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Table 1.  Demographic, Social, and Clinical Characteristics of Transgender Patients
Demographic, Social, and Clinical Characteristics of Transgender Patients
Table 2.  Earliest Age of First Memory of GD Among Transgender Patients
Earliest Age of First Memory of GD Among Transgender Patients
1.
Ruble  DN, Taylor  LJ, Cyphers  L, Greulich  FK, Lurye  LE, Shrout  PE.  The role of gender constancy in early gender development.  Child Dev. 2007;78(4):1121-1136. doi:10.1111/j.1467-8624.2007.01056.xPubMedGoogle ScholarCrossref
2.
Tustin  K, Hayne  H.  Defining the boundary: age-related changes in childhood amnesia.  Dev Psychol. 2010;46(5):1049-1061. doi:10.1037/a0020105PubMedGoogle ScholarCrossref
3.
Heylens  G, Elaut  E, Kreukels  BP,  et al.  Psychiatric characteristics in transsexual individuals: multicentre study in four European countries.  Br J Psychiatry. 2014;204(2):151-156. doi:10.1192/bjp.bp.112.121954PubMedGoogle ScholarCrossref
4.
Costa  R, Colizzi  M.  The effect of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: a systematic review.  Neuropsychiatr Dis Treat. 2016;12:1953-1966. doi:10.2147/NDT.S95310PubMedGoogle ScholarCrossref
5.
Padula  WV, Heru  S, Campbell  JD.  Societal implications of health insurance coverage for medically necessary services in the U.S. transgender population: a cost-effectiveness analysis.  J Gen Intern Med. 2016;31(4):394-401. doi:10.1007/s11606-015-3529-6PubMedGoogle ScholarCrossref
6.
Coleman  E, Bockting  W, Botzer  M,  et al.  Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.  Int J Transgenderism. 2012;13(4):165-232. doi:10.1080/15532739.2011.700873Google ScholarCrossref
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    Research Letter
    Public Health
    March 16, 2020

    Age at First Experience of Gender Dysphoria Among Transgender Adults Seeking Gender-Affirming Surgery

    Author Affiliations
    • 1Division of Urology, Cedars-Sinai Medical Center, Los Angeles, California
    • 2Biostatistics and Bioinformatics Core, Cedars-Sinai Samuel Oschin Comprehensive Cancer Center, Los Angeles, California
    • 3Department of Urology, University of California, San Francisco
    • 4Department of Anatomy, University of California, San Francisco
    • 5Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, California
    JAMA Netw Open. 2020;3(3):e201236. doi:10.1001/jamanetworkopen.2020.1236
    Introduction

    To our knowledge, the mean earliest age at which adult transgender women (TW) and transgender men (TM) first experienced gender dysphoria (GD) has not been quantified and reported among a US population of adults seeking genital gender-affirming surgery (GAS). Because gender is an innate part of an individual’s identity, we hypothesized that untreated GD would be part of an individual’s earliest memories. Our aim was to identify the age at which patients first experienced GD and the number of life-years that a diverse US sample of transgender adult presurgical patients spent living with untreated GD and its comorbidities. This information is important because it can help guide health care practitioners to as to when and how to best focus outreach and care to patients not yet identified as transgender.

    Methods

    The Cedars-Sinai Medical Center institutional review board reviewed and approved this cross-sectional study. This study was conducted in accordance with all relevant guidelines and procedures of Cedars-Sinai Medical Center. A waiver of informed consent was granted by the institutional review board for the collection and reporting of the data because they were deidentified.

    All study data were obtained at a single study site (Cedars-Sinai Medical Center). All participants received a diagnosis of GD from a mental health specialist in accordance with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria. All patients were presenting for consultation for GAS and already met the criteria for surgery. During consultation for genital GAS, all consecutive TW and TM were asked to report how old they were at their earliest general (non–gender-related) memories and how old they were at their first experience of GD.

    Pearson correlation coefficients were computed to test the association between variables. Two-sample t tests were used to test for differences in mean ages. Data are presented as mean (SD). Differences were considered statistically significant where 2-tailed P < .05. Data were analyzed using SAS statistical software version 9.4 (SAS Institute). Data analysis was performed in April 2019.

    Results

    Data from 155 TW (mean [SD] age, 41.3 [16.3] years) and 55 TM (mean age 35.4 [10.8] years) were collected (Table 1). Approximately one-half (52%) of all TM and TW were white and non-Hispanic (110 patients), and nearly one-half (101 patients [48%]) had an active or recent history of anxiety or depression. Among TW, 7% (11 patients) were HIV positive. For TM, the mean (SD) age of earliest general memory and age at first experience of GD were 4.7 (2.3) and 6.2 (3.1) years, respectively; for TW, these ages were 4.5 (2.0) and 6.7 (3.6) years, respectively (Table 2). Most of the patients (112 TW [73%] and 41 TM [78%]) first experienced GD by the age of 7 years. TM and TW lived for a mean (SD) of 22.9 (12.6) and 27.1 (16.4) years, respectively, with untreated GD before commencing gender transition (nonsurgical). Birth sex, age at commencement of transition, sexual orientation, and age at presentation for surgery were not associated with age at earliest memory of GD.

    Discussion

    To our knowledge, this study is the first to quantify the earliest age at which GD was experienced in a US patient population seeking genital GAS. We found that nearly all TM and TW first experienced GD by age 7 years (gender identity typically becomes constant at ages 5-7 years),1 which is only 1.5 and 2.2 years later than each cohort’s first life memories (which typically occur at ages 3-4 years).2 Our findings are consistent with prior research3 that found that GD generally develops early in life.

    Another important finding from our study is the number of years that transgender adults live with untreated GD before commencing treatment (social transition and/or hormonal therapy): 22.9 years for TM and 27.1 years for TW. When we consider that life-years spent with any untreated condition are associated with morbidity and decreased quality of life, then the high number of life-years spent living with GD and its associated morbidities is striking.4,5 This large cumulative burden strongly supports the argument for early GD care, counseling, and education about transition-related options, both for patients and for their parents or guardians.6 Gender transition–related care has been shown to substantially improve quality of life and reduce health care costs.3-6

    This study has some limitations. The participants included only patients presenting for genital GAS and, thus, may not be representative of transgender people who do not seek GAS. Patients were not queried about the severity of their GD and mental health during their childhood, when they may have experienced a different degree of distress and/or other consequences.

    Conclusions

    Our findings suggest that GD typically manifests very early in childhood and can persist for many years until gender transition. As such, GD and its associated adverse health effects are conditions of childhood as much as adolescence or adulthood. Diagnosis and early management during childhood and adolescence can decrease morbidity and improve quality of life and overall survival.

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    Article Information

    Accepted for Publication: January 20, 2020.

    Published: March 16, 2020. doi:10.1001/jamanetworkopen.2020.1236

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Zaliznyak M et al. JAMA Network Open.

    Corresponding Author: Maurice M. Garcia, MD, MAS, Division of Urology, Cedars-Sinai Medical Center, 8635 W Third St, Ste 1070, Los Angeles, CA 90048 (maurice.garcia@csmc.edu).

    Author Contributions: Dr Garcia had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Garcia.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: All authors.

    Critical revision of the manuscript for important intellectual content: Zaliznyak, Garcia.

    Statistical analysis: Zaliznyak, Bresee.

    Administrative, technical, or material support: Garcia.

    Supervision: Garcia.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Ruble  DN, Taylor  LJ, Cyphers  L, Greulich  FK, Lurye  LE, Shrout  PE.  The role of gender constancy in early gender development.  Child Dev. 2007;78(4):1121-1136. doi:10.1111/j.1467-8624.2007.01056.xPubMedGoogle ScholarCrossref
    2.
    Tustin  K, Hayne  H.  Defining the boundary: age-related changes in childhood amnesia.  Dev Psychol. 2010;46(5):1049-1061. doi:10.1037/a0020105PubMedGoogle ScholarCrossref
    3.
    Heylens  G, Elaut  E, Kreukels  BP,  et al.  Psychiatric characteristics in transsexual individuals: multicentre study in four European countries.  Br J Psychiatry. 2014;204(2):151-156. doi:10.1192/bjp.bp.112.121954PubMedGoogle ScholarCrossref
    4.
    Costa  R, Colizzi  M.  The effect of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: a systematic review.  Neuropsychiatr Dis Treat. 2016;12:1953-1966. doi:10.2147/NDT.S95310PubMedGoogle ScholarCrossref
    5.
    Padula  WV, Heru  S, Campbell  JD.  Societal implications of health insurance coverage for medically necessary services in the U.S. transgender population: a cost-effectiveness analysis.  J Gen Intern Med. 2016;31(4):394-401. doi:10.1007/s11606-015-3529-6PubMedGoogle ScholarCrossref
    6.
    Coleman  E, Bockting  W, Botzer  M,  et al.  Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.  Int J Transgenderism. 2012;13(4):165-232. doi:10.1080/15532739.2011.700873Google ScholarCrossref
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