Table 2 Descriptions of themes and exemplary quotes

Doing Bad: Experiencing Distress Before GAMT

This theme captures the emotional, psychological and physical suffering of TGD youth due to gender dysphoria. This suffering is often described as the object of treatment in these articles and manifests in various forms, including dysphoria, anxiety, and depression. The notion of distress (which manifests in different forms) is a key metric for measuring, treating, and evaluating the “effectiveness” of GAMT.

“GD refers to the distress a person may experience when an incongruence exists between one’s sex assigned at birth and one’s experienced gender identity” (69 p302)

“Gender-affirming hormones (GAH; estrogen or testosterone) are administered to help alleviate the distress associated with GD” (69 p302)

“These individuals have a high prevalence of body image dysphoria, depression and suicidal ideation” (70 p1)

“Adolescence is a particularly difficult time for trans-gender persons who experience the development of secondary sexual characteristics that are incongruous with their gender identity, and is associated with a high prevalence of depression and suicidal thoughts and gestures” (70 p1)

“As reported in most clinical research among transgender adolescents, the overall psychosocial health of this cohort is impaired at baseline” (21 p1756)

“Gender dysphoria (GD) […] is associated with considerable distress or impairment in social, school or other important areas of functioning” (22 p2)

“GD refers to this stressful condition resulting in clinically significant distress or impairment in important areas of functioning” (75 p2206)

“Some adolescents, who have shown an extreme pattern of cross-gender identification from their earliest years, suffer deeply from the fact that they cannot be open about their gender feelings” (77 pp263-264)

“Knowing that they will have to await treatment for many years engenders feelings of hopelessness and slows down their social, psychological, and intellectual development” (77 p264)

“They have to cope with adverse consequences of living with a self-concept that is never socially acknowledged or reinforced. In such cases, early treatment would prevent much unnecessary, suffering” (77 p264)

“Once these young persons, who are already experiencing con-siderable distress over their gender identity, undergo the pubertal development of their biological sex, their psychological well-being deteriorates significantly” (75 p2207)

“Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes, including depression, anxiety, and suicidal ideation and attempts” (74 p2)

“Unfortunately, these young people face a range of mental health disparities, including elevated rates of anxiety, depression, and suicide attempts” (72 p2)

“Adolescents referred to specialized gender identity clinics have prevalence rates of depression ranging from 12–58% and for anxiety 16–24%” (73 p700)

“… found more behavioral and emotional problems in transgender youth compared with the normative samples of these measures” (73 p700)

“… they have a gender identity problem” (77 p263)

“… the extreme gender identity disorder, called transsexualism” (77 p265)

“… with regard to the reduction of GD, the effectiveness of these requirements is not evidence-based” (71 p633)

Moving Toward a Static Gender Identity and Binary Presentation

This theme examines the concept of gender transition as a linear, unidirectional process, characterized by a clear beginning and end point, reflecting a binary understanding of gender. In these articles, adolescence is perceived as a critical period for gender identity development. Gender transition is then framed as being completed in (young) adulthood, with an expectation that gender identity stabilizes (suggesting that adulthood brings a sense of permanence). This theme emphasizes gender transition as a linear path within a binary framework (i.e., moving from “man” to “woman” or vice versa).

“… identity development during adolescence is in progress and consolidates only later in adulthood [18], highlighting the need to weigh affirmative treatment practices against a developmental perspective of adolescent identity development during clinical decision making” (21 p1756)

“Interventions include psychosocial support, therapy and medical or surgical interventions to align the body with the identified gender” (22 p2)

“During the real-life test applicants have to live full-time in the desired gender role. Thus they can discover whether they are able to pass as someone of the opposite sex and experience all advantages and disadvantages of the new situation. Depending on the situation, the role change may occur gradually or at once. (77 p265)

“Preventing the development of a body contrary to the experienced gender, puberty suppression allows GD adolescents to experience a smooth transition into their desired gender role” (75 p2212)

“…although in most prepubertal children GD will desist, onset of puberty serves as a critical diagnostic stage, because the likelihood that GD will persist into adulthood is much higher in adolescence than in the case of childhood GD” (8 p697)

“…participants further along in their transition (higher ITPS) had more subjective positive experiences of receiving TRC… (71 p641)

“It is also likely that adolescents with less extreme or more fluctuating cross-gender identities do not pursue SR so early in life. (31 p480)

“…clinicians might want to take special notice of MFs who report inconsistencies in past and present gender dysphoria…” (78 p98)

“There may also be sex differences related to the social aspect of medical transition. For instance, compared with transgender girls/women, it may be easier for transgender boys/men to integrate socially because of clear vocal changes (i.e., voice deepening) and facial hair growth, which are traditionally seen as indicators of one’s gender” (69 p303)

“…adolescents who had undergone a full social transition” (21 p303)

“…given that GnRHa does not change the body in the desired direction, but only temporarily prevents further masculinization or feminization” (22 p20).

“Strong feelings of belonging to the opposite sex and corresponding behavioural manifestations have been reported as beginning as early as 2 to 3 years of age” (77 p263)

“If an adolescent continues to pursue GR, arresting the development of secondary sex characteristics results in a lifelong advantage of a convincing physical appearance congruent with the desired gender role” (80 p2277)

“The phenomenon of transsexualism refers to individuals who are born with the normal sexual characteristics of one sex, but have the irrefutable conviction of belonging to the other” (78 p89)

“GAH treatment may be a relief to many transgender youths due to both the knowledge that the “correct” hormones are present and the alignment of physical appearance with gender identity” (76 p2)

“Early gender dysphoria has been associated with early-onset transsexualism and favourable SR outcome” (78 p98)

“Early gender dysphoria has been associated with early-onset transsexualism and favourable SR outcome” (78 p98)

“These disparities are generally thought to be due to two processes: gender minority stress and dysphoria related to one’s body developing in ways that are incongruent with one’s gender identity (i.e., a person’s psychological sense of their own gender)” (72 p2)

“… we doubt that the reported cases reflect a complete and stable (re)establishment of a gender identity corresponding with genital sex in persons with a lifelong and extreme cross-gender identity” (77 p264)

“Despite the fact that developing evidence suggests that cognitve and affective cross-gender identification, social role transition, and age at assessment are related to persistence of childhood GD into adolescence, predicting individual persistence at a young age will always remain difficult” (8 p703)

“… according to observers, their appearance better matched the new gender” (78 p96)

“The chance of making the wrong diagnosis and the consequent risk of postoperative regret is therefore felt to be higher in adolescents than in adults, as a consequence of the developmental phase itself” (77 p263)

“SRS has resolved the patients’ gender identity problem and enabled them to live in the new gender role in quite an inconspicuous way” (77 p269)

Doing Better: Overall Improvement After GAMT

This theme highlights the improvements on various registers (global functioning, body (dis)satisfaction, mental health, psychosocial health, psychosocial functioning, social functioning, quality of life, well-being, psychological functioning, decreased gender dysphoria, decreased depression, decreased suicidality) that are measured as outcomes from GAMT, signifying the “effectiveness” of the care.

“Our findings also support the notion that transgender people tend to have more positive life experiences when they receive gender-affirming care” (69 p308)

“Further research is needed to statistically assess pre- and post-intervention differences as well as to identify which treatment path fits which adolescent best in order to achieve the best psychosocial health outcomes” (21 p1765)

“An alleviation of gender dysphoria can be expected to be closely associated with improvement in other areas of life, such as psychological, social, and sexual functioning” (77 p266)

“Even adolescent applicants who are functioning well will need a lot of guidance through the process of sex reassignment. However, provided they manage to pass SRS without problems, they have a lot to gain. They can catch up with their peers and devote their attention to friendships, partnership, and career” (77 p270)

“Psychological functioning improved steadily over time, resulting in rates of clinical problems that are indistinguishable from general population samples (eg, percent in the clinical range dropped from 30–7% on the YSR/ASR30) and quality of life, satisfaction with life, and subjective happiness comparable to same-age peers” (8 p702)

“Our second aim was to examine how transgender youth body dissatisfaction, depression, and anxiety symptoms change over the first year of receiving gender-affirming hormone therapy. We anticipated improvements in each of these domains but did not have any a priori hypotheses regarding which domains would demonstrate the greatest improvements” (79 p2)

“Access to GAH during adolescence appears to be related to more favorable mental health outcomes” (72 p11)

“Previous studies have shown that only GR consisting of CSH treatment and surgery may end the actual gender dysphoria” (80 p2281)

“This suggests that some internalizing symptoms may be related to improvements in body image dissatisfaction, likely in response to the knowledge that the “correct” hormone is in their body and the physical effects of T” (76 p6)

“We hypothesized that (a) suicidality will decrease between pretest and final assessment with the administration of GAH and (b) general well-being will improve between pretest and final assessment with the administration of GAH” (69 p303)

“Do gender dysphoric youth improve over time with medical intervention consisting of GnRHa, CSH, and GRS? […] Finally, do young people who report relatively greater gains in psychological functioning also report a higher subjective well-being after gender reassignment?” (8 p697)

“We hypothesized that the T treated group would experience fewer anxiety and depression symptoms, and less suicidality; higher satisfaction with body image” (76 p2)

“We hypothesized that access to GAH during both early and late adolescence would be associated with more favorable mental health outcomes reported in adulthood, when compared to desiring but never accessing GAH” (72 p3)

“We hypothesized a poor general functioning at baseline, an improvement after psychological support, and a further improvement after the beginning of the GnRHa” (75 p2207)

“… added as important outcome measures objective and subjective well-being (often referred to as “quality of life”), that is, the individuals’ social life circumstances and their perceptions of satisfaction with life and happiness” (8 p697)

“Whereas some studies show that poor surgical results are a determinant of postoperative psychopathology and of dissatisfaction and regret all young adults in this study were generally satisfied with their physical appearance and none regretted treatment” (8 p701)

“Overall, the evidence suggests that youth who received GAH and gender confirmation surgery (GCS) for gender dysphoria experience a corresponding alleviation of the dysphoria and overall improved well-being and mental health outcomes” (69 p302)

“The findings contribute to a growing literature supporting the hypothesis that transgender adolescents and adults benefit from GAH in terms of quality of life and psychological functioning” (69 p308)

“These partially reversible/irreversible treatments aim to align the individuals’ physical appearance with their internal gender identity and have been shown to improve the patients’ psychosocial well-being” (75 p2212)

“Results of this study provide first evidence that, after CSH and GRS, a treatment protocol including puberty suppression leads to improved psychological functioning of transgender adolescents.While enabling them to make important age-appropriate developmental transitions, it contributes to a satisfactory objective and subjective well-being in young adulthood” (8 p703)

“Recent research points to gender affirmation being the appropriate care for youth GD, when indicated by a thorough assessment process, as trans adolescents are likely to experience improvements to general mental well-being through social and/or medical transition” (71 p633)

“Our preliminary results show negative associations between depression scores/suicidal ideation and endocrine intervention, while quality of life scores showed positive associations with intervention, in transgender youths over time in the US” (70 p4)

“Symptoms of general anxiety, social anxiety, depression, and suicidality were all lower in the treated than untreated group” (76 p6)

“The primary results indicate that transgender adolescent boys undergoing T treatment display lower levels of self-reported anxiety, depression, and suicidality relative to a similar group of adolescents not undergoing GAH therapy. T treatment was also associated with improvements in body image satisfaction” (76 p7)

“Participants’ suicidality scores had significantly decreased following administration of GAH” (69 p307)

“Ultimately, we may infer from our findings that GAH is associated with less suicidality and greater well-being for all youth” (69 p308)

“For each time period of GAH initiation examined (early adolescence, late adolescence, and adulthood), access to GAH was associated with lower odds of past-year suicidal ideation and past-month severe psychological distress” (72 p10)

“When it comes to satisfaction with TRMI, the physical effects, particularly as a result of GAH or GAS, seemed to be of paramount importance for adolescents. This is in line with studies showing that medical transition has positive effects on young trans individuals who began transition in adolescence, including decreases in GD and improvements in psychosocial functioning (ie, decrease in depression and anxiety)” (71 p641)

“In the group receiving puberty suppression, the externalizing problems (YSR/ASR) score and mental and physical health-related quality of life scores (Kidscreen/SF-8) were within the norm, and clinicians’ ratings of global functioning (CGAS) indicative of good functioning levels at follow-up” (21 p1763)

“Moreover, puberty suppression was associated with a further improvement in global functioning. Finally, global functioning improved steadily over time in GD adolescents receiving both psychological support and GnRHa” (75 p2212)

“Our results suggest that endocrine intervention is associated with improved mental health among transgender youth” (70 p3)

“… participants who accessed GAH earlier had better mental health outcomes, including lower odds of past-year suicidal ideation, past-month severe psychological distress, past-month binge drinking, and lifetime illicit drug use” (72 p11)

“Clinicians and advocates working with transgender youth and their families can cite these data as support that GAH is associated with improved psychological outcomes among transgender youth” (69 p308)

“The findings contribute to a growing literature showing that transgender adolescents and adults benefit from GAH in terms of improved quality of life and psychological functioning” (69 p309)

“This is the first prospective study showing that psychological functioning of adolescents diagnosed with GID had improved in many respects after an average of nearly 2 years of GnRHa use. Adolescents showed fewer behavioral and emotional problems, reported fewer depressive symptoms, feelings of anxiety and anger remained stable, and their general functioning improved” (80 p2281)

“This translates into an improvement in many aspects of their psychosocial functioning, such as mood improvement and school integration [2, 9]. Consistently, these results underline the importance of puberty suppression for GD adolescents’ well-being” (75 pp2212)

“The present study, together with this previous research [2], indicate that both psychological support and puberty suppression enable young GD individuals to reach a psychosocial functioning comparable with peers” (75 pp2213)

Absence of Regret

This theme highlights the importance placed on minimizing the chances of regret in GAMT for adolescents, aligning with the idea that gender identity can be fluid during adolescence and may solidify in young adulthood. Avoiding regret is commonly seen as essential for achieving “effective” GAMT outcomes for adolescents.

“The chance of making the wrong diagnosis and the consequent risk of postoperative regret is therefore felt to be higher in adolescents than in adults, as a consequence of the developmental phase itself.” (77 p263)

“Whereas some studies show that poor surgical results are a determinant of postoperative psychopathology and of dissatisfaction and regret, [37, 38] all young adults in this study were generally satisfied with their physical appearance and none regretted treatment.” (8 p701)

“Adolescents and young adults rarely regret or stop TRMIs, provided they fulfill the criteria for a GD diagnosis and their readiness for treatment is sufficiently assessed” (71 p633)

“With respect to prevailing uncertainties when it comes to treatment of trans youth and desires of HCPs to avoid mis-diagnoses, […] an important finding is that no adolescents and young adults in the present study regretted TRC at the time of

follow-up, mirroring other studies that determined no regret of GnRHa administration or GAH and GAS” (71 p641)

“One of the main objections of profes-sionals against a start of the SR procedure before 18 years is the risk of postoperative regrets” (31 p472)

“…postoperative regret or any other unfavorable result is a matter of serious concern” (31 p472)

“Above all, no one expressed feelings of regret concerning the decision to undergo SRS” (31 p472)

“Considering the invasive and irreversible treat-ment of SR, it is imperative to try and prevent

post-operative regret. This requires the identi-fication of predictors of regret or poor post-operative functioning” (78 p90)