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Objective: To describe and reflect on the development process of GenderJourney: an ethics support tool that seeks to foster (dialogue and reflection on) shared decision-making (SDM) in gender-affirming medical care (GAMC). Methods: Part of a larger project, this study used a participatory design. We included transgender and gender diverse (TGD) clients and healthcare professionals (HCPs) throughout the study in co-creation workshops. In an iterative process, we (1) established stakeholders’ needs, (2) reached a consensus on the aims, content, and design, (3) developed and tested successive renditions, and (4) presented the final version of the tool. Results: The final tool aims to (A) elucidate the client's care request and corresponding treatment preferences, (B) foster an explicit dialogue between TGD client and HCP about expected/preferred decisional roles and collaboration, (C) stimulate a systematic joint reflection on and handling of SDM-related ethical challenges. Conclusion: The GenderJourney provides non-directive ethics support to jointly reflect on and foster good SDM, including its inherent ethical challenges. Future studies should focus on its implementation and actual contribution to good SDM. Practice implications: GenderJourney may be used in GAMC to support the dialogue on what good SDM entails and the identification, discussion, and handling of SDM-related ethical challenges.

Item does not contain fulltext Uncertainty is increasingly recognized as a crucial phenomenon throughout medical practice. Research on uncertainty so far has been scattered across disciplines, leading to a lack of consensus about what uncertainty represents and minimal integration of knowledge obtained within isolated disciplines. Currently, a comprehensive view of uncertainty which does justice to normatively or interactionally challenging healthcare settings is lacking. This impedes research teasing apart when and how uncertainty manifests, how all stakeholders experience and value it, and how it affects medical communication and decision-making. In this paper, we argue that we need a more integrated understanding of uncertainty. We illustrate our argument using the context of adolescent transgender care, in which uncertainty occurs in myriad ways. We first sketch how theories of uncertainty have emerged from isolated disciplines, leading to a lack of conceptual integration. Subsequently, we emphasize why it is problematic that no comprehensive approach to uncertainty has yet been developed, using examples from adolescent transgender care. Finally, we advocate an integrated approach of uncertainty to further advance empirical research and to ultimately benefit clinical practice. 01 juli 2023

Adolescent transgender care is increasingly surrounded by controversies and criticism. One of these concerns expressed in a review article by Levine et al. entitled 'Reconsidering Informed Consent for Trans-Identified Children, Adolescents and Young Adults' is the limited evidence base, especially of the Dutch studies which provided the first and mostly cited basis for medical intervention at a young age. This Response is written by the first author of two of those studies that showed effectiveness of the approach that included puberty blockers. The author rebuts several of the concerns that Levine et al.have regarding these Dutch studies, among which are the limited statistical improvements of psychological measures, the use of the Utrecht Gender Dysphoria and the selection of participants. The author further refers to several shorter term longitudinal follow up studies that have been published, which are not mentioned by Levine et al.. They also show improvement or stable psychological functioning and relief of gender incongruence. Finally, a careful evaluation and informed consent provision has always been recommended in all editions of the WPATH's Standards of Care and are also part of the 8th version as well as the Endocrine Society guidelines. The author agrees therefore with Levine et al. that clinicians in transgender care should follow these international guidelines and provide such an assessment in order to ensure that medical interventions are appropriately provided for those transgender adolescents who need them.

BackgroundTwenty years ago, the Dutch Protocol—consisting of a gonadotropin-releasing hormone agonist (GnRHa) to halt puberty and subsequent gender-affirming hormones (GAHs)—was implemented to treat adolescents with gender dysphoria.AimTo study trends in trajectories in children and adolescents who were referred for evaluation of gender dysphoria and/or treated following the Dutch Protocol.MethodsThe current study is based on a retrospective cohort of 1766 children and adolescents in the Amsterdam Cohort of Gender Dysphoria.OutcomesOutcomes included trends in number of intakes, ratio of assigned sex at birth, age at intake, age at start of GnRHa and GAH, puberty stage at start of GnRHa, proportions of adolescents starting and stopping GnRHa, reasons for refraining from GnRHa, and proportions of people undergoing gender-affirming surgery.ResultsA steep increase in referrals was observed over the years. A change in the AMAB:AFAB ratio (assigned male at birth to assigned female at birth) was seen over time, tipping the balance toward AFAB. Age at intake and at start of GnRHa has increased over time. Of possibly eligible adolescents who had their first visit before age 10 years, nearly half started GnRHa vs around two-thirds who had their first visit at or after age 10 years. The proportion starting GnRHa rose only for those first visiting before age 10. Puberty stage at start of GnRHa fluctuated over time. Absence of gender dysphoria diagnosis was the main reason for not starting GnRHa. Very few stopped GnRHa (1.4%), mostly because of remission of gender dysphoria. Age at start of GAH has increased mainly in the most recent years. When a change in law was made in July 2014 no longer requiring gonadectomy to change legal sex, percentages of people undergoing gonadectomy decreased in AMAB and AFAB.Clinical ImplicationsA substantial number of adolescents did not start medical treatment. In the ones who did, risk for retransitioning was very low, providing ongoing support for medical interventions in comprehensively assessed gender diverse adolescents.Strengths and LimitationsImportant topics on transgender health care for children and adolescents were studied in a large cohort over an unprecedented time span, limited by the retrospective design.ConclusionTrajectories in diagnostic evaluation and medical treatment in children and adolescents referred for gender dysphoria are diverse. Initiating medical treatment and need for surgical procedures depends on not only personal characteristics but societal and legal factors as well.

Background Young people who have psychiatric problems are more likely than their peers to endure difficulties during their sexual and gender identity development. Aim This study aims to examine the communication between mental health care providers and their patients about the topics of relations, sexuality and gender identity, including a description of professionals’ attitudes toward these topics and the factors that contribute to and inhibit communication. Methods Study participants (n = 242, response rate = 31%) were a representative sample of a large multicenter cohort of 768 mental health care professionals (eg, medical doctors, psychiatrists, psychologists, group counselors, parent counselors) of 7 institutions and 5 solo practices in the Netherlands, who completed a survey on communication about sexuality and gender identity with their young patients (age 12–21 years). Outcomes Sexuality and gender identity are infrequently discussed by mental health care providers with their young patients or their patients’ parents. Results Of the study sample, 99.5 % valued sexuality as an important topic to discuss with their patients. However, only 17.1% of the professionals reported that they discussed sexuality-related issues with the majority (>75%) of their patients (adolescents: 19.9%, parents: 14.4%) Additionally, only 2.3 % of the participants discussed gender nonconformity regularly with patients. Information about sexual side effects of prescribed medication was infrequently (20.3%) provided: antidepressants (40.0%), antipsychotics (34.0%), benzodiazepines (5.1%) and stimulants (2.4%). The most frequently cited reasons for not discussing these topics were a lack of awareness, own feelings of discomfort, and the patients’ supposed feelings of shame. There was no gender differences observed. Clinical implications Recommendations for professionals include to be aware of these topics, initiating age-appropriate conversation and use inclusive language. Strengths and limitations The present study included a diverse and representative group of mental health care professionals. Frequency of sexual communication was based on self-report, which brings a risk of bias. Conclusion Despite a recognized need to engage in age-appropriate communication about sexuality and gender identity in youth mental health care, mental health providers seem to remain hesitant to discuss such topics.

For various reasons, sexuality of individuals with differences/disorders of sex development (DSD) may be affected. The aim of the study was to describe sexual activity, satisfaction with sex life, satisfaction with genital function, and sexual problems in people with different DSD conditions. Data were collected from 1,040 participants in Europe. Many people with a variety of DSD conditions do not appear to be satisfied with their sex life, experience a variety of sexual problems, and are less sexually active than the general population; therefore sexuality should be explicitly addressed in the care of people with DSD.

Autism spectrum disorder (ASD) is characterized by difficulties in social communication and interaction, repetitive behaviour and specific interests. In transgender care, it has become evident that individuals with ASD are more likely to report transgender feelings than might be expected by chance. Prenatal exposure to testosterone, rigid thinking typical of ASD that leaves little room for being a female boy or a tomboyish girl, and an inherent feeling of being different that might be experienced as gender dysphoria, are among the hypotheses brought forward to explain this frequent cooccurrence. To date, no evidence supports any one of these hypotheses. Clinically, it is clear that a diagnosis of ASD does not rule out transgender feelings. Although eligibility assessment for gender affirming medical treatment might take more time and can be complex, individuals in the autistic spectrum should have access to this type of health care.

Transgender youth are presenting at younger ages with increasing numbers being referred to transgender healthcare services. The introduction and more widespread use of puberty suppression, to suspend physical development, gives younger people an opportunity to receive medical gender affirmative treatment care without having to wait until adulthood. Young transgender individuals may have a diverse range of gender identities and/or expressions that differ from societal expectations based on the gender that they were assigned at birth. While some present with longstanding other-gender behaviour from childhood, others have transgender identity feelings that emerge during or after the onset of the physical changes brought on by puberty. For clinicians and other health professionals, helping all of the youth and their families may sometimes be a challenging task. For certain youth, the need for gender affirmative treatment is crystal clear, whereas for others there may be a need for further exploration of what their feelings mean. Other psychological and social challenges may add complexity when making decisions about social gender transition and the irreversible medical interventions that have far reaching consequences later on in life.