IMPORTANCETransgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes owing to decreased social support and increased stigma and discrimination.Although gender-affirming care is associated with decreased long-term adverse mental health outcomes among these youths, less is known about its association with mental health immediately after initiation of care. OBJECTIVE To investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality. DESIGN, SETTING, AND PARTICIPANTSThis prospective observational cohort study was conducted at an urban multidisciplinary gender clinic among TNB adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 through November 2021. EXPOSURES Time since enrollment and receipt of PBs or GAHs. MAIN OUTCOMES AND MEASURES Mental health outcomes of interest were assessed via thePatient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales, which were dichotomized into measures of moderate or severe depression and anxiety (ie, scores Ն10), respectively. Any self-report of self-harm or suicidal thoughts over the previous 2 weeks was assessed using PHQ-9 question 9. Generalized estimating equations were used to assess change from baseline in each outcome at 3, 6, and 12 months of follow-up. Bivariate and multivariable logistic models were estimated to examine temporal trends and investigate associations between receipt of PBs or GAHs and each outcome. RESULTS Among 104 youths aged 13 to 20 years (mean [SD] age, 15.8 [1.6] years) who participated in the study, there were 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26.0%), 10 nonbinary or gender fluid individuals (9.6%), and 4 youths who responded "I don't know" or did not respond to the gender identity question (3.8%). At baseline, 59 individuals (56.7%) had moderate to severe depression, 52 individuals (50.0%) had moderate to severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. By the end of the study, 69 youths (66.3%) had received PBs, GAHs, or both interventions, while 35 youths had not received either intervention (33.7%). After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. There was no association between PBs or GAHs and anxiety (aOR, 1.01; 95% CI, 0.41, 2.51).
Gender identity formation is a key part of normal adolescent development (Stieglitz, 2010). For transgender youth this is a multistage process that can be challenging both for the youth and for their families. In this sub analysis, we describe the journey transgender youth and their families experience throughout the stages of transitioning. Perspectives were solicited from transgender youth (age 14 -22 years) and parents of transgender youth. Theoretical thematic analysis was used to find common themes using Atlas.ti software. Thirty-three participants (15 youth, 18 parents) were recruited, 16 of which were interviewed. Analysis revealed almost all of the youth and caregiver participants initially lacked the language and knowledge to accurately describe feelings of gender confusion. Once embarking on the transition process participants experienced both positive and negative reactions from families, friends and peers, school administrators and providers. However, all participants described transitioning as a rewarding and vital experience. Finally, many participants reported needing and or seeking mental health care, but experienced barriers. Youth and caregivers described varying experiences for youth throughout the recognition, coming out and transitioning process that impacted the journey. This is one of the first studies to collect an in-depth recall of the transitioning process from youth and caregiver perspectives, giving youth and families a voice to enable a greater understanding of the process of gender transition during adolescence. Public Significance StatementGender identity is an important aspect of determining who we are as adults. In this study, researchers asked transgender youth and caregivers of transgender youth about their social gender transition. Participants in the study described the importance of family, peer, school staff in a social transition of their gender that lead to life satisfaction. Key themes of successful transition included having appropriate language to describe what was occurring, behavioral and mental health support, and a sense of community who understood the journey of coming out to friends and family.
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