Transgender Clinic Research Articles

Self-perception of transgender clinic referred gender diverse children and adolescents.

Transgender children and adolescents show high rates of co-occurring psychopathology, which might be related to low self-confidence. Earlier research showed that compared to the norm population, transgender clinic–referred children have lower self-perception on two domains: physical appearance and global self-worth. This study aimed to compare self-perception in a sample of transgender clinic–referred children and adolescents with their standardization samples and to examine differences between these two groups. To measure self-esteem, the Self-Perception Profile for Children was administered to 305 referred children (162 assigned males at birth (AMABs) and 143 assigned females at birth (AFABs), mean age = 9.05 (SD, 1.47), range = 5.9–13.00 years), and the Self-Perception Profile for Adolescents was administered to 369 referred adolescents (118 AMABs and 251 AFABs, mean age = 15.27 (SD, 1.80), range = 10.73–18.03 years). To measure the severity of gender dysphoria, the parents of the children completed the Gender Identity Questionnaire and the adolescents completed the Utrecht Gender Dysphoria Scale. Referred children and adolescents had a significantly lower self-concept compared to the normative population, whereby referred adolescents felt less competent compared to referred children. Compared to their peers, childhood referred AFABs perceived themselves even better on scholastic and athletic competence and social acceptance. With regard to gender differences, referred AFABs generally showed a better self-perception compared to referred AMABs. The lower self-perception of transgender clinic–referred children and adolescents compared to same age peers deserves clinical attention and interventions aimed at, for example, improving social and physical self-worth.

Effectiveness of a Gender Affirming Surgery Class for Transgender and non-binary Patients and their Caregivers in an Integrated Healthcare Setting

Background: Gender affirming surgeries are increasingly accessible to transgender and non-binary individuals due to changes in health care coverage policies and rising numbers of trained providers. Improved access to care has led to an increase in the number of individuals pursuing gender affirming surgeries. Little is known about how to optimally prepare patients for these surgeries.Aims: This evaluation examined attendees’ assessment of a four-hour single-session class developed to prepare transgender and non-binary patients and their caregivers for gender affirming surgeries in a multi-disciplinary transgender clinic within an integrated health care system.Methods: A multi-disciplinary group of providers within a health maintenance organization in Northern California designed and facilitated two separate curricula, one for patients preparing for metoidioplasty/phalloplasty and the other preparing for vaginoplasty. Between November 2015 and June 2017, 214 patients and caregivers took one of the two versions of the class and completed the post-class survey evaluating perceived favorability of the class and preparedness regarding surgery options, complications and postoperative care. Descriptive statistics were used to summarize the Likert scale questions, with 1 showing the least improvement and 5 showing the most.Results: Of the 214 patients and caregivers that completed the survey, the majority reported that they were better informed about their surgical options (mean: 4.4, SD: 0.7), more prepared for surgery (mean: 4.5, SD: 0.6), better informed about possible complications (mean: 4.5, SD: 0.7), and better understood their postoperative care needs (mean: 4.6, SD: 0.6). Of the respondents, 204 (95%) reported they would recommend the course to a friend preparing for gender affirming surgery.Discussion: Our findings demonstrate that a single-session class is a favorable method for preparing transgender and non-binary patients to make informed decisions regarding the perioperative gender affirming surgical process, from preoperative preparedness, to surgical complications, and postoperative care.

Disordered Eating in a Transgender Clinic: A Function of Body Shape Concern

Disordered Eating in a Transgender Clinic: A Function of Body Shape Concern

Characteristics of Adolescents Referred to a Gender Clinic: Are Youth Seen Now Different from Those in Initial Reports?

Background/Aims: To examine characteristics, including mental health comorbidities, among adolescents presenting to a transgender clinic and to compare these data to previous reports. Methods: Retrospective chart review among youth seen at The Hospital for Sick Children between January 2014 and June 2016. Demographic data, clinical characteristics, and mental health comorbidities were assessed. Baseline and repeat blood work were also examined. Results: Charts from 203 adolescents aged 12–18 years were reviewed (156 assigned female at birth [AFAB] (77%) aged 16.3 ± 1.63 years, 47 assigned male at birth [AMAB] aged 16.1 ± 1.70 years). There was no statistically significant difference between gender groups except for Tanner stage (AFAB, mean 4.42 ± 0.8 and AMAB, mean 4.03 ± 1.1, p = 0.040). Individuals from racial/ethnic minority populations were under-represented compared to the background population. Self-report and baseline psychological questionnaires showed high levels of gender dysphoria, mood disorders, and suicidal ideation, with higher levels of anxiety detected on questionnaires among AFAB (p = 0.03). Laboratory abnormalities identified on baseline and repeat testing were minor; on cross-sex hormones, hemoglobin levels increased slightly in AFAB (p = 0.002, highest = 166 g/L) and decreased among AMAB (p = 0.02, lowest = 132 g/L). Conclusion: Our study supports an evolving demographic trend with more AFAB than AMAB youth now presenting to gender clinics. The data also corroborate studies indicating that extensive laboratory testing may not be a necessary part of caring for these youths. Why more AFAB are now presenting to clinic and racial/ethnic minorities are underrepresented is not clear, but these trends have important implications for clinical care and warrant further study.

Review of Current Care Models for Transgender Youth and Application to the Development of a Multidisciplinary Clinic - The Seattle Children's Hospital Experience.

Care of transgender and gender diverse youth is complex and requires a multidisciplinary approach. Many transgender patients and providers feel the limited availability of affirming, knowledgeable professionals is a barrier to obtaining care. Such care can be provided through a clinic with providers from different disciplines who are trained in the unique care of transgender youth. In this paper, we discuss the care guidelines for transgender youth and the unresolved challenges that need to be addressed during the development of a transgender clinic. We describe our experience at Seattle Children's Hospital in the development of a multidisciplinary Gender Clinic which incorporates the expertise of social work, mental health professionals, pediatric endocrinology, adolescent medicine, and bioethics. Other institutions may build from our experience, with the ultimate goal of further decreasing health disparities for young transgender patients.

Teaching paediatric transgender care.

We aimed to evaluate the effect of online modules - as stand-alone training - on paediatric transgender-related self-perceived knowledge, objective knowledge, and clinical self-efficacy of learners. We previously evaluated the online modules as part of a larger curriculum that included observation in a paediatric transgender clinic, and assessed change in self-perceived knowledge. Paediatric interns, psychiatry interns, fourth-year medical students and nurse practitioner students were administered assessments before and after the completion of six online modules focused on medical and psychosocial considerations for transgender youth. The assessments queried learner demographics and transgender clinical exposure. Nine items tested transgender-related objective knowledge. Twenty-four items asked learners to rate self-perceived transgender-specific knowledge (1, not at all knowledgeable; 5, completely knowledgeable). Thirteen self-efficacy items asked learners to rate confidence in their ability to evaluate and counsel these youth (0,not at all confident; 10, completely confident). Overall and subscores were calculated for each domain. Wilcoxon signed-rank tests were used to compare the pre- and post-module scores. Thirty-six learners were eligible to join the study and 86% (n=31) participated. Among the participants, 90% (n=28) completed both assessments. The median number of transgender patients seen before the curriculum was one, and 10% had past experience in a transgender clinic. Comparing pre- and post-module scores, the overall objective knowledge scores increased from 22 to 56% (p<0.001), self-perceived knowledge scores increased from 1.8 to 3.8 (p<0.001) and self-efficacy scores increased from 3.5 to 7.0 (p<0.001). [What is] the effect of online modules on paediatric transgender-related self-perceived knowledge [?] DISCUSSION: This study suggests that e-learning was an effective stand-alone intervention to enhance transgender-related knowledge and self-efficacy in interdisciplinary learners.

204 - Using E-Learning to Enhance Interdisciplinary Pediatric Learners' Transgender-Related Objective Knowledge, Self-Perceived Knowledge and Clinical Self-Efficacy

Purpose: Our transgender youth curriculum is comprised of online modules and an observership in a pediatric transgender clinic. Previously, we demonstrated that our curriculum led to improvement in learner self-perceived knowledge. This study aims to evaluate the online modules as a stand-alone intervention and their impact on transgender-related self-perceived knowledge and two parameters not previously explored: transgender-related objective knowledge and clinical self-efficacy in evaluating and counseling transgender youth.

The Response of the Menstrual Cycle to Initiation of Hormonal Therapy in Transgender Men.

Purpose: Transition from female to male gender after initiation of hormonal therapy involves both phenotypic and physiological changes. The response to treatment can vary widely from person to person. In this study, we looked at the response of the menstrual cycle after the initiation of testosterone therapy and we wished to determine the time period and dose of testosterone leading to the cessation of menses in transgender men.Methods: A retrospective chart review of 114 transgender men (individuals assigned female gender at birth but later identify themselves as males) seen for hormonal therapy in our transgender clinic from 2006 through 2016.Results: Forty patients were excluded from the study as they were either not menstruating (19), started therapy elsewhere (13), had incomplete data (6), or were treated with transdermal testosterone (2). Of the 74 patients begun on low dose (20–40 mg weekly) intramuscular testosterone, 55% had cessation of menses within 6 months, 32% took more than 6 to 12 months, and 7% had not had complete cessation by 1 year and were prescribed progesterone (5% were given progesterone after menses had not ceased by 4 months for personal preference). The dose of testosterone correlated only loosely with the time of cessation (mean dose 40.1±8.1 mg/week for those <6 months and 56.1±12.0 mg/week for those who took 6–12 months).Conclusion: The initiation of low to moderate testosterone was sufficient in leading to menstrual cessation in the majority of patients by 6 months and nearly all by 1 year. There was individual variability in the time to cessation with little correlation to testosterone dose.

Health Concerns of Transgender and Gender Nonconforming Youth and Their Parents Upon Presentation to a Transgender Clinic

PurposeThe purpose of the study was to determine the frequency of specific health concerns identified by transgender and gender nonconforming patients and their parents at initial clinic visit. MethodsChecklists were developed in an iterative process and distributed to both patients and parents at their initial visit to a transgender clinic. Retrospective chart review and secondary data analyses were performed to determine the number of items endorsed, frequency with which each item was endorsed, and provider domain of each item endorsed: physician, social work, or both physician and social work. ResultsChecklists were collected from 118 patients and 103 parents. Patients endorsed a mean of 8.4 concerns (range 0–22) and parents 7.9 concerns (range 0–20). The most commonly endorsed patient concerns included use of gender-affirming hormones, steps for transition, gender-affirming surgery, restroom/dressing room use, and legal issues. Common parent concerns included general resources, child safety at school, acute mental health concerns, restroom/dressing room use, and steps for transition. Of the concerns endorsed by patients, 44% were in the social work domain, 37% in the physician domain, and 19% in both the social work and physician domain. Of the concerns endorsed by parents, 40% were in the social work domain, 31% in the physician domain, and 29% in the social work and physician domain. ConclusionsAlthough patients and parents had similar numbers of concerns, they primarily focused on different topics. Youth were more interested in hormones and transition, while parents were more interested with transition and acceptance. Many concerns for both patients and parents fell within the social work domain.

The Biologic Basis of Transgender Identity: 2D:4D Finger Length Ratios Implicate A Role for Prenatal Androgen Activity

The biologic basis for gender identity is unknown. Research has shown that the ratio of the length of the second and fourth digits (2D:4D) in mammals is influenced by biologic sex in utero, but data on 2D:4D ratios in transgender individuals are scarce and contradictory. We investigated a possible association between 2D:4D ratio and gender identity in our transgender clinic population in Albany, New York. We prospectively recruited 118 transgender subjects undergoing hormonal therapy (50 female to male [FTM] and 68 male to female [MTF]) for finger length measurement. The control group consisted of 37 cisgender volunteers (18 females, 19 males). The length of the second and fourth digits were measured using digital calipers. The 2D:4D ratios were calculated and analyzed with unpaired t tests. FTM subjects had a smaller dominant hand 2D:4D ratio (0.983 ± 0.027) compared to cisgender female controls (0.998 ± 0.021, P = .029), but a ratio similar to control males (0.972 ± 0.036, P =.19). There was no difference in the 2D:4D ratio of MTF subjects (0.978 ± 0.029) compared to cisgender male controls (0.972 ± 0.036, P = .434). Our findings are consistent with a biologic basis for transgender identity and the possibilities that FTM gender identity is affected by prenatal androgen activity but that MTF transgender identity has a different basis. 2D:4D = 2nd digit to 4th digit; FTM = female to male; MTF = male to female.

Self-Perception of “Normality” or “Abnormality” in Colombian Trans people

During the last century, the conceptualization and diagnosis of gender incongruence has varied under the influence of moral, political, and medical approaches as is reflected during the last decades both in the ICD and the DSM classifications. Although the DSM-5 (2013) gender dysphoria diagnosis still implies a certain degree of pathologization, the ICD-11 (Gender incongruence) will not probably classify transsexualism as a mental health condition. The trend is to consider gender incongruence as a normal variation on a continuum of gender identity. In this context, the purpose of this qualitative study was to answer the following research question: What degree of psychological normality or abnormality do trans people perceive in their gender incongruence? The study was conducted using a convenience sample of 15 Colombian trans-persons (10 trans-women and 5 trans-men). Nine of the participants were recruited at the Universidad de Caldas Transgender Clinic in the city of Manizales, Colombia, South America; and the other six were contacted through the Health Sciences Research Center of the Universidad Autónoma de Bucaramanga (UNAB) in Bucaramanga, Colombia.

Insuring Care: Paperwork, Insurance Rules, and Clinical Labor at a U.S. Transgender Clinic.

What is a clinician to do when people needing medical care do not have access to consistent or sufficient health insurance coverage and cannot pay for care privately? Analyzing ethnographically how clinicians at a university-based transgender clinic in the United States responded to this challenge, I examine the U.S. health insurance system, insurance paperwork, and administrative procedures that shape transgender care delivery. To buffer the impact of the system's failure to provide sufficient health insurance coverage for transgender care, clinicians blended administrative routines with psychological therapy, counseled people's minds and finances, and leveraged the prestige of their clinic in attempts to create space for gender nonconforming embodiments in gender conservative insurance policies. My analysis demonstrates that in a market-based health insurance system with multiple payers and gender binary insurance rules, health care may be unaffordable, or remain financially challenging, even for transgender people with health insurance. Moreover, insurance carriers' "reliance" on clinicians' insurance-related labor is problematic as it exacerbates existing insurance barriers to the accessibility and affordability of transgender care and obscures the workings of a financial payment model that prioritizes economic expediency over gender nonconforming health.

Screening for Spiritual Struggle in an Adolescent Transgender Clinic: Feasibility and Acceptability

Spiritual struggles are associated with poorer health outcomes, including depression, which has higher prevalence among transgender individuals than the general population. This study’s objective was to improve the quality of care in an outpatient transgender clinic by screening patients and caregivers for spiritual struggle and future intervention. The quality improvement questions addressed were whether screening for spiritual struggle was feasible and acceptable; and whether the sensitivity and specificity of the Rush Protocol were acceptable. Revision of the screening was based on cognitive interviews with the 115 adolescents and caregivers who were screened. Prevalence of spiritual struggle was 38–47%. Compared to the Negative R-COPE, the Rush Protocol screener had sensitivities of 44–80% and specificities of 60–74%. The Rush Protocol was acceptable to adolescents seen in a transgender clinic, caregivers, and clinic staff; was feasible to deliver during outpatient clinic visits, and offers a straightforward means of identifying transgender persons and caregivers experiencing spiritual struggle.

Health Concerns Identified by Transgender Youth and Their Caregivers Upon Presentation to a Transgender Clinic

Health Concerns Identified by Transgender Youth and Their Caregivers Upon Presentation to a Transgender Clinic

004–The Evolution of Randall Children's Transgender Clinic

Background: In 2010, a clinic diabetic patient was noticeably depressed with increasing A1C and school difficulties. He confided with the social worker that he had always felt female. The goal to coordinate quality care for transgender youth began.

A New Perspective on Gender Dysphoria and Repetitive Sex Reassignment Surgeries

To the Editor: Gender identity disorder (GID), also known as gender dysphoria or transgender identity, refers to the experience of major dysphoria or dissatisfaction with the sex that individuals were assigned at birth and the gender responsibilities related to their sex.1,2 Nationwide, stigma attached to transsexualism has made it a commonly shunned condition (with transsexualism also being a commonly shunned term) that can profoundly impact individuals’ lives, especially if left untreated. We present a unique case of repetitive sex reassignment surgeries from male to female and back again to male in a 28-year-old patient and discuss the outcomes. Case report. A 28-year-old shy, depressed married man with a DSM-IV diagnosis of major depressive disorder was referred to a psychiatric lesbian, gay, bisexual, and transgender clinic and explained his sexual identity problem that had caused him depression, anxiety, and suicidal ideas and plans. Although he was married at age 20 years and had fathered 2 children, he was still struggling to be identified as a male. He described his desire to be a girl and how he used to dress up as a girl when he was 5 years old. At the time of the visit, he had divorced his wife, had abandoned his children, and planned to marry his male lover and to live with him as his wife. He was conscious of the impact of his decision on others and was feeling guilty about abandoning his family to marry a male partner, but was unable to restrain himself from carrying out his plans. The patient attended 20 hourly psychiatric sessions over 12 months before presenting to the clinic with no improvement. Further endocrinology evaluations and laboratory workups for hormonal imbalance revealed no abnormalities. He received 20 more hourly psychiatry sessions and cognitive therapy for 6 months with no improvement. He was then referred to urologists for additional evaluation for sex reassignment surgery, which was completed successfully. However, the patient returned 10 years later with worsening anxiety and depression and suicidal ideas and plans. She stated how she had been married happily and enjoying life with her lover, yet she gradually started struggling with her gender as a female and the desire to switch back to a male. Her symptoms were so severe that she had twice attempted suicide to end her emotional pain. She underwent concurrent psychiatric counseling and rehabilitation for 6 months with no improvement. The decision was made for her to be referred for sex reassignment surgery and hormone therapy, which were completed successfully and which were followed by significant improvement in the symptoms of depression, anxiety, and suicidal ideation at 6-month follow-up. There was no long-term follow-up on this patient and his fate. There are no recently updated data on the prevalence of gender dysphoria. According to scant research, the prevalence of gender dysphoria is projected to be approximately 1 in 30,000, although this number is thought to significantly underestimate the true prevalence. To ensure quality of life, transgender individuals need professional medical and mental health care to transition from their birth sexual identity to their internal sense of gender.3–5 Even if the number of gender dysphoric individuals is on the rise, there is little research regarding this population and their health care needs. Given the stigma surrounding this population, they are less likely to receive appropriate help, which can result in further mental and health turmoil. On the other hand, there are individuals who self-identify as transgender and seek extensive interventions to satisfy their internal sense of gender. This group ends up changing their physical appearance frequently from one gender to another. Given the scope of the public health burden of unnecessary repetitive procedures, it is important to conduct more comprehensive studies on this population to make sure they receive appropriate treatment and to prevent unnecessary costs. In conclusion, investigating gender dysphoria and the individuals’ transition over time can benefit the treatment of psychiatric disorders among transgender individuals. It is a responsibility of psychiatrists to explore the patient’s hidden motives behind change of gender to help that patient attain a greater inner relational freedom.