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Despite research exploring autism in gender-diverse adolescents, no studies have elicited these individuals’ perspectives. In-depth interviews with 22 well-characterized autistic gender-diverse adolescents revealed critical themes, including: recollections of pre-pubertal gender nonconformity; vivid experiences of gender dysphoria; a fear of social gender expression due to perceived animosity toward transgender people; and specific challenges that result from the interplay of gender diversity and neurodiversity. During the ~ 22 month study social gender affirmation increased in six participants and gender dysphoria attenuated in four participants. Given the ethical imperative to understand and prioritize the voiced perspectives and needs of autistic gender minority adolescents as well as the discovery of shared themes and experiences in this population, results should inform clinical research approaches and priorities.

This 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.

ObjectiveTo examine trends in diagnosis of gender dysphoria and related conditions in children and young people attending primary care practices in England.DesignLongitudinal analysis of electronic primary care records from the Clinical Practice Research Datalink (CPRD) Aurum database linked to hospital and Index of Multiple Deprivation data.SettingPrimary care practices in England between 2011 and 2021.Participants3782 patients aged 0–18 years with a recorded history of gender dysphoria/incongruence and matched comparators with autism spectrum conditions or eating disorder.Main outcome measuresIncidence rates and prevalence of gender dysphoria/incongruence; prescribing rates for medical treatments; co-occurrence of anxiety, depression and self-harm.ResultsBetween 2011 and 2021, incidence rates of recorded gender dysphoria/incongruence increased from 0.14 (95% CI 0.08 to 0.20) to 4.4 (95% CI 4.1 to 4.7) per 10 000 person years, and from 2014 the rate increased more rapidly in recorded females than males. There was no significant association between gender dysphoria/incongruence and area level deprivation. Of the 3782 children and young people with a record of gender dysphoria/incongruence, 176 (4.7%) were prescribed puberty suppressing hormones; 302 (8.0%) were prescribed masculinising/feminising hormones; and 1994 (52.7%) had a record of anxiety, depression or self-harm. Compared with matched comparators, those experiencing gender dysphoria/incongruence had similar recorded rates of anxiety and higher rates of depression and self-harm.ConclusionsRecorded prevalence of gender dysphoria/incongruence increased substantially in children and young people between 2011 and 2021, particularly in recorded females. Levels of anxiety, depression and self-harm were high, indicating an urgent need for better prevention and treatment of mental health difficulties in these patients.

Persons 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.

In adolescents with severe and persistent gender dysphoria (GD), gonadotropin releasing hormone analogues (GnRHa) are used from early/middle puberty with the aim of delaying irreversible and unwanted pubertal body changes. Evidence of outcomes of pubertal suppression in GD is limited. We undertook an uncontrolled prospective observational study of GnRHa as monotherapy in 44 12-15 year olds with persistent and severe GD. Prespecified analyses were limited to key outcomes: bone mineral content (BMC) and bone mineral density (BMD); Child Behaviour CheckList (CBCL) total t-score; Youth Self-Report (YSR) total t-score; CBCL and YSR self-harm indices; at 12, 24 and 36 months. Semistructured interviews were conducted on GnRHa. 44 patients had data at 12 months follow-up, 24 at 24 months and 14 at 36 months. All had normal karyotype and endocrinology consistent with birth-registered sex. All achieved suppression of gonadotropins by 6 months. At the end of the study one ceased GnRHa and 43 (98%) elected to start cross-sex hormones. There was no change from baseline in spine BMD at 12 months nor in hip BMD at 24 and 36 months, but at 24 months lumbar spine BMC and BMD were higher than at baseline (BMC +6.0 (95% CI: 4.0, 7.9); BMD +0.05 (0.03, 0.07)). There were no changes from baseline to 12 or 24 months in CBCL or YSR total t-scores or for CBCL or YSR self-harm indices, nor for CBCL total t-score or self-harm index at 36 months. Most participants reported positive or a mixture of positive and negative life changes on GnRHa. Anticipated adverse events were common. Overall patient experience of changes on GnRHa treatment was positive. We identified no changes in psychological function. Changes in BMD were consistent with suppression of growth. Larger and longer-term prospective studies using a range of designs are needed to more fully quantify the benefits and harms of pubertal suppression in GD.

Gender incongruence (GI) is defined as a condition in which the gender identity of a person does not align with the gender assigned at birth. Awareness and more social acceptance have paved the way for early medical intervention about two decades ago and are now part of good clinical practice although much robust data is lacking. Medical and mental treatment in adolescents with GI is complex and is recommended to take place within a team of mental health professionals, psychiatrists, endocrinologists, and other healthcare providers. The somatic treatment generally consists of the use of GnRH analogues to prevent the progression of biological puberty and subsequently gender-affirming hormonal treatment to develop sex characteristics of the self-identified gender and surgical procedures. However to optimize treatment regimens, long-term follow-up and additional studies are still needed.What is known• The prevalence of gender dysphoria increased significantly in the past years and can lead to significant complaints and burdens especially during puberty.• Pubertal suppression and gender-affirmed treatment can be effectively used in adolescence with gender dysphoria.What is new• Transgender mental and medical healthcare is a long-lasting process during which not only the child/adolescent with GI but also their parents/family have to be counseled in making choices about their social, medical, and legal transitions.• There are an increasing number of transgender persons defining as nonbinary. Therefore, an individualized approach by an experienced team is necessary.

ObjectivesFor transgender and gender-diverse (TGD) people, it is known that there is a lack of healthcare professionals with experience in trans healthcare. This may result in either inadequate provision of healthcare or in an increased seeking of adequate trans healthcare. Little is known about healthcare services utilisation and resulting costs in treatment-seeking TGD people with gender incongruence or gender dysphoria (GIC/GD). Therefore, the aim of this study was to determine the excess costs associated with GIC/GD in Germany.DesignIn a secondary analysis, baseline data of a randomised controlled trial with a sample of TGD people with GIC/GD were combined with data of a telephone survey conducted in a representative sample of the general German population. The data sets were matched using entropy balancing. Self-reported healthcare services utilisation was valued by standardised unit costs for the German healthcare system, and absenteeism from work and unemployment were valued with the gross hourly wage of persons in manufacturing and services sectors.SettingsTGD people with GIC/GD living at least 50 km outside Hamburg in the federal state Bremen, Mecklenburg-Western Pomerania, Lower Saxony or Schleswig Holstein and the German general adult population.ParticipantsTreatment-seeking TGD people with GIC/GD (n=167) and people of the general German population (n=2811).Primary and secondary outcome measures6-month excess healthcare costs and indirect costs from a societal perspective were calculated for the year 2020 using two-part models with logit specification for the first part and a generalised linear model with gamma family and log link function for the second part.ResultsThe total 6-month excess costs associated with GIC/GD from a societal perspective were estimated to be €672 (95% CI: €−3315 to €4657; p=0.741) per person. The direct excess healthcare costs were estimated to be €2 (€−1115 to €1119; p=0.977) and the indirect excess costs due to absenteeism from work and unemployment were €669 (€−3031 to €4370; p=0.723) per person. The total excess costs associated with GIC/GD in trans men, trans women and non-binary people were estimated to be €−5572 (€−12 232 to €1088), €4238 (€−1694 to €10 170) and €3041 (€−4268 to €10 351) per person (all with p>0.05), respectively.ConclusionsThe total 6-month costs in TGD people with GIC/GD did not differ statistically significantly from the costs in the general German population. Indirect excess costs due to absenteeism from work accounted for the largest part of the excess costs associated with GIC/GD, yet with wide 95% CIs. Potential causes of absenteeism from work, such as experienced or expected discrimination, need to be identified and addressed so that TGD people can experience a healthy work environment.Trial registration numberNCT04290286.

Autism spectrum disorders (ASD) and attention-deficit hyperactivity disorder (ADHD) can compromise health and may be more prevalent amongst individuals with gender dysphoria (GD). Symptoms such as attention or social difficulties can impact assessment of GD, understanding of health information, and engagement in clinical care. To ensure neurodevelopmental conditions are adequately considered in gender health services, we aimed to systematically review the literature examining the prevalence of ASD and ADHD amongst individuals with GD. In this systematic review based on the PRISMA guidelines. MEDLINE and PsycINFO databases were searched for studies examining the prevalence of ASD and/or ADHD in individuals with GD or investigated the rate of GD in cohorts with ASD or ADHD. All English peer-reviewed publications were included. The search strategy identified 179 studies. After applying exclusion criteria, a total of 30 studies were identified, 22 studies which examined the prevalence of ASD or ADHD in people with GD. A further 8 studies examined the reverse; prevalence of GD in people with ASD. The few studies employing diagnostic criteria for ASD suggest a prevalence of 6–26% in transgender populations, higher than the general population, but no different from individuals attending psychiatry clinics. Few studies examine prevalence of ADHD. Low-level evidence exists to suggest a link between ASD and GD. Further population-based and controlled studies using diagnostic criteria for ASD and ADHD are required.

Abstract Context Erythrocytosis is a known side effect of testosterone therapy that can increase the risk of thromboembolic events. Objectives To study the prevalence and determinants in the development of erythrocytosis in trans men using testosterone. Methods A 20-year follow-up study in adult trans men who started testosterone therapy and had monitoring of hematocrit at our center (n = 1073). Results Erythrocytosis occurred in 11% (hematocrit > 0.50 L/L), 3.7% (hematocrit > 0.52 L/L), and 0.5% (hematocrit > 0.54 L/L) of trans men. Tobacco use (odds ratio [OR] 2.2; 95% CI, 1.6-3.3), long-acting undecanoate injections (OR 2.9; 95% CI, 1.7-5.0), age at initiation of hormone therapy (OR 5.9; 95% CI, 2.8-12.3), body mass index (BMI) (OR 3.7; 95% CI, 2.2-6.2), and pulmonary conditions associated with erythrocytosis and polycythemia vera (OR 2.5; 95% CI, 1.4-4.4) were associated with hematocrit > 0.50 L/L. In the first year of testosterone therapy hematocrit increased most: 0.39 L/L at baseline to 0.45 L/L after 1 year. Although there was only a slight continuation of this increase in the following 20 years, the probability of developing erythrocytosis still increased (10% after 1 year, 38% after 10 years). Conclusion Erythrocytosis occurs in trans men using testosterone. The largest increase in hematocrit was seen in the first year, but also after the first years a substantial number of people present with hematocrit > 0.50 L/L. A reasonable first step in the care for trans men with erythrocytosis while on testosterone is to advise them to quit smoking, to switch to a transdermal administration route, and if BMI is high, to lose weight.