Do Clinical Data from Transgender Adolescents Support the Phenomenon of “Rapid Onset Gender Dysphoria”?
2021; Elsevier BV; Volume: 243; Linguagem: Inglês
10.1016/j.jpeds.2021.11.020
ISSN1097-6833
AutoresGreta R. Bauer, Margaret L. Lawson, Daniel L. Metzger,
Tópico(s)African Sexualities and LGBTQ+ Issues
ResumoAlthough emergence of gender dysphoria at puberty is long established, a distinct pathway of rapid onset gender dysphoria was recently hypothesized based on parental data. Using adolescent clinical data, we tested a series of associations that would be consistent with this pathway, however, our results did not support the rapid onset gender dysphoria hypothesis. Although emergence of gender dysphoria at puberty is long established, a distinct pathway of rapid onset gender dysphoria was recently hypothesized based on parental data. Using adolescent clinical data, we tested a series of associations that would be consistent with this pathway, however, our results did not support the rapid onset gender dysphoria hypothesis. Puberty has long been understood as one period when gender dysphoria often first emerges.1World Professional Association for Transgender HealthStandards of care for the health of transsexual, transgender, and gender nonconforming people (7th version) [Internet].https://www.wpath.org/publications/socDate: 2012Date accessed: May 30, 2021Google Scholar Although most transgender (trans) older adolescents and adults report needing gender-affirming medical care (hormones and/or surgeries), and also report having been aware of their gender at young ages,2Scheim A.I. Bauer G.R. Sex and gender diversity among transgender persons in Ontario, Canada: results from a respondent-driven sampling survey.J Sex Res. 2015; 52: 1-14Google Scholar only a small proportion receive gender-affirming care as adolescents. Use of hormonal suppression with a gonadotropic-releasing hormone agonist, and hormones such as estrogen and testosterone therapies in trans and gender-diverse adolescents is supported by the American Academy of Pediatrics, the Pediatric Endocrine Society, the Endocrine Society, and the World Professional Association for Transgender Health.1World Professional Association for Transgender HealthStandards of care for the health of transsexual, transgender, and gender nonconforming people (7th version) [Internet].https://www.wpath.org/publications/socDate: 2012Date accessed: May 30, 2021Google Scholar,3Rafferty J. AAP Committee on Psychosocial Aspects of Child and Family HealthAAP Committee on AdolescenceAAP Section on Lesbian, Gay, Bisexual, and Transgender Health and WellnessEnsuring comprehensive care and support for transgender and gender-diverse children and adolescents.Pediatrics. 2018; 142: e20182162Google Scholar, 4Lopez X. Marinkovic M. Eimicke T. Rosenthal S.M. Olshan J.S. Statement on gender-affirmative approach to care from the Pediatric Endocrine Society Special Interest Group on Transgender Health.Curr Opin Pediatr. 2017; 29: 475-480Google Scholar, 5Hembree W.C. Cohen-Kettenis P.T. Gooren L. Hannema S.E. Meyer W.J. Murad M.H. et al.Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society Clinical Practice guideline.J Clin Endocrinol Metab. 2017; 102: 3869-3903Google Scholar Referrals to adolescent gender clinics have increased internationally, particularly among those assigned female at birth.6Spack N.P. Edwards-Leeper L. Feldman H.A. Leibowitz S. Mandel F. Diamond D.A. et al.Children and adolescents with gender identity disorder referred to a pediatric medical center.Pediatrics. 2012; 129: 418-425Google Scholar, 7Chen M. Fuqua J. Eugster E.A. Characteristics of referrals for gender dysphoria over a 13-year period.J Adolesc Health. 2016; 58: 369-371Google Scholar, 8Wiepjes C.M. Nota N.M. de Blok C.J.M. Klaver M. de Vries A.L.C. Wensing-Kruger S.A. et al.The Amsterdam Cohort of Gender Dysphoria Study (1972–2015): trends in prevalence, treatment, and regrets.J Sex Med. 2018; 15: 582-590Google Scholar, 9Aitken M. Steensma T.D. Blanchard R. VanderLaan D.P. Wood H. Fuentes A. et al.Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria.J Sex Med. 2015; 12: 756-763Google Scholar In 2018, a phenomenon of rapid onset gender dysphoria was hypothesized as a distinct pathway involving social contagion among youth vulnerable due to mental or neurodevelopmental disorders,10Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2018; 13: e0202330Google Scholar, 11Littman L. Correction: parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2019; 14: e0214157Google Scholar, 12Costa A.B. Formal comment on: parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2019; 14: e0212578Google Scholar raising public concerns regarding potential for later regret following gender-affirming medical care. This discussion has occurred primarily in the context of data from a single online parental survey.10Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2018; 13: e0202330Google Scholar,11Littman L. Correction: parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2019; 14: e0214157Google Scholar Although this parental study has generated controversy,13Wadman M. 'Rapid onset' of transgender identity ignites storm.Science. 2018; 361: 958-959Google Scholar methodologic and social critique,12Costa A.B. Formal comment on: parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2019; 14: e0212578Google Scholar,14Ashley F. A critical commentary on "rapid-onset gender dysphoria.".Sociol Rev. 2020; 68: 779-799Google Scholar,15Restar A.J. Methodological critique of Littman's (2018) parental-respondents accounts of "rapid-onset gender dysphoria.".Arch Sex Behav. 2020; 49: 61-66Google Scholar and calls for additional research,16Hutchinson A. Midgen M. Spiliadis A. In support of research into rapid-onset gender dysphoria.Arch Sex Behav. 2020; 49: 79-80Google Scholar,17Zucker K.J. Adolescents with gender dysphoria: reflections on some contemporary clinical and research issues.Arch Sex Behav. 2019; 48: 1983-1992Google Scholar its hypotheses have not yet been tested on data from youth themselves. Specifically, rapid onset gender dysphoria is hypothesized as a phenomenon in youth with gender dysphoria emerging at or after puberty, socially influenced through peer contagion, and with contributing factors including poor mental health, neurodevelopmental disabilities, parent-child conflict, and maladaptive coping strategies.10Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2018; 13: e0202330Google Scholar,11Littman L. Correction: parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2019; 14: e0214157Google Scholar If the rapid onset gender dysphoria hypothesis indeed characterizes a distinct clinical phenomenon, and these youth access referrals for hormone suppression or gender-affirming hormones, then we would expect to see differentiation within clinical samples between those with more-recent (ie, rapid-onset) vs more-remote knowledge regarding their gender. Based on the published hypothesis,10Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2018; 13: e0202330Google Scholar we would expect more recent gender knowledge to be associated with self-reported mental health measures, mental health and neurodevelopmental disability diagnoses, behaviors consistent with maladaptive coping (eg, self-harm), support from online and/or transgender friends but not parents, and lesser gender dysphoria. We aim to test these hypotheses. Baseline data (2017-2019) from the Trans Youth CAN! Cohort included pubertal/postpubertal adolescents age <16 years attending a first referral visit for hormone suppression or gender-affirming hormones at 10 Canadian medical clinics that provide specialized gender-affirming care to adolescents through a range of different care models. Ethics approval was received from all study sites. Years gender was known was missing for 1 participant (excluded), for a final sample of n = 173. Methods and measures are described in detail elsewhere.18Bauer G.R. Pacaud D. Couch R. Metzger D.L. Gale L. Gotovac S. et al.Transgender youth referred to clinics for gender-affirming medical care in Canada.Pediatrics. 2021; 148 (e2020047266)Google Scholar Self-reported measures were obtained from baseline interviewer-administered adolescent surveys,19Trans Youth CAN! Research TeamTrans Youth CAN! Baseline youth survey (English) [Internet].https://transyouthcan.ca/wp-content/uploads/2018/04/Youth-Baseline-Survey.pdfDate: 2017Date accessed: June 30, 2020Google Scholar and diagnoses from baseline clinical records.20Trans Youth CAN! Baseline case report form [Internet].https://transyouthcan.ca/wp-content/uploads/2019/03/Case-Report-Form-COMBINED-Baseline-Clean-Jan22.2018.pdfDate: 2017Date accessed: June 30, 2020Google Scholar Recent gender knowledge was coded by subtracting age in years from age adolescents self-reported they "realized your gender was different from what other people called you." As ages were whole numbers, a difference of 1 could indicate <1 year to just under 2 years. Values ≤1 were coded as recent gender knowledge, with an alternate definition (values ≤2) for sensitivity analysis. Mental health symptoms were assessed with the Overall Anxiety Severity and Impairment Scale,21Campbell-Sills L. Norman S.B. Craske M.G. Sullivan G. Lang A.J. Chavira D.A. et al.Validation of a brief measure of anxiety-related severity and impairment: the Overall Anxiety Severity and Impairment Scale (OASIS).J Affect Disord. 2009; 112: 92-101Google Scholar the Modified Depression Scale,22Dunn E.C. Johnson R.M. Green J.G. The Modified Depression Scale (MDS): a brief, no-cost assessment tool to estimate the level of depressive symptoms in students and schools.School Ment Health. 2012; 4: 34-45Google Scholar and the Kessler-6 scale for psychological distress.23Kessler R.C. Andrews G. Colpe L.J. Hiripi E. Mroczek D.K. Normand S.-L.T. et al.Short screening scales to monitor population prevalences and trends in nonspecific psychological distress.Psychol Med. 2002; 32: 959-976Google Scholar Mental health diagnoses extracted from chart included anxiety, depression, personality disorder, eating disorder, and neurodevelopmental disorder diagnoses included autism, obsessive compulsive disorder, or attention deficit hyperactivity disorder. Gender dysphoria symptoms were assessed using the Trans Youth CAN! Gender Distress Scale.24Bauer G. Churchill S. Ducharme J. Feder S. Gillis L. Gotovac S. et al.Trans Youth CAN! Gender Distress Scale (TYC-GDS) [Internet].https://transyouthcan.ca/wp-content/uploads/2021/04/Gender-Distress-Scale-vSHARE_EN-2021.pdfDate: 2021Date accessed: July 9, 2021Google Scholar Self-reported mental health behaviors included self-harm, substance use, and suicidal behavior. Three measures captured social connections to online and trans communities: having gender-supportive online friends was coded if adolescents reported online friends who knew their gender and were "very supportive," and having online or trans friends as general sources of support was indicated in checklist items. Parental support was coded if youth indicated all biological/step/foster parents were "very supportive" of their gender identity or expression. Statistical analyses were conducted using SAS v 9.4.1 (SAS Institute, Inc), weighted to account for clinics' different recruitment periods due to staggered start dates, to improve generalizability.18Bauer G.R. Pacaud D. Couch R. Metzger D.L. Gale L. Gotovac S. et al.Transgender youth referred to clinics for gender-affirming medical care in Canada.Pediatrics. 2021; 148 (e2020047266)Google Scholar For analyses of associations between recency of gender knowledge and hypothesized correlates, a series of multiple regressions was conducted, with recency as the independent variable of interest, controlling for age and sex assigned at birth. Linear regressions were used for continuous dependent variables (eg, psychometric scales). For dichotomous dependent variables, modified Poisson regression with robust variance estimation was used.25Zou G. A modified Poisson regression approach to prospective studies with binary data.Am J Epidemiol. 2004; 159: 702-706Google Scholar As "rapid-onset" has not been precisely defined, we conducted a sensitivity analysis repeating these analyses using the alternate (value ≤2) definition of recent gender knowledge. Recency of gender knowledge is presented in the Figure, results of hypothesized associations (recency value ≤ 1) in Table I, and variable means and frequencies in Table II (available at www.jpeds.com). Controlling for age and sex assigned at birth, recent gender knowledge was not significantly associated with depressive symptoms, psychological distress, past diagnoses with mental health issues or neurodevelopmental disorders, gender dysphoria symptoms, self-harm, past-year suicide attempt, having gender-supportive online friends, general support from online friends or transgender friends, or gender support from parents. Recent gender knowledge was associated with lower scores on anxiety severity/impairment (b = −3.272; 95% CI −5.172, −1.373), and lower prevalence of marijuana use (prevalence ratio = 0.11; 95% CI 0.02, 0.82), counter to hypothesized directions of effect. For sensitivity analysis using the alternate (value ≤2) definition of recent gender knowledge, we found all results substantively the same in statistical significance and direction of effect, except past-year marijuana use, which now only approached statistical significance (P = .0677).Table IAssociations between short-term awareness of gender and variables hypothesized to be associated with rapid-onset gender dysphoria, controlling for age and sex assigned at birthDependent variablesB∗Estimates adjusted for age in years and sex assigned at birth.SEPPR∗Estimates adjusted for age in years and sex assigned at birth.95% CI†95% CIs for betas (for linear regressions) or PRs (for modified Poisson regressions).Mental health scales Anxiety severity/impairment (OASIS)−3.2720.961.0008(−5.172, −1.373) Depressive symptoms (MDS)−1.2760.845.1328(−2.944, 0.392) Psychological distress (K6)−1.1561.060.2771(−3.248, 0.936)Record of diagnosis with mental health disorder‡Extracted from medical record: any diagnosis from clinic or referrer of anxiety, depression, personality disorder, eating disorder. Personality disorder diagnoses were uncommon (n = 2) and no youth had a record of eating disorder diagnosis.−0.5090.315.10590.60(0.32, 1.11)Record of diagnosis with neurodevelopmental disorder§Extracted from medical record: any diagnosis from clinic or referrer of attention deficit hyperactivity disorder, obsessive compulsive disorder, or autism.0.0660.362.85631.07(0.52, 2.17)Gender dysphoria/distress (TYC-GDS)−0.1930.122.1139(−0.434, 0.047)Mental health related behaviors Self-harm, past year−0.0520.191.78330.95(0.65, 1.38) Marijuana use, past year−2.1781.010.03100.11(0.02, 0.82) Past-year suicide attempt−0.5920.785.45050.55(0.12, 2.58)Social connection indicators¶Hypothesized by other authors based on a survey of parents recruited from websites generally unsupportive of gender-affirming care.10 Reports having online friends supportive of gender−0.0500.157.75050.95(0.70, 1.29) Indicates online friends as source of general support−0.2230.286.43660.80(0.46, 1.40) Indicates trans friends as source of general support−0.0490.298.10160.61(0.34, 1.10)All parents supportive of gender identity/expression−0.0040.202.98361.00(0.67, 1.48)B, beta regression; K6, Kessler-6 Scale MDS, Modified Depression Scale; OASIS, Overall Anxiety Severity and Impairment Scale; PR, prevalence ratio; TYC-GDS, Trans Youth CAN! Gender Distress Scale.∗ Estimates adjusted for age in years and sex assigned at birth.† 95% CIs for betas (for linear regressions) or PRs (for modified Poisson regressions).‡ Extracted from medical record: any diagnosis from clinic or referrer of anxiety, depression, personality disorder, eating disorder. Personality disorder diagnoses were uncommon (n = 2) and no youth had a record of eating disorder diagnosis.§ Extracted from medical record: any diagnosis from clinic or referrer of attention deficit hyperactivity disorder, obsessive compulsive disorder, or autism.¶ Hypothesized by other authors based on a survey of parents recruited from websites generally unsupportive of gender-affirming care.10Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2018; 13: e0202330Google Scholar Open table in a new tab B, beta regression; K6, Kessler-6 Scale MDS, Modified Depression Scale; OASIS, Overall Anxiety Severity and Impairment Scale; PR, prevalence ratio; TYC-GDS, Trans Youth CAN! Gender Distress Scale. We did not find support within a clinical population for a new etiologic phenomenon of rapid onset gender dysphoria during adolescence. Among adolescents under age 16 years seen in specialized gender clinics, associations between more recent gender knowledge and factors hypothesized to be involved in rapid onset gender dysphoria were either not statistically significant, or were in the opposite direction to what would be hypothesized. This putative phenomenon was posited based on survey data from a convenience sample of parents recruited from websites,10Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2018; 13: e0202330Google Scholar and may represent the perceptions or experiences of those parents, rather than of adolescents, particularly those who may enter into clinical care. Similar analyses should be replicated using additional clinical and community data sources. Our finding of lower anxiety severity/impairment scores in adolescents with more recent gender knowledge suggests the potential for longstanding experiences of gender dysphoria (or their social complications) playing a role in development of anxiety, which could also be explored in future research. The Trans Youth CAN! Study Team thank the trans youth and their families who have generously shared their time and experience with us. We acknowledge the contribution of the local site teams to participant recruitment, in particular the team of research assistants involved in data collection. Joseph Bonifacio, MD, FRCPC, Adolescent Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario Robert Couch, MSc, MD, FRCPC, Division of Pediatric Endocrinology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta Jennifer Ducharme, PhD, C.Psych, Department of Clinical Health Psychology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba Stephen Feder, MDCM, MPH, CCFP, Division of Adolescent Medicine, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario Lorraine Gale, MSW, Trans Youth CAN! Study Team, Toronto, Ontario Shuvo Ghosh, MD, FAAP, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec Sandra Gotovac, PhD, Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario Natasha Johnson, MD, FRCPC, Division of Adolescent Medicine, Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, Ontario Carys Massarella, MD, FRCPC, St. Joseph's Healthcare, Hamilton, Ontario Arati Mokashi, MD, FRCPC, Department of Pediatrics, Division of Endocrinology, Dalhousie University; IWK Health Centre, Halifax, Nova Scotia Danièle Pacaud, MD, FRCPC, Alberta Children's Hospital, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta Mark Palmert, MD, PhD, Division of Endocrinology, The Hospital for Sick Children, Departments of Pediatrics and Physiology, University of Toronto, Toronto, Ontario Joe Raiche, MD, FRCPC, Foothills Medical Centre, Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta Annie Pullen Sansfaçon, PhD, School of Social Work, University of Montreal, Montreal, Quebec Elizabeth Saewyc, PhD, RN, jFSAHM, FCAHS, FAAN, FCAN, School of Nursing, University of British Columbia, Vancover, British Columbia Kathy Nixon Speechley, PhD, Departments of Pediatrics and Epidemiology and Biostatistics. Schulich School of Medicine and Dentistry, Western University, London, Ontario Robert Stein, MDCM, FRCPC, Division of Pediatric Endocrinology, London Health Sciences Centre, Schulich School of Medicine & Dentistry, London, Ontario Françoise Susset, PsyD, Meraki Health Centre, Montreal, Quebec Julia Temple Newhook, PhD, Department of Gender Studies, Memorial University, St. John's, Newfoundland and Labrador Ashley Vandermorris, MD, MSc, FRCPC, Division of Adolescent Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario John Vandermeulen, MD, FRCPC, Division of Adolescent Medicine, Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, OntarioTable IIWeighted frequencies or means for sociodemographic and study variables (n = 173)VariablesValueAge, n (%weighted) 10-11 y17 (8.5) 12-13 y37 (22.6) 14-15 y119 (68.9)Ethnoracial background,∗Coded to match Statistics Canada categories of Indigenous, visible minority, and white. Nonwhite, nonindigenous ethnoracial backgrounds were indicated by the following numbers of participants: 6 Black Canadian or African American, 2 Black African, 4 Latin American, 4 East Asian, 1 Indo-Caribbean, 3 Black Caribbean, 1 Middle Eastern, and 1 Southeast Asian (participants could indicate more than 1). n (%weighted) Indigenous33 (18.4) Nonindigenous visible minority†The Canadian government defines visible minorities as "persons, other than Aboriginal peoples, who are non-Caucasian in race or nonwhite in color."2610 (6.6) Nonindigenous white128 (75.0)Immigration background, n (%weighted) 1 or more immigrant parent126 (28.7) No immigrant parents44 (71.3)Living environment, n (%weighted) City87 (55.2) Suburb59 (33.9) Rural27 (10.9)Gender identity, n (%weighted) Male or primarily a boy125 (75.7) Female or primarily a girl32 (15.9) Nonbinary‡Response option was "nonbinary or something other than male or female."14 (8.3)Mental health scales, meanweighted (SD) Anxiety severity/impairment (OASIS)8.842 (4.548) Depressive symptoms (MDS)15.077 (4.030) Psychological distress (K6)10.746 (5.100)Record of diagnosis with mental health disorder,§Extracted from medical record: any diagnosis from clinic or referrer of anxiety, depression, personality disorder, eating disorder. Personality disorder diagnoses were uncommon (n = 2) and no youth had a record of eating disorder diagnosis. n (%weighted)92 (51.6)Record of diagnosis with neurodevelopmental disorder,¶Extracted from medical record: any diagnosis from clinic or referrer of attention deficit hyperactivity disorder, obsessive compulsive disorder, or autism. n (%weighted)44 (25.9)Gender dysphoria/distress (TYC-GDS), meanw (SD)4.048 (0.557)Mental health related behaviors, n (%weighted) Self-harm, past year110 (67.9) Marijuana use, past year29 (20.0) Past-year suicide attempt24 (16.9)Social connection indicators,Hypothesized by other authors based on a survey of parents.10 n (%weighted) Reports having online friends supportive of gender109 (69.9) Indicates online friends as source of general support79 (49.3) Indicates trans friends as source of general support92 (55.8)All parents supportive of gender identity/expression109 (61.8)K6, Kessler-6 Scale; MDS, Modified Depression Scale; OASIS, Overall Anxiety Severity and Impairment Scale; TYC-GDS, Trans Youth CAN! Gender Distress Scale.∗ Coded to match Statistics Canada categories of Indigenous, visible minority, and white. Nonwhite, nonindigenous ethnoracial backgrounds were indicated by the following numbers of participants: 6 Black Canadian or African American, 2 Black African, 4 Latin American, 4 East Asian, 1 Indo-Caribbean, 3 Black Caribbean, 1 Middle Eastern, and 1 Southeast Asian (participants could indicate more than 1).† The Canadian government defines visible minorities as "persons, other than Aboriginal peoples, who are non-Caucasian in race or nonwhite in color."26Government of Canada SCVisible minority of person [Internet].https://www23.statcan.gc.ca/imdb/p3Var.pl?Function=DEC&Id=45152Date: 2015Date accessed: May 29, 2021Google Scholar‡ Response option was "nonbinary or something other than male or female."§ Extracted from medical record: any diagnosis from clinic or referrer of anxiety, depression, personality disorder, eating disorder. Personality disorder diagnoses were uncommon (n = 2) and no youth had a record of eating disorder diagnosis.¶ Extracted from medical record: any diagnosis from clinic or referrer of attention deficit hyperactivity disorder, obsessive compulsive disorder, or autism.∗∗ Hypothesized by other authors based on a survey of parents.10Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.PLoS One. 2018; 13: e0202330Google Scholar Open table in a new tab K6, Kessler-6 Scale; MDS, Modified Depression Scale; OASIS, Overall Anxiety Severity and Impairment Scale; TYC-GDS, Trans Youth CAN! Gender Distress Scale.
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