Bright Light Therapy as Add-On to Inpatient Treatment in Youth With Moderate to Severe Depression: A Randomized Clinical Trial.

Importance: Major depressive disorder is one of the most common mental disorders among adolescents, entailing severe, long-term psychosocial impairment and a high risk of chronicity. In view of the large number of patients requiring treatment, along with insufficient treatment responses with small effect sizes, innovative adjunctive treatment strategies are urgently needed. Objective: To investigate whether the effect of adolescent psychiatric inpatient treatment as usual for major depressive disorder can be enhanced by simultaneous use of morning bright light therapy. Design, Setting, and Participants: This was a double-blind, placebo-controlled randomized parallel-group trial with enrollment between March 2018 and November 2020 and follow-up completed in May 2021. The study took place among inpatients at 4 university hospitals for child and adolescent psychiatry across Germany. Of 248 eligible youth aged 12 to 18 years fulfilling ICD-10 criteria for major depressive disorder, 227 were randomized to bright light therapy (n = 116) or placebo red light (n = 111); 151 participants completed the study. Interventions: Up to 20 sessions of either morning bright light therapy with an intensity of 10 000 lux or placebo red light (100 lux) in addition to multimodal inpatient treatment as usual over 4 weeks. Main Outcomes and Measures: The primary outcome was the change in Beck Depression Inventory-II (BDI-II) score from baseline to posttreatment in the intention-to-treat sample. Results: Among the 224 patients included in the intention-to-treat analyses (192 girls and 32 boys; mean [SD] age, 15.5 [1.4] years), the mean (SD) BDI-II score at baseline was 37.3 (8.7). BDI-II scores were significantly reduced after 4 weeks (postassessment) by a mean of -7.5 (95% CI, -9.0 to -6.0; Hedges g = 0.71). Bright light therapy had no impact on this change (no significant group × time effect). Loss to follow-up was 31% (n = 69) at 16 weeks and 49% (n = 110) at 28 weeks. There were 10 serious adverse events throughout the whole trial, which were not considered related to study treatment. Conclusions and Relevance: The findings in this study did not indicate superiority of bright light therapy over placebo red light therapy in a large sample of adolescent inpatients with moderate or severe major depressive disorder. Both groups benefited equally from treatment as usual, showing relevant symptom reduction. Trial Registration: German Clinical Trials Register: DRKS00013188.

How social is social media for transgender and gender-diverse youth? Association of online social experiences with internalizing mental health problems.

Adolescents spend a critical amount of their free time on the Internet and social media. Transgender and gender-diverse (TGD) adolescents, who report elevated rates of mental health issues, especially internalizing problems, have both positive and negative online social experiences (e.g., support and cyberbullying). This can have both beneficial and/or harmful effects on their mental health. Given the lack of research, the present study examined TGD adolescents' online (social) experiences and the association of positive and negative online social experiences with internalizing problems. The sample consisted of n = 165 TGD adolescents (11-18 years) diagnosed with gender dysphoria who attended a Gender Identity Service for children and adolescents (Hamburg GIS) in Germany between January 2020 and December 2022 during the COVID-19 pandemic. Positive (use of online support networks) and negative online social experiences (cyberbullying or other adverse online interactions) were assessed using study-specific items and internalizing problems using the Youth Self-Report. Frequencies of various online (social) experiences were analyzed, and a multiple linear regression analysis was performed to test their association with internalizing problems. In total, 42% of participants reported positive online social experiences (use of online support networks) and 51% of participants reported negative online social experiences (cyberbullying or other adverse online interactions). There was no significant association between negative online social experiences and internalizing problems but between positive online social experiences and more internalizing problems (adjusted R2 = .01). TGD adolescents may seek online support, especially when struggling with mental health problems. Therefore, it is crucial to support youth navigating these online spaces more safely and positively and to empower them to buffer against potentially harmful experiences. Furthermore, strengthening offline relations with peers and family members is pivotal, given their importance for TGD adolescents' mental health.

Social media use and experiences among transgender and gender diverse adolescents.

Objectives: For transgender and gender diverse (TGD) adolescents, the internet and social media have several risks and benefits. The present study aims at assessing how and for which purposes TGD adolescents use the internet and social media and how often they experience support compared to cyberbullying online. Methods: The sample comprised 114 TGD adolescents diagnosed with gender dysphoria who attended a Gender Identity Service for children and adolescents (Hamburg GIS). Internet and social media use and experiences were assessed using modified items from a German representative study and self-constructed items relating to TGD-specific online experiences. Frequencies of internet/social media use and various online experiences were analyzed and compared to data from the German general population. Results: Compared to peers from the general population, TGD adolescents reported similar offline and online activities and spent similarly long time online (internet: M = 4.16 h, social media: M = 2.84 h). All TGD adolescents sought TGD-specific information online. TGD adolescents used the internet to experiment with their gender identity (60%), and for the purpose of their coming out (31%) and their social transition (88%). About half of the sample each reported either online support (45%) and/or cyberbullying (48%). Conclusions: While TGD adolescents used the internet and social media for similar purposes as peers from the general population, they also used the internet and social media to gain TGD-specific information and for gender identity expression and exploration. They reported both positive and negative experiences online, calling for future studies investigating how online experiences affect TGD adolescents' mental health and gender identity development.

[Gender Experiences of Transgender Youth: How Changeable is the Gender Experience of Binary vs. Nonbinary Identifying Transgender Youth and What Factors Are Involved?] / Wie veränderbar ist das Geschlechtserleben von binär vs. nichtbinär identifizierten transgeschlechtlichen Jugendlichen und welche Einflussfaktoren gibt es?

Gender Experiences of Transgender Youth: How Changeable is the Gender Experience of Binary vs. Nonbinary Identifying Transgender Youth and What Factors Are Involved? Abstract: Objectives: Nonbinary gender identities are becoming increasingly visible in transgender healthcare and research. However, little is known about the various gender identities of transgender adolescents - whether they are stable or fluid and which factors influence their gender experience. The present study investigates these different aspects of gender in transgender adolescents with various gender identities. Method: The sample comprised a recent cohort of 114 adolescents diagnosed with gender dysphoria (GD) attending the Hamburg Gender Identity Service for Children and Adolescents (Hamburg GIS). We used the Gender Diversity Questionnaire to assess the different aspects of gender. Results: In total, 83 % of the sample reported a binary (BI) and 17 % a nonbinary gender identity or were still questioning their gender identity (NBGQ). 15-18 % of the transgender adolescents reported gender fluidity. The NBGQ group reported significantly higher levels of gender fluidity or more often that their gender identity was still open to change, respectively, than the BI group. Puberty (79 %), physical distress (70 %), and social media (36 %) were the most frequently mentioned factors influencing their gender experience. Conclusions: The present study underscores that gender experience is not binary and fixed for all transgender adolescents, but that, in some cases, it may be nonbinary or fluid. This heterogeneity, the possible fluidity, and the puberty-related physical distress may challenge treatment decisions in transgender adolescents diagnosed with GD. This situation highlights the importance of developing individualized treatment plans.

Binary and Non-binary Gender Identities, Internalizing Problems, and Treatment Wishes Among Adolescents Referred to a Gender Identity Clinic in Germany.

Clinical research on transgender and gender-nonconforming (TGNC) adolescents has focused on binary individuals or often not differentiated among gender identities. Recent studies suggest that a considerable proportion of TGNC adolescents identify as non-binary and that these youth report more internalizing problems as well as different transition-related medical treatment wishes than binary adolescents. However, the results are inconclusive, and data for the German-speaking area are lacking. Therefore, the present study aimed to assess the percentage of binary and non-binary gender identities in a German sample of clinically referred TGNC adolescents and examine associations of gender identity with internalizing problems and transition-related medical treatment wishes. The sample consisted of 369 adolescents (11-18 years, Mage = 15.43; 305 birth-assigned female, 64 birth-assigned male) who attended the Hamburg Gender Identity Service for children and adolescents (Hamburg GIS) between 2013 and 2019. Gender identity and treatment wishes were assessed using study-specific items and internalizing problems using the Youth Self-Report. In total, 90% (n = 332) of the sample identified as binary and 10% (n = 37) as non-binary. Having a non-binary gender identity was significantly associated with more internalizing problems and with wishing for no transition-related medical treatment or only puberty-suppressing hormones. The results underscore that non-binary adolescents represent a specifically vulnerable subgroup within TGNC adolescents with unique mental health needs and treatment wishes. Future research should differentiate among various gender identities. In clinical practice, it is crucial to create an inclusive space for non-binary youth and provide mental health care if needed.

Pleasure please! Sexual pleasure and influencing factors in transgender persons: An ENIGI follow-up study.

Background: While the importance of sexual pleasure for physical and mental health becomes increasingly evident, research on sexual pleasure in transgender persons is lacking. Recently, the first version of the Amsterdam Sexual Pleasure Index (ASPI Vol. 0.1) was validated in cisgender persons. This questionnaire aims to assess the tendency to experience sexual pleasure independent of gender, sexual orientation or anatomy. Aim: The aims of this study were threefold. First, to perform exploratory scale validation analyses of the ASPI in transgender persons. Secondly, to compare transgender sexual pleasure scores to reference data in cisgender persons. Finally, to identify factors that are associated with sexual pleasure. Methods: In a follow-up study conducted within the European Network for the Investigation of Gender Incongruence (ENIGI), online questionnaires were distributed to persons who had a first clinical contact at gender clinics in Amsterdam, Ghent or Hamburg four to six years earlier. Internal consistency of the ASPI was assessed by calculating McDonald's omega (ωt). ASPI scores were compared to scores from the cisgender population using a one sample t-test, and linear regressions were conducted to study associations with clinical characteristics, psychological wellbeing, body satisfaction and self-reported happiness. Results: In total, 325 persons filled out the ASPI. The ASPI showed excellent internal consistency (ωt, all: 0.97; transfeminine: 0.97, transmasculine: 0.97). Compared to data from cisgender persons, transgender participants had significantly lower total ASPI scores (i.e., lower sexual pleasure; transgender vs. cisgender, mean(SD): 4.13(0.94) vs. 4.71(0.61)). Lower age, current happiness and genital body satisfaction were associated with a higher tendency to experience sexual pleasure. Conclusion & discussion: The ASPI can be used to assess the tendency to experience sexual pleasure and associated factors in transgender persons. Future studies are needed to understand interplaying biopsychosocial factors that promote sexual pleasure and hence transgender sexual health and wellbeing.

Desired decision-making role and treatment satisfaction among trans people during medical transition: results from the ENIGI follow-up study.

BACKGROUND: Shared decision making (SDM) is particularly important in transition-related medical interventions (TRMIs) given the nature of treatment and history of gatekeeping in transgender health care. Yet few studies have investigated trans people's desired decision-making role within TRMI and factors that influence these desires. AIMS: The study investigated trans people's desired level of decision making during medical transition as well as possible sociodemographic predictors and correlations between decision-making desires and satisfaction with treatment. METHODS: Data were collected from a clinical sample from 3 trans health care centers, as part of the larger ENIGI study. The data consisted of 568 trans individuals (60.2% assigned male at birth) 20 to 82 years of age (mean age = 38.58 years) who took part in the study 4 to 6 years after initial clinical contact. Binary logistic regressions were conducted to determine whether independent variables predicted group membership in decision-making role subgroups while a Spearman rank-order correlation was conducted to determine the relationship between desired decision-making involvement and satisfaction with care. OUTCOMES: Main measures were desired decision-making role, satisfaction with treatment, age, education level, country of residence, treatment status, individual treatment progress score (ITPS), gender identity, and sex assigned at birth. RESULTS: The vast majority of participants wanted to make medical decisions themselves. Age, education level, country of residence, treatment status, gender identity, and sex assigned at birth showed no significant effects in desired level of decision making, while the ITPS neared significance. Satisfaction with treatment was overall very high. For participants assigned male at birth, desire for a more active role in decision making was negatively correlated with satisfaction of labia surgery. CLINICAL IMPLICATIONS: A desired decision-making role cannot be predicted based on the trans person's sociodemographic characteristics. More involvement from health professionals addressing medical information and education obligations may be needed when offering surgical construction of labia to individuals assigned male at birth. STRENGTHS AND LIMITATIONS: This study builds on the few existing analyses of desired levels of decision-making role among trans people during transition. It is the first to investigate the role of education level and treatment status/ITPS on the desire of decision-making role. Gender identity and influence of nonbinary identity were not investigated for treatment satisfaction as these items were presented based on sex assigned at birth. CONCLUSION: This study highlights that trans people in 3 European trans health care centers during medical transition desire a more active role in decision making. Satisfaction with treatment received was overall very high.

Systematic Review of Gender-Specific Child and Adolescent Mental Health Care.

Gender differences in mental health emerge as early as in childhood and adolescence, highlighting the potential need for gender-specific child and adolescent mental health care. However, it is unclear how gender-specific child and adolescent mental health care is implemented and whether its' approaches are useful. Therefore, this study reviews gender-specific interventions and their effectiveness for child and adolescent mental health. Five databases were searched for articles published between 2000 and 2021. In total, 43 studies were included. Most interventions were conducted in school (n = 15) or community settings (n = 8). Substance-related disorders (n = 13) and eating disorders (n = 12) were addressed most frequently. Most interventions targeted girls (n = 31). Various gender-specific aspects were considered, including gender-specific risk and protective factors (n = 35) and needs (n = 35). Although most interventions yielded significant improvements in mental health outcomes (n = 32), only few studies reported medium or large effect sizes (n = 13). Additionally, there was a lack of strong causal evidence derived from randomized controlled trials, calling for more rigorous trials in the research field. Nevertheless, our findings indicate that gender-specific mental health care can be a promising approach to meet gender-specific mental health needs.

Experienced barriers of care within European treatment seeking transgender individuals: A multicenter ENIGI follow-up study.

Objectives: To evaluate the experienced barriers of care for treatment-seeking trans individuals (TSTG) in three large European clinics. Methods: An online follow-up questionnaire was filled out by 307 TSTG individuals as part of the research protocol of the European Network for the Investigation of Gender Incongruence (ENIGI). Data was collected during follow-up in 2017/2018, around 5 years after participants had their initial clinical appointments in Ghent (Belgium), Amsterdam (the Netherlands), or Hamburg (Germany). Background characteristics, country, treatment characteristics and mental health were analyzed in relation to experienced barriers of care (EBOC, measured though agreement with statements). Results: The majority of participants reported various EBOC, oftentimes more than one. The most-frequently reported EBOCs pertained to the lack of family and friends' support (28.7%, n = 88) and travel time and costs (27.7%, n = 85), whereas around one-fifth felt hindered by treatment protocols. Also, a significant share expressed the feeling that they had to convince their provider they needed care and/or express their wish in such way to increase their likelihood of receiving care. A higher number of EBOCs reported was associated with more mental health problems, lower income and female gender. Conclusions: A substantial number of TSTG individuals within three European health care systems experiences EBOCs. EBOCs relate to both personal and systemic characteristics. These findings can help health care providers and centers to improve care. More research must be done to better understand the diversity among TSTG individuals and the corresponding barriers experienced. Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1964409.

Suicidal and nonsuicidal self-harming thoughts and behaviors in clinically referred children and adolescents with gender dysphoria.

BACKGROUND: Young transgender or gender nonconforming (TGNC) children and adolescents or those with a gender dysphoria (GD) diagnosis show an increased risk of suicidal and nonsuicidal self-harming thoughts and behaviors (STBs). Data from German-speaking regions on this topic and studies comparing self- and parent-reported STBs have been scarce. The study aims were therefore to examine: (a) frequencies of self- and parent-reported STBs in a German clinical sample of children and adolescents with GD and (b) differences between age and gender groups, as well as between self- and parent-reports. METHODS: Two items from the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR) were used to assess self- and parent-reported STBs in a sample of 343 adolescents and 49 children who presented to the Hamburg Gender Identity Service (Hamburg GIS) between 2013 and 2019. Seventy-eight percent of the analysis sample was assigned female at birth (AFAB), and 22% were assigned male at birth (AMAB). RESULTS: Parents reported STBs on the CBCL for 16% and 6% of the cases in childhood and for 20% and 29% of the adolescent cases, respectively. STBs were self-reported by 38% and 45% of the adolescents who could report on the YSR. STBs were higher among adolescents than among children and in self-reports (YSR) compared to parent reports (CBCL). AFAB adolescents reported higher degrees of STBs than AMAB adolescents. CONCLUSIONS: Children and adolescents with GD are a high-risk population for STBs, especially pubescent and AFAB individuals. Mental health professionals should screen early for STBs to prevent possible suicidal ideation-to-action transitions.

Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study.

BACKGROUND: While much emphasis has been put on the evaluation of gender-affirming surgery (GAS) approaches and their effectiveness, little is known about the health care needs after completion of these interventions. AIM: To assess post-GAS aftercare needs using a mixed-method approach and relate these to participant characteristics. METHODS: As part of the ENIGI follow-up study, data was collected 5 years after first contact for gender-affirming treatments in 3 large European clinics. For the current analyses, only participants that had received GAS were included. Data on sociodemographic and clinical characteristics was collected. Standard aftercare protocols were followed. The study focused on participants' aftercare experiences. Participants rated whether they (had) experienced (predefined) aftercare needs and further elaborated in 2 open-ended questions. Frequencies of aftercare needs were analyzed and associated with participant characteristics via binary logistic regression. Answers to the open-ended questions were categorized through thematic analysis. OUTCOMES: Aftercare needs transgender individuals (had) experienced after receiving GAS and the relation to sociodemographic and clinical characteristics. RESULTS: Of the 543 individuals that were invited for the ENIGI follow-up study, a total of 260 individuals were included (122 (trans) masculine, 119 (trans) feminine, 16 other, 3 missing). The most frequently mentioned aftercare need was (additional) assistance in surgical recovery (47%), followed by consultations with a mental health professional (36%) and physiotherapy for the pelvic floor (20%). The need for assistance in surgical recovery was associated with more psychological symptoms (OR=1.65), having undergone genital surgery (OR=2.55) and lower surgical satisfaction (OR=0.61). The need for consultation with a mental health professional was associated with more psychological symptoms and lower surgical satisfaction. The need for pelvic floor therapy was associated with more psychological symptoms as well as with having undergone genital surgery. Thematic analysis revealed 4 domains regarding aftercare optimization: provision of care, additional mental health care, improvement of organization of care and surgical technical care. CLINICAL IMPLICATIONS: Deeper understanding of post-GAS aftercare needs and associated individual characteristics informs health care providers which gaps are experienced and therefore should be addressed in aftercare. STRENGTHS & LIMITATIONS: We provided first evidence on aftercare needs of transgender individuals after receiving GAS and associated these with participant characteristics in a large multicenter clinical cohort. No standardized data on aftercare received was collected, therefore the expressed aftercare needs cannot be compared with received aftercare. CONCLUSION: These results underline a widely experienced desire for aftercare and specify the personalized needs it should entail. IJ de Brouwer, E Elaut, I Becker-Hebly et al. Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study. J Sex Med 2021;18:1921-1932.

Individual Treatment Progress Predicts Satisfaction With Transition-Related Care for Youth With Gender Dysphoria: A Prospective Clinical Cohort Study.

BACKGROUND: The number of adolescents presenting with gender dysphoria (GD) in healthcare services has increased significantly, yet specialized services offering transition-related care (TRC) for trans youth is lacking. AIM: To investigate satisfaction with TRC, regret, and reasons for (dis)satisfaction with transition-related medical interventions (TRMIs) in trans adolescents who had presented to the Hamburg Gender Identity Service for children and adolescents (Hamburg GIS). METHODS: Data were collected from a clinical cohort sample of 75 adolescents and young adults diagnosed with GD (81% assigned female at birth) aged 11 to 21 years (M = 17.4) at baseline and follow-up (on a spectrum of ongoing care, on average 2 years after initial consultation). To determine progress of the youth's medical transitions, an individual treatment progress score (ITPS) was calculated based on number of desired vs received TRMIs. OUTCOMES: Main outcome measures were satisfaction with TRC at the time of follow-up, ITPS, social support, reasons for regret and termination of TRC, and (dis)satisfaction with TRMIs. RESULTS: Participants underwent different stages of TRMIs, such as gender-affirming hormone treatment or surgeries, and showed overall high satisfaction with TRC received at the Hamburg GIS. Regression analysis indicated that a higher ITPS (an advanced transition treatment stage) was predictive of higher satisfaction with TRC. Sex assigned at birth, age, and time since initial consultation at the clinic showed no significant effects for satisfaction with TRC, while degree of social support showed a trend. No adolescents regretted undergoing treatment at follow-up. Additional analysis of free-text answers highlighted satisfaction mostly with the physical results of TRMI. CLINICAL IMPLICATIONS: Because youth were more satisfied with TRC when their individual transition (ITPS) was more progressed, treatment should start in a timely manner to avoid distress from puberty or long waiting lists. STRENGTHS AND LIMITATIONS: This study is one of the first to report on treatment satisfaction among youth with GD from Europe. The ITPS allowed for a more detailed evaluation of TRMI wishes and experiences in relation to satisfaction with TRC and may close a gap in research on these treatments in adolescent populations. However, all participants were from the same clinic, and strict treatment eligibility criteria may have excluded certain trans adolescents from the study. Low identification rates with non-binary identities prevented comparisons between non-binary and binary genders. CONCLUSION: The study highlights the role of TRMI and individual treatment or transition progress for youth's overall high satisfaction with TRC received at the Hamburg GIS. Nieder TO, Mayer TK, Hinz S, et al. Individual Treatment Progress Predicts Satisfaction With Transition-Related Care for Youth With Gender Dysphoria: A Prospective Clinical Cohort Study. J Sex Med 2021;18:632-645.

Not social transition status, but peer relations and family functioning predict psychological functioning in a German clinical sample of children with Gender Dysphoria.

Research provides inconclusive results on whether a social gender transition (e.g. name, pronoun, and clothing changes) benefits transgender children or children with a Gender Dysphoria (GD) diagnosis. This study examined the relationship between social transition status and psychological functioning outcomes in a clinical sample of children with a GD diagnosis. Psychological functioning (Child Behavior Checklist; CBCL), the degree of a social transition, general family functioning (GFF), and poor peer relations (PPR) were assessed via parental reports of 54 children (range 5-11 years) from the Hamburg Gender Identity Service (GIS). A multiple linear regression analysis examined the impact of the social transition status on psychological functioning, controlled for gender, age, socioeconomic status (SES), PPR and GFF. Parents reported significantly higher scores for all CBCL scales in comparison to the German age-equivalent norm population. Peer problems and worse family functioning were significantly associated with impaired psychological functioning, whilst the degree of social transition did not significantly predict the outcome. Therefore, claims that gender affirmation through transitioning socially is beneficial for children with GD could not be supported from the present results. Instead, the study highlights the importance of individual social support provided by peers and family, independent of exploring additional possibilities of gender transition during counseling.

Psychosocial health in adolescents and young adults with gender dysphoria before and after gender-affirming medical interventions: a descriptive study from the Hamburg Gender Identity Service.

Empirical evidence concerning the psychosocial health outcomes after puberty suppression and gender-affirming (GA) medical interventions of adolescents with gender dysphoria (GD) is scarce. The aim of the present study was to describe how dimensions of psychosocial health were distributed among different intervention groups of adolescents with a GD diagnosis from the Hamburg Gender Identity Service before and after treatment. Participants included n = 75 adolescents and young adults from a clinical cohort sample, measured at their initial intake and on average 2 years later (M treatment duration = 21.4 months). All cases were divided into four different intervention groups, three of which received medical interventions. At baseline, both psychological functioning and quality of life scores were significantly below the norm mean for all intervention groups. At follow-up, adolescents in the gender-affirming hormone (GAH) and surgery (GAS) group reported emotional and behavioral problems and physical quality of life scores similar to the German norm mean. However, some of the psychosocial health outcome scores were still significantly different from the norm. Because this study did not test for statistically significant differences between the four intervention groups or before and after treatment, the findings cannot be generalized to other samples of transgender adolescents. However, GA interventions may help to improve psychosocial health outcomes in this sample of German adolescents. Long-term treatment decisions during adolescence warrant careful evaluation and informed, participatory decision-making by a multidisciplinary team and should include both medical interventions and psychosocial support. The present study highlights the urgent need for further ongoing longitudinal research.

[Autism Spectrum Disorders and Gender Dysphoria Among Children and Adolescents: Systematic Review on the Co-Occurrence]. / Autismus-Spektrum-Störungen und Geschlechtsdysphorie bei Kindern und Jugendlichen: Systematisches Review zur gemeinsamen Prävalenz.

OBJECTIVE: The review systematically reviews the literature on co-occurring gender dysphoria/gender variance and autism spectrum disorder among children and adolescents. METHODS: A systematic literature search was conducted for the years 1946 to December 2018. RESULTS: 144 publications could be identified in the literature search. Out of these, 22 publications met the inclusion criteria for the systematic review. 4.7 to 13.3 % of the children and adolescents with primarily diagnosed gender dysphoria/variance examined in the studies also had an autism diagnosis. In samples of children and adolescents with primarily diagnosed autism gender variance was overrepresented with a prevalence of 4 to 6.5 %. CONCLUSION: The results of the systematic review point towards an overrepresentation of co-occurring gender dysphoria/variance and autism spectrum disorder. Methodological and clinical implications are discussed.

[Transgender in Adolescence: State of the Art and Future Research Needs]. / Transgender im Jugendalter: Forschungsstand und zukünftiger Forschungsbedarf.

Transgender in adolescence is currently a widely discussed topic, additionally reflected by an increasing prevalence in clinical practice. The present review of the available literature on transgender, trans* , gender dysphoria or gender incongruence in youth reports results on the long-term results of medical interventions for the psychological well-being, prevalence, referral rates and sex ratio, developmental pathways, current developments and the role of the social environment. Finally, implications for clinical care and future research will be discussed.

Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study.

INTRODUCTION: Studies about sexual functioning in trans persons have mainly focused on sexual functioning after genital gender-affirming surgery, have had small sample sizes, and have not explored the broad range of possible sexual dysfunctions. Measuring sexual functioning in trans persons during transitioning is important to determine the kind of care trans persons may need in order to regain their sexual health. AIM: The first aim of the present study was to explore the prevalence of sexual function disturbances and dysfunctions (with distress) in trans women and trans men 4 to 6 years after initial clinical entry. The second aim was to compare the prevalence of sexual dysfunctions among the various treatment trajectories and between trans persons with or without further genital treatment intentions. METHODS: An online follow-up questionnaire was filled out by 518 trans persons (307 identifying predominantly feminine, 211 identifying predominantly masculine) as a part of the European Network for the Investigation of Gender Incongruence initiative. All participants had their initial clinical appointments in gender clinics in Ghent, Amsterdam, or Hamburg. MAIN OUTCOME MEASURE: The main outcome measures were the prevalence of sexual dysfunctions and medical treatment data, measured via self-report items. RESULTS: The most frequent sexual dysfunctions experienced by trans women and trans men were difficulties initiating and seeking sexual contact (26% and 32%, respectively) and difficulties achieving an orgasm (29% and 15%, respectively). Compared with trans women after hormone treatment and non-genital surgery, trans women after vaginoplasty less often experienced arousal difficulties, sexual aversion, and low sexual desire. Compared with trans men without medical treatment, trans men after a phalloplasty experienced sexual aversion and low sexual desire less often. No significant differences were found between participants with or without further genital treatment intentions. CLINICAL IMPLICATIONS: Clinicians should consider sexual counseling after medical treatments, paying particular attention to potential social and psychological barriers to the sexual health of their patients. STRENGTHS & LIMITATIONS: This study included all trans persons irrespective of treatment decisions, and focused on a broad range of potential sexual difficulties taking the distress criteria into account. Limitations include the cross-sectional design, the limited power for the comparison of treatment groups and the absence of validated questionnaires about sexual functioning for transgender persons. CONCLUSION: Sexual dysfunctions among trans men and women were very common among the various treatment groups and were unrelated to intentions to have further genital treatment. Although medical treatment may be helpful or even essential to developing good sexual health, a significant group of trans persons experienced sexual dysfunctions after genital surgery. Kerckhof ME, Kreukels BPC, Nieder TO, et al. Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study. J Sex Med 2019; 16:2018-2019.

Risk factors for psychological functioning in German adolescents with gender dysphoria: poor peer relations and general family functioning.

Adolescents with gender dysphoria (GD) often face various associated social, emotional, and behavioral difficulties. In such a marginalized group, it is crucial to identify factors that may impact psychological functioning to better accommodate their needs. Therefore, the present study investigated the impact of two specific risk factors, poor peer relations and general family functioning, on the development of psychological problems in adolescents with GD, and their possible interaction effect. The Youth Self-Report, a Peer Relations Scale, and a General Family Functioning scale were assessed in a sample of n = 180 clinically referred adolescents (mean age 15.5; 146 transgender boys with a female birth-assigned sex, and 34 transgender girls with a male birth-assigned sex) with a complete GD diagnosis (fulfillment of the DSM 5 criteria A and B) at their initial admission to the Hamburg Gender Identity Service. Multiple linear regression analysis was conducted to examine the relationship between peer relations, family functioning, and psychological functioning outcomes. Adolescents with GD presented significantly higher Internalizing and Total Problem scores compared to the German reference norm. Externalizing problems were above the norm for transgender boys, but within the normal range for transgender girls. Multiple regression analysis revealed that, overall, adolescents with an advanced age, a female birth-assigned sex, poorer peer relations, and poorer family functioning showed more behavioral and emotional problems. Consequently, incorporating both the family and social environment in transgender care is of high importance to adequately tend to the needs of adolescents with GD.