Inga skillnader i mental hälsa funna för socialt transitionerade barn

Påverkan av social övergång i relation till kön för barn och ungdomar: en systematisk översikt

Systematiska översikter Upphörande i barndomen Psykisk hälsa & suicid

Authors: Ruth Hall, Jo Taylor, Catherine Elizabeth Hewitt, Claire Heathcote, Stuart William Jarvis, Trilby Langton, Lorna Fraser
Journal: Archives of Disease in Childhood
Year: 2024
Source: adc.bmj.com/content/109/Suppl_2/s12

Summary

Social transition means changing name, pronouns or appearance to live as another gender. York researchers found only 11 studies of how this affects children and teenagers with gender dysphoria, mostly of low quality. Most were one-off snapshots rather than following children over time. Many recruited through support groups, and five used the same group of US children. Socially transitioned children generally did not differ in mental health from comparison groups. Results for teenagers conflicted: using a chosen name was linked to less depression, but transitioning as a teenager was linked to more suicide attempts than transitioning as an adult. Two studies linked childhood transition to dysphoria lasting longer. The authors conclude that neither benefit nor harm has been shown. The review supports 'we do not know'. Critics have disputed how the York reviews judged study quality.

Key findings

Av mer än 28 000 poster funna i fem forskningsdatabaser till april 2022 kvalificerade sig bara 11 studier. Åtta var ögonblicksbilder vid ett enda tillfälle, och bara en följde barn framåt i tiden.
Kvaliteten var låg till måttlig, 1,5 till 5 av 8. Huvudproblemet var urval av personer som valde att delta eller remitterades av kliniker, och bara 3 studier mätte utfall efter en uppföljningsperiod.
Fem av de 11 studierna använde samma amerikanska projekt, som rekryterade via stödgrupper. Dess familjer var mer välbeställda än genomsnittet, och de flesta föräldrar stödde tidig transition.
Barn som transitionerade socialt visade ingen skillnad i depression jämfört med den allmänna befolkningen, syskon eller matchade barn. Men föräldrar rapporterade mer ångest än i den allmänna befolkningen och hos matchade barn.
Hos tonåringar hängde användning av ett valt namn samman med färre depressionssymtom och färre självmordstankar. Men en studie fann att transition som tonåring snarare än som vuxen hängde samman med fler självmordstankar under det senaste året och fler självmordsförsök under livet.
Två studier kopplade social transition i barndomen till att dysforin fortsatte. En fann att den oftare höll i sig in i tonåren (tydligt för barn födda som pojkar). En annan fann att 92,7 % fortfarande identifierade sig som transpersoner cirka 5,4 år senare, och de flesta gick vidare till medicinsk behandling.
Författarna drar slutsatsen att ingen studie har följt barn framåt i tiden med en rättvis jämförelsegrupp. Läkare och riktlinjer bör erkänna att det inte finns stark evidens för varken nytta eller skada.

Abstract

BACKGROUND: Increasing numbers of children and adolescents experiencing gender dysphoria or incongruence are being referred to specialist gender services. Historically, social transitioning prior to assessment was rare but it is becoming more common. AIM: To identify and synthesise studies assessing the outcomes of social transition for children and adolescents (under 18) experiencing gender dysphoria/incongruence. METHODS: A systematic review and narrative sythesis. Database searches (Medline, Embase, CINAHL, PsycINFO, Web of Science) were perfomed in April 2022. Studies reporting any outcome of social transition (full or partial) for children and adolescents experiencing gender dysphoria/incongruence were included. An adapted version of the Newcastle-Ottawa Scale for cohort studies was used to appraise study quality. RESULTS: Eleven studies were included (children (n=8) and adolescents (n=3)) and most were of low quality. The majority were from the US, featured community samples and cross-sectional analyses. Different comparator groups were used, and outcomes related to mental health and gender identity reported. Overall studies consistently reported no difference in mental health outcomes for children who socially transitioned across all comparators. Studies found mixed evidence for adolescents who socially transitioned. CONCLUSIONS: It is difficult to assess the impact of social transition on children/adolescents due to the small volume and low quality of research in this area. Importantly, there are no prospective longitudinal studies with appropriate comparator groups assessing the impact of social transition on mental health or gender-related outcomes for children/adolescents. Professionals working in the area of gender identity and those seeking support should be aware of the absence of robust evidence of the benefits or harms of social transition for children and adolescents. PROSPERO REGISTRATION NUMBER: CRD42021289659.

Conclusion

The studies included in this review are of low quality, therefore, it is difficult to assess the impact of social transition in this population. Importantly, there are no prospective longitudinal studies with appropriate comparator groups which have assessed the impact of social transition on the mental health or gender-related outcomes for children or adolescents experiencing gender dysphoria/incongruence. Healthcare professionals, clinical guidelines and advocacy organisations should acknowledge the lack of robust evidence of the benefits or harms of social transition when working with children, adolescents and their families.

Methodological limitations

Weak studies: 8 of the 11 studies were one-time snapshots, quality scores ranged from 1.5 to 5 out of 8, and none followed children forward with a fair comparison group. So the review cannot say social transition caused any result (the authors agree).
The same children counted more than once: Five studies came from one US project and two from the Amsterdam clinic. 'Consistent' findings partly reflect the same children being counted again.
Poor comparison groups: None of the community studies of children had a suitable comparison group. Several compared transitioned children with the general population or with siblings without dysphoria, which cannot show whether transition helped or harmed.
Other explanations for lasting dysphoria: Children with stronger dysphoria may be more likely to transition. That could explain the link with dysphoria lasting, rather than transition causing it.
Results tallied, not combined: The studies were too different to combine mathematically, so the review mostly counted which direction results pointed. This ignores how big or how precise each result was.
Many tests in small studies: Small studies tested many outcomes (one study tested six measures of suicidality, and two came out positive). Single striking results in either direction may be chance (the authors note this).
Out of date and English only: Searches ended in April 2022 and only English-language journal studies were included (the authors note this), so later studies are missing.
Unclear measurement: Social transition was defined broadly and mostly reported by parents or the young people themselves. Only 3 studies measured it in a standard way, and definitions varied a lot.
May not apply to today's clinic patients: Most studies were US-based and drew on community or support-group samples. These may not resemble the mostly female teenagers whose dysphoria began in adolescence who now make up most clinic referrals.
Published criticism of the York reviews: Noone et al. (2025) and a Yale Integrity Project paper (McNamara et al., 2024) argued that the way the York reviews judged quality, and their conclusions, were flawed. Others have defended the reviews.
Paid for by NHS England: The review was funded to inform the Cass Review. The authors declare no conflicts and say the funder played no part in how it was done or interpreted.

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Summary

Key findings

Abstract

Conclusion