Introduction The aim of this study was to determine the annual age- and sex-specific prevalence of gender-affirming hormone and puberty blocker use among young people with a gender incongruence (GI) diagnosis in Norway. Methods We integrated data from multiple Norwegian national registers to perform a nationwide register-based study of individuals with known sex assigned at birth who were born in the period 1975-2017 and resident in Norway for all or part of the period 2008-2022. We first calculated the annual age- and sex-specific incidence of GI diagnoses in the population. Then, we calculated the annual age- and sex-specific prevalence of androgen, estrogen, and puberty blocker use among individuals with a GI diagnosis who were under age 25 (for androgens and estrogens) or 18 (for puberty blockers) in the year that they collected the prescription. Results The incidence of GI diagnoses has increased among youth in Norway, most notably since 2015 and with the largest increase among teens assigned female at birth. The prevalence of feminizing and masculinizing hormone therapy has increased in this period as well, but mainly among the oldest teens and young adults. The prevalence of puberty suppression is mostly low but has also increased since 2015, especially in recent years among teens assigned male at birth. Conclusion The prevalence of gender-affirming hormone and puberty blocker use has increased among transgender youth in Norway, concurrently with an increase in the incidence of GI diagnoses.

An overrepresentation of autism spectrum diagnoses (ASD) and autistic traits have been reported among people with gender incongruence. Several quantitative and qualitative studies have highlighted the intersection of autism and gender incongruence (GI). However, we have little knowledge on lived experiences of adolescents experiencing ASD and GI. The study aimed to shed light on lived experience of gender incongruence from the perspective of autistic adolescents. The analysis was guided by the following research question: How do adolescents with ASD and GI experience their bodies and gender in everyday life, and how do they make meaning of the intersection of autism and GI in everyday living? This study is based on semi-structured interview guide alongside life-mode interviews of adolescents experiencing both ASD and GI. We adopted reflexive thematic analysis with phenomenology as the theoretical backdrop. The analysis concluded with three overarching meta-themes; “The emergence of the mismatch of gender identity and body in autistic adolescents”, “The hard work of everyday routines – working all day and all night”, and “Experiences of Bodily Estrangement - A Chain Reaction of Discomfort”. The findings contribute to the existing literature by emphasising how sensory sensitivities and gender identity distress intensify each other and how the transition from child to adolescence, and the body, is perceived. Results indicate tailored clinical implications for adolescents experiencing ASD and GI. Clinicians should consider multidisciplinary collaboration, individualised and flexible interventions that address both sensory regulation and gender-related support to improve quality of care for adolescents with ASD and GI.

BACKGROUND:There is limited research and conflicting results on the mental health and health-related quality of life of individuals surgically treated for hypospadias in childhood. Furthermore, the significance of patient-reported outcomes (PRO) in hypospadias is growing. More research is necessary on these topics, particularly in adolescents. OBJECTIVE:We aimed to compare mental health, health-related quality of life, body satisfaction, self-esteem, penile appearance, and sexual function outcomes in 16-year-old adolescents who had surgery for hypospadias in childhood with a healthy comparison group. STUDY DESIGN:The study involved 16-year-old adolescents who had surgery for hypospadias in one Norwegian hospital. An age-matched comparison group of healthy adolescents was previously recruited. The study assessed self-reported outcomes on mental health using the Strengths and Difficulties Questionnaire, health-related quality of life using the Pediatric Quality of Life Inventory, body satisfaction and self-esteem using the Self-Perception Profile for Adolescents, and genital perception and sexual function using the Pediatric Penile Perception Score and a non-validated structured interview. RESULTS:In total, 117 adolescents operated for hypospadias and 61 healthy adolescents were included. The outcomes for mental health and health-related quality of life were not statistically different between groups. However, 18 (16%) hypospadias patients were classified as cases/borderline on mental health outcomes, compared to 2 (3%) in the comparison group (p = 0.01). Patients classified as cases/borderline on mental health reported lower health-related quality of life, self-esteem, and more stressful life events. Self-reported penile appearance and sexual function were comparable between groups, however the proximal hypospadias group displayed lower satisfaction. DISCUSSION:Although the present study had generally positive outcomes, a significant finding was that a higher number of adolescents who had previously undergone hypospadias surgery during childhood were classified as cases or borderline cases with respect to mental health issues. Hypospadias surgery in childhood may pose challenges for some patients during adolescence, particularly in the proximal group. Regular monitoring by healthcare professionals is crucial in providing necessary support. A limitation is the small size of the subgroups. CONCLUSION:Most patients report good mental health, quality of life, and self-esteem even though patients with hypospadias report more mental health issues than the comparison group. Proximal hypospadias were less satisfied with penile appearance and sexual function. However, due to the small sample size, conclusions about this group should be treated cautiously. Assessing self-reported outcomes in follow-ups is important to identify adolescents who had hypospadias surgery and are at risk for reduced mental health.

ObjectiveAs the number of transgender and non-binary (TGN) youth and young adults referred for gender-affirming medical treatment increases, there is a need to better understand how these individuals experience the interventions. The aim of the present study is to expand our understanding of how TGN youth and young adults perceive bodily changes following medical treatment as part of gender-affirming care.MethodTen life-mode interviews exploring individuals' everyday experiences and the meanings they attach to them were conducted with TGN youth and young adults in Norway, assigned female at birth, aged 17-22, three years after they initiated gender-affirming medical treatment to align their bodies with their gender identities. The data were analyzed using thematic analysis.ResultsBased on the analysis of the semi-structured interviews, we developed three major themes and six sub-themes: (1) A pragmatic approach to making decisions regarding medical treatment indicates that the participants are continuously weighing the risks and benefits, together with a gradual, step-by-step introduction of medical treatment. (2) Embodying medical treatment indicates that bodily changes are tangible but, over time, anchor a sense of masculinity and a sense of self as male. (3) Grounding medical treatment in everyday life indicates that bodily changes help connect the inside with the outside, with family and friends serving as sources of support and mediators of meaning, highlighting the psychosocial aspects of gender-affirming care.ConclusionThe psychosocial aspects related to medical treatment in gender-affirming care are important vantage points for exploring the social meaning of the body and bodily changes. We therefore suggest that psychosocial aspects of gender-affirming care should be attended to and integrated alongside medical treatment.

Background: Genital gender-affirming surgery is often considered an important step in the gender transition process. However, there is currently limited information available about the full surgical trajectory of trans men who choose to undergo metoidioplasty. Aim: This qualitative interview study explored the multifaceted experiences of transmasculine individuals who undergo metoidioplasty. Method: We conducted in-depth, semi-structured individual interviews with 15 participants who had previously undergone metoidioplasty at the national center in Norway. The interviews covered topics such as the participants' motivations prior to surgery, their experiences throughout the surgical process and the impact on their daily life. The interview data were analyzed via thematic analysis using the framework of van Manen's hermeneutic phenomenology, with the aim being to understand how individuals make sense of their lived experiences. Results: Three subthemes were developed during the analysis-namely, metoidioplasty as an important step toward affirming masculinity, the process of adjusting to the surgical outcome and the impact of the procedure on daily life. Clinical implications: The findings of this study provide valuable insights for health professionals and patients concerning shared decision-making before undergoing genital gender affirming surgery in regard to expectations and outcome. Conclusion: This study shows that metoidioplasty represents more than a physical change; rather, it is a significant step toward affirming one's masculinity and integrating one's gender identity. The subsequent transition into everyday life involves adjusting to the bodily outcomes of the procedure and navigating psychosocial challenges. These findings highlight the importance of comprehensive follow-up care that supports both the physical and psychosocial dimensions of this process.

Aim: We aimed to describe treatment trajectories, detransition and mortality rate among children and adolescents referred to the Norwegian National Center for Gender Incongruence (NCGI). Methods: The cohort included all 1258 persons under 18 years at referral to the NCGI from 2000 to 2020. Trajectories were registered until end of 2023. Results: In total, 861/1258 (68.4%) were assigned female gender at birth (AFAB). Mean age at referral was 14.4 years. Puberty suppression with gonadotropin-releasing hormone agonists (GnRHa) was initiated among 135/1258 (10.7%), significantly more persons assigned male gender at birth (AMAB) than AFAB (p < 0.001). Gender-affirming hormonal treatment (GAHT) was initiated in 783/1258 (62.2%). The continuation rate from GnRHa to GAHT was 97%. Discharge rate from NCGI without gender-affirming medical treatment among those who attended at least one appointment, was 264/1198 (22.0%). Eighteen AFAB detransitioned after initiated GAHT, eleven due to a cessation of transgender identity. Mortality rate in the cohort until end of 2023 was 11/1258 (0.9%). Conclusion: Different trajectories including medical pathways and assessments without gender-affirming treatment were observed. GAHT was initiated in 783/1258 (62.2%), including eighteen AFAB detransitioning after testosterone treatment. There was a high continuation rate from GnRHa to GAHT. Various trajectories highlights the need for long-term follow-up in care.

Background: Differences of Sex Development (DSD) are congenital conditions where the chromosomal, gonadal and anatomical sex characteristics do not strictly belong to male or female categories, or that belong to both at the same time. Surgical interventions for individuals with DSD remain controversial, among affected individuals, caregivers, and health-care providers. A lack of evidence in support of, for deferring, or for avoiding surgery complicates the decision-making process. This study explores Norwegian health-care professionals’ (HCPs) perspectives on decision-making in DSD-related surgeries and the dilemmas they are facing in this process.Methods: Focus group interviews with 14 HCPs integrated into or collaborating with multidisciplinary DSD teams were analyzed using reflexive thematic analysis.Results: Two overarching dilemmas shed light on the intricate considerations and challenges that HCPs encounter when guiding affected individuals and caregivers through surgical decision-making processes in the context of DSD. The first theme describes how shared decision-making was found to be influenced by fear of stigma and balancing the interplay between concepts of normality, personal experiences and external expectations when navigating the child’s and caregivers’ needs. The second theme illuminated dilemmas due to a lack of evidence-based practice. The core concepts within each theme were the dilemmas health-care professionals face during consultations with caregivers and affected individuals.Conclusion: HCPs were aware of the controversies with DSD-related surgeries. However, they struggled to reconcile knowledge with parents’ wishes for surgery and faced dilemmas making decisions in the best interests of the child. This study draws attention to the benefits of increased knowledge on the consequences of performing or withholding surgery as well as incorporating tools enabling shared decision-making between HCPs and affected individuals/caregivers.

Over the last decade, there has been a sharp increase in young people seeking medical treatment for gender dysphoria/gender incongruence (GD/GI). The aims of this study were to calculate yearly population-adjusted numbers of children and adolescents referred to the Norwegian National Center for Gender Incongruence (NCGI) at Oslo University Hospital (OUS) from 2000 to 2022; to describe the demographic characteristics and prevalence of psychiatric diagnoses, self-harm and suicide attempts among the referred from 2000 to 2020; and to investigate time trends. The study used data from the Gender Incongruence Registry for Children and Adolescents (GIRCA) in Norway. All persons under 18 years (n = 1258) referred to the NCGI between 2000 and 2020 were included: 68.4

Background: Genital surgery is often considered the final step in surgical gender-affirming treatment. Metoidioplasty is a variant where the enlarged clitoris is lengthened and straightened. The technique has several advantages but is not without complications. We evaluated the surgical outcomes after metoidioplasty from our national center from 2007 to 2020. Methods: All patients who had undergone the metoidioplasty procedure at Oslo University Hospital from January 1, 2007, to December 31, 2020, were identified by the Local Quality Register of Gender Incongruence. Demographic, clinical, and surgical variables were recorded. Statistical analysis was carried out with SPSS. Results: A total of 84 patients were identified. The median age at the time of surgery was 27.5 years. Of 84 patients, 48 (57.1%) experienced some kind of complication after the surgery, with an average of 1.7 complications. Complications related to the urethroplasty were the most common, with strictures occurring in 19 (22.6%) patients and urethral fistulas occurring in 11 (13.1%) patients. Forty-one patients (48.8%) needed 1 or more secondary procedures. After the management of strictures and fistulas, a secondary testis implant correction was the most frequent revision procedure performed in 38.1% (32) of patients. With increasing body mass index, the risk of complications and of undergoing secondary procedures also increased significantly (P = 0.045 and 0.019, respectively). Conclusions: Metoidioplasty is an operation with a relatively high complication rate, mainly related to urethroplasty. There is an urgent need for future research with a focus on quality of life and long-term follow-up.

From the early years of this century, many Western countries adopted the “Dutch Protocol” as a new medical pathway for treating children and adolescents with childhood-onset gender dysphoria. On this approach, gonadotrophin-releasing hormone agonists (GnRHa) were used to suppress puberty, followed by cross-sex hormones (testosterone or oestrogen). This perspective article traces—in each of the countries where we, the authors, live and work—how the Dutch Protocol came to be incorporated into clinical practice or formally adopted into national guidelines. Over time, guidelines across different countries were progressively shaped by a rights-based approach that removed previous safeguards and increased availability of gender-reassignment medical interventions for children and adolescents. From 2010 onward, two developments raised new concerns, generating alternate perspectives and wide-ranging differences in clinical approach. Numerous countries reported an unexpected increase in adolescent-onset presentations, especially among girls. During the same period, an increasing number of individuals who had undergone gender-reassignment medical interventions as minors reported harm and regret. Worldwide, questions were raised about the safety of clinical guidelines for children and adolescents presenting with gender dysphoria. Government bodies in Finland, Sweden, the United Kingdom, and the U.S. state of Florida commissioned systematic reviews pertaining to hormone treatments and issued formal reports. In a parallel process, “conversion therapy” laws, passed in many countries, closed access to exploratory psychotherapy that enables exploration of gender-identity issues from a neutral therapeutic stance. Taken together, these three developments introduced evidence-based and legal considerations into the debate, resulting in tensions that remain unresolved.

BackgroundThe importance of patient-reported outcomes (PRO) in hypospadias is increasing. However, more knowl-edge is needed concerning genital self-perception on appearance and function in adolescents. The complication rates for distal hypospadias is different from that for severe hypospadias, and expected outcomes related to sexual well-being and cosmetics may also differ.ObjectiveTo investigate 16-year-olds' self-reported outcomes on penile appearance, sexual well-being, and void-ing function in distal hypospadias, and compare with that of healthy male adolescents and a surgeon's view.Study designSixteen-year-old patients operated for distal hypo-spadias were included in this cross-sectional study and compared to a group of healthy adolescents. The assessment tools included the adolescents' self perception on genital appearance and function measured by Pediatric Penile Perception Score (PPPS) and their responses to a structured interview. We also included information on clinical data from the electronic medical records, together with a physical examination and an uroflowmetry.ResultsSeventy patients and 61 healthy adolescents participated. Patients and the comparison group reported no differences on sexual well-being. The patients were satisfied with penile appearance, however their overall PPPS was significantly lower (8.9), compared to the comparison group (9.6, p Z 0.03). Thirty-nine percent of patients had complications leading to re-interventions and re-ported lower scores on genital self-perception on appearance and function compared to those who had not re-interventions. Voiding function was normal. The surgeon's score on appearance was comparable to the patients' score.DiscussionA key finding in our study is the patients' high satisfaction on sexual well-being, which was similar to healthy adolescents. The patients were also satisfied with penile appearance but scored signifi-cantly lower than the comparison group. Surgeons and patients had comparable scores on appearance; however, they seemed to emphasize different as-pects of appearance. Our results on penile appear-ance and sexual well-being are comparable to those of other studies on distal hypospadias. In our study, re-interventions were associated with more negative genital self-perception on appearance and function, similar to findings in other studies.ConclusionOur results show overall positive satisfaction on sexual well-being, voiding function and penile appearance despite less satisfaction on penile appearance when compared with the comparison group. Satisfaction was reported to be good also in patients experiencing re-interventions.

Purpose Differences of sex development (DSD) are congenital conditions that involve variations in individuals' sex chromosomes, genes, external and/or internal genitalia, hormones, and/or secondary sex characteristics. This study sought to elucidate the experiences of adolescents and young adults living with DSD by focusing on their experiences of intimacy and sexual health. Methods An interpretative phenomenological research design was adopted. Semi-structured qualitative interviews were conducted with 11 Norwegian adolescents and young adults aged 16-26 years who had five different DSD conditions. The interview findings were analysed by means of a reflexive thematic analysis. Results The participants reported feeling different, both in terms of how their body functioned and how their body looked. Lack of knowledge increased this feeling of differentness. Moreover, lack of everyday language with which to talk about intimacy and sexual concerns resulted in the participants feeling stigma. Anticipating stigmatization and lacking everyday language complicated the participants' communication regarding their DSD and sexual health. Conclusions The sexual experiences of adolescents and young adults with DSD are diverse. Fear of stigmatization and lack of everyday language complicate communication with healthcare professionals and others. Understanding their unique needs is crucial to helping individuals achieve good sexual health.

Purpose Several studies have reported on the intersection of autism and gender incongruence (GI) in clinical populations. This study aims to investigate autistic characteristics and registered autism spectrum diagnoses (ASD) in a clinical cohort of 83 adolescents referred to the National Gender Team for Children and Adolescents in Norway during 2020. Methods Parents completed the Social Responsiveness Scale (SRS). Background information and registered psychiatric diagnoses were extracted from patient files. Results The results showed that 25% of the participants scored within the clinical range on the SRS: 27.4% of adolescents who were assigned female at birth (AFAB) and 19.0% of adolescents who were assigned male at birth (AMAB). AFAB had significantly higher scores on SRS Total Scale and the Social Motivation and Autistic Mannerisms subscales compared to the female norm group. AMAB had higher scores on the Social Motivation subscale and lower scores on the Social Awareness subscale, compared to the male norm population. Information from patient files revealed that 67.5% had one or more registered psychiatric diagnosis. 9.6% had received an ASD diagnosis, all AFAB. 18.1% had received an attention deficit hyperactivity disorder (ADHD) diagnosis. The most common psychiatric diagnoses were depression (25.3%) and anxiety disorders (18.1%). Further, 44.6% had a history of self-harm, and 15.7% had a history of a suicide attempt. Conclusion The results showed an overrepresentation of ASD diagnoses and autistic characteristics measured by SRS for AFAB. There was an overrepresentation of psychiatric diagnoses for both the AFAB and the AMAB group in this study sample. Implications for treatment and future research are discussed.

Background:Several western countries have experienced a drastic increase of referrals to specialist gender services of transgender and gender-diverse people. Chest wall contouring is an important element in treatment of gender dysphoria. National data concerning this group have yet to be investigated. The aim of this study was to examine and evaluate the techniques and surgical outcome of chest wall contouring from the last 20 years from a single center in Norway. Methods:This study is a retrospective review of all female-to-male patients who underwent chest wall contouring surgery at Oslo University Hospital between 2000 and 2020. Statistical analysis with comparison of techniques and evaluation of development over time was examined. Results:In total, 333 patients underwent bilateral chest wall contouring, 209 (62.8%) with inframammary incision with free nipple graft (IM), and 124 (37.2%) with periareolar technique (PA). In 20 years, the average age decreased from 31 (19-68) to 24.9 years (17-61). Average body mass index was significantly lower in the PA-group than in the IM-group. Complication rate was 20.7%, with postoperative bleeding being the most frequent (9.6%). Revision surgery was required in 24.9% of the cases; periareolar technique required significantly more procedures. Conclusions:The number of patients referred and operated on has increased drastically over a 20-year period. When comparing the techniques, the outcome concerning complications and revisions is at an acceptable level. Postoperative bleeding and revision surgery occur more often with the periareolar technique. There remains a knowledge gap concerning quality of life and satisfaction after surgery within this patient group.

Background: The aim of the study was to present metal health, psychosocial functioning and quality of life (QoL) of children and adolescents with a difference in sex development (DSD) from their first visit in the newly established multidisciplinary team in 2002–2004 in Norway. A secondary aim was to explore mental health, psychosocial functioning and QoL in the same cohort patient’s as for today and finally explore any childhood predictors for these outcomes in adulthood.Methods: The first part of the study took place in 2002–2004 in a mixed cohort of children and adolescents born with a DSD in 1982–2002, compared to a healthy comparison group. This part involved semi-structured interviews and self-reported and proxy-reported questionnaires. The second part of the study is a longitudinal study of the same participants 15–20 years later (2018–2020).Results: The participants at baseline of the study consisted of 33 patients; 24 assigned females (congenital adrenal hyperplasia, androgen insensitivity syndrome, gonadal dysgenesis and ovotesticular DSD) and nine assigned males; all with a hypospadias diagnosis. Significant differences were found for behavioral and emotional problems between groups, 46, XX females with significant higher total scores on YSR (49.43 + 24.17, p = .047); 46, XY females (21.00 + 12.04, p = .032); and higher internalizing problems scores (YSR) in 46, XX females (16.57 + 9.74), compared with the 46, XY females (5.60 + 5.32, p = .047). A positive association between QoL of the participants in adulthood and PedsQL’ social function (r = .657, p = .020) and psychosocial function in childhood (r = .596, p = .041) was found.Conclusions: In summary, this study demonstrated that adolescents assigned females with DSD might have more psychiatric problems and a poorer degree of psychosocial functioning compared to a healthy comparison group. As we do find an association with these problems in adolescence and later adult QoL, it is of great importance to respond to these behaviors in early life.

Background:Differences of sex development (DSD) are a group of congenital conditions that involve variations in sex chromosomes, genes, external and/or internal genitalia, hormones, and secondary sex characteristics. The present study sought to highlight the everyday challenges faced by adults with DSD as well as to understand how issues such as disclosure, information sharing, and stigma affect their daily life. Method:We applied an interpretative phenomenological study design to explore the first-person perspectives. Semi-structured qualitative interviews of 15 adults aged 30-70 years living in Norway with five different DSD conditions (Turner syndrome, Klinefelter syndrome, congenital adrenal hyperplasia, Mayer-Rokitansky-Küster-Hauser syndrome and hypospadias) were analyzed using reflexive thematic analysis. Results:Living with DSD, indicated doing a balancing act between hiding and/or exposing what participants perceived differed from others bodies. Communication regarding sensitive topics proved to be important. The participants were doing invisible work to manage the balance between concealing and revealing their feeling of differentness, a work effort that was not necessarily perceivable to others but still affected everyday life of the participants. Furthermore, the participants' experiences of disclosure changed over time, as those who were diagnosed during childhood found that disclosure became easier with advancing age. However, being diagnosed as an adult seemed to increase the feeling of difference and complicate disclosure. Conclusion:Individuals with DSD should receive adequate information and have someone to practice disclosure towards, which could possibly strengthen the psychosocial aspects of living with their condition. The results emphasize the need to help individuals with DSD achieve a balance between disclosure and self-protection, overcome stigma, and determine when and how information about their DSD should be provided to others.

Our main aim was to explore any associations in mental health, psychosocial functioning and quality of life (QoL) between childhood, adolescence, and adulthood in the same cohort of patients with a difference in sex development (DSD) born from four decades ago up until early 2000. The first part of the study took place in 2002-2004 in a mixed cohort of children and adolescents born with a DSD in 1982 to 2002, compared to a control group. This part involved semi structured interviews and self-reported and proxy reported questionnaires. The second part of the study is a longitudinal study of the same participants 15-20 years later (2018-2020). The participants in part 1 of the study consisted of 33 patients; 24 assigned females (congenital adrenal hyperplasia, androgen insensitivity syndrome, gonadal dysgenesis and ovotesticular DSD) and nine assigned males; all with a hypospadias diagnosis. A key finding was more psychopathology in the adolescents with a DSD, and females with a 46, XX karyotype had more psychosocial problems compared to the 46, XY females. Two of the 16 patients in the follow-up had performed gender reassignment. Less than half of the female participants reported a heterosexual orientation. Another important finding was a correlation between psychosocial function in childhood with later adult QoL. As we do find a correlation with psychosocial problems in adolescence and later adult QoL, it is of great importance to respond to these behaviors in early life and to have a psychological aspect in the follow up.

A growing number of adolescents are seeking medical care to alleviate gender dysphoria (GD). This qualitative study explored the subjective experiences of GD among help-seeking transgender and gender nonconforming (TGNC) youth in order to develop a more nuanced conceptualization of the phenomenon. Fifteen life-mode interviews were conducted with newly referred youth between the ages of 13 and 19. All participants were assigned female at birth. The data were analyzed using thematic analysis. The participants targeted five major themes that characterize GD: (1) Bodily sensations were constant reminders of GD throughout the day, (2) emotional memories from the past of being different and outside triggered GD, (3) the process of coming out was a transformative experience that changed how the participants understood themselves, (4) GD both increased and decreased in relation to others, (5) everyday life required careful negotiation to feel whole without developing new forms of GD. Based on the results, we suggest a more conceptually nuanced model of GD, one which accounts for how bodily sensations and emotional memories from the past were sources that elicited GD. The sources were mediated through the process of coming out and relating to others, and this resulted in the negotiation of GD today. The conceptual model suggested in the present study could ideally shed light on preexisting knowledge on TGNC youth struggling with GD. In addition, an improved understanding of GD could ideally help clinicians when addressing individual treatment needs.