Later Receipt of Gender-Affirming Care for Youth Linked to Worse Mental Health

By Linda Carroll

September 22, 2020

(Reuters Health) - Worse mental health may result when gender incongruent youth seek gender affirming care at an older age and a later stage of puberty, a new Canadian study suggests.

After an analysis of medical records from 300 gender incongruent youth, researchers concluded that those who didn't get gender affirming care until later in puberty were five-fold more likely than those who sought care earlier to suffer from depressive disorders and four-fold more likely to suffer from anxiety disorders, according to the report published in Pediatrics.

"Our study looked to identify whether timing at presentation to gender-affirming medical care, which can involve the use of puberty blockers and/or hormones (testosterone or estrogen), is associated with the mental health status of youth with gender dysphoria," said the study's lead author, Dr. Julia Sobara, an associate professor of pediatrics at the University of Toronto.

"We found that youth who presented to care later in age and further along in puberty had more mental health problems than those who presented earlier," Dr. Sobara said in an email. "In particular, being at the late stages of puberty upon presentation was associated with higher rates of anxiety and depression. This is not a surprising finding as youth with gender dysphoria often describe feeling distressed during puberty as they develop physical changes that are not in keeping with their gender identity."

The new study underscores the importance of timely access to gender affirming medical care for youth with gender dysphoria, Dr. Sobara said.

To look at the potential relationship between the age at which young people with gender dysphoria seek out gender affirming medical care and the likelihood of mental health problems, Dr. Sobara and her colleagues reviewed the charts of patients who came to the Transgender Youth Clinic at The Hospital for Sick Children in Toronto, an interdisciplinary clinic that provides care to youth under age 18 who are in gender dysphoria.

Data from patients with initial visits to the clinic between October 2013 and June 2016 or between August 2017 and June 2018 were included in the analysis. Information on gender incoherence, age of coming out, social transition and age of social transition were extracted from the medical records of patients' first visit. Also gleaned from the notes from that visit were youth or caregiver reports of formal diagnoses of depressive, anxiety and autism spectrum disorders.

Of the 300 youth, there were 116 younger-presenting youth (<15 years of age at presentation) and 184 older-presenting youth.

At the time of their first visit, 78% of the patients reported one or more mental health problems. Depressive and anxiety disorders were reported by 40% and 44.3%, respectively, and 34.7% said they had engaged in self-harm.

Just over one in 10 patients (12.3%) reported suicidal ideation, 47.3% said they had considered suicide and 14.0% had attempted suicide.

Compared with earlier presentation, seeking help in late puberty (Tanner stage 4 or 5) was associated with higher odds of depressive disorders (odds ratio: 5.49), and anxiety disorders (OR: 4.18).

It's not surprising that kids seeking help at a later stage of puberty might have more mental health issues, said Dr. John Steever, an associate professor of pediatrics at the Icahn School of Medicine at Mount Sinai and the Mount Sinai Adolescent Health Center in New York City.

"Puberty does bring out more depressive symptoms," Dr. Steever said. "Prepubescent kids can mask their gender pretty well socially through clothes, makeup and hair. Once those assigned female gender at birth start developing breasts and those assigned male gender at birth will start to grow facial hair, so it can become much harder to pass as the gender they want to be."

SOURCE: Pediatrics, online September 21, 2020.