University of Southern California Dissertations and Theses

Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria

(USC Thesis Other)

Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content

Baseline Physiologic and Psychosocial Characteristics of Transgender Youth Seeking Care
for Gender Dysphoria
by
Johanna Olson, MD

Thesis Submitted in Partial Fulfillment

of the Requirements for the Degree of

Master of Science

Clinical, Biomedical, and Translational Investigations

University of Southern California

May, 2015

ii
Abstract
This manuscript describes baseline characteristics of participants in a prospective observational
study of transgender youth (age 12-24) seeking care for gender dysphoria at a large, urban
transgender youth clinic. Eligible participants presenting consecutively for care between
February 2011 and June 2013 completed a computer-assisted survey at their initial study visit.
Physiologic data were abstracted from medical charts. Data were analyzed by descriptive
statistics, with limited comparisons between transmasculine and transfeminine participants.
One hundred one youth were evaluated for physiologic parameters, 96 completed surveys
assessing psychosocial parameters. About half (50.5%) of the youth were assigned a male sex at
birth. Baseline physiologic values were within normal ranges of the corresponding assigned sex
youth. Youth recognized gender incongruence at a mean age of 8.3 years (standard deviation
[SD] 4.5), yet disclosed to their family much later (mean 17.1; [SD] 4.2). Gender dysphoria was
high among all participants. Thirty-five percent of the participants reported depression symptoms
in the clinical range. Over half of the youth reported having thought about suicide at least once in
their lifetime, and nearly a third had made at least one attempt.
Baseline physiologic parameters were within normal ranges for corresponding assigned
sex at birth. Transgender youth are aware of the incongruence between their internal gender
identity and their assigned sex at early ages. Prevalence of depression and suicidality
demonstrate that youth may benefit from timely and appropriate intervention. Evaluation of these
youth over time will help determine the impact of medical intervention and mental health
therapy.

Key Words: Transgender, Transgender Youth, Cross Sex Hormone Therapy, Gender Transition,
Sex Reassignment

iii
Acknowledgements

This work was supported in part by The Saban Research Institute Clinical Research Academic
Career Development Award, as well as the National Center for Research Resources and the
National Center for Advancing Translational Sciences, National Institutes of Health (NIH),
through Grant Award Number KL2TR000131.
The following individuals were instrumental in the development of this research
endeavor and crafting of the manuscript: Marvin Belzer, Leslie Clark, Lisa Simons, Sheree
Schrager, and Cecilia Patino-Sutton. I would like to extend additional thanks to my patient and
tirelessly supportive partner, Aydin Kennedy.

iv
Table of Contents

Chapter 1: Introduction………………………………………………………...1
Chapter 2: Methods…………………………………………………………….3
Socio-demographic and Gender Measures…………………………….5
Physiologic Measurements…………………………………………….6
Psychosocial Parameters………………………………………………7
Risk Behavior………………………………………………………….7
Statistical analysis……………………………………………………..8
Chapter 3: Results of the Study……………………………………………......8
Demographic information……………………………………………..8
Physiologic Parameters………………………………………………..9
Gender demographics………………………………………………….9
Sexual orientation…………………………………………………….10
Psychosocial parameters……………………………………………...10
Risk Behavior………………………………………………………...10
Hormone therapy……………………………………………………..11
Chapter 4: Discussion………………………………………………………...11
Limitations…………………………………………………………...13
Chapter 5: Conclusion………………………………………………………..14
References……………………………………………………………………19

1

Chapter 1: Introduction
“Transgender” is a broad term that is often used to describe individuals whose gender
self-identification or expression transgresses established gender norms. Specifically, it is the
state of one's internal gender identity (male, female, both or neither) not matching one's assigned
sex at birth (identification by others as male or female based on natal sex) (Grossman, 2007).
Gender dysphoria is defined as the discomfort or anxiety that arises and persists when there is
discordance between assigned sex at birth and internal experience of gender that results in an
impairment of function (Diagnostic and Statistical Manual 2013). The identity and behavior of
transgender individuals are often socially and medically stigmatized, resulting in a markedly
underserved population at high risk for significant negative health outcomes (Grossman, 2007).
As detailed in the May 2011 Institute of Medicine [IOM 2011] report, “The Health of Lesbian,
Gay, Bisexual, and Transgender People,” the existing body of scientific evidence documenting
health and well-being of transgender individuals, and particularly among transgender youth, is
sparse. The report explicitly calls for research on transgender health needs, including the
development of evidence-based data for providing transgender-specific health care to address
gender dysphoria and rigorous research aimed at understanding the health implications of
hormone use and other transgender-specific issues. Not all transgender people undertake a
phenotypic gender transition with hormones and/or surgical interventions to align their physical
bodies with their internal gender. Some may encounter existing barriers to care, for others it may
simply be unnecessary for their personal well-being. For those individuals who do desire changes
in their physical appearance to more closely resemble their internal experience of gender,
hormonal and/or surgical intervention can be life-saving.

2

Transgender youth are presenting at gender clinics for treatment related to gender dysphoria in
higher numbers than ever before (Khatchadourian, 2014 and deVries, 2012). Few providers feel
educated and comfortable enough to treat transgender people (Snelgrove, 2012) and even fewer
feel comfortable treating transgender youth. Experiencing the wrong puberty for transgender
youth leaves them extremely vulnerable and often triggers symptoms of depression, anxiety,
maladaptive coping, and suicidality (Olson, 2011). Transgender youth are likely to experience
societal discrimination resulting in economic marginalization, incarceration, social isolation, and
physical abuse leaving them at significantly higher risk for drug abuse, suicide, depression,
violence, human immunodeficiency virus (HIV), other sexually transmitted infections, and
homelessness (Corliss, 2007 and Wilson 2009). Studies have estimated the prevalence of suicide
attempts among transgender youth to be between 25% and 32% (Grossman, 2007 and Russell,
2001). A 2013 report of transgender youth presenting to the Gender Management Service
(GeMS) at Boston Children’s Hospital showed high prevalence of psychiatric morbidities
including depression (58.1%), suicide attempts (9.3%), anxiety (16.3%) and self-mutilation
(20.6%) (Spack, 2013). In 2014, a report from Vancouver, BC reported similar psychiatric
morbidity amongst 84 transgender youth, including mood disorders (35%), anxiety disorder
(25%), suicide attempt (12%) and psychiatric hospitalizations (12%) (Khatchadourian, 2014).
In 2009, The Endocrine Society published guidelines outlining the importance of
treatment for transgender youth with recommendations for medical intervention. The Endocrine
Society Guidelines recommend using gonadotropin releasing hormone agonists (GnRHa’s) to
suppress undesired puberty in early adolescence, with the addition of cross sex hormones for
masculinization or feminization as youth get older (Hembree 2009). One recent study from the

3
Netherlands points to the positive impact of a protocol incorporating puberty suppression, cross
sex hormones and gender reassignment surgery on psychological functioning and well-being of
55 transgender individuals who began their interventions in adolescence (deVries, 2014).
Prospective studies about the physical and psychosocial impact of medical treatment are rare and
have not fully explored the effects of the recommended treatment protocol outlined by the
Endocrine Society.
The data presented in this manuscript represent the baseline physiologic and psychosocial
characteristics obtained from the first 101 participants in a large, prospective observational study
examining a population of multi-ethnic transgender youth seeking care related to gender
dysphoria. Future manuscripts will report on the follow up of these youth over time.
Chapter 2: Methods
Self-identified transgender youth between the ages of 12 and 24 years presenting
consecutively for care at the Center for Transyouth Health and Development (CTHD) at
Children’s Hospital Los Angeles between February 2011 and June 2013 were screened for
participation in the study. The CTHD has been providing care for transgender youth for over 20
years. Currently, the clinic serves over 400 patients between the ages of 4 and 25 years. The
clinic offers a range of services including mental health counseling and referrals, family and
youth support groups, hormonal intervention for those youth interested in a phenotypic
transition, and referrals for appropriate surgical interventions.
Eligibility criteria for the study included age between 12 and 24 years old, self-
identification with a gender identity different than the one’s assigned sex at birth, presence of
gender dysphoria, desire to undergo phenotypic gender transition, naivety to cross sex hormones
or less than three months of previous cross sex hormone use, and ability to read and comprehend

4
English. Prior to enrollment in the study participants underwent mental health screening by a
gender specialized therapist to diagnose gender dysphoria, identify major mental health concerns
and social risk factors that might interfere with gender transition, and provide a recommendation
that medical intervention would benefit the participant in their transition process. Family
dynamics related to the participants’ gender transition and contribution to familial support during
the process are also part of the mental health assessment. All of the therapists that our Center
collaborates with are vetted by our own internal mental health providers, and are considered
competent in the care and assessment of transgender youth. The two medical providers involved
in the initial assessments are experienced physicians in the care of transgender youth. Our Center
believes that the presence or absence of family support is critical in the evaluation of transgender
youth, whereas intelligence testing, Child Behavioral Checklist, and other elements of
psychodiagnostic testing aimed at identifying psychopathology are not.
At the time of enrollment, the Diagnostic and Statistical Manual of Mental Disorders
(DSM IV-TR, 2000) described criteria for Gender Identity Disorder, a diagnosis that has since
been removed and replaced with Gender Dysphoria in the DSM 5. However, despite this recent
revision for the purposes of this study, both the mental health and medical provider agreed that
the participant met the DSM IV-TR criteria for a diagnosis of gender identity disorder prior to
participation. Participants under the age of 18 required consent from their legal guardians to
participate in the study.
Demographic data and psychosocial measures were collected via computer-assisted
survey at baseline after participants were screened and consented. Baseline physiological data
was abstracted from the medical charts of the participants. One hundred one participants were
evaluated for physiologic parameters. Four baseline surveys were lost on a hard drive that could

5
not be recovered; one participant enrolled in the study but never returned to complete the survey.
Therefore, 96 baseline surveys assessing psychosocial parameters were available for
analysis. Nine additional youth were screened but ineligible due to prior hormone use, and one
otherwise eligible subject declined to participate due to concerns about potential unintentional
disclosure of their transgender status. Participants received a twenty-dollar gift card for their
time. The Institutional Review Board at Children’s Hospital Los Angeles approved this study.
Socio-demographic and Gender Measures
Demographics including age (years), country of birth (United States not including Puerto
Rico, Puerto Rico, or another country), and ethnicity (African American/Black,
Caucasian/White, Latino(a), Asian/Pacific Islander, or other) were collected in the study.
Assigned sex at birth was assessed with the question “What was your assigned sex at birth”
(male or female). The lexicon of gender is constantly evolving, requiring academicians,
advocates, and community members who wish to practice cultural sensitivity to find words that
most accurately represent cohorts in any given moment. For the purposes of this manuscript, we
will use “transmasculine” to describe those youth assigned a female sex at birth who identify
somewhere along the masculine gender spectrum, and “transfeminine” to describe those youth
who were assigned a male sex at birth, and identify along the feminine gender spectrum. Sexual
orientation was assessed as heterosexual/straight, gay/lesbian, bisexual or other. The
investigators made the assumption that respondents would consider their gender identity as the
referent for self-labeling of sexual orientation rather than their assigned sex at birth. For
example, if a transmasculine individual reported being sexually or romantically attracted to men,
they would identify as gay. Additionally, a transfeminine individual attracted to women might
identify as a lesbian. Current living situation was assessed with the question “Which describes

6
your living situation right now” (house or apartment you rent, parent’s house or apartment, lover
or sexual partner’s house or apartment, hotel/motel, group home, halfway house/drug treatment
center, homeless shelter, foster home, on the streets, in a vehicle, or in an abandoned building or
squat, jail or juvenile hall, hospital medical facility, or other).
Seven questions explored gender identification and the age at which participants
disclosed their identity to family and non-family members. First, gender identity was examined
with the question “How do you identify in regards to your internal gender identity” (male,
female, gender fluid, gender queer, bi-gendered, gender bender, other)? Next, participants
reported (in years) the ages at which they a) realized that their gender identity was different from
the their assigned sex at birth, b) disclosed their gender identity (“came out”) to their family, and
c) disclosed their gender identity (“came out”) to people other than family members. Finally,
participants reported whether they were currently living as their asserted gender and the age in
years that they began living as their asserted gender. In addition, gender dysphoria was
measured with the 12-item Utrecht Gender Dysphoria Scale Adolescent Version (deVries, 2006).
Higher numbers on this scale indicate higher or more intense levels of gender dysphoria.
Physiologic Measurements
At the initial visit, weight, standing height, blood pressure and body mass index were
collected per routine clinical care. Non-fasting laboratory test values that had been obtained
during routine visits were abstracted from patient charts and included: total cholesterol, high-
density lipoprotein (HDL), triglycerides, aspartate aminotransferase (AST), alanine
aminotransferase (ALT), potassium, glucose, prolactin, free testosterone, total testosterone,
estradiol, and hemoglobin. Physiologic measurements are categorized according to transfeminine
or transmasculine gender identity, but are referenced according to assigned sex at birth.

7

Psychosocial Parameters
A computer-assisted, self-administered interview survey assessed baseline demographics
and psychosocial variables of interest. The 21-item Beck Depression Inventory (BDI II) (Beck,
1996) assessed the existence and severity of depression within the past few days (α=0.93).
Scores were summed to provide a total scale score ranging from 0-63 and subsequently
categorized into severity ranges of normal or minimal mood disturbance (0-13), mild depression
(14-19), moderate depression (20-28), and severe to extreme depression (29-63). Suicidality was
assessed using two binary (yes/no) questions; “Have you ever thought about killing yourself”
and “Have you ever tried to kill yourself” to capture suicidal ideation and attempts.
Risk Behavior
The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST 2002) was
used to assess lifetime use of alcohol, tobacco, cannabis, and other illicit drugs including
cocaine, sedatives, opioids, amphetamine, inhalants, hallucinogens and “other drugs.” Use of
each substance was measured with a binary (yes/no) item; participants were considered to have
used “other illicit drugs” if they reported having previously used at least one of the drugs
specified by the ASSIST other than alcohol, tobacco, or cannabis. Sexual activity was assessed
by asking the participant’s age at their first sexual encounter; participants were instructed to enter
“0” if they had never been sexually active. Among sexually active participants, sex work was
measured with the binary (yes/no) question “Have you ever traded sexual activity or favors for
food, money, a place to sleep, drugs or other material goods?”

8
Statistical analysis
Descriptive statistics are reported for all variables measured. Means and standard
deviations (SD) were used to summarize continuous variables; frequencies and percentages
summarize categorical variables. The demographics, gender demographics, and psychosocial
parameters of transfeminine and transmasculine youth were compared using independent-
samples t-tests for continuous measures, chi-square tests for categorical measures where
appropriate, and Fisher’s exact test for dichotomous comparisons with small cell sizes (expected
value <5 for any cell).
Chapter 3: Results of the Study
Demographic information
One hundred and one participants were enrolled in the study. Fifty-two (51.5%) were
transmasculine spectrum individuals, those participants who were assigned a female sex at birth
based on female genital anatomy, and forty-nine (48.5%) were transfeminine spectrum
individuals, those who had been assigned a male sex at birth based on male genital anatomy.
Though youth ranged in age from 12 to 24 years (mean 19.2, SD 2.9 years); the transfeminine
youth in our sample were significantly older than the transmasculine youth (t(94)=2.18, p=.03).
Half of the sample (52%) reported their ethnicity as Caucasian, 26% Latino/a, 11% African
American, 2% Asian/Pacific Islander, and 7% other ethnicity, with significant racial/ethnic
variation between genders as well (χ
2
(2)=9.45, p=.009); transfeminine youth were equally likely
to be Caucasian, Latina, or another race, whereas transmasculine youth were more likely to be
Caucasian. The majority of participants were living with their parents (53%), 19% lived in their
own or rented house or apartment, 5% lived with a family member, and the remainder (23%)

9
were in a group home, homeless shelter, foster home or other domicile. There were no significant
differences in country of origin or living situation (see Table 1)
Physiologic Parameters
Physiologic parameters including blood pressure, glucose, alanine aminotransferase
(ALT), and lipids were within normal clinical range for most of the participants. Body mass
index (BMI) scores ranged from 17 to 41.3 kg/m2 (transfeminine youth) and 16.9 to 44.2 kg/m2
(transmasculine youth). Nine transfeminine youth (18%) had a BMI between 25 and 30 kg/m2;
ten (20%) had a BMI above 30 kg/m2. Nineteen (37%) transmasculine youth had a BMI between
25 and 30 kg/m2, and eleven (21.5%) had BMIs above 30 kg/m2.
Baseline total testosterone levels for transmasculine youth ranged from 7 to 288 ng/dL,
with a mean of 42.5 ng/dL (normal female range 2-45 ng/dL). Four participants with pre-existing
diagnoses of polycystic ovarian syndrome, and one with another virilizing condition, may have
accounted for the higher baseline levels of total testosterone in the sample. Baseline estradiol
levels in the transfeminine youth were within the normal male range for all of the participants
(range 2-61 pg/mL; mean 27.8 pg/mL). Transfeminine youth had prolactin levels within normal
range (see Table 2a and 2b).
Gender Demographics
Fifty-seven percent of transfeminine youth and 94% of transmasculine youth were living
in the role of their asserted gender at the initial study visit. The average age participants began
living in the asserted gender role was 16.8 years (SD 3.9). At the initial study visit, eighty-six
(88%) of the participants had come out as transgender to their family, at an average age of 17.1
(SD 4.2) years. Ten participants defined their gender outside of the gender binary; gender queer
(5), gender fluid (1), bi-gender (1), gender bender (2) and other (1). Transmasculine youth had a

10
significantly higher level of gender dysphoria than transfeminine youth at baseline (55.9 vs. 50.1
respectively, t(78)=-4.418, p<0.001). There were no other significant differences in gender
demographics (see Table 3).
Sexual Orientation
The majority of transfeminine youth identified their sexual orientation as heterosexual females
(59.6%); other sexual orientations included lesbian (12.8%), bisexual female (12.8%), other
(12.8%) and unsure (2%). Of the transmasculine youth, just over half (55%) identified their
sexual orientation as heterosexual male. Other sexual orientations included bisexual male (10%),
gay male (2%), asexual (2%), other (27%) and unsure/don’t know (4%).There were no
differences between genders in the likelihood of youth of endorsing a non-heterosexual identity.
Psychosocial Parameters
Twenty-four percent of participants had Beck Depression Inventory scores in the mild to
moderate depression range, and 11% had scores indicating severe to extreme depression. Fifty-
one percent of participants reported ever thinking about suicide, and 30% had attempted suicide
at least once in their lives (see Table 4).
Risk Behavior
The majority of participants reported ever using alcohol, tobacco, and cannabis (75.5%,
58%, and 61.5%, respectively). Forty-three percent reported ever using other drugs, including
cocaine, inhalants, hallucinogens, opioids, tranquilizers, and stimulants.
Nearly half (45%) of the participants reported being sexually active, including 55% of
transfeminine youth and 37% of transmasculine youth. Six transfeminine and three
transmasculine youth reported engaging in survival sex, i.e. trading sex for money, food, drugs,

11
or a place to live. There were no differences between transfeminine and transmasculine youth in
psychosocial parameters or risk behavior.
Hormone therapy
All participants expressed a desire to begin hormonal intervention to assist in bringing
their physical bodies into better alignment with their internal gender identity. Two youth were on
gonadotropin releasing hormone agonist treatment for suppression of their endogenous puberty.
Chapter 4: Discussion
These data represent the first examination of a large, multi-ethnic cohort of transgender
youth in the United States seeking care for gender dysphoria. Our results demonstrating baseline
physiologic data that are in line with the normal ranges of the same assigned sex non-transgender
youth population help to alleviate lingering concerns that caregivers and providers might have
regarding “hormone imbalance” as an explanation and possible cure for youth presenting with
gender dysphoria. Of note are the high numbers of overweight and obese youth in this sample.
Transgender individuals may be using increased body fat to hide undesirable physical features
(Office for Victims of Crime, Responding to Transgender Victims of Sexual Assault, retreived
from: http://ovc.gov/pubs/forge/index.html). Future analyses on forthcoming longitudinal data
will describe changes in physiologic parameters after initiation of treatment related to gender
transition.
Ten participants identified their gender as “non-binary,” reflecting a growing trend
experienced clinically around the country. Addressing the medical and mental health needs of
non-binary identified youth will be an additional challenge for the community of providers
caring for gender non-conforming youth.

12
Of interest in this sample of youth are the higher than expected numbers with sexual
orientations other than heterosexual. While the investigators made the assumption that
participants would use their gender identity as the referent for self-labeling sexual orientation, it
is possible that assigned sex at birth might have been the referent. For future work, it would be
important to think about alternative responses that would more accurately reflect the sexual
preferences and attractions of transgender youth. Future information and reflection on the
intersection of sexuality and gender identities is warranted.
These baseline data indicate that despite improved understanding and exposure of gender
non-conformity within the medical and lay community, transgender youth still have high levels
of depression, suicidal thoughts and attempt rates, as well as drug and alcohol use. Twenty -
percent of the participants had BDI scores in the moderate to extreme range. This is considerably
higher than the estimated 6.7% of the general population of youth ages 12-17 years (CDC
National Center for Health Statistics (NCHS). National Health and Nutrition Examination
Survey Data retreived from:
http://www.cdc.gov/mmwr/preview/mmwrhtml/su6202a1.htm?s_cid=su6202a1_w#Tab7) and
the 10.9% of young adults ages 18-24 (CDC) Behavioral Risk Factor Surveillance System,
United States, [2006 and 2008]. Retrieved from:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5938a2.htm#tab1). Suicidal thoughts and
attempts reported by this sample are three and four times higher, respectively, than the
prevalence for general youth reported in the Youth Risk Behavior Survey (YRBS) data in 2013
(54% vs. 17% thought about; 33% vs. 8% attempted) (CDC 1991-2013 High School Youth Risk
Behavior Survey Data. Retrieved from: http://nccd.cdc.gov/youthonline/). Considering that
transgender youth in this sample did not disclose their authentic gender to their families until ten

13
years after discovery on average, it might not be surprising that many are using maladaptive
coping mechanisms to manage such a profound undisclosed element of their core selves.
Although both transmasculine and transfeminine spectrum youth reported high levels of
gender dysphoria, transmasculine youth reported significantly higher numbers than their
transfeminine counterparts. These results mirror the results from previous Dutch cohorts
(deVries, 2011) Because the Utrecht Gender Dysphoria Scale does not ask identical questions of
transmasculine and transfeminine spectrum youth, it is unclear if this difference is meaningful
and warrants further investigation. Future studies examining the differences in experience
between young transmasculine and transfeminine spectrum youth as well as non-gender binary
identified adolescents would be useful in the design of ideal treatment models for transgender
youth.
Limitations
These data represent the first cohort of an ongoing study. Over time, variable
distributions may change as a function of the wrap-around services youth receive. Additionally,
these data describe those who are able to access care related to gender dysphoria and desire
medical intervention for gender transition. These results may not be generalizable to transgender
youth who are not receiving care or to those who do not desire a phenotypic transition with
cross-sex hormones. Furthermore, the current findings are not necessarily generalizable to extant
literature in which recruitment procedures generate especially high-risk samples (e.g. studies of
street youth). Lastly, data collected about early childhood gender non-conforming feelings or
behaviors are subject to potential recall bias. Ideally, this information could be collected in a
cohort of younger children currently experiencing gender non-conformity.

14

Chapter 5: Conclusion
Transgender youth remain a very vulnerable population at high risk for many
psychosocial challenges. As the medical care for these young people becomes better understood
and more widely practiced, collecting longitudinal data from this cohort will assist providers in
making difficult treatment decisions. While there are guidelines and recommendations for the
treatment of transgender-identified youth with puberty suppression in early adolescence followed
by appropriate hormone therapy, there remain fundamental questions about when to start puberty
suppression with GnRH analogues, when to add cross-sex hormones and how young is too
young for gender confirmation surgery.
Finally, the trajectory of gender non-conformity among peri-pubertal youth is still
difficult to predict, creating serious concerns for providers and families about the possibility of
future regret in response to more permanent aspects of hormone therapy, such as breast
development and voice deepening. The data we have begun to collect are an attempt to
understand the transgender youth population and follow them over time, tracking the safety and
efficacy of medical intervention as well as the impact of intervention on quality of life, high-risk
behaviors, suicidality, depression indices, gender dysphoria and potential regret in response to
early medical intervention. We will continue to publish our follow-up data as they are collected,
and we recommend other medical centers providing this care consider collecting information and
publishing about their experiences of treating transgender youth.

15

Table 1

Demographics of Study Sample (N=96 participants’ results available for analysis).

Transfeminine
Youth
Mean (SD)
Transmasculine
Youth
Mean (SD)
Total
Mean (SD)
Age* Range 12 - 24 yrs 19.84 (2.78) 18.59 (2.84) 19.21 (2.86)
N (%) N (%) N (%)
Assigned Sex at
Birth Male 47 (49%) Female 49 (51%) 96 (100%)

Ethnicity/Race**
African American/Black 7 (15%) 4 (8%) 11 (12%)
Caucasian 18 (38%) 33 (69%) 51 (53%)
Latino(a) 17 (35%) 8 (17%) 25 (26%)
Asian/Pacific Islander 1 (2%) 1 (2%) 2 (3%)
Other 5 (10%) 2 (4%) 7 (7%)
Country of Birth
US, except Puerto Rico 42 (86%) 46 (94%) 88 (90%)
Other 7 (14%) 3 (6%) 10 (10%)
Current Living
Situation
Rented house/apt 11 (23%) 8 (17%) 19 (20%)
Parent's house/apt 23 (49%) 29 (60%) 52 (55%)
Family member's house/apt 3 (6%) 2 (4%) 5 (5%)
Lover/ partner's house/apt 0 (0%) 4 (8%) 4 (4%)
Group home 2 (4%) 0 (0%) 2 (2%)
Homeless shelter 3 (6%) 0 (0%) 3 (3%)
Foster home 1 (2%) 1 (2%) 2 (2%)
Other 4 (9%) 4 (8%) 8 (8%)
*p<.05, **p<.01, ***p<.001.

16
Table 2a

Physiologic Parameters- Transfeminine Youth
n=50

Normal
Cisgender
Male Range
Transfeminine
Youth
Mean (SD)
Systolic BP (mm HG)
90-132
123.08 (12.23)
Diastolic BP (mm HG)
60-83
71.50 (8.85)
Weight (kg)
-
162.26 (45.79)
Height (cm)
-
67.56 (3.44)
BMI (kg/m
2
)
-
24.95 (5.79)
Total Cholesterol (mg/dL)
65-175
162.88 (34.03)
HDL (mg/dL)
35-70
45.58 (10.83)
Triglycerides (mg/dL)
40-160
125.33 (83.82)
ALT (U/L)
3-35
30.98 (17.51)
Potassium (mEq/L)
3.6-5
4.22 (0.34)
Glucose (mg/dL)
60-115
87.74 (12.44)
Hemoglobin (g/dL)
13-16
15.38 (1.02)
Testosterone free (pg/ml)
35-155
99.28 (102.55)
Testosterone total (ng/dl)
250-1100
468.52 (209.48)
Estradiol (pg/ml)
<29
27.75 (12.55)
Prolactin (ng/ml)
2-18
7.94 (4.01)

Table 2b: Physiologic Parameters- Transmasculine Youth
n=51

Normal
Cisgender Female
Range
Transmasculine
Youth
Mean (SD)
Systolic BP (mm HG)
90-132
115.86 (13.83)
Diastolic BP (mm HG)
60-83
66.16 (10.96)
Weight (kg)
-
159.06 (39.55)
Height (cm)
-
64.71 (2.46)
BMI (kg/m
2
)
-
26.54 (5.76)
Total Cholesterol (mg/dL)
65-175
166.06 (33.03)
HDL (mg/dL)
35-70
51.26 (11.25)
Triglycerides (mg/dL)
35-135
103.60 (79.14)
ALT (U/L)
3-35
22.60 (9.97)
Potassium (mEq/L)
3.6-5.0
4.24 (0.34)
Glucose (mg/dL)
60-115
88.43 (15.06)
Hemoglobin (g/dL)
12-15.5
13.21 (0.98)
Testosterone free (pg/ml)
0.5-3.9
7.00 (10.45)
Testosterone total (ng/dl)
<41 ng/dL
42.53 (41.21)
Estradiol (pg/ml)
39-440 pg/mL
83.51 (86.63)

17
Table 3

Gender Demographics

Transfeminine
Youth
N (%)
Transmasculine
Youth
N (%)
Total
N (%)
Living as Asserted Gender Yes 26 (57%) 45 (94%) 71 (76%)
Mean (SD) Mean (SD) Mean (SD)
Age, Realized Gender Different
from Assigned (years)
Range 2-
22 8.42 (4.72) 8.17 (4.35) 8.29 (4.52)
Age, Coming Out to Family
(years)
Range 3-
23 17.93 (3.51) 16.60 (4.16)
17.26
(3.89)
Age, Coming Out to Others
(years)
Range 7-
24 17.24 (3.45) 16.73 (3.55)
16.99
(3.49)
Age, Living as Asserted Gender
(years)
Range 2-
23 16.57 (4.73) 16.59 (4.16)
16.58
(4.35)
Utrecht Gender Dysphoria
Scale***
Range
23-60 50.06 (7.91) 55.86 (4.69)
52.96
(7.09)
Note: eleven participants did not report coming out to family; five did not report coming out to others.
*p<.05, **p<.01, ***p<.001.

Gender
Identity

Transfeminine
Youth
N (%)
Transmasculine
Youth
N (%)
Total
N (%)

Male 0 44 (90%) 44 (45%)

Female 44 (90 %) 0 44 (45%)

Gender queer 2 (4.3%) 3 (6.1%) 5 (5%)

Bigender 0 1 (2%) 1 (1%)

Gender bender 1 (2%) 1 (2%) 2 (2%)

Gender Fluid 0 1 (2%) 1 (1%)

Other 1 (2%) 0 1 (1%)
Sexual
Orientation

Heterosexual/straight
female 28 (60%) 0 28 (29%)

Heterosexual/straight
male 0 27 (57%) 27 (28%)

Lesbian female 6 (12.8%) 0 6 (6.2%)

Gay male 0 1 (2%) 1 (1%)

Bisexual 6 (13%) 5 (11%) 11 (12%)

Asexual 0 1 (2%) 1 (1%)

Unsure/Undecided 1 (2%) 2 (4%) 3 (3%)

Other 6 (12.8%) 13 (26.5%) 19 (19.8%)

18
Table 4

Psychosocial Parameters and Risk Behavior

Transfeminine
Youth
N (%)
Transmasculine
Youth
N (%)
Total
N (%)
Depression

Normal or minimal
mood disturbance:
BDI 0-13 31 (66%) 28 (64%) 59 (65%)

Mild depression:
BDI 14-19 5 (11%) 9 (21%) 14 (15%)

Moderate
depression: BDI 20-
28 5 (11%) 3 (7%) 8 (9%)

Severe to extreme
depression: BDI 29-
63 6 (13%) 4 (9%) 10 (11%)
Thought About
Suicide (ever) Yes 20 (43%) 29 (60%) 49 (51%)
Attempted Suicide
(ever) Yes 13 (27%) 16 (33%) 29 (30%)
Substance Use
(ever)
Alcohol 37 (79%) 34 (72%) 71 (76%)
Tobacco 24 (51%) 31 (65%) 55 (58%)
Cannabis 30 (63%) 29 (60%) 59 (62%)
Other illicit drugs 19 (40%) 22 (46%) 41 (43%)
Initiated Sexual
Activity Yes 27 (55%) 18 (37%) 45 (46%)
Sex Work (ever) Yes
6 (12%; 22% of
sexually active)
3 (6%; 17% of
sexually active)

9 (9%;
20% of
sexually
active)

19
References

American Psychiatric Association, Task Force on DSM-IV. (2000). Diagnostic And Statistical
Manual Of Mental Disorders: DSM-IV-TR. 4th ed. Washington, DC: American Psychiatric
Association

American Psychiatric Association, DSM-5 Task Force. (2013). Diagnostic and Statistical
Manual of Mental Disorders : DSM-5. 5th ed. Washington, D.C.: American Psychiatric
Association

Beck AT, Steer RA, Ball R, Ranieri W. (1996). Comparison of Beck Depression Inventories -IA
and -II in psychiatric outpatients. J Pers Assess, 67(3):588-597

Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System,
United States, [2006 and 2008].
[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5938a2.htm#tab1]

Centers for Disease Control and Prevention (CDC). 1991-2013 High School Youth Risk Behavior
Survey Data. http://nccd.cdc.gov/youthonline/

Centers for Disease Control and Prevention (CDC). National Center for Health Statistics
(NCHS). National Health and Nutrition Examination Survey Data. Hyattsville, MD: U.S.
Department of Health and Human Services, Centers for Disease Control and Prevention, [2007–
2010] [http://www.cdc.gov/mmwr/preview/mmwrhtml/su6202a1.htm?s_cid=su6202a1_w#Tab7]

Corliss H, Belzer M. (2007). An evaluation of service utilization among male to female
transgender youth: Qualitative study of a clinic-based sample. Journal of LGBT Health
Research, 3(2):53-69

de Vries A, Cohen-Kettenis P.T.,Delamarre-van de Waal H. (2006). Clinical Management of
Gender Dysphoria in Adolescents. Int J of Transgenderism, 9(3/4):83-94

de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. (2011). Puberty suppression in
adolescents with gender identity disorder: A prospective follow-up study. J Sex Med, 8(8):2276-
2283

de Vries A, Cohen-Kettenis P. (2012). Clinical Management of Gender Dysphoria in Children
and Adolescents: The Dutch Approach, Journal of Homosexuality, 59:3, 301-320

deVries A, McGuire J, Steensma T, Wagenaar E, Doreleijers T, Cohen-Kettenis P. (2014).
Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment,
Pediatrics, 134(4):696 -704

Grossman AH, D'Augelli AR. (2007). Youth and life-threatening behaviors. Suicide Life Threat
Behav, 37(5):527-537

20

Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. (2009). Endocrine
Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline. J Clin
Endocr Metab, 94(9):3132-3154.

Institute of Medicine. (2011). The Health of Lesbian, Gay, Bisexual, and Transgender People:
Building a Foundation for Better Understanding. Washington, DC: The National Academies
Press

Khatchadourian K, Amed S, Metzger DL. (2014). Clinical management of youth with gender
dysphoria in Vancouver, J Pediatr, 164(4):906-11

Office for Victims of Crime, Responding to Transgender Victims of Sexual Assault, Office of
Justice, US Dept of Justice (2014). http://ovc.gov/pubs/forge/index.html

Olson J, Forbes C, Belzer M. (2011). Treatment of the Transgender Adolescent, Arch Pediatr
Adolesc Med, 165(2):171-6

Russell ST, Joyner K. (2001). Adolescent sexual orientation and suicide risk: evidence from a
national study. Am J Public Health, 91(8):1276-1281

Snelgrove JW, Jasudavisius AM, Rowe BW, Head EM, Bauer GR. (2012). "Completely out-at-
sea" with "two-gender medicine": A qualitative analysis of physician-side barriers to providing
healthcare for transgender patients. BMC Health Serv Res, 12(1):110

Spack NP, Edwards-Leeper L, Feldman HA, et al. (2012). Children and Adolescents With
Gender Identity Disorder Referred to a Pediatric Medical Center. Pediatrics, 129(5):418-425

Wilson EC, Garofalo R, Harris RD, et al. (2009). Transgender female youth and sex work: HIV
risk and a comparison of life factors related to engagement in sex work. AIDS Behav, 13(5):902-
913

WHO Assist Working Group. (2012). The alcohol, smoking and subtance involvement screening
test (ASSIST): development, reliability and feasibility. Addiction, 97:1183-1194

Abstract (if available)

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Risk factors for unanticipated hospitalizations in children and youth with spina bifida at an urban children’s hospital: a cross-sectional study

PDF

Clinical outcomes of allogeneic hematopoietic stem cell transplant in acute lymphoblastic leukemia patients: a quality improvement project and systematic review meta-analysis

PDF

Relationships matter: contextualizing developmental outcomes of high risk infants

PDF

Medical comorbidities and multiple sclerosis in the Hispanic population: linking healthcare disparities

PDF

A cross-sectional study of the association of PTH on bone quality across levels of propionic acid among adult patients with uremia

PDF

Cilostazol and its effects on human oocyte maturation in vivo: a pilot study

PDF

Potential of aqueous humor as a liquid biopsy for uveal melanoma

PDF

Understanding anti-depressant treatment failure in an underserved vulnerable population

PDF

Clinical research in women's reproductive health and the human immunodeficiency virus

PDF

Using mobile health to improve social support for low-income Latino patients with diabetes: a randomized mixed methods feasibility trial of TExT-MED FANS

PDF

The Filipino family initiative: preliminary effects of an evidence-based parenting intervention offered in churches on parent and child outcomes

PDF

Outcomes for small intestinal atresia at high and low-volume hospitals in California

PDF

The relationship of right and left sleeping position with apnea hypopnea index (AHI) in patients with obstructive sleep apnea (OSA)

PDF

The pharmacokinetics and pharmacodynamics of vincristine in the adolescent and young adult population compared to younger patients

PDF

Effects of protease inhibitor use on combined oral contraceptive pharmacokinetics and pharmacodynamics in HIV-positive women

PDF

Transgender patients’ perceptions of healthcare: A study of gender minority stress and resilience factors in predicting healthcare behavioral intentions

PDF

Comparison of secondary and primary thyroid cancer in adolescents and young adults (AYA)

PDF

Barriers to surgery for in low- and middle-income countries: a cross-sectional study of cleft lip and cleft palate patients in Vietnam

PDF

Age related macular degeneration in Latinos: risk factors and impact on quality of life

PDF

Long-term effects on vertebral body height growth of dose sculpting intensity modulated radiation therapy for children with neuroblastoma

Asset Metadata

Creator Olson, Johanna L. (author)

Core Title Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria

School Keck School of Medicine

Degree Master of Science

Degree Program Clinical, Biomedical and Translational Investigations

Publication Date 04/28/2015

Defense Date 04/27/2015

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag cross sex hormone therapy,gender transition,OAI-PMH Harvest,sex reassignment,transgender,Transgender youth

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Azen, Stanley P. (committee chair), Belzer, Marvin (committee member), Clark, Leslie F. (committee member), Patino Sutton, Cecilia M. (committee member)

Creator Email jolson@chla.usc.edu,jolson2012@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-562712

Unique identifier UC11299957

Identifier etd-OlsonJohan-3415.pdf (filename),usctheses-c3-562712 (legacy record id)

Legacy Identifier etd-OlsonJohan-3415.pdf

Dmrecord 562712

Document Type Thesis

Format application/pdf (imt)

Rights Olson, Johanna L.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA