Illuminating the gender-expansive pathway


A new report provides insight into the path of gender-expansive behavior to gender dysphoria and gender-affirming hormonal treatment.

For children and adolescents who are gender diverse, the progress from gender-expansive behavior to gender dysphoria and gender-affirming hormonal treatment remains little understood. A report in Pediatrics sought to elucidate the pathway.1

Investigators used data from the Study of Transition, Outcomes, and Gender cohort, which included participants in the Kaiser Permanente integrated health care systems in Georgia, Northern California, and Southern California. The current protocols for transgender health care protocols align with the Endocrine and World Professional Association for Transgender Health guidelines, which include feminizing and masculinizing hormones, surgery, gonadotropin-releasing hormone agonists, and mental health support. Participants were found using electronic health records from January 2006 to December 2014 by searching for keywords that reflected gender diverse behaviors, such as transgender or gender identity. Potential participants who did not have available information on sex at birth were excluded from the analysis.

A total of 958 gender diverse children and adolescents who did not have a gender dysphoria–related diagnosis or gender-affirming hormonal treatment at the index appointment, which was the first appointment where evidence of gender diverse behaviors was noted, were found. The investigators found that 29% of the participants were given a gender dysphoria–related diagnosis and 25% were prescribed gender-affirming hormonal treatment during follow-up, which averaged 3.5 years and had a maximum period of 9 years. They found that when compared to children assigned male sex at birth, that those who had been assigned female sex at birth were more likely to have a diagnosis of gender dysphoria (hazard ratio [HR] 1.3, 95% CI 1.0–1.7) and initiate gender-affirming hormonal treatment (HR 2.5, 95% CI 1.8–3.3). Progression to a gender dysphoria diagnosis was found to be more common among teenagers aged 15 years at initial presentation, when compared to those aged 10 to 14 years and those aged 3 to 9 years (37% vs 28% vs 16%, respectively). Racial and ethnic minorities were also not as likely to get a diagnosis or be prescribed gender-affirming hormonal treatment.

The investigators concluded that gender diverse adolescents are more likely to receive a gender dysphoria–related diagnosis or hormone treatment than younger gender diverse children. Additionally, both diagnosis and treatment initiation were found to be more common in children assigned female sex at birth as well as non-Hispanic White children than their counterparts. Future research should compare quality of life and health outcomes in gender diverse pediatric patients who received care at different ages, which could assist with creating evidence-based guidelines for caring for gender diverse patients.


1. Wagner S, Panagiotakopoulos L, Nash R, et al. Progression of gender dysphoria in children and adolescents: a longitudinal study. Pediatrics. June 7 2021. Epub ahead of print. doi:10.1542/peds.2020-027722

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