Hayley Wood’s research while affiliated with Toronto District School Board and other places

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Publications (20)


Suicidality in clinic-referred transgender adolescents
  • Article
  • Full-text available

January 2022

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2,161 Reads

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47 Citations

European Child & Adolescent Psychiatry

Nastasja M De Graaf

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· Polly Carmichael

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Gender and sexually diverse adolescents have been reported to be at an elevated risk for suicidal thoughts and behaviors. For transgender adolescents, there has been variation in source of ascertainment and how suicidality was measured, including the time-frame (e.g., past 6 months, lifetime). In studies of clinic-referred samples of transgender adolescents, none utilized any type of comparison or control group. The present study examined suicidality in transgender adolescents (M age, 15.99 years) seen at specialty clinics in Toronto, Canada, Amsterdam, the Netherlands, and London, UK (total N = 2771). Suicidality was measured using two items from the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR). The CBCL/ YSR referred and non-referred standardization samples from both the U.S. and the Netherlands were used for comparative purposes. Multiple linear regression analyses showed that there was significant between-clinic variation in suicidality on both the CBCL and the YSR; in addition, suicidality was consistently higher among birth-assigned females and strongly associated with degree of general behavioral and emotional problems. Compared to the U.S. and Dutch CBCL/YSR standardization samples, the relative risk of suicidality was somewhat higher than referred adolescents but substantially higher than non-referred adolescents. The results were discussed in relation to both gender identity specific and more general risk factors for suicidality.

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Traits of Autism Spectrum Disorder in School-Aged Children With Gender Dysphoria: A Comparison to Clinical Controls

September 2019

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1,321 Reads

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23 Citations

Clinical Practice in Pediatric Psychology

Objective: Studies of children with gender dysphoria (GD) have reported an overrepresentation of autism spectrum disorder (ASD) or traits. One limitation of these studies has been the absence of a concurrent comparison group of children referred for other clinical problems. The present study addressed this gap by comparing 61 children referred for GD with 40 children referred for other clinical concerns (age range, 4–12 years). Method: ASD caseness was measured in 2 ways: (a) a Diagnostic and Statistical Manual of Mental Disorders ( DSM) diagnosis of ASD or cut-off scores for caseness or (b) dimensionally on 2 standardized measures. Results: Children with GD had a higher proportion with a co-occurring DSM diagnosis of ASD and a higher proportion who met the criterion for caseness on the Social Communications Questionnaire than the clinical controls. In contrast, on the Social Responsiveness Scale, the 2 groups were similar with regard to caseness and traits of ASD. Conclusions: The results of our study showed evidence of both specificity and nonspecificity with regard to ASD traits and caseness. Future research can adopt the principle of multifinality to understand better why only a minority of children with GD have a co-occurring diagnosis of ASD, but the majority does not. Implications for Impact Statement The present study draws specific attention to the overrepresentation of autism spectrum disorder traits among children referred for gender dysphoria. Children with gender dysphoria should be screened for a possible autism spectrum disorder (ASD) and, when warranted, receive a more comprehensive ASD diagnostic assessment to facilitate more holistic clinical care.


TABLE 2 DSM-IV-TR Diagnoses 
TABLE 2 (Continued) 
Psychosocial and Psychological Vulnerability in Adolescents with Gender Dysphoria: A "Proof of Principle" Study

October 2016

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2,785 Reads

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54 Citations

For adolescents with gender dysphoria, it has become common to be offered hormonal treatment to either delay or suppress pubertal development and/or to masculinize or feminize the body. At the same time, it has been our clinical impression that the psychological vulnerability of at least some of these youth has been overlooked. Fifty consecutive referrals of adolescents with a DSM-IV-TR diagnosis of Gender Identity Disorder (GID) constituted the sample. Information obtained at intake was coded for the presence or absence of 15 psychosocial and psychological vulnerability factors. The mean number of psychosocial/psychological vulnerability factors coded as present was 5.56 (range, 0-13). Over half of the sample had 6 or more of the vulnerability factors. The number of factors coded as present was significantly correlated with behavioral and emotional problems on the Youth Self-Report form and the Child Behavior Checklist, but not with demographic variables or IQ. The findings supported the clinical impression that a large percentage of adolescents referred for gender dysphoria have a substantial co-occurring history of psychosocial and psychological vulnerability, thus supporting a "proof of principle" for the importance of a comprehensive psychologic/psychiatric assessment that goes beyond an evaluation of gender dysphoria per se.


TABLE 2 Sample Size, Age, and Percentage of Sample With Only-Child Status by Group and Sex 
TABLE 3 Odds of Gender-Referred Natal Males Being Only Children Compared to Clinical Comparison Group 
TABLE 4 Odds of Gender-Referred Natal Females Being Only Children Compared to Clinical Comparison Group 
The Prevalence of Only-Child Status among Children and Adolescents Referred to a Gender Identity Service vs. a Clinical Comparison Group

July 2016

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1,407 Reads

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6 Citations

Several studies indicate that homosexual males have a high proportion of older brothers compared to heterosexual males. Natal males with gender dysphoria who are likely to be homosexual also display this sibship pattern. Until recently, there was little evidence linking homosexuality and/or gender dysphoria in females to unique sibship characteristics. Two studies have indicated that natal female youth clinically referred for gender dysphoria are more likely to be only children (Schagen et al., 2012 ; VanderLaan et al., 2014 ). However, these studies did not include control groups of youth clinically referred for other reasons. Thus, it is unclear whether the increased likelihood of only-child status is specific to gender-referred natal females. This study compared only-child status among youth referred to a mental health service for gender dysphoria (778 males, 245 females) vs. other reasons (783 males, 281 females). Prehomosexual gender-referred males were less likely to be only children than clinical controls. Contrary to previous findings, gender-referred females were not more likely to be only children, indicating that increased likelihood of only child status is not specific to gender-referred females, but is characteristic of clinic-referred females more generally.



Behavioral and Emotional Problems as a Function of Peer Relationships in Adolescents With Gender Dysphoria: A Comparison With Clinical and Nonclinical Controls

December 2015

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2,125 Reads

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54 Citations

Psychology of Sexual Orientation and Gender Diversity

This study examined peer relations in adolescents with gender dysphoria, clinical controls, and nonreferred controls. Specifically, we examined group differences in 2 types of bullying experienced (gender identity/sexuality vs. “general” forms), numbers of same- and opposite-sex friends (relative to birth sex), and the influences of bullying and friends on behavioral and emotional problems. Participants (N = 158; M age, 16.94 years, SD = 1.82) completed measures of gender dysphoria, bullying, numbers of same- and opposite-sex friends at school and in the community, and behavioral and emotional problems. The gender-dysphoric and clinical control adolescents reported significantly more behavioral and emotional problems relative to the nonclinical adolescents. When examining the 2 major forms of bullying, the gender-dysphoric adolescents reported more gender/sexual bullying than the 2 other groups, but both the gender-dysphoric group and the clinical control group reported more general bullying than the nonclinical controls. The gender-dysphoric adolescents had fewer same-sex friends, but more opposite-sex friends, compared with controls. In the gender-dysphoric group, gender bullying, general bullying, and fewer same-sex friends at school were all significantly correlated with a greater number of self-reported behavioral and emotional problems. Strategies for reducing behavioral and emotional problems among adolescents with gender dysphoria are discussed. (PsycINFO Database Record (c) 2015 APA, all rights reserved)


Figure 1: Number of adolescent patients assessed by sex and year
Table 1 Number and percentage of adolescent referrals by group and time period 
Figure 2: Curvilinear relationship between number of patients assessed by year (1975–2013)
Table 2 Logistic regression: proportion of adolescent referred males vs. females by group × time period 
Table 3 Number and percentage of adolescent referrals by sex, sexual orientation, and time period 
Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents with Gender Dysphoria

January 2015

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5,300 Reads

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425 Citations

Journal of Sexual Medicine

The number of adolescents referred to specialized gender identity clinics for gender dysphoria appears to be increasing and there also appears to be a corresponding shift in the sex ratio, from one favoring natal males to one favoring natal females. We conducted two quantitative studies to ascertain whether there has been a recent inversion of the sex ratio of adolescents referred for gender dysphoria. The sex ratio of adolescents from two specialized gender identity clinics was examined as a function of two cohort periods (2006-2013 vs. prior years). Study 1 was conducted on patients from a clinic in Toronto, and Study 2 was conducted on patients from a clinic in Amsterdam. Across both clinics, the total sample size was 748. In both clinics, there was a significant change in the sex ratio of referred adolescents between the two cohort periods: between 2006 and 2013, the sex ratio favored natal females, but in the prior years, the sex ratio favored natal males. In Study 1 from Toronto, there was no corresponding change in the sex ratio of 6,592 adolescents referred for other clinical problems. Sociological and sociocultural explanations are offered to account for this recent inversion in the sex ratio of adolescents with gender dysphoria. Aitken M, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A, Spegg C, Wasserman L, Ames M, Fitzsimmons CL, Leef JH, Lishak V, Reim E, Takagi A, Vinik J, Wreford J, Cohen-Kettenis PT, de Vries ALC, Kreukels BPC, and Zucker KJ. Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. J Sex Med **;**:**-**. © 2015 International Society for Sexual Medicine.


Citations (17)


... The psychological problems and psychiatric comorbidities of minors who are AFAB and AMAB are still debated. Some studies have reported poorer mental health in young individuals who are AFAB, particularly in terms of depression and anxiety [25], self-harm [26], and suicidality [27]. However, other studies have shown the opposite, indicating that individuals who are AMAB might have worse mental health [28, 29]. ...

Reference:

Clinical profiles and care of transgender children and adolescents who receive specialized consultations: do individuals who are assigned female at birth differ?
Suicidality in clinic-referred transgender adolescents

European Child & Adolescent Psychiatry

... A group that requires specific attention when it comes to mental health are adolescents with gender incongruence and co-occurring autism spectrum disorder (ASD). The cooccurrence of ASD in gender incongruent children and adolescents has been widely reported (de Vries et al., 2010;Holt et al., 2016;Leef et al., 2019;Mahfouda et al., 2019;Strang et al., 2018b;van der Miesen et al., 2018b;Warrier et al., 2020), and both ASD and gender incongruence are associated with experiencing additional mental health difficulties. Although little research has been done to assess the psychological functioning of adolescents with intersecting gender incongruence and ASD, the available studies show that these adolescents seem especially at risk for mental health problems (Mahfouda et al., 2019;van der Miesen et al., 2018c). ...

Traits of Autism Spectrum Disorder in School-Aged Children With Gender Dysphoria: A Comparison to Clinical Controls

Clinical Practice in Pediatric Psychology

... The existing literature includes several studies that suggest no significant relationship between psychological vulnerability and gender. For example, Bechard et al. (2017) reported that levels of psychological vulnerability did not significantly differ based on gender. Likewise, Nogueira et al. (2021) found no gender-related differences in the psychological vulnerability levels among Portuguese university students. ...

Psychosocial and Psychological Vulnerability in Adolescents with Gender Dysphoria: A "Proof of Principle" Study

... The number of referrals over time was reported for 11 countries (figure 2). 2 21-26 Around 5-6 years into the data presented by year in the individual studies there is a sharp increase (twofold to threefold) in referral numbers across all countries except the Netherlands which started to increase in 2011 25 and Denmark which only had 2 years of data. 2 There was a mixture of child and/or adolescent data presented across countries with the average age of children being 7/8 and adolescents 14-17 (online supplemental table S3). The combined child and adolescent data showed mixed findings, with a group of studies conducted relatively early having ages around 10/11, [27][28][29][30] and later studies of around 13-16, which is more closely aligned to studies with adolescent samples. This indicates a potential increase in the number of adolescents within the combined samples. ...

The Prevalence of Only-Child Status among Children and Adolescents Referred to a Gender Identity Service vs. a Clinical Comparison Group

... The number of those identifying with transgender identities have been increasing in recent years. The size of this increase can be different based on the methodology used (Zucker, 2017;Zucker et al., 2016). One meta-analysis, reviewing studies on the clinic referrals of GD, suggested a global prevalence of 4.6:100,000; 6.8 for transgender women (TW) and 2.6 for transgender men (TM) (Arcelus et al., 2015). ...

Increasing referrals for gender dysphoria [Letter to the Editor]

Journal of Adolescent Health

... 15,17,19 Female-assigned individuals who identify as male generally enter puberty earlier than male-assigned individuals who identify as female. 20 Therefore, the demand for somatic interventions tends to arise at younger ages, 15,17-20 driving greater demand for healthcare services to manage somatic experiences that are inconsistent with the individual's gender identity. ...

Behavioral and Emotional Problems as a Function of Peer Relationships in Adolescents With Gender Dysphoria: A Comparison With Clinical and Nonclinical Controls

Psychology of Sexual Orientation and Gender Diversity

... Suicidal ideation (SI) and attempts (Macmullin et al., 2019;Mak et al., 2020;Spivey & Prinstein, 2018;Strauss et al., 2020), and generalised anxiety disorders (Chodzen, Hidalgo, Chen, & Garofalo, 2019), for example, are much more prevalent in GNC and trans young people compared to their age-matched, gender-conforming (GC) peers. Reasons for poor mental health outcomes in these groups are multifactorial but stem from a combination of body dysphoria and minority-related stressors, which often include societal and family non-acceptance, victimisation, and internalised prejudices (Chodzen et al., 2019;Rabasco & Andover, 2020;Reisner et al., 2016;Roberts, Rosario, Slopen, Calzo, & Austin, 2013;Robles et al., 2016;Strauss et al., 2020;Zucker, Wood, & VanderLaan, 2014). ...

Focus on Sexuality Research

... Alongside the increase in the number of consultations with transgender children and adolescents, a gender proportion reversal was observed, similar to previous studies, where from the 2010s onward, male-identified individuals and their guardians increasingly sought genderaffirming healthcare services earlier in life. [15][16][17][18] Access to information and efforts to combat prejudice may be responsible for the growing number of guardians seeking guidance regarding gender variability, including during childhood and adolescence. The increasing scientif ic discussion on transgender and transvestite issues in Brazil is evident through the growing number of academic works, such as dissertations and theses, particularly after 2010, the year the National Policy for Comprehensive Health of LGBT was published. ...

Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents with Gender Dysphoria

Journal of Sexual Medicine

... The most cited study, by five clinical guidance documents, was de Vries et al. . 61 Relatively few studies have been cited across all 31 guidance documents; many of which do not directly provide recommendations for caring for autistic TGD individuals, and a few of which are only tangentially related to the cooccurrence. ...

Autism Spectrum Disorder Risk Factors and Autistic Traits in Gender Dysphoric Children

Journal of Autism and Developmental Disorders

... Also, it appears to be prenatal in origin. Maternal immune activation during pregnancy is associated with relatively lower birth weight (Christensen et al., 2012;Kahn & Baltimore, 2010) and androphilic, compared with gynephilic, males with older brothers have lower birth weight (Blanchard & Ellis, 2001;VanderLaan et al., 2015). In a direct test of the mechanism, Bogaert et al. (2018) found that mothers of gay sons, and especially gay sons with older brothers, had elevated antibodies to neuroligin 4 Y-linked (NLGN4Y), which is a malespecific protein produced by the Y-chromosome thought to be involved in fetal brain development. ...

Birth Weight and Two Possible Types of Maternal Effects on Male Sexual Orientation: A Clinical Study of Children and Adolescents Referred to a Gender Identity Service

Developmental Psychobiology