Qualitative Research Article

· Article must be peer reviewed, research study and related to the current healthcare issue/trend.

· Article must have been published within last 3-5 years.

· Identify and discuss the research question, hypothesis, sampling size, and research finding.

100 to 150 word maximum synopsis for the article, identifying the points stated above; as well as the APA formatted reference

Respiratory Attendance Questions

Please answer the 5 questions below for attendance credit. Submit your answers to the proper assignment folder. Please do not share work.

1. Respiratory illnesses account for the majority of acute illness in children. Typically, four variables influence a child’s respiratory illness. Describe each of these four variables and how they impact a child’s respiratory illness.

2. You are the nurse tasked with providing Metered Dose Inhaler (MDI) teaching to the parents of an asthmatic child. Please identify key teaching points you would include when presenting this information to the parents.

3. What is a peak flow meter and what do the results mean in the care of the pediatric patient?

4. Identify and explain the responsibilities of the members of Interprofessional Care Team necessary for the effective management of a patient with Cystic Fibrosis.

5. Explain the pathophysiology of Cystic Fibrosis and identify the primary causation for the clinical manifestations a child might experience.

Qualitative Research Article

· Article must be peer reviewed, research study and related to the current healthcare issue/trend.

· Article must have been published within last 3-5 year

· Identify and discuss the research question, hypothesis, sampling size, and research finding.

100 to 150 word maximum synopsis for the article, identifying the points stated above; as well as the APA formatted reference

ARTICLE

Mental Health of Transgender
and Gender Nonconforming Youth
Compared With Their Peer

Tracy A. Becerra-Culqui, PhD, MPH, OT/L, a Yuan Liu, PhD, b Rebecca Nash, MPH, c Lee Cromwell, MS, d W. Dana Flanders,
MD, DSc, c Darios Getahun, MD, PhD, MPH, a Shawn V. Giammattei, PhD, e Enid M. Hunkeler, MA, f Timothy L. Lash,
DSc, c Andrea Millman, MA, f Virginia P. Quinn, PhD, MPH, a Brandi Robinson, MPH, d Douglas Roblin, PhD, g David E.
Sandberg, PhD, h Michael J. Silverberg, PhD, MPH, f Vin Tangpricha, MD, PhD, i, j Michael Goodman, MD, MPHc

BACKGROUND: Understanding the magnitude of mental health problems, particularly life-
threatening ones, experienced by transgender and/or gender nonconforming (TGNC) youth
can lead to improved management of these conditions.
METHODS: Electronic medical records were used to identify a cohort of 588 transfeminine and
745 transmasculine children (3–9 years old) and adolescents (10–17 years old) enrolled in
integrated health care systems in California and Georgia. Ten male and 10 female referent
cisgender enrollees were matched to each TGNC individual on year of birth, race and/
or ethnicity, study site, and membership year of the index date (first evidence of gender
nonconforming status). Prevalence ratios were calculated by dividing the proportion of
TGNC individuals with a specific mental health diagnosis or diagnostic category by the
corresponding proportion in each reference group by transfeminine and/or transmasculine
status, age group, and time period before the index date.
RESULTS: Common diagnoses for children and adolescents were attention deficit disorders
(transfeminine 15%; transmasculine 16%) and depressive disorders (transfeminine
49%; transmasculine 62%), respectively. For all diagnostic categories, prevalence was
severalfold higher among TGNC youth than in matched reference groups. Prevalence ratios
(95% confidence intervals [CIs]) for history of self-inf licted injury in adolescents 6 months
before the index date ranged from 18 (95% CI 4.4–82) to 144 (95% CI 36–1248). The
corresponding range for suicidal ideation was 25 (95% CI 14–45) to 54 (95% CI 18–218).
CONCLUSIONS: TGNC youth may present with mental health conditions requiring immediate
evaluation and implementation of clinical, social, and educational gender identity support
measures.

abstract

NIH

aDepartment of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California;
Departments of bBiostatistics and Bioinformatics and cEpidemiology, Rollins School of Public Health, and
iEmory School of Medicine, Emory University, Atlanta, Georgia; dCenter for Clinical and Outcomes Research,
Kaiser Permanente Georgia, Atlanta, Georgia; eRockway Institute, Alliant International University, San Francisco,
California; fDivision of Research, Kaiser Permanente, Northern California, Oakland, California; gMid-Atlantic
Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland; hDepartment of
Pediatrics, Medical School, University of Michigan, Ann Arbor, Michigan; and jAtlanta Veterans Affairs Medical
Center, Atlanta, Georgia

Drs Becerra-Culqui and Goodman conceptualized and designed the study, contributed to the
acquisition of data, conceptualized the analysis plan, coordinated the interpretation of results
(including contributing expertise in epidemiologic methods and childhood developmental and/
or psychological outcomes), and drafted and finalized the manuscript; Drs Getahun, Nash, Quinn,
Roblin, and Silverberg and Ms Hunkeler conceptualized and designed the study, contributed to
the acquisition of data, critically reviewed the manuscript for important intellectual content

PEDIATRICS Volume 141, number 5, May 2018:e20173845

WHAT’S KNOWN ON THIS SUBJECT: Small, specialized, clinic-
based studies reveal a high prevalence of mental health
diagnoses and self-reported emotional and behavioral
problems among transgender and/or gender nonconforming
youth.

WHAT THIS STUDY ADDS: In this large cohort study of an
unselected transgender and/or gender nonconforming group,
youth experienced a high relative prevalence of mental health
conditions such as anxiety, depression, and attention deficit
disorders compared with their cisgender counterparts.

To cite: Becerra-Culqui TA, Liu Y, Nash R, et al. Mental Health
of Transgender and Gender Nonconforming Youth Compared
With Their Peers. Pediatrics. 2018;141(5):e20173845

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

As gender identity develops, it may
not match the gender of rearing or
gender assigned at birth, which are
typically based on the appearance
of external genitalia.1 – 3 When
gender identity differs from the one
assigned at birth, the terms gender
diverse or gender nonconforming
may apply.4, 5 Although the natural
history of gender nonconformity
presented in early childhood remains
an area of ongoing research, some
gender nonconforming children may
go on to adopt an identity that is
different from their assigned gender
(10%–30%, according to reported
estimates).6, 7 Researchers in studies
of gender development in the general
population support that gender-
typed behavior is noticeable and
stable between 3 and 8 years of age,
especially in children with relatively
high or low gender-typical behavior.8, 9
Individuals may identify as
transgender, a term that refers more
narrowly to those whose identity is
“opposite” of their assigned gender.10
Conversely, individuals who identify
with the gender assigned to them at
birth are sometimes referred to as
cisgender.10

An important priority for the health
of transgender and/or gender
nonconforming (TGNC) children
and adolescents is the identification
and management of mental health
conditions.11 – 13 These conditions
may be related to gender dysphoria,
which is defined as a feeling of
distress when one’s assigned gender
does not match their identity.14
In addition, children with gender
nonconforming behavior may
experience stress from prejudice
and discrimination because of being
part of a minority group, which can
create or exacerbate emotional and
behavioral problems.15

The literature on TGNC youth
consistently reveals a high
prevalence of self-reported emotional
and behavioral problems and mental
health diagnoses.16 – 23 Most of the
available data used to address

the mental health status of TGNC
youth come from specialized clinics
providing care to this population.24
Although researchers in clinic-
based studies offer detailed and
high-quality data, 25, 26 they often
lack information on individuals who
have not sought or had no access
to specialized care. Moreover, a
reliance on specialized clinics to
identify study participants may yield
relatively small sample sizes, making
it difficult to select comparable
reference groups from the same
underlying population.27

These issues motivated the
researchers in the Study of
Transition, Outcomes, and Gender
(STRONG), which was designed to
assess morbidity among TGNC people
overall and in the transfeminine
and transmasculine subgroups of
different ages, and captured in any
care setting. However, this study
communication is focused on cohort
members who first presented as
TGNC before their 18th birthday.
Our objectives in this study were
to estimate the prevalence of
mental health diagnoses among
transfeminine and transmasculine
children and adolescents at the
time of their initial presentation
(index date) and compare their
mental health status to that of their
cisgender counterparts.

METHODS

The STRONG was designed as an
electronic medical record (EMR)–
based retrospective and prospective
cohort study of members at 3 Kaiser
Permanente (KP) sites (Georgia,
Northern California, and Southern
California) in partnership with the
coordinating center at the Emory
University Rollins School of Public
Health. These KP sites provide
comprehensive health services
to >8.8 million members who are
sociodemographically diverse and
representative of their respective
communities.28, 29 In the clinical

setting, the identification of TGNC
youth may begin at age 13 years
during physical examinations as part
of the psychosocial and/or behavioral
assessment recommended by the
American Academy of Pediatrics30;
however, some TGNC children
may be identified earlier or later
in life. All activities were reviewed
and approved by the institutional
review boards of the 4 participating
institutions.

As described previously, 31, 32
persons with first evidence of
TGNC status between January 1,
2006, and December 31, 2014,
were identified on the basis of
International Classification of
Diseases, Ninth Edition (ICD-9)
codes and the presence of specific
keywords in free-text clinical notes
(Supplemental Table 5). TGNC status
was then verified (Supplemental Fig
1). A second free-text program was
developed with additional anatomy-
related or gender-affirmation
keywords, which were reviewed and
adjudicated for transfeminine or
transmasculine status (Supplemental
Table 6). Transfeminine and/or
transmasculine status was assigned
by using demographic information
from the EMRs of 220 children
whose gender assignment could
not be determined from text strings
because a validation revealed that
the demographic variable accurately
reflected assigned gender in 96%
of youth. Subjects with evidence of
disorders of sex development (eg,
variation of chromosomal, gonadal,
and/or anatomic sex development)
were excluded because they may
have distinct medical histories and
gender identity trajectories.33

Ten male and 10 female cisgender
KP enrollees were matched to each
member of the final validated TGNC
cohort on the basis of year of birth,
race and/or ethnicity, site, and
membership year of the index date.
Because reference group enrollees
had not been identified as TGNC by
the methods described above, they

BECERRA-CULQUI et al2
by guest on January 12, 2021www.aappublications.org/newsDownloaded from

http://pediatrics.aappublications.org/lookup/suppl/doi:10.1542/peds.2017-3845/-/DCSupplemental

were assumed to be cisgender (ie,
no evidence that gender identity
does not correspond to assigned
gender at birth). The race and/or
ethnicity categories used were non-
Hispanic white, non-Hispanic African
American, Asian American and/or
Pacific Islander, Hispanic, and other
races. Index date was defined on the
basis of the first recorded evidence of
TGNC status. For some TGNC cohort
members, <10 matched reference cisgender males or females were available; no TGNC individual was matched to <7 referents of either sex.

Subjects 3 through 17 years old
at the index date were included in
this study. Children <3 years old were excluded to reduce possible instability in gender identification and mental health diagnoses among the cohort.8 The ICD-9 codes for mental health diagnoses were grouped into

categories of conditions according
to recommendations from the
Mental Health Research Network34:
anxiety disorders, attention deficit
disorders, autism spectrum disorders,
bipolar disorders, conduct and/
or disruptive disorders, depressive
disorders, eating disorders, other
psychoses, personality disorders,
schizophrenia spectrum disorders,
self-inflicted injuries (including
poisonings), substance use disorders,
and suicidal ideation (Supplemental
Table 7). People could be represented
more than once if they had multiple
diagnoses and were thus counted in
each category for which they had a
diagnosis.

The prevalence of mental health
conditions in each of these categories
was calculated for 2 time windows:
any time (ever) and within 6 months
before the index date. These 2 time

windows were selected to examine
mental health status just proximal to
TGNC identification and to capture
longer-standing conditions diagnosed
at earlier ages (eg, autism spectrum
disorders). In these calculations,
the numerator for each disorder
or group of disorders included
persons with at least 1 relevant
diagnostic code recorded during
the time interval of interest. All
prevalence estimates were calculated
separately for transfeminine and
transmasculine subjects within 2
age groups: 3 to 9 years (children)
and 10 to 17 years (adolescents).
Age categorization was selected to
separately represent young school-
aged children and adolescents by
using the adolescent starting age of
10 years, corresponding to the World
Health Organization’s definition.35 To
assess differences in the severity of
the conditions of interest, additional

PEDIATRICS Volume 141, number 5, May 2018 3

TABLE 1 Characteristics of the TGNC Children and Adolescents Enrolled in the STRONG

Child and Adolescent Characteristics Transfeminine Cohort Transmasculine Cohort

Transfeminine
Cohort, n (%

)

Reference
Males, n (%)

Reference
Females, n (%)

Transmasculine
Cohort, n (%)

Reference
Males, n (%)

Reference
Females, n (%)

Age, a y
3–9 161 (27) 1605 (28) 1598 (28) 90 (12) 892 (12) 888 (12)
10–17 427 (73) 4206 (72) 4204 (72) 655 (88) 6448 (88) 6459 (88)
Health plan site
KPNC 344 (59) 3392 (58) 3378 (58) 431 (58) 4238 (58) 4245 (58)
KPSC 227 (39) 2249 (39) 2254 (39) 295 (40) 2915 (40) 2912 (40)
KPGA 17 (2.9) 170 (2.9) 170 (2.9) 19 (2.6) 187 (2.6) 190 (2.6)
Race and/or ethnicity
Non-Hispanic white 268 (46) 2633 (45) 2629 (45) 374 (50) 3663 (50) 3671 (50)
Non-Hispanic African American 53 (9.0) 523 (9.0) 521 (9.0) 57 (7.7) 564 (7.7) 564 (7.7)
Asian American and/or Pacific Islander 37 (6.3) 367 (6.3) 370 (6.4) 60 (8.1) 596 (8.1) 594 (8.1)
Hispanic 179 (30) 1779 (31) 1772 (31) 204 (27) 2018 (27) 2020 (27)
Other and/or unknown 51 (8.7) 509 (8.8) 510 (8.8) 50 (6.7) 499 (6.8) 498 (6.8)
Use ever before index date (average visits per y)
0 22 (3.7) 325 (5.6) 321 (5.5) 23 (3.1) 367 (5.0) 350 (4.8)
<1 15 (2.6) 568 (9.8) 530 (9.1) 25 (3.4) 763 (10) 746 (10) 1–3 127 (22) 1815 (31) 1879 (32) 154 (21) 2583 (35) 2562 (35) >3–6 171 (29) 1712 (29) 1781 (31) 240 (32) 2200 (30) 2235 (30)
>6–9 115 (20) 757 (13) 763 (13) 107 (14) 795 (11) 777 (11)
>9 137 (23) 631 (11) 528 (9.1) 196 (26) 630 (8.6) 675 (9.2)
Unknown 1 (0.2) 3 (0.1) 0 (0.0) 0 (0.0) 2 (0.0) 2 (0.0)
Use 6 mo before index date (average visits per mo)
0 101 (17) 2225 (38) 2062 (36) 111 (15) 2825 (39) 2502 (34)
<1 258 (44) 2846 (49) 2903 (50) 277 (37) 3531 (48) 3640 (50) 1–2 141 (24) 552 (9.5) 625 (11) 195 (26) 757 (10) 901 (12) >2 87 (15) 186 (3.2) 212 (3.7) 162 (22) 225 (3.1) 302 (4.1)
Unknown 1 (0.2) 2 (0.0) 0 (0.0) 0 (0.0) 2 (0.0) 2 (0.0)
Total 588 (2.1) 5811 (21) 5802 (21) 745 (2.7) 7340 (27) 7347 (27)

KPGA, Kaiser Permanente Georgia; KPNC, Kaiser Permanente Northern California; KPSC, Kaiser Permanente Southern California.
a Assessed at index date (date of first evidence of transgender status in EMRs).

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

http://pediatrics.aappublications.org/lookup/suppl/doi:10.1542/peds.2017-3845/-/DCSupplemental

analyses were conducted for
admittance or most serious diagnoses
associated with hospitalizations.

Each prevalence estimate in the
TGNC cohort was compared with
corresponding estimates among
matched cisgender male and female
referents. For ease in presenting
results, cisgender males and females
will be referred to as male or female
referents. Referents were assigned
the same index date as the matched
TGNC cohort member. For rare
events (prevalence ≤10% in both
the TGNC and referent cohorts),
the prevalence ratios (PRs) were
approximated by calculating the odds
ratios with exact 95% confidence
intervals (CIs). For events with >10%
prevalence in either group, PRs and
CIs were calculated by using logistic
regression with the log link option.

In addition to the primary analysis
that captures the true prevalence
of mental health conditions, we

conducted sensitivity analyses to
address possible differences in
the prevalence of mental health
conditions because of differences
in health care visit frequency (use)
between TGNC cohort members and
those in the referent groups. We
excluded the index date from the
time window, and when the sample
size was sufficient (>5 cases in
each group), the PR estimates were
adjusted for use of care. Average
health care use was calculated for
each individual by dividing the total
number of visits by the cumulative
duration of enrollment; this was
expressed as the number of visits per
year of enrollment in the analyses of
“ever” prevalence and as the number
of visits per month of enrollment in
the analyses within 6 months before
the index date. In adjusted analyses,
average use was dichotomized for
each time interval as above (high)
or below (low) the median by using
cutoffs for the overall population.

Analyses were conducted by using
SAS version 9.4 (SAS Institute, Inc,
Cary, NC) with custom macros
developed at the Biostatistics and
Bioinformatics Shared Resource
at the Winship Cancer Institute of
Emory University.36

RESULTS

A total of 2164 cohort candidates 3
to 17 years of age at the index date
were initially identified in the EMR.
After validation, 1347 (62%) were
confirmed as TGNC. People excluded
from the TGNC cohort were most
often those with keywords referring
to family or partners, standard
disclaimers not related to care (eg,
listing indications for hormone
use), or evidence of disorders of
sex development. After excluding
subjects with unknown gender
assigned at birth (N = 14), the final
analysis data set was based on a
cohort of 1333 subjects matched with

BECERRA-CULQUI et al4

TABLE 2 Prevalence of Mental Health Diagnoses in TGNC Children Ages 3–9 Years Relative to Those in Referent Groups

Categories of Mental Health
Disorders

Prevalence in
Transfeminine
Subjects, N (%)

PR (95% CI)a in Transfeminine
Subjects

Prevalence in
Transmasculine
Subjects, N (%)

PR (95% CI)a in Transmasculine Subjects

Versus
Reference

Males

Versus Reference
Females

Versus Reference
Males

Versus Reference
Females

All diagnoses of interest
Ever before index date 51 (31.7) 3.0 (2.3–3.9) 5.7 (4.2–7.7) 31 (34.4) 3.3 (2.3–4.6) 5.4 (3.7–7.8)
6 mo before index date 46 (28.6) 6.0 (4.3–8.4) 13.0 (8.7–19.6) 26 (28.9) 5.9 (3.8–9.0) 10.7 (6.4–17.8)
Anxiety disorders
Ever before index date 19 (11.8) 4.4 (2.6–7.4) 6.3 (3.6–10.9) 14 (15.6) 6.3 (3.3–11.9) 6.0 (3.2–11.3)
6 mo before index date 15 (9.3) 16.3 (6.7–41.4) 23.3 (8.8–68.5) 9 (10.0) 9.8 (3.4–27.6) 12.2 (4.0–37.3)
Attention deficit disorders
Ever before index date 24 (14.9) 3.3 (2.1–5.0) 6.1 (3.8–9.9) 14 (15.6) 2.8 (1.6–4.9) 6.9 (3.6–13.2)
6 mo before index date 22 (13.7) 5.0 (3.1–8.1) 10.9 (6.1–19.6) 14 (15.6) 4.2 (2.3–7.6) 12.6 (5.9–26.8)
Autism spectrum disorders
Ever before index date 8 (5.0) 2.2 (0.9–4.9) 11.8 (3.7–38.9) 0 NC NC
6 mo before index date 8 (5.0) 3.9 (1.5–9.5) 20.8 (5.5–95.3) 0 NC NC
Conduct and/or disruptive

disorders
Ever before index date 12 (7.5) 3.3 (1.5–6.7) 14.2 (5.4–38.8) 7 (7.8) 6.2 (2.0–17.5) 12.3 (3.5–45.5)
6 mo before index date 8 (5.0) 8.3 (2.8–23.8) 83.0 (11.0–3707.3) b 13.7 (2.3–95.1) 20.5 (2.9–229.2)
Depressive disorders
Ever before index date 9 (5.6) 6.7 (2.5–17.0) 7.8 (2.9–20.6) 10 (11.1) 27.5 (7.7–123.0) 12.3 (5.0–30.5)
6 mo before index date 6 (3.7) 8.8 (2.4–31.1) 12.3 (3.1–51.5) 8 (8.9) 43.0 (8.4–422.3) 28.5 (6.7–170.2)
Eating disorders
Ever before index date b 3.7 (0.8–12.6) 6.7 (1.4–28.8) 0 NC NC
6 mo before index date b 10.0 (0.1–787.4) 10.0 (0.1–784.0) 0 NC NC

NC, not calculated because there were 0 cases among transgender subjects.
a Logistic regression with exact 95% CIs for rare events (prevalence ≤10% in both the transgender and referent cohorts) or logistic regression with log link and approximate 95% CIs for
not-rare events (>10% prevalence in either the transgender or referent cohorts).
b Fewer than 5 cases were not reported.

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

PEDIATRICS Volume 141, number 5, May 2018 5

TA
B

LE
3

P
re

va
le

nc
e

of
M

en
ta

l H
ea

lt
h

D
ia

gn
os

es
in

T
G

N
C

Ad
ol

es
ce

nt
s

Ag
es

1
0–

17
Y

ea
rs

R
el

at
iv

e
to

T
ho

se
in

R
ef

er
en

t
G

ro
up

Ca
te

go
ri

es
o

f
M

en
ta

l H
ea

lt
h

D
is

or
de

rs
Pr

ev
al

en
ce

Tr
an

sf
em

in
in

e
Su

bj
ec

ts
, N

(
%

)

PR
(

95
%

C
I)

a
in

T
ra

ns
fe

m
in

in
e

Su
bj

ec
ts

Pr
ev

al
en

ce
in

an
sm

as
cu

lin
e

Su
bj

ec
ts

, N
(

%
)

PR
(

95
%

C
I)

a
in

T
ra

ns
m

as
cu

lin
e

Su
bj

ec
ts

Ve
rs

us
R

ef
er

en
ce

M
al

es
Ve

rs
us

R
ef

er
en

ce
F

em
al

es
Ve

rs
us

R
ef

er
en

ce
M

al
es

Ve
rs

us
R

ef
er

en
ce

F
em

al
es

Al
l d

ia
gn

os
es

o
f

in
te

re
st

er
b

ef
or

e
in

de
x

da
te

30
3

(7
1.

)
3.

0
(2

.8
–3

.3
)

3.
6

(3
.3

–3
.9

)
48

8
(7

4.
5)

3.
0

(2
.8

–3
.2

)
3.

7
(3

.4
–3

.9
)

m
o

be
fo

re
in

de
x

da
te

25
3

(5
9.

)
7.

8
(6

.8
–8

.9
)

8.
6

(7
.5

–9
.8

)
42

9
(6

5.
5)

7.
8

(7
.1

–8
.7

)
8.

7
(7

.8
–9

.6
)

An
xi

et
y

di
so

rd
er

Ev
er

b
ef

or
e

in
de

x
da

te
15

9
(3

7.
2)

5.
0

(4
.2

–5
.8

)
4.

2
(3

.6
–4

.9
)

25
5

(3
8.

9)
4.

9
(4

.3
–5

.6
)

4.
0

(3
.5

–4
.5

)

6
m

o
be

fo
re

in
de

x
da

te
10

6
(2

4.
8)

18
.0

(
13

.3
–2

4.
4)

9.
2

(7
.2

–1
1.

)
17

5
(2

6.
7)

15
.7

(
12

.5
–1

9.
6)

8.
7

(7
.2

–1
0.

5)
At

te
nt

io
n

de
fic

it
d

is
or

de
rs

er
b

ef
or

e
in

de
x

da
te

10
7

(2
5.

)
2.

0
(1

.7
–2

.4
)

5.
3

(4
.3

–6
.5

)
10

6
(1

6.
2)

1.
3

(1
.0

–1
.5

)
3.

3
(2

.7
–4

.1
)

m
o

be
fo

re
in

de
x

da
te

68
(

15
.9

)
3.

8
(2

.9
–4

.9
)

9.
0

(6
.6

–1
2.

4)
69

(
10

.5
)

2.
5

(1
.9

–3
.3

)
6.

4
(4

.6
–8

.8
)

Au
ti

sm
s

pe
ct

ru
m

d
is

or
de

Ev
er

b
ef

or
e

in
de

x
da

te
31

(
7.

3)
4.

1
(2

.6
–6

.4
)

25
.2

(
12

.7
–5

2.
9)

24
(

3.
7)

1.
8

(1
.1

–2
.8

)
7.

6
(4

.3
–1

3.
5)

m
o

be
fo

re
in

de
x

da
te

25
(

5.
9)

8.
1

(4
.6

–1
4.

)
26

0.
8

(4
2.

5–
10

73
3.

9)
17

(
2.

6)
3.

4
(1

.8
–6

.1
)

17
.2

(
7.

4–
42

.1
)

B
ip

ol
ar

d
is

or
de

Ev
er

b
ef

or
e

in
de

x
da

te
23

(
5.

)
9.

9
(5

.3
–1

8.
5)

10
.3

(
5.

5–
19

.5
)

34
(

5.
2)

8.
6

(5
.2

–1
3.

9)
8.

0
(4

.9
–1

2.
9)

m
o

be
fo

re
in

de
x

da
te

16
(

3.
8)

18
.1

(
7.

5–
46

.9
)

14
.8

(
6.

4–
35

.6
)

19
(

2.
9)

11
.3

(
5.

5–
23

.3
)

14
.8

(
6.

9–
32

.8
)

Co
nd

uc
t

an
d/

or
d

is
ru

pt
iv

e
di

so
rd

er
s

er
b

ef
or

e
in

de
x

da
te

60
(

14
.1

)
2.

8
(2

.1
–3

.7
)

6.
6

(4
.8

–9
.0

)
59

(
9.

0)
1.

7
(1

.3
–2

.3
)

4.
5

(3
.2

–6
.2

)

6
m

o
be

fo
re

in
de

x
da

te
22

(
5.

)
5.

3
(3

.0
–9

.1
)

12
.6

(
6.

4–
25

.2
)

27
(

4.
1)

5.
5

(3
.3

–9
.0

)
10

.6
(

5.
9–

19
.1

)
D

ep
re

ss
iv

e
di

so
rd

er
s

er
b

ef
or

e
in

de
x

da
te

20
7

(4
8.

5)
5.

8
(5

.1
–6

.7
)

4.
4

(3
.9

–5
.0

)
40

3
(6

1.
5)

7.
0

(6
.4

–7
.8

)
5.

7
(5

.2
–6

.2
)

m
o

be
fo

re
in

de
x

da
te

17
2

(4
0.

3)
23

.5
(

18
.2

–3
0.

4)
10

.1
(

8.
4–

12
.2

)
32

6
(4

9.
8)

22
.8

(
19

.0
–2

7.
3)

13
.3

(
11

.5
–1

5.
4)

Ea
ti

ng
d

is
or

de
rs

er
b

ef
or

e
in

de
x

da
te

18
(

4.
2)

7.
7

(3
.9

–1
4.

9)
3.

3
(1

.8
–5

.7
)

28
(

4.
3)

6.
0

(3
.6

–9
.8

)
3.

2
(2

.0
–5

.0
)

m
o

be
fo

re
in

de
x

da
te

11
(

2.
6)

18
.5

(
6.

2–
61

.2
)

6.
1

(2
.6

–1
3.

8)
19

(
2.

9)
27

.5
(

11
.0

–7
7.

6)
8.

7
(4

.4
–1

7.
0)

Ps
yc

ho
se

Ev
er

b
ef

or
e

in
de

x
da

te
19

(
4.

5)
19

.5
(

8.
6 –

47
.3

)
12

.2
(

5.
9–

25
.5

)
32

(
4.

9)
12

.2
(

7.
0–

21
.3

)
14

.4
(

8.
1–

25
.9

)

6
m

o
be

fo
re

in
de

x
da

te
10

(
2.

)
20

.1
(

6.
2–

75
.4

)
10

0.
6

(1
4.

2–
43

75
.0

)
18

(
2.

8)
22

.7
(

9.
4–

60
.6

)
30

.4
(

11
.5

–9
3.

8)
Pe

rs
on

al
it

y
di

so
rd

er
s

er
b

ef
or

e
in

de
x

da
te

10
(

2.
3)

14
.4

(
4.

9 –
44

.7
)

11
.2

(
4.

1–
31

.2
)

15
(

2.
3)

11
.6

(
5.

1–
26

.6
)

7.
9

(3
.7

–1
6.

6
m

o
be

fo
re

in
de

x
da

te
b

19
.8

(
2.

8–
22

0.
0)

19
.8

(
2.

8–
21

9.
9)

9
(1

.4
)

29
.9

(
7.

4–
17

2.
1)

29
.9

(
7.

4–
17

2.
4)

Sc
hi

zo
ph

re
ni

a
sp

ec
tr

um
d

is
or

de
rs

er
b

ef
or

e
in

de
x

da
te

5
(1

.2
)

49
.7

(
5.

5–
23

57
.0

)
24

.9
(

4.
1–

26
1.

)
13

(
2.

)
21

.7
(

7.
7–

69
.9

)
32

.6
(

10
.0

–1
37

.8
)

m
o

be
fo

re
in

de
x

da
te

b
c

14
.8

(
1.

7–
17

8.
2)

10
(

1.
5)

99
.8

(
14

.2
–4

33
8.

3)
50

.0
(

10
.6

–4
70

.2
)

Se
lf

-in
fl

ic
te

d
in

ju
ri

Ev
er

b
ef

or
e

in
de

x
da

te
11

(
2.

6)
3.

9
(1

.8
–8

.2
)

4.
1

(1
.8

–8
.6

)
54

(
8.

2)
14

.0
(

9.
1–

21
.8

)
8.

7
(5

.9
–1

2.
8)

m
o

be
fo

re
in

de
x

da
te

7
(1

.6
)

69
.9

(
9.

0–
31

59
.2

)
17

.5
(

4.
4–

81
.7

)
28

(
4.

3)
14

3.
7

(3
6.

1–
12

47
.8

)
20

.5
(

10
.4

–4
2.

)
Su

bs
ta

nc
e

us
e

di
so

rd
er

Ev
er

b
ef

or
e

in
de

x
da

te
33

(
7.

7)
3.

0
(1

.9
–4

.5
)

3.
7

(2
.4

–5
.6

)
46

(
7.

0)
2.

4
(1

.7
–3

.4
)

3.
3

(2
.3

–4
.7

)

6
m

o
be

fo
re

in
de

x
da

te
24

(
5.

6)
5.

8
(3

.3
–9

.8
)

8.
9

(4
.9

–1
6.

0)
34

(
5.

2)
4.

5
(2

.9
–6

.9
)

8.
2

(5
.0

–1
3.

2)
Su

ic
id

al
id

ea
ti

Ev
er

b
ef

or
e

in
de

x
da

te
32

(
7.

5)
17

.8
(

9.
7–

33
.6

)
11

.3
(

6.
5–

19
.4

)
68

(
10

.4
)

21
.2

(
13

.8
–3

3.
2)

11
.0

(
7.

7–
15

.9
)

m
o

be
fo

re
in

de
x

da
te

21
(

4.
9)

54
.2

(
18

.2
–2

18
.3

)
31

.0
(

12
.6

–8
6.

7)
47

(
7.

2)
45

.2
(

22
.9

–9
7.

1)
24

.9
(

14
.3

–4
4.

6)
a

Lo
gi

st
ic

r
eg

re
ss

io
n

w
it

h
ex

ac
t

95
%

C
Is

fo
r

ra
re

e
ve

nt
s

(p
re

va
le

nc
e

≤
10

%
in

b
ot

h
th

e
tr

an
sg

en
de

r
an

d
re

fe
re

nt
c

oh
or

ts
)

or
lo

gi
st

ic
r

eg
re

ss
io

n
w

it
h

lo
g

lin
k

an
d

ap
pr

ox
im

at
e

95
%

C
Is

fo
r

no
t-

ra
re

e
ve

nt
s

(>
10

%
p

re
va

le
nc

e
in

e
it

he
r

th
e

tr
an

sg
en

de
r

or
r

ef
er

en
t

co
ho

rt
s)

.
b

Fe
w

er
t

ha
n

5
ca

se
s

w
er

e
no

t
re

po
rt

ed
.

c
N

ot
c

al
cu

la
te

d
be

ca
us

e
th

er
e

w
er

e
0

ca
se

s
am

on
g

re
fe

re
nt

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

BECERRA-CULQUI et al6

TA
B

LE
4

P
re

va
le

nc
e

of
H

os
pi

ta
liz

at
io

n
fo

r
M

en
ta

l H
ea

lt
h

D
ia

gn
os

es
in

T
G

N
C

Ch
ild

re
n

Ag
es

1
0–

17
Y

ea
rs

R
el

at
iv

e
to

T
ho

se
in

R
ef

er
en

t
G

ro
up

Ca
te

go
ri

es
o

f
M

en
ta

l H
ea

lt
h

D
is

or
de

rs
Pr

ev
al

en
ce

Tr
an

sf
em

in
in

e
Su

bj
ec

ts
, N

(
%

)

PR
(

95
%

C
I)

a
in

T
ra

ns
fe

m
in

in
e

Su
bj

ec
ts

Pr
ev

al
en

ce
in

an
sm

as
cu

lin
e

Su
bj

ec
ts

, N
(

%
)

PR
(

95
%

C
I)

a
in

T
ra

ns
m

as
cu

lin
e

Su
bj

ec
ts

Ve
rs

us
R

ef
er

en
ce

M
al

es
Ve

rs
us

R
ef

er
en

ce
F

em
al

es
Ve

rs
us

R
ef

er
en

ce
M

al
es

Ve
rs

us
R

ef
er

en
ce

F
em

al
es

Al
l d

ia
gn

os
es

o
f

in
te

re
st

er
b

ef
or

e
in

de
x

da
te

58
(

13
.6

)
9.

9
(6

.9
–1

4.
0)

8.
9

(6
.3

–1
2.

5)
99

(
15

.1
)

10
.2

(
7.

8–
13

.3
)

7.
8

(6
.1

–1
0.

6
m

o
be

fo
re

in
de

x
da

te
33

(
7.

7)
43

.9
(

19
.7

–1
10

.7
)

35
.1

(
16

.7
–8

0.
4)

59
(

9.
0)

35
.3

(
20

.4
–6

4.
1)

21
.9

(
13

.7
–3

5.
8)

An
xi

et
y

di
so

rd
er

Ev
er

b
ef

or
e

in
de

x
da

te
9

(2
.1

)
9.

0
(3

.2
–2

4.
9)

6.
0

(2
.3

–1
4.

8)
25

(
3.

)
15

.0
(

7.
7–

29
.8

)
13

.4
(

7.
1–

26
.0

)

6
m

o
be

fo
re

in
de

x
da

te
6

(1
.4

)
59

.8
(

7.
2–

27
57

.2
)

29
.9

(
5.

3–
30

3.
7)

13
(

2.
0)

43
.4

(
11

.9
–2

38
.3

)
32

.6
(

10
.0

–1
37

.8
)

At
te

nt
io

n
de

fic
it

d
is

or
de

Ev
er

b
ef

or
e

in
de

x
da

te
20

(
4.

7)
9.

8
(5

.0
–1

9.
1)

14
.7

(
7.

0–
31

.7
)

14
(

2.
1)

4.
0

(2
.0

–7
.7

)
9.

4
(4

.2
–2

0.
9)

m
o

be
fo

re
in

de
x

da
te

6
(1

.4
)

19
.9

(
4.

2–
12

3.
6)

59
.8

(
7.

2–
27

55
.8

)
b

c
9.

9
(1

.3
–7

4.
0)

Au
ti

sm
s

pe
ct

ru
m

d
is

or
de

Ev
er

b
ef

or
e

in
de

x
da

te
b

6.
6

(1
.4

–2
8.

0)
39

.7
(

3.
9–

19
57

.7
)

5
(0

.8
)

5.
0

(1
.3

–1
6.

0)
8.

3
(2

.0
–3

2.
6)

m
o

be
fo

re
in

de
x

da
te

b
c

c
b

3.
3

(0
.1

–4
1.

)
c

B
ip

ol
ar

d
is

or
de

Ev
er

b
ef

or
e

in
de

x
da

te
12

(
2.

8)
30

.3
(

9.
1–

12
9.

6)
13

.5
(

5.
2–

36
.4

)
18

(
2.

8)
10

.1
(

4.
9–

20
.7

)
9.

1
(4

.5
–1

8.
2)

m
o

be
fo

re
in

de
x

da
te

b
39

.7
(

3.
9–

19
58

.7
)

19
.8

(
2.

8–
21

9.
9)

8
(1

.2
)

15
.9

(
4.

6–
62

.0
)

19
.9

(
5.

3–
90

.7
)

Co
nd

uc
t

an
d/

or
d

is
ru

pt
iv

e
di

so
rd

er
s

er
b

ef
or

e
in

de
x

da
te

10
(

2.
3)

16
.8

(
5.

5–
56

.4
)

16
.8

(
5.

5–
56

.4
)

10
(

1.
5)

5.
9

(2
.4

–1
3.

6)
6.

7
(2

.7
–1

5.
9)

m
o

be
fo

re
in

de
x

da
te

5
(1

.2
)

49
.7

(
5.

5–
23

57
.0

)
c

b
39

.6
(

3.
9–

19
51

.1
)

39
.6

(
3.

9–
19

54
.4

)
D

ep
re

ss
iv

e
di

so
rd

er
s

er
b

ef
or

e
in

de
x

da
te

41
(

9.
6)

21
.1

(
12

.1
–3

8.
1)

10
.3

(
6.

4–
16

.4
)

83
(

12
.7

)
17

.8
(

12
.5

–2
5.

2)
9.

1
(6

.8
–1

2.
1)

m
o

be
fo

re
in

de
x

da
te

26
(

6.
1)

68
.0

(
23

.4
–2

69
.3

)
54

.3
(

20
.4

–1
82

.2
)

49
(

7.
5)

10
4.

0
(4

1.
5–

33
5.

9)
21

.7
(

12
.9

–3
7.

2)
Ea

ti
ng

d
is

or
de

Ev
er

b
ef

or
e

in
de

x
da

te
b

6.
6

(0
.5

–5
7.

7)
2.

8
(0

.3
–1

4.
9)

6
(0

.9
)

29
.8

(
5.

3–
30

2.
1)

4.
0

(1
.3

–1
0.

6
m

o
be

fo
re

in
de

x
da

te
b

c
3.

3
(0

.1
–4

1.
0)

b
29

.8
(

5.
3–

30
2.

1)
4.

0
(1

.3
–1

0.
9)

Ps
yc

ho
se

Ev
er

b
ef

or
e

in
de

x
da

te
8

(1
.9

)
26

.7
(

6.
4–

15
6.

9)
11

.4
(

3.
6–

37
.2

)
10

(
1.

5)
20

.0
(

6.
2–

74
.7

)
12

.5
(

4.
4–

36
.6

)

6
m

o
be

fo
re

in
de

x
da

te
5

(1
.2

)
49

.7
(

5.
5–

23
57

.0
)

49
.7

(
5.

5–
23

55
.8

)
b

19
.8

(
2.

8–
21

9.
1)

9.
9

(1
.8

–5
3.

3)
Pe

rs
on

al
it

y
di

so
rd

er
s

er
b

ef
or

e
in

de
x

da
te

b
39

.7
(

3.
9–

19
58

.7
)

19
.8

(
2.

8–
21

9.
9)

8
(1

.2
)

26
.5

(
6.

3–
15

5.
7)

8.
9

(3
.0

–2
6.

6
m

o
be

fo
re

in
de

x
da

te
0

(0
)

N
C

7
(1

.1
)

c
69

.7
(

8.
9–

31
44

.6
)

Sc
hi

zo
ph

re
ni

a
sp

ec
tr

um
d

is
or

de
rs

er
b

ef
or

e
in

de
x

da
te

b
c

14
.8

(
1.

7–
17

8.
2)

b
9.

9
(1

.8
–5

3.
2)

13
.2

(
2.

2–
90

.4
)

m
o

be
fo

re
in

de
x

da
te

0
(0

)
N

C
N

C
b

9.
9

(0
.1

–7
73

.9
)

9.
9

(0
.1

–7
75

.2
)

Se
lf

-in
fl

ic
te

d
in

ju
ri

Ev
er

b
ef

or
e

in
de

x
da

te
b

6.
6

(0
.5

–5
7.

7)
4.

9
(0

.4
–3

4.
6)

13
(

2.
0)

65
.2

(
14

.7
–5

96
.2

)
13

.0
(

5.
3–

33
.4

)

6
m

o
be

fo
re

in
de

x
da

te
b

c
c

7
(1

.1
)

c
34

.8
(

6.
6–

34
4.

4)
Su

bs
ta

nc
e

us
e

di
so

rd
er

Ev
er

b
ef

or
e

in
de

x
da

te
8

(1
.9

)
5.

7
(2

.1
–1

4.
7)

4.
2

(1
.6

–1
0.

1)
16

(
2.

4)
6.

2
(3

.1
– 1

2.
0)

6.
2

(3
.1

–1
2.

6
m

o
be

fo
re

in
de

x
da

te
6

(1
.4

)
29

.9
(

5.
3–

30
3.

9)
12

.0
(

3.
0–

49
.7

)
9

(1
.4

)
11

.2
(

3.
8–

33
.5

)
11

.2
(

3.
8–

33
.6

)
Su

ic
id

al
id

ea
ti

Ev
er

b
ef

or
e

in
de

x
da

te
9

(2
.1

)
15

.1
(

4.
8–

51
.7

)
5.

6
(2

.2
–1

3.
6)

29
(

4.
4)

19
.8

(
10

.2
–4

0.
1)

11
.5

(
6.

5–
20

.4
)

m
o

be
fo

re
in

de
x

da
te

7
(1

.6
)

c
23

.3
(

5.
3–

14
0.

2)
17

(
2.

6)
24

.5
(

9.
6–

70
.1

)
21

.5
(

8.
7–

57
.7

)

N
C,

n
ot

c
al

cu
la

te
d

be
ca

us
e

th
er

e
w

er
e

0
ca

se
s

am
on

g
tr

an
sg

en
de

r
su

bj
ec

ts
.

a
Lo

gi
st

ic
r

eg
re

ss
io

n
w

it
h

ex
ac

t
95

%
C

Is
fo

r
ra

re
e

ve
nt

s
(p

re
va

le
nc

e
≤

10
%

in
b

ot
h

th
e

tr
an

sg
en

de
r

an
d

re
fe

re
nt

c
oh

or
ts

)
or

lo
gi

st
ic

r
eg

re
ss

io
n

w
it

h
lo

g
lin

k
an

d
ap

pr
ox

im
at

e
95

%
C

Is
fo

r
no

t-
ra

re
e

ve
nt

s
(>

10
%

p
re

va
le

nc
e

in
e

it
he

r
th

e
tr

an
sg

en
de

r
or

r
ef

er
en

t
co

ho
rt

s)
.

b
Fe

w
er

t
ha

n
5

ca
se

s
w

er
e

no
t

re
po

rt
ed

.
c

N
ot

c
al

cu
la

te
d

be
ca

us
e

th
er

e
w

er
e

0
ca

se
s

am
on

g
re

fe
re

nt
s.

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

13 151 reference males and 13 149
reference females.

The cohort included 588 (44%)
transfeminine and 745 (56%)
transmasculine children and
adolescents (Table 1). Children
<10 years old represented 27% of the transfeminine cohort and 12% of the transmasculine cohort. Compared with TGNC children (n = 251), in which 36% (n = 90) were transfeminine, 61% (n = 655) of adolescents (n = 1082) were transmasculine. More than 45% of subjects in both groups were white; Hispanics represented 30% of transfeminine and 27% of transmasculine subjects, whereas the remainder of the study population was approximately equally distributed among African Americans, Asian Americans and/ or Pacific Islanders, and persons whose race and/or ethnicity was characterized as other or unknown. Health care use levels were much higher in both transfeminine and transmasculine subjects than in those in the corresponding reference groups.

The most common diagnostic
categories among TGNC children
3 to 9 years of age were attention
deficit disorders (15% transfeminine;
16% transmasculine) and anxiety
disorders (12% transfeminine; 16%
transmasculine; Table 2). The PR
(95% CI) estimates for attention
deficit disorders ranged from 2.8
(95% CI 1.6–4.9) to 13 (95% CI
5.9–27). The PR (95% CI) estimates
for anxiety disorders ranged from
4.4 (95% CI 2.6–7.4) to 23 (95%
CI 8.8–69) depending on the time
window before the index date
and the reference group. Among
transfeminine children, 5% had an
autism spectrum disorder diagnosis;
however, no cases were observed
in transmasculine children. For
all the diagnostic categories, the
most pronounced PR estimates
were observed within the 6-month

period before the index date.
Among transfeminine children,
the highest PR (95% CI) estimate
was for conduct and/or disruptive
disorders relative to reference
females (83 [95% CI 11–3707]).
Among transmasculine children, the
highest PR (95% CI) estimate was
for depressive disorders relative
to reference males (43 [95% CI
8.4–422]). Additional analyses of the
prevalence of hospitalizations by
mental health diagnostic category
were not possible in this age group
because of small sample sizes.

In the adolescent group (age 10–17
years), like in the younger age
group, attention deficit disorders
and anxiety disorders remained
common (“ever” prevalence:
25% transfeminine and 16%
transmasculine; 40% both
transfeminine and transmasculine,
respectively; Table 3). The
diagnostic category with the highest
prevalence in this age group was
depressive disorders, which were
found in 49% of transfeminine and
62% of transmasculine subjects.
For all diagnostic categories, PR
estimates used to compare STRONG
adolescents to matched reference
groups were highest within 6
months before the index date.
Compared with reference females,
transfeminine and transmasculine
adolescents experienced particularly
pronounced increased prevalence
in psychoses (PR 101 and 95% CI
14–4375; PR 30 and 95% CI 12–94,
respectively). Additionally, the PR
estimates among transfeminine
subjects were particularly elevated
for autism spectrum disorders
(PR 261; 95% CI 43–10 734) and
among transmasculine subjects for
schizophrenia spectrum disorders
(PR 50; 95% CI 11–470) compared
with reference females. Compared
with reference males, PR estimates
for suicidal ideation and self-inflicted
injuries for transfeminine subjects
were 54 (95% CI 18–218) and 70

(95% CI 9.0–159), respectively,
which were also high among
transmasculine subjects, (45 [95% CI
23–97] and 144 [95% CI 14–4338],
respectively).

When prevalence estimates were
limited to mental health conditions
recorded during hospitalizations,
the patterns among adolescents
generally remained the same. In
several instances, however, the PR
estimates could not be calculated
because of the absence of cases in the
reference groups (Table 4).

The median cutoff values used for
adjusted analyses were 3.2 average
visits per year for the “ever” analyses
and 0.2 average visits per month for
the 6-month analyses. The prevalence
estimates were slightly attenuated or
remained approximately the same for
most diagnostic categories. However,
some estimates changed appreciably.
For children 3 to 9 years, adjusting
for use 6 months before and
excluding the index date produced
the largest decrease in the PR (95%
CI) for anxiety disorders, from 23
(95% CI 8.8–69) to 9.0 (95% CI
2.9–29) when transfeminine children
were compared with reference males
(Supplemental Table 8). The PR
(95% CI) for suicidal ideation among
transfeminine adolescents compared
with reference males within 6
months of the index date decreased
from 54 (95% CI 18–218) to 38 (95%
CI 12–159; Supplemental Table 9).

DISCUSSION

The results of this study reveal that
among TGNC youth, mental health
conditions, specifically anxiety
and depression, are common and
often severe among adolescents, as
evidenced by diagnoses associated
with hospitalizations. Gender
nonconforming children (3–9 years
of age) have a higher prevalence
of anxiety and attention deficit
disorders compared with their
cisgender counterparts. In nearly all

PEDIATRICS Volume 141, number 5, May 2018 7
by guest on January 12, 2021www.aappublications.org/newsDownloaded from

http://pediatrics.aappublications.org/lookup/suppl/doi:10.1542/peds.2017-3845/-/DCSupplemental

instances, mental health diagnoses
were more common in the TGNC
youth than in referent children and
adolescents.

These results support findings
from previous research in which
the sample sizes were much
smaller.17, 19 –22, 37 – 42 Researchers in
a survey of 101 transfeminine and
transmasculine patients ages 12
to 24 years in a transgender youth
clinic in Los Angeles found that
35% had symptoms of depression
and >50% had suicidal thoughts.19
In comparison, we found that
adolescents had a higher prevalence
(40%–60%) of depression but a
lower prevalence of suicidal ideation
(5%–10%). In a medical record
abstraction study of 97 transfeminine
and transmasculine patients ages 4
to 20 years presenting to the Gender
Management Service Clinic at Boston
Children’s Hospital, 44% presented
with a significant psychiatric history,
21% had a history of self-mutilation,
and 9% had documentation of
suicide attempts.22 In a UK study, a
baseline chart review of children 5
to 11 years old referred to a national
specialty clinic revealed that 17%
had symptoms of anxiety, and 15%
had a history of suicidal ideation,
self-harm, and/or a diagnosis of
attention-deficit/hyperactivity
disorder recorded before entering
services.39 Our results for children
were similar for demonstrated
anxiety (9%–16%) and attention
deficit disorders (14%–16%). Direct
comparisons to the current study
are challenging because there are
methodological differences. Two
important differences are the way
in which mental health conditions
were ascertained and presentations
of age. In addition, we included a
broader population of children and
adolescents who were not necessarily
seeking treatment for gender-related
issues.

In recent years, researchers in
several studies have suggested that
gender dysphoria may be associated

with autism spectrum disorders.43 – 45
The most widely cited evidence
supporting this hypothesis comes
from a study of 204 children and/or
adolescents referred to the Gender
Identity Clinic in Amsterdam.46 The
presence of an autism spectrum
disorder was established via a
standardized diagnostic interview, 47
yielding a prevalence of 10%
among transfeminine patients and
4% among transmasculine patients,
which was reported by the authors
to be higher than the 1% estimate
reported in the general population.
The prevalence of autism spectrum
disorders in our study was somewhat
lower (7% in transfeminine and
3% in transmasculine subjects
across both age groups), but our
case ascertainment was based on
documented diagnostic codes, and
the denominator in our calculations
was not limited to children with
established gender dysphoria.
With these differences in mind,
our results are generally comparable
to those reported in the Dutch
study.

The gender ratio in this TGNC cohort
reveals that transfeminine youth
may present earlier in age than
transmasculine individuals, which
may pose a unique challenge to the
early identification of mental health
needs in transmasculine children and
adolescents. Historically, researchers
in studies of TGNC adolescents have
reported a greater proportion of
transfeminine than transmasculine
subjects, but in recent years, the
direction of the transmasculine:
transfeminine ratio appears to have
changed.48 For example, researchers
in 1 recent study observed that
transmasculine youth with gender
dysphoria (aged 12–24 years)
presented in significantly higher
numbers than their transfeminine
counterparts.19 Our data, which
were based on EMRs, were used to
confirm this observation. Therefore,
providers should also be aware of the
growing transmasculine population

needing timely and appropriate
medical and psychosocial services.

An important contribution of the
STRONG to the extant literature is
its relatively large cohort, which
allowed for focusing on previously
understudied groups (such as
young children), and an evaluation
of relatively rare events (such
as hospitalizations). In addition,
the current study was based on
children and adolescents who
were not necessarily in specialized
care and enrolled in a large health
care system; and we did not
require participant opt-in. The
availability of a well-defined source
population allowed for matching
transfeminine and transmasculine
study subjects to male and female
referents of the same age, race and/
or ethnicity, and geographic region.
This design feature permitted
direct comparisons of prevalence
estimates among transfeminine,
transmasculine, and cisgender
referent groups.

A limitation of this study is its cross-
sectional design. Although we were
able to retrospectively ascertain
mental health conditions before
the index date and we matched
on the basis of membership year,
a differential ascertainment of
diagnoses could have occurred. The
identification of the TGNC cohort was
based on health care use, which is
different from the matched referent
groups. Results from sensitivity
analyses adjusting for use and
excluding the index date revealed
a similar or slight attenuation of
the PR results for most diagnostic
categories. However, when adjusting
for use 6 months before the index
date, a more notable attenuation of
PRs was seen in anxiety disorders
in transfeminine children and
suicidal ideation in transfeminine
adolescents compared with reference
males, indicating possible higher
surveillance of mental health
conditions in the several months

BECERRA-CULQUI et al8
by guest on January 12, 2021www.aappublications.org/newsDownloaded from

before cohort identification.
Nevertheless, this baseline study
reveals that TGNC youth experience a
multitude of mental health problems
before initial presentation. However,
there is indication that TGNC
children who receive meaningful
gender identity support do not
necessarily experience elevated rates
of depression and anxiety.49 As the
STRONG cohort follow-up extends, it
will be possible to examine temporal
changes in the frequency and
severity of mental health problems,
particularly in relation to the age of
gender affirmation, which is an area
of considerable uncertainty, and
the impact of interventions to treat
gender dypshoria.50 –53

CONCLUSIONS
The most important finding is the
high frequency of mental health
conditions that TGNC children and
adolescents experience. Especially
worrisome are the results for
suicidal ideation and self-inflicted
injuries with prevalence estimates
orders of a magnitude that is higher
in TGNC children and adolescents
than in matched cisgender reference
groups. For nearly all mental
health disorders, the PRs increased
during the time window closest to
the index date. Overall, these data
reveal that children and adolescents
presenting as TGNC to health care
providers may require not only
thorough and immediate evaluation

of mental health needs but also
urgent implementation of social
and educational measures of gender
identity support.

PEDIATRICS Volume 141, number 5, May 2018 9

within their areas of expertise (such as epidemiologic methods, bias, health care access and health service use interpretation, and the broad messaging of the
manuscript), and revised the manuscript; Drs Liu, Flanders, and Nash provided substantial statistical analysis consultation, conducted the analyses, and critically
reviewed and revised the manuscript for important statistical interpretation of the data; Ms Cromwell substantially contributed to the design of multisite data
collection, critically reviewed the manuscript for appropriate interpretation of the data variables with respect to the results, and revised the manuscript; Ms
Millman and Ms Robinson conceptualized the study and substantially contributed to the acquisition of data by coordinating site data collection, critically reviewed
and revised the manuscript by providing and ensuring the interpretation of results with respect to site-specific patient populations, and revised the manuscript;
Drs Giammattei, Sandberg, and Tangpricha provided clinical consultation regarding the interpretation of results, revised the manuscript, and critically reviewed
the manuscript for important intellectual content specific to transgender and/or gender nonconforming youth, gender transitioning, and the mental health
outcomes discussed in the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

DOI: https:// doi. org/ 10. 1542/ peds. 2017- 3845

Accepted for publication Feb 22, 2018

Address correspondence to Michael Goodman, MD, MPH, Department of Epidemiology, Emory University School of Public Health, 1518 Clifton Rd, NE, CNR 3021,
Atlanta, GA 30322. E-mail: mgoodm2@emory.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Funded by contract AD-12-11-4532 from the Patient-Centered Outcomes Research Institute and grant R21HD076387 from the Eunice Kennedy Shriver
National Institute of Child Health and Human Development. Funded by the National Institutes of Health (NIH).

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

COMPANION PAPER: Companions to this article can be found online at www. pediatrics. org/ cgi/ doi/ 10. 1542/ peds. 2017- 3004 and www. pediatrics. org/ cgi/ doi/ 10.
1542/ peds. 2018- 0361.

ABBREVIATIONS

CI: confidence interval
EMR: electronic medical record
ICD-9: International Classification

of Diseases, Ninth Edition
KP: Kaiser Permanente
PR: prevalence ratio
STRONG: Study of Transition,

Outcomes, and Gender
TGNC: transgender and/or

gender nonconforming

REFERENCES

1. Lombardi E. Enhancing transgender
health care. Am J Public Health.
2001;91(6):869–872

2. Wallien MS, Cohen-Kettenis
PT. Psychosexual outcome of
gender-dysphoric children. J Am
Acad Child Adolesc Psychiatry.
2008;47(12):1413–1423

3. Steensma TD, van der Ende J,
Verhulst FC, Cohen-Kettenis PT.

Gender variance in childhood and
sexual orientation in adulthood:
a prospective study. J Sex Med.
2013;10(11):2723–2733

4. Leibowitz SF, Spack NP. The
development of a gender identity
psychosocial clinic: treatment
issues, logistical considerations,
interdisciplinary cooperation,
and future initiatives. Child

Adolesc Psychiatr Clin N Am.
2011;20(4):701–724

5. Chen D, Hidalgo MA, Leibowitz S,
et al. Multidisciplinary care for
gender-diverse youth: a narrative
review and unique model of gender-
affirming care. Transgend Health.
2016;1(1):117–123

6. Costa R, Carmichael P, Colizzi M.
To treat or not to treat: puberty

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

https://doi.org/10.1542/peds.2017-3845

mailto:

http://www.pediatrics.org/cgi/doi/10.1542/peds.2017-3004

http://www.pediatrics.org/cgi/doi/10.1542/peds.2018-0361

suppression in childhood-onset
gender dysphoria. Nat Rev Urol.
2016;13(8):456–462

7. Fast AA, Olson KR. Gender development
in transgender preschool children
[published online ahead of print April 25,
2017]. Child Dev. doi: 10. 1111/ cdev. 12758

8. Golombok S, Rust J, Zervoulis K,
Croudace T, Golding J, Hines M.
Developmental trajectories of sex-
typed behavior in boys and girls: a
longitudinal general population study
of children aged 2.5-8 years. Child Dev.
2008;79(5):1583–1593

9. Martin CL, Ruble DN. Patterns of
gender development. Annu Rev
Psychol. 2010;61:353–381

10. Rosenthal SM. Transgender youth:
current concepts. Ann Pediatr
Endocrinol Metab. 2016;21(4):185–192

11. Coleman E, Bockting WO, Botzer M, et al.
Standards of care for the health of
transsexual, transgender, and gender-
nonconforming people, version 7. Int
J Transgenderism. 2012;13(4):165–232

12. Wilczynski C, Emanuele MA. Treating
a transgender patient: overview
of the guidelines. Postgrad Med.
2014;126(7):121–128

13. Levine DA; Committee on Adolescence.
Office-based care for lesbian, gay,
bisexual, transgender, and questioning
youth. Pediatrics. 2013;132(1).
Available at: www. pediatrics. org/ cgi/
content/ full/ 132/ 1/ e297

14. Schneider C, Cerwenka S, Nieder TO,
et al. Measuring gender dysphoria:
a multicenter examination and
comparison of the Utrecht Gender
Dysphoria Scale and the Gender Identity/
Gender Dysphoria Questionnaire for
adolescents and adults. Arch Sex Behav.
2016;45(3):551–558

15. Grossman AH, D’Augelli AR.
Transgender youth and life-threatening
behaviors. Suicide Life Threat Behav.
2007;37(5):527–537

16. Cohen-Kettenis PT, Steensma TD, de
Vries AL. Treatment of adolescents with
gender dysphoria in the Netherlands.
Child Adolesc Psychiatr Clin N Am.
2011;20(4):689–700

17. de Vries AL, Doreleijers TA, Steensma
TD, Cohen-Kettenis PT. Psychiatric
comorbidity in gender dysphoric
adolescents. J Child Psychol
Psychiatry. 2011;52(11):1195–1202

18. Nahata L, Quinn GP, Caltabellotta NM,
Tishelman AC. Mental health concerns
and insurance denials among
transgender adolescents. LGBT Health.
2017;4(3):188–193

19. Olson J, Schrager SM, Belzer
M, Simons LK, Clark LF. Baseline
physiologic and psychosocial
characteristics of transgender youth
seeking care for gender dysphoria.
J Adolesc Health. 2015;57(4):374–380

20. Reisner SL, Biello KB, White Hughto
JM, et al. Psychiatric diagnoses and
comorbidities in a diverse, multicity
cohort of young transgender women:
baseline findings from project LifeSkills.
JAMA Pediatr. 2016;170(5):481–486

21. Reisner SL, Vetters R, Leclerc M, et al.
Mental health of transgender youth
in care at an adolescent urban
community health center: a matched
retrospective cohort study. J Adolesc
Health. 2015;56(3):274–279

22. Spack NP, Edwards-Leeper L, Feldman
HA, et al. Children and adolescents
with gender identity disorder
referred to a pediatric medical center.
Pediatrics. 2012;129(3):418–425

23. de Vries AL, Kreukels BP, Steensma
TD, Doreleijers TA, Cohen-Kettenis
PT. Comparing adult and adolescent
transsexuals: an MMPI-2 and
MMPI-A study. Psychiatry Res.
2011;186(2–3):414–418

24. Olson-Kennedy J, Cohen-Kettenis
PT, Kreukels BP, et al. Research
priorities for gender nonconforming/
transgender youth: gender identity
development and biopsychosocial
outcomes. Curr Opin Endocrinol
Diabetes Obes. 2016;23(2):172–179

25. Dekker MJ, Wierckx K, Van Caenegem
E, et al. A European network for the
investigation of gender incongruence:
endocrine part. J Sex Med.
2016;13(6):994–999

26. Kreukels BP, Haraldsen IR, De Cuypere
G, Richter-Appelt H, Gijs L, Cohen-
Kettenis PT. A European network for the
investigation of gender incongruence:
the ENIGI initiative. Eur Psychiatry.
2012;27(6):445–450

27. Reisner SL, Deutsch MB, Bhasin S, et al.
Advancing methods for US transgender
health research. Curr Opin Endocrinol
Diabetes Obes. 2016;23(2):198–207

28. Koebnick C, Langer-Gould AM,
Gould MK, et al. Sociodemographic
characteristics of members of a
large, integrated health care system:
comparison with US Census Bureau
data. Perm J. 2012;16(3):37–41

29. Gordon NP. How Does the Adult Kaiser
Permanente Membership in Northern
California Compare With the Larger
Community? Oakland, CA: Kaiser
Permanente Division of Research; 2006

30. American Academy of Pediatrics.
Periodicity schedule. 2017. Available
at: https:// www. aap. org/ en- us/
Documents/ periodicity_ schedule. pdf.
Accessed July 12, 2017

31. Roblin D, Barzilay J, Tolsma D, et al. A
novel method for estimating transgender
status using electronic medical records.
Ann Epidemiol. 2016;26(3):198–203

32. Quinn VP, Nash R, Hunkeler E, et al.
Cohort profile: Study of Transition,
Outcomes and Gender (STRONG) to
assess health status of transgender
people. BMJ Open. 2017;7(12):e018121

33. Lee PA, Houk CP, Ahmed SF, Hughes IA;
International Consensus Conference
on Intersex Organized by the Lawson
Wilkins Pediatric Endocrine Society and
the European Society for Paediatric
Endocrinology. Consensus statement
on management of intersex disorders.
International Consensus Conference
on Intersex. Pediatrics. 2006;118(2).
Available at: www. pediatrics. org/ cgi/
content/ full/ 118/ 2/ e488

34. Coleman KJ, Stewart C, Waitzfelder
BE, et al. Racial-ethnic differences in
psychiatric diagnoses and treatment
across 11 health care systems in
the mental health research network.
Psychiatr Serv. 2016;67(7):749–757

35. World Health Organization. Recognizing
adolescence. 2014. Available at: http://
apps. who. int/ adolescent/ second- decade/
section2/ page1/ recognizing- adolescence.
html. Accessed November 7, 2017

36. Nickleach D, Liu Y, Shrewsberry A,
Ogan K, Kim S, Wang Z. SAS macros
to conduct common biostatistical
analyses and generate reports. In:
SouthEast SAS User Group; October
20-23, 2013; St. Pete Beach, FL

37. Arcelus J, Claes L, Witcomb GL,
Marshall E, Bouman WP. Risk
factors for non-suicidal self-injury

BECERRA-CULQUI et al10
by guest on January 12, 2021www.aappublications.org/newsDownloaded from

www.pediatrics.org/cgi/content/full/132/1/e297

https://www.aap.org/en-us/Documents/periodicity_schedule

www.pediatrics.org/cgi/content/full/118/2/e488

http://apps.who.int/adolescent/second-decade/section2/page1/recognizing-adolescence.html

PEDIATRICS Volume 141, number 5, May 2018 11

among trans youth. J Sex Med.
2016;13(3):402–412

38. Kaltiala-Heino R, Sumia M, Työläjärvi
M, Lindberg N. Two years of
gender identity service for minors:
overrepresentation of natal girls
with severe problems in adolescent
development. Child Adolesc Psychiatry
Ment Health. 2015;9:9

39. Holt V, Skagerberg E, Dunsford
M. Young people with features of
gender dysphoria: demographics
and associated difficulties. Clin Child
Psychol Psychiatry. 2016;21(1):108–118

40. Shields JP, Cohen R, Glassman JR,
Whitaker K, Franks H, Bertolini I.
Estimating population size and
demographic characteristics of
lesbian, gay, bisexual, and transgender
youth in middle school. J Adolesc
Health. 2013;52(2):248–250

41. Diemer EW, Grant JD, Munn-Chernoff
MA, Patterson DA, Duncan AE. Gender
identity, sexual orientation, and eating-
related pathology in a national sample
of college students. J Adolesc Health.
2015;57(2):144–149

42. Chen M, Fuqua J, Eugster EA.
Characteristics of referrals for gender
dysphoria over a 13-year period. J
Adolesc Health. 2016;58(3):369–371

43. Glidden D, Bouman WP, Jones
BA, Arcelus J. Gender dysphoria
and autism spectrum disorder: a
systematic review of the literature. Sex
Med Rev. 2016;4(1):3–14

44. Jacobs LA, Rachlin K, Erickson-Schroth
L, Janssen A. Gender dysphoria
and co-occurring autism spectrum
disorders: review, case examples, and
treatment considerations. LGBT Health.
2014;1(4):277–282

45. Van Der Miesen AI, Hurley H, De
Vries AL. Gender dysphoria and
autism spectrum disorder: a
narrative review. Int Rev Psychiatry.
2016;28(1):70–80

46. de Vries AL, Noens IL, Cohen-
Kettenis PT, van Berckelaer-Onnes
IA, Doreleijers TA. Autism spectrum
disorders in gender dysphoric children
and adolescents. J Autism Dev Disord.
2010;40(8):930–936

47. Wing L, Leekam SR, Libby SJ, Gould J,
Larcombe M. The diagnostic interview
for social and communication
disorders: background, inter-rater
reliability and clinical use. J Child
Psychol Psychiatry. 2002;43(3):
307–325

48. Aitken M, Steensma TD, Blanchard
R, et al. Evidence for an altered sex

ratio in clinic-referred adolescents
with gender dysphoria. J Sex Med.
2015;12(3):756–763

49. Olson KR, Durwood L, DeMeules M,
McLaughlin KA. Mental health of
transgender children who
are supported in their identities.
Pediatrics. 2016;137(3):
e20153223

50. Hembree WC. Guidelines for pubertal
suspension and gender reassignment
for transgender adolescents.
Child Adolesc Psychiatr Clin N Am.
2011;20(4):725–732

51. Milrod C. How young is too young:
ethical concerns in genital surgery of
the transgender MTF adolescent. J Sex
Med. 2014;11(2):338–346

52. Milrod C, Karasic DH. Age is just a
number: WPATH-affiliated surgeons’
experiences and attitudes toward
vaginoplasty in transgender
females under 18 years of age
in the United States. J Sex Med.
2017;14(4):624–634

53. Shumer DE, Spack NP. Current
management of gender identity
disorder in childhood and adolescence:
guidelines, barriers and areas of
controversy. Curr Opin Endocrinol
Diabetes Obes. 2013;20(1):69–73

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

DOI: 10.1542/peds.2017-3845 originally published online April 16, 2018;
2018;141;Pediatrics

Michael J. Silverberg, Vin Tangpricha and Michael Goodman
Millman, Virginia P. Quinn, Brandi Robinson, Douglas Roblin, David E. Sandberg,

Darios Getahun, Shawn V. Giammattei, Enid M. Hunkeler, Timothy L. Lash, Andrea
Tracy A. Becerra-Culqui, Yuan Liu, Rebecca Nash, Lee Cromwell, W. Dana Flanders,

With Their Peers
Mental Health of Transgender and Gender Nonconforming Youth Compared

Services
Updated Information &

http://pediatrics.aappublications.org/content/141/5/e20173845
including high resolution figures, can be found at:

References
http://pediatrics.aappublications.org/content/141/5/e20173845#BIBL
This article cites 49 articles, 4 of which you can access for free at:

Subspecialty Collections

http://www.aappublications.org/cgi/collection/public_health_sub
Public Health
y_sub
http://www.aappublications.org/cgi/collection/psychiatry_psycholog
Psychiatry/Psychology
following collection(s):
This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml
in its entirety can be found online at:
Information about reproducing this article in parts (figures, tables) or

Reprints
http://www.aappublications.org/site/misc/reprints.xhtml
Information about ordering reprints can be found online:

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

http://http://pediatrics.aappublications.org/content/141/5/e20173845

http://pediatrics.aappublications.org/content/141/5/e20173845#BIBL

http://www.aappublications.org/cgi/collection/psychiatry_psychology_sub

http://www.aappublications.org/cgi/collection/public_health_sub

http://www.aappublications.org/site/misc/Permissions.xhtml

http://www.aappublications.org/site/misc/reprints.xhtml

DOI: 10.1542/peds.2017-3845 originally published online April 16, 2018;
2018;141;Pediatrics

Michael J. Silverberg, Vin Tangpricha and Michael Goodman
Millman, Virginia P. Quinn, Brandi Robinson, Douglas Roblin, David E. Sandberg,

Darios Getahun, Shawn V. Giammattei, Enid M. Hunkeler, Timothy L. Lash, Andrea
Tracy A. Becerra-Culqui, Yuan Liu, Rebecca Nash, Lee Cromwell, W. Dana Flanders,

With Their Peers
Mental Health of Transgender and Gender Nonconforming Youth Compared

http://pediatrics.aappublications.org/content/141/5/e20173845
located on the World Wide Web at:

The online version of this article, along with updated information and services, is

http://pediatrics.aappublications.org/content/suppl/2018/04/12/peds.2017-3845.DCSupplemental
Data Supplement at:

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2018
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

http://pediatrics.aappublications.org/content/141/5/e20173845

http://pediatrics.aappublications.org/content/suppl/2018/04/12/peds.2017-3845.DCSupplemental

Turn in your highest-quality paper
Get a qualified writer to help you with

“ Qualitative Research Article ”

Get high-quality paper

NEW! AI matching with writer