SEGM has been compiling a compendium of literature to highlight our position of concern over the proliferation of hormonal and surgical "gender-affirmative" interventions for gender dysphoric youth. This is NOT an all-inclusive list of all the studies in the field of pediatric gender medicine. Rather, we aim to highlight unsettled debates in the field. Some of the studies have been curated by SEGM. These studies show a "SEGM Analysis" tab.

This is an ongoing project. We welcome any feedback from the research community that will help improve this compendium. Please check this site frequently for updates.

A. Novel epidemiological trend: adolescent-onset gender dysphoria with mental health comorbidities
Sapir, L., Littman, L., & Biggs, M. (2023). The U.S. Transgender Survey of 2015 Supports Rapid-Onset Gender Dysphoria: Revisiting the “Age of Realization and Disclosure of Gender Identity Among Transgender Adults.” Archives of Sexual Behavior. https://doi.org/10.1007/s10508-023-02754-9
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Bailey, M., & Diaz, S. (2023). Rapid-Onset Gender Dysphoria: Parent Reports on 1,655 Possible Cases. Journal of Open Inquiry in the Behavioral Sciences. https://doi.org/10.58408/issn.2992-9253.2023.01.01.00000012
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Journal AbstractDuring the past decade, there has been a dramatic increase in adolescents and young adults (AYAs) complaining of gender dysphoria. One influential if controversial explanation is that the increase reflects a socially contagious syndrome among emotionally vulnerable youth: rapid-onset gender dysphoria (ROGD). We report results from a survey of parents who contacted the website ParentsofROGDKids.com because they believed their AYA children had ROGD. Results focused on parent reports on 1,655 AYA children whose gender dysphoria began between ages 11 and 21 years, inclusive. These youths were disproportionately (75%) natal female. Natal males had later onset (by 1.9 years) than females, and they were much less likely to have taken steps towards social gender transition (65.7% for females versus 28.6% for males). Pre-existing mental health issues were common, and youths with these issues were more likely than those without them to have socially and medically transitioned. Parents reported that they had often felt pressured by clinicians to affirm their AYA child’s new gender and support their transition. According to the parents, AYA children’s mental health deteriorated considerably after social transition. We discuss potential biases of survey responses from this sample and conclude that there is presently no reason to believe that reports of parents who support gender transition are more accurate than those who oppose transition. To resolve controversies regarding ROGD, it is desirable that future research include data provided by both pro-transition and anti-transition parents, as well as their gender dysphoric AYA children.
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Kulatunga-Moruzi, C. (2023). Research and Analyses by Turban et al. Fail to Refute Rapid-Onset Gender Dysphoria. Journal of Adolescent Health, 73(6), 1162. https://doi.org/10.1016/j.jadohealth.2023.07.031
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Sinai, J. (2022). Rapid onset gender dysphoria as a distinct clinical phenomenon. The Journal of Pediatrics, S0022347622001858. https://doi.org/10.1016/j.jpeds.2022.03.005
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Littman, L. (2022). Saying that Bauer et al studied rapid onset gender dysphoria is inaccurate and misleading. The Journal of Pediatrics, S0022347622001834. https://doi.org/10.1016/j.jpeds.2022.03.003
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More Studies
Giovanardi, G., Fortunato, A., Mirabella, M., Speranza, A. M., & Lingiardi, V. (2020). Gender Diverse Children and Adolescents in Italy: A Qualitative Study on Specialized Centers’ Model of Care and Network. International Journal of Environmental Research and Public Health, 17(24), 9536. https://doi.org/10.3390/ijerph17249536
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Journal AbstractIn recent years, Italy, similar to many other countries, has witnessed an increase in children and adolescents presenting gender incongruence. This trend has led to the development and implementation of specialized centers providing care and support for these youths and their families. The present study aimed at investigating the functioning of agencies specialized in working with transgender and gender non-conforming youths in the Italian territory. Professionals in these agencies were interviewed about their perspectives on their agency’s functioning, networks with other services, and work with trans* youths and their families. A semi-structured interview was developed and administered to professionals in specialized centers and associations dedicated to trans * youths, and deductive thematic analysis was applied to the transcripts. Eight professionals were interviewed: six working in specialized centers and two working in associations. The qualitative analyses of transcripts revealed four main themes, pertaining to service referrals, assessment protocols and intervention models, psychological support for youths and families, and agency shortcomings. The study explored the functioning of Italian agencies specialized in caring for transgender and gender non-conforming youths, from the perspective of professionals working in these agencies. While several positive aspects of the work emerged, the study highlighted a lack of uniformity across the Italian territory and the need for better networks between agencies and other medical professionals.
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de Vries, A. L. C. (2020). Challenges in Timing Puberty Suppression for Gender-Nonconforming Adolescents. Pediatrics, 146(4), e2020010611. https://doi.org/10.1542/peds.2020-010611
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Hutchinson, A., Midgen, M., & Spiliadis, A. (2020). In Support of Research Into Rapid-Onset Gender Dysphoria. Archives of Sexual Behavior, 49(1), 79–80. https://doi.org/10.1007/s10508-019-01517-9
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Littman, L. (2020). The Use of Methodologies in Littman (2018) Is Consistent with the Use of Methodologies in Other Studies Contributing to the Field of Gender Dysphoria Research: Response to Restar (2019). Archives of Sexual Behavior, 49(1), 67–77. https://doi.org/10.1007/s10508-020-01631-z
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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
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Journal AbstractThis article provides an overview of five contemporary clinical and research issues pertaining to adolescents with a diagnosis of gender dysphoria: (1) increased referrals to specialized gender identity clinics; (2) alteration in the sex ratio; (3) suicidality; (4) “rapid-onset gender dysphoria” (ROGD) as a new developmental pathway; (5) and best practice clinical care for adolescents who may have ROGD.
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de Graaf, N. M., & Carmichael, P. (2019). Reflections on emerging trends in clinical work with gender diverse children and adolescents. Clinical Child Psychology and Psychiatry, 24(2), 353–364. https://doi.org/10.1177/1359104518812924
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Journal AbstractGender is a fast-evolving and topical field which is often the centre of attention in the media and in public policy debates. The current cultural and social climate provides possibilities for young people to express themselves. Gender diverse young people are not only developing new
ways of describing gender, but they are also shaping what is required of clinical interventions.

Emerging cultural, social and clinical trends, such as increases in referrals, shifts in sex ratio and diversification in gender identification, illustrate that gender diverse individuals are not a homogeneous group. How do evolving concepts of gender impact the clinical care of gender diverse young people presenting to specialist gender clinics today?
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Littman, L. (2018). Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLOS ONE, 13(8), e0202330. https://doi.org/10.1371/journal.pone.0202330
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Journal AbstractPURPOSE: In on-line forums, parents have reported that their children seemed to experience a sudden or rapid onset of gender dysphoria, appearing for the first time during puberty or even after its completion. Parents describe that the onset of gender dysphoria seemed to occur in the context of belonging to a peer group where one, multiple, or even all of the friends have become gender dysphoric and transgender-identified during the same timeframe. Parents also report that their children exhibited an increase in social media/internet use prior to disclosure of a transgender identity. Recently, clinicians have reported that post-puberty presentations of gender dysphoria in natal females that appear to be rapid in onset is a phenomenon that they are seeing more and more in their clinic. Academics have raised questions about the role of social media in the development of gender dysphoria. The purpose of this study was to collect data about parents’ observations, experiences, and perspectives about their adolescent and young adult (AYA) children showing signs of an apparent sudden or rapid onset of gender dysphoria that began during or after puberty, and develop hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among this demographic group.

METHODS: For this descriptive, exploratory study, recruitment information with a link to a 90-question survey, consisting of multiple-choice, Likert-type and open-ended questions was placed on three websites where parents had reported sudden or rapid onsets of gender dysphoria occurring in their teen or young adult children. The study’s eligibility criteria included parental response that their child had a sudden or rapid onset of gender dysphoria and parental indication that their child’s gender dysphoria began during or after puberty. To maximize the chances of finding cases meeting eligibility criteria, the three websites (4thwavenow, transgender trend, and youthtranscriticalprofessionals) were selected for targeted recruitment. Website moderators and potential participants were encouraged to share the recruitment information and link to the survey with any individuals or communities that they thought might include eligible participants to expand the reach of the project through snowball sampling techniques. Data were collected anonymously via SurveyMonkey. Quantitative findings are presented as frequencies, percentages, ranges, means and/or medians. Open-ended responses from two questions were targeted for qualitative analysis of themes.

RESULTS: There were 256 parent-completed surveys that met study criteria. The AYA children described were predominantly natal female (82.8%) with a mean age of 16.4 years at the time of survey completion and a mean age of 15.2 when they announced a transgender-identification. Per parent report, 41% of the AYAs had expressed a non-heterosexual sexual orientation before identifying as transgender. Many (62.5%) of the AYAs had reportedly been diagnosed with at least one mental health disorder or neurodevelopmental disability prior to the onset of their gender dysphoria (range of the number of pre-existing diagnoses 0–7). In 36.8% of the friendship groups described, parent participants indicated that the majority of the members became transgender-identified. Parents reported subjective declines in their AYAs’ mental health (47.2%) and in parent-child relationships (57.3%) since the AYA “came out” and that AYAs expressed a range of behaviors that included: expressing distrust of non-transgender people (22.7%); stopping spending time with non-transgender friends (25.0%); trying to isolate themselves from their families (49.4%), and only trusting information about gender dysphoria from transgender sources (46.6%). Most (86.7%) of the parents reported that, along with the sudden or rapid onset of gender dysphoria, their child either had an increase in their social media/internet use, belonged to a friend group in which one or multiple friends became transgender-identified during a similar timeframe, or both.

CONCLUSION: This descriptive, exploratory study of parent reports provides valuable detailed information that allows for the generation of hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among AYAs. Emerging hypotheses include the possibility of a potential new subcategory of gender dysphoria (referred to as rapid-onset gender dysphoria) that has not yet been clinically validated and the possibility of social influences and maladaptive coping mechanisms. Parent-child conflict may also explain some of the findings. More research that includes data collection from AYAs, parents, clinicians and third party informants is needed to further explore the roles of social influence, maladaptive coping mechanisms, parental approaches, and family dynamics in the development and duration of gender dysphoria in adolescents and young adults.
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Bonfatto, M., & Crasnow, E. (2018). Gender/ed identities: an overview of our current work as child psychotherapists in the Gender Identity Development Service. Journal of Child Psychotherapy, 44(1), 29–46. https://doi.org/10.1080/0075417X.2018.1443150
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Journal AbstractThis paper is adapted from a presentation first given at the 2017 Association of Child Psychotherapists (ACP) Conference. We hope to give a feel of our work as psychoanalytic child psychotherapists working in a Tier 4 national assessment service for gender variant children and connect with our colleagues working therapeutically with these families in Child and Adolescent Mental Health Services (CAMHS) and other settings.

Gender variance does not have a single cause, or straightforward developmental pathway; rather it is a complex interplay of multiple factors, akin to sexuality in the diverse manifestations and ‘tributaries’ taken. This paper is given as a plea for complexity, to counter the current intense focus on gender identity and the consequent reductionism this can lead to.

To this end, three case studies from the clinic, taken from Under Five, Latency and Adolescent phases of development, are explored. The complexity of the cases is then discussed, followed by parallel issues of development, divergence and difference. These three ‘average’ cases from the Gender Identity Development Services (GIDS) serve to demonstrate the need for child psychotherapy as part of multi-disciplinary thinking about gender variance and how attention must be maintained to each unique story and process of identity development; as well as our clinical task to establish and encourage depressive functioning and secondary processes where possible.
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de Graaf, N. M., Carmichael, P., Steensma, T. D., & Zucker, K. J. (2018). Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London (2000–2017). The Journal of Sexual Medicine, 15(10), 1381–1383. https://doi.org/10.1016/j.jsxm.2018.08.002
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Journal AbstractINTRODUCTION: The prevalence of gender dysphoria in children is not known; however, there are some data on the sex ratio of children referred to specialized gender identity clinics.

AIM: We sought to examine the sex ratio of children, and some associated factors (age at referral and year of referral), referred to the Gender Identity Development Service in the United Kingdom, the largest such clinic in the world.

METHODS: The sex ratio of children (N ¼ 1,215) referred to the Gender Identity Development Service between 2000-2017 was examined, along with year of referral, age-related patterns, and age at referral.

MAIN OUTCOME MEASURE: Sex ratio of birth-assigned boys vs birth-assigned girls.

RESULTS: The sex ratio significantly favored birth-assigned boys over birth-assigned girls (1.27:1), but there were also age and year of referral effects. The sex ratio favored birth-assigned boys at younger ages (3-9 years), but favored birth-assigned girls at older ages (10-12 years). The percentage of referred birth-assigned boys significantly decreased when 2 cohorts were compared (2000-2006 vs 2007-2017). On average, birth-assigned boys were referred at a younger age than birth-assigned girls.

CLINICAL IMPLICATIONS: The evidence for a change in the sex ratio of children referred for gender dysphoria, particularly in recent years, matches a similar change in the sex ratio of adolescents referred for gender dysphoria. The reasons for this remain understudied.

STRENGTH & LIMITATIONS: The United Kingdom data showed both similarities and differences when compared to data from 2 other gender identity clinics for children (Toronto, Ontario, Canada, and Amsterdam, The Netherlands). Such data need to be studied in more gender identity clinics for children, perhaps with the establishment of an international registry.

CONCLUSION: Further study of the correlates of the sex ratio for children referred for gender dysphoria will be useful in clinical care and management.
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de Graaf, N. M., Giovanardi, G., Zitz, C., & Carmichael, P. (2018). Sex Ratio in Children and Adolescents Referred to the Gender Identity Development Service in the UK (2009–2016). Archives of Sexual Behavior, 47(5), 1301–1304. https://doi.org/10.1007/s10508-018-1204-9
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Kaltiala-Heino, R., Bergman, H., Työläjärvi, M., & Frisen, L. (2018). Gender dysphoria in adolescence: current perspectives. Adolescent Health, Medicine and Therapeutics, Volume 9, 31–41. https://doi.org/10.2147/AHMT.S135432
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Journal AbstractIncreasing numbers of adolescents are seeking treatment at gender identity services in Western countries. An increasingly accepted treatment model that includes puberty suppression with gonadotropin-releasing hormone analogs starting during the early stages of puberty, cross-sex hormonal treatment starting at ~16 years of age and possibly surgical treatments in legal adulthood, is often indicated for adolescents with childhood gender dysphoria (GD) that intensifies during puberty. However, virtually nothing is known regarding adolescent-onset GD, its progression and factors that influence the completion of the developmental tasks of adolescence among young people with GD and/or transgender identity. Consolidation of identity development is a central developmental goal of adolescence, but we still do not know enough about how gender identity and gender variance actually evolve. Treatment-seeking adolescents with GD present with considerable psychiatric comorbidity. There is little research on how GD and/or transgender identity are associated with completion of developmental tasks of adolescence.
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Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015). Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health, 9(1), 9. https://doi.org/10.1186/s13034-015-0042-y
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Journal AbstractBACKGROUND: Increasing numbers of adolescents present in adolescent gender identity services, desiring sex reassignment (SR). The aim of this study is to describe the adolescent applicants for legal and medical sex reassignment during the first two years of adolescent gender identity team in Finland, in terms of sociodemographic, psychiatric and gender identity related factors and adolescent development.

METHODS: Structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of 2013.

RESULTS: The number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common.

CONCLUSION: The findings do not fit the commonly accepted image of a gender dysphoric minor. Treatment guidelines need to consider gender dysphoria in minors in the context of severe psychopathology and developmental difficulties.
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Aitken, M., Steensma, T. D., Blanchard, R., VanderLaan, D. P., Wood, H., Fuentes, A., Spegg, C., Wasserman, L., Ames, M., Fitzsimmons, 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. The Journal of Sexual Medicine, 12(3), 756–763. https://doi.org/10.1111/jsm.12817
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Journal AbstractINTRODUCTION. 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.

AIM. We conducted two quantitative studies to ascertain whether there has been a recent inversion of the sex ratio of adolescents referred for gender dysphoria.

METHODS. 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.

RESULTS. 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.

CONCLUSIONS. Sociological and sociocultural explanations are offered to account for this recent inversion in the sex ratio of adolescents with gender dysphoria.

SEGM Summary

Short Summary: 

This research empirically documents a change in the demographics of gender dysphoric adolescents referred to gender clinics, notable for: 1) an increased rate of referrals for gender dysphoric adolescents; and 2) a reversal of the sex ratio of referred gender dysphoric adolescents from a population that favored natal males to a population that favors natal females. These changes occurred in two independent specialty gender clinics (Toronto and Amsterdam) around 2006. The etiology of these changes is unknown. None of the hypotheses offered fully explain the demographic changes observed for gender dysphoric adolescents and the absence of similar changes in adults.

Detail:

This is one of the earlier research studies to empirically document a change in the sex ratio of gender dysphoric adolescent patients referred to gender clinics, from a patient population that favored natal males (prior to 2006) to a patient population favoring natal females (2006-2013).

The current research consists of two studies that analyzed the sex ratio of gender dysphoric adolescent patients referred to the Gender Identity Service at the Center for Addiction and Mental Health (CAMH) in Toronto, Canada (the Toronto Clinic) and to the Center of Expertise on Gender Dysphoria at the VU University Medical Center in Amsterdam, the Netherlands (the Amsterdam clinic), respectively.

Study 1 evaluated data from 328 adolescents (13-19 years of age) referred to the Toronto clinic between 1976 and 2013. Over time, there was a significant increase in referred adolescents. Two time periods (1999-2005 and 2006-2013) were selected to analyze the patient natal sex data. Prior to 2006 (1999-2005), the percentage of natal males (67.9%) was greater than natal females (32.1%) but from 2006-2013, the percentage of natal females (63.9%) was greater than natal males (36.1%). In other words, the male to female sex ratio shifted from 2.11:1 to 1:1.76. The population of adolescents referred for gender dysphoria was compared to a control group which consisted of 6,592 adolescents who were referred for other reasons (not gender dysphoria) to the Children Youth and Family Services. The change in the sex ratio of referred patients was specific to the gender dysphoric youth and was not observed in the population of adolescents referred for other diagnoses.

Study 2 evaluated data from 420 adolescents (13 years of age and older) who were referred to the Amsterdam clinic between 1989 and 2013. Similar to the findings from the Toronto clinic, the Amsterdam clinic also documented a reversal in the sex ratio in adolescents referred for gender dysphoria. Prior to 2006 (1989-2005), the percentage of natal males (58.6%) was greater than natal females (41.4%) but from 2006-2013, the percentage of natal females (63.3%) was greater than natal males (36.7%). In other words, the male to female sex ratio shifted from 1.41: 1 to 1:1.72.

The authors of this research stated that “This inversion in the sex ratio of gender dysphoric youth is a new development, which requires an explanation or set of explanations” and offered several hypotheses about possible factors that may have contributed to the identified demographic changes.

They considered that the increase in visibility of transgender people in the media; wider availability of online information; reduction of stigma; and the growing awareness about the availability of medical treatments for gender dysphoria could contribute to the increased number of referrals. However, those factors would not explain the change in the sex ratio of referred adolescents. The authors offered that sex-based differences in stigma could plausibly contribute to greater numbers of natal females seeking care. However, SEGM points out that sex-based differences in stigma would not explain why the sex ratio has changed for adolescents but not for older adults.

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Fewer Studies
B. Scientists debate medical affirmation of minors
Baxendale, S. (2024). The impact of suppressing puberty on neuropsychological function: A review. Acta Paediatrica, apa.17150. https://doi.org/10.1111/apa.17150
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Journal AbstractAbstract

Aim
Concerns have been raised regarding the impact of medications that interrupt puberty, given the magnitude and complexity of changes that occur in brain function and structure during this sensitive window of neurodevelopment. This review examines the literature on the impact of pubertal suppression on cognitive and behavioural function in animals and humans.


Methods
All studies reporting cognitive impacts of treatment with GnRH agonists/antagonists for pubertal suppression in animals or humans were sought via a systematic search strategy across the PubMed, Embase, Web of Science and PsycINFO databases.


Results

Sixteen studies were identified. In mammals, the neuropsychological impacts of puberty blockers are complex and often sex specific (
n
 = 11 studies). There is no evidence that cognitive effects are fully reversible following discontinuation of treatment. No human studies have systematically explored the impact of these treatments on neuropsychological function with an adequate baseline and follow‐up. There is some evidence of a detrimental impact of pubertal suppression on IQ in children.



Conclusion
Critical questions remain unanswered regarding the nature, extent and permanence of any arrested development of cognitive function associated with puberty blockers. The impact of puberal suppression on measures of neuropsychological function is an urgent research priority.
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Ocasio, M. A., Fernandez, M. I., Ward, D. H. S., Lightfoot, M., Swendeman, D., & Harper, G. W. (2024). Fluidity in Reporting Gender Identity Labels in a Sample of Transgender and Gender Diverse Adolescents and Young Adults, Los Angeles, California, and New Orleans, Louisiana, 2017-2019. Public Health Reports, 00333549231223922. https://doi.org/10.1177/00333549231223922
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Journal AbstractObjectives:
Treating gender identity as a fixed characteristic may contribute to considerable misclassification and hinder accurate characterization of health inequities and the design of effective preventive interventions for transgender and gender diverse (TGD) adolescents and young adults. We examined changes in how an ethnically and racially diverse sample of TGD adolescents and young adults reported their gender identity over time, the implications of this fluidity on public health, and the potential effects of misclassification of gender identity.

Methods:
We recruited 235 TGD adolescents and young adults (aged 15-24 y) in Los Angeles, California, and New Orleans, Louisiana, from May 2017 through August 2019 to participate in an HIV intervention study. We asked participants to self-report their gender identity and sex assigned at birth every 4 months for 24 months. We used a quantitative content analysis framework to catalog changes in responses over time and classified the changes into 3 main patterns: consistent, fluctuating, and moving in 1 direction. We then calculated the distribution of gender identity labels at baseline (initial assessment) and 12 and 24 months and described the overall sample by age, race, ethnicity, and study site.


Results:
Of 235 TGD participants, 162 (69%) were from Los Angeles, 89 (38%) were Latinx, and 80 (34%) were non-Latinx Black or African American. Changes in self-reported gender identity were common (n = 181; 77%); in fact, 39 (17%) changed gender identities more than twice. More than 50% (n = 131; 56%) showed a fluctuating pattern.

Conclusions:
Gender identity labels varied over time, suggesting that misclassification may occur if data from a single time point are used to define gender identity. Our study lays the foundation for launching studies to elucidate the associations between shifting gender identities and health outcomes.
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Morssinkhof, M. W. L., Wiepjes, C. M., Van Den Heuvel, O. A., Kreukels, B. P. C., Van Der Tuuk, K., T’Sjoen, G., Den Heijer, M., & Broekman, B. F. P. (2024). Changes in depression symptom profile with gender-affirming hormone use in transgender persons. Journal of Affective Disorders, 348, 323–332. https://doi.org/10.1016/j.jad.2023.12.056
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Journal AbstractAbstract
Background
Women show higher prevalence of depression and different symptomatology than men, possibly influenced by sex hormones. Many transgender persons, who face a high risk of depression, use Gender-Affirming Hormone Therapy (GAHT), but the impact of GAHT on depressive symptom profiles is unknown.

Methods
This study examined depressive symptoms in transgender persons before GAHT and after 3- and 12 months of GAHT. We used the Inventory of Depressive Symptomatology-Self Report to assess depressive symptoms, exploratory factor analysis (EFA) to assess symptom clusters, and linear mixed models to assess changes in symptom clusters.

Results
This study included 110 transmasculine (TM) and 89 transfeminine (TF) participants. EFA revealed four symptom clusters: mood, anxiety, lethargy, and somatic symptoms. Changes in total depressive symptoms significantly differed between TM and TF groups. After 3 months of GAHT, TM participants reported improvement in lethargy (−16 %; 95%CI: −29 %; −2 %), and after 12 months TF participants reported worsening in low mood (24 %; 95%CI: 3 %; 51 %), but absolute score changes were modest. Neither group showed changes in anxiety or somatic symptoms.

Limitations
This study had limited sample sizes at 12 months follow-up and did not include relevant biological or psychosocial covariates.

Discussion
Changes in depressive symptoms after GAHT use differ in TM and TF persons: TM persons report slight improvements in lethargy, whereas TF persons report a slight increase in low mood. Starting GAHT represents a significant life event with profound social and physical effects, and further research should assess social and biological effects of GAHT on mood-related symptoms.
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Ruuska, S.-M., Tuisku, K., Holttinen, T., & Kaltiala, R. (2024). All-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996–2019: a register study. BMJ Mental Health, 27(1), e300940. https://doi.org/10.1136/bmjment-2023-300940
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Journal AbstractBackground All-cause and suicide mortalities of gender-referred adolescents compared with matched controls have not been studied, and particularly the role of psychiatric morbidity in mortality is unknown.
Objective To examine all-cause and suicide mortalities in gender-referred adolescents and the impact of psychiatric morbidity on mortality.
Methods Finnish nationwide cohort of all <23 year-old gender-referred adolescents in 1996–2019 (n=2083) and 16 643 matched controls. Cox regression models with HRs and 95% CIs were used to analyse all-cause and suicide mortalities. Findings Of the 55 deaths in the study population, 20 (36%) were suicides. In bivariate analyses, allcause mortality did not statistically significantly differ between gender-referred adolescents and controls (0.5% vs 0.3%); however, the proportion of suicides was higher in the gender-referred group (0.3% vs 0.1%). The all-cause mortality rate among gender-referred adolescents (controls) was 0.81 per 1000 person-years (0.40 per 1000 person-years), and the suicide mortality rate was 0.51 per 1000 person-years (0.12 per 1000 person-years). However, when specialist-level psychiatric treatment was controlled for, neither all-cause nor suicide mortality differed between the two groups: HR for allcause mortality among gender-referred adolescents was 1.0 (95% CI 0.5 to 2.0) and for suicide mortality was 1.8 (95% CI 0.6 to 4.8).
Conclusions Clinical gender dysphoria does not appear to be predictive of all-cause nor suicide mortality when psychiatric treatment history is accounted for. Clinical implications It is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing gender dysphoria to prevent suicide.
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Nadrowski, K. (2023). A New Flight from Womanhood? The Importance of Working Through Experiences Related to Exposure to Pornographic Content in Girls Affected by Gender Dysphoria. Journal of Sex & Marital Therapy, 1–10. https://doi.org/10.1080/0092623X.2023.2276149
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Journal AbstractParallel to the advent of social media and the easy access to online pornographic content there is a sharp increase in adolescent females expressing gender dysphoria worldwide. This paper argues that treatment of gender dysphoria in female adolescents must include explicit exploration into their use and exchange of pornographic content, as well as possible online or offline contacts with adults. Possible avenues of how pornographic content may increase the shame and fear of becoming a woman include the acquisition of misogynistic sexual scripts based on false assumptions on sexuality including the normalization of the violation of females as pleasurable for them, peer influence among female friendship groups, the susceptibility of our medical systems to “mass hysteria” phenomena, easier access of adults with sexually abusive intentions to youth through social media, sexual abuse and victim blaming on females, as well as the influence of pornography on mentalization capacities. As the influence of pornography on gender dysphoria in girls is understudied, this paper provides questions for qualitative and quantitative research, case studies and history taking. Especially the lack of an adequate other during exposure may aggravate false assumptions on gender roles and gender inequality seen in mainstream pornography. Girls affected by autism might be at higher risk because of their reduced mentalization capacities. Working through experiences associated with pornographic content and sexually abusive experiences may correct false beliefs about gender inequality and therefore might alleviate gender dysphoria.
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More Studies
Halasz, G., & Amos, A. (2023). Gender dysphoria: Reconsidering ethical and iatrogenic factors in clinical practice. Australasian Psychiatry, 10398562231211130. https://doi.org/10.1177/10398562231211130
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Journal AbstractObjective
To examine the treatment of gender dysphoria described in Bell v Tavistock (UK 2020). Bell documents the treatment and sequelae of a 16-year-old adolescent referred to the Tavistock with gender dysphoria. Her case highlights contrasts between gender affirming care and comprehensive care.


Conclusions
Consistent with other western centres, in the 2010s, the Tavistock began treating patients with gender dysphoria under the ‘Dutch protocol’ for gender affirming care. Bell reveals concerning lapses of clinical governance influenced by activists and linked to patient harm. The recent suspension of a senior child psychiatrist from an Australian public hospital service after questioning the evidence base and ethical foundation of gender affirming care underlines the need to resolve these uncertainties to address the crisis in the treatment of gender dysphoria.
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Smids, J., & Vankrunkelsven, P. (2023). [Uncertainties around the current gender care: five problems with the clinical lesson ’Youth with gender incongruence’]. Nederlands Tijdschrift Voor Geneeskunde, 167, D7941.
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Journal AbstractThe clinical lesson 'Youth with gender incongruence' by Dutch gender clinicians aims to describe Dutch adolescent gender care and its dilemma's. This commentary discusses five serious objections. First, the lesson fails to draw the implications from its acknowledgement of the paucity of evidence: puberty blockers and cross-sex hormones most likely do not meet the requirements for standard care. Second, it does not make the crucial distinction between childhood and adolescent onset gender dysphoria. Third, its claim that from those children that continue from GnRHa to cross-sex hormones '98% continues to use these hormones in the long term' is unfounded. Fourth, it does not acknowledge the dilemma that puberty blockers may impede, rather than facilitate, time for reflection. Fifth, it inaccurately represents the literature on the potential detrimental effects of GnRHa on brain development. The commentary concludes with a call to reform Dutch gender care, following the examples of Sweden and Finland.
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Block, J. (2023). US paediatric leaders back gender affirming approach while also ordering evidence review. BMJ, p1877. https://doi.org/10.1136/bmj.p1877
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Pilgrim, D. (2023). British mental healthcare responses to adult homosexuality and gender non-conforming children at the turn of the twenty-first century. History of Psychiatry, 0957154X231181461. https://doi.org/10.1177/0957154X231181461
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Journal AbstractThe roots of the recent controversy about how mental health professionals should respond to gender nonconforming children are traced. To make historical sense, this paper distinguishes between epistemological (discursive) and ontological (non-discursive) aspects and describes their features, since 1970. This helps to clarify some of the confusions at the centre of the still heated debate about sexuality and gender identity today. In the concluding discussion, the philosophical resource of critical realism is used to interpret the historical narrative provided. It cautions against the anachronistic tendency to amalgamate the shortlived, and now defunct, experiment of aversion therapy for homosexuality with more recent defences of exploratory psychotherapy. The latter have challenged a different form of experimentation: the biomedicalisation of gender non-conforming children.
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Hruz, P. W. (2023). A clarion call for high‐quality research on gender dysphoric youth. Acta Paediatrica, apa.16895. https://doi.org/10.1111/apa.16895
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Cohn, J. (2023). Politics Aside, Healthcare Considerations Motivate More Caution before Medical Intervention for Trans-Identifying Youth. Journal of Controversial Ideas, 3(1), 1. https://doi.org/10.35995/jci03010010
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Journal AbstractThe 2022 article “Legislation restricting gender-affirming care for transgender youth: Politics eclipse healthcare” by K. L. Kraschel et al. implies that attempts in the United States to restrict medical interventions for gender dysphoria are due to political motivations. Although there are likely some whose stance on these interventions is based upon politics, there are sound medical reasons, independent of politics, for advocating for more cautious medical intervention protocols. Neglecting mention of these reasons obscures the fact that medical intervention outcomes are difficult to predict and that serious risks and irreversible consequences are present. In other countries, following extensive evidence review, supportive alternatives to medical intervention are being prioritized instead. Here, several claims of Kraschel et al. regarding the state of medical intervention healthcare are compared to the research evidence and shown to fall short. Healthcare issues alone justify challenging current United States medical treatment protocols.
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Levine, S. B., & Abbruzzese, E. (2023). Current Concerns About Gender-Affirming Therapy in Adolescents. Current Sexual Health Reports. https://doi.org/10.1007/s11930-023-00358-x
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Journal AbstractAbstract

Purpose of Review
Results of long-term studies of adult transgender populations failed to demonstrate convincing improvements in mental health, and some studies suggest that there are treatment-associated harms. The purpose of this review is to clarify concerns about the rapid proliferation of hormonal and surgical care for the record numbers of youth declaring transgender identities and seeking gender reassignment procedures.


Recent Findings
Systematic reviews of evidence conducted by public health authorities in Finland, Sweden, and England concluded that the risk/benefit ratio of youth gender transition ranges from unknown to unfavorable. As a result, there has been a shift from “gender-affirmative care,” which prioritizes access to medical interventions, to a more conservative approach that addresses psychiatric comorbidities and psychotherapeutically explores the developmental etiology of the trans identity. Debate about the safety and efficacy of “gender-affirming care” in the USA is only recently emerging.


Summary
The question, “Do the benefits of youth gender transitions outweigh the risks of harm?” remains unanswered because of a paucity of follow-up data. The conclusions of the systematic reviews of evidence for adolescents are consistent with long-term adult studies, which failed to show credible improvements in mental health and suggested a pattern of treatment-associated harms. Three recent papers examined the studies that underpin the practice of youth gender transition and found the research to be deeply flawed. Evidence does not support the notion that “affirmative care” of today’s adolescents is net beneficial. Questions about how to best care for the rapidly growing numbers of gender-dysphoric youth generated an intensity of divisiveness within and outside of medicine rarely seen with other clinical uncertainties. Because the future well-being of young patients and their families is at stake, the field must stop relying on social justice arguments and return to the time-honored principles of evidence-based medicine.
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Block, J. (2023). Norway’s guidance on paediatric gender treatment is unsafe, says review. BMJ, p697. https://doi.org/10.1136/bmj.p697
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Abbasi, K. (2023). Caring for young people with gender dysphoria. BMJ, p553. https://doi.org/10.1136/bmj.p553
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Block, J. (2023). Gender dysphoria in young people is rising—and so is professional disagreement. BMJ, p382. https://doi.org/10.1136/bmj.p382
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Evans, M. (2023). Assessment and treatment of a gender-dysphoric person with a traumatic history. Journal of Child Psychotherapy, 1–16. https://doi.org/10.1080/0075417X.2023.2172741
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Journal AbstractThis paper presents a composite case based on a group of female-tomale transitioners with a history of trauma due to early separation or family illness. These early traumas may interfere with the process of integrating the mind and body. Symptoms of gender dysphoria often arise from, or increase in response to, subsequent separations later in life, as individuals transition from childhood to adulthood. Increased referrals to gender clinics are noted at puberty or the point of separation from the family, as individuals face the prospect of leaving home to go to university. Affected by anxieties associated with the onset of puberty or separation anxieties, these individuals sometimes seek a medical transition to gain control over their bodies. Exploring underlying psychoanalytic issues can help clinicians assess various conscious and unconscious influences, and help patients make more informed decisions on whether to pursue a medical transition. A focus on defence mechanisms and forms of thinking can help clinicians find ways of working with individuals who may be highly defensive and concrete in their thinking and feel threatened by the functioning of their minds.
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Elkadi, J., Chudleigh, C., Maguire, A. M., Ambler, G. R., Scher, S., & Kozlowska, K. (2023). Developmental Pathway Choices of Young People Presenting to a Gender Service with Gender Distress: A Prospective Follow-Up Study. Children, 10(2), 314. https://doi.org/10.3390/children10020314
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Journal AbstractThis prospective case-cohort study examines the developmental pathway choices of 79 young people (13.25–23.75 years old; 33 biological males and 46 biological females) referred to a tertiary care hospital’s Department of Psychological Medicine (December 2013–November 2018, at ages 8.42–15.92 years) for diagnostic assessment for gender dysphoria (GD) and for potential gender-affirming medical interventions. All of the young people had attended a screening medical assessment (including puberty staging) by paediatricians. The Psychological Medicine assessment (individual and family) yielded a formal DSM-5 diagnosis of GD in 66 of the young people. Of the 13 not meeting DSM-5 criteria, two obtained a GD diagnosis at a later time. This yielded 68 young people (68/79; 86.1%) with formal diagnoses of GD who were potentially eligible for gender-affirming medical interventions and 11 young people (11/79; 13.9%) who were not. Follow-up took place between November 2022 and January 2023. Within the GD subgroup (n = 68) (with two lost to followup), six had desisted (desistance rate of 9.1%; 6/66), and 60 had persisted on a GD (transgender) pathway (persistence rate of 90.9%; 60/66). Within the cohort as a whole (with two lost to followup), the overall persistence rate was 77.9% (60/77), and overall desistance rate for gender-related distress was 22.1% (17/77). Ongoing mental health concerns were reported by 44/50 (88.0%), and educational/occupational outcomes varied widely. The study highlights the importance of careful screening, comprehensive biopsychosocial (including family) assessment, and holistic therapeutic support. Even in highly screened samples of children and adolescents seeking a GD diagnosis and gender-affirming medical care, outcome pathways follow a diverse range of possibilities.
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Abbruzzese, E., Levine, S. B., & Mason, J. W. (2023). The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed. Journal of Sex & Marital Therapy, 1–27. https://doi.org/10.1080/0092623X.2022.2150346
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Lopez, D. L., & Wortman, A. (2023). Gender as the New Language of Teen Rebellion. Psychodynamic Psychiatry, 51(4), 434–452. https://doi.org/10.1521/pdps.2023.51.4.434
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Journal AbstractThe growing occurrence of adolescents with gender nonconforming identities appears to be associated with what the authors believe is the contemporary manifestation of the adolescent identity crisis phenomenon. This phenomenon is expressed through a deliberate rejection and reappraisal of conventional gender roles and norms. The adolescent identity crisis, as initially conceptualized by Erik Erikson (1956), constitutes an unconscious multifaceted phenomenon that is outwardly displayed within familial and societal frameworks. A historical overview of pertinent terminology is provided, followed by the presentation of four clinical vignettes chosen to exemplify this phenomenon, alongside the resultant family conflicts that often ensue. Additionally, an anonymized clinical case is presented, encompassing the evaluation process, the subsequent psychodynamic formulation, treatment considerations, parent work, and the available resources for patients and families. The clinical illustrations are case composites and the data disguised to protect patient privacy and confidentiality. A plea is made to the scientific community for in-depth long-term research into this clinical phenomenon.
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Byrne, A. (2023). More on “Gender Identity.” Archives of Sexual Behavior, 52(7), 2719–2721. https://doi.org/10.1007/s10508-023-02695-3
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Byrne, A. (2023). The Origin of “Gender Identity.” Archives of Sexual Behavior, 52(7), 2709–2711. https://doi.org/10.1007/s10508-023-02628-0
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Armitage, R. (2023). Misrepresentations of evidence in “gender-affirming care is preventative care.” The Lancet Regional Health - Americas, 24, 100567. https://doi.org/10.1016/j.lana.2023.100567
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Restar, A. J. (2023). Gender-affirming care is preventative care. The Lancet Regional Health - Americas, 24, 100544. https://doi.org/10.1016/j.lana.2023.100544
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Cohn, J. (2023). Elaboration of some points in “The association of gender dysphoria with psychosis.” Psychiatry Research, 325, 115264. https://doi.org/10.1016/j.psychres.2023.115264
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Masson, C., Ledrait, A., Cognet, A., & Athéa, N. (2023). De la transidentité à la transidentification. Déclenchement rapide de la « dysphorie de genre » chez des adolescents confrontés au malaise pubertaire. L’Évolution Psychiatrique, S0014385523000312. https://doi.org/10.1016/j.evopsy.2023.02.002
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Kaltiala, R., Holttinen, T., & Tuisku, K. (2023). Have the psychiatric needs of people seeking gender reassignment changed as their numbers increase? A register study in Finland. European Psychiatry, 66(1), e93. https://doi.org/10.1192/j.eurpsy.2023.2471
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Journal AbstractBackground. The number of people seeking gender reassignment (GR) has increased everywhere and these increases particularly concern adolescents and emerging adults with female sex. It is not known whether the psychiatric needs of this population have changed alongside the demographic changes.
Methods. A register-based follow-up study of individuals who contacted the nationally centralized gender identity services (GIS) in Finland in 1996–2019 (gender dysphoria [GD] group, n = 3665), and 8:1 age and sex-matched population controls (n = 29,292). The year of contacting the GIS was categorized to 5-year intervals (index periods). Psychiatric needs were assessed by specialist-level psychiatric treatment contacts in the Finnish Care Register for Hospital Care in 1994–2019.
Results. The GD group had received many times more specialist-level psychiatric treatment both before and after contacting specialized GIS than had their matched controls. A marked increase over time in psychiatric needs was observed. Among the GD group, relative risk for psychiatric needs after contacting GIS increased from 3.3 among those with the first appointment in GIS during 1996–2000 to 4.6 when the first appointment in GIS was in 2016–2019. When index period and psychiatric treatment before contacting GIS were accounted for, GR patients who had and who had not proceeded to medical GR had an equal risk compared to controls of needing subsequent psychiatric treatment.
Conclusion. Contacting specialized GIS is on the increase and occurs at ever younger ages and with more psychiatric needs. Manifold psychiatric needs persist regardless of medical GR.
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Gorin, M., & Caraballo, A. (2023). Letters to the Editor. Journal of Law, Medicine & Ethics, 51(3), 717–723. https://doi.org/10.1017/jme.2023.144
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Cohn, J. (2022). Some Limitations of “Challenges in the Care of Transgender and Gender-Diverse Youth: An Endocrinologist’s View.” Journal of Sex & Marital Therapy, 1–17. https://doi.org/10.1080/0092623X.2022.2160396
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Clayton, A. (2022). Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect—The Implications for Research and Clinical Practice. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-022-02472-8
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Journal AbstractIn the last decade, there has been a rapid increase in the numbers of young people with gender dysphoria (GD youth) presenting to health services (Kaltiala et al., 2020). There has also been a marked change in the treatment approach. The previous “common practice” of providing psychosocial care only to those under 18 or 21 years (Smith et al., 2001) has largely been replaced by the gender affirmative treatment approach (GAT), which for adolescents includes hormonal and surgical interventions (Coleman et al., 2022). However, as a recent review concluded, evidence on the appropriate management of youth with gender incongruence and dysphoria is inconclusive and has major knowledge gaps (Cass, 2022). Previous papers have discussed that the weaknesses of the studies investigating the efficacy of GAT for GD youth mean they are at high risk of bias and confounding and, thus, provide very low certainty evidence (Clayton, 2022a, b; Levine et al., 2022). To date, however, there has been little discussion of the inability of these studies to differentiate specific treatment effects from placebo effects.
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Kohls, G., & Roessner, V. (2022). Editorial Perspective: Medical body modification in youth with gender dysphoria or body dysmorphic disorder – is current practice coherent and evidence‐based? Journal of Child Psychology and Psychiatry, jcpp.13717. https://doi.org/10.1111/jcpp.13717
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Journal AbstractIn recent decades, there has been a steady increase in the number of people, including adolescents, undergoing medical body modification (MBM) to alter their physically healthy bodies in invasive and nearly irreversible ways through medical treatment (e.g. surgery). While MBM is often recommended for youth with persisting gender dysphoria (GD), in body dysmorphic disorder (BDD) it has been considered contraindicated. Here, we outline the current controversies surrounding MBM practice and recommendations in adolescents with GD versus those with BDD in order to better understand under what circumstances we may or may not support adolescents who want to change their bodies medically and often irreversibly. We compare the two disorders in terms of the overlap and uniqueness of their behavioural and psychological features. In doing so, we discuss limitations of the existing (often low-quality) evidence for and against MBM in young patients. We conclude that the currently available evidence is too preliminary and far from conclusive to make any robust recommendations in terms of benefits and harms of MBM in youth with persisting GD or BDD. However, we strongly recommend further urgent scientific discussions and systematic research efforts into more robust evaluations and the identification of more precise psychological characteristics that may serve as decision criteria for or against MBM – particularly in those adolescents who did not respond to non-MBM, that is, psychiatric/psychological treatment and psychosocial support, if available at all. This will greatly benefit youth healthcare professionals in their challenging clinical practice of making decisions regarding MBM today and in the future.
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Kulesa, R. (2022). Toward a Standard of Medical Care: Why Medical Professionals Can Refuse to Prescribe Puberty Blockers. The New Bioethics, 1–17. https://doi.org/10.1080/20502877.2022.2137906
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Journal AbstractThat a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient’s well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical care must not cause dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria.
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Levine, S. B., Abbruzzese, E., & Mason, J. W. (2022). What Are We Doing to These Children? Response to Drescher, Clayton, and Balon Commentaries on Levine et al., 2022. Journal of Sex & Marital Therapy, 1–11. https://doi.org/10.1080/0092623X.2022.2136117
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Block, J. (2022). US transgender health guidelines leave age of treatment initiation open to clinical judgment. BMJ, o2303. https://doi.org/10.1136/bmj.o2303
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Biggs, M. (2022). The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence. Journal of Sex & Marital Therapy, 1–21. https://doi.org/10.1080/0092623X.2022.2121238
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Journal AbstractIt has been a quarter of a century since Dutch clinicians proposed puberty suppression as an intervention for “juvenile transsexuals,” which became the international standard for treating gender dysphoria. This paper reviews the history of this intervention and scrutinizes the evidence adduced to support it. The intervention was justified by claims that it was reversible and that it was a tool for diagnosis, but these claims are increasingly implausible. The main evidence for the Dutch protocol came from a longitudinal study of 70 adolescents who had been subjected to puberty suppression followed by cross-sex hormones and surgery. Their outcomes shortly after surgery appeared positive, except for the one patient who died, but these findings rested on a small number of observations and incommensurable measures of gender dysphoria. A replication study conducted in Britain found no improvement. While some effects of puberty suppression have been carefully studied, such as on bone density, others have been ignored, like on sexual functioning.
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McIntosh, B., & Koseda, E. (2022). The interim report of the Cass review into the NHS gender identity development service: a discussion. British Journal of Healthcare Management, 28(8), 1–4. https://doi.org/10.12968/bjhc.2022.0089
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Journal AbstractProfessor Bryan McIntosh and Ellie Koseda provide an overview of the review into the NHS's only gender identity development service, led by Dr Hilary Cass, following the publication of the interim report in February 2022. Key issues in this complex and developing field are discussed.
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MacKinnon, K. R., Kia, H., Salway, T., Ashley, F., Lacombe-Duncan, A., Abramovich, A., Enxuga, G., & Ross, L. E. (2022). Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments. JAMA Network Open, 5(7), e2224717. https://doi.org/10.1001/jamanetworkopen.2022.24717
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Journal AbstractOBJECTIVE: To examine the physical and mental health experiences of people who initiated medical or surgical detransition to inform clinical practice. DESIGN, SETTING, AND PARTICIPANTS Using constructivist grounded theory as a qualitative approach, data were collected in the form of in-depth interviews. Data were analyzed using an inductive 2-stage coding process to categorize and interpret detransition-related health care experiences to inform clinical practice. Between October 2021 and January 2022, individuals living in Canada who were aged 18 years and older with experience of stopping, shifting, or reversing a gender transition were invited to partake in semistructured virtual interviews. Study advertisements were circulated over social media, to clinicians, and within participants’ social networks. A purposive sample of 28 participants who discontinued, shifted, or reversed a gender transition were interviewed.

MAIN OUTCOMES AND MEASURES: In-depth, narrative descriptions of the physical and mental health experiences of people who discontinued or sought to reverse prior gender-affirming medical and/or surgical interventions.

RESULTS: Among the 28 participants, 18 (64%) were assigned female at birth and 10 (36%) were assigned male at birth; 2 (7%) identified as Jewish and White, 5 (18%) identified as having mixed race and ethnicity (which included Arab, Black, Indigenous, Latinx, and South Asian), and 21 (75%) identified as White. Participants initially sought gender-affirmation at a wide range of ages (15 [56%] were between ages 18 and 24 years). Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Participants reported divergent perspectives about their past gender-affirming medical or surgical treatments. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Medical detransition was often experienced as physically and psychologically challenging, yet health care avoidance was common. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs.

CONCLUSIONS AND RELEVANCE: This study’s results suggest that further research and clinical guidance is required to address the unmet needs of this population who discontinue or seek to reverse prior gender-affirming interventions.
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Clayton, A., D’Angelo, R., & Clarke, P. (2022). Parental consent and the treatment of transgender youth: the impact of Re Imogen. Medical Journal of Australia, mja2.51643. https://doi.org/10.5694/mja2.51643
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Latham, A. (2022). Puberty Blockers for Children: Can They Consent? The New Bioethics, 1–24. https://doi.org/10.1080/20502877.2022.2088048
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Journal Abstractender dysphoria is a persistent distress about one’s assigned gender. Referrals regarding gender dysphoria have recently greatly increased, often of a form that is rapid in onset. The sex ratio has changed, most now being natal females. Mental health issues pre-date the dysphoria in most. Puberty blockers are offered in clinics to help the child avoid puberty. Puberty blockers have known serious side effects, with uncertainty about their long-term use. They do not improve mental health. Without medication, most will desist from the dysphoria in time. Yet over 90% of those treated with puberty blockers progress to cross-sex hormones and often surgery, with irreversible consequences. The brain is biologically and socially immature in childhood and unlikely to understand the long-term consequences of treatment. The prevailing culture to affirm the dysphoria is critically reviewed. It is concluded that children are unable to consent to the use of puberty blockers.
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Boogers, L. S., Wiepjes, C. M., Klink, D. T., Hellinga, I., van Trotsenburg, A. S. P., den Heijer, M., & Hannema, S. E. (2022). Transgender Girls Grow Tall: Adult Height Is Unaffected by GnRH Analogue and Estradiol Treatment. The Journal of Clinical Endocrinology & Metabolism, dgac349. https://doi.org/10.1210/clinem/dgac349
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Journal AbstractAbstract

Context
Transgender adolescents can receive gonadotropin-releasing hormone analogues (GnRH) and gender-affirming hormone therapy (GAHT), but little is known about effects on growth and adult height. This is of interest since height differs between sexes and some transgender girls wish to limit their growth.


Objective
This work aims to investigate the effects of GnRHa and GAHT on growth, and the efficacy of growth-reductive treatment.


Methods
This retrospective cohort study took place at a specialized tertiary gender clinic. A total of 161 transgender girls were treated with GnRHa and estradiol at a regular dose (2 mg) or high growth-reductive doses of estradiol (6 mg) or ethinyl estradiol (EE, 100-200 µg). Main outcome measures included growth, adult height, and the difference from predicted adult height (PAH) and target height.


Results
Growth velocity and bone maturation decreased during GnRHa, but increased during GAHT. Adult height after regular-dose treatment was 180.4 ± 5.6 cm, which was 1.5 cm below PAH at the start GnRHa (95% CI, 0.2 cm to 2.7 cm), and close to target height (–1.1 cm; 95% CI, –2.5 cm to 0.3 cm). Compared to regular-dose treatment, high-dose estradiol and EE reduced adult height by 0.9 cm (95% CI, –0.9 cm to 2.8 cm) and 3.0 cm (95% CI, 0.2 cm to 5.8 cm), respectively.


Conclusion
Growth decelerated during GnRHa and accelerated during GAHT. After regular-dose treatment, adult height was slightly lower than predicted at start of GnRHa, likely due to systematic overestimation of PAH as described in boys from the general population, but not significantly different from target height. High-dose EE resulted in greater reduction of adult height than high-dose estradiol, but this needs to be weighed against possible adverse effects.
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Clayton, A. (2022). Commentary on Levine: A Tale of Two Informed Consent Processes. Journal of Sex & Marital Therapy, 1–8. https://doi.org/10.1080/0092623X.2022.2070565
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Journal AbstractThis commentary compares two recently published informed consent recommendations for gender dysphoria. One key difference identified is in their assessment of the strength of the evidence base for the gender affirming treatment model. An evaluation of both authors’ citations supports the claims of a weak evidence base for the use of puberty blockers and gender affirming hormonal treatments in youth with gender dysphoria. This commentary then reflects on the implications of this. In particular, it asks whether it would be best practice to provide gender affirming treatments for youth only under clinical research conditions, rather than as routine clinical practice.
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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. The Journal of Clinical Endocrinology & Metabolism, dgac251. https://doi.org/10.1210/clinem/dgac251
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Journal AbstractINTRODUCTION: Concerns about future regret and treatment discontinuation have led to restricted access to gender-affirming medical treatment for transgender and gender-diverse (TGD) minors in some jurisdictions. However, these concerns are merely speculative because few studies have examined gender-affirming hormone continuation rates among TGD individuals.

METHODS: We performed a secondary analysis of 2009 to 2018 medical and pharmacy records from the US Military Healthcare System. We identified TGD patients who were children and spouses of active-duty, retired, or deceased military members using International Classification of Diseases-9/10 codes. We assessed initiation and continuation of gender-affirming hormones using pharmacy records. Kaplan-Meier and Cox proportional hazard analyses estimated continuation rates.

RESULTS: The study sample included 627 transmasculine and 325 transfeminine individuals with an average age of 19.2 ± 5.3 years. The 4-year gender-affirming hormone continuation rate was 70.2% (95% CI, 63.9-76.5). Transfeminine individuals had a higher continuation rate than transmasculine individuals 81.0% (72.0%-90.0%) vs 64.4% (56.0%-72.8%). People who started hormones as minors had higher continuation rate than people who started as adults 74.4% (66.0%-82.8%) vs 64.4% (56.0%-72.8%). Continuation was not associated with household income or family member type. In Cox regression, both transmasculine gender identity (hazard ratio, 2.40; 95% CI, 1.50-3.86) and starting hormones as an adult (hazard ratio, 1.69; 95% CI, 1.14-2.52) were independently associated with increased discontinuation rates.

DISCUSSION: Our results suggest that >70% of TGD individuals who start gender-affirming hormones will continue use beyond 4 years, with higher continuation rates in transfeminine individuals. Patients who start hormones, with their parents’ assistance, before age 18 years have higher continuation rates than adults.
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Balon, R. (2022). Commentary on Levine et al: Festina Lente (Rush Slowly). Journal of Sex & Marital Therapy, 1–4. https://doi.org/10.1080/0092623X.2022.2055686
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Journal AbstractQuidquid agis, prudenter agas et respice finem Whatever you do, do it deliberately and consider the end Lately, we have lived in times of increasingly ideologized debates that weaponize various medical and ethical issues. Data in these debates are misinterpreted, overinterpreted, forgotten, or are not available. Some of these debates are presented as evidence-based, even when the evidence is weak or not available. Unfortunately, patient benefits may get, to various degrees, lost in these debates. Examples of such debates also include gender dysphoria, gender identity, transgenderism, and gender transition. These debates have permeated media, schools, sports, and a host of other areas. It seems that most of the time ideology, emotions and personal convictions beat knowledge and evidence in these debates, which makes important related issues muddy and “unimportant” by pushing them aside or into the background. Dr. Levine (2022) discusses an important issue in the area of gender transition, and interventions related to transgenderism – the issue of informed consent. I am emphasizing the word informed as it is central to the issue of consent for numerous reasons. I would also like to emphasize that in my (and clearly Dr. Levine’s) opinion, the word informed does not relate “just” to patients’ (and their families) side of the informed consent equation, but also to the clinicians’ side. It is obvious that our state of knowledge regarding appropriate and timely gender transition (whatever the intervention is) and its consequences is not where we would like it to be. Simply said, the ship has sailed, and we assume that its course is correct and landing will be correct and the life after will be happy. Is that so, though? What should clinicians include in informed consent? As noted by Katz et al (2016), “informed consent should be seen as an essential part of health care practice.” Katz also reminds us that “Physicians must realize that informed consent/permission/assent/refusal constitutes a process, not a discrete event, and requires the sharing of information in ongoing physician-patient-family communication and education” (Katz et al, 2016). It is also important to note that, as Levine (2022) writes, informed consent should be explicit and not implied, especially in this area, because of the complexity, uncertainty, and risk involved, and because informed consent for social transition represents gray area. Similar to Levine (2022), I am also not sure whether, with the increased incidence of gender identity variation, all parties involved in the informed consent process are well and appropriately informed and educated. As Levine (2022) notes, there are models of the informed consent process that do not require mental health evaluation, and hormones can be provided just after...
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Levine, S. B., Abbruzzese, E., & Mason, J. M. (2022). Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults. Journal of Sex & Marital Therapy, 1–22. https://doi.org/10.1080/0092623X.2022.2046221
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Journal AbstractIn less than a decade, the western world has witnessed an unprecedented rise in the numbers of children and adolescents seeking gender transition. Despite the precedent of years of gender-affirmative care, the social, medical and surgical interventions are still based on very low-quality evidence. The many risks of these interventions, including medicalizing a temporary adolescent identity, have come into a clearer focus through an awareness of detransitioners. The risks of gender-affirmative care are ethically managed through a properly conducted informed consent process. Its elements—deliberate sharing of the hoped-for benefits, known risks and long-term outcomes, and alternative treatments—must be delivered in a manner that promotes comprehension. The process is limited by: erroneous professional assumptions; poor quality of the initial evaluations; and inaccurate and incomplete information shared with patients and their parents. We discuss data on suicide and present the limitations of the Dutch studies that have been the basis for interventions. Beliefs about gender-affirmative care need to be separated from the established facts. A proper informed consent process can both prepare parents and patients for the difficult choices that they must make and can ease professionals’ ethical tensions. Even when properly accomplished, however, some clinical circumstances exist that remain quite uncertain.
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Cass, H. (2022). Review of gender identity services for children and young people. BMJ, o629. https://doi.org/10.1136/bmj.o629
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Bradley, S. J. (2022). Understanding Vulnerability in Girls and Young Women with High-Functioning Autism Spectrum Disorder. Women, 2(1), 64–67. https://doi.org/10.3390/women2010007
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Journal AbstractThere is a population of young women with autism spectrum disorder (ASD) who function relatively well so that their disorder is not easily recognized. If their difficulties with emotion regulation in childhood continue into adolescence they are vulnerable to the development of a number of mental disorders, treatment of which can be difficult if the presence of ASD is not understood. In this commentary, I use the example of gender dysphoria to illustrate the issues.
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Canvin, L., Hawthorne, O., & Panting, H. (2022). Supporting young people to manage gender-related distress using third-wave cognitive behavioural theory, ideas and practice. Clinical Child Psychology and Psychiatry, 135910452110687. https://doi.org/10.1177/13591045211068729
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Journal AbstractThe Gender Identity Development Service (GIDS) supports gender diverse young people, and their families but currently does not provide weekly psychological therapy as part of its core work. In addition, local Child and Adolescent Mental Health Services (CAMHS), may feel deskilled in providing support for this population. We, a group of three Clinical Psychologists, aim to share some common themes and observations gained from our work in GIDS. We talk about how existing Cognitive Behavioural Therapy (CBT) models can be relevant and helpful for the challenges facing gender diverse young people, without pathologising, or aiming to change a young person’s gender identity. An illustrative case study is presented, based on an amalgamation of young people we have worked with highlighting how third-wave cognitive behavioural theory, ideas and practice can be used to support young people to manage gender-related distress. Further reflections on the broader socio-political context, and implications for clinical practice and future research are discussed.
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Biggs, M. (2022). Suicide by Clinic-Referred Transgender Adolescents in the United Kingdom. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-022-02287-7
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Boyd, I., Hackett, T., & Bewley, S. (2022). Care of Transgender Patients: A General Practice Quality Improvement Approach. Healthcare (Basel, Switzerland), 10(1), 121. https://doi.org/10.3390/healthcare10010121
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Journal AbstractPrimary care must ensure high quality lifelong care is offered to trans and gender minority patients who are known to have poor health and adverse healthcare experiences. This quality improvement project aimed to interrogate and audit the data of trans and gender minority patients in one primary care population in England. A new data collection instrument was created examining pathways of care, assessments and interventions undertaken, monitoring, and complications. General practitioners identified a sample from the patient population and then performed an audit to examine against an established standard of care. No appropriate primary care audit standard was found. There was inconsistency between multiple UK gender identity clinics' (GIC) individual recommended schedules of care and between specialty guidelines. Using an international, secondary care, evidence-informed guideline, it appeared that up to two-thirds of patients did not receive all recommended monitoring standards, largely due to inconsistencies between GIC and international guidance. It is imperative that an evidence-based primary care guideline is devised alongside measurable standards. Given the findings of long waits, high rates of medical complexity, and some undesired treatment outcomes (including a fifth of patients stopping hormones of whom more than half cited regret or detransition experiences), this small but population-based quality improvement approach should be replicated and expanded upon at scale.
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Helyar, S., Jackson, L., & Ion, R. (2022). Gender dysphoria in young people: The Interim Cass Review and its implications for nursing. Journal of Clinical Nursing, 31(23–24). https://doi.org/10.1111/jocn.16553
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Karvonen, M., Karukivi, M., Kronström, K., & Kaltiala, R. (2022). The nature of co-morbid psychopathology in adolescents with gender dysphoria. Psychiatry Research, 114896. https://doi.org/10.1016/j.psychres.2022.114896
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Journal AbstractGender-referred adolescents (GR) have been reported to present with considerable psychiatric symptomatology compared to their age-peers. There is, however, little research on how they compare to adolescents referred due to mental health problems (MHR). We set out to compare psychopathology in adolescents referred to our specialized gender identity unit (n = 84) and adolescents referred to a general adolescent psychiatric clinic (n = 293) in a university hospital setting in Finland. Of the GR adolescents, 40.9% had not received any psychiatric diagnosis during adolescence. Eating disorders were less common in the GR than in the MHR group, but otherwise the prevalences of disorders did not differ statistically significantly. At the symptom level, the GR adolescents displayed significantly more suicidal ideation and talk and less alcohol abuse and eating disorder symptoms than did the MHR adolescents, but otherwise their symptom profiles were comparable. Additionally, the GR adolescents had significantly fewer total externalizing symptoms than did the MHR adolescents. Adolescents seeking gender affirming treatments present with psychiatric symptoms and disorders comparable to those seen among adolescent psychiatric patients. Medical gender affirming care may not be a sufficient intervention for treating psychiatric comorbidities of adolescents with gender dysphoria.
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Evans, M. (2022). ‘If only I were a boy …’: Psychotherapeutic Explorations of Transgender in Children and Adolescents. British Journal of Psychotherapy, 38(2), 269–285. https://doi.org/10.1111/bjp.12733
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Journal AbstractThis paper is based on the author’s experience of working with a particular group of female/male trans children and young people who present a similar clinical profile: a fragile ego prone to fragmentation and concrete thinking. Often, there is evidence of a grievance over the failed ideal object, which is internalized, projected into the body, and then attacked. Faced with the developmental challenge of sexuality at puberty, young adults withdraw to a psychic retreat designed to halt development. This paper focuses on the development of a trans identity in defence against an underlying fear of depressive anxieties and psychic collapse. It describes the ongoing assessment of Joanne, a 19-year-old biological female who wanted to be known as Luke in therapy and wished to transition in the belief that this was the only way she could have a life. The concrete nature of Joanne’s thinking created problems in the therapy, as thoughts were often experienced as physical actions. This paper describes the function of the phantasy that transitioning performs in creating a psychic retreat from the demands of psychological development.
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Sinai, J. (2022). Rapid onset gender dysphoria as a distinct clinical phenomenon. The Journal of Pediatrics, S0022347622001858. https://doi.org/10.1016/j.jpeds.2022.03.005
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Littman, L. (2022). Saying that Bauer et al studied rapid onset gender dysphoria is inaccurate and misleading. The Journal of Pediatrics, S0022347622001834. https://doi.org/10.1016/j.jpeds.2022.03.003
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Clayton, A. (2022). The Gender Affirmative Treatment Model for Youth with Gender Dysphoria: A Medical Advance or Dangerous Medicine? Archives of Sexual Behavior, 51(2), 691–698. https://doi.org/10.1007/s10508-021-02232-0
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Jorgensen, S. C. J., Hunter, P. K., Regenstreif, L., Sinai, J., & Malone, W. J. (2022). Puberty blockers for gender dysphoric youth: A lack of sound science. Journal of the American College of Clinical Pharmacy, 1005–1007(9), 3. https://doi.org/10.1002/jac5.1691
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Clayton, A., Malone, W. J., Clarke, P., Mason, J., & D’Angelo, R. (2021). Commentary: The Signal and the Noise—questioning the benefits of puberty blockers for youth with gender dysphoria—a commentary on Rew et al. (2021). Child and Adolescent Mental Health, camh.12533. https://doi.org/10.1111/camh.12533
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Journal Abstracthis commentary is a critique of a recent systematic review of the evidence for the use of puberty blockers for youth with gender dysphoria (GD) by Rew et al. (2021). In our view, the review suffers from several methodological oversights including the omission of relevant studies and suboptimal analysis of the quality of the included studies. This has resulted in an incomplete and incorrect assessment of the evidence base for the use of puberty blockers. We find that Rew et al.’s conclusions and clinician recommendations are problematic, especially when discussing suicidality. A key message of the review’s abstract appears to be that puberty blockers administered in childhood reduce adult suicidality. However, the study used for the basis of this conclusion (Turban et al., 2020) did not make a causal claim between puberty blockers and decreased adult suicidality. Rather, it reported a negative association between using puberty blockers and lifetime suicidal ideation. The study design did not allow for determination of causation. Our commentary concludes by demonstrating how the GD medical literature, as it moves from one publication to the next, can overstate the evidence underpinning clinical practice recommendations for youth with GD.
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Hunter, P. K. (2021). Political Issues Surrounding Gender-Affirming Care for Transgender Youth. JAMA Pediatrics. https://doi.org/10.1001/jamapediatrics.2021.5348
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Journal AbstractTo the Editor Responding to the Viewpoint1 regarding Arkansas Act 626, I agree medicine must be concerned when legislatures act to regulate health care. However, US politicians are not alone. Many others have concerns regarding the care of youth with gender dysphoria.

Internationally, standards are changing. Finland and Sweden have curtailed or stopped youth sex transitions, citing safety, efficacy, and ethical issues. Sex transition now only proceeds under strict research protocols, recognizing the experimental nature of this care. The National Health Service of England commissioned the Cass Review to evaluate the safety and effectiveness of gender dysphoria care as it is currently practiced.
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Helyar, S., Jackson, L., Patrick, L., Hill, A., & Ion, R. (2021). Gender Dysphoria in children and young people: The implications for clinical staff of the Bell V’s Tavistock Judicial Review and Appeal Ruling. Journal of Clinical Nursing, jocn.16164. https://doi.org/10.1111/jocn.16164
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Journal AbstractIn the past few years, there has been a very significant rise in the number of children and young people seeking treatment for gender dysphoria

This area is the subject of much discussion, as evidenced in a recent court case in the UK which examined competence and capacity of young people to consent to potentially irreversible interventions.

Clinicians involved in gaining consent to puberty blockers for gender dysphoric young people, must understand the evidence in this area and be aware of the heavy burden of accountability placed upon them.
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Moschella, M. (2021). Trapped in the Wrong Body? Transgender Identity Claims, Body-Self Dualism, and the False Promise of Gender Reassignment Therapy. The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, 46(6), 782–804. https://doi.org/10.1093/jmp/jhab030
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Journal AbstractIn this article, I explore difficult and sensitive questions regarding the nature of transgender identity claims and the appropriate medical treatment for those suffering from gender dysphoria. I first analyze conceptions of transgender identity, highlighting the prominence of the wrong-body narrative and its dualist presuppositions. I then briefly argue that dualism is false because our bodily identity (including our body’s biological organization for sexual reproduction as male or female) is essential and intrinsic to our overall personal identity and explain why a sound, nondualist anthropology implies that gender identity cannot be entirely divorced from sexual identity. Finally, I make the case that arguments in favor of hormonal and surgical treatments for gender dysphoria rest on this mistaken dualist anthropology, and that these treatments therefore give false hope to those suffering from gender dysphoria, while causing irreversible bodily harm and diverting attention from underlying psychological problems that often need to be addressed. I also briefly discuss how these philosophical claims relate to empirical studies on the outcomes of hormonal and surgical treatments for gender dysphoria and to testimonies of transgender individuals who regret having undergone these treatments.
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Schwartz, D. (2021). Clinical and Ethical Considerations in the Treatment of Gender Dysphoric Children and Adolescents: When Doing Less Is Helping More. Journal of Infant, Child, and Adolescent Psychotherapy, 1–11. https://doi.org/10.1080/15289168.2021.1997344
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Journal AbstractThrough an analysis of recently published treatment protocols, research findings and clinical experience, and guided by the principle of “first, do no harm,” the author argues that the use of pharmacological and surgical interventions in the treatment of gender dysphoric youth, especially in light of what is known about the transience of cross-gender identification in children, is mistaken both clinically and ethically. He further argues that psychotherapy, neglected by most of those advocating pharmacological and surgical interventions, is the best treatment option for these patients. The author elaborates some of the modifications of psychotherapeutic technique with both patients and their parents that he has found to be most effective with this population.
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Expósito-Campos, P., & D’Angelo, R. (2021). Letter to the Editor: Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence. Plastic and Reconstructive Surgery - Global Open, 9(11), e3951. https://doi.org/10.1097/GOX.0000000000003951
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Littman, L. (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-021-02163-w
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Journal AbstractThe study’s purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.
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Levine, S. B. (2021). Reflections on the Clinician’s Role with Individuals Who Self-identify as Transgender. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-021-02142-1
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Journal AbstractThe fact that modern patterns of the treatment of trans individuals are not based on controlled or long-term comprehensive followup studies has allowed many ethical tensions to persist. These have been intensifying as the numbers of adolescent girls declare themselves to be trans, have gender dysphoria, or are “boys.” This essay aims to assist clinicians in their initial approach to trans patients of any age. Gender identity is only one aspect of an individual’s multifaceted identity. The contributions to the passionate positions in the trans culture debate are discussed along with the controversy over the official, not falsifiable, position that all gender identities are inherently normal. The essay posits that it is relevant and ethical to investigate the forces that may have propelled an individual to create and announce a new identity. Some of these biological, social, and psychological forces are enumerated. Using the adolescent patient as an example, a model for a comprehensive evaluation process and its goals are provided. The essay is framed within a developmental perspective.
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Lemma, A., & Savulescu, J. (2021). To be, or not to be? The role of the unconscious in transgender transitioning: identity, autonomy and well-being. Journal of Medical Ethics, medethics-2021-107397. https://doi.org/10.1136/medethics-2021-107397
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Journal AbstractThe exponential rise in transgender self-identification invites consideration of what constitutes an ethical response to transgender individuals’ claims about how best to promote their well-being. In this paper, we argue that ‘accepting’ a claim to medical transitioning in order to promote well-being would be in the person’s best interests iff at the point of request the individual is correct in their self-diagnosis as transgender (i.e., the distress felt to reside in the body does not result from another psychological and/or societal problem) such that the medical interventions they are seeking will help them to realise their preferences. If we cannot assume this—and we suggest that we have reasonable grounds to question an unqualified acceptance in some cases—then ‘acceptance’ potentially works against best interests. We propose a distinction between ‘acceptance’ and respectful, in-depth exploration of an individual’s claims about what promotes their well-being. We discuss the ethical relevance of the unconscious mind to considerations of autonomy and consent in working with transgender individuals. An inquisitive stance, we suggest, supports autonomous choice about how to realise an embodied form that sustains well-being by allowing the individual to consider both conscious and unconscious factors shaping wishes and values, hence choices.
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Laidlaw, M. K., Van Mol, A., Van Meter, Q., & Hansen, J. E. (2021). Letter to the Editor from Laidlaw et al: “Erythrocytosis in a Large Cohort of Transgender Men Using Testosterone: A Long-Term Follow-Up Study on Prevalence, Determinants, and Exposure Years.” The Journal of Clinical Endocrinology & Metabolism, dgab514. https://doi.org/10.1210/clinem/dgab514
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Vandenbussche, E. (2021). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, 20. https://doi.org/10.1080/00918369.2021.1919479
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Journal AbstractThe aim of this study is to analyze the specific needs of detransi­ tioners from online detrans communities and discover to what extent they are being met. For this purpose, a cross-sectional online survey was conducted and gathered a sample of 237 male and female detransitioners. The results showed important psychological needs in relation to gender dysphoria, comorbid conditions, feelings of regret and internalized homophobic and sexist prejudices. It was also found that many detransitioners need medical support notably in relation to stopping/changing hormone therapy, surgery/treatment complications and rever­ sal interventions. Additionally, the results indicated the need for hearing about other detransitioners’ experiences and meeting each other. A major lack of support was reported by the respon­ dents overall, with a lot of negative experiences coming from medical and mental health systems and from the LGBT+ com­ munity. The study highlights the importance of increasing awareness and support given to detransitioners.
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Biggs, M. (2021). Revisiting the effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria. Journal of Pediatric Endocrinology and Metabolism, 0(0), 000010151520210180. https://doi.org/10.1515/jpem-2021-0180
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Kozlowska, K., McClure, G., Chudleigh, C., Maguire, A. M., Gessler, D., Scher, S., & Ambler, G. R. (2021). Australian children and adolescents with gender dysphoria: Clinical presentations and challenges experienced by a multidisciplinary team and gender service. Human Systems, 26344041211010776. https://doi.org/10.1177/26344041211010777
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Journal AbstractThis prospective study examines the clinical characteristics of children (n = 79; 8.42–15.92 years old; 33 biological males and 46 biological females) presenting to a newly established, multidisciplinary Gender Service in New South Wales, Australia, and the challenges faced by the clinicians providing clinical services to these patients and their families. The clinical characteristics of the children were comparable to those described by other paediatric clinics providing gender services: a slight preponderance of biological females to males (1.4: 1); high levels of distress (including dysphoria about gender), suicidal ideation (41.8%), self-harm (16.3%), and suicide attempts (10.1%); and high rates of comorbid mental health disorders: anxiety (63.3%), depression (62.0%), behavioural disorders (35.4%), and autism (13.9%). The developmental stories told by the children and their families highlighted high rates of adverse childhood experiences, with family conflict (65.8%), parental mental illness (63.3%), loss of important figures via separation (59.5%), and bullying (54.4%) being most common. A history of maltreatment was also common (39.2%). Key challenges faced by the clinicians included the following: the effects of increasingly dominant, polarized discourses on daily clinical practice; issues pertaining to patient and clinician safety (including pressures to abandon the holistic [biopsychosocial] model); the difficulties of untangling gender dysphoria from comorbid factors such as anxiety, depression, and sexual abuse; and the factual uncertainties present in the currently available literature on longitudinal outcomes. Our results suggest the need to bring into play a biopsychosocial, trauma-informed model of mental health care for children presenting with gender dysphoria. Ongoing therapeutic work needs to address unresolved trauma and loss, the maintenance of subjective well-being, and the development of the self.
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Malone, W. J., Hruz, P. W., Mason, J. W., & Beck, S. (2021). Letter to the Editor from William J. Malone et al: “Proper Care of Transgender and Gender-diverse Persons in the Setting of Proposed Discrimination: A Policy Perspective.” The Journal of Clinical Endocrinology & Metabolism, dgab205. https://doi.org/10.1210/clinem/dgab205
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Bewley, S., McCartney, M., Meads, C., & Rogers, A. (2021). Sex, gender, and medical data. BMJ, n735. https://doi.org/10.1136/bmj.n735
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Journal AbstractDistinction is critical for good healthcare

Sex and gender are not synonymous. Sex, unless otherwise specified, relates to biology: the gametes, chromosomes, hormones, and reproductive organs. Gender relates to societal roles, behaviours, and expectations that vary with time and place, historically and geographically. These categories describe different attributes that must be considered depending on the purpose they are intended for.1 The World Health Organization states, “Gender is used to describe the characteristics of women and men that are socially constructed, while sex refers to those that are biologically determined.”2

However, contemporary medical research and clinical practice often erroneously use sex and gender interchangeably. Furthermore, there are other categories, again with distinct purposes. UK law allows registered sex on a birth certificate to be changed when a gender recognition certificate has been issued. This certificate, of legal sex, requires a medical diagnosis and approval by a committee. Administrative sex categories such as those recorded in passports or NHS numbers can be changed from female to male, or vice versa, on request.3

The right question must be asked to obtain the information desired; recent debate around the 2021 census in …
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Giordano, S., Garland, F., & Holm, S. (2021). Gender dysphoria in adolescents: can adolescents or parents give valid consent to puberty blockers? Journal of Medical Ethics, medethics-2020-106999. https://doi.org/10.1136/medethics-2020-106999
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Journal AbstractThis article considers the claim that gender diverse minors and their families should not be able to consent to hormonal treatment for gender dysphoria. The claim refers particularly to hormonal treatment with so-called ‘blockers’, analogues that suspend temporarily pubertal development. We discuss particularly four reasons why consent may be deemed invalid in these cases: (1) the decision is too complex; (2) the decision-makers are too emotionally involved; (3) the decision-makers are on a ‘conveyor belt’; (4) the possibility of detransitioning. We examine each of these reasons and we show that none of these stand up to scrutiny, and that some are based on a misunderstanding of the nature and purposes of this stage of treatment and of the circumstances in which it is usually prescribed. Moreover, accepting these claims at face value could have serious negative implications, not just for gender diverse youth, but for many other minors and families and in a much broader range of healthcare settings.
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Dyer, C. (2021). Puberty blockers do not alleviate negative thoughts in children with gender dysphoria, finds study. BMJ, n356. https://doi.org/10.1136/bmj.n356
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Journal AbstractPuberty blockers used to treat children aged 12 to 15 who have severe and persistent gender dysphoria had no significant effect on their psychological function, thoughts of self-harm, or body image, a study has found.

However, as expected, the children experienced reduced growth in height and bone strength by the time they finished their treatment at age 16.

The findings, from a study of 44 children treated by the Gender Identity Development Service (GIDS) run by the Tavistock and Portman NHS Foundation Trust in London, have emerged as the trust prepares to appeal against a High Court ruling that led NHS England to pause referrals of under 16s for puberty blockers.

The appeal, expected to be heard on …
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Biggs, M. (2021, February 3). More questions than answers about the outcomes of puberty suppression. https://journals.plos.org/plosone/article/comment?id=10.1371%2Fannotation%2F71faadb8-de18-4c65-9482-93ded40984b6&s=08
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Walch, A., Davidge-Pitts, C., Safer, J. D., Lopez, X., Tangpricha, V., & Iwamoto, S. J. (2021). Proper Care of Transgender and Gender Diverse Persons in the Setting of Proposed Discrimination: A Policy Perspective*. The Journal of Clinical Endocrinology & Metabolism, 106(2), 305–308. https://doi.org/10.1210/clinem/dgaa816
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Journal AbstractTransgender and gender diverse (TGD) individuals face significant barriers to accessing health care. Recent introductions of regulatory policies at state and federal levels raise concerns over the politicization of gender-affirming health care, the risks of further restricting access to quality care, and the potential criminalization of healthcare professionals who care for TGD patients. The Endocrine Society and the Pediatric Endocrine Society have published several news articles and comments in the last couple of years supporting safe and effective gender-affirming interventions as outlined in the 2017 Endocrine Society’s Clinical Practice Guidelines. The Endocrine Society Position Statement on Transgender Health also acknowledges the rapid expansion in understanding the biological underpinning of gender identity and the need for increased funding to help close gaps in knowledge about the optimal care of TGD individuals. This Policy Perspective affirms these principles in the context of pending and future legislation attempting to discriminate against TGD patients while also stressing the need for science and health care experts to inform health policies.
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Expósito-Campos, P. (2021). A Typology of Gender Detransition and Its Implications for Healthcare Providers. Journal of Sex & Marital Therapy. https://www.tandfonline.com/doi/abs/10.1080/0092623X.2020.1869126
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Journal AbstractGender detransition is an emerging yet poorly understood phenomenon in our society. In the absence of research, clinicians and researchers have applied the concept of detransition differently, leading to inconsistencies in its use. The article suggests a typology of gender detransition based on the cessation or the continuation of a transgender identity to address this issue. Implications of this typology for healthcare providers are discussed, emphasizing the increasing necessity of developing clinical guidelines for detransitioners. Finally, the article reflects on the possibilities of preventing detransition, which underlines the challenges that clinicians face when treating individuals with gender dysphoria.
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Marchiano, L. (2021). Gender detransition: a case study. Journal of Analytical Psychology, 66(4), 813–832. https://doi.org/10.1111/1468-5922.12711
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Journal AbstractWithin the last decade, there has been a sharp global rise in the number of young people identifying as transgender. More recently, there appears to be an increase in the numbers of young people detransitioning or returning to identifying with their natal sex after pursuing medical transition. A case is presented of a young woman who pursued a gender transition and returned to identifying as female after almost two years on testosterone. The author considers and critiques the affirmative model of care for gender dysphoric youth in light of this case.
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Malone, W., D’Angelo, R., Beck, S., Mason, J., & Evans, M. (2021). Puberty blockers for gender dysphoria: the science is far from settled. The Lancet Child & Adolescent Health, 5(9), e33–e34. https://doi.org/10.1016/S2352-4642(21)00235-2
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Journal AbstractThe Editorial in The Lancet Child & Adolescent Health stated that trans youth “have the same right to health and wellbeing as all humans”. However what constitutes good health care for this population is far from clear based on the available evidence.
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O’Malley, S., Garner, M., Withers, R., Caspian, J., & Jenkins, P. (2021). The communication of evidence to inform trans youth health care. The Lancet Child & Adolescent Health, S2352464221001978. https://doi.org/10.1016/S2352-4642(21)00197-8
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Journal AbstractAs a group of psychotherapists working in the area of gender, we have concerns about the arguments and statistics presented in The Lancet Child & Adolescent Health's Editorial. 1
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Armitage, R. (2021). The communication of evidence to inform trans youth health care. The Lancet Child & Adolescent Health, S2352464221001929. https://doi.org/10.1016/S2352-4642(21)00192-9
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Journal AbstractI read with interest The Lancet Child & Adolescent Health's Editorial 1 regarding transgender and gender diverse (trans) youth, and strongly agree that “as clinicians, it is important to use evidence”, especially if we are to honour the equally valid statement that “children need protecting”. It is, therefore, paramount that evidence to inform trans youth health care is communicated honestly, transparently, and responsibly. As such, the use of evidence to support two claims made in the Editorial requires critical appraisal.
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Dahlen, S., Connolly, D., Arif, I., Junejo, M. H., Bewley, S., & Meads, C. (2021). International clinical practice guidelines for gender minority/trans people: systematic review and quality assessment. BMJ Open, 11(4), e048943. https://doi.org/10.1136/bmjopen-2021-048943
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Journal AbstractOBJECTIVES: To identify and critically appraise published clinical practice guidelines (CPGs) regarding healthcare of gender minority/trans people.

DESIGN: Systematic review and quality appraisal using AGREE II (Appraisal of Guidelines for Research and Evaluation tool), including stakeholder domain prioritisation.

SETTING: Six databases and six CPG websites were searched, and international key opinion leaders approached.

PARTICIPANTS: CPGs relating to adults and/or children who are gender minority/trans with no exclusions due to comorbidities, except differences in sex development.

INTERVENTION: Any health-related intervention connected to the care of gender minority/trans people.

MAIN OUTCOME MEASURES: Number and quality of international CPGs addressing the health of gender minority/trans people, information on estimated changes in mortality or quality of life (QoL), consistency of recommended interventions across CPGs, and appraisal of key messages for patients.

RESULTS: Twelve international CPGs address gender minority/trans people’s healthcare as complete (n=5), partial (n=4) or marginal (n=3) focus of guidance. The quality scores have a wide range and heterogeneity whichever AGREE II domain is prioritised. Five higher-quality CPGs focus on HIV and other blood-borne infections (overall assessment scores 69%–94%). Six lower-quality CPGs concern transition-specific interventions (overall assessment scores 11%–56%). None deal with primary care, mental health or longer-term medical issues. Sparse information on estimated changes in mortality and QoL is conflicting. Consistency between CPGs could not be examined due to unclear recommendations within the World Professional Association for Transgender Health Standards of Care Version 7 and a lack of overlap between other CPGs. None provide key messages for patients.

CONCLUSIONS: A paucity of high-quality guidance for gender minority/trans people exists, largely limited to HIV and transition, but not wider aspects of healthcare, mortality or QoL. Reference to AGREE II, use of systematic reviews, independent external review, stakeholder participation and patient facing material might improve future CPG quality.
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Singh, D., Bradley, S. J., & Zucker, K. J. (2021). A Follow-Up Study of Boys With Gender Identity Disorder. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.632784
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Journal AbstractThis study reports follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139) with regard to gender identity and sexual orientation. In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33-12.99) at a mean year of 1989 and followed-up at a mean age of 20.58 years (range, 13.07-39.15) at a mean year of 2002. In childhood, 88 (63.3%) of the boys met the DSM-III, III-R or IV criteria for gender identity disorder; the remaining 51 (36.7%) boys were subthreshold for the criteria. At follow-up, gender identity/dysphoria was assessed via multiple methods and the boys were classified as either persisters or desisters. Sexual orientation was ascertained for both fantasy and behavior and then dichotomized as either biphilic/androphilic or gynephilic. Of the 139 boys, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters. Data on sexual orientation in fantasy were available for 129 boys: 82 (63.6%) were classified as biphilic/ androphilic, 43 (33.3%) were classified as gynephilic, and 4 (3.1%) reported no sexual fantasies. For sexual orientation in behavior, data were available for 108 boys: 51 (47.2%) were classified as biphilic/androphilic, 29 (26.9%) were classified as gynephilic, and 28 (25.9%) reported no sexual behaviors. Multinomial logistic regression examined predictors of outcome for the biphilic/androphilic persisters and the gynephilic desisters, with the biphilic/androphilic desisters as the reference group. Compared to the reference group, the biphilic/androphilic persisters tended to be older at the time of the assessment in childhood, were from a lower social class background, and, on a dimensional composite of sex-typed behavior in childhood were more gender-variant. The biphilic/androphilic desisters were more gender-variant compared to the gynephilic desisters. Boys clinic-referred for gender identity concerns in childhood had a high rate of desistance and a high rate of a biphilic/androphilic sexual orientation. The implications of the data for current models of care for the treatment of gender dysphoria in children are discussed.
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Kozlowska, K., Chudleigh, C., McClure, G., Maguire, A. M., & Ambler, G. R. (2021). Attachment Patterns in Children and Adolescents With Gender Dysphoria. Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.582688
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Journal AbstractThe current study examines patterns of attachment/self-protective strategies and rates of unresolved loss/trauma in children and adolescents presenting to a multidisciplinary gender service. Fifty-seven children and adolescents (8.42–15.92 years; 24 birth-assigned males and 33 birth-assigned females) presenting with gender dysphoria participated in structured attachment interviews coded using dynamic-maturational model (DMM) discourse analysis. The children with gender dysphoria were compared to age- and sex-matched children from the community (non-clinical group) and a group of school-age children with mixed psychiatric disorders (mixed psychiatric group). Information about adverse childhood experiences (ACEs), mental health diagnoses, and global level of functioning was also collected. In contrast to children in the non-clinical group, who were classified primarily into the normative attachment patterns (A1-2, B1-5, and C1-2) and who had low rates of unresolved loss/trauma, children with gender dysphoria were mostly classified into the high-risk attachment patterns (A3-4, A5-6, C3-4, C5-6, and A/C) (χ2=52.66; p<.001) and had a high rate of unresolved loss/trauma (χ2=18.64; p<.001). Comorbid psychiatric diagnoses (n=50; 87.7%) and a history of self-harm, suicidal ideation, or symptoms of distress were also common. Global level of functioning was impaired (range 25-95/100; mean=54.88; SD=15.40; median=55.00). There were no differences between children with gender dysphoria and children with mixed psychiatric disorders on attachment patterns (χ2=2.43; p=.30) and rates of unresolved loss and trauma (χ2=0.70; p=.40). Post hoc analyses showed that lower SES, family constellation (a non-traditional family unit), ACEs—including maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence)—increased the likelihood of the child being classified into a high risk attachment pattern. Akin to children with other forms of psychological distress, children with gender dysphoria present in the context of multiple interacting risk factors that include at-risk attachment, unresolved loss/trauma, family conflict and loss of family cohesion, and exposure to multiple ACEs.
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D’Angelo, R., Syrulnik, E., Ayad, S., Marchiano, L., Kenny, D. T., & Clarke, P. (2020). One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-020-01844-2
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Bailey, J. (2020). The Minority Stress Model Deserves Reconsideration, Not Just Extension. Archives of Sexual Behavior, 49. https://doi.org/10.1007/s10508-019-01606-9
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D’Angelo, R. (2020). The man I am trying to be is not me. The International Journal of Psychoanalysis, 101(5), 951–970. https://doi.org/10.1080/00207578.2020.1810049
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Journal AbstractThis paper explores the therapeutic process between analyst and Josh, a trans man whose life had fallen apart after transition. Repetitive enactments involving hiding, deceiving and mystification constituted a prolonged therapeutic impasse. The analyst’s struggle with these binds and with countertransference confusion and anxiety, ultimately illuminated zones that had remained off-limits for a prolonged period of time. Where the couple had been snared in a bind structured by gender, they were now able to access a history of violation and to ask more profound questions about connection, aloneness, authenticity and loss.
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Bell, D. (2020). First do no harm. The International Journal of Psychoanalysis, 101(5), 1031–1038. https://doi.org/10.1080/00207578.2020.1810885
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Journal AbstractFirst do no harm* David Bell Every social order creates those character forms which it needs for its own preservation ... The character structure ... is the crystallization of the sociological process of a given epoch. (Wilhelm Reich) What I have to say will be divided into three sections. In the first, I will elaborate on what I have learnt about the healthcare of children suffering from gender dysphoria, focusing on the serious clinical and ethical concerns that I, like many others who have become involved in this field of work, have come to recognise. I will go on to discuss the socio-cultural factors that may be relevant to understanding the sudden huge increase in children and adolescents being referred to specialist centres. Finally, I will examine some of the characteristics of a peculiar form of thinking or, more precisely, non-thinking, that seems to have come to dominate the discourse in this area. The understanding/knowledge that I have been developing comes from a number of sources, including my engagement with colleagues in the UK, other European countries (particularly Sweden), Australia and the USA. First, I need to state an important rider – and the fact that I have to do so is symptomatic of the highly charged atmosphere in which discussions of this area take place, resulting in important and often highly motivated misunderstandings. Questions about the appropriateness of medical and surgical intervention, most particularly in children, need to be kept entirely distinct from questions of discrimination. I say this as there is pressure for these two matters to be elided, and I will return to this later. We are all appalled by the violent hatred that many trans people have to suffer and indeed we may have some psychoanalytic thoughts as to its sources. I also need to make it clear that I can see that for some individuals, medical transition is the only reasonable option. Concerns regarding the understanding and treatment of trans children It is vital to differentiate gender dysphoria from transgender – the former refers to deep feelings of discomfort with the sexual body that has multiple sources and multiple appropriate therapeutic approaches. “Transgender” refers to those individuals who have completed or are embarking upon medical and surgical interventions aimed at altering their gender identity. However, services pressured by trans lobbies and by an increasingly hegemonic zeitgeist fail to discriminate between the two, with disastrous consequences. There are multiple routes to gender dysphoria – the list is long but would include the presence of various psychological disorders including depression or autistic spectrum...
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Anckarsäter, H., & Gillberg, C. (2020). Methodological Shortcomings Undercut Statement in Support of Gender-Affirming Surgery. American Journal of Psychiatry, 177(8), 764–765. https://doi.org/10.1176/appi.ajp.2020.19111117
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Ring, A., & Malone, W. J. (2020). Confounding Effects on Mental Health Observations After Sex Reassignment Surgery. American Journal of Psychiatry, 177(8), 768–769. https://doi.org/10.1176/appi.ajp.2020.19111169
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Van Mol, A., Laidlaw, M. K., Grossman, M., & McHugh, P. R. (2020). Gender-Affirmation Surgery Conclusion Lacks Evidence. American Journal of Psychiatry, 177(8), 765–766. https://doi.org/10.1176/appi.ajp.2020.19111130
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Evans, M. (2020). Freedom to think: the need for thorough assessment and treatment of gender dysphoric children. BJPsych Bulletin, 1–5. https://doi.org/10.1192/bjb.2020.72
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Journal AbstractSUMMARY: Referrals (particularly natal female) to gender identity clinics have increased significantly in recent years. Understanding the reasons for this increase, and how to respond, is hampered by a politically charged debate regarding gender identity. This article starts with a discussion of the so-called 'affirmative approach' to gender dysphoria and considers the implications of the Memorandum of Understanding on conversion therapy. I then say something about the relationship between gender dysphoria and the developmental problems that are characteristic of adolescence. Finally, I outline what changes to the current approach are needed to do our best to ensure these patients receive the appropriate treatment.
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Griffin, L., Clyde, K., Byng, R., & Bewley, S. (2020). Sex, gender and gender identity: a re-evaluation of the evidence. BJPsych Bulletin, 1–9. https://doi.org/10.1192/bjb.2020.73
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Journal AbstractSummary
In the past decade there has been a rapid increase in gender diversity, particularly in children and young people, with referrals to specialist gender clinics rising. In this article, the evolving terminology around transgender health is considered and the role of psychiatry is explored now that this condition is no longer classified as a mental illness. The concept of conversion therapy with reference to alternative gender identities is examined critically and with reference to psychiatry's historical relationship with conversion therapy for homosexuality. The authors consider the uncertainties that clinicians face when dealing with something that is no longer a disorder nor a mental condition and yet for which medical interventions are frequently sought and in which mental health comorbidities are common.
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Pilgrim, D., & Entwistle, K. (2020). GnRHa (‘Puberty Blockers’) and Cross Sex Hormones for Children and Adolescents: Informed Consent, Personhood and Freedom of Expression. The New Bioethics, 26(3), 224–237. https://doi.org/10.1080/20502877.2020.1796257
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Journal AbstractEthical concerns have been raised about routine practice in paediatric gender clinics. We discuss informed consent and the risk of iatrogenesis in the prescribing of gonadotropin-releasing hormone analogues (GnRHas) and cross sex hormones to children and adolescents respectively. We place those clinical concerns in a wider societal context and invite consideration of two further relevant ethical domains: competing rights-based claims about male and female personhood; and freedom of expression about those claims. When reflecting on the assessment and medicalization of children and adolescents presenting at gender clinics, the matters of informed consent and iatrogenic risk should be the most pressing for clinicians. However, this is not just a matter of medical ethics, it also implies the need for a full ethical debate on competing notions of personhood and the defence of freedom of expression about transgender and its implications within contemporary democracies.
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Cantor, J. M. (2020). Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy. Journal of Sex & Marital Therapy, 46(4), 307–313. https://doi.org/10.1080/0092623X.2019.1698481
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Journal AbstractThe American Academy of Pediatrics (AAP) recently published a policy statement: Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Although almost all clinics and professional associations in the world use what's called the watchful waiting approach to helping gender diverse (GD) children, the AAP statement instead rejected that consensus, endorsing gender affirmation as the only acceptable approach. Remarkably, not only did the AAP statement fail to include any of the actual outcomes literature on such cases, but it also misrepresented the contents of its citations, which repeatedly said the very opposite of what AAP attributed to them.
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Entwistle, K. (2020). Debate: Reality check – Detransitioner’s testimonies require us to rethink gender dysphoria. Child and Adolescent Mental Health, camh.12380. https://doi.org/10.1111/camh.12380
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Journal AbstractButler and Hutchinson's clarion call (Butler and Hutchinson, 2020) for empirical research on desistance and detransition deserves careful consideration. It formally documents the needs of the emerging cohort of detransitioners, many of whom are in their teens and early twenties. In the absence of specialist services, some detransitioners have been sharing their experiences in public forums. The anecdotal reports by detransitioners indicate that systematic long-term follow-up of those who have been prescribed medical interventions by NHS and private clinics is essential to understanding the gestalt. Decision-making on the basis of misinformation on the effectiveness and necessity of medical interventions for gender dysphoria is a problem, and detransitioners indicate that nonmedical interventions for gender dysphoria are sorely needed. Analysis of the political and organisational systems that have brought us to the current situation is required in order to prevent more young people from being prescribed unnecessary medical interventions for gender dysphoria.
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Kaltiala, R., Heino, E., Työläjärvi, M., & Suomalainen, L. (2020). Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria. Nordic Journal of Psychiatry, 74(3), 213–219. https://doi.org/10.1080/08039488.2019.1691260
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Journal AbstractPurpose: To assess how adolescent development progresses and psychiatric symptoms develop among transsexual adolescents after starting cross-sex hormone treatment.

Materials and methods: Retrospective chart review among 52 adolescents who came into gender identity assessment before age 18, were diagnosed with transsexualism and started hormonal gender reassignment. The subjects were followed over the so-called real-life phase of gender reassignment.

Results: Those who did well in terms of psychiatric symptoms and functioning before cross-sex hormones mainly did well during real-life. Those who had psychiatric treatment needs or problems in school, peer relationships and managing everyday matters outside of home continued to have problems during real-life.

Conclusion: Medical gender reassignment is not enough to improve functioning and relieve psychiatric comorbidities among adolescents with gender dysphoria. Appropriate interventions are warranted for psychiatric comorbidities and problems in adolescent development.
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D’Angelo, R. (2020). Who is Phoenix? Journal of Medical Ethics, 46(11), 753–754. https://doi.org/10.1136/medethics-2020-106822
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D’Angelo, R. (2020). The complexity of childhood gender dysphoria. Australasian Psychiatry, 28(5), 530–532. https://doi.org/10.1177/1039856220917076
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Journal AbstractOBJECTIVE: To explore a developmental understanding of childhood gender dysphoria and to compare it to the prevailing paradigm, gender-affirming care.

CONCLUSION: Viewing gender dysphoria through a contemporary developmental frame generates a different understanding of the nature of the phenomenon and its treatment and raises ethical questions about our current gender-affirming approach.
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de Vries, A. L. C. (2020). Challenges in Timing Puberty Suppression for Gender-Nonconforming Adolescents. Pediatrics, 146(4), e2020010611. https://doi.org/10.1542/peds.2020-010611
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Biggs, M. (2020). Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria. Archives of Sexual Behavior, 49(7), 2227–2229. https://doi.org/10.1007/s10508-020-01743-6
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Biggs, M. (2020). Gender Dysphoria and Psychological Functioning in Adolescents Treated with GnRHa: Comparing Dutch and English Prospective Studies. Archives of Sexual Behavior, 49(7), 2231–2236. https://doi.org/10.1007/s10508-020-01764-1
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Hruz, P. W. (2020). Deficiencies in Scientific Evidence for Medical Management of Gender Dysphoria. The Linacre Quarterly, 87(1), 34–42. https://doi.org/10.1177/0024363919873762
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Journal AbstractIndividuals who experience a gender identity that is discordant with biological sex are increasingly presenting to physicians for assistance in alleviating associated psychological distress. In contrast to prior efforts to identify and primarily address underlying psychiatric contributors to gender dysphoria, interventions that include uncritical social affirmation, use of gonadotropin-releasing hormone agonists to suppress normally timed puberty, and administration of cross-sex steroid hormones to induce desired secondary sex characteristics are now advocated by an emerging cohort of transgender medicine specialists. For patients with persistent gender dysphoria, surgery is offered to alter the appearance of breasts and genital organs. Efforts to address ethical concerns regarding this contentious treatment paradigm are dependent upon reliable evidence on immediate and long-term risks and benefits. Although strong recommendations have been made for invasive and potentially irreversible interventions, high-quality scientific data on the effects of this approach are generally lacking. Limitations of the existing transgender literature include general lack of randomized prospective trial design, small sample size, recruitment bias, short study duration, high subject dropout rates, and reliance on “expert” opinion. Existing data reveal significant intervention-associated morbidity and raise serious concern that the primary goal of suicide prevention is not achieved. In addition to substantial moral questions, adherence to established principles of evidence-based medicine necessitates a high degree of caution in accepting gender-affirming medical interventions as a preferred treatment approach. Continued consideration and rigorous investigation of alternate approaches to alleviating suffering in people with gender dysphoria are warranted.

Summary:
This paper provides an overview of what is currently known about people who experience a gender identity that differs from their biological sex and the associated desire to engage the medical profession in alleviating associated discomfort and distress. The scientific evidence used to support current recommendations for affirming one’s preferred gender, halting normally timed puberty, administering cross-sex hormones, and surgically altering primary and secondary sexual traits are summarized and critically evaluated. Serious deficits in understanding the cause of this condition, the reasons for the marked increase in people presenting for medical care, together with immediate and long-term risks relative to benefit of medical intervention are exposed.
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Zucker, K. J. (2020). Debate: Different strokes for different folks. Child and Adolescent Mental Health, 25(1), 36–37. https://doi.org/10.1111/camh.12330
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Journal AbstractA gender social transition in prepubertal children is a form of psychosocial treatment that aims to reduce gender dysphoria, but with the likely consequence of subsequent (lifelong) biomedical treatments as well (gender-affirming hormonal treatment and surgery). Gender social transition of prepubertal children will increase dramatically the rate of gender dysphoria persistence when compared to follow-up studies of children with gender dysphoria who did not receive this type of psychosocial intervention and, oddly enough, might be characterized as iatrogenic. Parents who bring their children for clinical care hold different philosophical views on what is the best way to help reduce the gender dysphoria, which require both respect and understanding.
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Hutchinson, A., Midgen, M., & Spiliadis, A. (2020). In Support of Research Into Rapid-Onset Gender Dysphoria. Archives of Sexual Behavior, 49(1), 79–80. https://doi.org/10.1007/s10508-019-01517-9
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Withers, Robert. (2020). Transgender medicalization and the attempt to evade psychological distress. Journal of Analytical Psychology, 65(5), 865–889. https://onlinelibrary.wiley.com/doi/10.1111/1468-5922.12641
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Journal AbstractIn this paper the author argues that trans-identification and its associated medical treatment can constitute an attempt to evade experiences of psychological distress. This occurs on three levels. Firstly, the trans person themselves may seek to evade dysregulated affects associated with such experiences as attachment trauma, childhood abuse, and ego-alien sexual feelings. Secondly, therapists may attempt to evade feelings, such as fear and hatred, evoked by engaging with these dysregulated affects. Thirdly, we, as a society, may wish to evade acknowledging the reality of such trauma, abuse and sexual distress by hypothesizing that trans-identification is a biological issue, best treated medically. The author argues that the quality of evidence supporting the biomedical approach is extremely poor. This puts young trans people at risk of receiving potentially damaging medical treatment they may later seek to reverse or come to regret, while their underlying psychological issues remain unaddressed.
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Byng, R., & Bewley, S. (2019). Gender dysphoria: scientific oversight falling between responsible institutions should worry us all. BMJ, l6439. https://doi.org/10.1136/bmj.l6439
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Journal AbstractThe troubles around the Gender Identity Development Service’s study12 seem to be symptomatic of our wider collective failure to determine whether, and when, we should prescribe puberty blockers, or cross sex hormones, to children and young people identifying as transgender.

The ethics of research conduct belongs to the Health Research Authority (HRA), and the quality of science is an important consideration when …
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Levine, S. B. (2019). Informed Consent for Transgendered Patients. Journal of Sex & Marital Therapy, 45(3), 218–229. https://doi.org/10.1080/0092623X.2018.1518885
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Journal AbstractThe request of a transgendered-identified patient for psychiatric, medical, or surgical services creates ethical tensions in mental health professionals, primary care physicians, endocrinologists, and surgeons. These may be summarized as follows: Does the patient have a clear idea of the risks of the services that are being requested? Is the consent truly informed? While this question is starkly evident among cross-gender identified children contemplating puberty suppression and social gender transition and young adolescents with rapid-onset gender dysphoria, it is also relevant to young, middle-aged, and older adults requesting assistance. Many patients cannot tolerate detailed discussion of the risks. This article reviews the history of informed consent, presents the conflicts of ethical principles, and presents three categories of risk that must be appreciated before informed consent is accomplished. The risks involve biological, social, and psychological consequences. Four specific risks exist in each category. The World Professional Association for Transgender Health's Standards of Care recommend an informed consent process, which is at odds with its recommendation of providing hormones on demand. With the knowledge of these 12 risks and benefits of treatment, it is possible to organize the informed consent process by specialty, and for the specific services requested. As it now stands, in many settings informed consent is a perfunctory process creating the risk of uninformed consent.
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Laidlaw, M. K., Van Meter, Q. L., Hruz, P. W., Van Mol, A., & Malone, W. J. (2019). Letter to the Editor: “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, 104(3), 686–687. https://doi.org/10.1210/jc.2018-01925
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Heneghan, Carl, & Jefferson, Tom. (2019, February 25). Gender-affirming hormone in children and adolescents. BMJ EBM Spotlight. https://blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormone-in-children-and-adolescents-evidence-review/
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Journal AbstractGender dysphoria occurs when a person experiences discomfort or distress because of a mismatch between their biological sex and gender identity.  Gender dysphoria can arise in childhood and adolescent which raises many questions about how best to handle the condition. This post sets out some of  the current evidence for gender-affirming hormones in adolescents [...]Read More...
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Biggs, M. (2019). A Letter to the Editor Regarding the Original Article by Costa et al: Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria. The Journal of Sexual Medicine, 16(12), 2043. https://doi.org/10.1016/j.jsxm.2019.09.002
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Journal AbstractI read with interest the article by Costa et al, 1 published in the Journal of Sexual Medicine, which investigates the effects of gonadotropin-releasing hormone analogs (GnRHa) to suppress puberty in adolescents suffering from gender dysphoria. According to the Abstract, “adolescents receiving also puberty suppression had significantly better psychosocial functioning after 12 months of GnRHa … compared with when they had received only psychological support.” The literature now treats this article as providing evidence in favor of puberty suppression. 2 ,3
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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
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Journal AbstractThis article provides an overview of five contemporary clinical and research issues pertaining to adolescents with a diagnosis of gender dysphoria: (1) increased referrals to specialized gender identity clinics; (2) alteration in the sex ratio; (3) suicidality; (4) “rapid-onset gender dysphoria” (ROGD) as a new developmental pathway; (5) and best practice clinical care for adolescents who may have ROGD.
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Richards, C., Maxwell, J., & McCune, N. (2019). Use of puberty blockers for gender dysphoria: a momentous step in the dark. Archives of Disease in Childhood, 104(6), 611–612. https://doi.org/10.1136/archdischild-2018-315881
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Churcher Clarke, A., & Spiliadis, A. (2019). ‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties. Clinical Child Psychology and Psychiatry, 24(2), 338–352. https://doi.org/10.1177/1359104518825288
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Journal AbstractAs the number of young people referred to specialist gender identity clinics in the western world increases, there is a need to examine ways of making sense of the range and diversity of their developmental pathways and outcomes. This article presents a joint case review of the authors caseloads over an 18-month period, to identify and describe those young people who presented to the Gender Identity Development Service (GIDS) with gender dysphoria (GD) emerging in adolescence, and who, during the course of assessment, ceased wishing to pursue medical (hormonal) interventions and/or who arrived at a different understanding of their embodied distress.

From the 12 cases identified, 2 case vignettes are presented. Implications for the development of clinical practice, service delivery and research are considered.
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Bewley, S., Clifford, D., McCartney, M., & Byng, R. (2019). Gender incongruence in children, adolescents, and adults. British Journal of General Practice, 69(681), 170–171. https://doi.org/10.3399/bjgp19X701909
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Laidlaw, M., Cretella, M., & Donovan, K. (2019). The Right to Best Care for Children Does Not Include the Right to Medical Transition. The American Journal of Bioethics, 19(2), 75–77. https://doi.org/10.1080/15265161.2018.1557288
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Spiliadis, A. (2019). Towards a gender exploratory model: Slowing things down, opening things up and exploring identity development. Metalogos Systemic Therapy Journal, 35, 1–9. https://www.researchgate.net/publication/334559847_Towards_a_Gender_Exploratory_Model_slowing_things_down_opening_things_up_and_exploring_identity_development
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Journal AbstractThroughout the western world, the care of children and adolescents whose sexed corporeality is at odds with their gender-related feelings raises medical, psychological, and ethical dilemmas. There are currently differing views around what constitutes responsive and timely support for these young people and how professionals can operate within a rapidly shifting and contested field, in which evidence-base is scarce. In this article I aim to reposition the theoretical framework away from ‘affirmative’ or ‘reparative’ polarities, arguing that both can be problematic, and to invite the reader into a Gender Exploratory Model (GEM) grounded in a systemic-developmental framework; such a model acknowledges and often embraces the notion of uncertainty with regards to young people’s developmental trajectories and clinician’s ‘unknown unknowns’ and exploratory responsibilities. A short introduction to the service (GIDS), as well as a presentation of the current theoretical and clinical debates, will offer a contextual base for clinicians supporting young people experiencing gender dysphoria. This is not an attempt to explore the multifactorial aetiology of gender dysphoria but rather one to add on the theoretical underpinning of therapeutic approaches in supporting these young people.
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Byng, R., Bewley, S., Clifford, D., & McCartney, M. (2018). Redesigning gender identity services: an opportunity to generate evidence. BMJ, k4490. https://doi.org/10.1136/bmj.k4490
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Zucker, K. J. (2018). The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender non-conforming children” by Temple Newhook et al. (2018). International Journal of Transgenderism, 19(2), 231–245. https://doi.org/10.1080/15532739.2018.1468293
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Journal AbstractTemple Newhook et al. (2018) provide a critique of recent follow-up studies of children referred to specialized gender identity clinics, organized around rates of persistence and desistance. The critical gaze of Temple Newhook et al. examined three primary issues: (1) the terms persistence and desistance in their own right; (2) methodology of the follow-up studies and interpretation of the data; and (3) ethical matters. In this response, I interrogate the critique of Temple Newhook et al. (2018).
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Levine, S. B. (2018). Ethical Concerns About Emerging Treatment Paradigms for Gender Dysphoria. Journal of Sex & Marital Therapy, 44(1), 29–44. https://doi.org/10.1080/0092623X.2017.1309482
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Journal AbstractThe increasing incidence of requests for medical services to support gender transition for children, adolescents, and adults has consequences for society, governmental institutions, schools, families, health-care professionals, and, of course, patients. The sociological momentum to recognize and accommodate to trans phenomena has posed ethical dilemmas for endocrinologists, mental health professionals, and sexual specialists as they experience within themselves the clash between respect for patient autonomy, beneficence, nonmaleficence, and informed consent. The larger ethical clashes are cultural and therefore political. There is a distinct difference between pronouncements that represent human rights ideals and the reality of clinical observations. Some interpret this clash as a moral issue. This article delves into these tensions and reminds apologists from both passionate camps that clinical science has a rich tradition of resolving controversy through careful follow-up, which is not yet well developed in this arena.
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de Graaf, N. M., Carmichael, P., Steensma, T. D., & Zucker, K. J. (2018). Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London (2000–2017). The Journal of Sexual Medicine, 15(10), 1381–1383. https://doi.org/10.1016/j.jsxm.2018.08.002
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Journal AbstractINTRODUCTION: The prevalence of gender dysphoria in children is not known; however, there are some data on the sex ratio of children referred to specialized gender identity clinics.

AIM: We sought to examine the sex ratio of children, and some associated factors (age at referral and year of referral), referred to the Gender Identity Development Service in the United Kingdom, the largest such clinic in the world.

METHODS: The sex ratio of children (N ¼ 1,215) referred to the Gender Identity Development Service between 2000-2017 was examined, along with year of referral, age-related patterns, and age at referral.

MAIN OUTCOME MEASURE: Sex ratio of birth-assigned boys vs birth-assigned girls.

RESULTS: The sex ratio significantly favored birth-assigned boys over birth-assigned girls (1.27:1), but there were also age and year of referral effects. The sex ratio favored birth-assigned boys at younger ages (3-9 years), but favored birth-assigned girls at older ages (10-12 years). The percentage of referred birth-assigned boys significantly decreased when 2 cohorts were compared (2000-2006 vs 2007-2017). On average, birth-assigned boys were referred at a younger age than birth-assigned girls.

CLINICAL IMPLICATIONS: The evidence for a change in the sex ratio of children referred for gender dysphoria, particularly in recent years, matches a similar change in the sex ratio of adolescents referred for gender dysphoria. The reasons for this remain understudied.

STRENGTH & LIMITATIONS: The United Kingdom data showed both similarities and differences when compared to data from 2 other gender identity clinics for children (Toronto, Ontario, Canada, and Amsterdam, The Netherlands). Such data need to be studied in more gender identity clinics for children, perhaps with the establishment of an international registry.

CONCLUSION: Further study of the correlates of the sex ratio for children referred for gender dysphoria will be useful in clinical care and management.
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Marchiano, L. (2017). Outbreak: On Transgender Teens and Psychic Epidemics. Psychological Perspectives, 60(3), 345–366. https://doi.org/10.1080/00332925.2017.1350804
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Journal AbstractHaving lived through both World Wars, Jung was aware of the dangers of what he termed “psychic epidemics.” He discussed the spontaneous manifestation of an archetype within collective life as indicative of a critical time during which there is a serious risk of a destructive psychic epidemic. Currently, we appear to be experiencing a significant psychic epidemic that is manifesting as children and young people coming to believe that they are the opposite sex, and in some cases taking drastic measures to change their bodies. Of particular concern to the author is the number of teens and tweens suddenly coming out as transgender without a prior history of discomfort with their sex.“Rapid-onset gender dysphoria” is a new presentation of a condition that has not been well studied. Reports online indicate that a young person's coming out as transgender is often preceded by increased social media use and/or having one or more peers also come out as transgender. These factors suggest that social contagion may be contributing to the significant rise in the number of young people seeking treatment for gender dysphoria.Current psychotherapeutic practice involves immediate affirmation of a young person's self-diagnosis, which often leads to support for social and even medical transition. Although this practice will likely help small numbers of children, there may also be many false positives.
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Hakeem, A. (2012). Psychotherapy for gender identity disorders. Advances in Psychiatric Treatment, 18(1), 17–24. https://doi.org/10.1192/apt.bp.111.009431
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Journal AbstractThis article describes a special adaptation of group psychotherapy as a psychological treat­ ment for people with a variety of gender identity disorders. It can be used as an alternative to or concurrently with hormonal and/or surgical interventions for transgender people. It is also suit­able for individuals whose gender identity disorder remains after physical interventions. The article draws from a UK specialist pilot for such a treatment service and describes the explicit aims of the psychotherapy, the specialist adaptation of therapeutic technique required and observed thematic features relevant to working in this specific field.
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Ruuska, S.-M., Tuisku, K., & KalGala, R. (n.d.). Hormonal and surgical treatment for gender dysphoria in young people – beneficial or not? [Sukupuoliahdistuksen hormonaalinen ja kirurginen hoito nuoruusiässä – hyötyä vai ei?]. Suom Lääkäril [Finnish Medical Journal]. https://www.laakarilehti.fi/site/assets/files/654775/article_pdf_73878.pdf
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Journal AbstractGender dysphoria refers to anxiety or suffering due to conflict between gender identity and biological sex.
– Treatments can be divided into medical and surgical. The gold standard for treating
juveniles, the Dutch model, is based on follow-up research, the quality of which has
been challenged.
– Later evidence of treatment outcomes is likewise inconsistent and the methodology is
of poor quality.
– Based on current knowledge, conclusions cannot be drawn, especially regarding the
psychosocial effectiveness of hormonal treatments.
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Biggs, Michael, Hare, D., Jorgensen, S. C. J., Thompson, P., & Barker, A. (n.d.). Correspondence: Psychosocial Functioning in Transgender Youth after Hormones. https://www.nejm.org/doi/full/10.1056/NEJMoa2206297#article_letters
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Fewer Studies
C. Health risks of medical and surgical affirmation
Bone health complications
van der Loos, M. A. T. C., Vlot, M. C., Klink, D. T., Hannema, S. E., Den Heijer, M., & Wiepjes, C. M. (2023). Bone Mineral Density in Transgender Adolescents Treated With Puberty Suppression and Subsequent Gender-Affirming Hormones. JAMA Pediatrics, 177(12), 1332. https://doi.org/10.1001/jamapediatrics.2023.4588
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Journal AbstractOBJECTIVE: To assess BMD after long-term GAH treatment in transgender adults who used puberty suppression in adolescence. DESIGN, SETTING, AND PARTICIPANTS This single-center cohort study with follow-up duration of 15 years selected participants from a database containing all people visiting a gender identity clinic at an academic hospital in the Netherlands between 1972 and December 31, 2018. Recruitment occurred from March 1, 2020, to August 31, 2021. A total of 75 participants diagnosed with gender dysphoria who had used puberty suppression before age 18 years prior to receiving at least 9 years of long-term GAH were included. EXPOSURES Puberty suppression with a GnRH agonist followed by GAH treatment. MAIN OUTCOMES AND MEASURES Lumbar spine, total hip, and femoral neck BMD and z scores before the start of puberty suppression, at start of GAH, and at short- and long-term follow-up.

RESULTS: Among 75 participants, 25 were assigned male at birth, and 50 were assigned female at birth. At long-term follow-up, the median (IQR) age was 28.2 (27.0-30.8) years in participants assigned male at birth and 28.2 (26.6-30.6) years in participants assigned female at birth. The median (IQR) duration of GAH treatment was 11.6 (10.1-14.7) years among those assigned male at birth and 11.9 (10.2-13.8) years among those assigned female at birth. The z scores decreased during puberty suppression. In individuals assigned male at birth, the mean (SD) z score after long-term GAH use was −1.34 (1.16; change from start of GnRH agonist: −0.87; 95% CI, −1.15 to −0.59) at the lumbar spine, −0.66 (0.75; change from start of GnRH agonist: −0.12; 95% CI, −0.31 to 0.07) at the total hip, and −0.54 (0.84; change from start of GnRH agonist: 0.01; 95% CI, −0.20 to 0.22) at the femoral neck. In individuals assigned female at birth, after long-term GAH use, the mean (SD) z score was 0.20 (1.05; change from start of GnRH agonist: 0.09; 95% CI, −0.09 to 0.27) at the lumbar spine, 0.07 (0.91; change from start of GnRH agonist: 0.10; 95% CI, −0.06 to 0.26) at the total hip, and −0.19 (0.94; change from start of GnRH agonist: −0.20; 95% CI, −0.26 to 0.06) at the femoral neck.

CONCLUSIONS AND RELEVANCE: In this cohort study, after long-term use of GAH, z scores in individuals treated with puberty suppression caught up with pretreatment levels, except for the lumbar spine in participants assigned male at birth, which might have been due to low estradiol concentrations. These findings suggest that treatment with GnRH agonists followed by long-term GAH is safe with regard to bone health in transgender persons receiving testosterone, but bone health in transgender persons receiving estrogen requires extra attention and further study. Estrogen treatment should be optimized and lifestyle counseling provided to maximize bone development in individuals assigned male at birth.
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Boogers, L. S., Van Der Loos, M. A. T. C., Wiepjes, C. M., Van Trotsenburg, A. S. P., Den Heijer, M., & Hannema, S. E. (2023). The dose-dependent effect of estrogen on bone mineral density in trans girls. European Journal of Endocrinology, lvad116. https://doi.org/10.1093/ejendo/lvad116
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Journal AbstractOBJECTIVE: Treatment in transgender girls can consist of puberty suppression (PS) with a GnRH agonist (GnRHa) followed by gender affirming hormonal treatment (GAHT) with estrogen. Bone mineral density (BMD) Z-scores decrease during PS and remain relatively low during GAHT, possibly due to insufficient estradiol dosage. Some adolescents receive high dose estradiol or ethinylestradiol (EE) to limit growth allowing comparison of BMD outcome with different dosages.

DESIGN: Retrospective study.

METHODS: Adolescents treated with GnRHa for ≥1 year prior to GAHT followed by treatment with a regular estradiol dose (gradually increased to 2mg), 6mg estradiol or 100-200µg EE were included to evaluate height-adjusted BMD Z-scores (HAZ-scores) on DXA.

RESULTS: 87 adolescents were included. During 2.3±0.7 years PS, lumbar spine HAZ-scores decreased by 0.69 (95%CI -0.82; -0.56). During 2 years HT, lumbar spine HAZ-scores hardly increased in the regular group (0.14, 95%CI -0.01; 0.28, n=59) versus 0.42 (95%CI 0.13; 0.72) in the 6mg group (n=13), and 0.68 (95%CI 0.20; 1.15) in the EE group (n=15). Compared with the regular group, the increase with EE treatment was higher (0.54, 95%CI 0.05; 1.04). After two years HT, HAZ-scores approached baseline levels at start of PS in individuals treated with 6mg or EE (difference in 6mg group -0.20, 95%CI -0.50; 0.09; in EE 0.17, 95%CI -0.16; 0.50) but not in the regular group (-0.64, 95%CI -0.79; -0.49).

CONCLUSION: Higher estrogen dosage is associated with a greater increase in lumbar spine BMD Z-scores. Increasing dosage up to 2mg estradiol is insufficient to optimize BMD and approximately 4 mg may be required for adequate serum concentrations.
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Ciancia, S., Dubois, V., & Cools, M. (2022). Impact of gender-affirming treatment on bone health in transgender and gender diverse youth. Endocrine Connections, 11(11), e220280. https://doi.org/10.1530/EC-22-0280
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Journal AbstractBoth in the United States and Europe, the number of minors who present at transgender healthcare services before the onset of puberty is rapidly expanding. Many of those who will have persistent gender dysphoria at the onset of puberty will pursue long-term puberty suppression before reaching the appropriate age to start using gender-affirming hormones. Exposure to pubertal sex steroids is thus significantly deferred in these individuals. Puberty is a critical period for bone development: increasing concentrations of estrogens and androgens (directly or after aromatization to estrogens) promote progressive bone growth and mineralization and induce sexually dimorphic skeletal changes. As a consequence, safety concerns regarding bone development and increased future fracture risk in transgender youth have been raised. We here review published data on bone development in transgender adolescents, focusing in particular on differences in age and pubertal stage at the start of puberty suppression, chosen strategy to block puberty progression, duration of puberty suppression, and the timing of re-evaluation after estradiol or testosterone administration. Results consistently indicate a negative impact of long-term puberty suppression on bone mineral density, especially at the lumbar spine, which is only partially restored after sex steroid administration. Trans girls are more vulnerable than trans boys for compromised bone health. Behavioral health measures that can promote bone mineralization, such as weight-bearing exercise and calcium and vitamin D supplementation, are strongly recommended in transgender youth, during the phase of puberty suppression and thereafter.
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Nasomyont, N., Meisman, A. R., Ecklund, K., Vajapeyam, S., Cecil, K. M., Tkach, J. A., Altaye, M., Corathers, S. D., Conard, L. A., Kalkwarf, H. J., Dolan, L. M., & Gordon, C. M. (2022). Changes in Bone Marrow Adipose Tissue in Transgender and Gender Non-Conforming Youth Undergoing Pubertal Suppression: A Pilot Study. Journal of Clinical Densitometry, 25(4), 485–489. https://doi.org/10.1016/j.jocd.2022.06.006
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Journal AbstractPubertal suppression with gonadotropin-releasing hormone (GnRH) agonists in transgender and gender non-conforming (TGNC) youth may affect acquisition of peak bone mass. Bone marrow adipose tissue (BMAT) has an inverse relationship with bone mineral density (BMD). To evaluate the effect of pubertal suppression on BMAT, in this pilot study we prospectively studied TGNC youth undergoing pubertal suppression and cisgender control participants with similar pubertal status over a 12-month period. BMD was measured by dual-energy X-ray absorptiometry and peripheral quantitative computed tomography. Magnetic Resonance T1 relaxometry (T1-R) and spectroscopy (MRS) were performed to quantify BMAT at the distal femur. We compared the change in BMD, T1-R values, and MRS lipid indices between the two groups. Six TGNC (two assigned female and four assigned male at birth) and three female control participants (mean age 10.9 and 11.7 years, respectively) were enrolled. The mean lumbar spine BMD Z-score declined by 0.29 in the TGNC group, but increased by 0.48 in controls (between-group difference 0.77, 95% CI: 0.05, 1.45). Similar findings were observed with the change in trabecular volumetric BMD at the 3% tibia site (-4.1% in TGNC, +3.2% in controls, between-group difference 7.3%, 95% CI: 0.5%-14%). Distal femur T1 values declined (indicative of increased BMAT) by 7.9% in the TGNC group, but increased by 2.1% in controls (between-group difference 10%, 95% CI: -12.7%, 32.6%). Marrow lipid fraction by MRS increased by 8.4% in the TGNC group, but declined by 0.1% in controls (between-group difference 8.5%, 95% CI: -50.2%, 33.0%). In conclusion, we observed lower bone mass acquisition and greater increases in BMAT indices by MRI and MRS in TGNC youth after 12 months of GnRH agonists compared with control participants. Early changes in BMAT may underlie an alteration in bone mass acquisition with pubertal suppression, including alterations in mesenchymal stem cells within marrow.
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Biggs, M. (2021). Revisiting the effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria. Journal of Pediatric Endocrinology & Metabolism: JPEM, 34(7), 937–939. https://doi.org/10.1515/jpem-2021-0180
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Suppressing puberty in children suffering from gender dysphoria by administering Gonadotropin-Releasing Hormone Agonist (GnRHa) entails several known risks. One is that patients could “end with a decreased bone density, which is associated with a high risk of osteoporosis" (Delemarre-van de Waal & Cohen-Kettenis 2006).

This study analyzed data from UK's Tavistock clinic regarding bone density of young gender dysphoric people undergoing puberty blockade. The analysis found that after two years on GnRHa, the Z-scores for a significant minority of the children had declined to clinically-concerning levels. For the hip, one third of Z-scores were below -2. For the spine, over a quarter of Z-scores were below the threshold of -2. Some scores fell below ‑3; such low bone density is found in only 0.13% of the population.

The clinical consequences of the failure to accrue normal bone mass are unknown, as no data on fractures experienced by children undergoing puberty suppression have been tracked. Biggs cites an example of one patient at the Tavistock clinic who started GnRHa at age 12 and then experienced four broken bones by the age of 16, however it is possible that this case is exceptional.

Researchers in the Netherlands have published similar results on bone density, suggesting that future studies should “investigate clinically important outcomes such as fracture risk” (Schagen et al. 2020).

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Schagen, S. E. E., Wouters, F. M., Cohen-Kettenis, P. T., Gooren, L. J., & Hannema, S. E. (2020). Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones. The Journal of Clinical Endocrinology & Metabolism, 105(12), dgaa604. https://doi.org/10.1210/clinem/dgaa604
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Journal AbstractCONTEXT: Hormonal interventions in adolescents with gender dysphoria may have adverse effects, such as reduced bone mineral accrual.

OBJECTIVE: To describe bone mass development in adolescents with gender dysphoria treated with gonadotropin-releasing hormone analogues (GnRHa), subsequently combined with gender-affirming hormones.

DESIGN: Observational prospective study.

SUBJECTS: 51 transgirls and 70 transboys receiving GnRHa and 36 transgirls and 42 transboys receiving GnRHa and gender-affirming hormones, subdivided into early- and late-pubertal groups.

MAIN OUTCOME MEASURES: Bone mineral apparent density (BMAD), age- and sex-specific BMAD z-scores, and serum bone markers.

RESULTS: At the start of GnRHa treatment, mean areal bone mineral density (aBMD) and BMAD values were within the normal range in all groups. In transgirls, the mean z-scores were well below the population mean. During 2 years of GnRHa treatment, BMAD stabilized or showed a small decrease, whereas z-scores decreased in all groups. During 3 years of combined administration of GnRHa and gender-affirming hormones, a significant increase of BMAD was found. Z-scores normalized in transboys but remained below zero in transgirls. In transgirls and early pubertal transboys, all bone markers decreased during GnRHa treatment.

CONCLUSIONS: BMAD z-scores decreased during GnRHa treatment and increased during gender-affirming hormone treatment. Transboys had normal z-scores at baseline and at the end of the study. However, transgirls had relatively low z-scores, both at baseline and after 3 years of estrogen treatment. It is currently unclear whether this results in adverse outcomes, such as increased fracture risk, in transgirls as they grow older.

SEGM Summary

This prospective but uncontrolled observational study investigated the effect of GnRH agonist therapy alone or with subsequent cross-sex hormone administration on markers of bone turnover, apparent bone density (BMAD) and bone density z-scores, with analysis of subjects started early (Tanner state 1-2) and late (Tanner 3-4) in pubertal development.  The study included 51 MTF and 70 FTM subjects receiving GnRH agonsits for 2 years, with 36 MTF and 42 FTM receiving cross-sex hormones for 3 years.

This study confirmed reduction in bone turnover and failure to increase BMAD during exposure to GnRH agonists.  Administration of estrogen to biological males led to increased bone density accrual but did not normalize BMAD z-scores after 3 years.  Biological females receiving testosterone showed improvement in BMAD z-scores to those of biological female peers. 

 

SEGM Plain Language Conclusion:

This study confirmed that use of puberty blockers during normally timed puberty reduces bone turnover and prevents normal accrual of bone density. The addition of cross-sex hormones for three years after pubertal blockade did not result in normalization of bone density in males treated with estrogen. Females receiving testosterone showed near normalization of bone density. Effects on bone structure and fracture risk remain unknown. 

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Lee, J. Y., Finlayson, C., Olson-Kennedy, J., Garofalo, R., Chan, Y.-M., Glidden, D. V., & Rosenthal, S. M. (2020). Low Bone Mineral Density in Early Pubertal Transgender/Gender Diverse Youth: Findings From the Trans Youth Care Study. Journal of the Endocrine Society, 4(9), bvaa065. https://doi.org/10.1210/jendso/bvaa065
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Journal AbstractCONTEXT: Transgender youth may initiate GnRH agonists (GnRHa) to suppress puberty, a critical period for bone-mass accrual. Low bone mineral density (BMD) has been reported in late-pubertal transgender girls before gender-affirming therapy, but little is known about BMD in early-pubertal transgender youth.

OBJECTIVE: To describe BMD in early-pubertal transgender youth.

DESIGN: Cross-sectional analysis of the prospective, observational, longitudinal Trans Youth Care Study cohort.

SETTING: Four multidisciplinary academic pediatric gender centers in the United States.

PARTICIPANTS: Early-pubertal transgender youth initiating GnRHa.

MAIN OUTCOME MEASURES: Areal and volumetric BMD Z-scores.

RESULTS: Designated males at birth (DMAB) had below-average BMD Z-scores when compared with male reference standards, and designated females at birth (DFAB) had below-average BMD Z-scores when compared with female reference standards except at hip sites. At least 1 BMD Z-score was < -2 in 30% of DMAB and 13% of DFAB. Youth with low BMD scored lower on the Physical Activity Questionnaire for Older Children than youth with normal BMD, 2.32 ± 0.71 vs. 2.76 ± 0.61 (P = 0.01). There were no significant deficiencies in vitamin D, but dietary calcium intake was suboptimal in all youth.

CONCLUSIONS: In early-pubertal transgender youth, BMD was lower than reference standards for sex designated at birth. This lower BMD may be explained, in part, by suboptimal calcium intake and decreased physical activity–potential targets for intervention. Our results suggest a potential need for assessment of BMD in prepubertal gender-diverse youth and continued monitoring of BMD throughout the pubertal period of gender-affirming therapy.

SEGM Summary

This is a multi-center cross-sectional analysis of bone density in 63 early pubertal transgender youth prior to or just after initiation of GnRH agonist administration. 

Average BMAD z-scores were found to be lower in study subjects compared to sex in the general population.  Z-scores < -2 were found in 30% of males and 15% of females. 

Correlation was found between decreased physical activity (PAQ-C) and lower bone density.  Calcium intake was lower among the cohort but this did not correlate with differences in bone density.  No difference in 25OH vitamin D was observed.

The authors conclude that poor bone health prior to hormonal therapy is at least partially responsible for adverse bone density in this population. Direct comparison to a control population in all comparisons is needed to fully interpret the significance of their findings. 

Weaknesses:  A third of the subjects in the observational GnRH agonist study cohort were excluded from this analysis. No control group was included. 

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Joseph, T., Ting, J., & Butler, G. (2019). The effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria: findings from a large national cohort. Journal of Pediatric Endocrinology and Metabolism, 32(10), 1077–1081. https://doi.org/10.1515/jpem-2019-0046
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Journal AbstractBackground: More young people with gender dysphoria (GD) are undergoing hormonal intervention starting with gonadotropin-releasing hormone analogue (GnRHa) treatment. The impact on bone density is not known, with guidelines mentioning that bone mineral density (BMD) should be monitored without suggesting when. This study aimed to examine a cohort of adolescents from a single centre to investigate whether there were any clinically significant changes in BMD and bone mineral apparent density (BMAD) whilst on GnRHa therapy.
Methods: A retrospective review of 70 subjects aged 12–14 years, referred to a national centre for the management of GD (2011–2016) who had yearly dual energy X-ray absorptiometry (DXA) scans. BMAD scores were calculated from available data. Two analyses were performed, a complete longitudinal analysis (n = 31) where patients had scans over a 2-year treatment period, and a larger cohort over the first treatment year (n = 70) to extend the observation of rapid changes in lumbar spine BMD when puberty is blocked.
Results: At baseline transboys had lower BMD measures than transgirls. Although there was a significant fall in hip and lumbar spine BMD and lumbar spine BMAD Z-scores, there was no significant change in the absolute values of hip or spine BMD or lumbar spine BMAD after 1 year on GnRHa and a lower fall in BMD/BMAD Z-scores in the longitudinal group in the second year.
Conclusions: We suggest that reference ranges may need to be re-defined for this select patient cohort. Long-term

SEGM Summary

This is a retrospective single center study investigating longitudinal change in bone density in transgender 12-14 year old adolescents exposed to GnRH agonists. 70 subjects had DEXA scans at baseline and 12 months. 31 subjects had data at 24 months.  BMD and BMAD were unchanged but Z-scores significantly decreased. 

This study shows that pubertal blockade in gender dysphoric teens is associated with arrest of normal bone density accrual with resulting fall in bone density z-scores.

Strength:  Relatively large number of subjects.

Limitations: Limited follow up. Analysis limited to DEXA scans. Does not assess effects of subsequent cross-sex hormones. Does not assess bone turnover.

 

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Stoffers, I. E., de Vries, M. C., & Hannema, S. E. (2019). Physical changes, laboratory parameters, and bone mineral density during testosterone treatment in adolescents with gender dysphoria. The Journal of Sexual Medicine, 16(9), 1459–1468. https://doi.org/10.1016/j.jsxm.2019.06.014
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Journal AbstractINTRODUCTION: Current treatment guidelines for adolescents with gender dysphoria recommend therapy with gonadotropin-releasing hormone agonists (GnRHa) and testosterone in transgender males. However, most evidence on the safety and efficacy of testosterone is based on studies in adults.

AIM: This study aimed to investigate the efficacy and safety of testosterone treatment in transgender adolescents.

METHODS: The study included 62 adolescents diagnosed with gender dysphoria who had started GnRHa treatment and had subsequently received testosterone treatment for more than 6 months.

MAIN OUTCOME MEASURE: Virilization, anthropometry, laboratory parameters, and bone mineral density (BMD) were analyzed.

RESULTS: Adolescents were treated with testosterone for a median duration of 12 months. Voice deepening began within 3 months in 85% of adolescents. Increased hair growth was first reported on the extremities, followed by an increase of facial hair. Acne was most prevalent between 6 and 12 months of testosterone therapy. Most adolescents had already completed linear growth; body mass index and systolic blood pressure increased but diastolic blood pressure did not change. High-density lipoprotein (HDL) cholesterol and sex hormone binding globulin significantly decreased, but hematocrit, hemoglobin, prolactin, androstenedione, and dehydroepiandrosterone sulfate significantly increased, although not all changes were clinically significant. Other lipids and HbA1c did not change. Vitamin D deficiency was seen in 32-54% throughout treatment. BMD z-scores after 12 to 24 months of testosterone treatment remained below z-scores before the start of GnRHa treatment.

CLINICAL IMPLICATIONS: Adolescents need to be counseled about side effects with potential longer term implications such as increased hematocrit and decreased HDL cholesterol and decreased BMD z-scores. They should be advised on diet, including adequate calcium and vitamin D intake; physical exercise; and the use of tobacco and alcohol to avoid additional risk factors for cardiovascular disease and osteoporosis.

STRENGTHS & LIMITATIONS: Strengths are the standardized treatment regimen and extensive set of safety parameters investigated. Limitations are the limited duration of follow-up and lack of a control group so some of the observed changes may be due to normal maturation rather than to treatment.

CONCLUSION: Testosterone effectively induced virilization beginning within 3 months in the majority of adolescents. Acne was a common side effect, but no short-term safety issues were observed. The increased hematocrit, decreased HDL cholesterol, and decreased BMD z-scores are in line with previous studies. Further follow-up studies will need to establish if the observed changes result in adverse outcomes in the long term. Stoffers IE, de Vries MC, Hannema SE. Physical Changes, Laboratory Parameters, and Bone Mineral Density During Testosterone Treatment in Adolescents with Gender Dysphoria. J Sex Med 2019;16:1459-1468.

SEGM Summary

This retrospective uncontrolled study investigated the metabolic and bone effects of testosterone administration on 62 gender dysphoric female subjects after GnRH agonist mediated pubertal blockade.  Following 6 and 12 months of  testosterone administration, BMAD z-scores remained below those observed prior to the start of GnRH agonists. In addition, HDL cholesterol was significantly lower and Hct higher with testosterone administration.  Most subjects had completed linear growth prior to starting testosterone.  Vitamin D deficiency was seen in 32-54% of study subjects throughout the study period.

In gender dysphoric females who had received GnRH agonists for at least 6 months, bone density losses were not corrected 12 months after starting testosterone. 

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Delgado-Ruiz, R., Swanson, P., & Romanos, G. (2019). Systematic Review of the Long-Term Effects of Transgender Hormone Therapy on Bone Markers and Bone Mineral Density and Their Potential Effects in Implant Therapy. Journal of Clinical Medicine, 8(6), 784. https://doi.org/10.3390/jcm8060784
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Journal AbstractThis study seeks to evaluate the long-term effects of pharmacologic therapy on the bone markers and bone mineral density of transgender patients and to provide a basis for understanding its potential implications on therapies involving implant procedures. Following the referred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and well-defined PICOT (Problem/Patient/Population, Intervention, Comparison, Outcome, Time) questionnaires, a literature search was completed for articles in English language, with more than a 3 year follow-up reporting the long-term effects of the cross-sex pharmacotherapy on the bones of adult transgender patients. Transgender demographics, time under treatment, and treatment received were recorded. In addition, bone marker levels (calcium, phosphate, alkaline phosphatase, and osteocalcin), bone mineral density (BMD), and bone turnover markers (Serum Procollagen type I N-Terminal pro-peptide (PINP), and Serum Collagen type I crosslinked C-telopeptide (CTX)) before and after the treatment were also recorded. The considerable variability between studies did not allow a meta-analysis. All the studies were completed in European countries. Transwomen (921 men to female) were more frequent than transmen (719 female to male). Transwomen’s treatments were based in antiandrogens, estrogens, new drugs, and sex reassignment surgery, meanwhile transmen’s surgeries were based in the administration of several forms of testosterone and sex reassignment. Calcium, phosphate, alkaline phosphatase, and osteocalcin levels remained stable. PINP increased in transwomen and transmen meanwhile, CTX showed contradictory values in transwomen and transmen. Finally, reduced BMD was observed in transwomen patients receiving long-term cross-sex pharmacotherapy. Considering the limitations of this systematic review, it was concluded that long-term cross-sex pharmacotherapy for transwomen and transmen transgender patients does not alter the calcium, phosphate, alkaline phosphatase, and osteocalcin levels, and will slightly increase the bone formation in both transwomen and transmen patients. Furthermore, long-term pharmacotherapy reduces the BMD in transwomen patients.

SEGM Summary

This systematic literature review aimed to determine the effects of long-term (follow-up >3 years) cross-sex hormone administration and non-hormonal pharmacological treatments on bone markers and bone mineral density (BMD) of adults with gender dysphoria. The review also sought to determine how these long-term treatments might affect the success of orthopedic or dental implants.

This review of nine European studies found that BMD in natal males was somewhat reduced by these treatments. Because of this finding and the lack of information about bone healing in persons undergoing hormone treatment, the authors recommend using precautions intended for osteoporotic patients and monitoring of bone parameters prior to dental implant therapy.

SEGM Plain-Language Conclusion: A systematic review of 9 studies concluded that cross-sex hormones treatments reduced bone mineral in male to female adult patients. Adolescent and young patients were excluded from the analysis. The authors noted the substantial group variability in age, drug and dosage, time under treatment, and biomarkers analyzed, which contributed to contradictory findings and precluded a statistical analysis.

 

 

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Stevenson, M. O., & Tangpricha, V. (2019). Osteoporosis and Bone Health in Transgender Persons. Endocrinology and Metabolism Clinics of North America, 48(2), 421–427. https://doi.org/10.1016/j.ecl.2019.02.006
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Journal AbstractThis review summarizes current studies, systematic reviews, and clinical practice guidelines regarding the screening, diagnosis, and treatment of osteoporosis in transgender persons. Gender-affirming hormone therapy has been shown to maintain or promote acquisition of bone density as measured by dual-energy x-ray absorptiometry. No differences in fracture rates have been seen in trans women or men in short, prospective trials. Trans children and adolescents on gonadotropin-releasing hormone may be at risk for decreasing bone density while not on sex steroid hormone replacement. Screening for osteoporosis should be based on clinical factors. Treatment for osteoporosis follows the same guidelines as cisgender populations.
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Dobrolińska, M., van der Tuuk, K., Vink, P., van den Berg, M., Schuringa, A., Monroy-Gonzalez, A. G., García, D. V., Schultz, W. C. M. W., & Slart, R. H. J. A. (2019). Bone Mineral Density in Transgender Individuals After Gonadectomy and Long-Term Gender-Affirming Hormonal Treatment. The Journal of Sexual Medicine, 16(9), 1469–1477. https://doi.org/10.1016/j.jsxm.2019.06.006
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Journal AbstractINTRODUCTION: Establishing the influence of long-term, gender-affirming hormonal treatment (HT) on bone mineral density (BMD) in transgender individuals is important to improve the therapeutic guidelines for these individuals.
AIM: To examine the effect of long-term HT and gonadectomy on BMD in transgender individuals.
METHODS: 68 transwomen and 43 transmen treated with HT who had undergone gonadectomy participated in this study. Dual-energy x-ray absorptiometry (DXA) scans were performed to measure BMD at the lumbar spine and total hip. Laboratory values related to sex hormones were collected within 3 months of performing the DXA scan and analyzed.
MAIN OUTCOME MEASURE: BMD and levels of sex hormones in transwomen and transmen.
RESULTS: In transwomen, the mean BMD values at the lumbar spine and total hip at the first DXA scan were, respectively, 0.99 ± 0.15 g/cm2 (n = 68) and 0.94 ± 0.28 g/cm2 (n = 65). In transmen, the mean BMD values at the lumbar spine and total hip at the first DXA scan were, respectively, 1.08 ± 0.16 g/cm2 (n = 43) and 1.01 ± 0.18 g/cm2 (n = 43). A significant decrease in total hip BMD was found in both transwomen and transmen after 15 years of HT compared with 10 years of HT (P = .02).
CONCLUSION: In both transwomen and transmen, a decrease was observed in total hip bone mineral density after 15 years of HT compared to the first 10 years of HT. Dobrolińska M, van der Tuuk K, Vink P, et al. Bone Mineral Density in Transgender Individuals After Gonadectomy and Long-Term Gender-Affirming Hormonal Treatment. J Sex Med 2019; 16:1469-1477.

SEGM Summary

This retrospective study of 111 gender-dysphoric individuals was conducted to determine the long-term effects of gonadectomy and long-term hormonal treatment (HT) on bone mineral density (BMD).  The individuals were on average 36 (MTF) and 30 (FMT) years old at the time of the initiation of HT.  Dual-energy x-ray absorptiometry (DXA) scans measured BMD at the lumbar spine and hip after 10 and 15 years of HT.

At 15 years, males and females on HT had reduced BMD, compared to measurements taken after 10 years. The duration of treatment with HT and the time since gonadectomy correlated with an observed decrease in total hip BMD in males and females. A high prevalence of osteoporosis in the treated population was observed.

SEGM Plain-Language Conclusion: Given the relatively old age of the initiation of HT (36 and 30 years old for trans women and trans men respectively), and a presumed lack of pubertal suppression, this finding suggests that even after peak bone mass density has been achieved, gonadectomy and long-term HT are associated with an adverse impact on BMD.

 

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Vlot, M. C., Klink, D. T., den Heijer, M., Blankenstein, M. A., Rotteveel, J., & Heijboer, A. C. (2017). Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents. Bone, 95, 11–19. https://doi.org/10.1016/j.bone.2016.11.008
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Journal AbstractPuberty is highly important for the accumulation of bone mass. Bone turnover and bone mineral density (BMD) can be affected in transgender adolescents when puberty is suppressed by gonadotropin-releasing hormone analogues (GnRHa), followed by treatment with cross-sex hormone therapy (CSHT). We aimed to investigate the effect of GnRHa and CSHT on bone turnover markers (BTMs) and bone mineral apparent density (BMAD) in transgender adolescents. Gender dysphoria was diagnosed based on diagnostic criteria according to the DSM-IV (TR). Thirty four female-to-male persons (transmen) and 22 male-to-female persons (transwomen)were included. Patients were allocated to a young (bone age of <15years in transwomen or <14 in transmen) or old group (bone age of ≥15years in transwomen or ≥14years in transmen). All were treated with GnRHa triptorelin and CSHT was added in incremental doses from the age of 16years. Transmen received testosterone esters (Sustanon, MSD) and transwomen received 17-β estradiol. P1NP, osteocalcin, ICTP and BMD of lumbar spine (LS) and femoral neck (FN) were measured at three time points. In addition, BMAD and Z-scores were calculated. We found a decrease of P1NP and 1CTP during GnRHa treatment, indicating decreased bone turnover (young transmen 95% CI -74 to -50%, p=0.02, young transwomen 95% CI -73 to -43, p=0.008). The decrease in bone turnover upon GnRHa treatment was accompanied by an unchanged BMAD of FN and LS, whereas BMAD Z-scores of predominantly the LS decreased especially in the young transwomen. Twenty-four months after CSHT the BTMs P1NP and ICTP were even more decreased in all groups except for the old transmen. During CSHT BMAD increased and Z-scores returned towards normal, especially of the LS (young transwomen CI 95% 0.1 to 0.6, p=0.01, old transwomen 95% CI 0.3 to 0.8, p=0.04). To conclude, suppressing puberty by GnRHa leads to a decrease of BTMs in both transwomen and transmen transgender adolescents. The increase of BMAD and BMAD Z-scores predominantly in the LS as a result of treatment with CSHT is accompanied by decreasing BTM concentrations after 24months of CSHT. Therefore, the added value of evaluating BTMs seems to be limited and DXA-scans remain important in follow-up of bone health of transgender adolescents.

SEGM Summary

In healthy adolescents, bone mass accumulates during puberty. The first retrospective study of the effects of suppressing puberty and cross-sex hormones on bone turnover markers in 56 adolescents with gender dysphoria examined the effects of pubertal suppression by gonadotropin-releasing hormone analogues (GnRHa) and subsequent cross-sex hormone administration on bone turnover markers (BTM), bone mineral apparent density (BMAD), and the associated Z-scores. 

In this in study, administration GnRHa treatment led to a decrease in BTM, a reduction in BMAD Z-scores, and a stable, rather than increased  BMAD, suggesting a loss of bone density in the GnRHa-treated adolescents compared to their peers. After the initiation of CSH, BTM continued to decrease, while BMAD increased. Although BMAD Z-scores increased, the pre-treatment BMAD Z-scores were not reached in most adolescents treated with CSH after 24 months.

SEGM Plain Language Conclusion: In this study, puberty-blocker treatment led to a delay in bone mass accumulation. Although  the subsequent cross-sex hormone administration stimulated bone growth, it was not sufficient to catch up to the bone density of the untreated peers. Thus, the treatment pathway of puberty blockade followed by cross-sex hormones for at least two years lead to a failure to achieve peak bone density for both biologically male and female adolescents.

 

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Klink, D., Caris, M., Heijboer, A., van Trotsenburg, M., & Rotteveel, J. (2015). Bone Mass in Young Adulthood Following Gonadotropin-Releasing Hormone Analog Treatment and Cross-Sex Hormone Treatment in Adolescents With Gender Dysphoria. The Journal of Clinical Endocrinology & Metabolism, 100(2), E270–E275. https://doi.org/10.1210/jc.2014-2439
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Journal AbstractCONTEXT: Sex steroids are important for bone mass accrual. Adolescents with gender dysphoria (GD) treated with gonadotropin-releasing hormone analog (GnRHa) therapy are temporarily sex-steroid deprived until the addition of cross-sex hormones (CSH). The effect of this treatment on bone mineral density (BMD) in later life is not known.
OBJECTIVE: This study aimed to assess BMD development during GnRHa therapy and at age 22 years in young adults with GD who started sex reassignment (SR) during adolescence.
DESIGN AND SETTING: This was a longitudinal observational study at a tertiary referral center.
PATIENTS: Young adults diagnosed with gender identity disorder of adolescence (DSM IV-TR) who started SR in puberty and had undergone gonadectomy between June 1998 and August 2012 were included. In 34 subjects BMD development until the age of 22 years was analyzed.
INTERVENTION: GnRHa monotherapy (median duration in natal boys with GD [transwomen] and natal girls with GD [transmen] 1.3 and 1.5 y, respectively) followed by CSH (median duration in transwomen and transmen, 5.8 and 5.4 y, respectively) with discontinuation of GnRHa after gonadectomy.
MAJOR OUTCOME MEASURES: How BMD develops during SR until the age of 22 years.
RESULTS AND CONCLUSION: Between the start of GnRHa and age 22 years the lumbar areal BMD z score (for natal sex) in transwomen decreased significantly from -0.8 to -1.4 and in transmen there was a trend for decrease from 0.2 to -0.3. This suggests that the BMD was below their pretreatment potential and either attainment of peak bone mass has been delayed or peak bone mass itself is attenuated.

SEGM Summary

This retrospective study looked at bone mineral density (BMD) in 34 young gender dysphoric adults at the average age of 22, who had been given gonadotropin releasing hormone analog (GnRHa) to suppress or delay puberty for 1.3  - 1.5 years, followed by cross-sex hormones for about 3 years.

The main finding of this study is that young adults treated with GnRHa during adolescence have decreased BMD and loss of bone mass despite the subsequent administration of cross-sex hormones. Importantly, most of the study subjects were relatively late in their puberty when GnRHAs were initiated (average age 15), so much of their bone mass development had already occurred. It is not yet known how much BMD in children and younger adolescents treated with GnRHAs at a younger age will be affected, nor is it known whether these losses will lead to increased risk of fractures in later life.

SEGM Plain-Language Conclusion: In this study, young adults treated with puberty blockers during mid-adolescence had decreased bone mineral density and a loss of bone mass, despite a relatively late initiation of puberty blockers,  and despite a subsequent administration of cross-sex hormones.

 

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Fewer Studies
Cardiovascular complications
Moreira Allgayer, R. M. C., Borba, G. D. S., Moraes, R. S., Ramos, R. B., & Spritzer, P. M. (2023). The Effect of Gender-Affirming Hormone Therapy on the Risk of Subclinical Atherosclerosis in the Transgender Population: A Systematic Review. Endocrine Practice, 29(6), 498–507. https://doi.org/10.1016/j.eprac.2022.12.017
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Journal AbstractObjective: The impact of gender-affirming hormone therapy (GAHT) on cardiovascular (CV) health is still not entirely established. A systematic review was conducted to summarize the evidence on the risk of subclinical atherosclerosis in transgender people receiving GAHT.

Methods: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and data were searched in PubMed, LILACS, EMBASE, and Scopus databases for cohort, case-control, and cross-sectional studies or randomized clinical trials, including transgender people receiving GAHT. Transgender men and women before and during/after GAHT for at least 2 months, compared with cisgender men and women or hormonally untreated transgender persons. Studies reporting changes in variables related to endothelial function, arterial stiffness, autonomic function, and blood markers of inflammation/coagulation associated with CV risk were included.

Results: From 159 potentially eligible studies initially identified, 12 were included in the systematic review (8 cross-sectional and 4 cohort studies). Studies of trans men receiving GAHT reported increased carotid thickness, brachial-ankle pulse wave velocity, and decreased vasodilation. Studies of trans women receiving GAHT reported decreased interleukin 6, plasminogen activator inhibitor-1, and tissue plasminogen activator levels and brachial-ankle pulse wave velocity, with variations in flow-mediated dilation and arterial stiffness depending on the type of treatment and route of administration.

Conclusions: The results suggest that GAHT is associated with an increased risk of subclinical atherosclerosis in transgender men but may have either neutral or beneficial effects in transgender women. The evidence produced is not entirely conclusive, suggesting that additional studies are warranted in the context of primary prevention of CV disease in the transgender population receiving GAHT.
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Nokoff, N. J., Scarbro, S. L., Moreau, K. L., Zeitler, P., Nadeau, K. J., Reirden, D., Juarez-Colunga, E., & Kelsey, M. M. (2021). Body Composition and Markers of Cardiometabolic Health in Transgender Youth on Gonadotropin-Releasing Hormone Agonists. Transgender Health, 6(2), 111–119. https://doi.org/10.1089/trgh.2020.0029
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Journal AbstractPURPOSE: Up to 1.8% of youth identify as transgender; many will be treated with a gonadotropin-releasing hormone agonist (GnRHa). The impact of GnRHa on insulin sensitivity and body composition in transgender youth is understudied. We aimed to evaluate differences in insulin sensitivity and body composition in transgender youth on GnRHa therapy compared with cisgender youth.

METHODS: Transgender participants were matched to cisgender participants on age, body mass index, and sex assigned at birth. Transgender males (n=9, ages 10.1–16.0 years) on GnRHa (mean±standard deviation duration of exposure: 20.9±19.8 months) were compared with cisgender females (n=14, ages 10.6–16.2). Transgender females (n=8, ages 12.6–16.1) on GnRHa (11.3±7 months) were compared with cisgender males (n=17, ages 12.5–15.5). Differences in insulin sensitivity (1/[fasting insulin], homeostatic model of insulin resistance [HOMA-IR]), glycemia (hemoglobin A1C [HbA1c], fasting glucose), and body composition (dual-energy X-ray absorptiometry) were evaluated using a mixed linear regression model.

RESULTS: Transgender males had lower 1/fasting insulin and higher HOMA-IR (p=0.031, p=0.01, respectively), fasting glucose (89±4 vs. 79±13 mg/dL, p=0.012), HbA1c (5.4±0.2 vs. 5.2±0.2%, p=0.039), and percent body fat (36±7 vs. 32±5%, p=0.042) than matched cisgender females. Transgender females had lower 1/fasting insulin and higher HOMA-IR (p=0.028, p=0.035), HbA1c (5.4±0.1% vs. 5.1±0.2%, p=0.007), percent body fat (31±9 vs. 24±10%, p=0.002), and lower percent lean mass (66±8 vs. 74±10%, p<0.001) than matched cisgender males.

CONCLUSION: Transgender youth on a GnRHa have lower estimated insulin sensitivity and higher glycemic markers and body fat than cisgender controls with similar characteristics. Longitudinal studies are needed to understand the significance of these changes. Clinical Trial.gov ID: NCT02550431.
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Nota, N. M., Wiepjes, C. M., de Blok, C. J. M., Gooren, L. J. G., Kreukels, B. P. C., & den Heijer, M. (2019). Occurrence of Acute Cardiovascular Events in Transgender Individuals Receiving Hormone Therapy: Results From a Large Cohort Study. Circulation, 139(11), 1461–1462. https://doi.org/10.1161/CIRCULATIONAHA.118.038584
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Alzahrani, T., Nguyen, T., Ryan, A., Dwairy, A., McCaffrey, J., Yunus, R., Forgione, J., Krepp, J., Nagy, C., Mazhari, R., & Reiner, J. (2019). Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population. Circulation: Cardiovascular Quality and Outcomes, 12(4). https://doi.org/10.1161/CIRCOUTCOMES.119.005597
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Journal AbstractBACKGROUND: As of 2016, ≈1.4 million people in the United States identify as transgender. Despite their growing number and increasing specific medical needs, there has been a lack of research on cardiovascular disease (CVD) and CVD risk factors in this population. Recent studies have reported that the transgender population had a significantly higher rate of CVD risk factors without a significant increase in overall CVD morbidity and mortality. These studies are limited by their small sample sizes and their predominant focus on younger transgender populations. With a larger sample size and inclusion of broader age range, our study aims to provide insight into the association between being transgender and cardiovascular risk factors, as well as myocardial infarction.

METHODS AND RESULTS: The Behavioral Risk Factor Surveillance System data from 2014 to 2017 were used to evaluate the cross-sectional association between being transgender and the reported history of myocardial infarction and CVD risk factors. A logistic regression model was constructed to study the association between being transgender and myocardial infarction after adjusting for CVD risk factors including age, diabetes mellitus, hypertension, hypercholesterolemia, chronic kidney disease, smoking, and exercise. Multivariable analysis revealed that transgender men had a >2-fold and 4-fold increase in the rate of myocardial infarction compared with cisgender men (odds ratio, 2.53; 95% CI, 1.14–5.63; P=0.02) and cisgender women (odds ratio, 4.90; 95% CI, 2.21–10.90; P<0.01), respectively. Conversely, transgender women had >2-fold increase in the rate of myocardial infarction compared with cisgender women (odds ratio, 2.56; 95% CI, 1.78–3.68; P<0.01) but did not have a significant increase in the rate of myocardial infarction compared with cisgender men.

CONCLUSION: The transgender population had a higher reported history of myocardial infarction in comparison to the cisgender population, except for transgender women compared with cisgender men, even after adjusting for cardiovascular risk factors.
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Getahun, D., Nash, R., Flanders, W. D., Baird, T. C., Becerra-Culqui, T. A., Cromwell, L., Hunkeler, E., Lash, T. L., Millman, A., Quinn, V. P., Robinson, B., Roblin, D., Silverberg, M. J., Safer, J., Slovis, J., Tangpricha, V., & Goodman, M. (2018). Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons. Annals of Internal Medicine, 169(4), 205–213. https://doi.org/10.7326/M17-2785
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Journal AbstractBACKGROUND: Venous thromboembolism (VTE), ischemic stroke, and myocardial infarction in transgender persons may be related to hormone use.

OBJECTIVE: To examine the incidence of these events in a cohort of transgender persons.

DESIGN: Electronic medical record-based cohort study of transgender members of integrated health care systems who had an index date (first evidence of transgender status) from 2006 through 2014. Ten male and 10 female cisgender enrollees were matched to each transgender participant by year of birth, race/ethnicity, study site, and index date enrollment.

SETTING: Kaiser Permanente in Georgia and northern and southern California.

PATIENTS: 2842 transfeminine and 2118 transmasculine members with a mean follow-up of 4.0 and 3.6 years, respectively, matched to 48 686 cisgender men and 48 775 cisgender women.

MEASUREMENTS: VTE, ischemic stroke, and myocardial infarction events ascertained from diagnostic codes through the end of 2016 in transgender and reference cohorts.

RESULTS: Transfeminine participants had a higher incidence of VTE, with 2-and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women. The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for VTE and ischemic stroke were observed among transfeminine participants who initiated hormone therapy during follow-up. The evidence was insufficient to allow conclusions regarding risk among transmasculine participants.

LIMITATION: Inability to determine which transgender members received hormones elsewhere.

CONCLUSION: The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen.
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Olson-Kennedy, J., Okonta, V., Clark, L. F., & Belzer, M. (2018). Physiologic Response to Gender-Affirming Hormones Among Transgender Youth. Journal of Adolescent Health, 62(4), 397–401. https://doi.org/10.1016/j.jadohealth.2017.08.005
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Journal AbstractPURPOSE: The purpose of this study was to examine the physiologic impact of hormones on youth with gender dysphoria. These data represent follow-up data in youth ages 12–23 years over a twoyear time period of hormone administration.

METHODS: This prospective, longitudinal study initially enrolled 101 youth with gender dysphoria at baseline from those presenting consecutively for care between February 2011 and June 2013. Physiologic data at baseline and follow-up were abstracted from medical charts. Data were analyzed by descriptive statistics.

RESULTS: Of the initial 101 participants, 59 youth had follow-up physiologic data collected between 21 and 31 months after initiation of hormones available for analysis. Metabolic parameters changes were not clinically significant, with the exception of sex steroid levels, intended to be the target of intervention.

CONCLUSIONS: Although the impact of hormones on some historically concerning physiologic parameters, including lipids, potassium, hemoglobin, and prolactin, were statistically significant, clinical significance was not observed. Hormone levels physiologically concordant with gender of identity were achieved with feminizing and masculinizing medication regimens. Extensive and frequent laboratory examination in transgender adolescents may be unnecessary. The use of hormones in transgender youth appears to be safe over a treatment course of approximately two years.
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Endocrine complications
Islam, N., Nash, R., Zhang, Q., Panagiotakopoulos, L., Daley, T., Bhasin, S., Getahun, D., Haw, J. S., McCracken, C., Silverberg, M. J., Tangpricha, V., Vupputuri, S., & Goodman, M. (2021). Is There a Link Between Hormone Use and Diabetes Incidence in Transgender People? Data from the STRONG Cohort. The Journal of Clinical Endocrinology & Metabolism, dgab832. https://doi.org/10.1210/clinem/dgab832
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Journal AbstractBACKGROUND: Risk of type 2 diabetes mellitus (T2DM) in transgender and gender diverse (TGD) persons, especially those receiving gender affirming hormone therapy (GAHT) is an area of clinical and research importance.

METHODS: We used data from an electronic health record-based cohort study of persons 18 years and older enrolled in three integrated health care systems. The cohort included 2869 transfeminine members matched to 28,300 cisgender women and 28,258 cisgender men on age, race/ethnicity, calendar year, and site, and 2133 transmasculine members matched to 20,997 cisgender women and 20,964 cisgender men. Cohort ascertainment spanned 9 years from 2006 through 2014 and follow up extended through 2016. Data on T2DM incidence and prevalence were analyzed using Cox proportional hazards and logistic regression models, respectively. All analyses controlled for body mass index.

RESULTS: Both prevalent and incident T2DM was more common in the transfeminine cohort relative to cisgender female referents with odds ratio and hazard ratio (95% confidence interval) estimates of 1.3 (1.1-1.5) and 1.4 (1.1-1.8), respectively. No significant differences in prevalence or incidence of T2DM were observed across the remaining comparison groups, both overall and in TGD persons with evidence of GAHT receipt.

CONCLUSION: Although transfeminine people may be at higher risk for T2DM compared to cisgender females the corresponding difference relative to cisgender males is not discernable. Moreover, there is little evidence that T2DM occurrence in either transfeminine or transmasculine persons is attributable to GAHT use.
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Nokoff, N. J., Scarbro, S. L., Moreau, K. L., Zeitler, P., Nadeau, K. J., Reirden, D., Juarez-Colunga, E., & Kelsey, M. M. (2021). Body Composition and Markers of Cardiometabolic Health in Transgender Youth on Gonadotropin-Releasing Hormone Agonists. Transgender Health, 6(2), 111–119. https://doi.org/10.1089/trgh.2020.0029
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Journal AbstractPURPOSE: Up to 1.8% of youth identify as transgender; many will be treated with a gonadotropin-releasing hormone agonist (GnRHa). The impact of GnRHa on insulin sensitivity and body composition in transgender youth is understudied. We aimed to evaluate differences in insulin sensitivity and body composition in transgender youth on GnRHa therapy compared with cisgender youth.

METHODS: Transgender participants were matched to cisgender participants on age, body mass index, and sex assigned at birth. Transgender males (n=9, ages 10.1–16.0 years) on GnRHa (mean±standard deviation duration of exposure: 20.9±19.8 months) were compared with cisgender females (n=14, ages 10.6–16.2). Transgender females (n=8, ages 12.6–16.1) on GnRHa (11.3±7 months) were compared with cisgender males (n=17, ages 12.5–15.5). Differences in insulin sensitivity (1/[fasting insulin], homeostatic model of insulin resistance [HOMA-IR]), glycemia (hemoglobin A1C [HbA1c], fasting glucose), and body composition (dual-energy X-ray absorptiometry) were evaluated using a mixed linear regression model.

RESULTS: Transgender males had lower 1/fasting insulin and higher HOMA-IR (p=0.031, p=0.01, respectively), fasting glucose (89±4 vs. 79±13 mg/dL, p=0.012), HbA1c (5.4±0.2 vs. 5.2±0.2%, p=0.039), and percent body fat (36±7 vs. 32±5%, p=0.042) than matched cisgender females. Transgender females had lower 1/fasting insulin and higher HOMA-IR (p=0.028, p=0.035), HbA1c (5.4±0.1% vs. 5.1±0.2%, p=0.007), percent body fat (31±9 vs. 24±10%, p=0.002), and lower percent lean mass (66±8 vs. 74±10%, p<0.001) than matched cisgender males.

CONCLUSION: Transgender youth on a GnRHa have lower estimated insulin sensitivity and higher glycemic markers and body fat than cisgender controls with similar characteristics. Longitudinal studies are needed to understand the significance of these changes. Clinical Trial.gov ID: NCT02550431.
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Shadid, S., Abosi-Appeadu, K., De Maertelaere, A.-S., Defreyne, J., Veldeman, L., Holst, J. J., Lapauw, B., Vilsbøll, T., & T’Sjoen, G. (2020). Effects of Gender-Affirming Hormone Therapy on Insulin Sensitivity and Incretin Responses in Transgender People. Diabetes Care, 43(2), 411–417. https://doi.org/10.2337/dc19-1061
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Journal AbstractOBJECTIVE The long-term influences of sex hormone administration on insulin sensitivity and incretin hormones are controversial. We investigated these effects in 35 transgender men (TM) and 55 transgender women (TW) from the European Network for the Investigation of Gender Incongruence (ENIGI) study. RESEARCH DESIGN AND METHODS Before and after 1 year of gender-affirming hormone therapy, body composition and oral glucose tolerance tests (OGTTs) were evaluated.
RESULTS In TM, body weight (2.8 6 1.0 kg; P < 0.01), fat-free mass (FFM) (3.1 6 0.9 kg; P < 0.01), and waist-to-hip ratio (20.03 6 0.01; P < 0.01) increased. Fasting insulin (21.4 6 0.8 mU/L; P 5 0.08) and HOMA of insulin resistance (HOMA-IR) (2.2 6 0.3 vs. 1.8 6 0.2; P 5 0.06) tended to decrease, whereas fasting glucose (21.6 6 1.6 mg/dL), glucose-dependent insulinotropic polypeptide (GIP) (21.8 6 1.0 pmol/L), and glucagon-like peptide 1 (GLP-1) (20.2 6 1.1 pmol/L) were statistically unchanged. Post-OGTT areas under the curve (AUCs) for GIP (2,068 6 1,134 vs. 2,645 6 1,248 [pmol/L] 3 min; P < 0.01) and GLP-1 (2,352 6 796 vs. 2,712 6 1,015 [pmol/L] 3 min; P < 0.01) increased. In TW, body weight tended to increase (1.4 6 0.8 kg; P 5 0.07) with decreasing FFM (22.3 6 0.4 kg; P < 0.01) and waist-to-hip ratio (20.03 6 0.01; P < 0.01). Insulin (3.4 6 0.8 mU/L; P < 0.01) and HOMA-IR (1.7 6 0.1 vs. 2.4 6 0.2; P < 0.01) rose, fasting GIP (21.4 6 0.8 pmol/L; P < 0.01) and AUC GIP dropped (2,524 6 178 vs. 1,911 6 162 [pmol/L] 3 min; P < 0.01), but fasting glucose (20.3 6 1.4 mg/dL), GLP-1 (1.3 6 0.8 pmol/L), and AUC GLP-1 (2,956 6 180 vs. 2,864 6 93 [pmol/L] 3 min) remained unchanged.
CONCLUSIONS In this cohort of transgender persons, insulin sensitivity but also post-OGTT incretin responses tend to increase with masculinization and to decrease with feminization.
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Fertility complications
Bailie, E., Maidarti, M., Hawthorn, R., Jack, S., Watson, N., Telfer, E. E., & Anderson, R. A. (2023). The ovaries of transgender men indicate effects of high dose testosterone on the primordial and early growing follicle pool. Reproduction and Fertility, 4(2), e220102. https://doi.org/10.1530/RAF-22-0102
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Journal AbstractAndrogens are essential in normal ovarian function and follicle health, but hyperandrogenism, as seen in polycystic ovary syndrome, is associated with disordered follicle development. There are few data on the effect of long-term exposure to high levels of testosterone as found in transgender men receiving gender-affirming endocrine therapy. In this study, we investigate the effect of testosterone on the development, morphological health and DNA damage and repair capacity of human ovarian follicles in vivo and their survival in vitro. Whole ovaries were obtained from transgender men (mean age: 27.6 ± 1.7 years; range: 20–34 years, n = 8) at oophorectomy taking pre-operative testosterone therapy. This was compared to cortical biopsies from age-matched healthy women obtained at caesarean section (mean age: 31.8 ± 1.5 years; range: 25–35 years, n = 8). Cortical tissues were dissected into fragments and either immediately fixed for histological analysis or cultured for 6 days and subsequently fixed. Follicle classification and morphological health were evaluated from histological sections stained with hematoxylin and eosin and expression of γH2AX as a marker of DNA damage by immunohistochemistry (IHC). In uncultured tissue, testosterone exposure was associated with reduced follicle growth activation, poor follicle health and increased DNA damage. After 6 days of culture, there was enhanced follicle activation compared to the control with further deterioration in morphological health and increased DNA damage. These data indicate that high circulating concentrations of testosterone have effects on the primordial and small-growing follicles of the ovary. These results may have implications for transgender men receiving gender-affirming therapy prior to considering pregnancy or fertility preservation measures.
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Stolk, T. H. R., Asseler, J. D., Huirne, J. A. F., van den Boogaard, E., & van Mello, N. M. (2023). Desire for children and fertility preservation in transgender and gender-diverse people: A systematic review. Best Practice & Research Clinical Obstetrics & Gynaecology, 87, 102312. https://doi.org/10.1016/j.bpobgyn.2023.102312
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Journal AbstractThe decision to pursue one's desire for children is a basic human right. For transgender and gender-diverse (TGD) people, gender-affirming care may alter the possibilities to fulfill one's desire for children due to the impact of this treatment on their reproductive organs. We systematically included 76 studies of varying quality describing the desire for children and parenthood; fertility counseling and utilization; and fertility preservation options and outcomes in TGD people. The majority of TGD people expressed a desire for children. Fertility preservation utilization rates were low as there are many barriers to pursue fertility preservation. The most utilized fertility preservation strategies include oocyte vitrification and sperm banking through masturbation. Oocyte vitrification showed successful outcomes, even after testosterone cessation. Sperm analyses when banking sperm showed a lower quality compared to cis male samples even prior to gender-affirming hormone treatment and an uncertain recovery of spermatogenesis after discontinuing treatment.
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Mayhew, A. C., & Gomez-Lobo, V. (2020). Fertility Options for the Transgender and Gender Nonbinary Patient. The Journal of Clinical Endocrinology and Metabolism, 105(10). https://doi.org/10.1210/clinem/dgaa529
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Journal AbstractComprehensive care for transgender and gender nonbinary patients has been a priority established by the World Professional Association for Transgender Health. Because pubertal suppression, gender-affirming hormone therapy, and antiandrogen therapy used alone or in combination during medical transition can affect gonadal function, understanding the effects these treatments have on fertility potential is important for practitioners caring for transgender and gender nonbinary patients. In this review, we outline the impacts of gender-affirming treatments on fertility potential and discuss the counseling and the treatment approach for fertility preservation and/or family building in transgender and gender nonbinary individuals.
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Pang, K. C., Peri, A. J. S., Chung, H. E., Telfer, M., Elder, C. V., Grover, S., & Jayasinghe, Y. (2020). Rates of Fertility Preservation Use Among Transgender Adolescents. JAMA Pediatrics, 174(9), 890. https://doi.org/10.1001/jamapediatrics.2020.0264
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Dulohery, K., Trottmann, M., Bour, S., Liedl, B., Alba‐Alejandre, I., Reese, S., Hughes, B., Stief, C. G., & Kölle, S. (2020). How do elevated levels of testosterone affect the function of the human fallopian tube and fertility?—New insights. Molecular Reproduction and Development, 87(1), 30–44. https://doi.org/10.1002/mrd.23291
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Journal AbstractExcess testosterone levels affect up to 20% of the female population worldwide and are a key component in the pathogenesis of polycystic ovary syndrome. However, little is known about how excess testosterone affects the function of the human fallopian tube—the site of gamete transport, fertilization, and early embryogenesis. Therefore, this study aimed to characterize alterations caused by long‐term exposure to male testosterone levels. For this purpose, the Fallopian tubes of nine female‐to‐male transsexuals, who had been undergoing testosterone treatment for 1–3 years, were compared with the tubes of 19 cycling patients. In the ampulla, testosterone treatment resulted in extensive luminal accumulations of secretions and cell debris which caused ciliary clumping and luminal blockage. Additionally, the percentage of ciliated cells in the ampulla was significantly increased. Transsexual patients, who had had sexual intercourse before surgery, showed spermatozoa trapped in mucus. Finally, in the isthmus complete luminal collapse occurred. Our results imply that fertility in women with elevated levels of testosterone is altered by tubal luminal obstruction resulting in impaired gamete transport and survival.
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Baram, S., Myers, S. A., Yee, S., & Librach, C. L. (2019). Fertility preservation for transgender adolescents and young adults: a systematic review. Human Reproduction Update, 25(6), 694–716. https://doi.org/10.1093/humupd/dmz026
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Journal AbstractBACKGROUND: Many transgender individuals choose to undergo gender-affirming hormone treatment (GAHT) and/or sex reassignment surgery (SRS) to alleviate the distress that is associated with gender dysphoria. Although these treatment options often succeed in alleviating such symptoms, they can also negatively impact future reproductive potential.

OBJECTIVE AND RATIONALE: The purpose of this systematic review was to synthesize the available psychosocial and medical literature on fertility preservation (FP) for transgender adolescents and young adults (TAYAs), to identify gaps in the current research and provide suggestions for future research directions.

SEARCH METHODS: A systematic review of English peer-reviewed papers published from 2001 onwards, using the preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA-P) guidelines, was conducted. Four journal databases (Ovid MEDLINE, PubMed Medline, Ovid Embase and Ovid PsychINFO) were used to identify all relevant studies exploring psychosocial or medical aspects of FP in TAYAs. The search strategy used a combination of subject headings and generic terms related to the study topic and population. Bibliographies of the selected articles were also hand searched and cross-checked to ensure comprehensive coverage. All selected papers were independently reviewed by the co-authors. Characteristics of the studies, objectives and key findings were extracted, and a systematic review was conducted.

OUTCOMES: Included in the study were 19 psychosocial-based research papers and 21 medical-based research papers that explore fertility-related aspects specific for this population. Key psychosocial themes included the desire to have children for TAYAs; FP discussions, counselling and referrals provided by healthcare providers (HCPs); FP utilization; the attitudes, knowledge and beliefs of TAYAs, HCPs and the parents/guardians of TAYAs; and barriers to accessing FP. Key medical themes included fertility-related effects of GAHT, FP options and outcomes. From a synthesis of the literature, we conclude that there are many barriers preventing TAYAs from pursuing FP, including a lack of awareness of FP options, high costs, invasiveness of the available procedures and the potential psychological impact of the FP process. The available medical data on the reproductive effects of GAHT are diverse, and while detrimental effects are anticipated, the extent to which these effects are reversible is unknown.

WIDER IMPLICATIONS: FP counselling should begin as early as possible as a standard of care before GAHT to allow time for informed decisions. The current lack of high-quality medical data specific to FP counselling practice for this population means there is a reliance on expert opinion and extrapolation from studies in the cisgender population. Future research should include large-scale cohort studies (preferably multi-centered), longitudinal studies of TAYAs across the FP process, qualitative studies of the parents/guardians of TAYAs and studies evaluating the effectiveness of different strategies to improve the attitudes, knowledge and beliefs of HCPs.
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Leung, A., Sakkas, D., Pang, S., Thornton, K., & Resetkova, N. (2019). Assisted reproductive technology outcomes in female-to-male transgender patients compared with cisgender patients: a new frontier in reproductive medicine. Fertility and Sterility, 112(5), 858–865. https://doi.org/10.1016/j.fertnstert.2019.07.014
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Journal AbstractOBJECTIVE: To investigate assisted reproductive technology (ART) outcomes in a female-to-male transgender cohort and compare the results with those of a matched cisgender cohort.

DESIGN: Matched retrospective cohort study.

SETTING: In vitro fertilization clinic.

PATIENT(S): Female-to-male transgender patients (n = 26) who sought care from 2010 to 2018. A cisgender cohort (n = 130) was matched during the same time period by age, body mass index, and antimüllerian hormone levels.

INTERVENTION(S): Not applicable.

MAIN OUTCOME MEASURE(S): Cycle outcomes, including oocyte yield, number of mature oocytes, total gonadotropin dose, and peak E2 levels.

RESULT(S): The mean number of oocytes retrieved in the transgender group was 19.9 ± 8.7 compared with 15.9 ± 9.6 in the cisgender group. Peak E2 levels were the same between the two groups. The total dose of gonadotropins used was higher in the transgender group compared with the cisgender group (3,892 IU vs. 2,599 IU). Of the 26 patients, 16 performed oocyte banking only. Seven couples had fresh or frozen transfers, with all achieving live births.

CONCLUSION(S): This is the first study of this size investigating ART outcomes in female-to-male transgender patients. The findings may serve to reassure transgender patients and their care providers that outcomes can be excellent even if testosterone therapy has already been initiated. Further investigation needs to be performed on the generalizability of these findings, and whether similar results can be achieved without stopping testosterone therapy.
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Cheng, P. J., Pastuszak, A. W., Myers, J. B., Goodwin, I. A., & Hotaling, J. M. (2019). Fertility concerns of the transgender patient. Translational Andrology and Urology, 8(3), 209–218. https://doi.org/10.21037/tau.2019.05.09
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Journal AbstractTransgender individuals who undergo gender-affirming medical or surgical therapies are at risk for infertility. Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery (GAS) that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility. It is recommended that clinicians counsel transgender patients on fertility preservation (FP) options prior to initiation of gender-affirming therapy. Transmen can choose to undergo cryopreservation of oocytes or embryos, which requires hormonal stimulation for egg retrieval. Uterus preservation allows transmen to gestate if desired. For transwomen, the option for FP is cryopreservation of sperm either through masturbation or testicular sperm extraction. Experimental and future options may include cryopreservation and in vitro maturation of ovarian or testicular tissue, which could provide prepubertal transgender youth an option for FP since they lack mature gametes. Successful uterus transplantation with subsequent live birth is a new medical breakthrough for cisgender women with uterus factor infertility. Although it has not yet been performed in transgender women, uterus transplantation is a potential solution for those who wish to get pregnant. The transgender population faces many barriers to care, such as provider discrimination, lack of information, legal barriers, scarcity of fertility centers, financial burden, and emotional cost. Further research is necessary to investigate the feasibility of experimental FP options, provide better evidence-based information to clinicians and transgender patients alike, and to improve access to and quality of reproductive services for the transgender population.
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Bizic, M. R., Jeftovic, M., Pusica, S., Stojanovic, B., Duisin, D., Vujovic, S., Rakic, V., & Djordjevic, M. L. (2018). Gender Dysphoria: Bioethical Aspects of Medical Treatment. BioMed Research International, 2018, 1–6. https://doi.org/10.1155/2018/9652305
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Journal AbstractGender affirmation surgery remains one of the greatest challenges in transgender medicine. In recent years, there have been continuous discussions on bioethical aspects in the treatment of persons with gender dysphoria. Gender reassignment is a difficult process, including not only hormonal treatment with possible surgery but also social discrimination and stigma. There is a great variety between countries in specified tasks involved in gender reassignment, and a complex combination of medical treatment and legal paperwork is required in most cases. The most frequent bioethical questions in transgender medicine pertain to the optimal treatment of adolescents, sterilization as a requirement for legal recognition, role of fertility and parenthood, and regret after gender reassignment. We review the recent literature with respect to any new information on bioethical aspects related to medical treatment of people with gender dysphoria.
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Mattawanon, N., Spencer, J. B., Schirmer, D. A., & Tangpricha, V. (2018). Fertility preservation options in transgender people: A review. Reviews in Endocrine and Metabolic Disorders, 19(3), 231–242. https://doi.org/10.1007/s11154-018-9462-3
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Journal AbstractGender affirming procedures adversely affect the reproductive potential of transgender people. Thus, fertility preservation options should be discussed with all transpeople before medical and surgical transition. In transwomen, semen cryopreservation is typically straightforward and widely available at fertility centers. The optimal number of vials frozen depends on their reproductive goals and treatment options, therefore a consultation with a fertility specialist is optimal. Experimental techniques including spermatogonium stem cells (SSC) and testicular tissue preservation are technologies currently under development in prepubertal individuals but are not yet clinically available. In transmen, embryo and/or oocyte cryopreservation is currently the best option for fertility preservation. Embryo cryopreservation requires fertilization of the transman’s oocytes with a donor or partner’s sperm prior to cryopreservation, but this limits his future options for fertilizing the eggs with another partner or donor. Oocyte cryopreservation offers transmen the opportunity to preserve their fertility without committing to a male partner or sperm donor at the time of cryopreservation. Both techniques however require at least a two-week treatment course, egg retrieval under sedation and considerable cost. Ovarian tissue cryopreservation is a promising experimental method that may be performed at the same time as gender affirming surgery but is offered in only a limited amount of centers worldwide. In select places, this method may be considered for prepubertal children, adolescents, and adults when ovarian stimulation is not possible. Novel methods such as in-vitro activation of primordial follicles, in vitro maturation of immature oocytes and artificial gametes are under development and may hold promise for the future.
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Nahata, L., Tishelman, A. C., Caltabellotta, N. M., & Quinn, G. P. (2017). Low Fertility Preservation Utilization Among Transgender Youth. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 61(1), 40–44. https://doi.org/10.1016/j.jadohealth.2016.12.012
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Journal AbstractPURPOSE: Research demonstrates a negative psychosocial impact of infertility among otherwise healthy adults, and distress among adolescents facing the prospect of future infertility due to various medical conditions and treatments that impair reproductive health. Guidelines state that providers should counsel transgender youth about potential infertility and fertility preservation (FP) options prior to initiation of hormone therapy. The purpose of this study was to examine the rates of fertility counseling and utilization of FP among a cohort of adolescents with gender dysphoria seen at a large gender clinic.

METHODS: An Institutional Review Board-approved retrospective review of electronic medical records was conducted of all patients with ICD-9/10 codes for gender dysphoria referred to Pediatric Endocrinology for hormone therapy (puberty suppression and/or cross-sex hormones) from January 2014 to August 2016.

RESULTS: Seventy-eight patients met inclusion criteria. Five children were prepubertal, no hormone therapy was considered, and they were therefore excluded. Of the remaining 73 patients, 72 had documented fertility counseling prior to initiation of hormone therapy and 2 subjects attempted FP; 45% of subjects mentioned a desire or plan to adopt, and 21% said they had never wanted to have children.

CONCLUSIONS: Utilization rates of FP are low among transgender adolescents. More research is needed to understand parenthood goals among transgender youth at different ages and developmental stages and to explore the impact of gender dysphoria on decision-making about FP and parenthood. Discussions about infertility risk, FP, and other family building options should be prioritized in this vulnerable adolescent population.
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Delemarre-van de Waal, H. A., & 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
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Journal AbstractTreatment outcome in transsexuals is expected to be more favourable when puberty is suppressed than when treatment is started after Tanner stage 4 or 5. In the Dutch protocol for the treatment of transsexual adolescents, candidates are considered eligible for the suppression of endogenous puberty when they fulfil the Diagnostic and Statistic Manual of Mental Disorders-IV-RT criteria for gender disorder, have suffered from lifelong extreme gender dysphoria, are psychologically stable and live in a supportive environment. Suppression of puberty should be considered as supporting the diagnostic procedure, but not as the ultimate treatment. If the patient, after extensive exploring of his/her sex reassignment (SR) wish, no longer pursues SR, pubertal suppression can be discontinued. Otherwise, cross-sex hormone treatment can be given at 16 years, if there are no contraindications. Treatment consists of a GnRH analogue (GnRHa) to suppress endogenous gonadal stimulation from B2-3 and G34, and prevents development of irreversible sex characteristics of the unwanted sex. From the age of 16 years, cross-sex steroid hormones are added to the GnRHa medication.
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Fewer Studies
Other biomedical risks and uncertainties
Wilde, B., Diamond, J. B., Laborda, T. J., Frank, L., O’Gorman, M. A., & Kocolas, I. (2024). Bicalutamide-Induced Hepatotoxicity in a Transgender Male-to-Female Adolescent. Journal of Adolescent Health, 74(1), 202–204. https://doi.org/10.1016/j.jadohealth.2023.08.024
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Meece, M. S., Weber, L. E., Hernandez, A. E., Danker, S. J., & Paluvoi, N. V. (2023). Major complications of sigmoid vaginoplasty: a case series. Journal of Surgical Case Reports, 2023(6), rjad333. https://doi.org/10.1093/jscr/rjad333
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Journal AbstractThis case series explores the major complications following sigmoid vaginoplasty in two transgender female patients. Both patients experienced significant post-operative complications, including stenosis and abscess formation, leading to sigmoid conduit ischemia and necrosis. These complications required major surgical interventions and multidisciplinary care, highlighting the complexity of these procedures and their potential morbidity. Our analysis suggests that the initial stenotic insult led to obstruction and vascular insult to the sigmoid conduit, necessitating resection of the affected bowel. The outcomes underscore the need for collaboration across specialties for optimal post-operative monitoring and management. This study advocates for future management guidelines promoting multidisciplinary collaboration to reduce morbidity and resource burdens associated with complications. Despite the complications, sigmoid vaginoplasty remains a viable gender affirmation surgery, providing an effective analogue to vaginal mucosa and offering improved neovaginal depth.
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Tordoff, D. M., Lunn, M. R., Chen, B., Flentje, A., Dastur, Z., Lubensky, M. E., Capriotti, M., & Obedin-Maliver, J. (2023). Testosterone use and sexual function among transgender men and gender diverse people assigned female at birth. American Journal of Obstetrics and Gynecology, 229(6), 669.e1-669.e17. https://doi.org/10.1016/j.ajog.2023.08.035
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Journal AbstractBACKGROUND: Testosterone use among transgender people likely impacts their experience of sexual function and vulvovaginal pain via several complex pathways. Testosterone use is associated with decreased estrogen in the vagina and atrophic vaginal tissue, which may be associated with decreased vaginal lubrication and/or discomfort during sexual activity. At the same time, increased gender affirmation through testosterone use may be associated with improved sexual function. However, data on pelvic and vulvovaginal pain among transgender men and nonbinary people assigned female at birth are scarce.

OBJECTIVE: This study aimed to assess the association between testosterone and sexual function with a focus on symptoms that are commonly associated with vaginal atrophy.

STUDY DESIGN: We conducted a cross-sectional analysis of 1219 participants aged 18 to 72 years using data collected from 2019 to 2021 from an online, prospective, longitudinal cohort study of sexual and/or gender minority people in the United States (The Population Research in Identity and Disparities for Equality Study). Our analysis included adult transgender men and gender diverse participants assigned female at birth who were categorized as never, current, and former testosterone users. Sexual function was measured across 8 Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction domains.

RESULTS: Overall, 516 (42.3%) participants had never used testosterone, and 602 (49.4%) currently used testosterone. The median duration of use was 37.7 months (range, 7 days to >27 years). Most participants (64.6%) reported genital pain or discomfort during sexual activity in the past 30 days, most commonly in the vagina or frontal genital opening (52.2%), followed by around the clitoris (29.1%) and labia (24.5%). Current testosterone use was associated with a greater interest in sexual activity (β=6.32; 95% confidence interval, 4.91–7.74), higher ability to orgasm (β=1.50; 95% confidence interval, 0.19-2.81), and more vaginal pain or discomfort during sexual activity (β=1.80; 95% confidence interval, 0.61–3.00). No associations were observed between current testosterone use and satisfaction with sex life, lubrication, labial pain or discomfort, or orgasm pleasure.

CONCLUSION: Testosterone use among transgender men and gender diverse people was associated with an increased interest in sexual activity and the ability to orgasm, as well as with vaginal pain or discomfort during sexual activity. Notably, the available evidence demonstrates that >60% of transgender men experience vulvovaginal pain during sexual activity. The causes of pelvic and vulvovaginal pain are poorly understood but are likely multifactorial and include physiological (eg, testosterone-associated vaginal atrophy) and psychological factors (eg, gender affirmation). Given this high burden, there is an urgent need to identify effective and acceptable interventions for this population.
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Barger, B. T., Pakvasa, M., Lem, M., Ramamurthi, A., Lalezari, S., & Tang, C. (2023). Non-typhoidal Salmonella soft-tissue infection after gender affirming subcutaneous mastectomy case report. Case Reports in Plastic Surgery & Hand Surgery, 10(1), 2185621. https://doi.org/10.1080/23320885.2023.2185621
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Journal AbstractWe present a case of a 32-year-old transgender male who underwent chest masculinization, complicated by purulent soft tissue infection of bilateral chest incisions. Cultures tested positive for non-typhoidal Salmonella, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa. Herein, we discuss multiple factors contributing to the complexity of treating this patient's clinical course.
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Millington, K., Barrera, E., Daga, A., Mann, N., Olson-Kennedy, J., Garofalo, R., Rosenthal, S. M., & Chan, Y.-M. (2022). The effect of gender-affirming hormone treatment on serum creatinine in transgender and gender-diverse youth: implications for estimating GFR. Pediatric Nephrology, 37(9), 2141–2150. https://doi.org/10.1007/s00467-022-05445-0
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Journal AbstractBACKGROUND: Equations for estimated glomerular filtration rate (eGFR) based on serum creatinine include terms for sex/gender. For transgender and gender-diverse (TGD) youth, gender-affirming hormone (GAH) treatment may affect serum creatinine and in turn eGFR.

METHODS: TGD youth were recruited for this prospective, longitudinal, observational study prior to starting GAH treatment. Data collected as part of routine clinical care were abstracted from the medical record.

RESULTS: For participants designated male at birth (DMAB, N = 92), serum creatinine decreased within 6 months of estradiol treatment (mean ± SD 0.83 ± 0.12 mg/dL to 0.76 ± 0.12 mg/dL, p < 0.001); for participants designated female at birth (DFAB, n = 194), serum creatinine increased within 6 months of testosterone treatment (0.68 ± 0.10 mg/dL to 0.79 ± 0.11 mg/dL, p < 0.001). Participants DFAB treated with testosterone had serum creatinine similar to that of participants DMAB at baseline, whereas even after estradiol treatment, serum creatinine in participants DMAB remained higher than that of participants DFAB at baseline. Compared to reference groups drawn from the National Health and Nutritional Examination Survey, serum creatinine after 12 months of GAH was more similar when compared by gender identity than by designated sex.

CONCLUSION: GAH treatment leads to changes in serum creatinine within 6 months of treatment. Clinicians should consider a patient's hormonal exposure when estimating kidney function via eGFR and use other methods to estimate GFR if eGFR based on serum creatinine is concerning.
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Xu, R., Diamond, D. A., Borer, J. G., Estrada, C., Yu, R., Anderson, W. J., & Vargas, S. O. (2022). Prostatic metaplasia of the vagina in transmasculine individuals. World Journal of Urology, 40(3), 849–855. https://doi.org/10.1007/s00345-021-03907-y
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Journal AbstractPurpose: To determine the prevalence of prostatic metaplasia in an expanded cohort of transmasculine individuals undergoing gender-affirming resection of vaginal tissue.

Methods: Institutional Review Board approval was obtained. Clinical records were reviewed for all transmasculine individuals undergoing vaginal tissue resection at our institution between January 2018 and July 2021. Corresponding pathology specimens were examined grossly and microscopically, including immunohistochemical stains for NKX3.1, prostate-specific antigen (PSA), and androgen receptor (AR). Vaginal specimens from three patients without androgen supplementation were used as controls.

Results: Twenty-one patients met inclusion criteria. The median age at surgery was 26.4 years (range 20.6-34.5 years). All patients had been assigned female gender at birth and lacked endocrine or genetic abnormalities. All were on testosterone therapy; median duration of therapy at surgery was 4.4 years (range 1.4-12.1 years). In the transmasculine group, no gross lesions were identified. Microscopically, all specimens demonstrated patchy intraepithelial glandular proliferation along the basement membrane and/or nodular proliferation of prostate-type tissue within the subepithelial stroma. On immunohistochemical staining, performed for a subset of cases, the glandular proliferation was positive for NKX3.1 (16/16 cases; 100%), PSA (12/14 cases; 85.7%), and AR (8/8 cases; 100%). Controls showed no evidence of prostatic metaplasia.

Conclusion: One hundred percent of vaginal specimens obtained from transmasculine individuals on testosterone therapy (21/21 cases) demonstrated prostatic metaplasia. Further investigation is warranted to characterize the natural history and clinical significance of these changes. Patients seeking hormone therapy and/or gender-affirming surgery should be counseled on the findings and their yet-undetermined significance.
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Chaudhry, A., Yelisetti, R., Millet, C., Biggiani, C., & Upadhyay, S. (2021). Acute Pancreatitis in the Transgender Population. Cureus. https://doi.org/10.7759/cureus.16140
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Journal AbstractHypertriglyceridemia (HTG) is an uncommon but well-established etiology of acute pancreatitis (AP) leading to significant morbidity and mortality. Hormone replacement therapy in the transgender population is an underrecognized cause of elevated triglyceride (TG) levels and may put this group at a higher risk for severe pancreatitis. We present a case of AP in a genetically male patient receiving hormone therapy for female gender transformation.A 51-year-old with a past medical history of type 2 diabetes mellitus presented with severe epigastric abdominal pain associated with nonbilious, nonbloody vomiting and anorexia for two days. The patient was diagnosed with hypertriglyceridemia-induced acute pancreatitis (HTG-AP) in the setting of elevated lipase levels of 2,083 u/L and TGs of >5,000 mg/dL. In addition, a computerized tomography scan of the abdomen showed pancreatitis without evidence of necrosis. The patient was admitted to the medical intensive care unit for the management of AP in the setting of elevated TG levels. She was treated with intravenous fluids and an insulin drip. Her home medications including estradiol and Aldactone were held. Once the TG levels were reduced to <500 mg/dL, she was taken off the Insulin drip and transitioned to a subcutaneous insulin regimen along with gemfibrozil and omega-3 fatty acid over the next three days, and then discharged to home. HTG accounts for only about 7% of pancreatitis cases and increases in severity as TG levels increase. The clinical presentation of patients suffering from HTG-AP is similar to patients with AP from other etiologies and presents in a relatively younger population compared to AP from other causes. Treatment options for HTG-AP usually utilize insulin and heparin; however, plasma exchange and venovenous filtration may be used for severe cases of HTG-AP. The goal of treatment is to lower the TG levels. Physicians should be aware of such complications and should counsel patients while utilizing hormone replacement therapy, especially in patients with a prior family history of dyslipidemia.
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Nokoff, N. J., Scarbro, S. L., Moreau, K. L., Zeitler, P., Nadeau, K. J., Reirden, D., Juarez-Colunga, E., & Kelsey, M. M. (2021). Body Composition and Markers of Cardiometabolic Health in Transgender Youth on Gonadotropin-Releasing Hormone Agonists. Transgender Health, 6(2), 111–119. https://doi.org/10.1089/trgh.2020.0029
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Journal AbstractPURPOSE: Up to 1.8% of youth identify as transgender; many will be treated with a gonadotropin-releasing hormone agonist (GnRHa). The impact of GnRHa on insulin sensitivity and body composition in transgender youth is understudied. We aimed to evaluate differences in insulin sensitivity and body composition in transgender youth on GnRHa therapy compared with cisgender youth.

METHODS: Transgender participants were matched to cisgender participants on age, body mass index, and sex assigned at birth. Transgender males (n=9, ages 10.1–16.0 years) on GnRHa (mean±standard deviation duration of exposure: 20.9±19.8 months) were compared with cisgender females (n=14, ages 10.6–16.2). Transgender females (n=8, ages 12.6–16.1) on GnRHa (11.3±7 months) were compared with cisgender males (n=17, ages 12.5–15.5). Differences in insulin sensitivity (1/[fasting insulin], homeostatic model of insulin resistance [HOMA-IR]), glycemia (hemoglobin A1C [HbA1c], fasting glucose), and body composition (dual-energy X-ray absorptiometry) were evaluated using a mixed linear regression model.

RESULTS: Transgender males had lower 1/fasting insulin and higher HOMA-IR (p=0.031, p=0.01, respectively), fasting glucose (89±4 vs. 79±13 mg/dL, p=0.012), HbA1c (5.4±0.2 vs. 5.2±0.2%, p=0.039), and percent body fat (36±7 vs. 32±5%, p=0.042) than matched cisgender females. Transgender females had lower 1/fasting insulin and higher HOMA-IR (p=0.028, p=0.035), HbA1c (5.4±0.1% vs. 5.1±0.2%, p=0.007), percent body fat (31±9 vs. 24±10%, p=0.002), and lower percent lean mass (66±8 vs. 74±10%, p<0.001) than matched cisgender males.

CONCLUSION: Transgender youth on a GnRHa have lower estimated insulin sensitivity and higher glycemic markers and body fat than cisgender controls with similar characteristics. Longitudinal studies are needed to understand the significance of these changes. Clinical Trial.gov ID: NCT02550431.
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Shirazi, T. N., Self, H., Dawood, K., Cárdenas, R., Welling, L. L. M., Rosenfield, K. A., Ortiz, T. L., Carré, J. M., Balasubramanian, R., Delaney, A., Crowley, W., Breedlove, S. M., & Puts, D. A. (2020). Pubertal timing predicts adult psychosexuality: Evidence from typically developing adults and adults with isolated GnRH deficiency. Psychoneuroendocrinology, 119, 104733. https://doi.org/10.1016/j.psyneuen.2020.104733
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Journal AbstractEvidence suggests that psychosexuality in humans is modulated by both organizational effects of prenatal and peripubertal sex steroid hormones, and by activational effects of circulating hormones in adulthood. Experimental work in male rodents indicates that sensitivity to androgen-driven organization of sexual motivation decreases across the pubertal window, such that earlier puberty leads to greater sex-typicality. We test this hypothesis in typically developing men (n = 231) and women (n = 648), and in men (n = 72) and women (n = 32) with isolated GnRH deficiency (IGD), in whom the precise timing of peripubertal hormone exposure can be ascertained via the age at which hormone replacement therapy (HRT) was initiated. Psychosexuality was measured with the Sexual Desire Inventory-2 (SDI-2) and Sociosexual Orientation Inventory-Revised (SOI-R). In both sexes, earlier recalled absolute pubertal timing predicted higher psychosexuality in adulthood, although the magnitude of these associations varied with psychosexuality type and group (i.e., typically developing and IGD). Results were robust when controlling for circulating steroid hormones in typically developing participants. Age of initiation of HRT in men with IGD negatively predicted SOI-R. We discuss the clinical implications of our findings for conditions in which pubertal timing is medically altered.
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Hruz, P. W. (2020). Deficiencies in Scientific Evidence for Medical Management of Gender Dysphoria. The Linacre Quarterly, 87(1), 34–42. https://doi.org/10.1177/0024363919873762
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Journal AbstractIndividuals who experience a gender identity that is discordant with biological sex are increasingly presenting to physicians for assistance in alleviating associated psychological distress. In contrast to prior efforts to identify and primarily address underlying psychiatric contributors to gender dysphoria, interventions that include uncritical social affirmation, use of gonadotropin-releasing hormone agonists to suppress normally timed puberty, and administration of cross-sex steroid hormones to induce desired secondary sex characteristics are now advocated by an emerging cohort of transgender medicine specialists. For patients with persistent gender dysphoria, surgery is offered to alter the appearance of breasts and genital organs. Efforts to address ethical concerns regarding this contentious treatment paradigm are dependent upon reliable evidence on immediate and long-term risks and benefits. Although strong recommendations have been made for invasive and potentially irreversible interventions, high-quality scientific data on the effects of this approach are generally lacking. Limitations of the existing transgender literature include general lack of randomized prospective trial design, small sample size, recruitment bias, short study duration, high subject dropout rates, and reliance on “expert” opinion. Existing data reveal significant intervention-associated morbidity and raise serious concern that the primary goal of suicide prevention is not achieved. In addition to substantial moral questions, adherence to established principles of evidence-based medicine necessitates a high degree of caution in accepting gender-affirming medical interventions as a preferred treatment approach. Continued consideration and rigorous investigation of alternate approaches to alleviating suffering in people with gender dysphoria are warranted.

Summary:
This paper provides an overview of what is currently known about people who experience a gender identity that differs from their biological sex and the associated desire to engage the medical profession in alleviating associated discomfort and distress. The scientific evidence used to support current recommendations for affirming one’s preferred gender, halting normally timed puberty, administering cross-sex hormones, and surgically altering primary and secondary sexual traits are summarized and critically evaluated. Serious deficits in understanding the cause of this condition, the reasons for the marked increase in people presenting for medical care, together with immediate and long-term risks relative to benefit of medical intervention are exposed.
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Stoffers, I. E., de Vries, M. C., & Hannema, S. E. (2019). Physical changes, laboratory parameters, and bone mineral density during testosterone treatment in adolescents with gender dysphoria. The Journal of Sexual Medicine, 16(9), 1459–1468. https://doi.org/10.1016/j.jsxm.2019.06.014
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Journal AbstractINTRODUCTION: Current treatment guidelines for adolescents with gender dysphoria recommend therapy with gonadotropin-releasing hormone agonists (GnRHa) and testosterone in transgender males. However, most evidence on the safety and efficacy of testosterone is based on studies in adults.

AIM: This study aimed to investigate the efficacy and safety of testosterone treatment in transgender adolescents.

METHODS: The study included 62 adolescents diagnosed with gender dysphoria who had started GnRHa treatment and had subsequently received testosterone treatment for more than 6 months.

MAIN OUTCOME MEASURE: Virilization, anthropometry, laboratory parameters, and bone mineral density (BMD) were analyzed.

RESULTS: Adolescents were treated with testosterone for a median duration of 12 months. Voice deepening began within 3 months in 85% of adolescents. Increased hair growth was first reported on the extremities, followed by an increase of facial hair. Acne was most prevalent between 6 and 12 months of testosterone therapy. Most adolescents had already completed linear growth; body mass index and systolic blood pressure increased but diastolic blood pressure did not change. High-density lipoprotein (HDL) cholesterol and sex hormone binding globulin significantly decreased, but hematocrit, hemoglobin, prolactin, androstenedione, and dehydroepiandrosterone sulfate significantly increased, although not all changes were clinically significant. Other lipids and HbA1c did not change. Vitamin D deficiency was seen in 32-54% throughout treatment. BMD z-scores after 12 to 24 months of testosterone treatment remained below z-scores before the start of GnRHa treatment.

CLINICAL IMPLICATIONS: Adolescents need to be counseled about side effects with potential longer term implications such as increased hematocrit and decreased HDL cholesterol and decreased BMD z-scores. They should be advised on diet, including adequate calcium and vitamin D intake; physical exercise; and the use of tobacco and alcohol to avoid additional risk factors for cardiovascular disease and osteoporosis.

STRENGTHS & LIMITATIONS: Strengths are the standardized treatment regimen and extensive set of safety parameters investigated. Limitations are the limited duration of follow-up and lack of a control group so some of the observed changes may be due to normal maturation rather than to treatment.

CONCLUSION: Testosterone effectively induced virilization beginning within 3 months in the majority of adolescents. Acne was a common side effect, but no short-term safety issues were observed. The increased hematocrit, decreased HDL cholesterol, and decreased BMD z-scores are in line with previous studies. Further follow-up studies will need to establish if the observed changes result in adverse outcomes in the long term. Stoffers IE, de Vries MC, Hannema SE. Physical Changes, Laboratory Parameters, and Bone Mineral Density During Testosterone Treatment in Adolescents with Gender Dysphoria. J Sex Med 2019;16:1459-1468.

SEGM Summary

This retrospective uncontrolled study investigated the metabolic and bone effects of testosterone administration on 62 gender dysphoric female subjects after GnRH agonist mediated pubertal blockade.  Following 6 and 12 months of  testosterone administration, BMAD z-scores remained below those observed prior to the start of GnRH agonists. In addition, HDL cholesterol was significantly lower and Hct higher with testosterone administration.  Most subjects had completed linear growth prior to starting testosterone.  Vitamin D deficiency was seen in 32-54% of study subjects throughout the study period.

In gender dysphoric females who had received GnRH agonists for at least 6 months, bone density losses were not corrected 12 months after starting testosterone. 

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Hough, D., Bellingham, M., Haraldsen, I. R. H., McLaughlin, M., Rennie, M., Robinson, J. E., Solbakk, A. K., & Evans, N. P. (2017). Spatial memory is impaired by peripubertal GnRH agonist treatment and testosterone replacement in sheep. Psychoneuroendocrinology, 75, 173–182. https://doi.org/10.1016/j.psyneuen.2016.10.016
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Journal AbstractChronic gonadotropin-releasing hormone agonist (GnRHa) is used therapeutically to block activity within the reproductive axis through down-regulation of GnRH receptors within the pituitary gland. GnRH receptors are also expressed in non-reproductive tissues, including areas of the brain such as the hippocampus and amygdala. The impact of long-term GnRHa-treatment on hippocampus-dependent cognitive functions, such as spatial orientation, learning and memory, is not well studied, particularly when treatment encompasses a critical window of development such as puberty. The current study used an ovine model to assess spatial maze performance and memory of rams that were untreated (Controls), had both GnRH and testosterone signaling blocked (GnRHa-treated), or specifically had GnRH signaling blocked (GnRHa-treated with testosterone replacement) during the peripubertal period (8, 27 and 41 weeks of age). The results demonstrate that emotional reactivity during spatial tasks was compromised by the blockade of gonadal steroid signaling, as seen by the restorative effects of testosterone replacement, while traverse times remained unchanged during assessment of spatial orientation and learning. The blockade of GnRH signaling alone was associated with impaired retention of long-term spatial memory and this effect was not restored with the replacement of testosterone signaling. These results indicate that GnRH signaling is involved in the retention and recollection of spatial information, potentially via alterations to spatial reference memory, and that therapeutic medical treatments using chronic GnRHa may have effects on this aspect of cognitive function.
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Schagen, S. E. E., Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., & Hannema, S. E. (2016). Efficacy and Safety of Gonadotropin-Releasing Hormone Agonist Treatment to Suppress Puberty in Gender Dysphoric Adolescents. The Journal of Sexual Medicine, 13(7), 1125–1132. https://doi.org/10.1016/j.jsxm.2016.05.004
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Journal AbstractINTRODUCTION: Puberty suppression using gonadotropin-releasing hormone agonists (GnRHas) is recommended by current guidelines as the treatment of choice for gender dysphoric adolescents. Although GnRHas have long been used to treat precocious puberty, there are few data on the efficacy and safety in gender dysphoric adolescents. Therefore, the Endocrine Society guideline recommends frequent monitoring of gonadotropins, sex steroids, and renal and liver function. Aim: To evaluate the efficacy and safety of GnRHa treatment to suppress puberty in gender dysphoric adolescents.

METHODS: Forty-nine male-to-female and 67 female-to-male gender dysphoric adolescents treated with triptorelin were included in the analysis. Main Outcome Measures: Physical examination, including assessment of Tanner stage, took place every 3 months and blood samples were drawn at 0, 3, and 6 months and then every 6 months. Body composition was evaluated using dual energy x-ray absorptiometry.

RESULTS: GnRHa treatment caused a decrease in testicular volume in 43 of 49 male-to-female subjects. In one of four female-to-male subjects who presented at Tanner breast stage 2, breast development completely regressed. Gonadotropins and sex steroid levels were suppressed within 3 months. Treatment did not have to be adjusted because of insufficient suppression in any subject. No sustained abnormalities of liver enzymes or creatinine were encountered. Alkaline phosphatase decreased, probably related to a slower growth velocity, because height SD score decreased in boys and girls. Lean body mass percentage significantly decreased during the first year of treatment in girls and boys, whereas fat percentage significantly increased.

CONCLUSION: Triptorelin effectively suppresses puberty in gender dysphoric adolescents. These data suggest routine monitoring of gonadotropins, sex steroids, creatinine, and liver function is not necessary during treatment with triptorelin. Further studies should evaluate the extent to which changes in height SD score and body composition that occur during GnRHa treatment can be reversed during subsequent cross-sex hormone treatment.
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Wiemels, J., Wrensch, M., & Claus, E. B. (2010). Epidemiology and etiology of meningioma. Journal of Neuro-Oncology, 99(3), 307–314. https://doi.org/10.1007/s11060-010-0386-3
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Journal AbstractAlthough most meningiomas are encapsulated and benign tumors with limited numbers of genetic aberrations, their intracranial location often leads to serious and potentially lethal consequences. They are the most frequently diagnosed primary brain tumor accounting for 33.8% of all primary brain and central nervous system tumors reported in the United States between 2002 and 2006. Inherited susceptibility to meningioma is suggested both by family history and candidate gene studies in DNA repair genes. People with certain mutations in the neurofibromatosis gene (NF2) have a very substantial increased risk for meningioma. High dose ionizing radiation exposure is an established risk factor for meningioma, and lower doses may also increase risk, but which types and doses are controversial or understudied. Because women are twice as likely as men to develop meningiomas and these tumors harbor hormone receptors, an etiologic role for hormones (both endogenous and exogenous) has been hypothesized. The extent to which immunologic factors influence meningioma etiology has been largely unexplored. Growing emphasis on brain tumor research coupled with the advent of new genetic and molecular epidemiologic tools in genetic and molecular epidemiology promise hope for advancing knowledge about the causes of intra-cranial meningioma. In this review, we highlight current knowledge about meningioma epidemiology and etiology and suggest future research directions.
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Mul, D., Versluis-den Bieman, H. J., Slijper, F. M., Oostdijk, W., Waelkens, J. J., & Drop, S. L. (2001). Psychological assessments before and after treatment of early puberty in adopted children. Acta Paediatrica (Oslo, Norway: 1992), 90(9), 965–971. https://doi.org/10.1080/080352501316978011
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Journal AbstractEarly puberty is frequently observed in adopted children. This randomized trial treated 30 adopted children with early puberty and short stature with either gonadotropin-releasing hormone agonist (GnRHa) alone or in combination with growth hormone (GH) for 3 y. Before the start of treatment (T1) in the trial and at discontinuation (T2) the children and their parents underwent a psychological evaluation. At the start of treatment the children did not have increased levels of behavioural or emotional problems as assessed by the Child Behaviour Checklist (CBCL). During treatment the CBCL scores did not increase. Self-perception of the children appeared to be normal, and after 3 y a significantly higher score for acceptance by peers was observed. At T1, an overestimation of future height was present in 80% of the children and 17% of the parents. Lower family stress was observed at T1 and T2 compared with reference values. Intelligence quotient levels decreased significantly during treatment. The findings are discussed with reference to the reported levels of behavioural and emotional problems in adopted children and the psychosocial effects of precocious puberty.
CONCLUSION: This psychological evaluation did not reveal any consistent abnormalities in adopted children with early puberty. Treatment with GnRHa with or without GH did not increase emotional and behavioural problems in adopted children, nor was their self-perception decreased.
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Fewer Studies
Jorgensen, S. C. J., Hunter, P. K., Regenstreif, L., Sinai, J., & Malone, W. J. (2022). Puberty blockers for gender dysphoric youth: A lack of sound science. Journal of the American College of Clinical Pharmacy, 1005–1007(9), 3. https://doi.org/10.1002/jac5.1691
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D. Desistence, detransition and regret
Adolescent-onset gender dysphoria
Ocasio, M. A., Fernandez, M. I., Ward, D. H. S., Lightfoot, M., Swendeman, D., & Harper, G. W. (2024). Fluidity in Reporting Gender Identity Labels in a Sample of Transgender and Gender Diverse Adolescents and Young Adults, Los Angeles, California, and New Orleans, Louisiana, 2017-2019. Public Health Reports, 00333549231223922. https://doi.org/10.1177/00333549231223922
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Journal AbstractObjectives:
Treating gender identity as a fixed characteristic may contribute to considerable misclassification and hinder accurate characterization of health inequities and the design of effective preventive interventions for transgender and gender diverse (TGD) adolescents and young adults. We examined changes in how an ethnically and racially diverse sample of TGD adolescents and young adults reported their gender identity over time, the implications of this fluidity on public health, and the potential effects of misclassification of gender identity.

Methods:
We recruited 235 TGD adolescents and young adults (aged 15-24 y) in Los Angeles, California, and New Orleans, Louisiana, from May 2017 through August 2019 to participate in an HIV intervention study. We asked participants to self-report their gender identity and sex assigned at birth every 4 months for 24 months. We used a quantitative content analysis framework to catalog changes in responses over time and classified the changes into 3 main patterns: consistent, fluctuating, and moving in 1 direction. We then calculated the distribution of gender identity labels at baseline (initial assessment) and 12 and 24 months and described the overall sample by age, race, ethnicity, and study site.


Results:
Of 235 TGD participants, 162 (69%) were from Los Angeles, 89 (38%) were Latinx, and 80 (34%) were non-Latinx Black or African American. Changes in self-reported gender identity were common (n = 181; 77%); in fact, 39 (17%) changed gender identities more than twice. More than 50% (n = 131; 56%) showed a fluctuating pattern.

Conclusions:
Gender identity labels varied over time, suggesting that misclassification may occur if data from a single time point are used to define gender identity. Our study lays the foundation for launching studies to elucidate the associations between shifting gender identities and health outcomes.
[+notes+]
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Littman, L., O’Malley, S., Kerschner, H., & Bailey, J. M. (2023). Detransition and Desistance Among Previously Trans-Identified Young Adults. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-023-02716-1
JOURNAL ABSTRACT
SEGM ANALYSIS
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Journal AbstractPersons who have renounced a prior transgender identification, often after some degree of social and medical transition, are increasingly visible. We recruited 78 US individuals ages 18–33 years who previously identified as transgender and had stopped identifying as transgender at least six months prior. On average, participants first identified as transgender at 17.1 years of age and had done so for 5.4 years at the time of their participation. Most (83%) participants had taken several steps toward social transition and 68% had taken at least one medical step. By retrospective reports, fewer than 17% of participants met DSM-5 diagnostic criteria for Gender Dysphoria in Childhood. In contrast, 53% of participants believed that “rapid-onset gender dysphoria” applied to them. Participants reported a high rate of psychiatric diagnoses, with many of these prior to trans-identification. Most participants (N = 71, 91%) were natal females. Females (43%) were more likely than males (0%) to be exclusively homosexual. Participants reported that their psychological health had improved dramatically since detransition/desistance, with marked decreases in self-harm and gender dysphoria and marked increases in flourishing. The most common reason given for initial trans-identification was confusing mental health issues or reactions to trauma for gender dysphoria. Reasons for detransition were more likely to reflect internal changes (e.g., the participants’ own thought processes) than external pressures (e.g., pressure from family). Results suggest that, for some transgender individuals, detransition is both possible and beneficial.
[+notes+]
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MacKinnon, K. R., Gould, W. A., Enxuga, G., Kia, H., Abramovich, A., Lam, J. S. H., & Ross, L. E. (2023). Exploring the gender care experiences and perspectives of individuals who discontinued their transition or detransitioned in Canada. PLOS ONE, 18(11), e0293868. https://doi.org/10.1371/journal.pone.0293868
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractBACKGROUND: Those who detransition have received increased public and scholarly attention and their narratives are often presented as evidence of limitations with contemporary gender-affirming care practices. However, there are scant empirical studies about how this population experienced their own process of gaining access to gender-affirming medical/surgical interventions, or their recommendations for care practice.

AIMS: To qualitatively explore the care experiences and perspectives of individuals who discontinued or reversed their gender transitions (referred to as detransition).

METHODS: Between October 2021-January 2022, Canadian residents aged 18 and older with experience of stopping, shifting, or reversing a gender transition were invited to participate in semi-structured, one-on-one, virtual interviews. A purposive sample of 28 was recruited by circulating study adverts over social media, to clinicians in six urban centres, and within participants’ social networks. Interviews ranged between 50–90 minutes, were audio-recorded, and transcribed verbatim. Following constructivist grounded theory methodology, interview data were analyzed inductively and thematically following a two-phase coding process to interpret participants’ experiences of, and recommendations for, gender care.

RESULTS: Participants were between the ages of 20–53 (71% were between 20–29). All participants identified along the LGBTQ2S+ spectrum. Twenty-seven out of 28 of the participants received medical/surgical interventions (60% were ages 24 and younger). A majority (57%) reported three or more past gender identities, with 60% shifting from a binary transgender identity at the time of initiating transition to a nonbinary identity later in their transition journey. To access medical/surgical interventions, most participants were assessed via the gender-affirming care model pathway and also engaged in talk therapy with a mental healthcare provider such as a psychologist or psychiatrist. Some participants experienced their care as lacking the opportunity to clarify their individual treatment needs prior to undergoing medical/surgical transition. Decisional regret emerged as a theme alongside dissatisfaction with providers’ “informed consent” procedures, such that participants felt they would have benefitted from a more robust discussion of risks/benefits of interventions prior to treatment decision-making. Overall, participants recommended an individualized approach to care that is inclusive of mental healthcare supports.

CONCLUSIONS: To optimize the experiences of people seeking and receiving gender care, a thorough informed consent process inclusive of individualized care options is recommended, as outlined by the World Professional Association of Transgender Health, standards of care, version 8.
[+notes+]
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Irwig, M. S. (2022). Detransition among transgender and gender diverse people – an increasing and increasingly complex phenomenon. The Journal of Clinical Endocrinology & Metabolism, dgac356. https://doi.org/10.1210/clinem/dgac356
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
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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. The Journal of Clinical Endocrinology & Metabolism, dgac251. https://doi.org/10.1210/clinem/dgac251
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractINTRODUCTION: Concerns about future regret and treatment discontinuation have led to restricted access to gender-affirming medical treatment for transgender and gender-diverse (TGD) minors in some jurisdictions. However, these concerns are merely speculative because few studies have examined gender-affirming hormone continuation rates among TGD individuals.

METHODS: We performed a secondary analysis of 2009 to 2018 medical and pharmacy records from the US Military Healthcare System. We identified TGD patients who were children and spouses of active-duty, retired, or deceased military members using International Classification of Diseases-9/10 codes. We assessed initiation and continuation of gender-affirming hormones using pharmacy records. Kaplan-Meier and Cox proportional hazard analyses estimated continuation rates.

RESULTS: The study sample included 627 transmasculine and 325 transfeminine individuals with an average age of 19.2 ± 5.3 years. The 4-year gender-affirming hormone continuation rate was 70.2% (95% CI, 63.9-76.5). Transfeminine individuals had a higher continuation rate than transmasculine individuals 81.0% (72.0%-90.0%) vs 64.4% (56.0%-72.8%). People who started hormones as minors had higher continuation rate than people who started as adults 74.4% (66.0%-82.8%) vs 64.4% (56.0%-72.8%). Continuation was not associated with household income or family member type. In Cox regression, both transmasculine gender identity (hazard ratio, 2.40; 95% CI, 1.50-3.86) and starting hormones as an adult (hazard ratio, 1.69; 95% CI, 1.14-2.52) were independently associated with increased discontinuation rates.

DISCUSSION: Our results suggest that >70% of TGD individuals who start gender-affirming hormones will continue use beyond 4 years, with higher continuation rates in transfeminine individuals. Patients who start hormones, with their parents’ assistance, before age 18 years have higher continuation rates than adults.
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More Studies
Boyd, I., Hackett, T., & Bewley, S. (2022). Care of Transgender Patients: A General Practice Quality Improvement Approach. Healthcare (Basel, Switzerland), 10(1), 121. https://doi.org/10.3390/healthcare10010121
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractPrimary care must ensure high quality lifelong care is offered to trans and gender minority patients who are known to have poor health and adverse healthcare experiences. This quality improvement project aimed to interrogate and audit the data of trans and gender minority patients in one primary care population in England. A new data collection instrument was created examining pathways of care, assessments and interventions undertaken, monitoring, and complications. General practitioners identified a sample from the patient population and then performed an audit to examine against an established standard of care. No appropriate primary care audit standard was found. There was inconsistency between multiple UK gender identity clinics' (GIC) individual recommended schedules of care and between specialty guidelines. Using an international, secondary care, evidence-informed guideline, it appeared that up to two-thirds of patients did not receive all recommended monitoring standards, largely due to inconsistencies between GIC and international guidance. It is imperative that an evidence-based primary care guideline is devised alongside measurable standards. Given the findings of long waits, high rates of medical complexity, and some undesired treatment outcomes (including a fifth of patients stopping hormones of whom more than half cited regret or detransition experiences), this small but population-based quality improvement approach should be replicated and expanded upon at scale.
[+notes+]
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Littman, L. (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-021-02163-w
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThe study’s purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.

SEGM Summary

This is a study of 100 detransitioners. To qualify as medically or surgically transitioned, participants needed to have had one or more of the following interventions for the purpose of transitioning: puberty blockers, cross-sex hormones, anti-androgens, or a surgical procedure, and then detransitioned by stopping the medications or having surgery to reverse the changes from transition.

The demographics of the detransitioners reveal that the majority are female (70%) and white (90%), and over 80% have graduated from college or completed some college coursework. Slightly more experienced an early onset of gender dysphoria (56%) vs. the post-puberty onset (44.0%). However, more than half of the female participants had a post-puberty onset of gender dysphoria (55%). The female study participants were on average 20 years old when they sought care to transition and 24 when they decided to detransition. Males were considerably older: the average ages to seek medical transition and to subsequently detransition were 26 and 33, respectively. 

Specific to endocrine interventions, the vast majority (96%) took cross-sex hormones as part of their transition. Females took testosterone for an average 2 years, while males took estrogen for 5 years and anti-androgens for 3 years. Surgically, one third of females underwent a mastectomy and 16% of males had breast augmentation. Genital surgeries in females were uncommon (1%), while men had genital surgeries as frequently as breast augmentation (16% each). 

In order to detransition, the vast majority of respondents (95%) stopped cross-sex hormones and 9% underwent surgical procedures.

Reasons for Transition / Detransition

Besides wanting to be perceived as the target gender, which was the top reason to transition among both sexes (77%), the leading reasons for transition for females were not wanting to be associated with their natal sex/gender (74%), feeling "wrong" in their bodies (73%), and the belief that transition was the only option for feeling better (73%). For males, the key reasons for transition were that they identified with the target gender (77%), a belief that they would become their true self through transition (71%), and the belief that transition would eliminate their gender dysphoria (71%). Another marked difference between female and male study subjects is in gender-related harassment. While only 16% of male participants reported transitioning to reduce gender-related harassment, 51% of female participants named it as a reason for transition.

Nearly a third (30%) endorsed the response “someone else told me that the feelings I was having meant that I was transgender and I believed them” to describe how they felt about identifying as transgender in the past. Many participants selected social media, online communities, and in-person friend groups as sources that encouraged them to believe that transitioning would help them.

The leading reason for detransition for both sexes was becoming more comfortable with identifying with their natal sex due to a change in personal definition of female and male; this notion was cited by 65% of females and 48% of males. However, other reasons for detransition differed between female and male participants. For females, the second and third most frequently cited reasons for detransition were concerns about potential medical complications from transitioning (58%) and dissatisfaction with the physical results/too much change (51%). In contrast, males endorsed dissatisfaction with the physical results/too little change, deteriorating physical health, continued mental health problems, and feeling that they were discriminated against (36% each). For females, discrimination was among the less frequently endorsed reasons for detransition (17%). 

Although not all detransitioned patients expressed regret, 50% reported strong or very strong regret. Eleven percent of respondents indicated that they were glad that they transitioned and 30% indicated that they wished they had never transitioned.  The majority of respondents were dissatisfied with their decision to transition (70%) and were satisfied with their decision to detransition (85%). At the time of survey completion, 61% had returned to identifying with their birth sex, 14% identified as nonbinary, and 8% identified as transgender.

Gaps in Medical Care

The study raises concerns about the the quality of medical and mental health care provided to many of the participants. Although 55% of the respondents had been diagnosed with at least one psychiatric or neurodevelopmental issue and 37% reported experiencing trauma prior to the onset of gender dysphoria, the majority of participants (65%) reported that their clinicians did not evaluate whether their desire to transition was secondary to trauma or a mental health condition. Only 27% reported that the counseling and information they received prior to transition was accurate in terms of the benefits and risks associated with transition, with nearly half (46%) reporting that the counseling was overly positive about the benefits of transition.

Alarmingly, some participants reported that mental health and medical clinicians pressured them to medically transition. Less than a quarter of the participants (24%) told their treating clinicians that they discontinued medical treatment. This, in turn, suggests that clinicians may be unaware of their own patients who detransition and that clinic rates of detransition are likely underestimated.

SEGM take-away

This study describes the experiences of the individuals who transitioned largely before 2015, the year when the landscape of gender care drastically changed. The numbers of young people expressing gender-related distress have sharply risen in 2015 for reasons that remain poorly understood. At the same time, the "gender-affirmative" approach to treating gender dysphoria, which supports the use of hormonal and surgical interventions as first-line treatment, has become widely adopted, while the "informed consent model of care" eliminated the requirement for mental health evaluations. It is likely that the problems highlighted by the study are even more prevalent today, and if not addressed, they may lead to increasing numbers of individuals subjected to inappropriate medical interventions for their gender distress.

The study suggests that the rate of detransition should be systematically studied to ascertain its prevalence and to begin to develop alternative, non-invasive approaches for gender dysphoria management in young people. SEGM supports the study's call for inclusion of a measure of detransition in nationally representative surveys that collect health data, such as the Behavioral Risk Factor Surveillance System (BRFSS) and Youth Behavior Risk Survey (YRBS). According to the latest available estimates from the YRBS, 1.8% of youth identify as transgender and an additional 1.6% are unsure. As the number of young people seeking and receiving irreversible medical and surgical gender interventions grows, it is vital to begin to track detransition data to prepare the healthcare system to better meet the needs of this novel patient segment.

Hide
Vandenbussche, E. (2021). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, 20. https://doi.org/10.1080/00918369.2021.1919479
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThe aim of this study is to analyze the specific needs of detransi­ tioners from online detrans communities and discover to what extent they are being met. For this purpose, a cross-sectional online survey was conducted and gathered a sample of 237 male and female detransitioners. The results showed important psychological needs in relation to gender dysphoria, comorbid conditions, feelings of regret and internalized homophobic and sexist prejudices. It was also found that many detransitioners need medical support notably in relation to stopping/changing hormone therapy, surgery/treatment complications and rever­ sal interventions. Additionally, the results indicated the need for hearing about other detransitioners’ experiences and meeting each other. A major lack of support was reported by the respon­ dents overall, with a lot of negative experiences coming from medical and mental health systems and from the LGBT+ com­ munity. The study highlights the importance of increasing awareness and support given to detransitioners.
[+notes+]
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Expósito-Campos, P. (2021). A Typology of Gender Detransition and Its Implications for Healthcare Providers. Journal of Sex & Marital Therapy. https://www.tandfonline.com/doi/abs/10.1080/0092623X.2020.1869126
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractGender detransition is an emerging yet poorly understood phenomenon in our society. In the absence of research, clinicians and researchers have applied the concept of detransition differently, leading to inconsistencies in its use. The article suggests a typology of gender detransition based on the cessation or the continuation of a transgender identity to address this issue. Implications of this typology for healthcare providers are discussed, emphasizing the increasing necessity of developing clinical guidelines for detransitioners. Finally, the article reflects on the possibilities of preventing detransition, which underlines the challenges that clinicians face when treating individuals with gender dysphoria.
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Hall, R., Mitchell, L., & Sachdeva, J. (2021). Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review. BJPsych Open, 7(6), e184. https://doi.org/10.1192/bjo.2021.1022
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractBACKGROUND: UK adult gender identity clinics (GICs) are implementing a new streamlined service model. However, there is minimal evidence from these services underpinning this. It is also unknown how many service users subsequently ‘detransition’.

AIMS: To describe service users’ access to care and patterns of service use, specifically, interventions accessed, reasons for discharge and re-referrals; to identify factors associated with access; and to quantify ‘detransitioning’.

METHOD: A retrospective case-note review was performed as a service evaluation for 175 service users consecutively discharged by a tertiary National Health Service adult GIC between 1 September 2017 and 31 August 2018. Descriptive statistics were used for rates of accessing interventions sought, reasons for discharge, re-referral and frequency of detransitioning. Using multivariate analysis, we sought associations between several variables and ‘accessing care’ or ‘other outcome’.

RESULTS: The treatment pathway was completed by 56.1%. All interventions initially sought were accessed by 58%; 94% accessed hormones but only 47.7% accessed gender reassignment surgery; 21.7% disengaged; and 19.4% were re-referred. Multivariate analysis identified coexisting neurodevelopmental disorders (odds ratio [OR] = 5.7, 95% CI = 1.7–19), previous adverse childhood experiences (ACEs) per reported ACE (OR = 1.5, 95% CI = 1.1–1.9), substance misuse during treatment (OR = 4.3, 95% CI = 1.1–17.6) and mental health concerns during treatment (OR = 2.2, 95% CI 1.1–4.4) as independently associated with accessing care. Twelve people (6.9%) met our case definition of detransitioning.

CONCLUSIONS: Service users may have unmet needs. Neurodevelopmental disorders or ACEs suggest complexity requiring consideration during the assessment process. Managing mental ill health and substance misuse during treatment needs optimising. Detransitioning might be more frequent than previously reported.
[+notes+]
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Marchiano, L. (2021). Gender detransition: a case study. Journal of Analytical Psychology, 66(4), 813–832. https://doi.org/10.1111/1468-5922.12711
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractWithin the last decade, there has been a sharp global rise in the number of young people identifying as transgender. More recently, there appears to be an increase in the numbers of young people detransitioning or returning to identifying with their natal sex after pursuing medical transition. A case is presented of a young woman who pursued a gender transition and returned to identifying as female after almost two years on testosterone. The author considers and critiques the affirmative model of care for gender dysphoric youth in light of this case.
[+notes+]
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Entwistle, K. (2020). Debate: Reality check – Detransitioner’s testimonies require us to rethink gender dysphoria. Child and Adolescent Mental Health, camh.12380. https://doi.org/10.1111/camh.12380
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractButler and Hutchinson's clarion call (Butler and Hutchinson, 2020) for empirical research on desistance and detransition deserves careful consideration. It formally documents the needs of the emerging cohort of detransitioners, many of whom are in their teens and early twenties. In the absence of specialist services, some detransitioners have been sharing their experiences in public forums. The anecdotal reports by detransitioners indicate that systematic long-term follow-up of those who have been prescribed medical interventions by NHS and private clinics is essential to understanding the gestalt. Decision-making on the basis of misinformation on the effectiveness and necessity of medical interventions for gender dysphoria is a problem, and detransitioners indicate that nonmedical interventions for gender dysphoria are sorely needed. Analysis of the political and organisational systems that have brought us to the current situation is required in order to prevent more young people from being prescribed unnecessary medical interventions for gender dysphoria.
[+notes+]
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Butler, C., & Hutchinson, A. (2020). Debate: The pressing need for research and services for gender desisters/detransitioners. Child and Adolescent Mental Health, 25(1), 45–47. https://doi.org/10.1111/camh.12361
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThe number of people presenting at gender clinics is increasing worldwide. Many people undergo a gender transition with subsequent improved psychological well-being (Paediatrics, 2014, 134, 696). However, some people choose to stop this journey, ‘desisters’, or to reverse their transition, ‘detransitioners’. It has been suggested that some professionals and activists are reluctant to acknowledge the existence of desisters and detransitioners, possibly fearing that they may delegitimize persisters’ experiences (International Journal of Transgenderism, 2018, 19, 231). Certainly, despite their presence in all follow-up studies of young people who have experienced gender dysphoria (GD), little thought has been given to how we might support this cohort. Levine (Archives of Sexual Behaviour, 2017, 47, 1295) reports that the 8th edition of the WPATH Standards of Care will include a section on detransitioning – confirming that this is an increasingly witnessed phenomenon worldwide. It also highlights that compared to the extensive protocols for working with children, adolescents and adults who wish to transition, nothing exists for those working with desisters or detransitioners. With very little research and no clear guidance on how to work with this population, and with numbers of referrals to gender services increasing, this is a timely juncture to consider factors that should be taken into account within clinical settings and areas for future research.
[+notes+]
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Hutchinson, A., Midgen, M., & Spiliadis, A. (2020). In Support of Research Into Rapid-Onset Gender Dysphoria. Archives of Sexual Behavior, 49(1), 79–80. https://doi.org/10.1007/s10508-019-01517-9
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
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Fewer Studies
Childhood-onset gender dysphoria
Littman, L. (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-021-02163-w
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractThe study’s purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.

SEGM Summary

This is a study of 100 detransitioners. To qualify as medically or surgically transitioned, participants needed to have had one or more of the following interventions for the purpose of transitioning: puberty blockers, cross-sex hormones, anti-androgens, or a surgical procedure, and then detransitioned by stopping the medications or having surgery to reverse the changes from transition.

The demographics of the detransitioners reveal that the majority are female (70%) and white (90%), and over 80% have graduated from college or completed some college coursework. Slightly more experienced an early onset of gender dysphoria (56%) vs. the post-puberty onset (44.0%). However, more than half of the female participants had a post-puberty onset of gender dysphoria (55%). The female study participants were on average 20 years old when they sought care to transition and 24 when they decided to detransition. Males were considerably older: the average ages to seek medical transition and to subsequently detransition were 26 and 33, respectively. 

Specific to endocrine interventions, the vast majority (96%) took cross-sex hormones as part of their transition. Females took testosterone for an average 2 years, while males took estrogen for 5 years and anti-androgens for 3 years. Surgically, one third of females underwent a mastectomy and 16% of males had breast augmentation. Genital surgeries in females were uncommon (1%), while men had genital surgeries as frequently as breast augmentation (16% each). 

In order to detransition, the vast majority of respondents (95%) stopped cross-sex hormones and 9% underwent surgical procedures.

Reasons for Transition / Detransition

Besides wanting to be perceived as the target gender, which was the top reason to transition among both sexes (77%), the leading reasons for transition for females were not wanting to be associated with their natal sex/gender (74%), feeling "wrong" in their bodies (73%), and the belief that transition was the only option for feeling better (73%). For males, the key reasons for transition were that they identified with the target gender (77%), a belief that they would become their true self through transition (71%), and the belief that transition would eliminate their gender dysphoria (71%). Another marked difference between female and male study subjects is in gender-related harassment. While only 16% of male participants reported transitioning to reduce gender-related harassment, 51% of female participants named it as a reason for transition.

Nearly a third (30%) endorsed the response “someone else told me that the feelings I was having meant that I was transgender and I believed them” to describe how they felt about identifying as transgender in the past. Many participants selected social media, online communities, and in-person friend groups as sources that encouraged them to believe that transitioning would help them.

The leading reason for detransition for both sexes was becoming more comfortable with identifying with their natal sex due to a change in personal definition of female and male; this notion was cited by 65% of females and 48% of males. However, other reasons for detransition differed between female and male participants. For females, the second and third most frequently cited reasons for detransition were concerns about potential medical complications from transitioning (58%) and dissatisfaction with the physical results/too much change (51%). In contrast, males endorsed dissatisfaction with the physical results/too little change, deteriorating physical health, continued mental health problems, and feeling that they were discriminated against (36% each). For females, discrimination was among the less frequently endorsed reasons for detransition (17%). 

Although not all detransitioned patients expressed regret, 50% reported strong or very strong regret. Eleven percent of respondents indicated that they were glad that they transitioned and 30% indicated that they wished they had never transitioned.  The majority of respondents were dissatisfied with their decision to transition (70%) and were satisfied with their decision to detransition (85%). At the time of survey completion, 61% had returned to identifying with their birth sex, 14% identified as nonbinary, and 8% identified as transgender.

Gaps in Medical Care

The study raises concerns about the the quality of medical and mental health care provided to many of the participants. Although 55% of the respondents had been diagnosed with at least one psychiatric or neurodevelopmental issue and 37% reported experiencing trauma prior to the onset of gender dysphoria, the majority of participants (65%) reported that their clinicians did not evaluate whether their desire to transition was secondary to trauma or a mental health condition. Only 27% reported that the counseling and information they received prior to transition was accurate in terms of the benefits and risks associated with transition, with nearly half (46%) reporting that the counseling was overly positive about the benefits of transition.

Alarmingly, some participants reported that mental health and medical clinicians pressured them to medically transition. Less than a quarter of the participants (24%) told their treating clinicians that they discontinued medical treatment. This, in turn, suggests that clinicians may be unaware of their own patients who detransition and that clinic rates of detransition are likely underestimated.

SEGM take-away

This study describes the experiences of the individuals who transitioned largely before 2015, the year when the landscape of gender care drastically changed. The numbers of young people expressing gender-related distress have sharply risen in 2015 for reasons that remain poorly understood. At the same time, the "gender-affirmative" approach to treating gender dysphoria, which supports the use of hormonal and surgical interventions as first-line treatment, has become widely adopted, while the "informed consent model of care" eliminated the requirement for mental health evaluations. It is likely that the problems highlighted by the study are even more prevalent today, and if not addressed, they may lead to increasing numbers of individuals subjected to inappropriate medical interventions for their gender distress.

The study suggests that the rate of detransition should be systematically studied to ascertain its prevalence and to begin to develop alternative, non-invasive approaches for gender dysphoria management in young people. SEGM supports the study's call for inclusion of a measure of detransition in nationally representative surveys that collect health data, such as the Behavioral Risk Factor Surveillance System (BRFSS) and Youth Behavior Risk Survey (YRBS). According to the latest available estimates from the YRBS, 1.8% of youth identify as transgender and an additional 1.6% are unsure. As the number of young people seeking and receiving irreversible medical and surgical gender interventions grows, it is vital to begin to track detransition data to prepare the healthcare system to better meet the needs of this novel patient segment.

SEGM Summary

This is a study of 100 detransitioners. To qualify as medically or surgically transitioned, participants needed to have had one or more of the following interventions for the purpose of transitioning: puberty blockers, cross-sex hormones, anti-androgens, or a surgical procedure, and then detransitioned by stopping the medications or having surgery to reverse the changes from transition.

The demographics of the detransitioners reveal that the majority are female (70%) and white (90%), and over 80% have graduated from college or completed some college coursework. Slightly more experienced an early onset of gender dysphoria (56%) vs. the post-puberty onset (44.0%). However, more than half of the female participants had a post-puberty onset of gender dysphoria (55%). The female study participants were on average 20 years old when they sought care to transition and 24 when they decided to detransition. Males were considerably older: the average ages to seek medical transition and to subsequently detransition were 26 and 33, respectively. 

Specific to endocrine interventions, the vast majority (96%) took cross-sex hormones as part of their transition. Females took testosterone for an average 2 years, while males took estrogen for 5 years and anti-androgens for 3 years. Surgically, one third of females underwent a mastectomy and 16% of males had breast augmentation. Genital surgeries in females were uncommon (1%), while men had genital surgeries as frequently as breast augmentation (16% each). 

In order to detransition, the vast majority of respondents (95%) stopped cross-sex hormones and 9% underwent surgical procedures.

Reasons for Transition / Detransition

Besides wanting to be perceived as the target gender, which was the top reason to transition among both sexes (77%), the leading reasons for transition for females were not wanting to be associated with their natal sex/gender (74%), feeling "wrong" in their bodies (73%), and the belief that transition was the only option for feeling better (73%). For males, the key reasons for transition were that they identified with the target gender (77%), a belief that they would become their true self through transition (71%), and the belief that transition would eliminate their gender dysphoria (71%). Another marked difference between female and male study subjects is in gender-related harassment. While only 16% of male participants reported transitioning to reduce gender-related harassment, 51% of female participants named it as a reason for transition.

Nearly a third (30%) endorsed the response “someone else told me that the feelings I was having meant that I was transgender and I believed them” to describe how they felt about identifying as transgender in the past. Many participants selected social media, online communities, and in-person friend groups as sources that encouraged them to believe that transitioning would help them.

The leading reason for detransition for both sexes was becoming more comfortable with identifying with their natal sex due to a change in personal definition of female and male; this notion was cited by 65% of females and 48% of males. However, other reasons for detransition differed between female and male participants. For females, the second and third most frequently cited reasons for detransition were concerns about potential medical complications from transitioning (58%) and dissatisfaction with the physical results/too much change (51%). In contrast, males endorsed dissatisfaction with the physical results/too little change, deteriorating physical health, continued mental health problems, and feeling that they were discriminated against (36% each). For females, discrimination was among the less frequently endorsed reasons for detransition (17%). 

Although not all detransitioned patients expressed regret, 50% reported strong or very strong regret. Eleven percent of respondents indicated that they were glad that they transitioned and 30% indicated that they wished they had never transitioned.  The majority of respondents were dissatisfied with their decision to transition (70%) and were satisfied with their decision to detransition (85%). At the time of survey completion, 61% had returned to identifying with their birth sex, 14% identified as nonbinary, and 8% identified as transgender.

Gaps in Medical Care

The study raises concerns about the the quality of medical and mental health care provided to many of the participants. Although 55% of the respondents had been diagnosed with at least one psychiatric or neurodevelopmental issue and 37% reported experiencing trauma prior to the onset of gender dysphoria, the majority of participants (65%) reported that their clinicians did not evaluate whether their desire to transition was secondary to trauma or a mental health condition. Only 27% reported that the counseling and information they received prior to transition was accurate in terms of the benefits and risks associated with transition, with nearly half (46%) reporting that the counseling was overly positive about the benefits of transition.

Alarmingly, some participants reported that mental health and medical clinicians pressured them to medically transition. Less than a quarter of the participants (24%) told their treating clinicians that they discontinued medical treatment. This, in turn, suggests that clinicians may be unaware of their own patients who detransition and that clinic rates of detransition are likely underestimated.

SEGM take-away

This study describes the experiences of the individuals who transitioned largely before 2015, the year when the landscape of gender care drastically changed. The numbers of young people expressing gender-related distress have sharply risen in 2015 for reasons that remain poorly understood. At the same time, the "gender-affirmative" approach to treating gender dysphoria, which supports the use of hormonal and surgical interventions as first-line treatment, has become widely adopted, while the "informed consent model of care" eliminated the requirement for mental health evaluations. It is likely that the problems highlighted by the study are even more prevalent today, and if not addressed, they may lead to increasing numbers of individuals subjected to inappropriate medical interventions for their gender distress.

The study suggests that the rate of detransition should be systematically studied to ascertain its prevalence and to begin to develop alternative, non-invasive approaches for gender dysphoria management in young people. SEGM supports the study's call for inclusion of a measure of detransition in nationally representative surveys that collect health data, such as the Behavioral Risk Factor Surveillance System (BRFSS) and Youth Behavior Risk Survey (YRBS). According to the latest available estimates from the YRBS, 1.8% of youth identify as transgender and an additional 1.6% are unsure. As the number of young people seeking and receiving irreversible medical and surgical gender interventions grows, it is vital to begin to track detransition data to prepare the healthcare system to better meet the needs of this novel patient segment.

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Singh, D., Bradley, S. J., & Zucker, K. J. (2021). A Follow-Up Study of Boys With Gender Identity Disorder. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.632784
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Journal AbstractThis study reports follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139) with regard to gender identity and sexual orientation. In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33-12.99) at a mean year of 1989 and followed-up at a mean age of 20.58 years (range, 13.07-39.15) at a mean year of 2002. In childhood, 88 (63.3%) of the boys met the DSM-III, III-R or IV criteria for gender identity disorder; the remaining 51 (36.7%) boys were subthreshold for the criteria. At follow-up, gender identity/dysphoria was assessed via multiple methods and the boys were classified as either persisters or desisters. Sexual orientation was ascertained for both fantasy and behavior and then dichotomized as either biphilic/androphilic or gynephilic. Of the 139 boys, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters. Data on sexual orientation in fantasy were available for 129 boys: 82 (63.6%) were classified as biphilic/ androphilic, 43 (33.3%) were classified as gynephilic, and 4 (3.1%) reported no sexual fantasies. For sexual orientation in behavior, data were available for 108 boys: 51 (47.2%) were classified as biphilic/androphilic, 29 (26.9%) were classified as gynephilic, and 28 (25.9%) reported no sexual behaviors. Multinomial logistic regression examined predictors of outcome for the biphilic/androphilic persisters and the gynephilic desisters, with the biphilic/androphilic desisters as the reference group. Compared to the reference group, the biphilic/androphilic persisters tended to be older at the time of the assessment in childhood, were from a lower social class background, and, on a dimensional composite of sex-typed behavior in childhood were more gender-variant. The biphilic/androphilic desisters were more gender-variant compared to the gynephilic desisters. Boys clinic-referred for gender identity concerns in childhood had a high rate of desistance and a high rate of a biphilic/androphilic sexual orientation. The implications of the data for current models of care for the treatment of gender dysphoria in children are discussed.
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Zucker, K. J. (2018). The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender non-conforming children” by Temple Newhook et al. (2018). International Journal of Transgenderism, 19(2), 231–245. https://doi.org/10.1080/15532739.2018.1468293
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Journal AbstractTemple Newhook et al. (2018) provide a critique of recent follow-up studies of children referred to specialized gender identity clinics, organized around rates of persistence and desistance. The critical gaze of Temple Newhook et al. examined three primary issues: (1) the terms persistence and desistance in their own right; (2) methodology of the follow-up studies and interpretation of the data; and (3) ethical matters. In this response, I interrogate the critique of Temple Newhook et al. (2018).
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Ristori, J., & Steensma, T. D. (2016). Gender dysphoria in childhood. International Review of Psychiatry, 28(1), 13–20. https://doi.org/10.3109/09540261.2015.1115754
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Journal AbstractGender dysphoria (GD) in childhood is a complex phenomenon characterized by clinically significant distress due to the incongruence between assigned gender at birth and experienced gender. The clinical presentation of children who present with gender identity issues can be highly variable; the psychosexual development and future psychosexual outcome can be unclear, and consensus about the best clinical practice is currently under debate.

In this paper a clinical picture is provided of children who are referred to gender identity clinics. The clinical criteria are described including what is known about the prevalence of childhood GD. In addition, an overview is presented of the literature on the psychological functioning of children with GD, the current knowledge on the psychosexual development and factors associated with the persistence of GD, and explanatory models for psychopathology in children with GD together with other co-existing problems that are characteristic for children referred for their gender. In light of this, currently used treatment and counselling approaches are summarized and discussed, including the integration of the literature detailed above.
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Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry, 52(6), 582–590. https://doi.org/10.1016/j.jaac.2013.03.016
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Journal AbstractOBJECTIVE: To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence.
METHOD: The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence.
RESULTS: We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls.
CONCLUSION: Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.
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More Studies
Fewer Studies
Detransition
Littman, L., O’Malley, S., Kerschner, H., & Bailey, J. M. (2023). Detransition and Desistance Among Previously Trans-Identified Young Adults. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-023-02716-1
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Journal AbstractPersons who have renounced a prior transgender identification, often after some degree of social and medical transition, are increasingly visible. We recruited 78 US individuals ages 18–33 years who previously identified as transgender and had stopped identifying as transgender at least six months prior. On average, participants first identified as transgender at 17.1 years of age and had done so for 5.4 years at the time of their participation. Most (83%) participants had taken several steps toward social transition and 68% had taken at least one medical step. By retrospective reports, fewer than 17% of participants met DSM-5 diagnostic criteria for Gender Dysphoria in Childhood. In contrast, 53% of participants believed that “rapid-onset gender dysphoria” applied to them. Participants reported a high rate of psychiatric diagnoses, with many of these prior to trans-identification. Most participants (N = 71, 91%) were natal females. Females (43%) were more likely than males (0%) to be exclusively homosexual. Participants reported that their psychological health had improved dramatically since detransition/desistance, with marked decreases in self-harm and gender dysphoria and marked increases in flourishing. The most common reason given for initial trans-identification was confusing mental health issues or reactions to trauma for gender dysphoria. Reasons for detransition were more likely to reflect internal changes (e.g., the participants’ own thought processes) than external pressures (e.g., pressure from family). Results suggest that, for some transgender individuals, detransition is both possible and beneficial.
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MacKinnon, K. R., Kia, H., Gould, W. A., Ross, L. E., Abramovich, A., Enxuga, G., & Lam, J. S. H. (2023). A typology of pathways to detransition: Considerations for care practice with transgender and gender diverse people who stop or reverse their gender transition. Psychology of Sexual Orientation and Gender Diversity. https://doi.org/10.1037/sgd0000678
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Journal AbstractResearch and care provider interest in gender detransition has grown in recent years, yet there are limited resources to clinically support the emerging population of transgender and gender diverse (TGD) people who stop or reverse their gender transition. Though some research and typologies exist to guide clinicians, no prior typologies are based upon the lived experiences and in-depth narratives of individuals who themselves have detransitioned. Drawing from the concept of transnormativity, the present study introduces a typology of four detransition pathways to address knowledge and practice gaps. Following constructivist grounded theory methodology, this typology was developed empirically by analyzing in-depth interview data gathered from 28 individuals living in Canada who experienced a change in self-conceptualized gender identity after initiating a transition and who ultimately detransitioned. Interviews were virtual, semi-structured, and ranged between 50 and 90 min. Following a thematic and constant comparative method of data analysis, the analysis discovered four discrete detransition subtypes: (a) discrimination and TGD identity repression; (b) gender-affirming hormone discontinuation and identity evolution; (c) binary transition to nonbinary detransition; and (d) detrans identity development within the social context. This article explicates how the broader sociocultural milieu can influence transnormative transition trajectories and identity development processes, and it discusses implications for practice with those who shift or reverse their gender transition.
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MacKinnon, K. R., Gould, W. A., Enxuga, G., Kia, H., Abramovich, A., Lam, J. S. H., & Ross, L. E. (2023). Exploring the gender care experiences and perspectives of individuals who discontinued their transition or detransitioned in Canada. PLOS ONE, 18(11), e0293868. https://doi.org/10.1371/journal.pone.0293868
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Journal AbstractBACKGROUND: Those who detransition have received increased public and scholarly attention and their narratives are often presented as evidence of limitations with contemporary gender-affirming care practices. However, there are scant empirical studies about how this population experienced their own process of gaining access to gender-affirming medical/surgical interventions, or their recommendations for care practice.

AIMS: To qualitatively explore the care experiences and perspectives of individuals who discontinued or reversed their gender transitions (referred to as detransition).

METHODS: Between October 2021-January 2022, Canadian residents aged 18 and older with experience of stopping, shifting, or reversing a gender transition were invited to participate in semi-structured, one-on-one, virtual interviews. A purposive sample of 28 was recruited by circulating study adverts over social media, to clinicians in six urban centres, and within participants’ social networks. Interviews ranged between 50–90 minutes, were audio-recorded, and transcribed verbatim. Following constructivist grounded theory methodology, interview data were analyzed inductively and thematically following a two-phase coding process to interpret participants’ experiences of, and recommendations for, gender care.

RESULTS: Participants were between the ages of 20–53 (71% were between 20–29). All participants identified along the LGBTQ2S+ spectrum. Twenty-seven out of 28 of the participants received medical/surgical interventions (60% were ages 24 and younger). A majority (57%) reported three or more past gender identities, with 60% shifting from a binary transgender identity at the time of initiating transition to a nonbinary identity later in their transition journey. To access medical/surgical interventions, most participants were assessed via the gender-affirming care model pathway and also engaged in talk therapy with a mental healthcare provider such as a psychologist or psychiatrist. Some participants experienced their care as lacking the opportunity to clarify their individual treatment needs prior to undergoing medical/surgical transition. Decisional regret emerged as a theme alongside dissatisfaction with providers’ “informed consent” procedures, such that participants felt they would have benefitted from a more robust discussion of risks/benefits of interventions prior to treatment decision-making. Overall, participants recommended an individualized approach to care that is inclusive of mental healthcare supports.

CONCLUSIONS: To optimize the experiences of people seeking and receiving gender care, a thorough informed consent process inclusive of individualized care options is recommended, as outlined by the World Professional Association of Transgender Health, standards of care, version 8.
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Jorgensen, S. C. J. (2023). Transition Regret and Detransition: Meanings and Uncertainties. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-023-02626-2
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Journal AbstractAbstract
Gender transition is undertaken to improve the well-being of people suffering from gender dysphoria. However, some have argued that the evidence supporting medical interventions for gender transition (e.g., hormonal therapies and surgery) is weak and inconclusive, and an increasing number of people have come forward recently to share their experiences of transition regret and detransition. In this essay, I discuss emerging clinical and research issues related to transition regret and detransition with the aim of arming clinicians with the latest information so they can support patients navigating the challenges of regret and detransition. I begin by describing recent changes in the epidemiology of gender dysphoria, conceptualization of transgender identification, and models of care. I then discuss the potential impact of these changes on regret and detransition; the prevalence of desistance, regret, and detransition; reasons for detransition; and medical and mental healthcare needs of detransitioners. Although recent data have shed light on a complex range of experiences that lead people to detransition, research remains very much in its infancy. Little is known about the medical and mental healthcare needs of these patients, and there is currently no guidance on best practices for clinicians involved in their care. Moreover, the term detransition can hold a wide array of possible meanings for transgender-identifying people, detransitioners, and researchers, leading to inconsistences in its usage. Moving forward, minimizing harm will require conducting robust research, challenging fundamental assumptions, scrutinizing of practice patterns, and embracing debate.
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Gribble, K. D., Bewley, S., & Dahlen, H. G. (2023). Breastfeeding grief after chest masculinisation mastectomy and detransition: A case report with lessons about unanticipated harm. Frontiers in Global Women’s Health, 4, 1073053. https://doi.org/10.3389/fgwh.2023.1073053
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Journal AbstractAn increasing number of young females are undergoing chest masculinsation mastectomy to affirm a gender identity and/or to relieve gender dysphoria. Some desist in their transgender identification and/or become reconciled with their sex, and then revert (or detransition). To the best of our knowledge, this report presents the first published case of a woman who had chest masculinisation surgery to affirm a gender identity as a trans man, but who later detransitioned, became pregnant and grieved her inability to breastfeed. She described a lack of understanding by maternity health providers of her experience and the importance she placed on breastfeeding. Subsequent poor maternity care contributed to her distress. The absence of breast function as a consideration in transgender surgical literature is highlighted. That breastfeeding is missing in counselling and consent guidelines for chest masculinisation mastectomy is also described as is the poor quality of existing research on detransition rates and benefit or otherwise of chest masculinising mastectomy. Recommendations are made for improving maternity care for detransitioned women. Increasing numbers of chest masculinsation mastectomies will likely be followed by more new mothers without functioning breasts who will require honest, knowledgeable, and compassionate support.
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More Studies
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
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Expósito-Campos, P., Salaberria, K., Pérez-Fernández, J. I., & Gómez-Gil, E. (2023). Gender detransition: A critical review of the literature. Actas Esp Psiquiatr, 51(3), 98–118. https://www.actaspsiquiatria.es/repositorio//26/143/ENG/26-143-ENG-98-118-437511.pdf
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Journal AbstractINTRODUCTION: Gender detransition is the act of stopping or reversing the social, medical, and/or administrative changes achieved during a gender transition process. It is an emerging phenomenon of significant clinical and social interest.

METHODS: We systematically searched seven databases between 2010 and 2022, manually traced article references, and consulted specialized books. Quantitative and content analyses were carried out.

RESULTS: We included 138 registers, 37% of which were empirical studies and 38.4% of which were published in 2021. At least eight terms related to detransition were identified, with differences in their definitions. Prevalence estimates differ according to the criteria used, being lower for detransition/regret (0-13.1%) than for discontinuation of care/medical treatment (1.9%-29.8%), and for detransition/ regret after surgery (0-2.4%) than for detransition/ regret after hormonal treatment (0-9.8%). More than 50 psychological, medical, and sociocultural factors influencing the decision to detransition and 16 predictors/associated factors are described. No health or legal guidelines are found. Current debates focus on the nature of gender dysphoria and identity development, the role of professionals in accessing medical treatments, and the impact of detransition on future access to these treatments.

CONCLUSIONS: Gender detransition is a complex, heterogeneous, under-researched, and poorly understood reality. A systematic study and approach to the topic is needed to understand its prevalence, implications, and management from a healthcare perspective.
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van der Loos, M. A. T. C., Hannema, S. E., Klink, D. T., den Heijer, M., & Wiepjes, C. M. (2022). Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands. The Lancet. Child & Adolescent Health, S2352-4642(22)00254-1. https://doi.org/10.1016/S2352-4642(22)00254-1
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Journal AbstractBACKGROUND: In the Netherlands, treatment with puberty suppression is available to transgender adolescents younger than age 18 years. When gender dysphoria persists testosterone or oestradiol can be added as gender-affirming hormones in young people who go on to transition. We investigated the proportion of people who continued gender-affirming hormone treatment at follow-up after having started puberty suppression and gender-affirming hormone treatment in adolescence.

METHODS: In this cohort study, we used data from the Amsterdam Cohort of Gender dysphoria (ACOG), which included people who visited the gender identity clinic of the Amsterdam UMC, location Vrije Universiteit Medisch Centrum, Netherlands, for gender dysphoria. People with disorders of sex development were not included in the ACOG. We included people who started medical treatment in adolescence with a gonadotropin-releasing hormone agonist (GnRHa) to suppress puberty before the age of 18 years and used GnRHa for a minimum duration of 3 months before addition of gender-affirming hormones. We linked this data to a nationwide prescription registry supplied by Statistics Netherlands (Centraal Bureau voor de Statistiek) to check for a prescription for gender-affirming hormones at follow-up. The main outcome of this study was a prescription for gender-affirming hormones at the end of data collection (Dec 31, 2018). Data were analysed using Cox regression to identify possible determinants associated with a higher risk of stopping gender-affirming hormone treatment.

FINDINGS: 720 people were included, of whom 220 (31%) were assigned male at birth and 500 (69%) were assigned female at birth. At the start of GnRHa treatment, the median age was 14·1 (IQR 13·0-16·3) years for people assigned male at birth and 16·0 (14·1-16·9) years for people assigned female at birth. Median age at end of data collection was 20·2 (17·9-24·8) years for people assigned male at birth and 19·2 (17·8-22·0) years for those assigned female at birth. 704 (98%) people who had started gender-affirming medical treatment in adolescence continued to use gender-affirming hormones at follow-up. Age at first visit, year of first visit, age and puberty stage at start of GnRHa treatment, age at start of gender-affirming hormone treatment, year of start of gender-affirming hormone treatment, and gonadectomy were not associated with discontinuing gender-affirming hormones.

INTERPRETATION: Most participants who started gender-affirming hormones in adolescence continued this treatment into adulthood. The continuation of treatment is reassuring considering the worries that people who started treatment in adolescence might discontinue gender-affirming treatment.

FUNDING: None.
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Vandenbussche, E. (2022). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, 69(9), 1602–1620. https://doi.org/10.1080/00918369.2021.1919479
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Journal AbstractThe aim of this study is to analyze the specific needs of detransitioners from online detrans communities and discover to what extent they are being met. For this purpose, a cross-sectional online survey was conducted and gathered a sample of 237 male and female detransitioners. The results showed important psychological needs in relation to gender dysphoria, comorbid conditions, feelings of regret and internalized homophobic and sexist prejudices. It was also found that many detransitioners need medical support notably in relation to stopping/changing hormone therapy, surgery/treatment complications and reversal interventions. Additionally, the results indicated the need for hearing about other detransitioners’ experiences and meeting each other. A major lack of support was reported by the respondents overall, with a lot of negative experiences coming from medical and mental health systems and from the LGBT+ community. The study highlights the importance of increasing awareness and support given to detransitioners.
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MacKinnon, K. R., Kia, H., Salway, T., Ashley, F., Lacombe-Duncan, A., Abramovich, A., Enxuga, G., & Ross, L. E. (2022). Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments. JAMA Network Open, 5(7), e2224717. https://doi.org/10.1001/jamanetworkopen.2022.24717
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Journal AbstractOBJECTIVE: To examine the physical and mental health experiences of people who initiated medical or surgical detransition to inform clinical practice. DESIGN, SETTING, AND PARTICIPANTS Using constructivist grounded theory as a qualitative approach, data were collected in the form of in-depth interviews. Data were analyzed using an inductive 2-stage coding process to categorize and interpret detransition-related health care experiences to inform clinical practice. Between October 2021 and January 2022, individuals living in Canada who were aged 18 years and older with experience of stopping, shifting, or reversing a gender transition were invited to partake in semistructured virtual interviews. Study advertisements were circulated over social media, to clinicians, and within participants’ social networks. A purposive sample of 28 participants who discontinued, shifted, or reversed a gender transition were interviewed.

MAIN OUTCOMES AND MEASURES: In-depth, narrative descriptions of the physical and mental health experiences of people who discontinued or sought to reverse prior gender-affirming medical and/or surgical interventions.

RESULTS: Among the 28 participants, 18 (64%) were assigned female at birth and 10 (36%) were assigned male at birth; 2 (7%) identified as Jewish and White, 5 (18%) identified as having mixed race and ethnicity (which included Arab, Black, Indigenous, Latinx, and South Asian), and 21 (75%) identified as White. Participants initially sought gender-affirmation at a wide range of ages (15 [56%] were between ages 18 and 24 years). Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Participants reported divergent perspectives about their past gender-affirming medical or surgical treatments. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Medical detransition was often experienced as physically and psychologically challenging, yet health care avoidance was common. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs.

CONCLUSIONS AND RELEVANCE: This study’s results suggest that further research and clinical guidance is required to address the unmet needs of this population who discontinue or seek to reverse prior gender-affirming interventions.
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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. The Journal of Clinical Endocrinology & Metabolism, dgac251. https://doi.org/10.1210/clinem/dgac251
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Journal AbstractINTRODUCTION: Concerns about future regret and treatment discontinuation have led to restricted access to gender-affirming medical treatment for transgender and gender-diverse (TGD) minors in some jurisdictions. However, these concerns are merely speculative because few studies have examined gender-affirming hormone continuation rates among TGD individuals.

METHODS: We performed a secondary analysis of 2009 to 2018 medical and pharmacy records from the US Military Healthcare System. We identified TGD patients who were children and spouses of active-duty, retired, or deceased military members using International Classification of Diseases-9/10 codes. We assessed initiation and continuation of gender-affirming hormones using pharmacy records. Kaplan-Meier and Cox proportional hazard analyses estimated continuation rates.

RESULTS: The study sample included 627 transmasculine and 325 transfeminine individuals with an average age of 19.2 ± 5.3 years. The 4-year gender-affirming hormone continuation rate was 70.2% (95% CI, 63.9-76.5). Transfeminine individuals had a higher continuation rate than transmasculine individuals 81.0% (72.0%-90.0%) vs 64.4% (56.0%-72.8%). People who started hormones as minors had higher continuation rate than people who started as adults 74.4% (66.0%-82.8%) vs 64.4% (56.0%-72.8%). Continuation was not associated with household income or family member type. In Cox regression, both transmasculine gender identity (hazard ratio, 2.40; 95% CI, 1.50-3.86) and starting hormones as an adult (hazard ratio, 1.69; 95% CI, 1.14-2.52) were independently associated with increased discontinuation rates.

DISCUSSION: Our results suggest that >70% of TGD individuals who start gender-affirming hormones will continue use beyond 4 years, with higher continuation rates in transfeminine individuals. Patients who start hormones, with their parents’ assistance, before age 18 years have higher continuation rates than adults.
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Boyd, I., Hackett, T., & Bewley, S. (2022). Care of Transgender Patients: A General Practice Quality Improvement Approach. Healthcare, 10(1), 121. https://doi.org/10.3390/healthcare10010121
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Journal AbstractPrimary care must ensure high quality lifelong care is offered to trans and gender minority patients who are known to have poor health and adverse healthcare experiences. This quality improvement project aimed to interrogate and audit the data of trans and gender minority patients in one primary care population in England. A new data collection instrument was created examining pathways of care, assessments and interventions undertaken, monitoring, and complications. General practitioners identified a sample from the patient population and then performed an audit to examine against an established standard of care. No appropriate primary care audit standard was found. There was inconsistency between multiple UK gender identity clinics’ (GIC) individual recommended schedules of care and between specialty guidelines. Using an international, secondary care, evidence-informed guideline, it appeared that up to two-thirds of patients did not receive all recommended monitoring standards, largely due to inconsistencies between GIC and international guidance. It is imperative that an evidence-based primary care guideline is devised alongside measurable standards. Given the findings of long waits, high rates of medical complexity, and some undesired treatment outcomes (including a fifth of patients stopping hormones of whom more than half cited regret or detransition experiences), this small but population-based quality improvement approach should be replicated and expanded upon at scale.
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Turban, J. L., Loo, S. S., Almazan, A. N., & Keuroghlian, A. S. (2021). Factors Leading to “Detransition” Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis. LGBT Health, 8(4), 273–280. https://doi.org/10.1089/lgbt.2020.0437
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Journal AbstractPurpose: There is a paucity of data regarding transgender and gender diverse (TGD) people who “detransition,” or go back to living as their sex assigned at birth. This study examined reasons for past detransition among TGD people in the United States.

Methods: A secondary analysis was performed on data from the U.S. Transgender Survey, a cross-sectional nonprobability survey of 27,715 TGD adults in the United States. Participants were asked if they had ever detransitioned and to report driving factors, through multiple-choice options and free-text responses. A mixed-methods approach was used to analyze the data, creating qualitative codes for free-text responses and applying summative content analysis.

Results: A total of 17,151 (61.9%) participants reported that they had ever pursued gender affirmation, broadly defined. Of these, 2242 (13.1%) reported a history of detransition. Of those who had detransitioned, 82.5% reported at least one external driving factor. Frequently endorsed external factors included pressure from family and societal stigma. History of detransition was associated with male sex assigned at birth, nonbinary gender identity, bisexual sexual orientation, and having a family unsupportive of one's gender identity. A total of 15.9% of respondents reported at least one internal driving factor, including fluctuations in or uncertainty regarding gender identity.

Conclusion: Among TGD adults with a reported history of detransition, the vast majority reported that their detransition was driven by external pressures. Clinicians should be aware of these external pressures, how they may be modified, and the possibility that patients may once again seek gender affirmation in the future.
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Expósito-Campos, P. (2021). A Typology of Gender Detransition and Its Implications for Healthcare Providers. Journal of Sex & Marital Therapy. https://www.tandfonline.com/doi/abs/10.1080/0092623X.2020.1869126
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Journal AbstractGender detransition is an emerging yet poorly understood phenomenon in our society. In the absence of research, clinicians and researchers have applied the concept of detransition differently, leading to inconsistencies in its use. The article suggests a typology of gender detransition based on the cessation or the continuation of a transgender identity to address this issue. Implications of this typology for healthcare providers are discussed, emphasizing the increasing necessity of developing clinical guidelines for detransitioners. Finally, the article reflects on the possibilities of preventing detransition, which underlines the challenges that clinicians face when treating individuals with gender dysphoria.
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Hall, R., Mitchell, L., & Sachdeva, J. (2021). Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review. BJPsych Open, 7(6), e184. https://doi.org/10.1192/bjo.2021.1022
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Journal AbstractBACKGROUND: UK adult gender identity clinics (GICs) are implementing a new streamlined service model. However, there is minimal evidence from these services underpinning this. It is also unknown how many service users subsequently ‘detransition’.

AIMS: To describe service users’ access to care and patterns of service use, specifically, interventions accessed, reasons for discharge and re-referrals; to identify factors associated with access; and to quantify ‘detransitioning’.

METHOD: A retrospective case-note review was performed as a service evaluation for 175 service users consecutively discharged by a tertiary National Health Service adult GIC between 1 September 2017 and 31 August 2018. Descriptive statistics were used for rates of accessing interventions sought, reasons for discharge, re-referral and frequency of detransitioning. Using multivariate analysis, we sought associations between several variables and ‘accessing care’ or ‘other outcome’.

RESULTS: The treatment pathway was completed by 56.1%. All interventions initially sought were accessed by 58%; 94% accessed hormones but only 47.7% accessed gender reassignment surgery; 21.7% disengaged; and 19.4% were re-referred. Multivariate analysis identified coexisting neurodevelopmental disorders (odds ratio [OR] = 5.7, 95% CI = 1.7–19), previous adverse childhood experiences (ACEs) per reported ACE (OR = 1.5, 95% CI = 1.1–1.9), substance misuse during treatment (OR = 4.3, 95% CI = 1.1–17.6) and mental health concerns during treatment (OR = 2.2, 95% CI 1.1–4.4) as independently associated with accessing care. Twelve people (6.9%) met our case definition of detransitioning.

CONCLUSIONS: Service users may have unmet needs. Neurodevelopmental disorders or ACEs suggest complexity requiring consideration during the assessment process. Managing mental ill health and substance misuse during treatment needs optimising. Detransitioning might be more frequent than previously reported.
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Littman, L. (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Archives of Sexual Behavior, 50(8), 3353–3369. https://doi.org/10.1007/s10508-021-02163-w
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Journal AbstractThe study’s purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.
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Marchiano, L. (2021). Gender detransition: a case study. Journal of Analytical Psychology, 66(4), 813–832. https://doi.org/10.1111/1468-5922.12711
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Journal AbstractWithin the last decade, there has been a sharp global rise in the number of young people identifying as transgender. More recently, there appears to be an increase in the numbers of young people detransitioning or returning to identifying with their natal sex after pursuing medical transition. A case is presented of a young woman who pursued a gender transition and returned to identifying as female after almost two years on testosterone. The author considers and critiques the affirmative model of care for gender dysphoric youth in light of this case.
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D’Angelo, R. (2020). The man I am trying to be is not me. The International Journal of Psychoanalysis, 101(5), 951–970. https://doi.org/10.1080/00207578.2020.1810049
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Journal AbstractThis paper explores the therapeutic process between analyst and Josh, a trans man whose life had fallen apart after transition. Repetitive enactments involving hiding, deceiving and mystification constituted a prolonged therapeutic impasse. The analyst’s struggle with these binds and with countertransference confusion and anxiety, ultimately illuminated zones that had remained off-limits for a prolonged period of time. Where the couple had been snared in a bind structured by gender, they were now able to access a history of violation and to ask more profound questions about connection, aloneness, authenticity and loss.
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Entwistle, K. (2020). Debate: Reality check – Detransitioner’s testimonies require us to rethink gender dysphoria. Child and Adolescent Mental Health, camh.12380. https://doi.org/10.1111/camh.12380
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Journal AbstractButler and Hutchinson's clarion call (Butler and Hutchinson, 2020) for empirical research on desistance and detransition deserves careful consideration. It formally documents the needs of the emerging cohort of detransitioners, many of whom are in their teens and early twenties. In the absence of specialist services, some detransitioners have been sharing their experiences in public forums. The anecdotal reports by detransitioners indicate that systematic long-term follow-up of those who have been prescribed medical interventions by NHS and private clinics is essential to understanding the gestalt. Decision-making on the basis of misinformation on the effectiveness and necessity of medical interventions for gender dysphoria is a problem, and detransitioners indicate that nonmedical interventions for gender dysphoria are sorely needed. Analysis of the political and organisational systems that have brought us to the current situation is required in order to prevent more young people from being prescribed unnecessary medical interventions for gender dysphoria.
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Pazos Guerra, M., Gómez Balaguer, M., Gomes Porras, M., Hurtado Murillo, F., Solá Izquierdo, E., & Morillas Ariño, C. (2020). Transsexuality: Transitions, detransitions, and regrets in Spain. Endocrinología, Diabetes y Nutrición (English Ed.), 67(9), 562–567. https://doi.org/10.1016/j.endien.2020.03.005
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Journal AbstractIntroduction: Health care demand by transsexual people has recently increased, mostly at the expense of young and adolescents. The number of people who report a loss of or change in the former identity feeling (identity desistance) has also increased. While these are still a minority, we face more and more cases of transsexual people who ask for detransition and reversal of the changes achieved due to regret.
Objective: To report our experience with a group of transsexual people in detransition phase, and to analyze their personal experience and their associated conflicts. Material and methods: A cohort of 796 people with gender incongruence attending the Identity Gender Unit of Doctor Peset University Hospital from January 2008 to December 2018 was studied. Four of the eight documented cases of detransition and/or regret are reported as the most representative.
Results: Causes of detransition included identity desistance, non-binary gender variants, associated psicomorbidities, and confusion between sexual identity and sexual orientation.
Conclusion: Detransition is a growing phenomenon that implies clinical, psychological, and social issues. Inadequate evaluation and use of medicalization as the only means to improve gender dysphoria may lead to later detransition in some teenagers. Comprehensive care by a multidisciplinary and experienced team is essential. As there are no studies reporting the factors predictive of detransition, caution is recommended in cases of atypical identity courses.
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Levine, S. B. (2018). Transitioning Back to Maleness. Archives of Sexual Behavior, 47(4), 1295–1300. https://doi.org/10.1007/s10508-017-1136-9
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Journal AbstractThirty-one years after living full time as a woman, a 53-year-old skilled machinist returned to have therapy with me, a psychiatrist, because of a decision to return to living as a man. As our work together continued, I suggested to this would-be published novelist that others might benefit from his experience. This led to his posting an extensive account of his life in September 2016 on Gender Trender. Now living in good mental and physical health as a male, he has given me permission to discuss his initial presentation, my understanding of his motivations, and to reflect on the broader questions that his life rises for the field of transgenderism. This report describes regret, defenses against regret, and a dramatic 3-day catharsis followed by the patient’s first loving relationship. He now ironically reflects that he escaped from the sensed inauthenticity of his youthful maleness only to create a felt inauthentic feminine social psychological state. The professional literature about the long-term outcome of the transgendered who do not have surgery is largely nonexistent in English. Anecdotal accounts, however, are readily accessible on the Internet.
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Mature adult transitioners
D’Angelo, R. (2018). Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry, 26(5), 460–463. https://doi.org/10.1177/1039856218775216
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Journal AbstractOBJECTIVE: To reflect on the role of psychiatry in authorising physical treatments for Gender Dysphoria and to examine the quality of evidence for gender-reassignment.
METHOD: A Medline search was performed with the subject term "transsexualism" or "gender dysphoria" and "outcome" or "follow-up" in the title. Studies published from 2005 onwards reporting psychosocial outcomes were selected for review.
RESULTS: Most available evidence indicating positive outcomes for gender reassignment is of poor quality. The few studies with robust methodology suggest that some patients have poor outcomes and may be at risk of suicide.
CONCLUSION: The author raises questions about the implications for ethical treatment of transgender individuals.

SEGM Summary

The paper examines the unusually high patient drop-out rates in studies examining satisfaction with gender-affirming surgeries. This raises the possibility that patients who refuse to engage in follow-up research or lose contact with the gender clinics who treat them may have worse outcomes, and that failure to account for their outcomes may be masking a higher than claimed regret rates.

The paper highlights the following:

  • Smith et al. report that sex reassignment is effective, based on a study of 162 adults who had undergone [gender confirmation surgery]. They were able to obtain follow-up data from only 126 (78%) of subjects because a significant number were “untraceable” or had moved abroad.
  • De Cuypere et al. report that [gender confirmation surgery] is an effective treatment for transsexuals. Of 107 patients who had undergone [gender confirmation surgery] between 1986 and 2001, 30 (28%) could not be contacted and 15 (14%) refused to participate.
  • Johannson et al. reported good outcomes for [gender confirmation surgery]. Of 60 patients who had undergone [gender confirmation surgery], 42 (70%) agreed to participate in the follow up research. Of the non-participants, 1 had died of complications of [gender confirmation surgery], 8 could not be contacted and 9 refused to participate.
  • Salvador et al. reported that [gender confirmation surgery] has a positive effect on psychosocial functioning. Only 55 of the 69 patients (80%) could
    be contacted as 17 were lost to follow-up
  • Van de Grift et al. reported 94–96% of patients are satisfied with SRS and have good quality of life. A total of 546
    patients with Gender Dysphoria who had applied for [gender confirmation surgery] at clinics in Amsterdam, Hamburg and Ghent were contacted to
    complete an online survey. Only 201 (37%) responded and completed the survey.
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Wiepjes, C. M., Nota, N. M., de Blok, C. J. M., Klaver, M., de Vries, A. L. C., Wensing-Kruger, S. A., de Jongh, R. T., Bouman, M.-B., Steensma, T. D., Cohen-Kettenis, P., Gooren, L. J. G., Kreukels, B. P. C., & den Heijer, M. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972–2015): Trends in Prevalence, Treatment, and Regrets. The Journal of Sexual Medicine, 15(4), 582–590. https://doi.org/10.1016/j.jsxm.2018.01.016
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Journal AbstractBackground
Over the past decade, the number of people referred to gender identity clinics has rapidly increased. This raises several questions, especially concerning the frequency of performing gender-affirming treatments with irreversible effects and regret from such interventions.

Aim
To study the current prevalence of gender dysphoria, how frequently gender-affirming treatments are performed, and the number of people experiencing regret of this treatment.

Methods
The medical files of all people who attended our gender identity clinic from 1972 to 2015 were reviewed retrospectively.

Outcomes
The number of (and change in) people who applied for transgender health care, the percentage of people starting with gender-affirming hormonal treatment (HT), the estimated prevalence of transgender people receiving gender-affirming treatment, the percentage of people who underwent gonadectomy, and the percentage of people who regretted gonadectomy, specified separately for each year.

Results
6,793 people (4,432 birth-assigned male, 2,361 birth-assigned female) visited our gender identity clinic from 1972 through 2015. The number of people assessed per year increased 20-fold from 34 in 1980 to 686 in 2015. The estimated prevalence in the Netherlands in 2015 was 1:3,800 for men (transwomen) and 1:5,200 for women (transmen). The percentage of people who started HT within 5 years after the 1st visit decreased over time, with almost 90% in 1980 to 65% in 2010. The percentage of people who underwent gonadectomy within 5 years after starting HT remained stable over time (74.7% of transwomen and 83.8% of transmen). Only 0.6% of transwomen and 0.3% of transmen who underwent gonadectomy were identified as experiencing regret.

Clinical Implications
Because the transgender population is growing, a larger availability of transgender health care is needed. Other health care providers should familiarize themselves with transgender health care, because HT can influence diseases and interact with medication. Because not all people apply for the classic treatment approach, special attention should be given to those who choose less common forms of treatment.

Strengths and Limitations
This study was performed in the largest Dutch gender identity clinic, which treats more than 95% of the transgender population in the Netherlands. Because of the retrospective design, some data could be missing.

Conclusion
The number of people with gender identity issues seeking professional help increased dramatically in recent decades. The percentage of people who regretted gonadectomy remained small and did not show a tendency to increase.
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Dhejne, C., Öberg, K., Arver, S., & Landén, M. (2014). An Analysis of All Applications for Sex Reassignment Surgery in Sweden, 1960–2010: Prevalence, Incidence, and Regrets. Archives of Sexual Behavior, 43(8), 1535–1545. https://doi.org/10.1007/s10508-014-0300-8
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Journal AbstractIncidence and prevalence of applications in Sweden for legal and surgical sex reassignment were examined over a 50-year period (1960-2010), including the legal and surgical reversal applications. A total of 767 people (289 natal females and 478 natal males) applied for legal and surgical sex reassignment. Out of these, 89% (252 female-to-males [FM] and 429 male-to-females [MF]) received a new legal gender and underwent sex reassignment surgery (SRS). A total of 25 individuals (7 natal females and 18 natal males), equaling 3.3%, were denied a new legal gender and SRS. The remaining withdrew their application, were on a waiting list for surgery, or were granted partial treatment. The incidence of applications was calculated and stratified over four periods between 1972 and 2010. The incidence increased significantly from 0.16 to 0.42/100,000/year (FM) and from 0.23 to 0.73/100,000/year (MF). The most pronounced increase occurred after 2000. The proportion of FM individuals 30 years or older at the time of application remained stable around 30%. In contrast, the proportion of MF individuals 30 years or older increased from 37% in the first decade to 60% in the latter three decades. The point prevalence at December 2010 for individuals who applied for a new legal gender was for FM 1:13,120 and for MF 1:7,750. The FM:MF sex ratio fluctuated but was 1:1.66 for the whole study period. There were 15 (5 MF and 10 MF) regret applications corresponding to a 2.2% regret rate for both sexes. There was a significant decline of regrets over the time period.
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MacKinnon, K. R., Kia, H., Gould, W. A., Ross, L. E., Abramovich, A., Enxuga, G., & Lam, J. S. H. (2023). A typology of pathways to detransition: Considerations for care practice with transgender and gender diverse people who stop or reverse their gender transition. Psychology of Sexual Orientation and Gender Diversity. https://doi.org/10.1037/sgd0000678
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Journal AbstractResearch and care provider interest in gender detransition has grown in recent years, yet there are limited resources to clinically support the emerging population of transgender and gender diverse (TGD) people who stop or reverse their gender transition. Though some research and typologies exist to guide clinicians, no prior typologies are based upon the lived experiences and in-depth narratives of individuals who themselves have detransitioned. Drawing from the concept of transnormativity, the present study introduces a typology of four detransition pathways to address knowledge and practice gaps. Following constructivist grounded theory methodology, this typology was developed empirically by analyzing in-depth interview data gathered from 28 individuals living in Canada who experienced a change in self-conceptualized gender identity after initiating a transition and who ultimately detransitioned. Interviews were virtual, semi-structured, and ranged between 50 and 90 min. Following a thematic and constant comparative method of data analysis, the analysis discovered four discrete detransition subtypes: (a) discrimination and TGD identity repression; (b) gender-affirming hormone discontinuation and identity evolution; (c) binary transition to nonbinary detransition; and (d) detrans identity development within the social context. This article explicates how the broader sociocultural milieu can influence transnormative transition trajectories and identity development processes, and it discusses implications for practice with those who shift or reverse their gender transition.
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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
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MacKinnon, K. R., Kia, H., Salway, T., Ashley, F., Lacombe-Duncan, A., Abramovich, A., Enxuga, G., & Ross, L. E. (2022). Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments. JAMA Network Open, 5(7), e2224717. https://doi.org/10.1001/jamanetworkopen.2022.24717
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Journal AbstractOBJECTIVE: To examine the physical and mental health experiences of people who initiated medical or surgical detransition to inform clinical practice. DESIGN, SETTING, AND PARTICIPANTS Using constructivist grounded theory as a qualitative approach, data were collected in the form of in-depth interviews. Data were analyzed using an inductive 2-stage coding process to categorize and interpret detransition-related health care experiences to inform clinical practice. Between October 2021 and January 2022, individuals living in Canada who were aged 18 years and older with experience of stopping, shifting, or reversing a gender transition were invited to partake in semistructured virtual interviews. Study advertisements were circulated over social media, to clinicians, and within participants’ social networks. A purposive sample of 28 participants who discontinued, shifted, or reversed a gender transition were interviewed.

MAIN OUTCOMES AND MEASURES: In-depth, narrative descriptions of the physical and mental health experiences of people who discontinued or sought to reverse prior gender-affirming medical and/or surgical interventions.

RESULTS: Among the 28 participants, 18 (64%) were assigned female at birth and 10 (36%) were assigned male at birth; 2 (7%) identified as Jewish and White, 5 (18%) identified as having mixed race and ethnicity (which included Arab, Black, Indigenous, Latinx, and South Asian), and 21 (75%) identified as White. Participants initially sought gender-affirmation at a wide range of ages (15 [56%] were between ages 18 and 24 years). Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Participants reported divergent perspectives about their past gender-affirming medical or surgical treatments. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Medical detransition was often experienced as physically and psychologically challenging, yet health care avoidance was common. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs.

CONCLUSIONS AND RELEVANCE: This study’s results suggest that further research and clinical guidance is required to address the unmet needs of this population who discontinue or seek to reverse prior gender-affirming interventions.
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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. The Journal of Clinical Endocrinology & Metabolism, dgac251. https://doi.org/10.1210/clinem/dgac251
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Journal AbstractINTRODUCTION: Concerns about future regret and treatment discontinuation have led to restricted access to gender-affirming medical treatment for transgender and gender-diverse (TGD) minors in some jurisdictions. However, these concerns are merely speculative because few studies have examined gender-affirming hormone continuation rates among TGD individuals.

METHODS: We performed a secondary analysis of 2009 to 2018 medical and pharmacy records from the US Military Healthcare System. We identified TGD patients who were children and spouses of active-duty, retired, or deceased military members using International Classification of Diseases-9/10 codes. We assessed initiation and continuation of gender-affirming hormones using pharmacy records. Kaplan-Meier and Cox proportional hazard analyses estimated continuation rates.

RESULTS: The study sample included 627 transmasculine and 325 transfeminine individuals with an average age of 19.2 ± 5.3 years. The 4-year gender-affirming hormone continuation rate was 70.2% (95% CI, 63.9-76.5). Transfeminine individuals had a higher continuation rate than transmasculine individuals 81.0% (72.0%-90.0%) vs 64.4% (56.0%-72.8%). People who started hormones as minors had higher continuation rate than people who started as adults 74.4% (66.0%-82.8%) vs 64.4% (56.0%-72.8%). Continuation was not associated with household income or family member type. In Cox regression, both transmasculine gender identity (hazard ratio, 2.40; 95% CI, 1.50-3.86) and starting hormones as an adult (hazard ratio, 1.69; 95% CI, 1.14-2.52) were independently associated with increased discontinuation rates.

DISCUSSION: Our results suggest that >70% of TGD individuals who start gender-affirming hormones will continue use beyond 4 years, with higher continuation rates in transfeminine individuals. Patients who start hormones, with their parents’ assistance, before age 18 years have higher continuation rates than adults.
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Vandenbussche, E. (2021). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, 20. https://doi.org/10.1080/00918369.2021.1919479
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Journal AbstractThe aim of this study is to analyze the specific needs of detransi­ tioners from online detrans communities and discover to what extent they are being met. For this purpose, a cross-sectional online survey was conducted and gathered a sample of 237 male and female detransitioners. The results showed important psychological needs in relation to gender dysphoria, comorbid conditions, feelings of regret and internalized homophobic and sexist prejudices. It was also found that many detransitioners need medical support notably in relation to stopping/changing hormone therapy, surgery/treatment complications and rever­ sal interventions. Additionally, the results indicated the need for hearing about other detransitioners’ experiences and meeting each other. A major lack of support was reported by the respon­ dents overall, with a lot of negative experiences coming from medical and mental health systems and from the LGBT+ com­ munity. The study highlights the importance of increasing awareness and support given to detransitioners.
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Butler, C., & Hutchinson, A. (2020). Debate: The pressing need for research and services for gender desisters/detransitioners. Child and Adolescent Mental Health, 25(1), 45–47. https://doi.org/10.1111/camh.12361
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Journal AbstractThe number of people presenting at gender clinics is increasing worldwide. Many people undergo a gender transition with subsequent improved psychological well-being (Paediatrics, 2014, 134, 696). However, some people choose to stop this journey, ‘desisters’, or to reverse their transition, ‘detransitioners’. It has been suggested that some professionals and activists are reluctant to acknowledge the existence of desisters and detransitioners, possibly fearing that they may delegitimize persisters’ experiences (International Journal of Transgenderism, 2018, 19, 231). Certainly, despite their presence in all follow-up studies of young people who have experienced gender dysphoria (GD), little thought has been given to how we might support this cohort. Levine (Archives of Sexual Behaviour, 2017, 47, 1295) reports that the 8th edition of the WPATH Standards of Care will include a section on detransitioning – confirming that this is an increasingly witnessed phenomenon worldwide. It also highlights that compared to the extensive protocols for working with children, adolescents and adults who wish to transition, nothing exists for those working with desisters or detransitioners. With very little research and no clear guidance on how to work with this population, and with numbers of referrals to gender services increasing, this is a timely juncture to consider factors that should be taken into account within clinical settings and areas for future research.
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Zucker, K. J. (2018). The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender non-conforming children” by Temple Newhook et al. (2018). International Journal of Transgenderism, 19(2), 231–245. https://doi.org/10.1080/15532739.2018.1468293
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Journal AbstractTemple Newhook et al. (2018) provide a critique of recent follow-up studies of children referred to specialized gender identity clinics, organized around rates of persistence and desistance. The critical gaze of Temple Newhook et al. examined three primary issues: (1) the terms persistence and desistance in their own right; (2) methodology of the follow-up studies and interpretation of the data; and (3) ethical matters. In this response, I interrogate the critique of Temple Newhook et al. (2018).
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Ristori, J., & Steensma, T. D. (2016). Gender dysphoria in childhood. International Review of Psychiatry, 28(1), 13–20. https://doi.org/10.3109/09540261.2015.1115754
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Journal AbstractGender dysphoria (GD) in childhood is a complex phenomenon characterized by clinically significant distress due to the incongruence between assigned gender at birth and experienced gender. The clinical presentation of children who present with gender identity issues can be highly variable; the psychosexual development and future psychosexual outcome can be unclear, and consensus about the best clinical practice is currently under debate.

In this paper a clinical picture is provided of children who are referred to gender identity clinics. The clinical criteria are described including what is known about the prevalence of childhood GD. In addition, an overview is presented of the literature on the psychological functioning of children with GD, the current knowledge on the psychosexual development and factors associated with the persistence of GD, and explanatory models for psychopathology in children with GD together with other co-existing problems that are characteristic for children referred for their gender. In light of this, currently used treatment and counselling approaches are summarized and discussed, including the integration of the literature detailed above.
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Dhejne, C., Öberg, K., Arver, S., & Landén, M. (2014). An Analysis of All Applications for Sex Reassignment Surgery in Sweden, 1960–2010: Prevalence, Incidence, and Regrets. Archives of Sexual Behavior, 43(8), 1535–1545. https://doi.org/10.1007/s10508-014-0300-8
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Journal AbstractIncidence and prevalence of applications in Sweden for legal and surgical sex reassignment were examined over a 50-year period (1960-2010), including the legal and surgical reversal applications. A total of 767 people (289 natal females and 478 natal males) applied for legal and surgical sex reassignment. Out of these, 89% (252 female-to-males [FM] and 429 male-to-females [MF]) received a new legal gender and underwent sex reassignment surgery (SRS). A total of 25 individuals (7 natal females and 18 natal males), equaling 3.3%, were denied a new legal gender and SRS. The remaining withdrew their application, were on a waiting list for surgery, or were granted partial treatment. The incidence of applications was calculated and stratified over four periods between 1972 and 2010. The incidence increased significantly from 0.16 to 0.42/100,000/year (FM) and from 0.23 to 0.73/100,000/year (MF). The most pronounced increase occurred after 2000. The proportion of FM individuals 30 years or older at the time of application remained stable around 30%. In contrast, the proportion of MF individuals 30 years or older increased from 37% in the first decade to 60% in the latter three decades. The point prevalence at December 2010 for individuals who applied for a new legal gender was for FM 1:13,120 and for MF 1:7,750. The FM:MF sex ratio fluctuated but was 1:1.66 for the whole study period. There were 15 (5 MF and 10 MF) regret applications corresponding to a 2.2% regret rate for both sexes. There was a significant decline of regrets over the time period.
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Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry, 52(6), 582–590. https://doi.org/10.1016/j.jaac.2013.03.016
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Journal AbstractOBJECTIVE: To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence.
METHOD: The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence.
RESULTS: We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls.
CONCLUSION: Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.
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Fewer Studies
E. Psychotherapy
Older studies
Hakeem, A. (2012). Psychotherapy for gender identity disorders. Advances in Psychiatric Treatment, 18(1), 17–24. https://doi.org/10.1192/apt.bp.111.009431
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Journal AbstractThis article describes a special adaptation of group psychotherapy as a psychological treat­ ment for people with a variety of gender identity disorders. It can be used as an alternative to or concurrently with hormonal and/or surgical interventions for transgender people. It is also suit­able for individuals whose gender identity disorder remains after physical interventions.

The article draws from a UK specialist pilot for such a treatment service and describes the explicit aims of the psychotherapy, the specialist adaptation of therapeutic technique required and observed thematic features relevant to working in this specific field.
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Meyer-Bahlburg, H. F. L. (2002). Gender Identity Disorder in Young Boys: A Parent- and Peer-Based Treatment Protocol. Clinical Child Psychology and Psychiatry, 7(3), 360–376. https://doi.org/10.1177/1359104502007003005
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Journal AbstractGender identity disorder (GID) as a psychiatric category is currently under debate. Because of the psychosocial consequences of childhood GID and the fact that childhood GID, in most cases, appears to have faded by the time of puberty, we think that a cost-effective treatment approach that speeds up the fading process would be beneficial.

Our treatment approach is informed by the known psychosocial factors and mechanisms that contribute to gender identity development in general, and focuses on the interaction of the child with the parents and with the same-gender peer group.

To minimize the child’s stigmatization, only the parents come to treatment sessions. A review of a consecutive series of 11 families of young boys with GID so treated shows a high rate of success with a relatively low number of sessions. We conclude that this treatment approach holds considerable promise as a cost-effective procedure for families in which both parents are present.
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Cohen-Kettenis, P., & Kuiper, B. (1984). Transexuality and psychotherapy. Tijdschrift Voor Psychotherapie. https://www.semanticscholar.org/paper/Transexuality-and-psychotherapy-Cohen-Kettenis-Kuiper/25337c85366442c712c4c11528f7ca2925890b7e?sort=relevance&pdf=true
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Journal AbstractIn this article, the effects of sex reassignment surgery and of psychotherapy are compared. As opposed to the contentions of some advocates of psychotherapy, no disqualifications of sex reassignment surgery have been encountered.

The authors argue that more attention should be paid to the possibilities of psychotherapy, and expect that its most important contributions are to be found in the treatment of those who have doubts concerning their gender identity or the sex reassignment procedure, and in extra support of those undergoing medical treatment.
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Lothstein, L. M., & Levine, S. B. (1981). Expressive Psychotherapy With Gender Dysphoric Patients. Archives of General Psychiatry, 38(8), 924. https://doi.org/10.1001/archpsyc.1981.01780330082009
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Journal AbstractThe dictum that transsexualism is resistant to psychotherapy has led many investigators to view sex reassignment surgery (SRS) as the treatment of choice and dismiss psychotherapy as unfeasible. The Gender Identity Clinic at Case Western Reserve University, Cleveland, was organized to treat transsexuals with individual and group psychotherapy and SRS.

Of 50 gender dysphoric (GD) patients, 70% have adjusted to nonsurgical solutions, 20% are receiving treatment, and 10% have received SRS and psychotherapy. The crux of psychotherapy is establishing a therapeutic alliance; this is aided by the context of the Gender Identity Clinic.

Clinical evidence suggests that new therapeutic techniques may enable psychotherapy to become the treatment of choice with most GD patients and that psychotherapy and SRS are not mutually exclusive. Most patients request and benefit from psychotherapy after SRS.
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Levine, S. B., & Lothstein, L. (1981). Transsexualism or the Gender Dysphoria Syndromes. Journal of Sex & Marital Therapy, 7(2), 85–113. https://doi.org/10.1080/00926238108406096
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Journal AbstractProfessional, patient and media forces tend to oversimplify the complexity of the gender dysphoria syndromes. Because sex reassignment surgery may be helpful to some patients with the syndrome and harmful to others, mental health professionals need to competently perform differential diagnoses of both the gender disorder and the associated psychopathologies. This frequently involves distinctions between subtle forms of psychosis, character pathologies of varying severity, and major developmental problems.

Surgery should not be considered the only, or the best, treatment for the syndrome. Contrary to popular belief, psychotherapy can help many patients, especially those with secondary gender dysphoria.
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More Studies
Morgan, A. J. (1978). Psychotherapy for transsexual candidates screened out of surgery. Archives of Sexual Behavior, 7(4), 273–283. https://doi.org/10.1007/BF01542035
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Davenport, C. W., & Harrison, S. I. (1977). Gender identity change in a female adolescent transsexual. Archives of Sexual Behavior, 6(4), 327–340. https://doi.org/10.1007/BF01541204
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Journal AbstractTwo years of individual and milieu therapy are described of a 14 1/2-year-old girl who had presented with the persistent request to have a sex-change operation since age 12. Her past history was obtained from her parents and the records of the child guidance clinic which evaluated her at 3 years of age. She gives a history of remarkable tomboyism during her latency years and increasing withdrawal from peers and family during early adolescence.

The patient's personal and family dynamics are explored, and these major therapeutic themes are discussed. The individual and milieu therapy are described and discussed with some speculation about the reasons for her positive response to psychotherapy. It would appear that this is a rare case of a postpubertal female transsexual reported to have made a gender identity change.
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Kirkpatrick, M., & Friedmann, C. (1976). Treatment of requests for sex-change surgery with psychotherapy. American Journal of Psychiatry, 133(10), 1194–1196. https://doi.org/10.1176/ajp.133.10.1194
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Journal AbstractThe authors describe two patients whose requests for sex-change surgery represented crises in sexual identity and anxiety-masking symptoms. Brief psychotherapy enabled these patients to relinquish their belief in a surgical "cure".

In evaluating such request, the psychiatrist should consider the patient's total personality rather than focusing on the genuineness of the perceived gender disorder. Whatever the final decision, the opportunity for continued psychotherapy should be provided.
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Fewer Studies
Recently-presenting cases
Evans, M. (2022). ‘If only I were a boy …’: Psychotherapeutic Explorations of Transgender in Children and Adolescents. British Journal of Psychotherapy, 38(2), 269–285. https://doi.org/10.1111/bjp.12733
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Journal AbstractThis paper is based on the author’s experience of working with a particular group of female/male trans children and young people who present a similar clinical profile: a fragile ego prone to fragmentation and concrete thinking. Often, there is evidence of a grievance over the failed ideal object, which is internalized, projected into the body, and then attacked. Faced with the developmental challenge of sexuality at puberty, young adults withdraw to a psychic retreat designed to halt development. This paper focuses on the development of a trans identity in defence against an underlying fear of depressive anxieties and psychic collapse. It describes the ongoing assessment of Joanne, a 19-year-old biological female who wanted to be known as Luke in therapy and wished to transition in the belief that this was the only way she could have a life. The concrete nature of Joanne’s thinking created problems in the therapy, as thoughts were often experienced as physical actions. This paper describes the function of the phantasy that transitioning performs in creating a psychic retreat from the demands of psychological development.
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Schwartz, D. (2021). Clinical and Ethical Considerations in the Treatment of Gender Dysphoric Children and Adolescents: When Doing Less Is Helping More. Journal of Infant, Child, and Adolescent Psychotherapy, 1–11. https://doi.org/10.1080/15289168.2021.1997344
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Journal AbstractThrough an analysis of recently published treatment protocols, research findings and clinical experience, and guided by the principle of “first, do no harm,” the author argues that the use of pharmacological and surgical interventions in the treatment of gender dysphoric youth, especially in light of what is known about the transience of cross-gender identification in children, is mistaken both clinically and ethically. He further argues that psychotherapy, neglected by most of those advocating pharmacological and surgical interventions, is the best treatment option for these patients. The author elaborates some of the modifications of psychotherapeutic technique with both patients and their parents that he has found to be most effective with this population.
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D’Angelo, R., Syrulnik, E., Ayad, S., Marchiano, L., Kenny, D. T., & Clarke, P. (2020). One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-020-01844-2
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D’Angelo, R. (2020). The man I am trying to be is not me. The International Journal of Psychoanalysis, 101(5), 951–970. https://doi.org/10.1080/00207578.2020.1810049
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Journal AbstractThis paper explores the therapeutic process between analyst and Josh, a trans man whose life had fallen apart after transition. Repetitive enactments involving hiding, deceiving and mystification constituted a prolonged therapeutic impasse. The analyst’s struggle with these binds and with countertransference confusion and anxiety, ultimately illuminated zones that had remained off-limits for a prolonged period of time. Where the couple had been snared in a bind structured by gender, they were now able to access a history of violation and to ask more profound questions about connection, aloneness, authenticity and loss.
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D’Angelo, R. (2020). The complexity of childhood gender dysphoria. Australasian Psychiatry, 28(5), 530–532. https://doi.org/10.1177/1039856220917076
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Journal AbstractOBJECTIVE: To explore a developmental understanding of childhood gender dysphoria and to compare it to the prevailing paradigm, gender-affirming care.

CONCLUSION: Viewing gender dysphoria through a contemporary developmental frame generates a different understanding of the nature of the phenomenon and its treatment and raises ethical questions about our current gender-affirming approach.
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More Studies
Withers, Robert. (2020). Transgender medicalization and the attempt to evade psychological distress. Journal of Analytical Psychology, 65(5), 865–889. https://onlinelibrary.wiley.com/doi/10.1111/1468-5922.12641
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Journal AbstractIn this paper the author argues that trans-identification and its associated medical treatment can constitute an attempt to evade experiences of psychological distress. This occurs on three levels. Firstly, the trans person themselves may seek to evade dysregulated affects associated with such experiences as attachment trauma, childhood abuse, and ego-alien sexual feelings. Secondly, therapists may attempt to evade feelings, such as fear and hatred, evoked by engaging with these dysregulated affects. Thirdly, we, as a society, may wish to evade acknowledging the reality of such trauma, abuse and sexual distress by hypothesizing that trans-identification is a biological issue, best treated medically. The author argues that the quality of evidence supporting the biomedical approach is extremely poor. This puts young trans people at risk of receiving potentially damaging medical treatment they may later seek to reverse or come to regret, while their underlying psychological issues remain unaddressed.
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Sevlever, M., & Meyer-Bahlburg, H. F. L. (2019). Late-Onset Transgender Identity Development of Adolescents in Psychotherapy for Mood and Anxiety Problems: Approach to Assessment and Treatment. Archives of Sexual Behavior, 48(7), 1993–2001. https://doi.org/10.1007/s10508-018-1362-9
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Journal AbstractThe rate of adolescents with gender-nonconforming behavior and/or gender dysphoria seeking mental health care has dramatically increased in the past decade. Many of these youths also present with co-occurring psychiatric problems, including depression, anxiety, suicidality, substance use, and others. This combination may generate a complex clinical picture that challenges the ability of clinicians to accurately diagnose gender distress and develop suitable treatment recommendations. This article illustrates those challenges with two adolescent patients who developed late-onset gender dysphoria in the course of long-term mental health care for diverse psychiatric problems preceding the emergence of gender dysphoria. One underwent full progression from gender dysphoria as a male through social and medical transition to female, the other a less definitive progression from gender dysphoria as female through social transition to male without deciding for any medical treatment. The report provides details on the assessment procedures and the resulting findings, the rationale for treatment recommendations, and short-term follow-up information.
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Churcher Clarke, A., & Spiliadis, A. (2019). ‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties. Clinical Child Psychology and Psychiatry, 24(2), 338–352. https://doi.org/10.1177/1359104518825288
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Journal AbstractAs the number of young people referred to specialist gender identity clinics in the western world increases, there is a need to examine ways of making sense of the range and diversity of their developmental pathways and outcomes. This article presents a joint case review of the authors caseloads over an 18-month period, to identify and describe those young people who presented to the Gender Identity Development Service (GIDS) with gender dysphoria (GD) emerging in adolescence, and who, during the course of assessment, ceased wishing to pursue medical (hormonal) interventions and/or who arrived at a different understanding of their embodied distress.

From the 12 cases identified, 2 case vignettes are presented. Implications for the development of clinical practice, service delivery and research are considered.
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Spiliadis, A. (2019). Towards a gender exploratory model: Slowing things down, opening things up and exploring identity development. Metalogos Systemic Therapy Journal, 35, 1–9. https://www.researchgate.net/publication/334559847_Towards_a_Gender_Exploratory_Model_slowing_things_down_opening_things_up_and_exploring_identity_development
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Journal AbstractThroughout the western world, the care of children and adolescents whose sexed corporeality is at odds with their gender-related feelings raises medical, psychological, and ethical dilemmas. There are currently differing views around what constitutes responsive and timely support for these young people and how professionals can operate within a rapidly shifting and contested field, in which evidence-base is scarce. In this article I aim to reposition the theoretical framework away from ‘affirmative’ or ‘reparative’ polarities, arguing that both can be problematic, and to invite the reader into a Gender Exploratory Model (GEM) grounded in a systemic-developmental framework; such a model acknowledges and often embraces the notion of uncertainty with regards to young people’s developmental trajectories and clinician’s ‘unknown unknowns’ and exploratory responsibilities. A short introduction to the service (GIDS), as well as a presentation of the current theoretical and clinical debates, will offer a contextual base for clinicians supporting young people experiencing gender dysphoria. This is not an attempt to explore the multifactorial aetiology of gender dysphoria but rather one to add on the theoretical underpinning of therapeutic approaches in supporting these young people.
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Lemma, A. (2018). Trans-itory identities: some psychoanalytic reflections on transgender identities. The International Journal of Psychoanalysis, 99(5), 1089–1106. https://doi.org/10.1080/00207578.2018.1489710
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Journal AbstractThe capacity of transgender to incorporate all gender variance and sexual preferences has become a powerful tool of activism and personal identification. Rather than being an index of marginality “trans” has become a central cultural site. In this paper, I will argue that this identity label encompasses a complex range of internal psychic positions in relation to consciously stated sexual preferences and gender identifications. My aim is to explore what can appear to be in some cases a premature embracement of the empowering potential of the transgender identification through my work with under 18-year-olds who are seeking medical intervention for gender dysphoria. This can undermine the painful psychic work required to establish what transgender means for any given young person. In an external culture where to ask “why transgender” (as opposed to “how transgender”) is felt to be pathologising, working with these young people can prove difficult for the analyst. The challenge is to tread the fine line between a dialogue based on an equidistant curiosity about meaning and function that is core to an analytic approach, and a posture of implicit skepticism.
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Bonfatto, M., & Crasnow, E. (2018). Gender/ed identities: an overview of our current work as child psychotherapists in the Gender Identity Development Service. Journal of Child Psychotherapy, 44(1), 29–46. https://doi.org/10.1080/0075417X.2018.1443150
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Journal AbstractThis paper is adapted from a presentation first given at the 2017 Association of Child Psychotherapists (ACP) Conference. We hope to give a feel of our work as psychoanalytic child psychotherapists working in a Tier 4 national assessment service for gender variant children and connect with our colleagues working therapeutically with these families in Child and Adolescent Mental Health Services (CAMHS) and other settings.

Gender variance does not have a single cause, or straightforward developmental pathway; rather it is a complex interplay of multiple factors, akin to sexuality in the diverse manifestations and ‘tributaries’ taken. This paper is given as a plea for complexity, to counter the current intense focus on gender identity and the consequent reductionism this can lead to.

To this end, three case studies from the clinic, taken from Under Five, Latency and Adolescent phases of development, are explored. The complexity of the cases is then discussed, followed by parallel issues of development, divergence and difference. These three ‘average’ cases from the Gender Identity Development Services (GIDS) serve to demonstrate the need for child psychotherapy as part of multi-disciplinary thinking about gender variance and how attention must be maintained to each unique story and process of identity development; as well as our clinical task to establish and encourage depressive functioning and secondary processes where possible.
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Parkinson, J. (2014). Gender dysphoria in Asperger’s syndrome: a caution. Australasian Psychiatry, 22(1), 84–85. https://doi.org/10.1177/1039856213497814
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Journal AbstractObjective:
The incidence of Asperger’s syndrome is reported as above average in young people presenting with gender dysphoria. Patients with Asperger’s syndrome, however, are prone to obsessive preoccupations. This paper points out that the apparent dysphoria may in some cases prove to be a transient obsession.

Method:
Cases from the author’s clinical practice were reviewed.

Results:
Two young men with histories suggesting Asperger’s syndrome presented with strong convictions of gender dysphoria, asking for hormonal and surgical treatment. Treatment was withheld and after several years both came to repudiate their ’transgender phase’.

Conclusions:
Patients asking for sex reassignment should be assessed for indications of Asperger’s syndrome. Irreversible treatments should be withheld until it is clear there is a genuine issue of transsexualism.
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Le Roux, N. (n.d.). GENDER VARIANCE IN CHILDHOOD/ADOLESCENCE: GENDER IDENTITY JOURNEYS NOT INVOLVING PHYSICAL INTERVENTION [University of East London]. https://repository.uel.ac.uk/item/85vvw
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Journal AbstractMuch of the current literature on gender-variant children and young people focuses on aetiology and developmental outcomes in adolescence, whereas their developmental experiences have been neglected. Furthermore, there is little understanding about the experiences of gender-variant youth for whom gender reassignment does not offer a straightforward solution.
This qualitative study interviewed 10 gender-variant young people (Mean age = 20; range 17-27) who were not actively pursuing gender reassignment. The aim was to gain a better understanding of the developmental process of their gender identity development and how they made sense of their gender variance; the challenges that they faced; the resources that they drew upon; and what is important to them. A grounded theory methodology was adopted.
The period between the approximate ages of 9 and 14 years was identified as crucial in their gender identity development and as a significant developmental challenge. A widening social gap between male and female gender roles and an emergent homosexual identity influenced how they made sense of their gender-variant expression and their bodily development, which in turn was situated within a context of widespread social exclusion. This promoted a profound lack of social belonging, which for most translated into a sense of not belonging in their bodies. A transgender identity afforded social membership, but brought with it a variety of challenges. A range of gender identities and views on gender reassignment were identified, that do not neatly fit into current conceptions of desisting and persisting gender dysphoria. Education on gender variance within the public, educational and health domain was an important priority for the participants. The findings of this study contribute to our understanding of the developmental trajectories of gender variant youth. It also intimates a number of recommendations for future research and clinical practice.
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Fewer Studies
D’Angelo, R. (2023). Supporting autonomy in young people with gender dysphoria: psychotherapy is not conversion therapy. Journal of Medical Ethics, jme-2023-109282. https://doi.org/10.1136/jme-2023-109282
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Journal AbstractOpinion is divided about the certainty of the evidence base for gender-affirming medical interventions in youth. Proponents claim that these treatments are well supported, while critics claim the poor-quality evidence base warrants extreme caution. Psychotherapy is one of the only available alternatives to the gender-affirming approach. Discussion of the treatment of gender dysphoria in young people is generally framed in terms of two binary approaches: affirmation or conversion. Psychotherapy/exploratory therapy offers a treatment option that lies outside this binary, although it is mistakenly conflated with conversion therapies. Psychotherapy does not impose restrictive gender stereotypes, as is sometimes claimed, but critically examines them. It empowers young people to develop creative solutions to their difficulties and promotes agency and autonomy. Importantly, an exploratory psychotherapeutic process can help to clarify whether gender dysphoria is a carrier for other psychological or social problems that may not be immediately apparent. Psychotherapy can therefore make a significant contribution to the optimal, ethical care of gender-dysphoric young people by ensuring that patients make appropriate, informed decisions about medical interventions which carry risks of harm and have a contested evidence base.
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Pilgrim, D. (2023). British mental healthcare responses to adult homosexuality and gender non-conforming children at the turn of the twenty-first century. History of Psychiatry, 0957154X231181461. https://doi.org/10.1177/0957154X231181461
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Journal AbstractThe roots of the recent controversy about how mental health professionals should respond to gender nonconforming children are traced. To make historical sense, this paper distinguishes between epistemological (discursive) and ontological (non-discursive) aspects and describes their features, since 1970. This helps to clarify some of the confusions at the centre of the still heated debate about sexuality and gender identity today. In the concluding discussion, the philosophical resource of critical realism is used to interpret the historical narrative provided. It cautions against the anachronistic tendency to amalgamate the shortlived, and now defunct, experiment of aversion therapy for homosexuality with more recent defences of exploratory psychotherapy. The latter have challenged a different form of experimentation: the biomedicalisation of gender non-conforming children.
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Evans, M. (2023). Assessment and treatment of a gender-dysphoric person with a traumatic history. Journal of Child Psychotherapy, 1–16. https://doi.org/10.1080/0075417X.2023.2172741
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Journal AbstractThis paper presents a composite case based on a group of female-tomale transitioners with a history of trauma due to early separation or family illness. These early traumas may interfere with the process of integrating the mind and body. Symptoms of gender dysphoria often arise from, or increase in response to, subsequent separations later in life, as individuals transition from childhood to adulthood. Increased referrals to gender clinics are noted at puberty or the point of separation from the family, as individuals face the prospect of leaving home to go to university. Affected by anxieties associated with the onset of puberty or separation anxieties, these individuals sometimes seek a medical transition to gain control over their bodies. Exploring underlying psychoanalytic issues can help clinicians assess various conscious and unconscious influences, and help patients make more informed decisions on whether to pursue a medical transition. A focus on defence mechanisms and forms of thinking can help clinicians find ways of working with individuals who may be highly defensive and concrete in their thinking and feel threatened by the functioning of their minds.
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Evans, M. (2022). ‘If only I were a boy …’: Psychotherapeutic Explorations of Transgender in Children and Adolescents. British Journal of Psychotherapy, 38(2), 269–285. https://doi.org/10.1111/bjp.12733
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Journal AbstractThis paper is based on the author’s experience of working with a particular group of female/male trans children and young people who present a similar clinical profile: a fragile ego prone to fragmentation and concrete thinking. Often, there is evidence of a grievance over the failed ideal object, which is internalized, projected into the body, and then attacked. Faced with the developmental challenge of sexuality at puberty, young adults withdraw to a psychic retreat designed to halt development. This paper focuses on the development of a trans identity in defence against an underlying fear of depressive anxieties and psychic collapse. It describes the ongoing assessment of Joanne, a 19-year-old biological female who wanted to be known as Luke in therapy and wished to transition in the belief that this was the only way she could have a life. The concrete nature of Joanne’s thinking created problems in the therapy, as thoughts were often experienced as physical actions. This paper describes the function of the phantasy that transitioning performs in creating a psychic retreat from the demands of psychological development.
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D’Angelo, R., Syrulnik, E., Ayad, S., Marchiano, L., Kenny, D. T., & Clarke, P. (2020). One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-020-01844-2
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D’Angelo, R. (2020). The complexity of childhood gender dysphoria. Australasian Psychiatry, 28(5), 530–532. https://doi.org/10.1177/1039856220917076
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Journal AbstractOBJECTIVE: To explore a developmental understanding of childhood gender dysphoria and to compare it to the prevailing paradigm, gender-affirming care.

CONCLUSION: Viewing gender dysphoria through a contemporary developmental frame generates a different understanding of the nature of the phenomenon and its treatment and raises ethical questions about our current gender-affirming approach.
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Sevlever, M., & Meyer-Bahlburg, H. F. L. (2019). Late-Onset Transgender Identity Development of Adolescents in Psychotherapy for Mood and Anxiety Problems: Approach to Assessment and Treatment. Archives of Sexual Behavior, 48(7), 1993–2001. https://doi.org/10.1007/s10508-018-1362-9
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Journal AbstractThe rate of adolescents with gender-nonconforming behavior and/or gender dysphoria seeking mental health care has dramatically increased in the past decade. Many of these youths also present with co-occurring psychiatric problems, including depression, anxiety, suicidality, substance use, and others. This combination may generate a complex clinical picture that challenges the ability of clinicians to accurately diagnose gender distress and develop suitable treatment recommendations. This article illustrates those challenges with two adolescent patients who developed late-onset gender dysphoria in the course of long-term mental health care for diverse psychiatric problems preceding the emergence of gender dysphoria. One underwent full progression from gender dysphoria as a male through social and medical transition to female, the other a less definitive progression from gender dysphoria as female through social transition to male without deciding for any medical treatment. The report provides details on the assessment procedures and the resulting findings, the rationale for treatment recommendations, and short-term follow-up information.
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Churcher Clarke, A., & Spiliadis, A. (2019). ‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties. Clinical Child Psychology and Psychiatry, 24(2), 338–352. https://doi.org/10.1177/1359104518825288
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Journal AbstractAs the number of young people referred to specialist gender identity clinics in the western world increases, there is a need to examine ways of making sense of the range and diversity of their developmental pathways and outcomes. This article presents a joint case review of the authors caseloads over an 18-month period, to identify and describe those young people who presented to the Gender Identity Development Service (GIDS) with gender dysphoria (GD) emerging in adolescence, and who, during the course of assessment, ceased wishing to pursue medical (hormonal) interventions and/or who arrived at a different understanding of their embodied distress.

From the 12 cases identified, 2 case vignettes are presented. Implications for the development of clinical practice, service delivery and research are considered.
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Spiliadis, A. (2019). Towards a gender exploratory model: Slowing things down, opening things up and exploring identity development. Metalogos Systemic Therapy Journal, 35, 1–9. https://www.researchgate.net/publication/334559847_Towards_a_Gender_Exploratory_Model_slowing_things_down_opening_things_up_and_exploring_identity_development
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Journal AbstractThroughout the western world, the care of children and adolescents whose sexed corporeality is at odds with their gender-related feelings raises medical, psychological, and ethical dilemmas. There are currently differing views around what constitutes responsive and timely support for these young people and how professionals can operate within a rapidly shifting and contested field, in which evidence-base is scarce. In this article I aim to reposition the theoretical framework away from ‘affirmative’ or ‘reparative’ polarities, arguing that both can be problematic, and to invite the reader into a Gender Exploratory Model (GEM) grounded in a systemic-developmental framework; such a model acknowledges and often embraces the notion of uncertainty with regards to young people’s developmental trajectories and clinician’s ‘unknown unknowns’ and exploratory responsibilities. A short introduction to the service (GIDS), as well as a presentation of the current theoretical and clinical debates, will offer a contextual base for clinicians supporting young people experiencing gender dysphoria. This is not an attempt to explore the multifactorial aetiology of gender dysphoria but rather one to add on the theoretical underpinning of therapeutic approaches in supporting these young people.
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Lemma, A. (2018). Trans-itory identities: some psychoanalytic reflections on transgender identities. The International Journal of Psychoanalysis, 99(5), 1089–1106. https://doi.org/10.1080/00207578.2018.1489710
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Journal AbstractThe capacity of transgender to incorporate all gender variance and sexual preferences has become a powerful tool of activism and personal identification. Rather than being an index of marginality “trans” has become a central cultural site. In this paper, I will argue that this identity label encompasses a complex range of internal psychic positions in relation to consciously stated sexual preferences and gender identifications. My aim is to explore what can appear to be in some cases a premature embracement of the empowering potential of the transgender identification through my work with under 18-year-olds who are seeking medical intervention for gender dysphoria. This can undermine the painful psychic work required to establish what transgender means for any given young person. In an external culture where to ask “why transgender” (as opposed to “how transgender”) is felt to be pathologising, working with these young people can prove difficult for the analyst. The challenge is to tread the fine line between a dialogue based on an equidistant curiosity about meaning and function that is core to an analytic approach, and a posture of implicit skepticism.
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Hakeem, A. (2012). Psychotherapy for gender identity disorders. Advances in Psychiatric Treatment, 18(1), 17–24. https://doi.org/10.1192/apt.bp.111.009431
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Journal AbstractThis article describes a special adaptation of group psychotherapy as a psychological treat­ ment for people with a variety of gender identity disorders. It can be used as an alternative to or concurrently with hormonal and/or surgical interventions for transgender people. It is also suit­able for individuals whose gender identity disorder remains after physical interventions.

The article draws from a UK specialist pilot for such a treatment service and describes the explicit aims of the psychotherapy, the specialist adaptation of therapeutic technique required and observed thematic features relevant to working in this specific field.
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Meyer-Bahlburg, H. F. L. (2002). Gender Identity Disorder in Young Boys: A Parent- and Peer-Based Treatment Protocol. Clinical Child Psychology and Psychiatry, 7(3), 360–376. https://doi.org/10.1177/1359104502007003005
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Journal AbstractGender identity disorder (GID) as a psychiatric category is currently under debate. Because of the psychosocial consequences of childhood GID and the fact that childhood GID, in most cases, appears to have faded by the time of puberty, we think that a cost-effective treatment approach that speeds up the fading process would be beneficial.

Our treatment approach is informed by the known psychosocial factors and mechanisms that contribute to gender identity development in general, and focuses on the interaction of the child with the parents and with the same-gender peer group.

To minimize the child’s stigmatization, only the parents come to treatment sessions. A review of a consecutive series of 11 families of young boys with GID so treated shows a high rate of success with a relatively low number of sessions. We conclude that this treatment approach holds considerable promise as a cost-effective procedure for families in which both parents are present.
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Lothstein, L. M., & Levine, S. B. (1981). Expressive Psychotherapy With Gender Dysphoric Patients. Archives of General Psychiatry, 38(8), 924. https://doi.org/10.1001/archpsyc.1981.01780330082009
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Journal AbstractThe dictum that transsexualism is resistant to psychotherapy has led many investigators to view sex reassignment surgery (SRS) as the treatment of choice and dismiss psychotherapy as unfeasible. The Gender Identity Clinic at Case Western Reserve University, Cleveland, was organized to treat transsexuals with individual and group psychotherapy and SRS.

Of 50 gender dysphoric (GD) patients, 70% have adjusted to nonsurgical solutions, 20% are receiving treatment, and 10% have received SRS and psychotherapy. The crux of psychotherapy is establishing a therapeutic alliance; this is aided by the context of the Gender Identity Clinic.

Clinical evidence suggests that new therapeutic techniques may enable psychotherapy to become the treatment of choice with most GD patients and that psychotherapy and SRS are not mutually exclusive. Most patients request and benefit from psychotherapy after SRS.
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Levine, S. B., & Lothstein, L. (1981). Transsexualism or the Gender Dysphoria Syndromes. Journal of Sex & Marital Therapy, 7(2), 85–113. https://doi.org/10.1080/00926238108406096
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Journal AbstractProfessional, patient and media forces tend to oversimplify the complexity of the gender dysphoria syndromes. Because sex reassignment surgery may be helpful to some patients with the syndrome and harmful to others, mental health professionals need to competently perform differential diagnoses of both the gender disorder and the associated psychopathologies. This frequently involves distinctions between subtle forms of psychosis, character pathologies of varying severity, and major developmental problems.

Surgery should not be considered the only, or the best, treatment for the syndrome. Contrary to popular belief, psychotherapy can help many patients, especially those with secondary gender dysphoria.
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Morgan, A. J. (1978). Psychotherapy for transsexual candidates screened out of surgery. Archives of Sexual Behavior, 7(4), 273–283. https://doi.org/10.1007/BF01542035
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Davenport, C. W., & Harrison, S. I. (1977). Gender identity change in a female adolescent transsexual. Archives of Sexual Behavior, 6(4), 327–340. https://doi.org/10.1007/BF01541204
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Journal AbstractTwo years of individual and milieu therapy are described of a 14 1/2-year-old girl who had presented with the persistent request to have a sex-change operation since age 12. Her past history was obtained from her parents and the records of the child guidance clinic which evaluated her at 3 years of age. She gives a history of remarkable tomboyism during her latency years and increasing withdrawal from peers and family during early adolescence.

The patient's personal and family dynamics are explored, and these major therapeutic themes are discussed. The individual and milieu therapy are described and discussed with some speculation about the reasons for her positive response to psychotherapy. It would appear that this is a rare case of a postpubertal female transsexual reported to have made a gender identity change.
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Kirkpatrick, M., & Friedmann, C. (1976). Treatment of requests for sex-change surgery with psychotherapy. American Journal of Psychiatry, 133(10), 1194–1196. https://doi.org/10.1176/ajp.133.10.1194
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Journal AbstractThe authors describe two patients whose requests for sex-change surgery represented crises in sexual identity and anxiety-masking symptoms. Brief psychotherapy enabled these patients to relinquish their belief in a surgical "cure".

In evaluating such request, the psychiatrist should consider the patient's total personality rather than focusing on the genuineness of the perceived gender disorder. Whatever the final decision, the opportunity for continued psychotherapy should be provided.
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Le Roux, N. (n.d.). GENDER VARIANCE IN CHILDHOOD/ADOLESCENCE: GENDER IDENTITY JOURNEYS NOT INVOLVING PHYSICAL INTERVENTION [University of East London]. https://repository.uel.ac.uk/item/85vvw
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Journal AbstractMuch of the current literature on gender-variant children and young people focuses on aetiology and developmental outcomes in adolescence, whereas their developmental experiences have been neglected. Furthermore, there is little understanding about the experiences of gender-variant youth for whom gender reassignment does not offer a straightforward solution.
This qualitative study interviewed 10 gender-variant young people (Mean age = 20; range 17-27) who were not actively pursuing gender reassignment. The aim was to gain a better understanding of the developmental process of their gender identity development and how they made sense of their gender variance; the challenges that they faced; the resources that they drew upon; and what is important to them. A grounded theory methodology was adopted.
The period between the approximate ages of 9 and 14 years was identified as crucial in their gender identity development and as a significant developmental challenge. A widening social gap between male and female gender roles and an emergent homosexual identity influenced how they made sense of their gender-variant expression and their bodily development, which in turn was situated within a context of widespread social exclusion. This promoted a profound lack of social belonging, which for most translated into a sense of not belonging in their bodies. A transgender identity afforded social membership, but brought with it a variety of challenges. A range of gender identities and views on gender reassignment were identified, that do not neatly fit into current conceptions of desisting and persisting gender dysphoria. Education on gender variance within the public, educational and health domain was an important priority for the participants. The findings of this study contribute to our understanding of the developmental trajectories of gender variant youth. It also intimates a number of recommendations for future research and clinical practice.
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Fewer Studies
F. Social Transition
Skeptical of social transition
Morandini, J. S., Kelly, A., De Graaf, N. M., Malouf, P., Guerin, E., Dar-Nimrod, I., & Carmichael, P. (2023). Is Social Gender Transition Associated with Mental Health Status in Children and Adolescents with Gender Dysphoria? Archives of Sexual Behavior, 52(3), 1045–1060. https://doi.org/10.1007/s10508-023-02588-5
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Journal AbstractSocial gender transition is an increasingly accepted intervention for gender variant children and adolescents. To date, there is scant literature comparing the mental health of children and adolescents diagnosed with gender dysphoria who have socially transitioned versus those who are still living in their birth-assigned gender. We examined the mental health of children and adolescents referred to the Gender Identity Development Service (GIDS), a specialist clinic in London, UK, who had socially transitioned (i.e., were living in their affirmed gender and/or had changed their name) versus those who had not socially transitioned. Referrals to the GIDS were aged 4–17 years. We assessed mental health correlates of living in one’s affirmed gender among 288 children and adolescents (208 birth-assigned female; 210 socially transitioned) and of name change in 357 children and adolescents (253 birth-assigned female; 214 name change). The presence or absence of mood and anxiety difficulties and past suicide attempts were clinician rated. Living in role and name change were more prevalent in birth-assigned females versus birth-assigned males. Overall, there were no significant effects of social transition or name change on mental health status. These findings identify the need for more research to understand how social transition influences mental health, including longitudinal studies that allow for more confident inferences to be made regarding the relationship between social transition and mental health in young people with gender dysphoria.
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Sievert, E. D., Schweizer, K., Barkmann, C., Fahrenkrug, S., & Becker-Hebly, I. (2020). 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, 135910452096453. https://doi.org/10.1177/1359104520964530
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Journal AbstractResearch provides inconclusive results on whether a social gender transition (e.g. name, pronoun, and clothing changes) benefits transgender children or children with a Gender Dysphoria (GD) diagnosis. This study examined the relationship between social transition status and psychological functioning outcomes in a clinical sample of children with a GD diagnosis. Psychological functioning (Child Behavior Checklist; CBCL), the degree of a social transition, general family functioning (GFF), and poor peer relations (PPR) were assessed via parental reports of 54 children (range 5–11 years) from the Hamburg Gender Identity Service (GIS). A multiple linear regression analysis examined the impact of the social transition status on psychological functioning, controlled for gender, age, socioeconomic status (SES), PPR and GFF. Parents reported significantly higher scores for all CBCL scales in comparison to the German age-equivalent norm population. Peer problems and worse family functioning were significantly associated with impaired psychological functioning, whilst the degree of social transition did not significantly predict the outcome. Therefore, claims that gender affirmation through transitioning socially is beneficial for children with GD could not be supported from the present results. Instead, the study highlights the importance of individual social support provided by peers and family, independent of exploring additional possibilities of gender transition during counseling.

SEGM Summary

This was a study of a clinical sample of 54 GD children (age 5-11) attending the Hamburg GIDS. Parental questionnaires were used to study the relationship between social transition status and psychological functioning outcomes. The findings: social transition status (living in the preferred gender role in different everyday life areas) was not significantly associated with psychological functioning. Rather social support in general (from family and peers), but not necessarily in terms of affirming the child’s gender status, impacts on psychological outcomes. This study was also a cross-sectional design so causal conclusions could not be drawn from these results.

 

SEGM Plain Language Conclusion: This study did not find that social gender transition was beneficial to the psychological functioning of the child. Rather, general family functioning and quality of peer relationships were identified as the key factors.

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Zucker, K. J. (2020). Debate: Different strokes for different folks. Child and Adolescent Mental Health, 25(1), 36–37. https://doi.org/10.1111/camh.12330
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Journal AbstractA gender social transition in prepubertal children is a form of psychosocial treatment that aims to reduce gender dysphoria, but with the likely consequence of subsequent (lifelong) biomedical treatments as well (gender-affirming hormonal treatment and surgery). Gender social transition of prepubertal children will increase dramatically the rate of gender dysphoria persistence when compared to follow-up studies of children with gender dysphoria who did not receive this type of psychosocial intervention and, oddly enough, might be characterized as iatrogenic. Parents who bring their children for clinical care hold different philosophical views on what is the best way to help reduce the gender dysphoria, which require both respect and understanding.
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Wong, W. I., van der Miesen, A. I. R., Li, T. G. F., MacMullin, L. N., & VanderLaan, D. P. (2019). Childhood social gender transition and psychosocial well-being: A comparison to cisgender gender-variant children. Clinical Practice in Pediatric Psychology, 7(3), 241–253. https://doi.org/10.1037/cpp0000295
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Journal AbstractOBJECTIVE: There is increasing interest regarding best practice for promoting well-being among gender-variant children. Social gender transition (e.g., name, pronoun, clothing changes) may benefit gender-variant children who desire to be of a gender that does not align with their birth-assigned sex. This study examined psychosocial challenges experienced by socially transitioned children and cisgender (i.e., birth-assigned sex and gender identity align) gender-variant children.

METHOD: We used data from published samples of gender-variant children (N = 266) reporting psychosocial well-being using the Child Behavior Checklist or similar measures. A statistical bootstrapping approach was used to control for birth-assigned sex, age, and degree of gender variance when comparing cisgender gender-variant (CGV) and socially transitioned children described as being supported in their gender identities. Within the CGV sample, we examined parental attitudes toward childhood gender variance, as well as correlations between these parental attitudes and peer relations with children’s psychological well-being.

RESULTS: There was little evidence that psychosocial well-being varied in relation to gender transition status. Parents of CGV children were generally accepting of childhood gender variance, but only poor peer relations predicted lower psychological well-being among these children.

CONCLUSION: Socially transitioned children appear to experience similar levels of psychosocial challenges as CGV children. While further research is needed to evaluate possible effects of childhood social gender transition on well-being, this study suggests experiences of psychosocial challenges among gender-variant children require monitoring irrespective of transition status, and relationships with peers may be especially important to consider. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

SEGM Summary

The researchers assessed the utility of childhood social gender transition (SGT) as a means of ameliorating psychological distress and improving wellbeing. Researchers used the Child Behavior Checklist (CBCL) to compare psychological function of gender-dysphoric children who socially transitioned (change of name, pronouns, and living as the member of the opposite sex) vs the children who remained in their gender role while allowed to express their gender non-conformity.

The researchers found no difference in any of the CBCL domain between the two groups. The domains included both internalizing and externalizing behaviors:

  • anxious

  • depressed

  • somatic complaints

  • social problems

  • thought problems

  • attention problems

  • rule-breaking behavior

  • aggressive behavior


The only predictor of challenges was poor peer relations, rather than the transition status.

This recent study summarizes the knowledge base about pre-pubertal social transition (SGT) as:

“It is possible that childhood SGT is associated with a decrease in psychological distress, as has been noted anecdotally; however, no studies to date have employed a longitudinal design assessing psychological well-being pre- and post-childhood SGT. The long-term implications of childhood SGT for psychological well-being are also unclear ... all of the studies to date on childhood SGT relied on the limited and potentially biased information that comes from brief parent and self-report screening instruments.”

The authors concluded: “There was little evidence that psychosocial well-being varied in relation to gender transition status ... only poor peer relationships predicted lower psychological well-being ... Socially transitioned children appear to experience similar levels of psychosocial challenges as CGV [gender-variant but not socially transitioned] children.”

 

SEGM Plain Language Conclusion:

This study’s reanalysis of previously published data (including Olson et al.'s 2016 study) found no evidence that social transition improved psychological outcomes. Rather, quality of peer relationships was found to be the key factor.

The benefit of social transition was not demonstrated. The risks are unknown but include an increased risk of persistence of gender dysphoria and subsequent medical and surgical interventions which carry additional health risks.

For desisting children (previously the majority desisted), the stress of having to revert to the original role may be significant.

 

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Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry, 52(6), 582–590. https://doi.org/10.1016/j.jaac.2013.03.016
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Journal AbstractOBJECTIVE: To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence.
METHOD: The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence.
RESULTS: We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls.
CONCLUSION: Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.
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de Vries, A. L. C., & Cohen-Kettenis, P. T. (2012). Clinical management of gender dysphoria in children and adolescents: the Dutch approach. Journal of Homosexuality, 59(3), 301–320. https://doi.org/10.1080/00918369.2012.653300
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Journal AbstractThe Dutch approach on clinical management of both prepubertal children under the age of 12 and adolescents starting at age 12 with gender dysphoria, starts with a thorough assessment of any vulnerable aspects of the youth's functioning or circumstances and, when necessary, appropriate intervention. In children with gender dysphoria only, the general recommendation is watchful waiting and carefully observing how gender dysphoria develops in the first stages of puberty. Gender dysphoric adolescents can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16 years. Currently, withholding physical medical interventions in these cases seems more harmful to wellbeing in both adolescence and adulthood when compared to cases where physical medical interventions were provided.

SEGM Summary

This study describes the "Dutch Protocol" for treating adolescents with hormonal and surgical interventions. The first and second steps of the protocol, puberty blockade and cross-sex hormones, were designed for, and tested in 70 teens with childhood-onset gender dysphoria that persisted into adolescence.

The authors highlight that the importance of not socially transitioning young gender dysphoric patients before starting the hormonal interventions. This is due to two factors: 

1. To prevent the significant emotional distress associated with the expected outcome of future detransitioning, since most gender dysphoric children will not remain gender dysphoric through adolescence.

2.  To ensure that the minority of children who do persist with their trans identification long- term have a firm grasp of biological reality, which will allow them to be mentally prepared for multiple invasive interventions and life-long medical treatment regiments that comprise gender reassignment.

The authors stress the importance of the caregivers and the child having realistic expectations of the invasive nature of the interventions if the child's gender dysphoria does not remit. 

SEGM Plain-Language Conclusion: The authors of the Dutch protocol were explicit in their strong discouragement of prepubescent and early pubescent social transition. They maintained that social transition is harmful to both the majority of the children who will eventually desist from trans identification, as well as the minority who will eventually pursue gender reassignment. In a sharp deviation from the Dutch protocol, the practice of early social transition is gaining popularity in the Western world.

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Steensma, T. D., & Cohen-Kettenis, P. T. (2011). Gender Transitioning before Puberty? Archives of Sexual Behavior, 40(4), 649–650. https://doi.org/10.1007/s10508-011-9752-2
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SEGM Summary

In this 2011 paper, the Dutch researchers observed that the rate of social transition of children had been steadily increasing. Prior to 2000, fewer than 2% of pre-pubertal children referred to gender services had already been socially transitioned by their parents. By 2009, this number had risen to 9% for complete social transition, and 33% for a partial social transition (change in physical presentation but no change in pronouns.)

The Dutch researchers expressed concern that the practice of early social transition is at odds with the observation that the majority of gender-dysphoric children (85%) do not grow up to be transgender-identified adults. They note the difficulty some of their young patients had in reverting to their original sex role once they realized they don't identify as transgender any longer. The authors posit that the psychological risks of premature social transition may outweigh its benefits.

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Fewer Studies
Supportive of social transition
Olson, K. R., Durwood, L., Horton, R., Gallagher, N. M., & Devor, A. (2022). Gender Identity 5 Years After Social Transition. Pediatrics. https://doi.org/10.1542/peds.2021-056082
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Journal AbstractBACKGROUND AND OBJECTIVES: Concerns about early childhood social transitions amongst transgender youth include that these youth may later change their gender identification (i.e., retransition), a process that could be distressing. The present study aimed to provide the first estimate of retransitioning and to report the current gender identities of youth an average of 5 years after their initial social transitions.

METHODS: The present study examined the rate of retransition and current gender identities of 317 initially-transgender youth (208 transgender girls, 109 transgender boys; M=8.1 years at start of study) participating in a longitudinal study, the Trans Youth Project. Data were reported by youth and their parents through in-person or online visits or via email or phone correspondence.

RESULTS: We found that an average of 5 years after their initial social transition, 7.3% of youth had retransitioned at least once. At the end of this period, most youth identified as binary transgender youth (94%), including 1.3% who retransitioned to another identity before returning to their binary transgender identity. 2.5% of youth identified as cisgender and 3.5% as nonbinary. Later cisgender identities were more common amongst youth whose initial social transition occurred before age 6 years; the retransition often occurred before age 10.

CONCLUSIONS: These results suggest that retransitions are infrequent. More commonly, transgender youth who socially transitioned at early ages continued to identify that way. Nonetheless, understanding retransitions is crucial for clinicians and families to help make them as smooth as possible for youth.

SEGM Summary

A recent study published in Pediatrics examined the 5-year gender identity development trajectory of transgender-identified children who underwent early social gender transition (SGT). The children were, on average, 6-7 years old at the time of SGT. Five years later, at the average age of 11-12, almost all—97.5%—continued to identify as transgender, including a small subset (3.5%) developing a non-binary identification. Only 2.5% of the children desisted from transgender identification by the end of the study period, and re-identified with their sex.

The authors concluded that detransition among previously socially gender transitioned youth is rare. A significant proportion of the youth in the study had already initiated interventions with puberty blockers (29%) and cross-sex hormones (31%) by the end of the study, and the authors opined that the remainder would likely initiate medical interventions in the future.This finding is in sharp contrast to earlier research demonstrating that most cases of childhood-onset gender incongruence tend to resolve sometime during adolescence and before reaching mature adulthood. However, the children in the prior research were not socially transitioned, and early social transition had been discouraged by prior protocols.

Some of the recent news coverage of this study incorrectly stated that the study confirmed that children who claim a transgender identity rarely change their minds. This statement is only partially accurate. A more accurate statement is that the study suggests that children who claim a transgender identity and undergo early social transition rarely change their minds, at least into their early teen years. This is because the Trans Youth Project, the source of the study's data, is specifically focused on evaluating the effects of early social gender transition in gender-diverse youth, and social gender transition was a prerequisite for participating in the study.

Below is SEGM’s critical analysis of the study: its strengths, weaknesses, and limitations.

What the Study Got Right

1. The authors are correct that little is known about the trajectories of children who undergo early social gender transition.

There is virtually no prior research into the developmental trajectories of socially-transitioned children, because the practice of pre-pubertal social transition was discouraged by the authors of the Dutch protocol. The Dutch clinicians discouraged it because most gender dysphoric children reidentified with their sex during puberty, making “watchful waiting” – rather than early transitioning – common sense. 

The following quotes from the Dutch clinicians encapsulated the Dutch concern with early SGT:

“As mentioned earlier, symptoms of GID [Gender Identity Disorder] at prepubertal ages decrease or even disappear in a considerable percentage of children (estimates range from 80–95%) [11,13]. Therefore, any intervention in childhood would seem premature and inappropriate." (Cohen-Kettenis et al., 2008, p. 1895)

"Because most gender dysphoric children will not remain gender dysphoric through adolescence (Wallien & Cohen-Kettenis, 2008), we recommend that young children not yet make a complete social transition (different clothing, a different given name, referring to a boy as “her” instead of “him”) before the very early stages of puberty." (de Vries and Cohen-Kettenis, 2012, p. 308)

"In making this recommendation, we aim to prevent youths with nonpersisting gender dysphoria from having to make a complex change back to the role of their natal gender (Steensma & Cohen-Kettenis, 2011). In a qualitative follow-up study, several youths indicated how difficult it was for them to realize that they no longer wanted to live in the role of the other gender and to make this clear to the people around them (Steensma, Biemond, et al., 2011). These children never even officially transitioned but just were considered by everyone around them as belonging to the other (non-natal) gender. One may wonder how difficult it would be for children living already for years in an environment where no one (except for the family) is aware of the child’s natal sex to make a change back." (de Vries and Cohen-Kettenis, 2012, p. 308)

2. The authors are correct in their observation that the children in their study who underwent early social transition appear to be persisting in their transgender identity at very high rates.

Historically, 61%-98% of gender incongruent children desisted from their trans identification before reaching adulthood (a finding confirmed by 11 of the 11 studies that studied this phenomenon). However, the current study suggests that 98% of early-socially-transitioned children persist in their wish to undergo gender transition.

Of note, the 61%-98% (or the 85%) historic desistance statistic has been critiqued as inflated, by those who noted that some of the children diagnosed with a “gender identity disorder” were merely extremely gender-nonconforming.  A reanalysis of these data focused on the subset of the children who met the full diagnostic criteria, and found that 67% of them desisted, with the majority growing up to become gay adults.

The high rate of desistance among gender variant children has been recognized multiple times by the pioneering researchers in the field of pediatric gender medicine, and also by the Endocrine Society’s treatment guidelines:

"With current knowledge, we cannot predict the psychosexual outcome for any specific child. Prospective follow-up studies show that childhood GD/gender incongruence does not invariably persist into adolescence and adulthood (so-called “desisters”). Combining all outcome studies to date, the GD/gender incongruence of a minority of prepubertal children appears to persist in adolescence (20, 40). In adolescence, a significant number of these desisters identify as homosexual or bisexual.” (Hembree et al., 2017, p. 3876)

3. The authors are also correct that most of the early-socially transitioned children in the study proceeded to medical transition, and the rest will likely do so as well.

According to the study, by the end of the 5-year period, at least 60% of the youth had already started to take puberty blockers and/or cross sex hormones (the rate may be even higher since 8% of the participants did not return the questionnaires in the final 2 years of the study—if some of those children started on hormonal interventions, the researchers would not know).  Given the focus that “gender-affirming” care places on the provision of medical interventions, it is probable that many of the remaining 40% of youth in the study will proceed to hormones and surgeries.

The Study's Limitations

1. Lack of equipoise, as evidenced by no discussion of risks

In medical research, “equipoise” requires researchers to approach their research question with genuine uncertainty about the effect of an intervention and is the ethical basis for medical research. The UK's independent review of gender dysphoria healthcare, the Cass Review, recently issued an interim report in which it said:

“Social transition – this may not be thought of as an intervention or treatment, because it is not something that happens within health services. However, it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning.64,65 There are different views on the benefits versus the harms of early social transition. Whatever position one takes, it is important to acknowledge that it is not a neutral act, and better information is needed about outcomes.” (Cass, 2022, p. 62)

Yet the investigators of this study presume that early social gender transition is largely beneficial, and that the only potential downside is the risk of detransition, which their findings suggest is low. They do not engage with evidence that social gender transition may not confer the claimed benefits (including research that disputes their own earlier findings of benefits). Nor do they consider that persistence increases the risk of undergoing invasive medical and surgical interventions with a lifelong burden of risk and aftercare.

With over 60% of study participants having already commenced hormonal interventions, the researchers should have included a discussion of these risks, including the potential harm to bone healthbrain developmentimpaired sexualitycardiovascular health, as well as the risks of infertility and sterility, whenever puberty blockers are administered at Tanner stage 2 and are followed by cross-sex hormones.

2. Non-representative sample

The data for this study came from the Trans Youth Project, a convenience sample of parents who opted into family meetings with the researchers face-to-face once every 1-3 years until the child turned 12 and, after that, periodic questionnaires. The research team did not provide diagnosis or treatment. The only benefit to the families was a small financial reward for participation, and the ability to contribute to the knowledge base.

Although it is not certain how the study participants were recruited, the resultant sample had a highly unusual composition. A full 17% of the research participants reported a “multiracial” identity, compared to just 2.8% of the US population. The study participants were also significantly more affluent than the average US family: 35% reported incomes over $125,000, compared to 24% in the US population.

It is unclear how applicable the findings from this demographically skewed sample are to the rest of the US population.

3. Poor applicability to youth diagnosed with gender dysphoria

The researchers observed that most of the families in the study did not believe that the DSM diagnosis of gender dysphoria was either “ethical or useful.” Consistent with this finding, the researchers noted that in many cases the “distress” criterion, necessary for the DSM-5 diagnosis, was not met. This allows for the inclusion of children with a certain parent profile: one who is heavily invested in the idea that their child is transgender even if they don’t meet diagnostic criteria for gender dysphoria. Currently, the diagnosis of gender dysphoria is a necessary condition for determining the medical necessity of interventions. Since this study did not require the diagnosis of gender dysphoria, it is unclear whether its findings are applicable to the population of gender-dysphoric youth. The lack of diagnosis also makes it unclear how this study could be reproduced. 

4. Unknown applicability to youth with adolescent-onset gender dysphoria in particular

It is notable that the ratio of natal boys to girls in this study is approximately 2:1. This predominately male presentation, combined with the early age of social transition (average 6.5 years) suggest that most of the sample came from the population with early-childhood emergence of transgender identity. Prior research using the same sample reported that all youth in the Trans Youth Project had excellent mental health function, with “no elevations in depression and slightly elevated anxiety relative to population averages. They did not differ from the control groups on depression symptoms and had only marginally higher anxiety symptoms."

In contrast, the population of youth desiring hormones currently is dominated by young people whose trans identity emerges for the first time around or shortly after puberty and who suffer from high rates of mental illness or neurocognitive comorbidities. In addition, the majority are natal females. It is not yet known whether the findings of persistence of trans identity among early socially-transitioned youth with early-childhood onset of gender dysphoria and good baseline mental health will apply to adolescents with a post-puberty onset of transgender identity which is further complicated by mental health issues.

5. Non-participation bias

Two sources of non-participation bias in the study are apparent. First, the children in the study had been socially transitioned for 1.5 years prior to enrolling in the study. Thus, it is likely that the study under-represents families where the child had experienced a briefer period of social transition and who then detransitioned. Second, a significant number of families (8%) failed to contact the researchers in the past two years, and an unknown number failed to stay in touch in the final year of the study (2020). These non-respondents may be disproportionately parents of detransitioners.

This bias can negatively impact the reliability of the study in several ways, including underestimating the true rate of detransition, and under-representing the experiences of the children who were socially transitioned for a period and later detransitioned.

6. Problems in reporting

There are several inaccuracies in reporting that impede the interpretation of the study results:

  • The study refers to a 5-year follow-up, but subjects were only followed for 3.8 years.  The 5-year estimate comes from the fact that the subjects had already socially transitioned for 1.5 years prior to enrolling. While the authors are correct in stating that the identity outcome occurred 5 years after social transition, they should have clearly stated that they could only validate the progression for 3.8 out of the 5 years.
  • Although the researchers disclosed that 8% of the study sample failed to return questionnaires in the 2-year time period 2019-2020, they did not make it clear how many had been expected to respond in 2020 specifically but failed to do so. Children’s identity development is often unpredictable and can change quickly. If non-participation in 2020 is not significantly different from 2019, it is a moot point. However, if it is significantly higher, then combining the two years may mask a much higher rate of non-response in the final year of the study. Non-responses may represent “silent” desistance, whereby parents do not officially withdraw from the study, but simply do not consider the study relevant since their children no longer consider themselves transgender. The title of the project (“Trans Youth Project") and its stated goal to study “transgender children” contribute to the possibility that parents of desisters may not wish to stay engaged in this research project.
  • The participant demographics presented in Table 1 contain only three variables: race, annual household income, and geographic location. Other important demographics are omitted, including parents’ educational attainment, marital status, and home ownership. Neither the age distribution of the study participants nor the age at which their trans identity emerged are reported. The children and adolescents’ pattern of sexual attraction/ orientation is not noted. This is an important omission, as gender incongruence in childhood is strongly associated with future homosexuality. If a significant proportion of the youth in the study are attracted to the individuals of their natal sex, it would suggest that early social transition poses risks of iatrogenic harm to LGB youth by exposing them to highly invasive and unnecessary medical interventions.
7. Commingling of interventions and lack of control group

The majority of participants started puberty blockers and/or cross-sex hormones during the study, so it is hard to separate the effects of social transition on persistence of transgender identity from the effects of these medications.  For example, four studies confirm that over 95% of children who start puberty blockers, persist in their trans identification and continue to cross-sex hormones. Thus, taking puberty blockers may be in part responsible for the persistence found by the study. More generally, the lack of a control group makes it hard to interpret which of the interventions are associated with the persistence of trans identity, and the study design precludes the determination of causation or its direction.

8. Lack of long-term follow-up

The study noted high rates of trans identity persistence at the age of 11-12. However, little is known how these adolescents will identify as they move through the later stages of adolescence and reach mature adulthood. All aspects of identity continue to significantly change in adolescence and young adulthood, and gender identity may be subject to similar changes. Moreover, based upon the initial ages of the study participants, many did not reach the age by which they would be likely to understand themselves as lesbian, gay, or bisexual (LGB). LGB individuals frequently go through a period of gender dysphoria in childhood. Many detransitioners also have come to understand themselves as LGB adults following a period of temporary transgender identification in their childhood or adolescence. 

9. Limitation in hypothesis

The authors assert that the main concern with early social gender transition is that the process of re-identifying with their natal sex following a period of social transition may be distressing to a child. Thus, their research question only deals with the rates of persistence and desistence. The authors are correct that researchers ­– including the authors of the original Dutch protocol ­– have observed that some children may find it excessively stressful to detransition, particularly when many adults around them are not even aware of the child's natal sex.

However, this is not the only concern about early social transition. Another key concern, also voiced by the Dutch researchers, is that children who are socially transitioned at an early age, and who end up persisting with their trans identity, lose touch with biological reality, and as a result, may have unrealistic expectations of what “gender-affirming” hormones and surgeries can realistically deliver. This may result in disappointing post-surgical outcomes or inability to participate in the lifelong medical maintenance required to preserve the desired appearance:

"Another reason we recommend against early transitions is that some children who have done so (sometimes as preschoolers) barely realize that they are of the other natal sex. They develop a sense of reality so different from their physical reality that acceptance of the multiple and protracted treatments they will later need is made unnecessarily difficult. Parents, too, who go along with this, often do not realize that they contribute to their child’s lack of awareness of these consequences." (de Vries and Cohen-Kettenis, 2012, p. 308)

The Director of the UK's Gender Identity Development Service (GIDS) has highlighted a closely-related complication of early childhood social transition, that it makes it difficult to obtain consent for later medical transition procedures:

“In the UK, we’re seeing much younger people socially transitioning. But sometimes it then becomes almost impossible for them to think about the reality of their physical body. They are living totally the gender they feel they are, but of course their body doesn’t match that, and it becomes something that can’t be talked about or thought about. Clearly, it then becomes quite difficult in terms of keeping their options open and ensuring fully informed consent for any appropriate physical interventions.” (The Times, 29 August 2015)

Another issue raised by researchers is the possibility that early social gender transition may steer a child toward persistence of a transgender identity, which would otherwise have naturally reverted to be congruent with one’s sex:

“With the emergence in the last 10–15 years of a pre-pubertal gender social transition as a type of psychosocial treatment – initiated by parents on their own (without formal clinical consultation) or with the support/advice of professional input [ref. omitted] – it is not clear if the desistance rates reported in the four core studies will be “replicated” in contemporary samples. Indeed, the data for birth-assigned males in Steensma et al. (2013a) already suggest this: of the 23 birth-assigned males classified as persisters, 10 (43%) had made a partial or complete social transition prior to puberty compared to only 2 (3.6%) of the 56 birth-assigned males classified as desisters. Thus, I would hypothesize that when more follow-up data of children who socially transition prior to puberty become available, the persistence rate will be extremely high. This is not a value judgment – it is simply an empirical prediction." (Zucker, 2018, p. 7)

Similarly, Dutch researcher Dr. Thomas Steensma suggested that:

"A childhood transition has an effect by itself and influences the cognitive gender identity representation of the child and/or their future development" and that this "link between social transitioning and the cognitive representation of the self [would] influence the future rates of persistence." (Steensma et al., 2013, p. 150).

The risks of early social transition are also acknowledged by the Endocrine Society’s treatment guidelines:

“However, the large majority (about 85%) of prepubertal children with a childhood diagnosis did not remain GD/ gender incongruent in adolescence (20). If children have completely socially transitioned, they may have great difficulty in returning to the original gender role upon entering puberty (40). Social transition is associated with the persistence of GD/gender incongruence as a child progresses into adolescence. It may be that the presence of GD/gender incongruence in prepubertal children is the earliest sign that a child is destined to be transgender as an adolescent/adult (20). However, social transition (in addition to GD/gender incongruence) has been found to contribute to the likelihood of persistence.” (Hembree et al., 2017, p. 3879)

10. Unnecessary and confusing change in terminology

Undergoing “gender-affirmation” is frequently described as “transitioning” or “gender transition.” When individuals stop the process of transitioning, it is commonly referred to as “detransition.” Detransition, which appears to be a growing phenomenon, is a well-established term used by several recently-published studies.

The authors’ attempt to change established terminology from the well-established “detransition” to the novel “retransition” is at best unnecessary, and at worst confusing. If “detransition” – ceasing to pursue gender transition—is recast as “retransition,” then what shall we call individuals who actually change their minds once again, and do choose to continue to pursue gender transition after all? Several children in the study did just that. Another study has reported on the experiences of transgender-identified individuals temporarily detransitioned.

While it’s admirable when medical terminology evolves to elucidate a concept, we feel that in this case, the change serves to obscure rather than enhance understanding of the topic.

Concluding Thoughts

This study finding of high rates of persistence of transgender identity in children following early social gender transition is consistent with two possible explanations. One is that the study was comprised of the parents who were exceptionally good at predicting their child's future transgender identification. This would imply that although most (61%-98%) of transgender-identified children naturally desist during early puberty, the parents in the study who had made the prediction that their children would persist turned out to be right nearly 100% of the time. While plausible, the probability of this is low. 

The other possible explanation is that early-childhood social gender transition may consolidate an otherwise transient childhood transgender identity. We believe the latter explanation is more likely. The hypothesis that early social gender transition is not neutral but may be a form of psychosocial intervention that predisposes an otherwise transient childhood transgender identity to persist has been voiced before. The study results lend support to this hypothesis. Parents considering undertaking a social gender transition of their gender-variant children need to be advised of this possibility. Notably, the boys in the study (“trans girls”) were transitioned on average one year earlier than girls (“trans boys”): at age 6 rather than 7 years old (Table 2). This may reflect societal discomfort with feminine gender nonconforming boys, which may lead some parents to socially transition gender non-conforming boys at an earlier age.

As the practice of early social gender transition becomes more common, it is reasonable to expect that many more gender-variant youth will persist in their trans identity. This in turn will likely significantly increase the number of young people seeking hormonal and surgical transition, which is of concern because of the poor state of medical knowledge: the longest available set of outcomes of individuals who medically transition in adolescence and young adulthood tracks patients only to an average of age 21, and the best evidence is rated as “low” or “very low” quality.

Currently, active debates are ongoing over the age at which children are old enough to provide meaningful consent (or assent) to undergoing gender transition, due to its inherent risks and uncertainties, as well as the near-certainty of infertility and even sterility, which occurs when puberty blockers at Tanner stage II are followed by cross-sex hormones. Debates whether 16-year olds or 12-year olds can consent to medical interventions with such profound life-long consequences are currently playing out all over Europe, and most recently, in several US states. Since almost all early-socially-transitioned children in the Olson et al study continued with the transgender identity into puberty and over 60% are already undergoing medical transition, the study suggests that many of these life-changing decisions are occurring not at 12, 14, or 16, but effectively at the much younger age of 6 or 7.

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Pollitt, A. M., Ioverno, S., Russell, S. T., Li, G., & Grossman, A. H. (2019). Predictors and Mental Health Benefits of Chosen Name Use Among Transgender Youth. Youth & Society, 53(2), 320–341. https://doi.org/10.1177/0044118X19855898
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractChosen name use among transgender youth (youth whose gender identities are different from their sex assigned at birth) can be part of the complex process of aligning gender presentation with gender identity and can promote mental health. However, little is known about the factors that predict whether or not transgender youth have a chosen name and outcomes of chosen name use, especially in specific social contexts. We examined, among a sample of 129 transgender youth from three cities in the United States, differences in sociodemographic characteristics and mental health outcomes between transgender youth with and without a chosen name and, among those with a chosen name, predictors and mental health benefits of being able to use a chosen name at home, school, and work. There were few differences between transgender youth with and without a chosen name. Among transgender youth with a chosen name, disclosure of gender identity to supportive family and teachers predicted chosen name use at home and school, respectively. Chosen name use was associated with large reductions in negative health outcomes and relatively smaller improvements in positive mental health outcomes. Our results show that chosen name use is part of the gender affirmation process for some, but not all, transgender youth and is associated with better mental health among transgender youth who adopt a chosen name.
[+notes+]
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Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A. H. (2018). Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 63(4), 503–505. https://doi.org/10.1016/j.jadohealth.2018.02.003
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractPURPOSE: This study aimed to examine the relation between chosen name use, as a proxy for youths' gender affirmation in various contexts, and mental health among transgender youth.

METHODS: Data come from a community cohort sample of 129 transgender and gender nonconforming youth from three U.S. cities. We assessed chosen name use across multiple contexts and examined its association with depression, suicidal ideation, and suicidal behavior.

RESULTS: After adjusting for personal characteristics and social support, chosen name use in more contexts was associated with lower depression, suicidal ideation, and suicidal behavior. Depression, suicidal ideation, and suicidal behavior were lowest when chosen names could be used in all four contexts.

CONCLUSION: For transgender youth who choose a name different from the one given at birth, use of their chosen name in multiple contexts affirms their gender identity and reduces mental health risks known to be high in this group.

SEGM Summary

The study concluded that for teenagers who have selected a name different from their birth name, the use of their chosen name is correlated with improved psychosocial outcomes in several domains.

As the editors of the journal cautioned in an accompanying editorial: "The study is correlational so causality cannot be assumed, and the sample size was small. Also, access to and treatment with gender-affirming hormones for medical transition were not evaluated. Access to gender-affirming medical treatment may confound the relationship between chosen name use and mental health symptoms". [Vance, SR, 'The Importance of Getting the Name Right for Transgender and Other Gender Expansive Youth', Journal of Adolescent Health (October 2018), vol 63 no.4, pp. 379-80]

 

 

 

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Durwood, L., McLaughlin, K. A., & Olson, K. R. (2017). Mental Health and Self-Worth in Socially Transitioned Transgender Youth. Journal of the American Academy of Child & Adolescent Psychiatry, 56(2), 116-123.e2. https://doi.org/10.1016/j.jaac.2016.10.016
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractOBJECTIVE: Social transitions are increasingly common for transgender children. A social transition involves a child presenting to other people as a member of the “opposite” gender in all contexts (e.g., wearing clothes and using pronouns of that gender). Little is known about the wellbeing of socially transitioned transgender children. This study examined self-reported depression, anxiety, and self-worth in socially transitioned transgender children compared with 2 control groups: age- and gender-matched controls and siblings of transgender children.

METHOD: As part of a longitudinal study (TransYouth Project), children (9–14 years old) and their parents completed measurements of depression and anxiety (n = 63 transgender children, n = 63 controls, n = 38 siblings). Children (6–14 years old; n = 116 transgender children, n = 122 controls, n = 72 siblings) also reported on their self-worth. Mental health and self-worth were compared across groups.

RESULTS: Transgender children reported depression and self-worth that did not differ from their matched-control or sibling peers (p = .311), and they reported marginally higher anxiety (p = . 076). Compared with national averages, transgender children showed typical rates of depression (p = .290) and marginally higher rates of anxiety (p = .096). Parents similarly reported that their transgender children experienced more anxiety than children in the control groups (p = .002) and rated their transgender children as having equivalent levels of depression (p = .728).

CONCLUSION: These findings are in striking contrast to previous work with gendernonconforming children who had not socially transitioned, which found very high rates of depression and anxiety. These findings lessen concerns from previous work that parents of socially transitioned children could be systematically underreporting mental health problems.

SEGM Summary

The 2017 study by Durwood et al. used the data from TransYouth Project, collecting both parental and self-reports of depression, anxiety and self-worth measures for children ages 9-14. The findings broadly confirmed those of the first study using the data from TransYouth Project (Olson et al., 2016), finding that social transition was associated with better psychological function.

It is important to note these authors' own statements in these papers:

a) that prepubescent social transition for GD children is controversial.

b) that there is little known about the well-being of socially transitioned transgender children.”

c) That there are numerous limitations to their own findings, including the acknowledgement that the study design does not allow one to draw a causal inference that social transition in prepubescent GD children improves mental health outcomes.

SEGM Plain Language Conclusion:

This is one of two key empirical studies quoted by those arguing for social transition of children (the other study is by Olson et al., 2016, both used the same data source known as TransYouth Project).

The study findings showed that gender-dysphoric children ages 9-14 who underwent social gender transition had psychological functioning similar to their gender-normative peers. The authors of the study contrast this high level of function to the typically lower-level of psychological function in gender-dysphoric children in other studies.

However, the study has a number of serious methodological limitations, and cannot be used to assert that social transition produces psychological benefits, or that the benefits outweigh the potential risks: 

  • The data source is TransYouth Project, an initiative targeting highly involved gender-affirming parents interested in tracking their children's outcomes overtime. A high level of function found in such children may or may not be related to their social transition status.
  • One other obvious limitation of the TransYouth Project data is that parents whose children stop identifying as transgender are not likely to stay in this longitudinal  project. Thus, the potential negative outcomes of a premature social transition for desisting children are likely not captured. Since historically, the majority of prepubertal children have eventually desisted from transgender identification, the study is unable to provide any information about the risks, or weigh the benefits vs the risks.
  • Further, a reanalysis of the subset of the data from TransYouth Project (Wong et al., 2019) that controlled for additional variables (including peer relations) with a multivariate analysis failed to demonstrate that social transition was associated with positive outcomes. Rather, the positive function was accounted for by positive peer relations. The study by Wong et al. concluded, "Socially transitioned children appear to experience similar levels of psychosocial challenges as CGV [gender-variant but not socially transitoned] children.

The study authors themselves warn against concluding that pediatric social transition improves psychological outcomes.

 

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Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016). Mental Health of Transgender Children Who Are Supported in Their Identities. Pediatrics, 137(3), e20153223. https://doi.org/10.1542/peds.2015-3223
JOURNAL ABSTRACT
SEGM ANALYSIS
FULL TEXT
Journal AbstractOBJECTIVE: Transgender children who have socially transitioned, that is, who identify as the gender “opposite” their natal sex and are supported to live openly as that gender, are increasingly visible in society, yet we know nothing about their mental health. Previous work with children with gender identity disorder (GID; now termed gender dysphoria) has found remarkably high rates of anxiety and depression in these children. Here we examine, for the first time, mental health in a sample of socially transitioned transgender children. abstract
METHODS: A community-based national sample of transgender, prepubescent children (n = 73, aged 3–12 years), along with control groups of nontransgender children in the same age range (n = 73 age- and gender-matched community controls; n = 49 sibling of transgender participants), were recruited as part of the TransYouth Project. Parents completed anxiety and depression measures.
RESULTS: Transgender children showed no elevations in depression and slightly elevated anxiety relative to population averages. They did not differ from the control groups on depression symptoms and had only marginally higher anxiety symptoms.
CONCLUSIONS: Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex.

SEGM Summary

This is a cross-sectional 2016 study that used the data from TransYouth Project. The study compared parent-reported measures of depression and anxiety, obtained through questionnaires, in a community sample of 73 socially transitioned prepubertal children (ages 3-12) to age and gender-matched community controls and their own non-GD siblings.

Results showed that socially transitioned gender-dysphoric children did not differ on depression scores and had only marginally higher anxiety scores as compared to the controls.

It should be noted that in 2017, TransYouth Project's data was used again in a study by Durwood et al., evaluating children aged 9-14, and had similar findings.

It is important to note these authors' own statements in these two related papers:

  • that prepubescent social transition for GD children is controversial.
  • that there is little known about the well-being of socially transitioned transgender children.”
  • That there are numerous limitations to their own findings, including the acknowledgement that the study design does not allow one to draw a causal inference that social transition in prepubescent GD children improves mental health outcomes.

SEGM Plain Language Conclusion:

This is the key empirical study quoted by those arguing for social transition of children. Its findings showed that gender-dysphoric prepubertal children who underwent social gender transition had psychological functioning similar to their gender-normative peers.The authors of the study contrast this high level of function to the typically lower-level of psychological function in gender-dysphoric children in other studies.

However, the study has a number of serious methodological limitations, and cannot be used to assert that social transition produces psychological benefits, or that the benefits outweigh the potential risks: 

  • The data source is TransYouth Project, an initiative targeting highly involved gender-affirming parents interested in tracking their children's outcomes overtime. A high level of function found in such children may or may not be related to their social transition status
  • One other obvious limitation of the TransYouth Project data is that parents whose children stop identifying as transgender are not likely to stay in this longitudinal project. Thus, the potential negative outcomes of a premature social transition for desisting children are likely not captured. Since historically, the majority of prepubertal children have eventually desisted from transgender identification, the study is unable to provide any information about the risks, or weigh the benefits vs the risks.
  • Further, a reanalysis of the Olson et al. study (Wong et al., 2019) that controlled for additional variables (including peer relations) with a multivariate analysis failed to demonstrate that social transition was associated with positive outcomes. Rather, the positive function was accounted for by positive peer relations. The study by Wong et al. concluded, "Socially transitioned children appear to experience similar levels of psychosocial challenges as CGV [gender-variant but not socially transitoned] children.

The study authors themselves warn against concluding that pediatric social transition improves psychological outcomes.

 

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G. Importance of biological sex
Gribble, K. D., Bewley, S., Bartick, M. C., Mathisen, R., Walker, S., Gamble, J., Bergman, N. J., Gupta, A., Hocking, J. J., & Dahlen, H. G. (2022). Effective Communication About Pregnancy, Birth, Lactation, Breastfeeding and Newborn Care: The Importance of Sexed Language. Frontiers in Global Women’s Health, 3, 818856. https://doi.org/10.3389/fgwh.2022.818856
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Bhargava, A., Arnold, A. P., Bangasser, D. A., Denton, K. M., Gupta, A., Hilliard Krause, L. M., Mayer, E. A., McCarthy, M., Miller, W. L., Raznahan, A., & Verma, R. (2021). Considering Sex as a Biological Variable in Basic and Clinical Studies: An Endocrine Society Scientific Statement. Endocrine Reviews, bnaa034. https://doi.org/10.1210/endrev/bnaa034
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Journal AbstractIn May 2014, the National Institutes of Health (NIH) stated its intent to “require applicants to consider sex as a biological variable (SABV) in the design and analysis of NIH-funded research involving animals and cells.” Since then, proposed research plans that include animals routinely state that both sexes/genders will be used; however, in many instances, researchers and reviewers are at a loss about the issue of sex differences. Moreover, the terms sex and gender are used interchangeably by many researchers, further complicating the issue. In addition, the sex or gender of the researcher might influence study outcomes, especially those concerning behavioral studies, in both animals and humans. The act of observation may change the outcome (the “observer effect”) and any experimental manipulation, no matter how well-controlled, is subject to it. This is nowhere more applicable than in physiology and behavior. The sex of established cultured cell lines is another issue, in addition to aneuploidy; chromosomal numbers can change as cells are passaged. Additionally, culture medium contains steroids, growth hormone, and insulin that might influence expression of various genes. These issues often are not taken into account, determined, or even considered. Issues pertaining to the “sex” of cultured cells are beyond the scope of this Statement. However, we will discuss the factors that influence sex and gender in both basic research (that using animal models) and clinical research (that involving human subjects), as well as in some areas of science where sex differences are routinely studied. Sex differences in baseline physiology and associated mechanisms form the foundation for understanding sex differences in diseases pathology, treatments, and outcomes. The purpose of this Statement is to highlight lessons learned, caveats, and what to consider when evaluating data pertaining to sex differences, using 3 areas of research as examples; it is not intended to serve as a guideline for research design.
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Lee, P. A., Nordenström, A., Houk, C. P., Ahmed, S. F., Auchus, R., Baratz, A., Baratz Dalke, K., Liao, L.-M., Lin-Su, K., Looijenga 3rd, L. H. J., Mazur, T., Meyer-Bahlburg, H. F. L., Mouriquand, P., Quigley, C. A., Sandberg, D. E., Vilain, E., Witchel, S., & and the Global DSD Update Consortium. (2016). Global Disorders of Sex Development Update since 2006: Perceptions, Approach and Care. Hormone Research in Paediatrics, 85(3), 158–180. https://doi.org/10.1159/000442975
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Journal AbstractThe goal of this update regarding the diagnosis and care of persons with disorders of sex development (DSDs) is to address changes in the clinical approach since the 2005 Consensus Conference, since knowledge and viewpoints change. An effort was made to include representatives from a broad perspective including support and advocacy groups.
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Lee, P. A., Houk, C. P., Ahmed, S. F., Hughes, I. A., & in collaboration with the participants in the International Consensus Conference on Intersex organized by the Lawson Wilkins Pediatric Endocrine Society and the European Society for Paediatric Endocrinology. (2006). Consensus Statement on Management of Intersex Disorders. PEDIATRICS, 118(2), e488–e500. https://doi.org/10.1542/peds.2006-0738
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