The present study is the first to utilise the GIDS-GQ to provide an overview of the feelings and experiences of gender-diverse young people prior to commencing gender care in a specialist service, with the primary aim of understanding each young person’s experience to help inform where clinical treatment may need to be focused. Overall, within this sample, the majority of young people had undergone a full social transition, and had more often experienced transphobic bullying and not being treated in a way that reflected their gender identity in the past than presently. They also described disliked body parts more readily than liked body parts, and had most commonly experienced a decrease in mood and social connections.
Most young people (75.3%) had fully socially transitioned before they were first seen at the GIDS, as has been reported by others [24]. This had increased from previous reportage by this service [19] by 20.7% and is likely reflecting a growing trend as well as owing to an increase in the waiting period before accessing services, due to an increase in referrals in recent years [6–8]. For those who had partially socially transitioned, the majority presented as their identified gender least frequently with strangers (40% of the time). This may be owing to concerns around experiencing discrimination from strangers as is commonly reported by gender-diverse communities [33], resulting in feeling uncomfortable presenting as their identified gender in these settings. Instead, young people were most comfortable presenting as their identified gender online, where they may have access to unique communities for gender-diverse adolescents to express and understand their gender identity, as has been found elsewhere [34, 35].
Of interest, more young people reported experiencing transphobic bullying (64.2%) and not being treated in a way that reflected their gender identity (85.1%) in the past than just prior to attending services (transphobic bullying: 12.3%; non-acceptance: 49.4%). This may be owing to the sample being further along in their social transition at the time of answering the questionnaire than in the past, resulting in a reduction of misgendering and more acceptance from others. Indeed, Kattari et al. [36] reported that adult gender-diverse samples who reported a higher level of ‘passing’ as their identified gender were also less likely to report discrimination. In addition, fewer instances of these external/distal stressors may be due to increased visibility and awareness of gender diversity in today’s society compared to ‘the past’, including in school settings [37, 38]. Levels of reported distress experienced in the past owing to transphobic bullying were also high in the present sample, indicating that these external/distal stressors were likely contributing negatively to mental health as has been described elsewhere [15–17]. Considering acceptance of gender identity, young people placed much importance on pronoun use, with 97.4% of the sample asking others to use preferred pronouns and expressing more satisfaction when pronouns were endorsed. Indeed, Brown et al. [39] found that others’ endorsement of preferred pronouns contributed to gender-diverse young people feeling supported and validated in their identified gender, and reduced reported emotional distress.
Most young people stated that they felt distress related to their assigned gender at birth, as would be expected in clinically referred young people [5]. Of note, most young people (94.5%) reported disliking parts of their body, with the most commonly reported (breasts, genitals, and hips) reflecting the demographic of the cohort (assigned female at birth young people in puberty), and the escalating distress that can be associated with the development of primary and secondary sex characteristic during puberty [9–11].
Importantly, the present sample most commonly reported that their experience of gender-related distress directly resulted in a decrease in their mood and all areas of social connectedness except friendships and school attendance, which had ‘stayed the same’. In addition, many young people also reported still experiencing transphobic bullying (12.3%) and/or non-acceptance (49.4%), and distress owing to this. These findings are crucial as relationships with caregivers, peers, and community connectedness are found to be central to the psychological wellbeing of gender-diverse young people [40], and negative peer relations have been noted as instrumental in predicting behavioural and emotional difficulties in clinically referred young people [31, 32]. Additionally, the Minority Stress Model highlights social connectedness as a key protective factor against minority stressors, such as bullying and non-acceptance [12–14].
Limitations
The sample consisted of a predominantly adolescent (pubertal) group and the majority were assigned female at birth, which limits study generalisability and comparison. However, the demographics of the sample does reflect the higher proportion of pubertal assigned female at birth young people referred to gender services, both in the GIDS [6, 19, 32], and elsewhere [7, 8, 41], although more recent assessment of community samples indicate a more even ratio in the United States [42].
Of note, the sample was significantly younger than the whole cohort of young people who first accessed GIDS in the timeframe. This may be owing to young people aged over 17 years old being more likely to be directly referred onto adult gender services. As it would be unethical to collect data from young people not requiring the service, this age group may receive questionnaires less frequently and not be represented in the study sample.
The majority of the sample (61%) were noted as a white ethnicity, which mirrors GIDS referral demographics [6, 43] and indicates that these findings may not be representative of ethnic minority gender-diverse youth, who are underrepresented in this research and across gender services more generally.
It is important to note that the baseline GIDS-GQ is completed after attending up to three appointments in the service, and, despite the questionnaire specifically focussing on experiences prior to service access, these initial appointments may have influenced questionnaire response. Indeed, it is important to note that a sub-set of young people (7.4%) reported no gender-related distress, despite this being a key referral acceptance criteria and an intrinsic part of assessment. It may be that these young people did not consider the six months prior to service attendance and responded in relation to their current experience, after accessing the service and receiving psychosocial support which consequently reduced distress.
Additionally, ‘stayed the same’ responses for social connectedness questions are difficult to quantify in isolation as it is not clear whether the response refers to negative or positive experience. These questions become more meaningful over time, at subsequent response points.