Access to this full-text is provided by Springer Nature.
Content available from Archives of Sexual Behavior
This content is subject to copyright. Terms and conditions apply.
Vol.:(0123456789)
Archives of Sexual Behavior (2025) 54:1341–1359
https://doi.org/10.1007/s10508-025-03118-1
ORIGINAL PAPER
Onset Age andInternalizing Problems inAdolescents withGender
Dysphoria: Is There anAssociation?
SaskiaFahrenkrug1 · IngaBecker‑Hebly1 · LenaHerrmann1 · ClausBarkmann1· SarahHohmann1 ·
CarolaBindt1
Received: 18 August 2023 / Revised: 5 February 2025 / Accepted: 6 February 2025 / Published online: 24 March 2025
© The Author(s) 2025
Abstract
An increasing heterogeneity of clinical presentations and varying levels of psychological problems characterize gender
dysphoria (GD) in adolescents. These clinical patterns suggest distinct developmental trajectories. Here, we examine the
onset age of GD, i.e., the percentage of early onset (EO) vs. late onset (LO), and its association with internalizing problems in
adolescents with GD. The sample consisted of 462 adolescents (11–18 years, Mage = 15.46 years; 392 birth-assigned females,
70 birth-assigned males) who attended the Hamburg Gender Identity Service for Children and Adolescents (Hamburg GIS) in
Germany between 2013 and 2021. Onset age was self-reported during clinical interviews and then later scored by clinicians
using a DSM-5 rating sheet. When adolescents retrospectively met criteria A and B for childhood-onset GD, they were rated as
having an EO. Those who fulfilled neither criteria A nor B in childhood were considered to have a LO. Internalizing problems
were assessed using the Youth Self-Report. Overall, 51% (n = 237) of adolescents with GD presented with an EO and 49%
(n = 225) reported diagnostic criteria related to a LO. More than half of the sample (58%, n = 266) fell within the clinical
range for internalizing problems. Furthermore, LO (as opposed to EO) was significantly associated with reporting more
internalizing problems. Our findings emphasize that adolescents with LO represent a particularly vulnerable group whose
needs should be considered more closely diagnostically and treatment-wise. A protocol-based approach to the indication of
physical interventions may not adequately address current clinical presentations and should be complemented by a differential
approach based on individual adolescent development.
Keywords Gender dysphoria· Adolescent· Onset age· Internalizing problems· Transgender· DSM-5
Introduction
The current controversial debate among clinicians and
researchers about gender dysphoria (GD) in adolescence is
based on observations that raise many questions: Worldwide,
specialized centers are showing increasing rates of youth,
with a presentation of predominantly birth-assigned female
adolescents who identify as boys/transmasculine and often
wish for gender-affirming medical interventions (Aitken
etal., 2015; Chen etal., 2016; de Graaf etal., 2018, 2021;
Herrmann etal., 2022; Kaltiala-Heino etal., 2015; Levitan
etal., 2019), or who identify as nonbinary, beyond the estab-
lished gender dualism of male or female (Chew etal., 2020;
Herrmann etal., 2023a, b). Similarly, there have been reports
of clinical subgroups of adolescents who, after gender-con-
forming development in childhood, first present with GD in
adolescence (Hutchinson etal., 2020; Zucker, 2019), rais-
ing questions about whether these clusters may be different
from earlier cases (often with prepubertal onset of GD), for
example, regarding their levels of psychological problems
(Abbruzzese etal., 2023).
In light of rising treatment numbers worldwide (Thomp-
son etal., 2022; Zhang etal., 2020), attempts are being made
to identify distinct developmental pathways in an increas-
ingly heterogeneous patients: In addition to the so-called
“rapid-onset GD (ROGD)” phenomenon (Littman, 2018),
which describes a presumably “sudden” onset of GD with-
out any previously recognizable clues, other differentiations
based on the duration of GD and age at first presentation
* Saskia Fahrenkrug
s.fahrenkrug@uke.de
1 Department ofChild andAdolescent Psychiatry,
Psychotherapy, andPsychosomatics, University
Medical Center Hamburg-Eppendorf, Martinistraße 52,
W35,20251Hamburg, Germany
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1342 Archives of Sexual Behavior (2025) 54:1341–1359
(Arnoldussen etal., 2023; de Rooy etal., 2024; Sorbara etal.,
2020) are also gaining attention. Similarly, it can be useful
to differentiate based on onset age, which describes a model
(Person & Ovesey, 1974) for the early or late onset of GD
criteria during childhood (before puberty) and during or after
adolescence. As recently critically discussed by Abbruzz-
ese etal. (2023), onset age has gained additional relevance
because previous treatment and follow-up data, which served
as evidence to support recommendations for the early use of
gender-affirming medical interventions, may not be entirely
applicable to the current clientele seen in specialized gender
identity services who more and more seem to present during
or after the onset of puberty.
The effort to differentiate more recent developmental
trajectories illustrates the ethical dilemma for practitioners,
who must balance their concern about possible false
indications and the thus unclear detransition rates (Cohn,
2023) with the simultaneous attempts to minimize the distress
of those affected by persistent GD through gender-affirming
medical interventions, as recommended, for example,
by the current Standards of Care (SOC-8) of the World
Professional Association for Transgender Health (Coleman
etal., 2022). A close look at newer developmental pathways
in the heterogeneous spectrum of self-definitions can help to
enable differentiated and individualized treatment planning
and thereby guarantee safe indications for the appropriate
treatment.
Most adolescents who attend specialized gender identity
clinics express the desire for gender-affirming medical
interventions, in the sense of hormone substitution. A
distinction must be made between explicit prerequisites, such
as a clinical diagnosis of GD (i.e., distress at a perceived
discrepancy between one’s gender identity and physical
sex characteristics or birth-assigned sex) according to
the fifth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5) (American Psychiatric
Association [APA], 2013) or the tenth edition of the
International Classification of Diseases (ICD-10) (World
Health Organization, 2019), and implicit prerequisites for
an indication (e.g., maturity of the adolescent, discussion
of other nonmedical options), as formulated by the SOC-8
(Coleman etal., 2022) or established treatment protocols (de
Vries etal., 2012, 2014). An approach based on the “Dutch
Protocol” (Cohen-Kettenis & Klink, 2015; Delemarre-van
de Waal & Cohen-Kettenis, 2006) has been established in
Europe in the last 20 years. This protocol is used to formulate
strict entry criteria, such as a retrospective “opposite-sex”
identification going back to childhood (i.e., prepuberty),
also known as early onset (EO) course (de Vries etal., 2011,
2012). The result was a homogeneous treatment group
(with relatively few psychological problems, an EO, and a
strong cross-gender identification), which was considered
eligible for treatment. This group was the first to receive
gender-affirming medical interventions, which were then
subsequently also assessed in several follow-up studies (de
Vries etal., 2011, 2014). Contrary, in the absence of an
EO and co-occurring psychological problems, adolescents
were not considered eligible for receiving gender-affirming
medical interventions (de Vries etal., 2012).
While mid- to long-term follow-up studies of the Dutch
cohort showed a clear improvement in the psychological
well-being of the treatment group (de Vries etal., 2014), the
same improvement could not be demonstrated as clearly in a
more heterogeneous sample from our short-term study from
Germany (Becker-Hebly etal., 2021) that also included late
onset (LO) courses (20% of the sample). Similarly, a short-
term study of a sample from the UK found no improvement
in psychological functioning following puberty-suppressing
treatment (Biggs, 2020; Carmichael etal., 2021). In this
respect, it must be asked whether, given the growing
diversity of developmental trajectories, a protocol-based
treatment approach can still meet the requirements of more
heterogeneous samples.
Onset Age
EO and LO (Blanchard, 1985; Lawrence, 2003, 2010) are
descriptions of the time of the initial manifestation, and the
onset age of the first presentation of GD. EO manifests in
childhood, before puberty, and is often accompanied (based
on clinical experience) by an early gender role change.
LO, on the other hand, manifests itself later, after the
onset of puberty, and can be more challenging to diagnose
from a clinical perspective, as much of the psychosexual
development has occurred without recognizable signs of
clinical distress. In addition to meeting diagnostic criteria,
it is important to consider how the GD developed following
a previous acceptance of one's body and how it may interact
with coexisting mental health conditions.
The onset age of GD has been considered a marker of
diagnostic certainty in the context of an indication for gender-
affirming medical interventions in adolescents, although
there are no follow-up studies assessing youth with LO
developmental trajectories and their mental health outcomes
specifically.
Researchers have recently attempted to quantitatively
capture the growing heterogeneity of their clientele and
the associated developmental trajectories by distinguishing
between the temporal duration of GD and the age group at
the initial presentation (Arnoldussen etal., 2023; de Rooy
etal., 2024; Sorbara etal., 2020). Two studies from the
Netherlands (Arnoldussen etal., 2023; de Rooy etal., 2024)
showed that among older adolescents (14 years or older
at initial presentation), there was an overrepresentation of
individuals assigned female at birth (AFAB), greater body-
related dissatisfaction, and more psychological problems
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1343Archives of Sexual Behavior (2025) 54:1341–1359
(measured with the Child Behavior Checklist (CBCL) and
Youth Self-Report (YSR), Achenbach, 1991), whereas,
within the younger group (younger than 14 years at initial
presentation), youth were more likely to have early signs of
gender-nonconforming behavior during childhood and more
likely to ultimately receive an indication for gender-affirming
medical interventions.
It should be noted that Arnoldussen etal. (2023) and de
Rooy etal. (2024) also included children before puberty
(under the age of 11; as young as 8.9 years) in their studies.
Hence, the differences between the younger-presenting and
older-presenting groups may arise because children may
seek gender identity services primarily because of gender
non-conformity, whereas adolescents may be more likely to
seek such services because of puberty-related body changes
and associated distress. Sorbara etal. (2020) compared two
younger and older than 15-year-old age groups and found that
the older group of adolescents at initial presentation reported
significantly more internalizing psychological problems such
as depressive disorders, self-harm, and suicidality and that
adolescents presenting at a younger age were significantly
more likely to notice their gender incongruence earlier.
Sorbara etal. (2020) found no sex differences but AFAB
individuals accounted for at least 75% of both groups.
Without explicitly capturing onset age as a variable in these
studies, the results suggest that older-presenting adolescents
are more likely to be AFAB and have psychological problems
than younger-presenting adolescents.
While the onset age of GD experiences is a dimension
along the timeline, the conceptualization of ROGD
(Littman, 2018) has been controversial due to its etiological
assumptions. Littman (2018) defined ROGD as a subtype of
GD and suggested that GD-related distress resulted less from
a persistent and profound cross-gender identification and
more from an expression of different psychological problems.
ROGD has been defined as the “sudden” onset of GD, often
surprisingly to others, without any prior signs. It has been
reported predominantly in AFAB adolescents; accompanied
by a high rate of psychological problems, especially
internalizing problems such as anxiety and depression, and
seems to be associated with a strong and urgent desire for
gender-affirming medical interventions. Littmann's study has
been criticized because the data were collected exclusively
on the basis of external assessments by parents who were
critical of their children's transgender identity.
Dolotina etal. (2022) and Turban etal. (2023), who
attempted to test Littman’s assumptions, came to different
conclusions. They asked adults retrospectively about the age
of realization of their transgender identity and distinguished
between early realization (under 10 years of age) and late
realization (10 years and older). In contrast to Littman's
study, Dolotina etal. found that the two groups did not differ
in most mental health measures, with the group with late
realization even reporting less past-year suicidal ideation
than the group with early realization of their transgender
identity. However, the study’s methods were criticized by
Sapir etal. (2024), highlighting the use of incorrect age
cohorts and an improper definition of the age of realization.
Similar to the findings of Dolotina etal. (2022), a small
study from Portugal reported no significant differences in
the frequency of co-occurring psychiatric diagnoses between
adolescents post- and prepubertal cross-gender behavior
(Pereira-Antunes etal., 2023).
Current Clinical Impressions andDevelopmental
Trajectories
In addition to the “classic” EO developmental trajectories,
possibly with a social role change in childhood, less body-
related distress until expected puberty, and a relatively higher
proportion of individuals assigned male at birth (AMAB),
in clinical settings, there seems to be a shifted sex ratio in
adolescence in many centers around the world, including our
outpatient clinic (84% AFAB vs. 16% AMAB presentations;
Hartig etal., 2022; Herrmann etal., 2022; Levitan etal.,
2019), with some additional clinical observations from our
experience:1
1) A considerable number of older adolescents report
severe and persistent distress about their sex
characteristics with previously gender-conforming
psychosexual development and puberty without
body-related distress. This group often presents with
etiologically unclear psychological problems, such as
social fears, depressive withdrawal, and self-injurious
behaviors. Inpatient psychiatric treatments and periods
of crisis are not uncommon in these cases. While the
psychological distress in these cases is notable and
should always be taken seriously, multiple factors
beyond GD likely contribute to these challenges.
2) In addition, we observe that in a subgroup of AFAB
adolescents, one specific body feature (most commonly
the breasts) becomes the primary focus for desired
change. The self-definition as trans-male is often
intellectually derived from a deep feeling of not being
able to be female.
3) A third group we encounter, consists of young
adolescents in early puberty who, alongside a cross-
gender or nonbinary identification, experience intense
anxiety about the demands and tasks of the adolescent
developmental phase. Their GD often emerges in
1 It is important to note that these observations are based on the clini-
cal experience of our gender identity service and that, at present, no
scientific evidence exists to substantiate them.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1344 Archives of Sexual Behavior (2025) 54:1341–1359
response to a feeling that they are “not yet able” to meet
these demands. In this group, adolescents often have a
limited social life, show only little interest in engaging
with peers, and demonstrate noticeable inhibition in other
areas of their identity.
Internalizing Psychological Problems
Studies from different countries suggest that more than half
of the children and adolescents with a GD diagnosis also have
at least one other psychiatric diagnosis (Becker etal., 2014;
Chen etal., 2016; de Vries etal., 2011; Holt etal., 2016;
Kaltiala-Heino etal., 2015; Nahata etal., 2017; Spack etal.,
2012; Wallien etal., 2007). For example, Kaltiala-Heino etal.
(2015) reported at least one preexisting or current mental
health disorder in 75% of the youth in their study. In German
studies, mostly internalizing problems, such as affective
and anxiety disorders, self-injury, and suicidality, are also
significantly overrepresented compared to norm populations
(Becker etal., 2014; Hartig etal., 2022; Levitan etal., 2019;
Sievert etal., 2021), both in childhood and adolescence.
Questionnaire assessments, mostly conducted with
the CBCL or the YSR (Achenbach, 1991), consistently
show levels of psychological problems in the clinical
range, regardless of the birth-assigned sex (Bechard etal.,
2017; de Graaf etal., 2018; de Vries etal., 2016; Levitan
etal., 2019; Zucker etal., 2012). For example, de Graaf
etal. (2018, 2022) found consistently elevated rates of
psychological problems and suicidality (reported with the
CBCL and YSR) among transgender adolescents from the
Netherlands, Belgium, Canada, Switzerland, and the UK.
Across different countries, there was a clear predominance
of internalizing over externalizing problems (de Graaf
etal., 2018, 2022; de Vries etal., 2016; Levitan etal., 2019;
Röder etal., 2018; Sievert etal., 2021), from which it can be
hypothesized that adolescents with GD have higher levels
of anxiety, depressive, and somatic complaints as well as
suicidality, with fewer aggressive-impulsive problems from
the externalizing spectrum in comparison.
Furthermore, there is evidence of the importance of peer rela-
tions and family support as key protective factors for psychologi-
cal well-being. Negative experiences with peers emerged as the
most important predictor for psychological problems (Aitken
etal., 2016; de Graaf etal., 2018; de Vries etal., 2016; Levitan
etal., 2019; Shiffman etal., 2016; Sievert etal., 2021; Steensma
etal., 2014), assuming that poor peer relations (PPR) may also be
an expression of increased psychosocial problems in general and,
as a consequence, increased mental health problems. Although
cause and effect are not yet sufficiently understood, adolescents
with GD have been identified as being particularly vulnerable to
experiences of discrimination and rejection by peers (Toomey
etal., 2010) and within the family (Grossman & D’Augelli, 2007).
In addition to age of onset, various attempts have been
made to classify GD subgroups based on sexual orientation
(Blanchard etal., 1987; Lawrence, 2003, 2010; Nieder etal.,
2011). This approach was predicated on the supposition that
the original "true transsexualism" (Benjamin, 1966) was
concomitant with an “opposite-sex”/heterosexual orienta-
tion (having undergone gender-confirming medical interven-
tions). Nieder etal. (2011) found that in AFAB adults with
EO GD, more than 90% reported a gynecophilic orientation,
compared to only 50% in LO GD. In contrast, AMAB adults
showed a more ambiguous picture with a similar proportion
of gynecophilic and androphilic orientation in EO and a pre-
dominantly gynecophilic orientation in LO.
From a developmental psychology perspective, clarity
about one's sexual attraction is an important step in
adolescent maturation. This process requires young people to
be able to develop relative freedom, both interpersonally and
intrapersonally (Erikson, 1968). It is about coming to terms
with oneself, one's own body, and one's sexual desires toward
others. In this sense, clarity about sexual orientation can also
be seen as a sign of the consolidation of adolescent identity.
Summary andDerivation oftheResearch Questions
Previous research suggests that the differentiation of
subgroups or clinical clusters of adolescents with GD may
improve our understanding of heterogeneous developmental
pathways and enable more individualized care and
treatment steps. This seems particularly necessary given the
increasingly variable clinical manifestations and resulting
different needs that find little place in current treatment
protocols. Therefore, the present study aims to systematically
assess a large sample of adolescents with GD concerning
their clinical characteristics of onset age and internalizing
problems in the German-speaking area. The studies will
investigate the relationship between self-reported (and then
later clinically rated) onset age and internalizing problems in
adolescents, while controlling for other possible influencing
factors, such as birth-assigned sex, age at assessment,
intensity of GD, body satisfaction, PPR, family functioning
level, and sexual orientation. Based on previous research and
clinical impressions, we hypothesize that a LO (as opposed
to an EO) would be related to more internalizing problems.
The following three research questions will be answered
in this article:
1. What is the percentage of different onset age (EO
vs. LO) among adolescents with GD presenting to a
specialized gender identity service?
2. What is the percentage of clinically relevant internalizing
problems in adolescents with GD (compared to the norm
population)?
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1345Archives of Sexual Behavior (2025) 54:1341–1359
3. What is the relationship between onset age and internal-
izing problems in adolescents with GD, while control-
ling for other possible influencing factors, such as birth-
assigned sex, age at assessment, intensity of GD, body
satisfaction, poor peer relations, family functioning level,
and sexual orientation?
In addition, exploratory analyses examined the association
between age of onset and externalizing problems, total
problems, and clinician-reported global functioning, and
investigated different criteria for a LO.
Method
Participants
The current study examined adolescents who presented to the
Hamburg Gender Identity Service for Children and Adoles-
cents (Hamburg GIS) between September 2013 and Decem-
ber 2021, participated in the study, and met diagnostic criteria
for GD according to the DSM-5 (APA, 2013). GD diagnoses
were rated by clinical experts using standardized diagnostic
checklists after a diagnostic period of several months. The
referral population comprised a total of 1122 children (aged
5 to 10 years) and adolescents (aged 11 years and above)
during the survey period. A total of 631 datasets were col-
lected from these families. There were no significant age
(t(557) = −1.12, p = 0.265, d = −0.13) or sex differences (χ2
(1, N = 559) = 1.77, p = 0.183, OR = 0.69) between included
and excluded adolescents. For various reasons, 169 cases had
to be excluded (Fig.1). Thus, the present study included the
complete data of 462 treatment naïve adolescents aged 11–18
years with a GD diagnosis and their families. The median
year of assessment was 2018.
Procedure
Since 2013, all families presenting to the Hamburg GIS
have been invited to participate in our study. Participation
is voluntary, and data collection takes place during the first
appointment, before the start of a diagnostic phase, and any
gender-affirming medical intervention. The study follows
a cross-sectional design with the use of internationally
established, psychometrically tested (self-report)
questionnaires alongside clinicians’ ratings.
Measures
Sociodemographics andOnset Age
Sociodemographic characteristics were: birth-assigned sex,
age at first presentation, nationality, parents’ marital status,
living situation, and socioeconomic status (SES) assessed
with the Winkler Index (Winkler & Stolzenberg, 1999; for
Fig. 1 Participants and sex ratios at the Hamburg GIS for children and adolescents
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1346 Archives of Sexual Behavior (2025) 54:1341–1359
a more detailed description, see Herrmann etal., 2023a, b;
Levitan etal., 2019).
In addition, cross-gender identification (experiences
of belonging to the gender that is “opposite” to the birth-
assigned sex) was recorded for all participants using a sum
score, as it has been done in previous studies (e.g., de Vries
etal., 2016): in the YSR, Items 5 and 110 refer to cross-
gender identification (“I act like the opposite sex” and “I wish
I were of the opposite sex”). The sum score of the two items
can be used as a measure of the intensity of cross-gender
identification. The score ranges from 0 to 4, with larger
values expressing a higher intensity of gender incongruence
(given a binary understanding of gender identity).
To obtain information on onset age, specialized clinicians
assessed the criteria for GD in childhood and adolescence
according to the DSM-5 with the help of a study-specific
checklist during the diagnostic sessions with the adolescents,
in which they described their own gender identity and GD
development. Later, onset age was operationalized by
dichotomous assignment to EO if the DSM-5 diagnosis of
GD was already applicable in childhood/before puberty
(defined for this purpose as before the age of 12 years)
or to LO in participants who retrospectively did not meet
the criteria for GD in childhood but did in adolescence
after the onset of puberty (defined for this purpose as age
of 12 years and older). Thus, two groups of participants
could be classified for the study: adolescents with an EO
developmental trajectory (who met DSM-5 criteria of GD
in both childhood and adolescence), and adolescents with a
LO (who met DSM-5 criteria of GD only in adolescence). In
additional exploratory analyses, we later subdivided the LO
group by GD duration (i.e., for how long the individuals had
fulfilled the various GD criteria in adolescence) and labeled
all participants whose GD had been present for less than
one year as “recent onset.” For the classification of recent
onset cases, we only used the first four A criteria of the GD
diagnosis to focus on the incongruence between gender
identity and body characteristics (and not the gender role).
Internalizing Problems
Internalizing problems were assessed using the 1991 German
version of the YSR (Achenbach, 1991; Döpfner etal., 1998)
for adolescents aged 11–18 years. The YSR consists of 120
items rated on a 3-point scale ranging from 0 = “not true” to
2 = “very true or often true.” The total sum of all problems is
reflected in the total problem score, which can be divided into
two main scales (internalizing and externalizing problems).
In addition, values in the clinical range (> 90th percentile;
T scores > 63) can be given for these three indices. Norm
values of adolescents (aged 11–18 years) from the German
general population are available for the different indices
and birth-assigned sex (Döpfner etal., 1998). These norm
or T values can be used to determine whether the values
of our sample are within the normal range. Cronbach’s α
for the internalizing scale was 0.91 in the present sample.
For exploratory purposes, the YSR score for externalizing
problems and the total problem score were also calculated to
examine psychological functioning/problems more broadly.
In this study, Cronbach’s α for the externalizing and total
problem scales was 0.83 and 0.93, respectively.
The Children’s Global Assessment Scale (CGAS) (Shaffer
etal., 1983) was used within the exploratory analyses to
assess adolescent global functioning using clinicians’
ratings. The CGAS is one of the most widely used assessment
scales for measuring everyday functioning in children and
adolescents (Schorre etal., 2004). Clinicians are asked to
score the patient's most impaired level of general functioning
over the past four weeks on a health-illness continuum. The
instrument is divided into 10-point intervals ranging from 10
(“needs constant supervision”) to 100 (“superior functioning
in all areas”), with higher scores (above 80) indicating good
global functioning.
Control Variables
Three items from the YSR were used to assess poor peer
relations (PPR): 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 PPR was developed by Zucker etal.
(1997) and has been used in previous studies to measure PPR
in youth with 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 0.66.
For general family functioning (GFF), the McMasters’
Family Assessment Device (FAD) (Epstein etal., 1983) was
used. Only the GFF subscale was evaluated. The GFF scale
comprises 12 items, such as family acceptance (“Individuals
are accepted for what they are”), rated on a 4-point scale (from
1 = “strongly agree” to 4 = “strongly disagree”). The sum of
the 12 items was divided by 12 to create a score ranging from
1 to 4, with higher scores indicating lower levels of family
functioning. The cutoff for categorical analyses (problematic
or unhealthy family functioning) is 2.17 (Byles etal., 1988).
Cronbach’s α was 0.88 in the present sample.
The pictorial measure Hamburg Body Drawing Scale (HBDS)
was used to assess body satisfaction (Appelt & Strauß, 1988;
Becker etal., 2016). Participants were asked to rate their satis-
faction with various body features and overall appearance on a
5-point scale (from 1 = “ver y dissatisfied” to 5 = “very satisfied”).
The HBDS has been revised and validated for transgender popu-
lations (Becker etal., 2016). Internal consistency for the HBDS
subscales (Cronbach’s α = 0.63–0.91) is satisfactory (Becker
etal., 2016). In the present study, only one item on satisfaction
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1347Archives of Sexual Behavior (2025) 54:1341–1359
with the overall appearance (“satisfaction with the overall appear-
ance”) was used.
Sexual orientation was assessed with a self-developed item
asking about physical (sexual) attraction in partner choice
(“To whom are you more physically [sexually] attracted?”)
and providing six response categories: “to no one,” “to girls,”
“more to girls, sometimes to boys,” “to both girls and boys,”
“to boys,” and “other” (free text response). From these, differ-
ent categories of sexual orientation were formed in relation to
birth-assigned sex: same-sex, opposite-sex, bisexual, asexual
or unsure, and pansexual. Later, two categories were formed
for the regression analysis: “same-sex” vs. “other” (based on
birth-assigned sex).
Statistical Analysis
Confidence intervals (95% CIs) were calculated for the
percentage of EO and LO. For continuous variables,
two-way analyses of variance were calculated to explore
differences in the sociodemographic and psychosocial
characteristics between birth-assigned sex (AFAB,
AMAB) and onset age groups (EO, LO). Exploratory chi-
square tests were conducted for categorical variables, with
Fisher–Freeman–Halton exact tests used when subsample
sizes were too small. Standardized effect sizes (partial eta
squared [ηp2], odds ratios [ORs], and Cramér’s V) were
calculated to quantify the magnitude of the effect.
Internalizing problems were assessed using raw scores, T
scores, and clinical ranges (> 90th percentile; T scores > 63).
In addition, confidence intervals for T scores were calculated
to compare the present sample with the age and sex equivalent
German norms (Döpfner etal., 1998). Whenever the 95% CIs
were not within the normal range of the T-distribution (M = 50,
SD = 10), a significant difference from the reference group can
be assumed. When the 95% CIs overlapped, the results were
not significantly different from each other (Cumming & Finch,
2005). Against the background of the literature, the study focused
on internalizing problems. However, we additionally evaluated
the externalizing scale and total problem score as presented for
exploratory purposes.
A multiple linear regression analysis was performed to
examine our hypothesis, i.e., the predictive value of onset age
for internalizing problems. For this purpose, the raw scores of
the YSR internalizing scale were used, and we controlled for
birth-assigned sex, age, PPR, GFF, sexual orientation, body
satisfaction, and cross-gender identification. In the explora-
tory analyses, the same control factors and tests were used
to examine the associations of onset age with externalizing
problems and the total problem score. For the total prob-
lem score, three items on PPR (Items 25, 38, and 48) were
excluded because PPR was a separate predictor in the model.
An a priori power analysis (using G*Power) showed that a
small effect (f = 0.02) with a power of 85% could be tested
in a multiple regression analysis with 462 cases and eight
predictors.
In the exploratory analyses, a multiple linear regression
analysis was also conducted to examine the association
between onset age (independent variable) and global
functioning (dependent variable). The control variables
described above were used.
Assumptions for the statistical analyses were checked and
met. Individual missing values were replaced using the expecta-
tion–maximization algorithm (Little & Rubin, 2014). All statisti-
cal analyses were performed using SPSS version 27.
Results
Description oftheSample andOnset Age
Table1 shows the details of the sociodemographic and
clinical characteristics of the participants. The sample
(n = 462) consisted of 85% AFAB and 15% AMAB
adolescents with a mean age of 15.5 years. EO was present
in 51% of participants and LO in 49%. In our study, AMAB
(but not AFAB) adolescents with an LO were significantly
older at initial presentation than those with an EO. There
was no significant association between birth-assigned sex
and onset age (χ2(1, N = 462) = 0.25, p = 0.620, OR = 0.88).
Almost all adolescents were German citizens (96%)
and came from a family with a medium (57%) or high SES
(30%). Participants with a LO had a significantly higher
parental SES than participants with an EO. When asked
about peer-related problems (PPR) in the past six months,
AFAB adolescents in the LO group reported significantly
more problems than those in the EO group, whereas no such
difference was observed among AMAB adolescents, as
indicated by a significant interaction effect. The GFF subscale
showed that family interactions/functioning were, on average,
unproblematic (scores below the cutoff at 2.17 for all groups),
with no significant group differences. Body satisfaction was,
on average, low, regardless of the birth-assigned sex or onset
age, but there was a significant interaction effect. AMAB
adolescents in the EO group reported higher body satisfaction
than those in the LO group, while there was no significant
difference between the AFAB EO and LO groups. Groups
differed in cross-gender identification or the intensity of
gender incongruence, respectively: it was significantly more
pronounced in AFAB adolescents than in AMAB adolescents
and among EO adolescents compared to LO adolescents.
In terms of SO, half of the participants reported a same-
sex sexual orientation (in relation to birth-assigned sex) and
about a quarter reported an opposite-sex sexual orientation.
The rest reported a bisexual or pansexual sexual orientation
or were asexual or unsure. There were significant differ-
ences between the onset age groups in the present study:
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1348 Archives of Sexual Behavior (2025) 54:1341–1359
Significantly more EO youth (63%) were same-sex oriented
than LO youth (30%); the latter were typically opposite-sex
oriented (35%) or bisexual (18%). There were no significant
sex differences. Tables4 and 5 show more information on
sexual orientation.
Internalizing Problems
Results for internalizing problems are shown in Table2. In
reference to the German norm population (M = 50, SD = 10),
adolescents with GD had significantly higher T scores (95%
CI without M = 50) for internalizing problems. Adolescents
with GD scored, on average, more than 1.5 SD higher on
the internalizing problems scale than peers from the YSR
reference group.
Regarding onset age, LO adolescents reported signifi-
cantly more internalizing problems than EO adolescents. A
closer examination of the 95% CIs indicated that these dif-
ferences were only present in AFAB adolescents but not in
AMAB adolescents (nonoverlapping 95% CIs). In the LO
group, 67% scored within the clinical range, whereas only
49% of the EO group did (T scores > 63). Overall, 58% of
adolescents in the sample had clinically relevant levels of
internalizing problems. There were no significant sex differ-
ences (overlapping 95% CIs).
Association betweenOnset Age andInternalizing
Problems
The results of the multiple linear regression analysis used to
test our hypothesis are shown in Table3. The regression anal-
ysis revealed a significant association between onset age and
internalizing problems. As hypothesized, a LO (as opposed
to an EO) was associated with reporting significantly more
Table 1 Sociodemographic and psychosocial characteristics as a function of birth-assigned sex (assigned female vs. male) and onset age (early
vs. late onset)
The Winkler Index ranges from 3 to 9 (9 = highest socioeconomic status), the poor peer relations score from 0 to 6 (6 = worst peer relations), the
FAD from 1 to 4 (4 = lowest levels of family functioning), the HBDS from 1 to 5 (5 = highest level of body satisfaction), and the cross-gender
identification sum from 0 to 4 (4 = highest level of cross-gender identification)
AFAB/AMAB assigned female/male at birth, FAD McMaster Family Assessment Device, HBDS Hamburg Body Drawing Scale, YSR Youth Self-
Report
AMAB (n = 70) AFAB (n = 392) Combined
(n = 462)
Comparison by sex Comparison by onset age Interaction (sex x onset
age)
M SD n M SD n M SD n F df p ηp2F df p ηp2F df p ηp2
Age at assessment (in years)
Early onset 14.92 1.71 34 15.23 1.54 203 15.18 1.56 237
Late onset 16.33 1.15 36 15.64 1.33 189 15.75 1.32 225
Combined 15.65 1.61 70 15.42 1.45 392 15.46 1.48 462 1.08 1, 458 .299 .00 23.88 1, 458 < .001 .05 7.30 1, 458 .007 .02
Parental socioeconomic status (Winkler Index)
Early onset 6.21 1.65 34 6.25 1.59 203 6.24 1.60 237
Late onset 6.94 1.57 36 6.81 1.59 189 6.83 1.58 225
Combined 6.59 1.64 70 6.52 1.61 392 6.53 1.61 462 0.05 1, 458 .829 .00 9.85 1, 458 .002 .02 0.19 1, 458 .663 .00
Poor peer relations (YSR)
Early onset 2.26 1.52 34 1.27 1.47 203 1.41 1.52 237
Late onset 1.94 1.49 36 1.73 1.39 189 1.76 1.40 225
Combined 2.10 1.51 70 1.49 1.45 392 1.58 1.47 462 10.40 1, 458 .001 .02 0.14 1, 458 .711 .00 4.33 1, 458 .038 .01
General family functioning (FAD)
Early onset 1.90 0.59 34 1.87 0.61 203 1.88 0.61 237
Late onset 1.99 0.46 36 2.03 0.57 189 2.02 0.55 225
Combined 1.95 0.52 70 1.95 0.60 392 1.95 0.59 462 0.00 1, 458 .992 .00 2.58 1, 458 .109 .01 0.18 1, 458 .671 .00
Body satisfaction (HBDS)
Early onset 2.62 0.91 34 2.37 0.84 203 2.41 0.85 237
Late onset 2.15 0.57 36 2.45 0.80 189 2.40 0.77 225
Combined 2.38 0.79 70 2.41 0.82 392 2.41 0.81 462 0.05 1, 458 .824 .00 3.53 1, 458 .061 .01 6.75 1, 458 .010 .02
Cross-gender identification (YSR)
Early onset 3.76 0.50 34 3.90 0.33 203 3.88 0.36 237
Late onset 3.53 0.65 36 3.75 0.60 189 3.71 0.61 225
Combined 3.64 0.59 70 3.83 0.49 392 3.80 0.51 462 7.58 1, 458 .006 .02 9.26 1, 458 .002 .02 0.40 1, 458 .528 .00
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1349Archives of Sexual Behavior (2025) 54:1341–1359
internalizing problems: having a LO was related to scoring,
on average, three points higher on the internalizing scale of
the YSR (YSR raw scores). Concerning the control varia-
bles, more internalizing problems were significantly related
to birth-assigned sex (AFAB), PPR (higher degrees of poor
peer relations), GFF (lower family functioning levels), body
satisfaction (lower degrees of body satisfaction), and sex-
ual orientation (no same-sex sexual orientation). Overall,
the model explained 44.5% of the variance in internalizing
problems: onset age explained 1.5% of the variance, which
can be interpreted as a small effect, and the control variables
explained a total of 43%.
Exploratory Data Analyses: Onset Age, Externalizing
Problems, Total Problems Score, andGlobal
Functioning
In exploratory analyses, the duration of the experienced
GD was examined only within the group of LO adolescents.
Between 23 and 36% of the adolescents met the criteria for a
recent onset, which implies that the onset of GD had occurred
less than 1 year ago (based on clinicians’ interviews with
adolescents; see Table4, 5 and 6).
Table 2 Internalizing problems
(YSR) as a function of birth-
assigned sex and onset age and
compared to German norm
scores
Age and birth-assigned sex equivalent German norm YSR T scores with M = 50 and SD = 10 were derived
from Döpfner etal. (1998). Raw scores for the internalizing scale range from 0 to 62, and T scores range
from 25 to 100. For the clinical range, the percentage and total number of individuals scoring within the
clinical range of internalizing problems are presented. These individuals scored lower than 89% of the age
and birth-assigned sex equivalent reference group
AFAB/AMAB assigned female/male at birth, GD gender dysphoria, YSR Youth Self-Report
Raw scores T scores (adolescents with GD with
reference to the norm)
Clinical
range (T
scores > 63)
M SD n 95% CI M SD n 95% CI % n
AMAB
Early onset 19.24 8.63 34 [16.22; 22.25] 67.12 9.61 34 [63.76; 70.47] 70.6 24
Late onset 22.92 8.69 36 [19.98; 25.86] 71.22 9.45 36 [68.03; 74.42] 80.6 29
Combined 21.13 8.80 70 [19.03; 23.23] 69.23 9.68 70 [66.92; 71.54] 75.7 53
AFAB
Early onset 19.41 10.71 203 [17.93; 20.89] 63.12 10.82 203 [61.62; 64.62] 45.3 92
Late onset 25.12 11.35 189 [23.49; 26.74] 69.30 11.28 189 [67.68; 70.92] 64.0 121
Combined 22.16 11.37 392 [21.03; 23.29] 66.10 11.45 392 [64.96; 67.24] 54.3 213
Combined
Early onset 19.38 10.42 237 [18.05; 20.72] 63.69 10.73 237 [62.32; 65.06] 48.9 116
Late onset 24.76 10.98 225 [23.32; 26.21] 69.61 11.01 225 [68.16; 71.06] 66.7 150
Combined 22.00 11.02 462 [21.00; 23.01] 66.57 11.25 462 [65.55; 67.60] 57.6 266
Table 3 Association between
internalizing problems (YSR
raw scores) and the onset age
*p < .05, **p < .01, ***p < .001, FAD McMasters’ Family Assessment Device, GD gender dysphoria,
HBDS Hamburg Body Drawing Scale, YSR Youth Self-Report
b SE b 95% CI for b ß p
Intercept 6.54 5.88 [− 5.02; 18.10] .267
Birth-assigned sex (0 = male, 1 = female) 2.69* 1.09 [0.55; 4.83] .09 .014
Age in years − 0.06 0.27 [− 0.60; 0.47] − .01 .819
Poor peer relations (YSR) 2.67*** 0.28 [2.11; 3.22] .36 < .001
General family functioning (FAD) 5.96*** 0.71 [4.57; 7.35] .32 < .001
Body satisfaction (HBDS) − 2.68*** 0.51 [− 3.67; − 1.68] − .20 < .001
Cross-gender identification (YSR) 0.56 0.78 [− 0.98; 2.10] .03 .477
Sexual orientation (0 = same-sex, 1 = other) 2.22** 0.82 [0.61; 3.83] .10 .007
Onset age (0 = early, 1 = late) 3.00*** 0.84 [1.35; 4.65] .14 < .001
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1350 Archives of Sexual Behavior (2025) 54:1341–1359
Additional exploratory data analyses were conducted to
examine the associations between onset age and externalizing
problems, as well as the total problem score and global function-
ing (CGAS) (Appendix Tables7–12). Externalizing problems
were less common than internalizing problems in adolescents
with GD but were still elevated compared with the norm popula-
tion (Table7). Clinically relevant externalizing problems were
reported by 15% of participants. There were no significant differ-
ences between EO and LO youth but AFAB adolescents scored
significantly higher on the externalizing scale than AMAB ado-
lescents. Also elevated was the total problem score: adolescents
with GD scored more than 1 SD higher than the reference group
and 46% of participants were in the clinical range. LO adoles-
cents reported, on average, significantly higher total problem
scores and tended to be more often in the clinical range than
EO adolescents. The differences were particularly evident in
AFAB adolescents. There was also a significant difference in
global functioning between the two onset age groups in AFAB
adolescents (but not in AMAB adolescents), with AFAB adoles-
cents in the LO group having a significantly lower level of global
functioning than AFAB adolescents in the EO group (Table8).
In multiple regression analysis for externalizing problems,
a significant association was identified between onset age
and externalizing problems (Table9). An inverse association
was found with internalizing problems, that is, LO adoles-
cents reported significantly fewer externalizing problems.
Significant control variables were birth-assigned sex, PPR,
and GFF. The model explained 16% of the variance in exter-
nalizing problems: onset age explained 1% of the variance
(small effect) and the control variables explained 15%.
Another regression model (Table10) tested whether onset
age affected the total problem score and global functioning
level. Onset age and total problem score were not associated.
Significant control variables were birth-assigned sex, PPR,
GFF, and body satisfaction. The model explained 39% of the
variance in the total problem score.
Table11 shows the results for the association between onset
age and global functioning. LO proved to be a significant predic-
tor of a worse global functioning as rated by clinicians. Signifi-
cant control variables were PPR and cross-gender identification/
intensity of gender incongruence. The model explained 11.6%
of the variance in the CGAS: onset age explained 2.2% (small
effect) and the control variables explained 9.4%.
Last, we explored whether onset age was related to internal-
izing problems when the recent onset and LO groups were con-
sidered separately (Table12). Belonging to the LO group (as
opposed to the EO group) was associated with significantly more
internalizing problems. Belonging to the recent onset group (GD
present for less than one year) as opposed to the EO group was not
associated with more internalizing problems but showed a ten-
dency to do so. Significant control variables were birth-assigned
sex, PPR, GFF, body satisfaction, and sexual orientation. The
model explained a total of 44.5% of the variance in internalizing
problems, of which onset age accounted for 1.4% (small effect)
and the control variables for 43.1%.
Discussion
The present study aimed to assess the frequency of EO vs. LO
developmental trajectories, and to investigate the association
between the onset age of GD and internalizing problems in
adolescents attending a specialized outpatient clinic for GD.
Our findings identified onset age as a significant predictor of
psychological problems, with LO in adolescence associated
with higher levels of internalizing problems.
The higher levels of internalizing problems in the LO group
than in the EO group correspond to recent findings in which a
group classification was made based on the age of presentation
(Arnoldussen etal., 2023; de Rooy etal., 2024; Sorbara etal.,
2020). In these studies, older-presenting youth were more likely
to have psychological problems (depressive and anxiety disorders
as well as higher CBCL and YSR scores) than the younger-pre-
senting ones (de Rooy etal., 2024; Sorbara etal., 2020), similar
to the higher T scores and the higher percentage of adolescents
scoring in the clinical range of internalizing problems in the LO
group (as opposed to the EO group) in our sample. Sorbara etal.
(2020) put forward two hypotheses for these differences: First, the
older-presenting group was more advanced in pubertal develop-
ment and, therefore, more distressed than the younger-presenting
group. Second, older-presenting youth may experience more
minority stress and less family support and hence present at an
older age than younger-presenting youth (de Rooy etal., 2024).
In contrast, our EO and LO groups did not significantly differ in
age (15.2 years to 15.7 years at first presentation). In addition,
we found that a longer duration of GD with onset already in
childhood (EO) was not associated with reporting more but less
internalizing problems.
In line with the present results, a study by Dolotina etal.
(2022) found a roughly even distribution of onset age. However,
in contrast to our findings, the group with later realization of
their gender identity reported significantly less suicidal thoughts
than the group with earlier realization, and no significant differ-
ences were found between groups for other mental health meas-
ures. That said, comparisons between these two studies should
be made carefully, considering the differences in methods (e.g.,
definition of onset age, sample selection), and the critique by
Sapir etal. (2024).
Contrary to our expectations, the sex ratio did not differ
between the EO and LO groups but was balanced with a share
of 86% and 84% AFAB, respectively. In this respect, it cannot
be assumed that the LO group shows an overrepresentation of
AFAB adolescents. On the other hand, the sex ratio in our study
should be considered with limitations: the physical maturation
and the fact that girls enter puberty much earlier than boys and
usually develop recognizable secondary sexual characteristics
well before the age of 12 (Grüters-Kieslich, 2009) points to a
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1351Archives of Sexual Behavior (2025) 54:1341–1359
methodological problem in the classification of onset age when
this is recorded using age cutoffs, as we did. Thus, AFAB adoles-
cents may be overrepresented in the EO group due to the earlier
onset of puberty. Notably, the EO group reported a greater inten-
sity of gender incongruence and cross-gender identification with
otherwise lower internalizing problems. This could correspond
to the assumption of Cohen-Kettenis and Klink (2015) that there
is a clinical subtype of AFAB adolescents with an EO course and
exceptionally strong GD who have an early desire for gender-
affirming medical interventions. At the same time, however, this
also shows that GD with high intensity and resulting distress
does not necessarily have to be connected to strong internalizing
problems but exhibits different or independent developmental
pathways under certain circumstances. A clinical approach to
understanding seems to be urgently required to more precisely
describe these developmental trajectories and to be able to make
well-founded treatment decisions on this basis.
Considering the findings of previous studies of onset age,
a dynamic developmental link between AFAB and LO was
suggested but not shown in our study (i.e., no significant asso-
ciation between birth-assigned sex and onset age). Nieder
etal. (2011) reported an EO rate of 78% in an adolescent
sample of AFAB individuals presenting to specialized Euro-
pean gender identity clinics. In contrast, our EO proportion
of 51% is not only lower but also contrary to the notion that
increased societal openness and information about transgen-
der people might result in an earlier age-related reflection
on the potential discrepancy between birth-assigned sex and
gender identity (e.g., Aitken etal., 2015). Rather, contrary
to this expectation, there appears to be a temporal shift to
later adolescence, when the incongruence is first perceived
(Sun etal., 2023).
However, it is possible that the decrease in stereotypical
role expectations and evolved possibilities of expression can
also be understood ambiguously: while this is associated in
some with relief from inflexible gender role expectations
and more individual freedom, it may lead others to a loss
of orientation and the search for new identifications to
counteract the insecurity. In both cases, the unresolved
question arises as to how it is possible to experience puberty
without distress in the case of a LO and how it generally leads
to the development of dysphoria.
Moreover, transgender adolescents spend a considerable
amount of time online and on social media (Herrmann etal.,
2023a), where the notion of one right way to be transgender
may be reinforced, often through a focus on binary-presenting
individuals and medical transitions (Etengoff, 2019). As a
result, it may be challenging for adolescents to shape their
gender identities and experiences in a fully independent
and individual way, separate from the often binary gender
expressions and expectations they encounter online.
Exploratory analyses of our study suggest that AFAB
adolescents with a LO reported, in addition to high levels of
internalizing problems, significantly more peer problems than
those with an EO. Identity is a process essentially determined
by interactions (Mertens, 1996), both between the individual and
relevant others and within the self in the process of reflecting
on and testing different conceptions of self. A consolidated and
stable experience of identity, also concerning a mature clarity
about one’s own gender identity, is accordingly clearly more dif-
ficult for individuals with high symptomatic stress and conflictual
peer relations. It can be assumed from this that LO adolescents
represent a particularly vulnerable group that would benefit from
an individually tailored treatment plan, in addition to long-term
psychotherapeutic support that will hopefully help them to con-
solidate their own identity, irrespective of their gender, and create
space for development again.
Clinical Implications
Our results raise three major questions: (1) Is there a clinical
LO subtype?; (2) On what basis or under what conditions
can reliable indications for gender-affirming medical
interventions be made?; and (3) Can a protocol-based
approach still meet the needs of individuals seeking treatment
given the diversity of clinical presentations and the different
developmental pathways that can be derived from them?
First, the present findings indicate the presence of increasing
heterogeneity not only in clinical presentations of treatment seek-
ers but also within the sample between EO and LO pathways. In
our study, the LO group reported significantly more internalizing
psychological and peer problems (at least AFAB adolescents)
but less cross-gender identification than the EO group. Other
influences are likely since neither the duration of the experience
of GD nor the intensity of cross-gender identification can be con-
vincingly assumed to be causal for the overall very high rate of
internalizing problems.
Drawing on the clinical manifestations briefly outlined at the
beginning, we can assume that for a substantial proportion of
adolescents with long psychiatric histories, LO will have a dif-
ferent developmental trajectory than a deeply felt incongruence
between body and gender identity. Clinical observations at our
center suggest that the proportion of LO (as opposed to EO)
adolescents has increased in recent years. Further (longitudinal)
studies are needed to identify possible shifts in developmental
pathways.
In contrast to Littman (2018), we understand different devel-
opmental pathways of GD as etiologically relevant but not neces-
sarily milder in course or less in need of treatment. Rather, the
question is: What interventions would benefit this particularly
vulnerable group of youth with LO development beyond the
desire for medical intervention?
Second, an indication for gender-affirming medical interven-
tions based purely on descriptive and external criteria appears
neither purposeful nor feasible given the reciprocal overlap of GD
experiences and other developmental conflicts (Edwards-Leeper,
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1352 Archives of Sexual Behavior (2025) 54:1341–1359
2017; Edwards-Leeper & Smith, 2017; Zucker & Bradley, 1995).
Our proposal is therefore a comprehensive, process-oriented
diagnostic phase that includes psychosexual development, nar-
ratives about one’s identity development, and a detailed anam-
nesis for other relevant adolescent issues and conflicts. This
diagnostic process would form the basis of an assessment of the
developmental course, in the context of which considerations
about gender-affirming interventions can be discussed. The focus
would be on the interaction between GD and relevant develop-
mental conflicts, allowing for a deeper understanding of the indi-
vidual's journey and the development of an individual narrative.
Co-occurring psychological problems do not represent a clear
contraindication for gender-affirming medical interventions, as
long as they can be understood in terms of developmental dynam-
ics. Nonetheless, the psychodynamic perspective and clinical
experience suggest that a substantial proportion of adolescents
at the time of the diagnostic phase may benefit less from physical
interventions than from adjunctive and developmental psycho-
therapy—considering how many cases present co-occurring psy-
chological problems. Given concerns about increasing numbers
of detransitions (Cohn, 2023), persistent distress or regret despite
gender-affirming medical interventions (Roberts etal., 2022),
and ambiguity regarding the stability of the GD experience over
time, cautious and intensely reflective indications for this group
of adolescents appear essential.
Third, although our total sample had similarly high levels of
internalizing problems as most samples from other European
gender identity services (see de Graaf etal., 2018), the group
of LO adolescents is characterized by particularly elevated
levels of internalizing problems (67% scoring in the clinical
range vs. 57% of the total sample). Abbruzzese etal. (2023)
question the applicability of the Dutch results to nowadays
more heterogeneous, non-preselected treatment groups, which
include youth with a LO developmental trajectory and severe
psychological problems. The growing diversity of developmental
trajectories in adolescents, with varying intensity of gender
dysphoric distress and co-occurring, with GD interacting
psychological problems, demonstrates the need for an
individualized treatment setting. The guiding question “What
works for whom, at what time, and in what setting” enables
a differential indication (Dorr etal., 2020) for outpatient or
inpatient psychotherapy, gender-affirming medical interventions,
or low-frequency counseling/support oriented to individual
needs.
Limitations
Our findings should be considered in light of several limitations.
The cross-sectional design of our study cannot provide infor-
mation on long-term trajectories or influencing factors. This is
especially true for the control variables studied, such as GD inten-
sity, sexual orientation, and body satisfaction, which should be
considered snapshots and may change over time.
Another difficulty lies in the operationalization of LO and
EO trajectories. Unfortunately, the literature lacks a clear
conceptualization/definition and measurement of onset age in
adolescents. Therefore, onset age was retrospectively assessed
by evaluating the clinicians’ ratings on the DSM-5 criteria for
childhood after conducting a comprehensive diagnostic process
with the adolescents, in which they described their gender
identity development. However, the cutoff age of 12 years for
EO vs. LO was artificially set. Given the age difference in puberty
onset in AFAB and AMAB adolescents and the now advanced
timing of AFAB pubertal development, the cutoff age is one
of our limitations. For future studies, a clearer determination of
puberty based on the development of physical/sex characteristics
would be useful.
Similarly, while the collection of internalizing problems using
YSR data is widespread, a categorical diagnostic using stand-
ardized questionnaires would be important. Another aspect that
should be considered in future studies is the systematic collection
of data on the course of treatment since this will make it clearer
to what extent there are also differences in the indication of treat-
ment and treatment trajectories.
Data interpretation is also limited by the high and increasing
proportion of AFAB youth, accounting for 85% of the present
study/analysis sample (see Fig.1). As a result, the subsample of
AMAB adolescents in the present study was relatively small.
Furthermore, the sample sizes for our hypothesis-testing analy-
sis (multiple linear regression) were, in some instances, unbal-
anced (e.g., AFAB vs. AMAB) but still sufficient (more than
10%). However, the descriptive and exploratory analyses (e.g.,
evaluating the 95% CIs of the YSR scores) should be interpreted
cautiously (estimates are less reliable in small samples, such as
AMAB adolescents with LO).
Conclusions
The present study showed that about half of the adolescents
attending a specialized gender identity service reported an
LO course. Adolescents with a GD diagnosis reported, on
average, significantly more internalizing problems than ado-
lescents from the norm population, and their scores often fell
within the clinical range. Furthermore, a LO developmental
trajectory was associated with particularly high levels of
internalizing problems.
Our findings indicate a specific subgroup of LO adoles-
cents in the growing spectrum of heterogeneous develop-
mental trajectories. The diverse trajectories and the presence
of particularly vulnerable subgroups highlight the need to
move away from a single protocol-based approach toward a
more individualized approach to indications that are based
on developmental dynamics during adolescence.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1353Archives of Sexual Behavior (2025) 54:1341–1359
Appendix
See Tables4, 5, 6, 7, 8, 9, 10, 11, and 12.
Table 4 Sexual orientation as a function of birth-assigned sex (assigned female vs. assigned male) and onset age (early vs. late onset).
***p < .001, AFAB/AMAB = assigned female/male at birth.
Early onset Late onset Combined Group comparisons
(n = 237) (n = 225) (n = 462) Test pEffect
Sexual orientation (in relation
to birth-assigned sex)
%n%n%n
Same-sex 63.3 150 29.8 67 47.0 217
Opposite sex 11.8 28 34.7 78 22.9 106
Bisexual 8.0 19 18.2 41 13.0 60
Asexual or unsure 15.2 36 13.8 31 14.5 67
Pansexual 1.7 4 3.6 8 2.6 12 χ2(4, 462) =
64.84
<.001 V = .38***
AMAB AFAB Combined Group comparisons
(n = 70) (n = 392) (n = 462) Test pEffect
Sexual orientation (in relation
to birth-assigned sex)
%n%n%n
Same-sex 48.6 34 46.7 183 47.0 217
Opposite sex 22.9 16 23.0 90 22.9 106
Bisexual 7.1 5 14.0 55 13.0 60
Asexual or unsure 20.0 14 13.5 53 14.5 67
Pansexual 1.4 1 2.8 11 2.6 12 χ2(4, 462) =
4.37
.358 V = .10
Table 5 Sexual orientation as a function of onset age (early vs. late onset) for adolescents assigned male vs. female at birth
This information was included at the request of a reviewer; however, as it is not the primary focus of the study, it is not discussed in further
detail.
***p < .001, FFH = Fisher–Freeman–Halton exact test.
Assigned male at birth adolescents Early onset Late onset Combined Group comparisons
(n = 34) (n = 36) (n = 70) Test pEffect
Sexual orientation (in relation to birth-
assigned sex)
%n%n%n
Same-sex 58.8 20 38.9 14 48.6 34
Opposite sex 14.7 5 30.6 11 22.9 16
Bisexual 2.9 1 11.1 4 7.1 5
Asexual or unsure 23.5 8 16.7 6 20.0 14
Pansexual 0.0 0 2.8 1 1.4 1 FFH = 6.07 .168 V = .30
Assigned female at birth adolescents Early onset Late onset Combined Group comparisons
(n = 203) (n = 189) (n = 392) Test pEffect
Sexual orientation (in relation to birth-
assigned sex)
%n%n%n
Same-sex 64.0 130 28.0 53 46.7 183
Opposite sex 11.3 23 35.4 67 23.0 90
Bisexual 8.9 18 19.6 37 14.0 55
Asexual or unsure 13.8 28 13.2 25 13.5 53
Pansexual 2.0 4 3.7 7 2.8 11 χ2(4, 392) =
61.04
<.001 V = .40***
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1354 Archives of Sexual Behavior (2025) 54:1341–1359
Table 6 Adolescents with a late
onset (n = 225) fulfilling the
criteria for recent onset given
various definitions.
DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
DSM-5 criteria n%
Fulfilling all of the A1 to A4 criteria for less than 1 year 52 23.1
Fulfilling at least 3 of the A1 to A4 criteria for less than 1 year 63 28.0
Fulfilling at least 2 of the A1 to A4 criteria for less than 1 year 81 36.0
Table 7 Externalizing problems
and total problem score (YSR)
as a function of birth-assigned
sex and onset age and compared
to German norm scores
Age and birth-assigned sex equivalent German norm YSR T-scores with M = 50 and SD = 10 were derived
from Döpfner etal. (1998). The following items were excluded for the calculation of the total problem
score: asthma, allergies, socially desirable items, and cross-gender identification. Raw scores for the
externalizing scale range from 0 to 60, raw scores for the total problem score from 0 to 198, and T scores
range from 25 to 100. For the clinical range, the percentage and total number of individuals scoring within
the clinical range of externalizing problems/total problems are presented. These individuals scored lower
than 89% of the age and birth-assigned sex equivalent reference group.
AFAB/AMAB assigned female/male at birth, GD gender dysphoria, YSR Youth Self-Report.
Raw scores T scores (adolescents with GD with
reference to the norm)
Clinical
range (T
scores >
63)
M SD n 95% CI M SD n 95% CI % n
Externalizing scale
AMAB
Early onset 11.32 6.91 34 [8.91; 13.73] 53.44 7.83 34 [50.71; 56.17] 5.9 2
Late onset 11.00 5.55 36 [9.12; 12.88] 53.06 6.22 36 [50.95; 55.16] 5.6 2
Combined 11.16 6.20 70 [9.68; 12.64] 53.24 7.00 70 [51.57; 54.91] 5.7 4
AFAB
Early onset 13.39 7.92 203 [12.29; 14.49] 56.49 9.16 203 [55.23; 57.76] 18.2 37
Late onset 12.40 6.81 189 [11.43; 13.38] 55.42 8.24 189 [54.24; 56.61] 13.8 26
Combined 12.91 7.41 392 [12.18; 13.65] 55.98 8.73 392 [55.11; 56.84] 16.1 63
Total
Early onset 13.09 7.81 237 [12.09; 14.09] 56.05 9.03 237 [54.90; 57.21] 16.5 39
Late onset 12.18 6.63 225 [11.31; 13.05] 55.04 7.98 225 [54.00; 56.09] 12.4 28
Combined 12.65 7.26 462 [11.98; 13.31] 55.56 8.54 462 [54.78; 56.34] 14.5 67
Total problem score
AMAB
Early onset 49.38 21.10 34 [42.02; 56.74] 62.15 8.33 34 [59.24; 65.05] 44.1 15
Late onset 54.92 16.40 36 [49.37; 60.47] 64.47 6.32 36 [62.33; 66.61] 52.8 19
Combined 52.23 18.90 70 [47.72; 56.73] 63.34 7.41 70 [61.58; 65.11] 48.6 34
AFAB
Early onset 51.74 24.29 203 [48.38; 55.11] 61.88 9.56 203 [60.55; 63.20] 39.9 81
Late onset 59.80 24.69 189 [56.26; 63.35] 65.14 9.61 189 [63.76; 66.52] 51.3 97
Combined 55.63 24.78 392 [53.17; 58.09] 63.45 9.71 392 [62.49; 64.41] 45.4 178
Combined
Early onset 51.41 23.83 237 [48.36; 54.46] 61.92 9.38 237 [60.72; 63.12] 40.5 96
Late onset 59.02 23.59 225 [55.92; 62.12] 65.03 9.15 225 [63.83; 66.23] 51.6 116
Combined 55.11 24.00 462 [52.92; 57.31] 63.43 9.39 462 [62.57; 64.29] 45.9 212
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1355Archives of Sexual Behavior (2025) 54:1341–1359
Table 8 Global functioning
(CGAS raw scores) as a
function of birth-assigned sex
and onset age
The CGAS is rated by clinicians (sum score: 1 to 100) and provides no norms (or T scores and clinical
ranges).
AFAB/AMAB assigned female/male at birth, CGAS Children’s Global Assessment Scale, GD gender
dysphoria.
M SD n 95% CI
AMAB
Early onset 66.76 12.73 34 [62.32; 71.20]
Late onset 63.89 14.60 36 [58.95; 68.83]
Combined 65.29 13.70 70 [62.02; 68.55]
AFAB
Early onset 66.79 13.46 203 [64.93; 68.66]
Late onset 60.53 14.36 189 [58.47; 62.59]
Combined 63.78 14.23 392 [62.36; 65.19]
Combined
Early onset 66.79 13.33 237 [65.09; 68.50]
Late onset 61.07 14.41 225 [59.17; 62.96]
Combined 64.00 14.15 462 [62.71; 65.30]
Table 9 Association between
externalizing problems (YSR
raw scores) and the onset age
*p < .05, **p < .01, ***p < .001, FAD = McMasters’ Family Assessment Device, GD gender dysphoria,
HBDS Hamburg Body Drawing Scale, YSR Youth Self-Report
b SE b 95% CI for b ß p
Intercept 2.76 4.77 [−6.62; 12.13] .564
Birth-assigned sex (0 = male, 1 = female) 2.33** 0.88 [0.59; 4.06] .12 .009
Age in years 0.05 0.22 [−0.39; 0.49] .01 .822
Poor peer relations (YSR) 0.85*** 0.23 [0.40; 1.29] .17 <.001
General family functioning (FAD) 4.09*** 0.57 [2.96; 5.21] .33 <.001
Body satisfaction (HBDS; M, SD) 0.24 0.41 [−0.56; 1.05] .03 .554
Cross-gender identification (YSR; M, SD) −0.39 0.64 [−1.64; 0.86] −.03 .537
Sexual orientation (0 = same-sex, 1 = other) −0.94 0.67 [−2.25; 0.36] −.07 .157
Onset age (0 = early, 1 = late) −1.54* 0.68 [−2.88; −0.20] −.11 .024
Table 10 Association between
the total problem score (YSR
raw scores) and the onset age
Results of the final model of the multiple linear regression analysis: F(8, 453) = 38.31, adjusted R2 = .39,
p < .001.
*p < .05, **p < .01, ***p < .001, FAD McMasters’ Family Assessment Device, GD gender dysphoria,
HBDS Hamburg Body Drawing Scale, YSR Youth Self-Report
b SE b 95% CI for b ß p
Intercept 15.52 13.01 [−10.05; 41.08] .234
Birth-assigned sex (0 = male, 1 = female) 7.17** 2.41 [2.44; 11.91] .11 .003
Age in years −0.19 0.60 [−1.37; 1.00] −.01 .758
Poor peer relations (YSR) 5.18*** 0.62 [3.96; 6.41] .33 <.001
General family functioning (FAD) 15.19*** 1.56 [12.12.; 18.26] .38 <.001
Body satisfaction (HBDS; M, SD) −3.59** 1.12 [−5.78; −1.39] −.13 .001
Cross-gender identification (YSR; M, SD) 0.84 1.73 [−2.57; 4.25] .02 .628
Sexual orientation (0 = same-sex, 1 = other) 1.91 1.81 [−1.65; 5.48] .04 .292
Onset age (0 = early, 1 = late) 2.96 1.86 [−0.69; 6.60] .06 .111
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1356 Archives of Sexual Behavior (2025) 54:1341–1359
Acknowledgements We would like to thank the young people and par-
ents for participating in and contributing to this study.
Author Contributions Data collection was carried out by Saskia Fahren-
krug and the clinical outpatient team. Material preparation and data
analysis were performed/supported by Saskia Fahrenkrug, Lena Her-
rmann, Claus Barkmann, and Inga Becker-Hebly. Saskia Fahrenkrug,
Inga Becker-Hebly, Carola Bindt, and Sarah Hohmann contributed to
the study conceptualization. The first draft of the manuscript was written
by Saskia Fahrenkrug. All authors reviewed the manuscript for impor-
tant intellectual content.
Funding Open Access funding enabled and organized by Projekt
DEAL. The authors have not disclosed any funding.
Declarations
Conflict of interest The authors have not disclosed any competing
interests.
Ethical approval The study was approved by the Ethics Committee of
the Hamburg Psychotherapeutic Association.
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://creativecommons.org/licenses/by/4.0/.
References
Abbruzzese, E., Levine, S. B., & Mason, J. W. (2023). The myth of
“reliable research” in pediatric gender medicine: A critical evalu-
ation of the Dutch studies–and research that has followed. Journal
of Sex and Marital Therapy, 49(6), 673–699. https:// doi. org/ 10.
1080/ 00926 23X. 2022. 21503 46
Achenbach, T. M. (1991). Manual for the Youth Self-Report and 1991
profile. University of Vermont Department of Psychiatry.
Table 11 Association between
the global functioning (CGAS)
and the onset age
Results of the final model of the multiple linear regression analysis: F(8, 453) = 8.54, adjusted R2 = .12, p
< .001
*p < .05, **p < .01, ***p < .001, CGAS Children’s Global Assessment Scale, FAD McMasters’ Family
Assessment Device, HBDS Hamburg Body Drawing Scale, YSR Youth Self-Report
b SE b ß 95% CI for b p
Intercept 90.66*** 9.54 [71.91; 109.41] <.001
Birth-assigned sex (0 = male, 1 = female) −2.22 1.77 −.06 [−5.70; 1.25] .210
Age in years −0.39 0.44 −.04 [−1.26; 0.48] .374
Poor peer relations (YSR) −1.72*** 0.46 −.18 [−2.62; −0.83] <.001
General family functioning (FAD) −2.18 1.15 −.09 [−4.43; 0.07] .058
Body satisfaction (HBDS; M, SD) 1.57 0.82 .09 [−0.04; 3.18] .057
Cross-gender identification (YSR; M, SD) −3.29* 1.27 −.12 [−5.79; −0.79] .010
Sexual orientation (0 = same-sex, 1 = other) −1.25 1.33 −.04 [−3.87; 1.36] .347
Onset age (0 = early, 1 = late) −4.75*** 1.36 −.17 [−7.43; −2.08] <.001
Table 12 Association between
internalizing problems (YSR
raw scores) and the onset age
(late and recent onset age
separated)
*p < .05, **p < .01, ***p < .001, CGAS Children’s Global Assessment Scale, FAD McMasters’ Family
Assessment Device, YSR Youth Self-Report
b SE b ß 95% CI for b p
Intercept 6.75 5.90 [−4.85; 18.35] .254
Birth-assigned sex (0 = male, 1 = female) 2.67* 1.09 .09 [0.52; 4.81] .015
Age in years −0.07 0.27 −.01 [−0.61; 0.47] .793
Poor peer relations (YSR) 2.68*** 0.28 .36 [2.13; 3.24] <.001
General family functioning (FAD) 5.94*** 0.71 .32 [4.55; 7.33] <.001
Body satisfaction (HBDS; M, SD) −2.67*** 0.51 −.20 [−3.67; −1.68] <.001
Cross-gender identification (YSR; M, SD) 0.55 0.79 .03 [−0.99; 2.09] .485
Sexual orientation (0 = same-sex, 1 = other) 2.20** 0.82 .10 [0.59; 3.82] .008
Late onset age (= 1, early = 0) 3.15*** 0.90 .14 [1.39; 4.91] <.001
Recent onset age (= 1, early = 0) 2.51 1.31 .07 [−0.06; 5.08] .055
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1357Archives of Sexual Behavior (2025) 54:1341–1359
Aitken, M., Steensma, T. D., Blanchard, R., VanderLaan, D. P., Wood,
H., Fuentes, A., Spegg, C., Wasserman, L., Ames, M., Fitzsim-
mons, C. L., Leef, J. H., Lishak, V., Reim, E., Takagi, A., Vinik,
J., Wreford, J., Cohen-Kettenis, P. T., de Vries, A. L. C., Kreukels,
B. P. C., & Zucker, K. J. (2015). Evidence for an altered sex ratio in
clinic-referred adolescents with gender dysphoria. Journal of Sex-
ual Medicine, 12(3), 756–763. https:// doi. org/ 10. 1111/ jsm. 12817
Aitken, M., VanderLaan, D. P., Wasserman, L., Stojanovski, S., &
Zucker, K. J. (2016). Self-harm and suicidality in children referred
for gender dysphoria. Journal of the American Academy of Child
and Adolescent Psychiatry, 55(6), 513–520. https:// doi. org/ 10.
1016/j. jaac. 2016. 04. 001
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). American Psychiatric Press.
Appelt, H., & Strauß, B. (1988). Psychoendokrinologische Gynäkologie
[Psychoendocrinological gynecology]. Enke.
Arnoldussen, M., de Rooy, F. B. B., de Vries, A. L. C., van der Miesen,
A. I. R., Popma, A., & Steensma, T. D. (2023). Demographics and
gender-related measures in younger and older adolescents present-
ing to a gender service. European Child & Adolescent Psychiatry,
32(12), 2537–2546. https:// doi. org/ 10. 1007/ s00787- 022- 02082-8
Bechard, M., VanderLaan, D. P., Wood, H., Wasserman, L., & Zucker,
K. J. (2017). Psychosocial and psychological vulnerability in
adolescents with gender dysphoria: A “proof of principle” study.
Journal of Sex & Marital Therapy, 43(7), 678–688. https:// doi. org/
10. 1080/ 00926 23X. 2016. 12323 25
Becker, I., Gjergji-Lama, V., Romer, G., & Möller, B. (2014). Merkmale
von Kindern und Jugendlichen mit Geschlechtsdysphorie in der
Hamburger Spezialsprechstunde [Characteristics of children and
adolescents with gender dysphoria referred to the Hamburg Gender
Identity Clinic]. Praxis der Kinderpsychologie und Kinderpsychi-
atrie, 63(6), 486–509.
Becker, I., Nieder, T. O., Cerwenka, S., Briken, P., Kreukels, B. P. C.,
Cohen-Kettenis, P. T., Cuypere, G., Hebold Haraldsen, I. R., &
Richter-Appelt, H. (2016). Body image in young gender dysphoric
adults: A European multi-center study. Archives of Sexual Behav-
ior, 45(3), 559–574. https:// doi. org/ 10. 1007/ s10508- 015- 0527-z
Becker-Hebly, I., Fahrenkrug, S., Campion, F., Richter-Appelt, H.,
Schulte-Markwort, M., & Barkmann, C. (2021). Psychosocial
health in adolescents and young adults with gender dysphoria
before and after gender-affirming medical interventions: A descrip-
tive study from the Hamburg Gender Identity Service. European
Child & Adolescent Psychiatry, 30(11), 1755–1767. https:// doi.
org/ 10. 1007/ s00787- 020- 01640-2
Benjamin, H. (1966). The transsexual phenomenon. Julian Press.
Biggs, M. (2020). Gender dysphoria and psychological function-
ing in adolescents treated with GnRHa: Comparing Dutch and
English prospective studies [Letter to the Editor]. Archives of
Sexual Behavior, 49(7), 2231–2236. https:// doi. org/ 10. 1007/
s10508- 020- 01764-1
Blanchard, R. (1985). Typology of male-to-female transsexualism.
Archives of Sexual Behavior, 14, 247–261. https:// doi. org/ 10.
1007/ BF015 42107
Blanchard, R., Clemmensen, L. H., & Steiner, B. W. (1987). Hetero-
sexual and homosexual gender dysphoria. Archives of Sexual
Behavior, 16(2), 139–152. https:// doi. org/ 10. 1007/ BF015 42067
Byles, J., Byrne, C., Boyle, M. H., & Offord, D. R. (1988). Ontario
child health study: reliability and validity of the general function-
ing subscale of the McMaster Family Assessment Device. Family
Process, 27(1), 97–104.
Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L.,
Davidson, S., Skageberg, E. M., Khadr, S., & Viner, R. M. (2021).
Short-term outcomes of pubertal suppression in a selected cohort
of 12 to 15 year old young people with persistent gender dysphoria
in the UK. PLoS ONE, 16(2), e0243894. https:// doi. org/ 10. 1371/
journ al. pone. 02438 94
Chen, M., Fuqua, J., & Eugster, E. A. (2016). Characteristics of referrals
for gender dysphoria over a 13-year period. Journal of Adolescent
Health, 58(3), 369–371. https:// doi. org/ 10. 1016/j. jadoh ealth. 2015.
11. 010
Chew, D., Tollit, M. A., Poulakis, Z., Zwickl, S., Cheung, A. S., & Pang,
K. C. (2020). Youths with a non-binary gender identity: A review
of their sociodemographic and clinical profile. Lancet Child and
Adolescent Health, 4(4), 322–330. https:// doi. org/ 10. 1016/ S2352-
4642(19) 30403-1
Cohen-Kettenis, P. T., & Klink, D. (2015). Adolescents with gender
dysphoria. Best Practice & Research Clinical Endocrinology &
Metabolism, 29(3), 485–495. https:// doi. org/ 10. 1016/j. beem. 2015.
01. 004
Cohn, J. (2023). The detransition rate is unknown. Archives of
Sexual Behavior, 52(5), 1937–1952. https:// doi. org/ 10. 1007/
s10508- 023- 02623-5
Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., de Vries, A.
L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green,
J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G.
A., Leibowitz, S. F., Meyer-Bahlburg, H. F. L., Monstrey, S. J.,
Motmans, J., Nahata, L., … Arcelus, J. (2022). Standards of care
for the health of transgender and gender diverse people, Version 8.
International Journal of Transgender Health, 23(sup1), S1–S259.
https:// doi. org/ 10. 1080/ 26895 269. 2022. 21006 44
Cumming, G., & Finch, S. (2005). Inference by eye: Confidence inter-
vals and how to read pictures of data. American Psychologist,
60(2), 170–180. https:// doi. org/ 10. 1037/ 0003- 066X. 60.2. 170
de Graaf, N. M., Cohen-Kettenis, P. T., Carmichael, P., de Vries, A. L.
C., Dhondt, K., Laridaen, J., Pauli, D., Ball, J., & Steensma, T. D.
(2018). Psychological functioning in adolescents referred to spe-
cialist gender identity clinics across Europe: A clinical comparison
study between four clinics. European Child and Adolescent Psychi-
atry, 27(7), 909–919. https:// doi. org/ 10. 1007/ s00787- 017- 1098-4
de Graaf, N. M., Huisman, B., Cohen-Kettenis, P. T., Twist, J., Hage,
K., Carmichael, P., Kreukels, B. P. C., & Steensma, T. D. (2021).
Psychological functioning in non-binary identifying adolescents
and adults. Journal of Sex & Marital Therapy, 47(8), 773–784.
https:// doi. org/ 10. 1080/ 00926 23X. 2021. 19500 87
de Graaf, N. M., Steensma, T. D., Carmichael, P., VanderLaan, D. P.,
Aitken, M., Cohen-Kettenis, P. T., de Vries, A. L. C., Kreukels,
B. P. C., Wasserman, L., Wood, H., & Zucker, K. J. (2022). Suici-
dality in clinic-referred transgender adolescents. European Child
& Adolescent Psychiatry, 31(1), 67–83. https:// doi. org/ 10. 1007/
s00787- 020- 01663-9
de Rooy, F. B. B., Arnoldussen, M., van der Miesen, A. I. R., Steensma,
T. D., Kreukels, B. P. C., Popma, A., & de Vries, A. L. C. (2024).
Mental health evaluation of younger and older adolescents referred
to the center of expertise on gender dysphoria in Amsterdam, the
Netherlands. Archives of Sexual Behavior, 53(8), 2883–2896.
https:// doi. org/ 10. 1007/ s10508- 024- 02940-3
de Vries, A. L. C., & Cohen-Kettenis, P. T. (2012). Clinical manage-
ment of gender dysphoria in children and adolescents: The Dutch
approach. Journal of Homosexuality, 59(3), 301–320. https:// doi.
org/ 10. 1080/ 00918 369. 2012. 653300
de Vries, A. L. C., Doreleijers, T. A. H., Steensma, T. D., & Cohen-
Kettenis, P. T. (2011). Psychiatric comorbidity in gender dysphoric
adolescents: Comorbidity in gender dysphoric adolescents. Jour-
nal of Child Psychology and Psychiatry, 52(11), 1195–1202.
https:// doi. org/ 10. 1111/j. 1469- 7610. 2011. 02426.x
de Vries, A. L. C., McGuire, J. K., Steensma, T. D., Wagenaar, E. C.
F., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014). Young
adult psychological outcome after puberty suppression and gen-
der reassignment. Pediatrics, 134(4), 696–704. https:// doi. org/ 10.
1542/ peds. 2013- 2958
de Vries, A. L. C., Steensma, T. D., Cohen-Kettenis, P. T., Vander-
Laan, D. P., & Zucker, K. J. (2016). Poor peer relations predict
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1358 Archives of Sexual Behavior (2025) 54:1341–1359
parent- and self-reported behavioral and emotional problems of
adolescents with gender dysphoria: A cross-national, cross-clinic
comparative analysis. European Child & Adolescent Psychiatry,
25(6), 579–588. https:// doi. org/ 10. 1007/ s00787- 015- 0764-7
Döpfner, M., Plück, J., Bölte, S., etal. (1998). Fragebogen für
Jugendliche; deutsche Bearbeitung der Youth Self-Report Form
der Child Behavior Checklist (YSR). Einführung und Anlei-
tung zur Handauswertung mit deutschen Normen: Arbeitsgruppe
Deutsche Child Behavior Checklist [Questionnaire for adoles-
cents; German adaptation of the Youth Self-Report form of the
Child Behavior Checklist (YSR). Introduction and instructions
for hand scoring with German norms: German Child Behavior
Checklist Working Group]. Arbeitsgruppe Kinder-, Jugend- und
Familiendiagnostik (KJFD).
Dolotina, B., Turban, J. L., Freitag, T. M., King, D., & Keuroghlian,
A. S. (2022). Age of realization of gender identity and mental
health outcomes among transgender and gender-diverse adults:
Evaluating the “rapid-onset gender dysphoria” hypothesis. Jour-
nal of the American Academy of Child and Adolescent Psychia-
try, 61(10), S264. https:// doi. org/ 10. 1016/j. jaac. 2022. 09. 390
Dorr, F., Lahmann, C., & Bengel, J. (2020). Differentielle Indika-
tion in der Versorgung von Patienten mit psychischen Störungen
[Differential indication in mental health care of patients with
mental disorders]. Psychotherapie, Psychosomatik, Medizinische
Psychologie, 70(6), 221–228.
Edwards-Leeper, L. (2017). Childhood gender nonconformity. In A.
Wenzel (Ed.), The SAGE Encyclopedia of abnormal and clinical
psychology (pp. 633–635). SAGE Publications.
Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (1983). The McMas-
ter Family Assessment Device. Journal of Marital and Family
Therapy, 9(2), 171–180. https:// doi. org/ 10. 1111/j. 1752- 0606.
1983. tb014 97.x
Erikson, E. H. (1968). Identity: Youth and crisis. Norton & Company.
Etengoff, C. (2019). Transvlogs: Online communication tools for
transformative agency and development. Mind, Culture, and
Activity, 26(2), 138–155. https:// doi. org/ 10. 1080/ 10749 039.
2019. 16124 38
Grossman, A. H., & D’Augelli, A. R. (2007). Transgender youth and
life-threatening behaviors. Suicide and Life-Threatening Behavior,
37(5), 527–537.
Grüters-Kieslich, A. (2009). Körperliche und biologische Entwicklung
in der Adoleszenz im Übergang zum Erwachsenenalter [Physical
and biological development in adolescence transition to adult-
hood].In J. M. Fegert, A. Streeck-Fischer, & H. J. Freyberger
(Eds.), Adoleszentenpsychiatrie (pp. 126–132). Schattauer.
Hartig, A., Voss, C., Herrmann, L., Fahrenkrug, S., Bindt, C., & Becker-
Hebly, I. (2022). Suicidal and nonsuicidal self-harming thoughts
and behaviors in clinically referred children and adolescents with
gender dysphoria. Clinical Child Psychology and Psychiatry,
27(3), 716–729. https:// doi. org/ 10. 1177/ 13591 04521 10739 41
Herrmann, L., Fahrenkrug, S., Bindt, C., Breu, F., Grebe, J., Reich-
ardt, C., Lammers, C. S., & Becker-Hebly, I. (2022). “Trans* ist
plural”: Behandlungsverläufe bei Geschlechtsdysphorie in einer
deutschen kinder- und jugendpsychiatrischen Spezialambulanz
[“Trans* is pluralistic”: Treatment trajectories for gender dyspho-
ria in a german child and adolescent psychiatry outpatient clinic].
Zeitschrift für Sexualforschung, 35(4), 209–219. https:// doi. org/
10. 1055/a- 1964- 1907
Henriette, A., de Waal, D.-V., & Cohen-Kettenis, P. T. (2006). Clinical
management of gender identity disorder in adolescents: A protocol
on psychological and paediatric endocrinology aspects. European
Journal of Endocrinology, 155(suppl_1), S131–S137. https:// doi.
org/ 10. 1530/ eje.1. 02231
Herrmann, L., Barkmann, C., Bindt, C., Fahrenkrug, S., Breu, F.,
Grebe, J., & Becker-Hebly, I. (2023a). Binary and non-binary
gender identities, internalizing problems, and treatment wishes
among adolescents referred to a gender identity clinic in Germany.
Archives of Sexual Behavior, 53(1), 91–106. https:// doi. org/ 10.
1007/ s10508- 023- 02674-8
Herrmann, L., Bindt, C., Hohmann, S., & Becker-Hebly, I. (2023b).
Social media use and experiences among transgender and gender
diverse adolescents. International Journal of Transgender Health,
25(1), 36–49. https:// doi. org/ 10. 1080/ 26895 269. 2023. 22524 10
Holt, V., Skagerberg, E., & Dunsford, M. (2016). Young people with
features of gender dysphoria: Demographics and associated diffi-
culties. Clinical Child Psychology and Psychiatry, 21(1), 108–118.
https:// doi. org/ 10. 1177/ 13591 04514 55843
Hutchinson, A., Midgen, M., & Spiliadis, A. (2020). In support of
research into rapid-onset gender dysphoria [Letter to the Editor].
Archives of Sexual Behavior, 49(1), 79–80. https:// doi. org/ 10. 1007/
s10508- 019- 01517-9
Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015).
Two years of gender identity service for minors: Overrepresenta-
tion of natal girls with severe problems in adolescent develop-
ment. Child and Adolescent Psychiatry and Mental Health, 9(1),
9. https:// doi. org/ 10. 1186/ s13034- 015- 0042-y
Lawrence, A. A. (2003). Factors associated with satisfaction or regret
following male-to-female sex reassignment surgery. Archives of
Sexual Behavior, 32, 299–315. https:// doi. org/ 10. 1023/a: 10240
86814 364
Lawrence, A. A. (2010). Sexual orientation versus age of onset as bases
for typologies (subtypes) for gender identity disorder in adoles-
cents and adults. Archives of Sexual Behavior, 39(2), 514–545.
https:// doi. org/ 10. 1007/ s10508- 009- 9594-3
Levitan, N., Barkmann, C., Richter-Appelt, H., Schulte-Markwort, M.,
& Becker-Hebly, I. (2019). Risk factors for psychological func-
tioning in German adolescents with gender dysphoria: Poor peer
relations and general family functioning. European Child & Ado-
lescent Psychiatry, 28(11), 1487–1498. https:// doi. org/ 10. 1007/
s00787- 019- 01308-6
Little, R. J. A., & Rubin, D. B. (2014). Statistical analysis with missing
data. John Wiley & Sons.
Littman, L. (2018). Parent reports of adolescents and young adults per-
ceived to show signs of a rapid onset of gender dysphoria. PLoS
ONE, 13(8), e0202330. https:// doi. org/ 10. 1371/ journ al. pone.
02023 30
Mertens, W. (1996). Entwicklung der Psychosexualität und der
Geschlechtsidentität: Kindheit und Adoleszenz [Development of
psychosexuality and gender identity: Childhood and adolescence].
Kohlhammer.
Nahata, L., Quinn, G. P., Caltabellotta, N. M., & Tishelman, A. C.
(2017). Mental health concerns and insurance denials among
transgender adolescents. LGBT Health, 4(3), 188–193. https://
doi. org/ 10. 1089/ lgbt. 2016. 0151
Nadal, K. L. (2017). The SAGE encyclopedia of psychology and gender.
SAGE Publications, Inc. https:// doi. org/ 10. 4135/ 97814 83384 269
Nieder, T. O., Herff, M., Cerwenka, S., Preuss, W. F., Cohen-Kettenis,
P. T., De Cuypere, G., Hebold Haraldsen, I. R., & Richter-Appelt,
H. (2011). Age of onset and sexual orientation in transsexual males
and females. Journal of Sexual Medicine, 8(3), 783–791. https://
doi. org/ 10. 1111/j. 1743- 6109. 2010. 02142.x
Pereira-Antunes, M., Lopes, A. F., Carvalho-e-Marques, P., Queirós,
O., Guerra, J., Falco, C., & Soeiro, D. (2023). Gender dysphoria/
gender incongruence of pre or post-pubertal onset: Differences
in psychiatric comorbidities and socio-familial determinants. A
cross-sectional study. Portuguese Journal of Pediatrics, 54, 236–
242. https:// doi. org/ 10. 24875/ PJP. M2300 0047
Person, E., & Ovesey, L. (1974). The transsexual syndrome in males:
I. Primary transsexualism. American Journal of Psychotherapy,
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1359Archives of Sexual Behavior (2025) 54:1341–1359
28(1), 4–20. https:// doi. org/ 10. 1176/ appi. psych other apy. 1974.
28.1.4
Roberts, C. M., Klein, D. A., Adirim, T. A., Schvey, N. A., & Hisle-
Gorman, E. (2022). Continuation of gender-affirming hormones
among transgender adolescents and adults. Journal of Clinical
Endocrinology & Metabolism, 107(9), e3937–e3943. https:// doi.
org/ 10. 1210/ clinem/ dgac2 51
Röder, M., Barkmann, C., Richter-Appelt, H., Schulte-Markwort, M.,
Ravens-Sieberer, U., & Becker, I. (2018). Health-related quality
of life in transgender adolescents: Associations with body image
and emotional and behavioral problems. International Journal of
Transgenderism, 19(1), 78–91. https:// doi. org/ 10. 1080/ 15532 739.
2018. 14256 49
Sapir, L., Littman, L., & Biggs, M. (2024). The U.S. Transgender Survey
of 2015 supports rapid-onset gender dysphoria: Revisiting the “Age
of Realization and Disclosure of Gender Identity among Transgen-
der Adults” [Letter to the Editor]. Archives of Sexual Behavior,
53(3), 863–868. https:// doi. org/ 10. 1007/ s10508- 023- 02754-9
Schorre, B. E. H., & Vandvik, I. H. (2004). Global assessment of psy-
chosocial functioning in child and adolescent psychiatry: A review
of three unidimensional scales (CGAS, GAP, GAPD). European
Child & Adolescent Psychiatry, 13(5), 273–286. https:// doi. org/
10. 1007/ s00787- 004- 0390-2
Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H.,
& Aluwahlia, S. (1983). A Children’s Global Assessment Scale
(CGAS). Archives of General Psychiatry, 40(11), 1228–1231.
https:// doi. org/ 10. 1001/ archp syc. 1983. 01790 10007 4010
Shiffman, M., VanderLaan, D. P., Hayley Wood, S., Hughes, K., Owen-
Anderson, A., Lumley, M. M., Lollis, S. P., & Zucker, K. J. (2016).
Behavioral and emotional problems as a function of peer relation-
ships in adolescents with gender dysphoria: A comparison with
clinical and nonclinical controls. Psychology of Sexual Orienta-
tion and Gender Diversity, 3(1), 27–36. https:// doi. org/ 10. 1037/
sgd00 00152
Sievert, E. D., Schweizer, K., Barkmann, C., Fahrenkrug, S., & Becker-
Hebly, I. (2021). Not social transition status, but peer relations and
family functioning predict psychological functioning in a German
clinical sample of children with gender dysphoria. Clinical Child
Psychology and Psychiatry, 26(1), 79–95. https:// doi. org/ 10. 1177/
13591 04520 964530
Sorbara, J. C., Chiniara, L. N., Thompson, S., & Palmert, M. R. (2020).
Mental health and timing of gender-affirming care. Pediatrics, 146.
https:// doi. org/ 10. 1542/ peds. 2019- 3600
Spack, N. P., Edwards-Leeper, L., Feldman, H. A., Leibowitz, S., Man-
del, F., Diamond, D. A., & Vance, S. R. (2012). Children and
adolescents with gender identity disorder referred to a pediatric
medical center. Pediatrics, 129(3), 418–425. https:// doi. org/ 10.
1542/ peds. 2011- 0907
Steensma, T. D., Zucker, K. J., Kreukels, B. P. C., VanderLaan, D. P.,
Wood, H., Fuentes, A., & Cohen-Kettenis, P. T. (2014). Behavioral
and emotional problems on the Teacher’s Report Form: A cross-
national, cross-clinic comparative analysis of gender dysphoric
children and adolescents. Journal of Abnormal Child Psychology,
42(4), 635–647. https:// doi. org/ 10. 1007/ s10802- 013- 9804-2
Sun, C.-F., Xie, H., Metsutnan, V., Draeger, J. H., Lin, Y., Hankey, M.
S. , & Kablinger, A. S. (2023). The mean age of gender dysphoria
diagnosis is decreasing. General Psychiatry, 36, e100972. https://
doi. org/ 10. 1136/ gpsych- 2022- 100972
Thompson, L., Sarovic, D., Wilson, P., Sämord, A., & Gillberg, C.
(2022). A prisma systematic review of adolescent gender dyspho-
ria literature: 1) Epidemiology. PLoS Global Public Health, 2(3),
e0000245. https:// doi. org/ 10. 1371/ journ al. pgph. 00002 45
Toomey, R. B., Ryan, C., Diaz, R. M., Card, N. A., & Russell, S. T.
(2010). Gender-nonconforming lesbian, gay, bisexual, and
transgender youth: School victimization and young adult psycho-
social adjustment. Developmental Psychology, 46(6), 1580–1589.
https:// doi. org/ 10. 1037/ a0020 705
Turban, J. L., Dolotina, B., Freitag, T. M., King, D., & Keuroghlian, A. S.
(2023). Age of realization and disclosure of gender identity among
transgender adults. Journal of Adolescent Health, 72(6), 852–859.
Wallien, M. S., van Goozen, S. H., & Cohen-Kettenis, P. T. (2007).
Physiological correlates of anxiety in children with gender iden-
tity disorder. European Child & Adolescent Psychiatry, 16(5),
309–315. https:// doi. org/ 10. 1007/ s00787- 007- 0602-7
Winkler, J., & Stolzenberg, H. (1999). Der Sozialschichtindex im Bun-
des-Gesundheitssurvey [Social class index in the Federal Health
Survey]. Gesundheitswesen, 61(S2), 178–183.
World Health Organization. (2019). International statistical classification
of diseases and related health problems (11th ed.). https:// ic d. who. int/
Zhang, Q., Goodman, M., Adams, N., Corneil, T., Hashemi, L., Kreu-
kels, B., Motmans, J., Snyder, R., & Coleman, E. (2020). Epi-
demiological considerations in transgender health: A systematic
review with focus on higher quality data. International Journal
of Transgender Health, 21(2), 125–137. https:// doi. org/ 10. 1080/
26895 269. 2020. 17531 36
Zucker, K. J. (2019). Adolescents with gender dysphoria: Reflections
on some contemporary clinical and research issues. Archives of
Sexual Behavior, 48(7), 1983–1992. https:// doi. org/ 10. 1007/
s10508- 019- 01518-8
Zucker, K. J., & Bradley, S. J. (1995). Gender identity disorder and psy-
chosexual problems in children and adolescents. Guilford Press.
Zucker, K. J., Bradley, S. J., Owen-Anderson, A., Kibblewhite, S. J.,
Wood, H., Singh, D., & Choi, K. (2012). Demographics, behavior
problems, and psychosexual characteristics of adolescents with
gender identity disorder or transvestic fetishism. Journal of Sex &
Marital Therapy, 38(2), 151–189. https:// doi. org/ 10. 1080/ 00926
23X. 2011. 611219
Zucker, K. J., Bradley, S. J., & Sanikhani, M. (1997). Sex differences
in referral rates of children with gender identity disorder: Some
hypotheses. Journal of Abnormal Child Psychology, 25(3), 217–
227. https:// doi. org/ 10. 1023/A: 10257 48032 640
Zucker, K. J., Owen, A., Bradley, S. J., & Ameeriar, L. (2002). Gender-
dysphoric children and adolescents: A comparative analysis of
demographic characteristics and behavioral problems. Clinical
Child Psychology and Psychiatry, 7(3), 398–411. https:// doi. org/
10. 1177/ 13591 04502 00700 3007
Publisher's Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com
