dysphoria—see
Supplemental Materials. Findings were identical to those
completed on the gender dysphoria cohort). The critical α
utilized in all analyses was p < 0.05.
As our sample size was determined by available data,
we wanted to assess the minimum effect sizes that the cur-
rent sample was equipped to identify with a power of 0.80
(α < 0.05). Thus, the existing values of the sample (Social
Transition: 179/310 for Living in birth gender/living in
affirmed gender, respectively, as well as Social Transition:
312/303; for still using birth name/name already changed,
respectively) were inserted to a power calculator (G*Power
version 3.1.9.7) for logistic regression to determine the small-
est effect sizes that the social transition indicators (living
in role and name change) are well powered to detect. The
analyses indicated that, given the existing data, the analyses
had 80% power to detect an effect size of 1.84/1.70 (in odds
ratio terms) for living in role/name change, respectively. That
means that given the data, the analyses were well powered to
identify even small-medium effect sizes that may differ as a
function of the main variable of interest—social transition.
Table 1 Breakdown of patients
“living in role” (yes, partly,
no) and “name change” (yes,
partly, no) among those with
a gender dysphoria diagnosis
confirmed as well as total
cases (irrespective of gender
dysphoria status)
Gender dysphoria diagnosis confirmed Total cases
Living in role (% [n]) Name change (% [n]) Living in role (% [n]) Name change (% [n])
Yes 59.4% (171) 59.9% (214) 50.7% (248) 49.3% (303)
Partly 13.5% (39) 2.2% (8) 12.7% (62) 2.3% (14)
No 27.1% (78) 37.8% (135) 36.6% (179) 48.5% (298)
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1051Archives of Sexual Behavior (2023) 52:1045–1060
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Results
Descriptive Statistics
Of those in our sample, 78.4% of birth-assigned females
and 58.8% of birth-assigned males had either partially or
fully socially transitioned prior to assessment, and 69.2% of
birth-assigned females and 37.5% of birth-assigned males
had changed their name prior to assessment (see Tables2
and 3). Chi-square tests (a 2 [Age group] by 2 [Social transi-
tion indicators]) demonstrated that, among AFAB patients,
proportions of prepubertal (4–12) versus adolescent (13–17)
patients who were “living in role” (χ2(1) = 0.34, p = 0.56)
and had undergone “name change” (χ2(1) = 0.10, p = 0.75)—
were similar (p > 0.5’s). On the other hand, among AMAB
patients, adolescent AMABs were significantly less likely to
be “living in role” (χ2(1) = 9.55, p = 0.002) bthan prepuber tal
AMABs, but did not differ in likelihood of “name change”
compared to prepubertal AMABs (χ2(1) = 0.09, p = 0.77).
Based on clinical assessment and referral documents,
among patients with a diagnosis of gender dysphoria and for
whom name change and/or living in role status was recorded,
52.6% of birth-assigned females and 46.2% of birth-assigned
males were experiencing mood difficulties, 33.6% of birth-
assigned females and 28.8% of birth-assigned males were
experiencing anxiety and 11.9% of birth-assigned females
and 7.4% of birth-assigned males had past suicide attempts.
Tables2 and 3 show these variables based on participant’s
birth-assigned gender, age at referral (4–12years of age, or
13–17years of age), and living in role/name change status.
Chi-square analyses indicated that there were no significant
differences (p’s > 0.10) in any of the pathological indica-
tors (i.e., mood disorders, anxiety disorders, and suicide
attempted), as a function of the social transition indicators
(i.e., living in birth/assigned gender, name change), within
each of the two groups for either AFAB or AMAB, except in
one case (out of the 12 tests). The sole exception indicated
that, among AMABs, mood disorder was more common
among individuals living in the birth (vs. affirmed) gender
(χ2(1) = 6.83, p = 0.009).
Table 2 Descriptives for mood
disorder, anxiety disorder, and
suicide attempt prevalence
in those living in their birth
gender role versus living in their
affirmed gender role
a The percentages in this row reflect the percentages of individuals in that specific age group who live in
birth vs affirmed gender
b The percentages in this row reflect the percentages of individuals with the psychopathological indicator as
a function of the gender they are living in
AFAB AMAB
Living in birth
gender (n = 45)
Living in affirmed
gender (n = 163)
Living in birth
gender (n = 33)
Living in
affirmed gender
(n = 47)
4–12a (years) 25.9% (7) 74.1% (20) 13.6% (3) 86.4% (19)
13–17a (years) 21.0% (38) 79.0% (143) 51.7% (30) 48.3% (28)
Age mean (SD) 14.40 (2.28) 14.61 (1.93) 14.94 (2.52) 12.62 (3.74)
Mood disorderb44.4% (20) 53.4% (87) 63.6% (21) 34.0% (16)
Anxiety disorderb33.3% (15) 33.7% (55) 33.3% (11) 27.7% (13)
Suicide attemptb6.7% (3) 11.7% (19) 6.1% (2) 8.5% (4)
Table 3 Descriptives for mood disorder, anxiety disorder, and suicide attempt prevalence in those using their birth name versus affirmed name
a The percentages in this row reflect the percentages of individuals in that specific age group who live in birth vs. affirmed gender
b The percentages in this row reflect the percentages of individuals with the psychopathological indicator as a function of the gender they are liv-
ing in
AFAB AMAB
Birth name (n = 78) Name change (n = 175) Birth name (n = 65) Name change (n = 39)
4–12a (years) 33.3% (10) 66.7% (20) 60% (15) 40% (10)
13–17a (years) 30.5% (68) 69.5% (155) 63.3% (50) 37.7% (29)
Age mean (SD) 14.55 (1.82) 14.61 (2.03) 14.04 (3.12) 13.56 (3.42)
Mood disorderb48.7% (38) 54.3% (95) 46.2% (30) 46.2% (18)
Anxiety disorderb29.5% (23) 35.4% (62) 33.8% (22) 20.5% (8)
Suicide attemptb9.0% (7) 13.1% (23) 6.2% (4) 10.3% (4)
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1052 Archives of Sexual Behavior (2023) 52:1045–1060
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Correlation Matrix: Social Transition, Birth‑Assigned
Gender, Age, andMental Health Status
First, we examined zero-order correlations between all var-
iables. As we had more data on patients who had “name
change” (Table4) than data in “living in role” or both
(Table5), we present two tables. Perusal of the correlation
matrixes showed that, relative to birth-assigned females,
birth-assigned males were younger at referral, less likely
to be “living in role,” or to have changed their name. Age
at referral was positively associated with the presence of a
mood or anxiety disorder and a suicide attempt. As would
be expected, all indices of social transition were highly cor-
related, as were all indices of mental health status. Critically,
there was no significant association between “living in role”
and “name change” on the mental health variables.
Living inRole: Logistic Regressions
Mood andAnxiety Difficulties andSuicide Attempts
Table6 shows the results from the binomial logistic regressions
assessing whether living in one’s affirmed gender (i.e., having
socially transitioned), birth-assigned gender, and age at assessment
(and their two-way and three-way interactions) predicted the like-
lihood of mood and anxiety difficulties or past suicide attempts.
For the regression on mood difficulties and suicide attempts, a
main effect of age was observed, such that older patients were
more likely to report mood issues and past suicide attempts but
not anxiety issues. Living in role and birth-assigned gender were
not associated with mood, anxiety, or suicide attempts. Likewise,
Step 2 and Step 3 were not significant, indicating no two-way or
three-way interactions were observed (p’s > 0.05).
Name Change: Logistic Regressions
Mood andAnxiety Difficulties andSuicide Attempts
Table7 reports results from the binomial logistic regres-
sions assessing whether name change, birth-assigned gender,
and age (and all interactions between these variables) were
related to the likelihood of mood or anxiety issues or suicide
attempts. As above, age was positively associated with like-
lihood of mood issues and suicide attempt, but not anxiety.
Name change and birth-assigned gender were not associated
with mental health status. No two-way or three-way interac-
tions were significant (p’s > 0.05).
Social Transition Composite: Logistic Regressions
Mood andAnxiety Difficulties andSuicide Attempts
Table8 shows the results from the binomial logistic regres-
sions assessing whether the social transition composite vari-
able, birth-assigned gender, and age (as well as interactions
between all variables) predicted the likelihood of mood and
anxiety difficulties and suicide attempts. A main effect of age
was observed such that older patients had a greater likelihood
of mood issues and suicide attempts, but not anxiety issues.
The social transition composite variable did not predict men-
tal health status nor did birth-assigned gender. No two-way or
three-way interactions were significant (p’s > 0.05).
Discussion
The present study was among the first to examine whether
children and adolescents diagnosed with gender dysphoria
who had socially transitioned showed fewer psychological
difficulties than those (also with gender dysphoria) who
were still living in their birth-assigned gender. Overall, we
failed to find robust evidence that social transition (living
in one’s affirmed gender role or adopting a name to reflect
one’s affirmed gender identity) was associated with mental
health status in the short term. Although we found that mood
disorders were more common among AMAB who did not
transition, in 11 other such comparisons (2—assigned gender
at birth × 3—pathological indicators × 2—social transition
indicator) there was no indication for differences as a func-
tion of social transition. It is possible that the mood finding
Table 4 Correlations between birth-assigned gender, age, name change, and mental health outcomes (n = 357)
Assigned Female at Birth (AFAB) = 1; Assigned Male at Birth (AMAB) = 2; Name Change, Mood, Anxiety, Suicide Attempt (No = 1; Yes = 2)
Note. *p<.05, **p<.01
MSD AFAB vs. AMAB Age Name change Mood Anxiety Suicide attempt
AFAB vs. AMAB 1.30 .46
Age 14.06 2.72 −.136
Name change 1.66 .47 −.198** −.081
Mood 1.50 .50 −.058 .272** .051
Anxiety 1.34 .48 −.046 .091 .013 .332**
Suicide attempt 1.90 .30 −.061 .153** .078 .195** .073
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1053Archives of Sexual Behavior (2023) 52:1045–1060
1 3
among AMAB was spurious (e.g., if a Bonferroni correc-
tion for multiple tests was used to account for the 12 tests,
the AMAB mood difference would have not reached signifi-
cance). The possibility of the spuriousness is strengthened, as
more sensitive analyses that treated age as a continuous rather
than as a categorical variable, failed to support that finding.
Our failure to observe significant differences in the men-
tal health status of gender variant children who had socially
transitioned versus gender variant children living in their
birth-assigned gender is consistent with findings from the
methodologically similar studies by Wong etal. (2019) and
Sievert etal. (2021). Our findings extend on Wong etal.
(who compared published data on the Olson etal. (2016)
and Kuvalanka etal. (2017) samples of socially transitioned
children with published data on cisgender gender variant chil-
dren) by failing to find a significant effect of social transition
on mental health in a sample of young people all of whom
were diagnosed with DSM-5 gender dysphoria—and thus
differed in their social transition status—not in their gender
dysphoria status. While our findings are consistent with Siev-
ert etal. (2021) in finding social transition was not associated
with the mental health status of clinic-referred child patients
with a DSM-5 gender dysphoria diagnosis—it extended these
findings to adolescents as well. Given adolescent patients
comprise the majority of contemporary referrals to gender
services (Aitken etal., 2015) and given management of ado-
lescent gender dysphoria has been an area of recent clinical
controversy (Littman, 2018; Restar, 2020), the absence of an
association between social transition status and mental health
status in adolescents is noteworthy.
Notably, contrary to one past study finding a positive
association between chosen name use and mental health
in gender variant youth (Russell etal., 2018), name change
status was not associated with mental health in our sample.
The divergence in results could relate to a number of differ-
ences between the two studies. First, Russell etal. (2018)
measured a more behavioral construct (i.e., in what contexts
“are you able to go by your chosen name?”) which, on reflec-
tion, seems to assess how safe and affirming one’s social
environment is for chosen name use. In our study, by con-
trast, name change status refers to whether the young person
with gender dysphoria had commenced this aspect of their
social transition. Second, Russell etal.’s sample was majority
young adult (15–21), whereas ours was child and adolescent
(4–17). Name change may not be associated with positive
mental health outcomes in our sample because: (1) our young
people were school age (and schools have been identified as
a high-risk environment for harassment of gender variant
young people, Martín-Castillo etal. 2020); (2) our sample
would have more recently adopted a chosen name (a period
when backlash would presumably be higher); and (3) were a
clinical sample and thus may have had greater pre-existing
mental health vulnerabilities.
Table 5 Correlations between birth-assigned gender, age group, social transition status, and mental health outcomes (n = 288)
Assigned Female at Birth (AFAB) = 1; Assigned Male at Birth (AMAB) = 2; In role, Name Change, Social Composite, Mood, Anxiety, Suicide Attempt (No = 1; Yes = 2)
Note. *p<.05, **p<.01
MSD AFAB vs. AMAB Age In role Name change Social composite Mood Anxiety Suicide attempt
AFAB vs. AMAB 1.28 .45
Age 14.29 2.54 −.176**
In role 1.73 .45 −.198** −.081
Name change 1.64 .48 −.314** .069 .458**
Social transition composite 3.37 .79 −.302** −.004 .842** .866**
Mood 1.50 .50 −.047 .288** −.031 .022 −.004
Anxiety 1.33 .47 −.035 .119* −.009 −.006 −.009 .355**
Suicide attempt 1.90 .30 −.047 .171** .068 .098 .098 .234** .047
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1054 Archives of Sexual Behavior (2023) 52:1045–1060
1 3
As reported in past studies among gender dysphoric
cohorts (Holt etal., 2016), we found that the risk of mood
difficulties and suicide attempts was higher in gender dys-
phoric adolescents than gender dysphoric children. Given
that psychiatric disorders (including anxiety disorders and
depression) and suicidality often first onset in adolescence
(e.g., Kessler etal., 2005), this finding is not surprising, and
may simply reflect normative developmental processes that
make adolescence a vulnerable period for psychopathology
in all adolescents. It is also possible, however, that the onset
of adolescence in gender dysphoric young people might
be a particularly high-risk period (above and beyond that
observed in cisgender samples) due to the development of
secondary sex characteristics and additional demands related
to navigating one’s social environment as a gender diverse
person. The failure to find an age-related increase in anxi-
ety disorders in our study was somewhat surprising, given
that increased prevalence of anxiety from childhood to ado-
lescence has been reported in non-gender dysphoric sam-
ples (Ford etal., 2003). However, developmental literature
finds that anxiety is more likely to onset in childhood than is
depression or suicidality (Axelson & Birmaher, 2001; Rapee
etal., 2009), and thus positive associations between anxiety
and age would be expected to be relatively weaker or perhaps
nonexistent in some samples.
Supporting previous observation (Holt etal., 2016), prepu-
bertal and adolescent birth-assigned females were more likely
to have socially transitioned prior to engagement with specialist
gender services than birth-assigned males of equivalent age. One
possible explanation for this pattern of findings is that there is less
social cost associated with masculine self-presentation among
birth-assigned females than feminine self-presentation among
birth-assigned males (Shiffman, 2013). It was also notable that
almost half of those aged 4–12 were living in their affirmed gen-
der and had changed their name (either partially or fully) prior to
contact with the service. In line with observations of Ehrensaft
(2016) and recent empirical studies (e.g., Morandini etal., 2022),
it appears that an increasing number of parents are facilitating
social transition with their gender variant child prior to contact
with specialist gender clinics.
Table 6 Logistic regressions
predicting the likelihood of a
mood disorder, anxiety disorder,
and suicide attempt in AFAB
versus AMAB referrals living
in their birth-assigned gender
role or affirmed gender role
(n = 288)
AGAB = Assigned Gender at Birth (1 = Female; 2 = Male); In role, Mood, Anxiety, Suicide Attempt
(No = 1; Yes = 2)
Mood disorder Anxiety disorder Suicide attempt
Variable β p-value Exp (β)β p-value Exp (β)β p-value Exp (β)
Model 1
Step χ2(3) 25.83 < .001 4.40 .221 14.99 .002
Nagelkerke R2.11 0.21 .11
AGAB −.02 .942 .98 −.09 .775 .92 −.15 .770 .86
Age .27 < .001 1.30 .11 .055 1.12 .48 .005 1.62
In role −.04 .898 .96 −.01 .961 .99 .71 .188 2.04
Model 2
Step χ2(7) 32.78 .073 4.51 .991 15.54 .906
Nagelkerke R2.14 .02 .03
AGAB −1.15 .640 .32 −.16 .940 .85 3.18 .568 23.93
Age .37 .306 1.45 .18 .556 1.19 .81 .386 2.24
In role 4.29 .102 72.61 .67 .761 1.95 .45 .950 1.57
AGAB × Age .18 .186 1.20 .01 .951 1.01 −.24 .463 .79
AGAB × In role −.21 .232 .82 −.04 .752 .96 −.00 .998 1.00
Age × In role −.94 .152 .39 −.03 .967 .97 .20 .863 1.22
Model 3
Step χ2(8) 32.86 .769 5.55 .309 15.63
Nagelkerke R2.14 .03 .11
AGAB 1.84 .856 6.32 7.11 .340 1224.73 −5.05 .870 .01
Age .63 .509 1.87 .91 .266 2.48 .12 .965 1.12
In role 6.40 .403 599.29 6.78 .307 874.00 −5.40 .805 .01
AGAB × Age −.02 .978 .98 −.48 .330 .62 .29 .883 1.33
AGAB × In role −.35 .497 .71 −.46 .303 .63 .37 .790 1.45
Age × In role −2.56 .637 .08 −4.12 .312 .02 4.58 .776 97.64
AGAB x Age × In role .11 .764 6.32 .28 .310 1.32 -.28 .784 .76
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1055Archives of Sexual Behavior (2023) 52:1045–1060
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Limitations
There were limitations of the present study that should be
kept in mind when interpreting key findings. We did not
have sufficient demographic data to determine whether our
sample was representative of clinic-referred samples of
gender variant youth and therefore how generalizable these
findings are. Next, owing to our cross-sectional design,
we were not able to capture how benefits (or adversities)
related to social transition might unfold overtime. For
instance, it is possible that benefits of social transition
accrue slowly, perhaps over years, as a young person’s peer
and family environment progressively accommodate their
affirmed gender. Relatedly, it is possible that social adver-
sity is heightened in the early stages of social transition
(e.g., anxiety around passing, misgendering), canceling
out benefits of greater gender congruence, with positive
effects on mental health only becoming evident as these
adversities subside or as coping strategies are developed.
Alternatively, young people might experience temporary
improvements in mental health related to social transition
that subside with time.
The absence of longitudinal data (tracking the same
individuals’ mental health status before and after social
transition) leaves open the possibility that young people
in our sample who socially transitioned were experienc-
ing more severe gender dysphoria than those who had not
socially transitioned. As such, it might be the case that
social gender transition had ameliorated distress in our
socially transitioned children and adolescents but that they
failed to demonstrate superior functioning than non-tran-
sitioned peers, owing to their more severe presentations
at baseline. It is also possible that social transition alone
without subsequent medical affirmation (e.g., puberty
suppression, gender affirming hormones, or surgery) is
insufficient to treat gender dysphoria and that benefits
of social transition might occur once young people feel
more gender-congruent in their bodies or pass more easily
in their affirmed gender following hormone replacement
therapy or gender affirming surgeries. Finally, there is a
Table 7 Logistic regressions predicting the likelihood of a mood disorder, anxiety disorder, and suicide attempt in AFAB versus AMAB refer-
rals with their birth-assigned name versus affirmed name (n = 357)
AGAB = Assigned Gender at Birth (1 = Female; 2 = Male); Name Change, Mood, Anxiety, Suicide Attempt (No = 1; Yes = 2)
Mood disorder Anxiety disorder Suicide attempt
Variable β p-value Exp (β)β p-value Exp (β)β p-value Exp (β)
Model 1
Step χ2(3) 29.27 < .001 3.53 .317 14.14 .004
Nagelkerke R2.11 0.14 .08
AGAB −.07 .781 .93 −.17 .524 .84 −.30 .506 .75
Age .26 < .001 1.30 .08 .107 1.09 .36 .006 1.43
Name change .19 .429 1.21 .00 .986 1.00 .47 .233 1.61
Model 2
Step χ2(7) 33.64 .224 6.59 .382 14.66 .915
Nagelkerke R2.12 .03 .08
AGAB −3.31 .127 .04 .47 .806 1.60 1.76 .683 5.79
Age .06 .845 1.06 .03 .930 1.03 .73 .253 2.07
Name change 1.19 .545 3.30 1.34 .481 3.82 1.57 .725 4.83
AGAB × Age .22 .091 1.25 .05 .682 1.05 −.16 .535 .85
AGAB × Name change −.02 .968 .98 −.92 .102 .40 .25 .777 1.29
Age × Name change −.07 .608 .94 −.01 .930 .99 −.09 .739 .91
Model 3
Step χ2(8) 33.64 .997 8.04 .227 14.77
Nagelkerke R2.12 .03 .08
AGAB −3.28 .621 .04 7.07 .236 1174.20 −3.31 .841 .04
Age .06 .924 1.07 .73 .284 2.08 .27 .864 1.30
Name change 1.22 .830 3.37 7.79 .185 2415.99 -2.56 .848 .08
AGAB × Age .22 .619 1.25 −.41 .315 .67 .17 .874 1.18
AGAB × Name change −.04 .992 .96 −5.28 .168 .01 3.18 .728 23.96
Age × Name change −.07 .861 .94 −.45 .254 .64 .18 .839 1.19
AGAB × Age × Name change .00 .997 1.00 .30 .246 1.35 −.19 .747 .83
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1056 Archives of Sexual Behavior (2023) 52:1045–1060
1 3
need for caution when interpreting the association (or lack
thereof) between likelihood of suicide attempts and social
transition status in this study. To the extent that social tran-
sition has an ameliorating effect on suicidality, all things
being equal, we may expect to see a reduced likelihood of
suicide attempts in the group who has undergone social
gender transition versus not undergone social transition.
However, it is possible that insufficient time has passed for
social gender transition to influence suicidality particu-
larly given suicide attempts are rare events. Second, if the
socially transitioned group had higher or lower likelihood
of suicide attempts prior to their social transition (than the
group who did not social transition) this could lead to spu-
riously attributing this difference to an intervention (social
transition) which could not have generated this group dif-
ference. Again, longitudinal research is required before
any confident claims regarding the relationship between
social gender transition and suicide attempts can be made.
Future studies should also measure the moderating influ-
ence of transition related discrimination and transition
related social support when assessing the mental health
consequences of social gender transition. Relevant to this
latter possibility, Durwood etal.’s (2021) study, examin-
ing parent reports of 265 socially transitioned transgender
youth, ages 3–15 (67.2% transgender girls, 32.8% transgen-
der boys) found that parents who reported higher levels of
family, peer, and school support for their child’s transgender
identity also reported fewer internalizing symptoms in their
child. Moreover, peer and school support for the young per-
son’s transgender identity moderated the association between
gender-related victimization and internalizing symptoms.
Such research will better identify how to avoid or ameliorate
negative psychosocial experiences related to social transition.
Our assessment of social gender transition was also lim-
ited in a number of respects. Firstly, our sample was almost
exclusively binary identified transgender young people (only
7% identified as a non-binary), and thus our assessment
of social gender transition was designed with this population
in mind. It is unclear what a “full” or “partial” transition
looks like for a non-binary individual. In this type of social
Table 8 Logistic regressions predicting the likelihood of a mood disorder, anxiety disorder, and suicide attempt in AFAB versus AMAB refer-
rals based on the social transition composite (n = 357)
AGAB = Assigned Gender at Birth (1 = Female; 2 = Male); Mood, Anxiety, Suicide Attempt (No = 1; Yes = 2)
Mood disorder Anxiety disorder Suicide attempt
Variable β p-value Exp (β)β p-value Exp (β)β p-value Exp (β)
Model 1
Step χ2(3) 25.81 < .001 4.46 .216 15.86 .001
Nagelkerke R2.11 .21 .11
AGAB −.02 .951 .98 −.11 .731 .95 −.03 .949 .97
Age .27 < .001 1.31 .11 .055 .01 .47 .006 1.60
Social transition −.01 .949 .99 −.04 .812 .11 .50 .113 1.65
Model 2
Step χ2(7) 31.09 .152 4.64 .591 16.53 .881
Nagelkerke R2.14 .02 .12
AGAB .39 .572 .25 .41 .849 1.50 4.08 .477 59.08
Age 2.00 .331 1.48 .13 .707 1.14 1.21 .269 3.34
Social transition .16 .150 7.41 .25 .839 1.28 2.28 .582 9.78
AGAB × Age −.11 .228 1.18 −.00 .979 1.00 −.25 .431 .78
AGAB × Social transition −.34 .251 .90 −.01 .936 1.00 −.11 .669 .90
Age × social transition −1.37 .359 .71 −.15 .680 .86 4.08 .925 .94
Model 3
Step χ2(8) 31.16 .798 7.06 .120 16.65
Nagelkerke R2.14 .03 .12
AGAB −3.96 .706 .02 12.62 .135 303,893.51 −6.27 .838 .00
Age .16 .870 1.17 1.39 .140 3.99 .25 .931 1.29
Social transition 1.03 .801 2.79 5.70 .146 297.50 −1.83 .882 .16
AGAB × Age .34 .628 1.40 −.83 .141 .43 .40 .834 1.50
AGAB × Social transition − .04 .886 .96 −.38 .152 .69 .15 .846 1.16
Age × Social transition .41 .890 1.51 −3.85 .124 .02 2.78 .736 16.03
AGAB × Age × social transition −.05 .799 .95 .25 .133 1.29 −.18 .729 .84
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1057Archives of Sexual Behavior (2023) 52:1045–1060
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transition, the goal may be to incorporate some mixture of
masculine and feminine presentation or to achieve fluidity in
gender presentation across contexts. Future studies should
not only aim to examine how social transition may impact
well-being in non-binary populations (separated out from
binary transgender patients) but also identify more accurate
ways of operationalizing and measuring what social gender
transition means in non-binary pediatric patients. This is
important given that non-binary identities are increasingly
prevalent in emerging cohorts of gender variant youngsters
(Tollit etal., 2023).
Next, mood and anxiety difficulties were assessed as
absent or present based on clinician ratings and relevant
referral information. This approach lacks standardization and
sensitivity to detect differences in psychological functioning
between socially transitioned and non-transitioned patients,
which exist in the non-clinical range (Durwood etal., 2017;
Olson etal., 2016). Future studies should utilize standard-
ized clinical interviews, as well as standardized self- and
parent-report scales, when assessing psychological outcomes
of social transition to increase sensitivity to detect differences
in mental health if they are present.
Clinical Implications
We stress the importance of not over interpreting cross-sec-
tional data such as that presented in this study—nor drawing
overly simplistic conclusions from our data (e.g., “social gen-
der transition has no benefit”). It is possible that although our
socially transitioned patients did not demonstrate superior
well-being compared to their non-transitioned counterparts,
they were nevertheless functioning better (either in terms
of mood/anxiety or gender dysphoria severity, or both) than
their own prior functioning pre-social transition. It is also
possible that benefits of social transition were not captured
in the present study for other reasons; for instance, they might
not have had time to emerge or were canceled out by stresses
related to adjustment in the short term (even though socially
transitioned cohorts may demonstrate superior functioning
in the longer term).
So, what may be a take home for parents, clinicians, and
educators? Our data suggest that social gender transition
may not render immediate and dramatic alleviation of mental
health difficulties for all or most children/adolescents suf-
fering with gender dysphoria. If it did, we would expect to
have found some lower prevalence of anxiety or depression
in our socially transitioned group. Perhaps our study hints
that social gender transition alone, at least in the short term,
is no panacea to mental health struggles of young people
with gender dysphoria and that clinicians and parents should
not expect immediate symptom alleviation specific to gender
dysphoria or related to mental health more generally. Ongo-
ing contact with mental health services to support young
people through social gender transitioned related stressors
(e.g., concealment stress, transphobia, misgendering, and
adjustment of family, peer, and community to the young per-
son’s gender) is indicated. Clinically we have observed par-
ents of transgender children lament that their child’s distress
should have resolved (or resolved more so) now that they
have socially transitioned. Although this perspective may be
an outlier, we believe it may be present more broadly in clini-
cians, educators, and parents with only passing familiarity
with struggles of young people with gender dysphoria. The
present data may encourage relevant parties to set realistic
expectations regarding social gender transition (including the
need for ongoing parental and clinical care) and encourage a
more holistic understanding of the young persons’ struggles
that also acknowledges how social gender transition may alle-
viate one set of challenges (e.g., alleviate felt gender incon-
gruence) while introducing some others (e.g., transphobia,
concealment/passing stress)—requiring clinical support of a
different type (e.g., assertiveness training). Again, we stress
that the present findings do not suggest that social gender
transition will not have positive impacts for some children/
adolescents in the short term or that it may not have posi-
tive effects on well-being in the longer term. We would urge
these findings not directly inform treatment without weigh-
ing findings from other relevant research, including those
demonstrating possible benefits of social gender transition
(Durwood etal., 2017; Kuvalanka etal., 2017; Olson etal.,
2016).
It would be negligent of us not to acknowledge other inter-
pretations of the null effects of social transition on the men-
tal health of young people in our study. Some might argue
that our failure to demonstrate an association between social
transition status and mental health outcomes is due to social
transition not effectively ameliorating distress in the short,
medium, or long-term for a substantial proportion of gen-
der dysphoric children and adolescents. While there was no
evidence that social transition had deleterious effects on the
mental health of young people in our study, some may argue
that in the absence of positive benefits of social transition
initiating early social transitions should be approached with
caution. Some authors have warned of possible "iatrogenic"
effects of early social transition, based on data suggesting
childhood social transition is associated with an increased
likelihood of persistence of gender dysphoria (Steensma
etal., 2011, 2013) into adolescence and adulthood. Given
a body of data suggests that the majority of cases of child-
hood onset gender dysphoria desist before adulthood (Singh
etal., 2021; Zucker, 2018, 2020), early social transition may
increase the likelihood that gender dysphoria will persist and
that hormonal and/or surgical transition will be required to
alleviate gender-related distress. It should be stressed that it
is beyond the scope of the present study to lend to support to
this or other interpretations of the data.
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1058 Archives of Sexual Behavior (2023) 52:1045–1060
1 3
Conclusion
The present findings, although preliminary, suggest that
social gender transition is not associated with mental health
status in children and adolescents, at least in the short term.
These findings are consistent with the only other study that
directly compared clinic-referred youth experiencing gender
dysphoria who had socially transitioned with those who had
not (Sievert etal., 2021). Critically, longitudinal research is
required in order to make more confident claims about the
relationship between social gender transition, mental health,
gender dysphoria severity, and the broader psychosocial
functioning of young people suffering gender dysphoria.
Supplementary Information The online version contains supplemen-
tary material available at https:// doi. org/ 10. 1007/ s10508- 023- 02588-5.
Acknowledgements We would like to thank Michael Dunsford at the
Tavistock and Portman Gender Identity Development Service (GIDS)
for developing the associated difficulties assessment form.
Funding Open Access funding enabled and organized by CAUL and
its Member Institutions.
Declarations
Conflict of interest The author(s) declare no competing interests.
Ethical Approval All procedures in this study were performed in accord-
ance with the ethical standards of the institutional or national research
committee and with the 1964 Declaration of Helsinki and its later
amendments or comparable ethical standards.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
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