Faculty Bibliography

Gender variance and dysphoria are present across all classes, ethnicities, and experiences, including among those with severe and chronic mental illness. In these, our most vulnerable populations, adequate assessment and treatment of gender dysphoria often is overlooked despite evidence that appropriate treatment of gender dysphoria leads to improvement in psychological functioning (Smith, van Goozen, Kuiper, & Cohen-Kettenis, 2005). The World Professional Association for Transgender Health recommend in their Standards of Care that somatic and surgical treatments for gender dysphoria should be made available to those with medical or mental illness with the caveat that "[the illness] must be reasonably well-controlled (2011)." In this article, we will utilize case-based material to elucidate the challenges of treating gender dysphoria in the context of complex mental illness such as bipolar disorder, schizophrenia, and sexual trauma, and the pitfalls of defining "well-controlled" for the sake of treatment.

In addition to the high prevalence of gender dysphoria among transgender youth, this population is at greater risk of suffering from additional mental health disorders, including social anxiety disorder, compared to their cisgender peers. Cognitive behavioral therapy (CBT) has been established as an effective form of treatment for social anxiety disorder. It is recommended that therapists modify and adapt CBT when working with minority groups such as transgender youth to ensure that the treatment is efficacious and culturally sensitive. However, literature assessing the efficacy of CBT for transgender youth with mental health issues is scant. As a result, there is no empirical literature on effective treatment for transgender youth who meet criteria for social anxiety disorder alone or youth who meet criteria for social anxiety disorder and gender dysphoria. This literature review aims to identify current research related to prevalence of mental health disorders in transgender youth, the current literature on adaptations of cognitive behavioral techniques, and the need for treatment research on adaptation of CBT for transgender individuals, specifically those with social anxiety disorder and gender dysphoria.

IMPORTANCE:Gender-diverse youths have higher rates of mental health problems compared with the general population, as shown in both clinical and nonclinical populations. Brain correlates of gender diversity, however, have been reported only among youths with gender dysphoria or in transgender individuals. OBJECTIVE:To examine brain morphologic correlates of gender diversity among adolescents from a general pediatric population who were assigned male or female at birth, separately. DESIGN, SETTING, AND PARTICIPANTS:This cross-sectional study was embedded in Generation R, a multiethnic population-based study conducted in Rotterdam, the Netherlands. Adolescents who were born between April 1, 2002, and January 31, 2006, and had information on self-reported or parent-reported gender diversity and structural neuroimaging at ages 13 to 15 years were included. Data analysis was performed from April 1 to July 31, 2022. EXPOSURES:Gender-diverse experiences among adolescents were measured with selected items from the Achenbach System of Empirically Based Assessment forms and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults, as reported by adolescents and/or their parents. MAIN OUTCOMES AND MEASURES:High-resolution structural neuroimaging data were collected using a 3-T magnetic resonance imaging scanner (at a single site). We used linear regression models to examine differences in global brain volumetric measures between adolescents who reported gender diversity and those who did not. RESULTS:This study included 2165 participants, with a mean (SD) age of 13.8 (0.6) years at scanning. A total of 1159 participants (53.5%) were assigned female at birth and 1006 (46.5%) were assigned male at birth. With regard to maternal country of origin, 1217 mothers (57.6%) were from the Netherlands and 896 (42.4%) were from outside the Netherlands. Adolescents who reported gender diversity did not differ in global brain volumetric measures from adolescents who did not report gender diversity. In whole-brain, vertexwise analyses among adolescents assigned male at birth, thicker cortices in the left inferior temporal gyrus were observed among youths who reported gender diversity compared with those who did not. No associations were observed between gender diversity and surface area in vertexwise analyses. CONCLUSIONS AND RELEVANCE:The findings of this cross-sectional study suggest that global brain volumetric measures did not differ between adolescents who reported gender diversity and those who did not. However, these findings further suggest that gender diversity in the general population correlates with specific brain morphologic features in the inferior temporal gyrus among youths who are assigned male at birth. Replication of these findings is necessary to elucidate the potential neurobiological basis of gender diversity in the general population. Future longitudinal studies should also investigate the directionality of these associations.

As more young people feel safe to outwardly identify as transgender or gender expansive (TGE), meaning that their gender identity does not align with the sex they were assigned at birth, an increasing number of youth who identify as TGE seek gender-affirming medical care (GAMC). GAMC raises a number of ethical questions, such as the capacity of a minor to assent or consent, the role of parents or legal guardians in decisions about treatment, and implications for equitable access to care when differing parental or custodial viewpoints are present. These questions are further complicated by the difficulties in explaining the limits of long-term research in GAMC, with regard to the preservation of fertility, for example. We present two de-identified composite case studies to highlight dilemmas that may arise and offer recommendations to better support patient- and family-centered decision making for GAMC. These include employing a multidisciplinary shared decision-making approach, disentangling informed consent and assent from chronological age, developing a consistent approach to the assessment of decisional capacity, and developing age-appropriate informational materials.

For individuals with gender dysphoria, gender-affirming surgeries (GAS) are one means of reducing the significant distress associated with primary and secondary sex characteristics misaligned with their gender identity. This article uses a systematic review to examine the existing literature on the psychological benefits of GAS. Findings from this review indicate that GAS can lead to multiple, significant improvements in psychological functioning. Methodological differences in the literature demonstrate the need for additional research to draw more definitive conclusions about the psychological benefits of GAS.