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Archives of Sexual Behavior (2024) 53:91–106
https://doi.org/10.1007/s10508-023-02674-8
ORIGINAL PAPER
Binary andNon‑binary Gender Identities, Internalizing Problems,
andTreatment Wishes Among Adolescents Referred toaGender
Identity Clinic inGermany
LenaHerrmann1 · ClausBarkmann1· CarolaBindt1· SaskiaFahrenkrug1· FranziskaBreu1· JörnGrebe1·
IngaBecker‑Hebly1
Received: 27 April 2022 / Revised: 20 July 2023 / Accepted: 21 July 2023 / Published online: 10 August 2023
© The Author(s) 2023
Abstract
Clinical research on transgender and gender-nonconforming (TGNC) adolescents has focused on binary individuals or often
not differentiated among gender identities. Recent studies suggest that a considerable proportion of TGNC adolescents
identify as non-binary and that these youth report more internalizing problems as well as different transition-related medical
treatment wishes than binary adolescents. However, the results are inconclusive, and data for the German-speaking area are
lacking. Therefore, the present study aimed to assess the percentage of binary and non-binary gender identities in a German
sample of clinically referred TGNC adolescents and examine associations of gender identity with internalizing problems and
transition-related medical treatment wishes. The sample consisted of 369 adolescents (11–18 years, Mage = 15.43; 305 birth-
assigned female, 64 birth-assigned male) who attended the Hamburg Gender Identity Service for children and adolescents
(Hamburg GIS) between 2013 and 2019. Gender identity and treatment wishes were assessed using study-specific items and
internalizing problems using the Youth Self-Report. In total, 90% (n = 332) of the sample identified as binary and 10% (n = 37)
as non-binary. Having a non-binary gender identity was significantly associated with more internalizing problems and with
wishing for no transition-related medical treatment or only puberty-suppressing hormones. The results underscore that non-
binary adolescents represent a specifically vulnerable subgroup within TGNC adolescents with unique mental health needs
and treatment wishes. Future research should differentiate among various gender identities. In clinical practice, it is crucial
to create an inclusive space for non-binary youth and provide mental health care if needed.
Keywords Non-binary· Transgender· Gender dysphoria· Internalizing problems
Introduction
Most clinical research on transgender and gender-noncon-
forming (TGNC) adolescents or youth with a gender dys-
phoria (GD) diagnosis focused on comparing TGNC with
cisgender individuals or subgroups of young TGNC individu-
als according to their birth-assigned sex (Turban & Ehrensaft,
2018). However, there are more subgroups within TGNC
youth with unique experiences and needs, and the experi-
ences of TGNC adolescents of the same birth-assigned sex
are therefore not always similar. For instance, non-binary
youth are an understudied subgroup with different mental
health issues and treatment desires who have only recently
become increasingly visible in clinical settings as well as in
clinical research (Richards etal., 2016).
The term TGNC refers to a broad range of individuals who
experience an incongruence between their gender and their
birth-assigned sex (gender incongruence; American Psycho-
logical Association, 2015). TGNC individuals with a male
sex assigned at birth are often referred to as AMAB (assigned
male at birth), and those with a female sex assigned at birth
are referred to as AFAB (assigned female at birth). Gender
dysphoria (GD) describes a clinical diagnosis related to dis-
tress that can arise from gender incongruence (American
Psychiatric Association, 2013).
Gender identity refers to one’s inherent sense of being a male ,
female, or an alternative gender (American Psychological
* Lena Herrmann
le.herrmann@uke.de
1 Department ofChild andAdolescent Psychiatry,
Psychotherapy, andPsychosomatics, University Medical
Center Hamburg-Eppendorf, Martinistraße 52, W29,
20246Hamburg, Germany
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92 Archives of Sexual Behavior (2024) 53:91–106
1 3
Association, 2015). TGNC individuals’ gender identities are
heterogeneous, which is increasingly acknowledged (Motmans
etal., 2019). The majority of TGNC individuals identify with
the “opposite” gender in a binary understanding, meaning that
they identify as either female or male or as either transmas-
culine or transfeminine (Chew etal., 2020; Richards etal.,
2016). However, a considerable and increasing proportion of
TGNC individuals (see paragraph further below) identify as
non-binary (James etal., 2016; Richards etal., 2016). Non-
binary individuals identify between, outside, or beyond the
gender binary (Thorne etal., 2019). The umbrella term “non-
binary” also embraces different identities, such as “genderfluid”
(alternating between different genders), “genderqueer” (gender
experience between or outside the gender binary), and “agen-
der” (not identifying with any gender or rejecting the idea of
genders). Of note, language for and conceptualizations of gen-
der (minority) identities have changed substantially in recent
years. Therefore, the above terms are also likely to change,
highlighting the need to respect the preferred self-definitions
of individuals (Richards etal., 2016).
For the adolescent and adult general population, three
population-based studies demonstrated that the experience
of gender identity includes more than just two congruent
(defined as stronger identification with one’s own birth-
assigned sex than the other sex) or incongruent categories
(defined as stronger identification with the other sex than
with the birth-assigned sex; Becker etal., 2017; Kuyper &
Wijsen, 2014; Van Caenegem etal., 2015). Across these
studies, various gender experiences (e.g., ambivalent, no
clear gender identity/ neither female nor male) were more
prevalent in the adolescent and adult general population than
binary-incongruent experiences as defined above (Becker
etal., 2017; Kuyper & Wijsen, 2014; Van Caenegem etal.,
2015). These findings emphasize the need to go beyond the
binary understanding of gender identities (i.e., cisgender
vs. transgender or transfemale vs. transmale) to capture the
whole range of gender identity—also, or especially, among
TGNC individuals.
Among TGNC adolescents specifically, percentages of
non-binary gender identities vary considerably across stud-
ies and study populations (for an overview of studies focusing
on binary vs. non-binary youth in clinical and non-clinical
studies, see TableS1 in the Supplementary Material). Alto-
gether, in non-clinical surveys, a wide range of approximately
20–70% of TGNC youth (primarily recruited through social
media) identify as non-binary (e.g., Atteberry-Ash etal.,
2021; Clark etal., 2018; McKay & Watson, 2020; Roberts
etal., 2021; Thoma etal., 2019; TableS1). Since not all and
therefore probably fewer non-binary than binary TGNC youth
attend specialized gender identity services, the proportion of
non-binary youth in clinical studies is lower: Clinical studies
indicate that 6–26% of youth attending specialized gender
identity services identify as non-binary (e.g., Cheung etal.,
2020; Mirabella etal., 2022; O'Bryan etal., 2018; Thorne
etal., 2018; Twist & de Graaf, 2019; TableS1). Handler
etal. (2019) reported that AFAB adolescents identified sig-
nificantly more often as non-binary than AMAB adolescents,
whereas three other clinical studies found no sex differences
in frequencies of non-binary gender identities (Mirabella
etal., 2022; Thorne etal., 2018; Twist & de Graaf, 2019).
Interestingly (although not the focus of the present study), in
an Italian survey, non-binary adolescents self-reported higher
levels of gender fluidity than binary adolescents, meaning
that they experienced their gender identity as less stable/fixed
and more fluid over time and context (Mirabella etal., 2022).
Internalizing Psychological Problems inNon‑binary
Adolescents
The minority stress model theorizes that mental health
disparities can be caused by the stress associated with gen-
der minority-related stigma, prejudice, and discrimination
(Hendricks & Testa, 2012; Meyer, 2003). Such mental health
disparities have been well documented for TGNC youth.
Compared to their cisgender counterparts, TGNC adoles-
cents report more psychological difficulties or so-called
behavioral and emotional problems, especially internalizing
problems and elevated rates of depression, suicidality, self-
harm, and eating disorders (Bechard etal., 2017; Connolly
etal., 2016; de Graaf etal., 2022; Hartig etal., 2022; Levitan
etal., 2019). Non-binary young individuals may face even
more discrimination and victimization than binary TGNC
individuals because their gender expression (e.g., gender-
neutral pronouns and non-binary outward appearance) is
more conflicting with the gender binary of either female or
male (Lefevor etal., 2019). As a result, non-binary youth
may have an even higher risk for mental health issues than
binary youth.
Studies focusing on these potential differences between
binary and non-binary adolescents, especially clinically
referred ones, remain scarce, and their results are inconsist-
ent (Chew etal., 2020; TableS1). In several clinical and non-
clinical studies, non-binary youth had more mental health
issues than binary TGNC youth (Atteberry-Ash etal., 2021;
Ciria-Barreiro etal., 2021; Thorne etal., 2018; Veale etal.,
2017; Wang etal., 2020). Across these studies, mental health
disparities between binary and non-binary adolescents were
most pronounced in internalizing disorders and symptoms
such as depression, anxiety, suicidality, and self-harming
behavior. Likewise, in a British and Dutch clinical study,
identifying more strongly with a non-binary gender identity
and being AFAB was associated with more internalizing
problems among clinically referred TGNC adolescents (de
Graaf etal., 2021).
In contrast, other clinical and non-clinical studies found
no evidence for elevated rates of internalizing conditions in
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93Archives of Sexual Behavior (2024) 53:91–106
1 3
non-binary youth compared to binary youth (e.g., Aparicio-
García etal., 2018; Fontanari etal., 2020; Rusow etal., 2022;
Tordoff etal., 2022; TableS1). Furthermore, some studies
highlight that there may be differences between AFAB and
AMAB non-binary adolescents, highlighting the need to take
the birth-assigned sex into account (McKay & Watson, 2020;
Parodi etal., 2022; Rimes etal., 2019; Thoma etal., 2019).
Research has identified several risk and protective factors
for behavioral and emotional problems in TGNC adolescents
in general. First, difficulties in social interactions with peers
(such as bullying) or so-called “poor peer relations” have a
significant and negative impact on psychological functioning
in young TGNC individuals (de Vries etal., 2016; Levitan
etal., 2019; Shiffman etal., 2016; Sievert etal., 2021). Sec-
ond, family support and general family functioning (or the
lack thereof) seem to contribute to better (or worse) psycho-
logical outcomes in TGNC children and adolescents (Levitan
etal., 2019; Sievert etal., 2021; Simons etal., 2013). Non-
binary adolescents might receive even less family support
and face even more peer problems/bullying than their binary
counterparts (due to a lack of societal understanding and
acceptance of non-binary gender identities), which might
contribute to the elevated rates of internalizing problems
in non-binary adolescents (Aparicio-García etal., 2018).
Furthermore, many TGNC adolescents report less body
satisfaction or less favorable body image scores than their
cisgender peers or norm comparison groups (Becker etal.,
2018). Additionally, studies show that body image may con-
tribute to the psychological functioning and quality of life
in TGNC adolescents (Röder etal., 2019; Verveen etal.,
2023). Researchers have suggested that better mental health
outcomes among non-binary than among binary TGNC
individuals, as observed in a few studies, may reflect higher
levels of body satisfaction and gender congruence (Jones
etal., 2019). In conclusion and in addition to gender identity,
several other factors (birth-assigned sex, poor peer relations,
family functioning, and body satisfaction) are related to men-
tal health outcomes in TGNC adolescents and should there-
fore be considered in the assessment of their psychological
functioning/mental health.
Transition‑Related Medical Treatment Wishes
ofNon‑binary Adolescents
Transition-related medical treatments—that is, puberty-
suppressing hormones (gonadotrophin-releasing hormone
analogues, GnRHa), gender-affirming hormones, and gender-
affirming surgeries—can contribute to better mental health
outcomes, more life satisfaction, and increased body satis-
faction among TGNC youth (Becker etal., 2018; Becker-
Hebly etal., 2021; de Vries etal., 2014; Green etal., 2022;
Kuper etal., 2020; van der Miesen etal., 2020). However,
non-binary TGNC individuals may not desire or need any or
fewer of the transition-related medical treatments mentioned
above (so-called partial treatment requests, e.g., requesting
gender-affirming hormones but not surgeries) because they
may experience lower gender incongruence and less body
related dysphoria or more body satisfaction than binary
TGNC individuals (Jones etal., 2019).
Little is known about the transition-related medical treat-
ment wishes of non-binary youth, with only a few studies
specifically focusing on clinical populations of TGNC youth
(TableS1). In most studies, non-binary youth were signifi-
cantly less likely to wish for transition-related medical treat-
ment than binary youth (Clark etal., 2018; Peng etal., 2019;
Todd etal., 2019). For instance, Clark etal. reported that 25%
of non-binary youth, compared to 85% of binary youth, stated
that gender-affirming hormones were necessary for them.
However, in a recent clinical Italian study, transition-
related medical treatment wishes did not significantly differ
between non-binary and binary adolescents, although non-
binary adolescents tended to wish more often for puberty-
suppressing hormones (60% vs. 49%) and less often for geni-
tal surgery (53% vs. 67%) than binary adolescents (Mirabella
etal., 2022). Several studies demonstrated in addition that
young non-binary individuals reported barriers to hormone
access (e.g., lack of parental support) more often and were
more often undecided regarding their own possible hor-
mone therapy than binary individuals (Clark etal., 2018,
2020; Cohen etal., 2022; Green etal., 2022). Young non-
binary TGNC people also hesitated to disclose their non-
binary gender identities for fear of not receiving the desired
transition-related medical treatment (Carlile etal., 2021).
Furthermore, two case studies document that non-binary ado-
lescents may desire treatment with puberty-suppressing but
not gender-affirming hormones to achieve a gender-neutral
or androgynous appearance (Notini etal., 2020; Pang etal.,
2020). In summary, the majority of these studies suggest that
non-binary adolescents may desire transition-related medi-
cal treatments that achieve an affirmation of the “opposite”
gender (according to traditional binary notions of gender)
less often than binary adolescents.
Study Aims andResearch Questions
To date, there are no studies assessing the percentage of
binary or non-binary gender identities in adolescents attend-
ing a German gender identity service. Additionally, there are
few clinical studies on the association between non-binary
gender identities and internalizing problems in TGNC ado-
lescents, and their results are inconclusive. Furthermore,
there is still little knowledge on how many non-binary ado-
lescents wish to undergo transition-related medical treat-
ment and which other factors might influence their treatment
wishes. Therefore, the present clinical study focuses on the
associations of gender identity with internalizing problems
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94 Archives of Sexual Behavior (2024) 53:91–106
1 3
and transition-related medical treatment wishes, aiming to
answer the following research questions:
1. What is the percentage of binary and non-binary gender
identities in AFAB and AMAB adolescents referred to a
specialized gender identity service?
2. How is gender identity (binary vs. non-binary) associated
with internalizing problems in clinically referred TGNC
adolescents?
3. How is gender identity (binary vs. non-binary) associ-
ated with transition-related medical treatment wishes in
clinically referred TGNC adolescents?
Based on previous findings, we had two hypotheses. First,
we hypothesized that having a non-binary gender identity
(as opposed to a binary gender identity) would be associated
with different levels of internalizing problems. Second, we
hypothesized that having a non-binary gender identity (as
opposed to a binary gender identity) would be associated
with different transition-related medical treatment wishes.
Method
Participants
The present study used a cross-sectional, questionnaire-based
study design and assessed a cohort of clinically referred ado-
lescents aged 11–18 years. Data were collected from Septem-
ber 2013 to December 2019 at the Hamburg Gender Identity
Service for children and adolescents (Hamburg GIS). The
Hamburg GIS at the University Medical Center Hamburg-
Eppendorf provides specialized diagnostics, counseling, and
treatment for TGNC children and adolescents. Since 2013,
all families attending the Hamburg GIS have been invited to
participate in the study and to complete a set of self-report
and parent-report questionnaires at the time of their first
appointment. Hence, voluntary participation took place prior
to undergoing any form of counseling or treatment. Ethi-
cal approval for this study was granted by the local ethics
committee. Written informed consent was obtained from all
participating adolescents and their parents/caregivers.
The study population consisted of adolescents (aged 11
years and older) who had been consecutively referred to the
Hamburg GIS. During that time, 761 adolescents and their
parents/caregivers attended the Hamburg GIS (78% AFAB,
22% AMAB; Fig.1). In total, complete data sets for 424
participants were available. However, 55 cases had to be
excluded for various reasons (Fig.1). For instance, adoles-
cents with prior hormonal treatment (n = 42) were excluded
because the study focused on treatment naïve adolescents.
Thus, in total, the study sample included 369 adolescents
with a diagnosis of GD (aged 11–18 years; 83% AFAB, 17%
AMAB).
Measures
Gender Identity
For gender identity, adolescents were asked, “How would you
currently describe your gender identity?” They were given
the following list of self-identifications and asked to choose
the one that fits best: 0 = “female”, 1 = “male”, 2 = “in-
between”, 3 = “trans woman/girl”, 4 = “trans man/boy”, and
5 = “other (namely)” (with a write-in option).
Based on their self-identifications, three categories were
assigned to the answers: 0 = binary (“female” or “male”), 1 =
binary trans (“trans woman/girl” or “trans man/boy”), and 2 =
non-binary (“in-between”). Respondents who indicated both
binary and binary trans identities (“male” and “trans woman/
girl” or “female” and “trans many/boy”) were allocated to the
binary trans group. The open answers of the respondents who
indicated having an “other” gender identity were screened
by the first and last authors and then assigned to one of the
three groups (e.g., answers such as “male and trans man/
boy” as binary trans and answers such as “agender,” “demi
boy,” or “queer and non-binary” as non-binary). If an open
answer included both binary trans and non-binary terminol-
ogies (e.g., “trans boy” and “non-binary”), the respondent
was categorized as non-binary. For analysis purposes, the
binary and binary trans groups were later combined, labeled
“binary” and compared to the non-binary group. Hence, two
gender identity groups were built: 0 = binary and 1 = non-
binary. Binary and non-binary adolescents were additionally
broken down by their birth-assigned sex to explore possible
differences between groups: 0 = AFAB and 1 = AMAB.
Sociodemographic Characteristics
The following sociodemographic characteristics were coded:
birth-assigned sex, age at assessment (upon clinical entry),
citizenship, parental marital status and living situation, and
parental socioeconomic status.
The socioeconomic status was assessed using the parent-
reported Winkler Index (Winkler & Stolzenberg, 1999). This
measure takes parents’ education, income, and job position
into account. The Winkler Index has a sum score that ranges
from 3 to 21. For this purpose, we used only the following
three 3-point variables resulting in a sum score ranging from
3 to 9: educational background of the parent with the high-
est status (1 = no or lower education, 2 = middle or techni-
cal school, 3 = higher education or university), household
income (1 = less than 2000 € per month, 2 = 2000–4000 €
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95Archives of Sexual Behavior (2024) 53:91–106
1 3
per month, 3 = more than 4000 € per month), and job position
of the parent with the highest status (1 = lower occupation or
unemployed, 2 = skilled occupation or self-employed, 3 =
executive or academic occupation). The following categories
were built: 0 = low socioeconomic status (scores from 3 to 4),
1 = medium socioeconomic status (scores from 5 to 7), and 2
= high socioeconomic status (scores from 8 to 9).
The parents’ marital status and living situation were meas-
ured by asking the parents about the current living situation
and the relationship status. As suggested by Levitan etal.
(2019), two categories were built: 0 = both parents living
together or married and 1 = other (living as a single parent,
separated, divorced, widowed, or living with a new partner).
Internalizing Problems
Internalizing problems were assessed by the German version
of the 1991 Youth Self-Report (YSR) (Achenbach, 1991;
Döpfner etal., 1998). The YSR is a 119-item self-report ques-
tionnaire for adolescents aged 11–18 years. Items are rated
on a 3-point scale ranging from 0 (“not true”) to 2 (“very true
or often true”) and refer to the past 6 months (“now or within
the past 6 months”). T scores for the three main scales (total
problem score, internalizing, and externalizing problems)
were calculated using the German population-based, age-
and sex-specific norms provided in Döpfner etal. (1998) to
determine whether the scores of the present sample lie within
the normal range of the German population. Additionally,
clinical range scores (> 90th percentile; T scores > 63) were
built. Cronbach’s α for the internalizing scale was .91.
For exploratory purposes, we also calculated the YSR
externalizing problem and the total problem scores (sum of
all problems) to examine psychological functioning more
broadly. The following items were excluded from the calcu-
lation of the total problem score: asthma (Item 2), allergies
(Item 4), socially desirable items (16 items), and cross-gen-
der identification (Item 5 and Item 110). TGNC adolescents
might endorse other items on the YSR (than Item 5 and Item
110) for gender-related reasons. Therefore, as described in
previous studies (Cohen-Kettenis etal., 2003; de Vries etal.,
2016), Item 84 and Item 85 were set to zero if the free-text
answers were gender-related to avoid artificial inflation. In
our study, Cronbach’s α for the externalizing and the total
problem scale were .85 and .94, respectively.
Baseline
Data Collection
n= 369 data sets
eligible for analysis
Clinical entry(Sep. 2013 –Dec. 2019):
N= 761 adolescents
n= 424complete data files
incl. informed consent
(children & adolescents)
Excluded cases:
-n = 42 with prior hormonal treatment
(GnRHa, gender-affirming hormones
and menstrual suppression)
-n= 6 with severe psychiatric
problems(e.g., psychosis)
-n= 5 diagnosis could not be assessed
for various reason (e.g., child does not
speak or only one appointment)
-n= 2 incomplete/ missing
information on gender identity
Drop-out:
n= 337 no participationor
missing data (missing informed
consent or incomplete
questionnaire sets)
Sex ratio upon clinical entry
(N = 761 adolescents):
78% birth-assigned females
22% birth-assigned males
Sex ratio (n = 424adolescents):
82.5% birth-assigned females
17.5% birth-assigned males
Sex ratio (n = 369 adolescents,
analysis sample):
83% birth-assigned females
17% birth-assigned males
Fig. 1 Participants and sex ratios at the Hamburg GIS for children and adolescents
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96 Archives of Sexual Behavior (2024) 53:91–106
1 3
Poor Peer Relations
We used the following three items from the YSR to create an
index of poor peer relations: Item 25 (“I don’t get along with
other kids”), Item 38 (“I get teased a lot”), and Item 48 (“I
am not liked by other kids”). The Poor Peer Relation index
was developed by Zucker etal. (1997) and has been used in
previous studies to measure problematic social interactions
with peers of young individuals referred for GD (de Vries
etal., 2016; Levitan etal., 2019; Sievert etal., 2021; Zucker
etal., 2002, 2012). The index ranges from 0 to 6, with higher
scores reflecting poorer peer relations. In the present study,
Cronbach’s α was .67.
General Family Functioning
General family functioning was assessed using the McMaster
Family Assessment Device (FAD; Epstein etal., 1983). The
questionnaire has been used in previous studies on TGNC
children and adolescents (Levitan etal., 2019; Sievert etal.,
2021). The FAD is a questionnaire evaluating family relation-
ships according to the McMaster Model of Family Function-
ing. For the present study, only the FAD subscale on general
family functioning was evaluated. The general family func-
tioning scale consists of 12 items, such as family acceptance
(e.g., “Individuals are accepted for what they are” or “We
feel accepted for what we are”). The adolescents are asked
to decide how well these items describe their own family
and to rate the items on a 4-point scale (from 1 = “strongly
agree” to 4 = “strongly disagree”). The items are then added
and divided by the number of items to determine an average
general family functioning score, which can range from 1 to
4, with higher scores indicating lower levels of family func-
tioning. The cutoff for categorical analyses (problematic or
unhealthy family functioning) is 2.17 (Byles etal., 1988).
Cronbach’s α in the present sample was .88.
Suicidality
We used two items from the YSR to create an index for suici-
dality: Item 18 on self-harming behavior and suicide attempt
(“I deliberately try to hurt or kill myself”) and Item 91 on sui-
cidal ideation/thoughts (“I think about killing myself”). The
index has been used in various previous studies on TGNC
adolescents’ suicidality (de Graaf etal., 2022; Hartig etal.,
2022; Van Cauwenberg etal., 2021). The sum score ranges
from 0 to 4, with higher scores indicating higher levels of
suicidality. Cronbach’s α for the present sample was .75.
Body Satisfaction
The pictorial measure Hamburg Body Drawing Scale
(HBDS) was used to assess body satisfaction (Appelt &
Strauß, 1988; Becker etal., 2016). Participants were given
a visualized body figure drawing and asked to rate their sat-
isfaction with 35 body features (e.g., chin, shoulders, and
height) and their overall appearance on a 5-point scale (from
1 = “very dissatisfied” to 5 = “very satisfied”). The HBDS
has been validated for TGNC populations, and the internal
consistency for the HBDS subscales (Cronbach’s α =.63–.91)
is satisfactory (Becker etal., 2016). For the present study,
only a single item to measure the satisfaction with the overall
appearance was used (“satisfaction with the overall appear-
ance”; Becker etal., 2016).
Transition‑Related Medical Treatment Wishes
To obtain information on transition-related medical treatment
wishes, adolescents were asked if they wished to receive the
following treatment options in the future: 0 = “puberty-
suppressing hormones”, 1 = “gender-affirming hormones”,
2 = “gender-affirming surgical treatment (namely)” (with a
write-in option), and 3 = “other (namely)” (with a write-in
option). Transition-related medical treatment wishes were
then divided into the following two categories based on
whether they achieved an affirmation of the “opposite” gen-
der in a binary sense: 0 = “gender-affirming hormones and/
or surgical treatments” and 1 = “no treatment wish or only
with puberty-suppressing hormones.”
Statistical Analyses
For the frequency of binary and non-binary gender identi-
ties, confidence intervals (95% CI) were calculated. For con-
tinuous variables, two-way analyses of variance (ANOVAs)
were used to explore differences in the sociodemographic
and clinical characteristics between sex (AFAB, AMAB)
and genders (binary, non-binary). For categorical variables,
exploratory chi-square tests were conducted. Standardized
effect sizes (partial eta squared, ηp2 and odds ratios, OR) were
calculated to quantify the magnitude of the effect.
Internalizing problems were descriptively evaluated using
raw scores, T scores, and clinical ranges (> 90th percentile;
T scores > 63) for the YSR internalizing scale. Addition-
ally, confidence intervals for the T scores were reported to
compare our study sample with the age- and sex-equivalent
population-based German norms (Döpfner etal., 1998).
Whenever confidence intervals were not within the normal
range of the T distribution (M = 50, SD = 10), a significant
difference from the reference group can be assumed. If confi-
dence intervals overlap, the results do not significantly differ
from each other (Cumming & Finch, 2005). Although the
present study focused on internalizing problems, given the
current state of the literature, the YSR externalizing scale
and the total problem score were also evaluated for explora-
tory purposes.
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97Archives of Sexual Behavior (2024) 53:91–106
1 3
A multiple linear regression analysis was performed to
evaluate our first hypothesis on the association between gen-
der identity and internalizing problems. The raw scores of the
YSR internalizing scale were used as an outcome variable
while controlling for birth-assigned sex, age, poor peer rela-
tions, general family functioning, body satisfaction, and the
interaction birth-assigned sex x age. The same was conducted
to explore the relationships of gender identity with external-
izing problems and the total problem score. For the total
problem score, three items on poor peer relations (Items 25,
38, and 48) were excluded since the poor peer relation index
was a separate predictor in the model. An a priori power
analysis (using G*Power) demonstrated that in a multiple
regression analysis with 369 cases and seven predictors, a
small effect (f = 0.02) could be tested with a power of 80%.
For testing our second hypothesis, a multiple logistic
regression analysis was conducted to study the association
between gender identity and medical treatment wishes while
controlling for birth-assigned sex, age, and body satisfaction.
A power analysis showed that in a logistic regression analysis
with 369 cases, an observed effect of OR = 1.45 could be
detected with a power of 80%.
Single missing values were imputed by using the expec-
tation maximization algorithm (Little & Rubin, 2019). All
statistical analyses were performed using SPSS 27.
Results
Percentage ofBinary andNon‑binary Gender
Identities
In total, 90% (95% CI = 86.4, 92.8; n = 332) of the clinically
referred adolescents identified as binary. In the binary group,
46% identified as binary (either male or female) and 54%
as binary trans (either trans woman/girl or trans man/boy).1
Among the 369 adolescents, 37 adolescents identified as
non-binary. Thus, the percentage of non-binary gender iden-
tities in the present sample was 10% (95% CI = 7.2, 13.6).
Most non-binary adolescents (76%) identified with a gender
between female and male.2 There was a significant associa-
tion between birth-assigned sex and gender identity (χ2(1,
369) = 6.53, p = .011, OR = 2.59): AMAB adolescents
reported a non-binary gender identity (19%) significantly
more often than AFAB adolescents (8%). Conversely, AFAB
adolescents identified significantly more often as binary
(92%) than AMAB adolescents (81%).
Sociodemographic andClinical Characteristics
Table1 presents more details on the sociodemographic and
clinical characteristics of the sample. The TGNC adolescents
(n = 369) consisted of 83% AFAB and 17% AMAB individu-
als with a mean age of 15.4 years. There were no age differ-
ences between groups.
Most adolescents were German citizens (96%) and came
from a family with a medium (57%) or high (30%) socioeco-
nomic background. Parents were still living together or mar-
ried for half of the adolescents (50%). More than two-thirds
of the adolescents reported having encountered at least one
peer-related problem in the past six months on the poor peer
relations scale. Family interactions measured via the gen-
eral family functioning scale were on average unproblematic
(below the cutoff at 2.17). One-third reported problematic
family functioning (above the cutoff at 2.17). AMAB ado-
lescents reported on average significantly more peer-related
problems than AFAB adolescents. There were no other sig-
nificant sex or gender differences for any of these variables.
Almost half of the adolescents (45%) reported that they
sometimes or often harmed themselves or attempted suicide.
Furthermore, 34% of the adolescents endorsed that they
sometimes or often had suicidal thoughts. AFAB adolescents
reported, on average, significantly higher levels of suicidality
than AMAB adolescents. There were no significant differ-
ences between binary and non-binary adolescents.
Body satisfaction was on average low. Both non-binary
and binary and AFAB and AMAB TGNC adolescents
reported that they were, on average, unsatisfied with their
overall appearance, with a tendency of more body satisfac-
tion in non-binary and AMAB adolescents. There were no
significant sex or gender differences.
Internalizing Problems
The results for internalizing problems are shown in Table2.
Compared to the German norm population (M = 50, SD =
10), TGNC adolescents (binary and non-binary as well as
AFAB and AMAB) had significantly higher T scores (95%
CI not including M = 50) for internalizing problems. TGNC
adolescents scored on average more than 1.5 SD higher on
the internalizing problem scale than same-aged and same-
sex adolescents from the YSR reference group. More than
half of the TGNC adolescents reported internalizing prob-
lems within the clinical range (> 90th percentile; T scores >
63). Non-binary and AMAB adolescents reported even more
internalizing problems (T scores 2 SD above M = 50): 70% of
1 Closer examination of the binary group revealed that 45% of the
AFAB adolescents identified as male and 55% as trans men/boys.
Among the AMAB adolescents, 52% identified as female and 48% as
trans women/girls.
2 “Other” non-binary gender identities, given as free-text answers
(24%), were “queer or non-binary” (n = 1), “demi boy” (n = 1), “I am
myself “ (n = 1), “transgender” (n = 2), “trans boy/non-binary” (n = 1),
“transgender non-binary guy” (n = 1), “rather nothing” (n = 1), and
“neither female nor male, ‘it’” (n = 1).
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98 Archives of Sexual Behavior (2024) 53:91–106
1 3
non-binary and AMAB adolescents scored within the clinical
range of internalizing problems, compared to 55% of binary
and 54% of AFAB adolescents. However, the groups did not
differ significantly (overlapping 95% CI).
The results of the multiple linear regression analysis are
shown in Table3. The regression analysis showed that a
female birth-assigned sex, poorer peer relations, lower lev-
els of family functioning, less body satisfaction, and hav-
ing a non-binary gender identity were associated with more
internalizing problems. The final model explained 40% of the
variance in internalizing problems, while the control varia-
bles in total explained 39% and gender identity explained 1%.
Transition‑Related Medical Treatment Wishes
In total, 91% of TGNC adolescents wished to be treated with
gender affirmation (hormones and/or surgeries). Conversely,
only 9% wished for no transition-related medical treatment
at all or only puberty-suppressing treatment with hormones
(GnRHa). The two gender identity groups differed signifi-
cantly in their transition-related medical treatment wishes
(χ2(1, 369) = 44.17, p <.001, OR = 10.62): compared to
95% of binary adolescents, only 62% of non-binary adoles-
cents wished for treatment with gender-affirming hormones
and/or surgeries. Conversely, 38% of the non-binary sample
compared to 5% of the binary sample wished for no treatment
or only puberty-suppressing treatment. The odds of wishing
for no transition-related medical treatment or only puberty-
suppressing treatment were 10.6 times higher in non-binary
adolescents than in binary adolescents.
Table4 provides an overview of the multiple logistic
regression analysis and the results of the final model. Birth-
assigned sex, age, and gender identity were significantly
associated with transition-related medical treatment wishes,
Table 1 Sociodemographic and clinical characteristics as a function of (birth-assigned) sex and gender (identity)
The Winkler Index ranges from 3 to 9 (9 = highest socioeconomic status), the poor peer relations sum score from 0 to 6 (6 = worst peer rela-
tions), the FAD from 1 to 4 (4 = lowest levels of family functioning), the suicidality index from 0 to 4 (4 = highest levels of suicidality), and the
HBDS from 1 to 5 (5 = most body satisfaction)
AFAB/AMAB assigned female/male at birth, FAD McMaster Family Assessment Device, HBDS Hamburg Body Drawing Scale, YSR Youth Self-
Report
AFAB
(n = 305)
AMAB
(n = 64)
Total
(n = 369)
Sex comparison Gender comparison Interaction (sex × gender)
M SD M SD M SD F df p ηp2F df p ηp2F df p ηp2
Age at assessment (in years)
Binary 15.44 1.49 15.48 1.64 15.45 1.51
Non-binary 15.22 1.95 15.49 1.82 15.31 1.89
Total 15.42 1.53 15.48 1.66 15.43 1.55 0.28 1 (365) .596 .00 0.12 1 (365) .726 .00 0.16 1 (365) .688 .00
Parental socioeconomic status (Winkler Index)
Binary 6.46 1.64 6.40 1.71 6.45 1.65
Non-binary 6.64 1.63 6.92 1.51 6.73 1.57
Total 6.48 1.64 6.50 1.67 6.48 1.64 0.12 1 (365) .732 .00 1.20 1 (365) .275 .00 0.29 1 (365) .593 .00
Poor peer relations (YSR)
Binary 1.45 1.39 1.94 1.53 1.53 1.42
Non-binary 1.72 1.70 2.33 1.50 1.92 1.64
Total 1.48 1.41 2.02 1.52 1.57 1.45 4.05 1 (365) .045 .01 1.44 1 (365) .231 .00 0.05 1 (365) .820 .00
General family functioning (FAD)
Binary 1.95 0.60 1.95 0.56 1.95 0.59
Non-binary 1.76 0.47 1.81 0.42 1.77 0.45
Total 1.94 0.59 1.92 0.53 1.93 0.58 0.04 1 (365) .846 .00 2.28 1 (365) .132 .01 0.05 1 (365) .828 .00
Suicidality index (YSR)
Binary 1.16 1.34 0.69 1.21 1.09 1.33
Non-binary 1.72 1.49 0.50 0.80 1.32 1.42
Total 1.21 1.36 0.66 1.14 1.11 1.34 11.22 1 (365) < .001 .03 0.53 1 (365) .467 .00 2.22 1 (365) .137 .01
Body satisfaction (HBDS)
Binary 2.34 0.84 2.50 0.86 2.36 0.85
Non-binary 2.61 0.91 2.57 0.62 2.60 0.82
Total 2.36 0.85 2.51 0.81 2.39 0.85 0.15 1 (365) .700 .00 1.18 1 (365) .277 .00 0.40 1 (365) .526 .00
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99Archives of Sexual Behavior (2024) 53:91–106
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Table 2 Internalizing problems
(YSR) in AFAB and AMAB
binary and non-binary
adolescents compared to the
German norm population
Age and birth-assigned sex equivalent German norms were derived from Döpfner etal. (1998). If confi-
dence intervals do not include the mean of the norm T distribution (M = 50), a significant deviation from
the reference group (adolescents from the general population) can be assumed. Clinical scores (T > 63)
indicate that 89% of the non-referred age- and sex-equivalent reference group had a lower internalizing
problem score. Raw scores for the internalizing scale range from 0 to 62, and T scores range from 25 to 100
AFAB/AMAB assigned female/male at birth, TGNC transgender and gender-nonconforming, YSR Youth
Self-Report
Raw scores (TGNC adolescents) T scores (TGNC adolescents with
reference to norms)
Clinical
range (T
scores > 63)
M SD 95% CI M SD 95% CI % n
AFAB
Binary 21.43 10.68 [20.18, 22.69] 65.24 10.68 [63.98, 66.50] 52.9 148
Non-binary 25.44 12.58 [20.25, 30.63] 69.16 13.17 [63.73, 74.59] 68.0 17
Total 21.76 10.88 [20.53, 22.99] 65.56 10.93 [64.33, 66.79] 54.1 165
AMAB
Binary 20.33 9.52 [17.68, 22.98] 68.31 10.60 [65.36, 71.26] 69.2 36
Non-binary 21.50 7.47 [16.76, 26.24] 69.75 7.82 [64.78, 74.72] 75.0 9
Total 20.55 9.13 [18.27, 22.83] 68.58 10.10 [66.06, 71.10] 70.3 45
Total
Binary 21.26 10.50 [20.13, 22.39] 65.72 10.71 [64.56, 66.88] 55.4 184
Non-binary 24.16 11.22 [20.42, 27.90] 69.35 11.59 [65.49, 73.22] 70.3 26
Total 21.55 10.60 [20.47, 22.64] 66.08 10.84 [64.97, 67.19] 56.9 210
Table 3 Multiple linear
regression analysis: Association
between gender identity and
internalizing problems (YSR)
Results of the final model: F(7, 361) = 35.74, adjusted R2 = .40, p < .001
FAD McMaster Family Assessment Device, HBDS Hamburg Body Drawing Scale, YSR Youth Self-Report
*p < .05, **p < .01, ***p < .001
b SE b ß p
Intercept 12.92*** 2.17 < .001
Birth-assigned sex (0 = assigned female at birth,
1 = assigned male at birth)
− 2.65* 1.16 − .10 .023
Age in years (centered) 0.36 0.32 .05 .252
Interaction [birth-assigned sex x age] 0.05 0.70 .00 .949
Poor peer relations (YSR) 2.75*** 0.32 .38 < .001
General family functioning (FAD) 5.55*** 0.80 .30 < .001
Body satisfaction (HBDS) − 2.66*** 0.53 − .21 < .001
Gender identity (0 = binary, 1 = non-binary) 3.94** 1.45 .11 .007
Table 4 Multiple logistic
regression analysis: Association
between gender identity and
medical treatment wishes
(0 = gender affirming hormones
and/or surgical treatments,
1 = no treatment wish or only
with puberty-suppressing
hormones)
Results of the final model: χ2(4) = 53.37, p < .001, R2 (Nagelkerke) = .30
HBDS Hamburg Body Drawing Scale
**p < .01, ***p < .001
B SE OR 95% CI for OR p
Intercept 2.02 2.14 7.57 .344
Birth-assigned sex (0 = assigned female at
birth, 1 = assigned male at birth)
1.42 0.44 4.13** [1.75, 9.78] .001
Age in years − 0.41 0.13 0.67** [0.52, 0.86] .002
Body satisfaction (HBDS) 0.33 0.26 1.39 [0.84, 2.29] .201
Gender identity (0 = binary, 1 = non-binary) 2.28 0.46 9.77*** [3.95, 24.15] < .001
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100 Archives of Sexual Behavior (2024) 53:91–106
1 3
meaning that the odds of wishing for no transition-related
medical treatment at all or only puberty-suppressing treat-
ment were higher among adolescents who were AMAB,
younger, and non-binary. After controlling for birth-assigned
sex, age, and body satisfaction, non-binary adolescents had
9.8 times higher odds of wishing for no transition-related
medical treatment or only puberty-suppressing treatment
than binary adolescents. The model explained 30% of the
variance in transition-related medical treatment wishes,
while all control variables together explained 18% and gen-
der identity explained 12%.
Exploratory Data Analyses
Additional exploratory data analyses were conducted to
assess the associations among gender identity with external-
izing problems and the total problem score (Supplementary
Material). Bivariate analyses showed that externalizing prob-
lems were less common than internalizing problems but were
still elevated in TGNC adolescents (T scores 0.5 SD above M
= 50) (TableS2). In total, 16% of the sample reported clini-
cally relevant externalizing problems. AFAB adolescents
reported, on average, significantly more externalizing prob-
lems than AMAB adolescents (non-overlapping 95% CI).
There were no significant differences between binary and
non-binary adolescents. The total problem score was also ele-
vated: TGNC adolescents scored more than 1 SD higher than
the reference group and 45% fell within the clinical range.
Non-binary adolescents tended to have higher total problem
scores and to score more often within the clinical range than
binary adolescents, but the differences were not significant.
In the multiple regression analysis for externalizing prob-
lems, significant predictors were birth-assigned sex, poor peer
relations, and general family functioning (TableS3). Gender
identity was not associated with externalizing problems. The
seven factors together explained 15% of the variance.
For the total problem score, birth-assigned sex, poor peer
relations, general family functioning, and body satisfaction
were significant predictors, whereas gender identity was not
(TableS4). The final model explained 38% of the variance
for the total problem score.
Discussion
The current study aimed to build on previous research by
examining the percentage of binary and non-binary gender
identities in clinically referred TGNC adolescents attending
a German gender identity service. In addition, the present
study intended to explore the associations between these two
gender identities and internalizing problems and transition-
related medical treatment wishes.
In total, 90% of the clinical sample of TGNC adolescents
identified as binary and 10% as non-binary. These numbers
are consistent with others reported from international gender
identity services (non-binary = 6–26%; e.g., Cheung etal.,
2020; Mirabella etal., 2022; O'Bryan etal., 2018; Thorne
etal., 2018; Twist & de Graaf, 2019). In contrast to other
services, however, the percentage of non-binary gender iden-
tities was significantly higher among AMAB adolescents
(19%) than among AFAB adolescents (8%). However, the
sex difference should be interpreted with caution because of
the small non-binary sample size (n = 37), especially among
AMAB adolescents (n = 12), and the extreme proportion of
referred AFAB individuals. Moreover, the sex ratio and the
percentage of non-binary identities among TGNC adoles-
cents may be different today than at the time of data collec-
tion (2013–2019), as TGNC individuals increasingly appear
to identify as non-binary (James etal., 2016). For instance,
in a subsequent (unpublished) study from the Hamburg GIS
assessing more recent data (2020–2021), 17% of TGNC ado-
lescents reported having a non-binary gender identity or were
still questioning their gender identity. However, most of these
adolescents, particularly AMAB adolescents, did not identify
as non-binary but were still questioning their gender identity
(Herrmann etal., 2023).
Although the effect was small, having a non-binary gender
identity was significantly associated with more internalizing
problems. Hence, our result is in line with several studies
documenting impaired mental health in non-binary youth
(Atteberry-Ash etal., 2021; Ciria-Barreiro etal., 2021;
Thorne etal., 2018; Veale etal., 2017; Wang etal., 2020). The
present study cannot answer for how long the internalizing
problems have existed and if they resulted from experienced
minority stress or if they may have existed before the onset
of the adolescents’ gender dysphoria. However, the minor-
ity stress model suggests that both binary and non-binary
TGNC individuals frequently experience stigmatization and
discrimination, which can result in mental health dispari-
ties (Hendricks & Testa, 2012; Meyer, 2003). Compared to
binary individuals, non-binary individuals may encounter
even more stigmatization and discrimination because they
may not conform to the societal expectation of presenting
in a binary way (i.e., as a woman or man) or may not pass as
a binary gender (Lefevor etal., 2019). Furthermore, experi-
ences such as being repeatedly misgendered may contribute
to the feeling of being invisible or not validated by others (de
Graaf etal., 2021). As a consequence, non-binary individu-
als may hide their gender identity because they fear negative
reactions or a lack of understanding (Lefevor etal., 2019).
Additionally, intrinsic factors also may be relevant; for
instance, having a gender identity that is not often represented
(e.g., lacking role models) and informed about (e.g., lacking
resources and information) can lead to a long-lasting search
for or struggling with one’s gender identity (de Graaf etal.,
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101Archives of Sexual Behavior (2024) 53:91–106
1 3
2021; Thorne etal., 2018). As a result, the process of gender
identity exploration may be more stressful and confusing for
young non-binary individuals (de Graaf etal., 2021) and may
also influence their presentation during counseling or when
they wish to undergo medical treatment. Non-binary indi-
viduals also may have fewer protective factors, such as self-
esteem or good peer relations (de Graaf etal., 2021; Thorne
etal., 2018). Additionally, in a few cases, a non-binary iden-
tification could theoretically also reflect fears of growing up
or intrapsychic conflicts (e.g., reluctance to identify as binary
trans or homosexual) (Notini etal., 2020; Pang etal., 2020).
In conclusion, non-binary youth may have even greater men-
tal health needs than binary TGNC youth, emphasizing the
importance of providing corresponding mental health care
or counseling for this vulnerable subgroup.
Our exploratory analyses revealed that gender identity was
not associated with externalizing problems and the YSR total
problem score, emphasizing that particularly internalizing
problems, such as depression, anxiety, and suicidal ideation,
seem to be elevated in non-binary adolescents specifically
(Atteberry-Ash etal., 2021; Thorne etal., 2018; Veale etal.,
2017; Wang etal., 2020). Of note, both binary and non-binary
adolescents reported significantly more problems on all YSR
scales (internalizing, externalizing, and total problem scores)
compared to adolescents from the general population, but
internalizing problems were especially elevated. Concern-
ing suicidality, nearly half of TGNC adolescents reported
self-harming behavior or suicide attempts, and one-third
had suicidal ideation/thoughts. Unfortunately, we could not
differentiate between self-harming behavior and suicide
attempts because the YSR assesses both behaviors with one
item, which might also explain the contra intuitive higher
prevalence of self-harm and suicide attempts (probably, in
most cases, rather self-harm than suicide attempts) than of
suicidal ideation/thoughts. When comparing our YSR data to
those of other international gender identity clinics, the pre-
sent sample scored similarly on all YSR scales and reported
similar levels of peer-related problems and suicidality (de
Graaf etal., 2018, 2022).
In accordance with most previous studies (Clark etal.,
2018; Peng etal., 2019; Todd etal., 2019), identifying as
non-binary was significantly associated with wishing for no
gender-affirming treatment. Non-binary youth may feel more
comfortable with living in their gender without needing gen-
der-affirming treatment, for example, because they are more
comfortable with an androgynous appearance or because they
do not want to acquire female or male sex characteristics
(Clark etal., 2018; Notini etal., 2020). On the other hand,
they may be less informed or undecided about possible treat-
ment options (Clark etal., 2018, 2020; Cohen etal., 2022).
These untraditional treatment pathways may raise new ethical
dilemmas. For instance, long-term puberty suppression, as a
way of achieving a gender-neutral/androgynous appearance,
is associated with increased health risks (e.g., reduced bone
density, impaired fertility and sexual functioning) and may
not be completely reversible (Notini etal., 2020). A strong
evidence base for such untraditional treatment decisions is
absent, which makes decisions in these cases even more com-
plex, especially for young individuals (Notini etal., 2020;
Pang etal., 2020). Given that young individuals are in the
middle of their development and gender might be even more
fluid in non-binary than in binary adolescents (Mirabella
etal., 2022), the assessment and decision-making process
might be more time-consuming and ethically complex.
Assisting the achievement of a more non-binary appearance
also may additionally lead to increased stigmatization by oth-
ers, highlighting the need to discuss such risks with adoles-
cents (Notini etal., 2020).
Limitations
The present findings should be interpreted in light of some
limitations. First, “non-binary” was not an exclusive/specific
option on the list of gender self-identifications that the par-
ticipants could choose, since the term was not so common
when the study was developed, and the fear was to overwhelm
youth with such terms. Instead, non-binary participants
could choose the option “in-between” (which is nowadays
an outdated term) or write in their gender identity as a free-
text answer. However, only three participants specifically
described themselves clearly as “non-binary.” This is not
only a limitation of the present study but also underscores
that “non-binary” is merely an emerging umbrella term that
tries to comprise different gender identities outside the binary
(Thorne etal., 2019). As a result, the constantly evolving lan-
guage for gender minority identities can make research in this
field more challenging and requires a continuous adaption of
measures. Working with community experts and allowing
participants to write in their preferred terms (e.g., for gender
identities or pronouns) is therefore recommended.
Second, all participants attended a specialized gender
identity service. This way, we could examine an underre-
searched topic in a clinical sample. It is, however, possible
that many non-binary adolescents do not seek specialized
care because they do not wish for any kind of transition-
related medical treatment. Therefore, our clinical sample
is probably not representative of the possibly diverse non-
binary population. Since the study was conducted in the same
clinic, in which the adolescents also were receiving support/
treatment, they may have hesitated to disclose their (non-
binary) gender identity or to participate in the study due to
fear of barriers to access of care (Carlile etal., 2021). In
Germany, transition-related medical interventions are cur-
rently neither recommended (or only in very few cases), nor
is it foreseen that insurance covers their costs for non-binary
adolescents (Arbeitsgemeinschaft der Wissenschaftlichen
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102 Archives of Sexual Behavior (2024) 53:91–106
1 3
Medizinischen Fachgesellschaften e. V. (AWMF), 2013;
Medizinischer Dienst des Spitzenverbandes Bund der Krank-
enkassen (MDS), 2020). Additionally, most TGNC adoles-
cents were AFAB, thus, further limiting the representative-
ness and diversity of the sample and our findings. Since the
sex ratio was also very unbalanced at clinical entry (Figure1),
this reflects less of a problem of drop-out or adherence but
rather underlines that internationally predominantly AFAB
adolescents present to gender identity clinics. Although the
reasons for the imbalanced sex ratio in TGNC adolescents are
unknown, various experts have suggested that, for example,
a different age of puberty onset (with an on average earlier
onset in AFAB youth) might lead to differential develop-
mental pathways (Aitken etal., 2015; de Graaf etal., 2018).
Third, although compared to other clinical studies, the
total sample was relatively large (n = 369), the non-binary
subsample was relatively small (n = 37). This difference
in subsample sizes is not surprising since non-binary ado-
lescents present a minority group within clinically referred
TGNC adolescents. As a result, the sample sizes (binary vs.
non-binary) for our hypothesis-testing analyses (i.e., multi-
ple regression analyses) were unbalanced, but still sufficient
(approximately 10%). However, the descriptive and explora-
tory testing results (e.g., externalizing symptoms) should be
interpreted cautiously (e.g., estimates of 95% CIs are less
reliable in small samples).
Fourth, we applied a cross-sectional study design. Hence,
it is not possible to draw any long-term conclusions from
the results. Since the participating adolescents completed
questionnaires upon clinical entry, before receiving any infor-
mation, support, or treatment, the transition-related medical
treatment wishes of some TGNC adolescents were not “final”
or informed. Therefore, the transition-related medical treat-
ment wishes of some TGNC adolescents may have or prob-
ably will have changed in the course of their treatment at the
Hamburg GIS. It is also possible that the gender identities of
some TGNC adolescents will change during the treatment,
highlighting the need for longitudinal studies.
Future Directions andClinical Implications
Future studies examining the mental health outcomes of
clinically referred non-binary adolescents may benefit from
investigating more diverse TGNC adolescent populations. A
better understanding of intersecting identities (e.g., sexual,
religious, and racial) in non-binary adolescents is needed.
There also is a need for more longitudinal studies, which can
overcome some of the mentioned limitations and provide
additional insights into the long-term mental health outcomes
of non-binary TGNC adolescents. Moreover, future research
would benefit from investigating why non-binary adolescents
report more internalizing problems than binary adolescents
and how they can be best supported.
Our study provides additional evidence that clinically
referred non-binary TGNC adolescents represent a vulner-
able group with unique mental health and treatment needs.
Both specialized gender identity services and individual
clinicians are encouraged to provide an inclusive setting
for non-binary youth to ensure that they seek support when
needed. An open, non-binary-inclusive setting and mindset
will probably make it easier for non-binary adolescents to
explore and disclose their gender identity.
The present results demonstrated that there was still a
considerable proportion of non-binary adolescents who
wanted to undergo gender-affirming medical treatment. In
light of the evidence that also non-binary youth benefit
from receiving transition-related medical treatment (Green
etal., 2022) and that the inability to access transition-
related medical treatments when desired contributes to
decreased well-being (Burgwal etal., 2019), giving access
to care to this population is essential. Therefore, clinicians
should provide information on the full range of transition-
related medical treatment available, without making any
assumptions, to ensure that non-binary youth can make
informed treatment decisions.
Conclusions
In the present study, a small but not negligible proportion
of TGNC adolescents identified as non-binary. Further-
more, having a non-binary gender identity was significantly
associated with more internalizing problems and wishing
for no gender-affirming treatment. Hence, the present find-
ings underscore the growing diversity of treatment-seeking
TGNC adolescents. As a result, individualized and patient-
centered treatment plans become increasingly important
to provide the best possible care for a heterogeneous and
vulnerable group of young individuals.
Supplementary Information The online version contains supplemen-
tary material available at https:// doi. org/ 10. 1007/ s10508- 023- 02674-8.
Acknowledgements We would like to thank the young people and par-
ents for participating in and contributing to this study.
Funding Open Access funding enabled and organized by Projekt
DEAL. No funding was received for conducting this study.
Data Availability The data are not publicly available.
Declarations
Conflict of interest The authors declare that they have no conflicts of
interest.
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103Archives of Sexual Behavior (2024) 53:91–106
1 3
Ethics Approval This study was performed in line with the principles
of the Declaration of Helsinki. Approval was granted by the local eth-
ics committee.
Informed Consent Written informed consent was obtained from all
participants included in the study.
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
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