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ImportanceGender-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.ObjectiveTo 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 ParticipantsThis 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.ExposuresGender-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 MeasuresHigh-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.ResultsThis 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 RelevanceThe 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.

Gender identity is a self-defined concept of being male, female, or other gender and can differ from what is assigned to someone at birth based on their chromosomal makeup and external genitalia. It is estimated that 2% of high school students in the United States identify as transgender, which is an umbrella term for someone whose self-concept of their gender differs from their biological sex. Some transgender children and youth experience gender dysphoria, which is a DSM-5 diagnosis for the distress related to the disconnect between the individual’s body and gender self-concept. Affirmative treatment for these children and youths is the standard of care recommended by all major medical and mental health associations. A portion of the population of transgender expansive youth have higher rates of psychological, emotional, behavioral, academic, and familial difficulties and higher rates of suicide contemplation or attempts. The cognitive behavioral and specifically rational emotive behavior therapy literature are lacking in conceptual work and empirical research to assist gender diverse children and adolescents in managing the unique difficulties and challenges they may face psychologically, socially, environmentally, and medically. This chapter is the first work of its kind to propose rational emotive cognitive behavioral therapy (RE-CBT) as a transgender affirmative approach to assisting gender-expansive children and youth who may be struggling with gender dysphoria.

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.

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.

For adolescents with gender dysphoria, puberty is an especially complicated time that may cause anxiety and distress, more so than what is typically experienced by cisgender adolescents. These physical and physiological changes can be addressed through medical interventions that are recognized by the World Professional Association of Transgender Health Standards of Care. Multidisciplinary teams that consist of psychologists, psychiatrists, pediatricians, social workers, advanced nurse specialists, and pediatric endocrinologists can guide families in the decision-making process around gender-affirming medical care. These exogenous interventions progress from most reversible to irreversible as an adolescent matures. This chapter aims to review pubertal stages for youth, to present the medical interventions recommended for adolescents who are experiencing gender dysphoria, and to comprehensively review the guidelines provided by the Endocrine Society and the World Professional Association for Transgender Health.

Transgender and gender nonconforming youth are an extremely vulnerable population presenting to mental health clinics; however, many mental health providers have not been trained to work with these youth and their families. This chapter will provide a comprehensive overview of the difference between sex assigned at birth and gender identity, role, and expression and discuss the prevalence rate of transgender and gender nonconforming youth. The writers also provide practical techniques that providers can use to assess gender identity, role, and expression, as well as methods to assist in making a diagnosis of gender dysphoria. Furthermore, the writers will review treatment options for gender dysphoria and the standards of care for medical and psychologic treatment for transgender and gender nonconforming youth. This chapter will also describe cooccurring mental health conditions commonly diagnosed in youth who meet criteria for gender dysphoria. Finally, this chapter will address protective factors for these youth, including the role of parental support.

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.