Gender Dysphoric Adolescents Research Articles

Mastectomy Surgical Recommendations for Female-to-Male Transgender Patients, and a Discussion of Gender-Affirming Care for Gender-Dysphoric Adolescents

Introduction: Subcutaneous mastectomy (top surgery) in female-to-male patients is one of the most common procedures gender-dysphoric patients will undergo in order to live as their desired gender. Procedure: By consistently using the technique described in this article, surgeons can achieve consistent and aesthetically pleasing results. Complications are rare, but it is important to inform the patient that there may be issues related to bleeding, infection, wound healing, nipple necrosis (if using a graft), or dog ears. Discussion: Multiple states in the United States are seeking to ban this type of care and are even attempting to restrict health care for adults. These bans are being enacted despite carefully researched and written guidelines from major international organizations. By following these guidelines, physicians can provide safe and evidence-based care to adolescents. Conclusion: The evidence conclusively demonstrates that providing gender-affirming care to patients of all ages improves their mental health, reduces rates of depression, and decreases the risk of suicide.

Beyond the Binary: Exploring the Lived Experiences of Gender Dysphoric Adolescents in Indonesia

Introduction: Gender dysphoria among adolescents is increasingly recognized globally, yet research on the lived experiences of transgender youth in Indonesia remains limited. This study aimed to explore the unique challenges, coping mechanisms, and support needs of Indonesian adolescents navigating gender dysphoria within a sociocultural context characterized by traditional gender norms and limited access to specialized healthcare. Methods: In-depth, semi-structured interviews were conducted with 15 adolescents (aged 13-19) who identified as experiencing gender dysphoria. Participants were recruited through LGBTQ+ youth organizations and community centers in Jakarta and Surabaya. Data were analyzed using thematic analysis to identify key themes and patterns within their narratives. Results: Four major themes emerged: (1) Early Recognition and Internal Conflict: Participants described an early awareness of their gender identity incongruence, often accompanied by feelings of confusion, shame, and fear due to societal expectations and potential rejection. (2) Navigating Disclosure and Social Support: Coming out to family and peers was a significant challenge, with varied responses ranging from acceptance to rejection. Support networks, primarily found within online communities and LGBTQ+ organizations, played a crucial role in fostering resilience. (3) Barriers to Accessing Healthcare: Participants reported significant obstacles in accessing gender-affirming care, including limited availability of specialized healthcare providers, financial constraints, and lack of family support. (4) Resilience and Hope for the Future: Despite the challenges, participants expressed resilience, hope, and a strong desire to live authentically. They emphasized the importance of self-acceptance, peer support, and advocacy for greater understanding and acceptance of gender diversity in Indonesia. Conclusion: This study provides valuable insights into the experiences of gender dysphoric adolescents in Indonesia. Findings highlight the urgent need for increased awareness, improved access to gender-affirming care, and supportive interventions to promote the well-being of this vulnerable population.

Mental Health of Transgender Youth: A Comparison of Assigned Female at Birth and Assigned Male at Birth Individuals.

Gender dysphoric adolescents report a gender identity which is incongruent with their assigned sex at birth, whereby the experienced incongruence is accompanied by clinically relevant distress. The aim of the study was to assess and compare the mental health of transgender youth by assigned sex at birth. A total of n = 49 adolescents (n = 29 assigned females at birth, n = 20 assigned male at birth) aged 12 to 18 years with the diagnosis of gender dysphoria according to DSM-5 were included in the study. The adolescents underwent a psychological assessment in a child and adolescent psychiatry outpatient department prior to starting gender-affirming medical treatment, completing relevant mental health questionnaires. Although no differences were found in psychiatric disorders, more externalizing problems above the clinical threshold were reported by parents in assigned female at birth (AFAB) adolescents. On the other hand, internalizing problems, both in general and within the clinical range, were found to be more prevalent in assigned male at birth (AMAB) adolescents, as indicated by self-report. Our results suggest that a comprehensive assessment of mental health in gender dysphoric adolescents is crucial for understanding the diverse range of challenges they may face and tailoring appropriate interventions to address their specific needs.

P-06-15 Efficacy of Gonadotropin-Releasing Hormone Agonists in the Clinical Management of Adolescents With Gender Dysphoria: A Prospective Follow-UP Study

Current guidelines recommend the use of gonadotropin-releasing hormone agonists (GnRHas) as the treatment of choice to suppress puberty in adolescents with Gender Incongruence/Gender Dysphoria (GI/GD). The onset of the pubertal physical changes in transgender youth usually leads to a worsening of GD, distress and psychological functioning. GnRHas reduce suffering caused by pubertal development, leaving the body in a neutral state and allowing these adolescents to explore their gender identity. The aim of the present study is to compare psychological functioning before and after GnRHas treatment in a sample of adolescents with GD assessed at the Florence Gender Incongruence Unit and to demonstrate that GnRHas are effective in relieving distress caused by the development of secondary sex characteristics. Fourteen gender dysphoric adolescents were evaluated at 0, 3 and 6 months after the start of GnRHas (triptorelin 3,75 mg every 28 days). The evaluation included physical examination, blood samples and psychometric tests, such as: Youth Self Report (YSR) to measure psychological functioning; Multi-Attitude Suicide Tendency Scale (MAST) to define suicide risk; Beck Depression Inventory (BDI) to evaluate depressive symptoms.

PS-01-005 Psychological characteristics of Italian gender dysphoric adolescents: a case control study

PS-01-005 Psychological characteristics of Italian gender dysphoric adolescents: a case control study

Psychological characteristics of Italian gender dysphoric adolescents: a case-control study.

Gender dysphoria (GD) is associated with clinically significant distress and impairment in social, scholastic, and other important areas of functioning, especially when early onset is reported. The aim of the present study is to assess the psychopathological features associated with GD in adolescence, comparing a group of gender dysphoric adolescents (GDs) with a group of non-referred adolescents (NRs), in terms of body uneasiness, suicide risk, psychological functioning, and intensity of GD. A sample of 46 adolescents with GD and 46 age-matched NRs was evaluated (mean ± SD age = 16.00 ± 1.49 and 16.59 ± 1.11 respectively, p > 0.05). Subjects were asked to complete the Body Uneasiness Test (BUT) to explore body uneasiness, the Youth Self Report (YSR) to measure psychological functioning, the Multi-Attitude Suicide Tendency Scale (MAST) for suicide risk, and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) for GD assessment. Adolescents with GD reported significantly higher levels of body uneasiness (BUT-GSI, F = 380.13, p < 0.0001), as well as a worse psychological functioning (YSR, F = 13.06 and p < 0.0001 for "total problem scale" and F = 12.53, p = 0.001 for "internalizing" scale) as compared to NRs. When YSR subscales were considered, GDs showed significantly higher scores in the "withdrawal/depression", "anxiety/depression", and "social problems" (all p < 0.0001). In addition, GDs showed significantly higher levels in the "attraction to death" and "repulsion by life" scales and lower scores in the "attraction to life" scale (all p < 0.0001). Finally, GIDYQ-AA score was significantly lower (meaning a higher level of gender dysphoria symptoms) in GDs vs. NRs (p < 0.0001). GD adolescents reported significantly higher body dissatisfaction and suicidal risk compared to NRs. In addition, results confirmed a significant impairment in social psychological functioning in adolescents with GD.

Efficacy and Safety of Gonadotropin-Releasing Hormone Agonist Treatment to Suppress Puberty in Gender Dysphoric Adolescents

IntroductionPuberty 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. AimTo evaluate the efficacy and safety of GnRHa treatment to suppress puberty in gender dysphoric adolescents. MethodsForty-nine male-to-female and 67 female-to-male gender dysphoric adolescents treated with triptorelin were included in the analysis. Main Outcome MeasuresPhysical 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. ResultsGnRHa 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. ConclusionTriptorelin 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.

Perceptions of Sex, Gender, and Puberty Suppression: A Qualitative Analysis of Transgender Youth.

International guidelines recommend the use of Gonadotropin-Releasing Hormone (GnRH) agonists in adolescents with gender dysphoria (GD) to suppress puberty. Little is known about the way gender dysphoric adolescents themselves think about this early medical intervention. The purpose of the present study was (1) to explicate the considerations of gender dysphoric adolescents in the Netherlands concerning the use of puberty suppression; (2) to explore whether the considerations of gender dysphoric adolescents differ from those of professionals working in treatment teams, and if so in what sense. This was a qualitative study designed to identify considerations of gender dysphoric adolescents regarding early treatment. All 13 adolescents, except for one, were treated with puberty suppression; five adolescents were trans girls and eight were trans boys. Their ages ranged between 13 and 18 years, with an average age of 16 years and 11 months, and a median age of 17 years and 4 months. Subsequently, the considerations of the adolescents were compared with views of clinicians treating youth with GD. From the interviews with the gender dysphoric adolescents, three themes emerged: (1) the difficulty of determining what is an appropriate lower age limit for starting puberty suppression. Most adolescents found it difficult to define an appropriate age limit and saw it as a dilemma; (2) the lack of data on the long-term effects of puberty suppression. Most adolescents stated that the lack of long-term data did not and would not stop them from wanting puberty suppression; (3) the role of the social context, for which there were two subthemes: (a) increased media-attention, on television, and on the Internet; (b) an imposed stereotype. Some adolescents were positive about the role of the social context, but others raised doubts about it. Compared to clinicians, adolescents were often more cautious in their treatment views. It is important to give voice to gender dysphoric adolescents when discussing the use of puberty suppression in GD. Otherwise, professionals might act based on assumptions about adolescents’ opinions instead of their actual considerations. We encourage gathering more qualitative research data from gender dysphoric adolescents in other countries.Electronic supplementary materialThe online version of this article (doi:10.1007/s10508-016-0764-9) contains supplementary material, which is available to authorized users.

HP-03-006 Psychological characteristics of gender dysphoric adolescents sample compared to a control group

HP-03-006 Psychological characteristics of gender dysphoric adolescents sample compared to a control group

Consecutive lynestrenol and cross-sex hormone treatment in biological female adolescents with gender dysphoria: a retrospective analysis.

BackgroundPrior to the start of cross-sex hormone therapy (CSH), androgenic progestins are often used to induce amenorrhea in female to male (FtM) pubertal adolescents with gender dysphoria (GD). The aim of this single-center study is to report changes in anthropometry, side effects, safety parameters, and hormone levels in a relatively large cohort of FtM adolescents with a diagnosis of GD at Tanner stage B4 or further, who were treated with lynestrenol (Orgametril®) monotherapy and in combination with testosterone esters (Sustanon®).MethodsA retrospective analysis of clinical and biochemical data obtained during at least 6 months of hormonal treatment in FtM adolescents followed at our adolescent gender clinic since 2010 (n = 45) was conducted. McNemar’s test to analyze reported side effects over time was performed. A paired Student’s t test or a Wilcoxon signed-ranks test was performed, as appropriate, on anthropometric and biochemical data. For biochemical analyses, all statistical tests were done in comparison with baseline parameters. Patients who were using oral contraceptives (OC) at intake were excluded if a Mann-Whitney U test indicated influence of OC.ResultsMetrorrhagia and acne were most pronounced during the first months of monotherapy and combination therapy respectively and decreased thereafter. Headaches, hot flushes, and fatigue were the most reported side effects. Over the course of treatment, an increase in musculature, hemoglobin, hematocrit, creatinine, and liver enzymes was seen, progressively sliding into male reference ranges. Lipid metabolism shifted to an unfavorable high-density lipoprotein (HDL)/low-density lipoprotein (LDL) ratio; glucose metabolism was not affected. Sex hormone-binding globulin (SHBG), total testosterone, and estradiol levels decreased, and free testosterone slightly increased during monotherapy; total and free testosterone increased significantly during combination therapy. Gonadotropins were only fully suppressed during combination therapy. Anti-Müllerian hormone (AMH) remained stable throughout the treatment. Changes occurred in the first 6 months of treatment and remained mostly stable thereafter.ConclusionsTreatment of FtM gender dysphoric adolescents with lynestrenol monotherapy and in combination with testosterone esters is effective, safe, and inexpensive; however, suppression of gonadotropins is incomplete. Regular blood controls allow screening for unphysiological changes in safety parameters or hormonal levels and for medication abuse.

Hormone treatment of children and adolescents with gender dysphoria: an ethical analysis.

In the context of transgender health, most people are not comfortable with allowing a twelve-year-old child with gender dysphoria to elect to undergo gender reassignment surgery. The likelihood is too high that the child would be unable to fully comprehend the scope of a decision that carries significant, permanent consequences, particularly because the decision to surgically change gender is based upon a conception of gender that can fluctuate during adolescent years. Conversely, however, most people would not contend that this fluidity is reason to wholly deny certain medical care such as hormonal treatments to transgender youth, a demographic with extremely high rates of violent behavior, self-harm, and suicide. This paper will explore ethical considerations to this emerging debate of what therapeutic options should be offered to transgender children and adolescents. Pediatric endocrinologists have been treating gender dysphoric adolescents with puberty-suppressing drugs and, to a lesser extent, with cross-sex hormone therapies for more than twenty years. Clinicians and thought leaders have mentioned ethical components of this emerging practice in the few cohort studies and clinical review articles about the subject. However, ethics have generally been a secondary consideration in the medical academic literature. In this paper, I will provide a brief overview of the practice, summarize the current research on hormone treatment for transgender minors, and provide an ethical analysis of the practice.

Geschlechtsdysphorie im Kindes- und Jugendalter

Despite rising demand for treatment, far too few specialist services for gender dysphoric children and adolescents exist. Due to complex issues related to indication of physical treatment with lifelong consequences a thorough interdisciplinary treatment service with development-related evaluation is necessary. The aim of this paper is to outline the professional and social tension, in which the practitioner works, as well as to provide insight into the diversity of developmental trajectories and difficult decisions or dilemmas.

Medical treatment in gender dysphoric adolescents endorsed by SIAMS-SIE-SIEDP-ONIG.

Despite international guidelines being available, not all gender clinics are able to face gender dysphoric (GD) youth population needs specifically. This is particularly true in Italy. Centers offering specialized support are relatively few and a commonly accepted Italian approach to GD youth has still not been defined. The aim of the present Position Statement is to develop and adhere to Italian guidelines for treatment of GD adolescents, in line with the "Dutch Approach", the Endocrine Society (ES), and the World Professional Association for Transgender Health (WPATH) guidelines. An in-depth brainstorming on the application of International guidelines in the Italian context was performed by several dedicated professionals. A staged approach, combining psychological support as well as medical intervention is suggested. In the first phase, individuals requesting medical help will undergo a psycho-diagnostic procedure to assess GD; for eligible adolescents, pubertal suppression should be made available (extended diagnostic phase). Finally, from the age of 16 years, cross-sex hormonal therapy can be added, and from the age of 18 years, surgical sex reassignment can eventually be performed. The current inadequacy of Italian services offering specialized support for GD youth may lead to negative consequences. Omitting or delaying treatment is not a neutral option. In fact, some GD adolescents may develop psychiatric problems, suicidality, and social marginalization. With access to specialized GD services, emotional problems, as well as self-harming behavior, may decrease and general functioning may significantly improve. In particular, puberty suppression seems to be beneficial for GD adolescents by relieving their acute suffering and distress and thus improving their quality of life.

Behavioral and Emotional Problems on the Teacher’s Report Form: A Cross-National, Cross-Clinic Comparative Analysis of Gender Dysphoric Children and Adolescents

For gender dysphoric children and adolescents, the school environment may be challenging due to peer social ostracism and rejection. To date, information on the psychological functioning and the quality of peer relations in gender dysphoric children and adolescents has been studied via parental report, peer sociometric methods, and social interactions in laboratory play groups. The present study was the first cross-national investigation that assessed behavior and emotional problems and the quality of peer relations, both measured by the Teacher's Report Form (TRF), in a sample of 728 gender dysphoric patients (554 children, 174 adolescents), who were referred to specialized gender identity clinics in the Netherlands and Canada. The gender dysphoric adolescents had significantly more teacher-reported emotional and behavioral problems than the gender dysphoric children. In both countries, gender dysphoric natal boys had poorer peer relations and more internalizing than externalizing problems compared to the gender dysphoric natal girls. Furthermore, there were significant between-clinic differences: both the children and the adolescents from Canada had more emotional and behavioral problems and a poorer quality of peer relations than the children and adolescents from the Netherlands. In conclusion, gender dysphoric children and adolescents showed the same pattern of emotional and behavioral problems in both countries. The extent of behavior and emotional problems was, however, higher in Canada than in the Netherlands, which appeared, in part, an effect of a poorer quality of peer relations. Per Bronfenbrenner's (American Psychologist, 32, 513-531, 1977) ecological model of human development and well-being, we consider various interpretations of the cross-national, cross-clinic differences on TRF behavior problems at the level of the family, the peer group, and the culture at large.

Commentary on the Treatment of Gender Variant and Gender Dysphoric Children and Adolescents: Common Themes and Ethical Reflections

This commentary offers preliminary ethical reflections on the range of treatments for gender variant and gender dysphoric children, adolescents, and young adults described in the preceding five clinical articles. After clarifying the terminology used to discuss these issues, this commentary reviews several common themes of the clinical articles. Focusing on ethical values of informed consent, full disclosure, the minimization or avoidance of harm, and the maximization of life options, the commentary expresses concerns about various treatment options endorsed by some of the articles. In particular, this commentary focuses on how these practices problematically reproduce social prejudices and stereotypes and how they fail to acknowledge and embrace the multiple pathways for expressing one's gender. It also compares and contrasts the ethical issues related to gender variant and gender dysphoric youths and youths who identify as lesbian, gay, bisexual, or queer.

Clinical Management of Gender Dysphoria in Children and Adolescents: The Dutch Approach

The 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.

Treatment of Adolescents With Gender Dysphoria in the Netherlands

In the Netherlands, gender dysphoric adolescents may be eligible for puberty suppression at age 12, subsequent cross-sex hormone treatment at age 16, and gender reassignment surgery at age 18. Initially, a thorough assessment is made of the gender dysphoria and vulnerabilities in functioning or circumstances. Psychological interventions and/or gender reassignment may be offered. Psychological interventions are offered if the adolescent needs to explore gender identity and treatment wishes, suffers from coexisting problems, or needs support and counseling during gender reassignment. Although more studies are necessary, this approach seems to contribute significantly to the well-being of gender dysphoric adolescents.

Sibling Sex Ratio and Birth Order in Early-Onset Gender Dysphoric Adolescents

Several sibship-related variables have been studied extensively in sexual orientation research, especially in men. Sibling sex ratio refers to the ratio of brothers to sisters in the aggregate sibships of a group of probands. Birth order refers to the probands’ position (e.g., first-born, middle-born, last-born) within their sibships. Fraternal birth order refers to their position among male siblings only. Such research was extended in this study to a large group of early-onset gender dysphoric adolescents. The probands comprised 94 male-to-female and 95 female-to-male gender dysphoric adolescents. The overwhelming majority of these were homosexual or probably prehomosexual. The control group consisted of 875 boys and 914 girls from the TRAILS study. The sibling sex ratio of the gender dysphoric boys was very high (241 brothers per 100 sisters) compared with the expected ratio (106:100). The excess of brothers was more extreme among the probands’ older siblings (300:100) than among their younger siblings (195:100). Between-groups comparisons showed that the gender dysphoric boys had significantly more older brothers, and significantly fewer older sisters and younger sisters, than did the control boys. In contrast, the only notable finding for the female groups was that the gender dysphoric girls had significantly fewer total siblings than did the control girls. The results for the male probands were consistent with prior speculations that a high fraternal birth order (i.e., an excess of older brothers) is found in all homosexual male groups, but an elevated sibling sex ratio (usually caused by an additional, smaller excess of younger brothers) is characteristic of gender dysphoric homosexual males. The mechanisms underlying these phenomena remain unknown.

Psychiatric comorbidity in gender dysphoric adolescents

This study examined psychiatric comorbidity in adolescents with a gender identity disorder (GID). We focused on its relation to gender, type of GID diagnosis and eligibility for medical interventions (puberty suppression and cross-sex hormones). To ascertain DSM-IV diagnoses, the Diagnostic Interview Schedule for Children (DISC) was administered to parents of 105 gender dysphoric adolescents. 67.6% had no concurrent psychiatric disorder. Anxiety disorders occurred in 21%, mood disorders in 12.4% and disruptive disorders in 11.4% of the adolescents. Compared with natal females (n = 52), natal males (n = 53) suffered more often from two or more comorbid diagnoses (22.6% vs. 7.7%, p = .03), mood disorders (20.8% vs. 3.8%, p = .008) and social anxiety disorder (15.1% vs. 3.8%, p = .049). Adolescents with GID considered to be 'delayed eligible' for medical treatment were older [15.6 years (SD = 1.6) vs. 14.1 years (SD = 2.2), p = .001], their intelligence was lower [91.6 (SD = 12.4) vs. 99.1 (SD = 12.8), p = .011] and a lower percentage was living with both parents (23% vs. 64%, p < .001). Although the two groups did not differ in the prevalence of psychiatric comorbidity, the respective odds ratios ('delayed eligible' adolescents vs. 'immediately eligible' adolescents) were >1.0 for all psychiatric diagnoses except specific phobia. Despite the suffering resulting from the incongruence between experienced and assigned gender at the start of puberty, the majority of gender dysphoric adolescents do not have co-occurring psychiatric problems. Delayed eligibility for medical interventions is associated with psychiatric comorbidity although other factors are of importance as well.

Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-Year Follow-Up

Puberty suppression by means of gonadotropin releasing hormone (GnRH) analogs is considered a diagnostic aid in gender dysphoric adolescents. However, there are also concerns about potential risks, such as poor outcome or post-surgical regret, adverse effects on metabolic and endocrine status, impaired increment of bone mass, and interference with brain development. This case report is on a 22-year follow-up of a female-to-male transsexual, treated with GnRH analogs at 13 years of age and considered eligible for androgen treatment at age 17, and who had gender reassignment surgery at 20 and 22 years of age. At follow-up, he indicated no regrets about his treatment. He was functioning well psychologically, intellectually, and socially; however, he experienced some feelings of sadness about choices he had made in a long-lasting intimate relationship. There were no clinical signs of a negative impact on brain development. He was physically in good health, and metabolic and endocrine parameters were within reference ranges. Bone mineral density was within the normal range for both sexes. His final height was short as compared to Dutch males; however, his body proportions were within normal range. This first report on long-term effects of puberty suppression suggests that negative side effects are limited and that it can be a useful additional tool in the diagnosis and treatment of gender dysphoric adolescents.