Psychological outcomes of gender-affirming medical treatment in transgender youth

An Examination of the Sex-Specific Nature of Nutrition Assessment within the Nutrition Care Process: Considerations for Nutrition and Dietetics Practitioners Working with Transgender and Gender Diverse Clients

* Abbreviation: TGNC — : transgender and gender nonconforming Although reports of health disparities are sobering, poor physical and mental health is not inevitable for transgender and gender nonconforming (TGNC) youth. It is true that data from a retrospective cohort study quantify disparities in mental health outcomes, revealing a two- to threefold increase in the risk of negative mental health outcomes in transgender youth, including depression, suicidal ideation, and suicide attempt.1 It is also true that the National Transgender Discrimination Survey, which is administered to adults, revealed the disheartening statistic that 41% of TGNC respondents had attempted suicide in their lifetimes in contrast with ∼1.6% of the general population who have done so.2 However, research that is focused on well-supported TGNC youth helps dispel the idea that simply being transgender is the cause of poor health outcomes. For example, long-term outcome data from the Netherlands demonstrate that children with gender dysphoria who were treated in a comprehensive gender center with gender-affirming treatment during … Address correspondence to Daniel Shumer, MD, MPH, Division of Pediatric Endocrinology, Department of Pediatrics, University of Michigan, 1500 E Medical Center Dr, SPC 5718 D1205 MPB, Ann Arbor, MI 48109-5718. E-mail: dshumer{at}med.umich.edu

Research has shown elevated rates of peer victimization among transgender youth in schools, placing them at risk of an array of negative social and psychological outcomes well into adulthood. We conducted a secondary analysis of the 2015–2016 California Healthy Kids Survey to examine rates of physical victimization (physical acts such as being pushed or shoved) and nonphysical victimization (nonphysical acts such as having mean rumors spread about them) and discriminatory peer bullying (any act of bullying based on gender, perceived lesbian or gay identity, and race) among transgender and nontransgender youth. In addition, this study explored the intersection of race and transgender identity and associations with victimization. Chi-square tests and logistic regression results indicated that transgender youth reported significantly higher rates of physical and nonphysical victimization and discriminatory peer bullying than nontransgender peers. Logistic regression results also revealed that disparities in race-based discriminatory peer bullying between transgender and nontransgender youth were greater among Latinx students than White students. The study’s findings illustrate the need for schools to create affirming environments for racially diverse transgender youth.

Gender-affirming treatments are reported to improve mental health significantly. However, a substantial number of transgender individuals report a relapse in, or persistence of, mental health problems following gender-affirming treatments. This is due to multiple stressors occurring during this period, and in general as a consequence of widespread stigma and minority stress. The aim of this pilot study was to identify different coping strategies that transgender individuals use in response to stressors prior to and following gender-affirming treatments, as mediator of mental health. Qualitative interviews were conducted to better understand the treatment outcomes and healthcare experiences of Dutch transgender individuals who had received gender-affirming treatments. Nineteen participants were included, of which 12 identified as (transgender) male, six as (transgender) female and one as transgender. Inductive coding and theory-informed thematic analysis were used to assess stressors (ncodes = 335) and coping strategies (ncodes = 869). Four stressor domains were identified, including lack of support system, stressors related to transition, and physical and psychosocial stressors post-transition. We identified six adaptive coping strategies of which acceptance, help seeking and adaptive cognitions concerning gender and transition were reported most frequently. Of the seven maladaptive strategies that we identified, social isolation and maladaptive cognitions concerning gender and transition were the most-reported maladaptive coping strategies Clinical implications: The results indicated that transgender individuals may experience significant stress, both transgender-specific and non-specific, prior to and following gender-affirming treatments and, as a result, use many coping strategies to adapt. Increased awareness of stressors and (mal)adaptive coping strategies may help to improve mental healthcare and overall support for transgender individuals. Strengths and Limitations: This is the first (pilot) study to provide insight into the range of stressors that transgender individuals experience during and after gender-affirming treatments, as well as the variety of coping strategies that are used to adapt. However, since this was a pilot study assumptions and generalizations of the evidence should be made cautiously. Results of this pilot study showed that transgender individuals may undergo significant stress during and after gender-affirming medical treatment related to the treatments and the social experiences that occur during this period, and as a result, use a range of coping strategies to adapt to the stress.

Objective As the number of transgender and non-binary (TGN) youth and young adults referred for gender-affirming medical treatment increases, there is a need to better understand how these individuals experience the interventions. The aim of the present study is to expand our understanding of how TGN youth and young adults perceive bodily changes following medical treatment as part of gender-affirming care. Method Ten life-mode interviews exploring individuals’ everyday experiences and the meanings they attach to them were conducted with TGN youth and young adults in Norway, assigned female at birth, aged 17–22, three years after they initiated gender-affirming medical treatment to align their bodies with their gender identities. The data were analyzed using thematic analysis. Results Based on the analysis of the semi-structured interviews, we developed three major themes and six sub-themes: (1) A pragmatic approach to making decisions regarding medical treatment indicates that the participants are continuously weighing the risks and benefits, together with a gradual, step-by-step introduction of medical treatment. (2) Embodying medical treatment indicates that bodily changes are tangible but, over time, anchor a sense of masculinity and a sense of self as male. (3) Grounding medical treatment in everyday life indicates that bodily changes help connect the inside with the outside, with family and friends serving as sources of support and mediators of meaning, highlighting the psychosocial aspects of gender-affirming care. Conclusion The psychosocial aspects related to medical treatment in gender-affirming care are important vantage points for exploring the social meaning of the body and bodily changes. We therefore suggest that psychosocial aspects of gender-affirming care should be attended to and integrated alongside medical treatment.

The scrutiny surrounding gender-affirming medical treatment (GAMT) for youth has increased, particularly concerning the limited evidence on long-term treatment outcomes. The Standards of Care 8 by the World Professional Association for Transgender Health addresses this by outlining research evidence suggesting "effective" outcomes of GAMT for adolescents. However, claims concerning what are considered "effective" outcomes of GAMT for adolescents remain implicit, requiring further reflection. Using trans negativity as a theoretical lens, we conducted a theory-informed reflexive thematic analysis of the literature cited in the "Research Evidence" section of the SOC8 Adolescents chapter. We selected 16 articles that used quantitative measures to assess GAMT outcomes for youth, examining how "effective" outcomes were framed and interpreted to uncover implicit and explicit normative assumptions within the evidence base. A total of 44 different measures were used to assess GAMT outcomes for youth, covering physical, psychological, and psychosocial constructs. We identified four main themes regarding the normative assumptions of "effective" treatment outcomes: (1)doing bad: experiencing distress before GAMT, (2)moving toward a static gender identity and binary presentation, (3)doing better: overall improvement after GAMT, and (4) the absence of regret. These themes reveal implicit norms about what GAMT for youth should achieve, with improvement being the benchmark for "effectiveness." We critically reflect on these themes through the lens of trans negativity to challenge what constitutes "effective" GAMT outcomes for youth. We explore how improvement justifies GAMT for youth and address the limitations of this notion. We emphasize the need for an explicit discussion on the objectives of GAMT for adolescents. The linear narrative of improvement in GAMT for adolescents is limited and fails to capture the complexity of GAMT experiences. With currently no consensus on how the "effectiveness" of GAMT for adolescents is assessed, this article calls for participatory action research that centers the voices of young TGD individuals.

In recent years, there has been a drastic increase in legislation across US states that aims to ban gender-affirming care (GAC) for transgender and nonbinary (trans) youth. We synthesized the literature on bans on GAC, its impacts on medical and mental health providers, trans communities, particularly trans youth and their caregivers (e.g., parents/families), and provided recommendations for future research and advocacy. We highlight several adverse impacts of legislation banning GAC, including: an increase in professional tensions for medical and mental health providers that work with trans youth and worse mental health outcomes for trans youth and their caregivers due to loss of autonomy in accessing evidence-based GAC. Bans on GAC undermine evidenced-based practices and are resulting in negative health effects for trans communities and youth. Research evidence highlights the need to examine effects of bans at the intersections of gender identity, socioeconomic status, race, and ethnicity.

Abstract: Background: Transgender youth face various difficulties including mental health due to discrimination in healthcare settings because of their gender orientation. This review investigates the mental health of transgender youth and health care discrimination leading to inadequate health care. Materials and Methods: The study complied with the latest publications using PRISMA reporting guidelines. For the selective review, 19 articles were selected over the last five years (between 2017 and 2022) which were primarily focused on mental health challenges and lack of health care due to health care discrimination among transgender youth. The study included publications at a global level, citing the global articles first, followed by Asia. The study only took into account biological and/or non-biological factors for the young transgender community, including both male and female factors. Result: All 19 articles confirmed the positive significance of the Mental Health of the transgender youth community due to discrimination meanwhile, 08 articles mainly indicated about lack of healthcare or unfair healthcare in settings due to being transgender along with mental health concerns. This review identified the differences in mental health and discrimination that the transgender population faces. Conclusion: As a reform, lower levels of depression and suicidality have been associated with social transition and having access to gender-affirming medical treatment. However, policies affecting this young transgender minority, who experience mental and social prejudice, must be changed. Multilevel intervention should also be advocated to address both of these severe issues. Keywords: Mental health, Transgender youth, Health care discrimination, Gender-affirming, Sexual assault, Stigma.

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Both 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.

Delay and probability discounting occur when the subjective value of an outcome decreases because it is delayed or uncertain, respectively. Research using monetary outcomes has shown that both types of discounting are influenced by the magnitude of the outcome, but in the opposite direction. In Experiment 1, university participants completed a delay-discounting task involving hypothetical monetary ($100 or $100,000) or medical treatment (acne or brain cancer) outcomes. In Experiment 2, university participants completed a probability-discounting task involving those same outcomes. Results from Experiment 1 replicated previous research in that participants discounted the “smaller” outcomes ($100 & acne treatment) more than the “larger” ones ($100,000 & brain-cancer treatment). Results from Experiment 2 demonstrated that this magnitude effect reversed for probability discounting of the monetary outcomes, with $100,000 discounted more than $100. However, acne treatment was discounted more than brain-cancer treatment. This study represents the novel finding that the magnitude effect for medical outcomes may not reverse between delay and probability discounting as it does for monetary outcomes. The results suggest that delay and probability discounting are at least partially independent.

Objective To determine long-term outcome of medical and surgical treatment of hiatal hernia (HH) in dogs and cats. Design Retrospective case series. Animals 22 dogs and 5 cats. Procedure Medical records of dogs and cats with HH were reviewed. Outcomes of treatment were obtained from reexamination or owner questionnaires. Results The most common breeds affected were English Bulldog and domestic shorthair cat. Mean age of all dogs and cats was 4 years. Hiatal hernia was diagnosed by use of contrast radiography of the esophagus (n = 19), fluoroscopy (7), or esophagoscopy (1). Eight of 15 dogs and cats treated medically for 30 days had complete resolution of signs. Of the 7 in this group that did not respond, 1 died on the 10th day of medical treatment and the remaining 6 were treated surgically. Eight of 10 dogs that underwent hiatal plication, esophagopexy, and gastropexy responded favorably. Four of 7 dogs that underwent fundoplication did well. However, 3 of these dogs did not have clinical signs. Fundoplication was successful in only 1 of 4 dogs with clinical signs. Clinical Implications Dogs and cats with clinical signs of reflux esophagitis associated with HH should undergo conservative treatment for 30 days. Most will be managed successfully by use of drugs, dietary alterations, or both. Those that do not respond to conservative treatment will likely require surgery. The best prognosis after surgery appears to be associated with the esophagopexy technique. (J Am Vet Med Assoc 1998;213:381-384)

Transgender children and adolescents face hardships in all domains of their lives, with many experiencing family rejection, social exclusion, discrimination, bullying and assaults. The mental health implications of these experiences include high rates of depression, anxiety, self-harm and attempted suicide. Gender-affirming social support and medical treatment has been shown to ameliorate the poor mental health outcomes of transgender youth, with those who are supported in their social and medical transition reporting rates of depression and self-worth equivalent to general population levels. Advocacy efforts that improve access to support and medical treatment are therefore likely to produce significant positive health and well-being outcomes for this vulnerable population. The transgender community in Australia identified the legal restrictions placed on children and adolescents accessing medical treatment as a significant barrier to positive psychological well-being. Australian law, unique internationally, required the parents of transgender adolescents to apply for court authorisation prior to the commencement of their child's gender-affirming medical treatment. Concerned by the harm created by this process, a coalition of experts, including transgender children, adolescents and their parents, as well as academic and clinical experts in the fields of law and medicine, was created to advocate for reform. Over a period of approximately 4 years, a collaborative process was undertaken, which ultimately led to law reform and improved access to medical treatment for the transgender community.

Thirty years ago, the transgender child would have made no sense to the general public, nor to young people. Today, children and adolescents declare themselves transgender, the National Health Service diagnoses 'gender dysphoria', and laws and policy are developed which uphold young people's 'choice' to transition and to authorize stages at which medical intervention is permissible and desirable. The figure of the 'transgender child' presumed by medicine and law is not a naturally occurring category of person external to medical diagnosis and legal protection. Medicine and law construct the 'transgender child' rather than that the 'transgender child' exists independently of medico-legal discourse. The ethical issue of whether the child and young person can 'consent' to social and medical transition goes beyond legal assessment of whether a person under16 years has the mental capacity to consent, understand to what s/he is consenting, and can express independent wishes. It shifts to examination of the recent making of 'the transgender child' through the complex of power/knowledge/ethics of medicine and the law of which the child can have no knowledge but within which its own desires are both constrained and incited.

Background:Concerns exist regarding effects of puberty suppression on neurodevelopment. Intelligence is strongly correlated with educational achievement in the general population. This study aimed to examine the association between pre-treatment intelligence and educational achievement after gender-affirming treatment including puberty suppression in transgender adolescents to contribute to the emerging understanding of the effect that gender-affirming treatment including puberty suppression may have on cognitive development.Methods:IQ was measured in 72 adolescents (45 trans boys, 27 trans girls) at clinical entry (mean age 12.78 years), educational achievement was evaluated after gender-affirming treatment (mean age 20.40 years).Results:IQ pre-treatment and educational achievement post-treatment were positively associated (Nagelkerke R = 0.71).Discussion:The association between IQ pre-treatment and educational achievement post-treatment in transgender adolescents who received gender-affirming medical treatment including puberty suppression appears to be similar to the general population. This may reflect that gender-affirming medical treatment including puberty suppression does not negatively affect the association between IQ and educational achievement.