BACKGROUND AND OBJECTIVES

Referrals of transgender and gender-diverse (trans) youth to medical clinics for gender-affirming care have increased. We described characteristics of trans youth in Canada at first referral visit.

METHODS

Baseline clinical and survey data (2017–2019) were collected for Trans Youth CAN!, a 10-clinic prospective cohort of n = 174 pubertal and postpubertal youth <16 years with gender dysphoria, referred for hormonal suppression or hormone therapy, and 160 linked parent-participants. Measures assessed health, demographics, and visit outcome.

RESULTS

Of youth, 137 were transmasculine (assigned female) and 37 transfeminine (assigned male); 69.0% were aged 14 to 15, 18.8% Indigenous, 6.6% visible minorities, 25.7% from immigrant families, and 27.1% low income. Most (66.0%) were gender-aware before age 12. Only 58.1% of transfeminine youth lived in their gender full-time versus 90.1% of transmasculine (P < .001). Although transmasculine youth were more likely than transfeminine youth to report depressive symptoms (21.2% vs 10.8%; P = .03) and anxiety (66.1% vs 33.3%; P < .001), suicidality was similarly high overall (past-year ideation: 34.5%, attempts: 16.8%). All were in school; 62.0% reported strong parental gender support, with parents the most common support persons (91.9%). Two-thirds of families reported external gender-related stressors. Youth had met with a range of providers (68.5% with a family physician). At clinic visit, 62.4% were prescribed hormonal suppression or hormone therapy, most commonly depot leuprolide acetate.

CONCLUSIONS

Trans youth in Canada attending clinics for hormonal suppression or gender-affirming hormones were generally healthy but with depression, anxiety, and support needs.

What’s Known on This Subject:

Transgender youth are increasingly presenting at younger ages for hormonal suppression or gender-affirming medical care; positive outcomes of gender-affirming care have been documented for highly selected clinical samples.

What This Study Adds:

Across 10 clinics in Canada, transgender and nonbinary youth represent a heterogeneous patient population, characterized by high anxiety and depression, strong parental support, and a social context of school and family stressors.

Research on the health of transgender and gender-diverse (trans) people has documented high levels of depression and anxiety,14  suicidal ideation and attempts,47  difficulty accessing primary and emergency health care,810  and discrimination.5,10,11  Studies have demonstrated that gender-affirming medical care (hormonal suppression, estrogen or testosterone therapy) can improve mental health1216  and is safe for adolescents and adults.1719 

It may be possible to avert adverse adult outcomes if trans people accessed gender-affirming medical care, if needed, at younger ages. In particular, hormonal suppression with a gonadotropin-releasing hormone agonist (GnRHa), first used in the Netherlands in the 1980s20  and North America in the 1990s,21,22  may improve adult physical outcomes and decrease gender dysphoria by arresting pubertal development discordant with gender.23  The Dutch Protocol23  consisted of hormonal suppression with fully reversible GnRHa medications started at or after age 12 and puberty induction with estrogen or testosterone at age 16, the age of medical consent in the Netherlands.23  Follow-up analyses revealed improvements in depressive symptoms, behavioral and emotional problems, and general functioning over the course of hormonal suppression,12  and resolution of gender dysphoria with subsequent gender-affirming hormones and surgeries.13 

However, the Dutch cohort sample, in which standardized protocols produced a circumscribed patient population,23  is not representative of the more heterogeneous adolescent patient populations in Canada22,24  or the United States.21,25  Moreover, referrals to youth gender clinics have increased over time internationally,21,2628  and a sex ratio shift now favors transmasculine youth (those assigned female at birth).24,28  Nonbinary identities have become common, and nonbinary youth report challenges in accessing health care.29  Although use of GnRHa, estrogen, and testosterone therapies in trans adolescents is supported by major medical organizations including the American Academy of Pediatrics,3033  ongoing collection of high-quality data is vital to counteract efforts to undermine the medical necessity of gender-affirming care for trans adolescents. Recent literature reviews show limited research on health care experiences34  and mental health and medical outcomes for trans youth receiving hormone therapy.35  Social and family factors have rarely been studied for youth in clinical care, despite the potentially moderating role of supportive parents36,37  and the challenges of parenting a trans child in a transphobic society.3841 

The expansion of Canadian medical clinics for trans and gender-diverse youth presented a unique opportunity for research at a crucial time point. Published research on GnRHa, estrogen, or testosterone therapies for adolescents internationally includes baseline data from only one other prospective multisite cohort study,42  limited Canadian content,22,24  and no published findings using standardized measures for patients’ family and social contexts. In the current article, we describe the gender, demographic, health, and social characteristics of the adolescent trans youth population at the first clinic visit after referral for consideration of hormonal suppression or hormone therapy, providing a baseline for follow-up, and document prescriptions provided at that visit.

Trans Youth CAN! is a 2-year prospective cohort of youth referred to Canadian medical clinics for hormonal suppression or gender-affirming hormone therapy. Participants enrolled between September 2017 and June 2019 at 10 clinics in Halifax, Montreal, Ottawa, Toronto, Hamilton, London, Winnipeg, Calgary, Edmonton, and Vancouver. All clinics have one or more pediatric specialists and links to mental health providers. The study protocol was approved by each institution’s Research Ethics Board (REB).

Inclusion criteria were (1) gender dysphoria,43  (2) age <16 years, (3) pubertal or postpubertal, (4) not previously using GnRHa, estrogen or testosterone therapy other than contraceptives, and (5) enrolled after referral for hormonal suppression or hormones. Recruitment processes differed based on clinic and REB requirements, and did not always allow eligibility prescreening. Clinic staff invited potential participants to contact the research assistant before their appointment; 174 youth participated (163 in English, 11 in French). With youth agreement, 160 matched parents enrolled to provide family and parental data. Informed consent was obtained, including parental and/or guardian consent, when locally required.

Data were from the baseline interviewer-administered youth survey,44  parent and/or caregiver survey,45  and extracts from medical records.46  Detail on each measure is provided as Supplemental Table 1.

Sociodemographics

Demographics were coded from data self-reported by youth in survey interviews.

Gender

Gender identity was collected as open text and a categorical item (male/boy, female/girl, or nonbinary). Youth self-reported ages they experienced discord between identified and assigned gender and began to live in their gender. Legal changes to name and gender marker were reported. Parental report captured types of professional and support persons with whom the youth and family had met to discuss gender. Transmasculine (assigned female at birth) and transfeminine (assigned male) were coded as gender groups for statistical comparisons.

Growth Parameters

Z scores for weight-, height- and BMI-for-age were calculated by using data from the clinical record and the WHO Growth Charts for Canada, 2014 revision.47  Because hormone therapy can affect adult height, z scores were calculated by using both male and female growth curves, reflecting growth relative to birth-assigned sex and gender identity.

Physical and Mental Health

Self-rated physical and mental health questionnaire items came from the Canadian Community Health Survey.48  The 5-item Modified Depression Scale (α = .7924 in our data) captures current depressive symptoms in adolescents, with a dichotomous score encoding probable depression.49  The 5-item Overall Anxiety Severity and Impairment Score (OASIS) (α = .8692) captured past-week anxiety, with a cut-point of ≥8 for probable anxiety disorder.50,51  Past-year self-harm was assessed with 5 items. Lifetime and past-year suicidal ideation and attempts were self-reported by using Canadian Community Health Survey items; substance use was self-reported. Previous or current mental or physical health diagnoses from the clinic or referring provider were extracted from the medical record.

Social Context

Youth self-reported school and living situations, whether they had left home because of family rejection, support sources, and parental support for their gender. Types of group spaces avoided (eg, school, transit) were summed from a checklist. Reduced access to material resources was assessed by using 3 measures: food insecurity, household poverty (Statistics Canada low-income measure [LIM]52 ), and 5-item youth deprivation index. Trans-specific external stressors on families were assessed with the Stressors on Families of Trans Youth Checklist.53 

Clinical Visit Outcome

Prescriptions provided, or reasons for no prescription, were extracted from the medical record.

Data were analyzed by using SAS version 9.4 (SAS Institute, Inc, Cary, NC).54  A SAS macro for World Health Organization Growth Charts for Canada (2014) was used to calculate Z scores.55  Sample weights were derived (see eMethods in Supplemental Materials) to account for variable-length recruitment periods across clinics (mean: 12.9 months; range: 6–22). Individual weights were identical within each clinic (range: 0.5809–2.1301) and summed to the total sample size of 174. Statistical analyses were weighted for inference to the larger patient population.

For the full sample and transmasculine and transfeminine gender subgroups, frequencies were calculated for categorical variables and means and SDs for continuous variables. To compare gender subgroups at α = .05, Rao-Scott χ2 tests were used for proportions and t tests with Satterthwaite estimators of variance for means. Fisher’s exact test was used with unweighted data when expected cell count was <5. Results for sex- or gender-specific measures are presented only for relevant groups.

Of 174 patient participants, 137 were assigned female at birth and 37 were assigned male. Results focus on weighted estimates for the patient population. An estimated 81.2% were transmasculine, and 18.8% transfeminine. A primarily nonbinary identity was reported by 7.8% of transmasculine and 10.5% of transfeminine patients (P = .68). Figure 1 displays age-related gender milestones; patients attended this referral visit an average of 3.9 years after they recognized their gender (SD = 2.6). Table 1 presents demographic and gender characteristics for the full population and gender groups. Of patients under age 16, 69.0% were age 14 or 15, 18.8% were Indigenous, 6.6% were racialized visible minorities, and 25.7% had 1 or more immigrant parents. Approximately half (55.4%) lived in urban environments. Although 84.0% lived in their gender full-time, few had legally changed their name (3.5%) or gender (5.4%). Youth had seen a wide range of providers to discuss gender, most commonly their family physician (68.5%). There were few statistically significant differences between gender groups, although transfeminine youth less frequently lived in their identified gender full-time (58.1% vs 90.1% of transmasculine youth; P < .001).

FIGURE 1

Key gender milestones: transgender and gender-diverse youth <16 years referred to Canadian medical clinics. A, Age when youth realized gender issues. Data for 1 missing. B, Age when youth started living in identified gender. Data for 2 missing, 2 youth were not living in their gender. C. Age at clinic visit for medication.

FIGURE 1

Key gender milestones: transgender and gender-diverse youth <16 years referred to Canadian medical clinics. A, Age when youth realized gender issues. Data for 1 missing. B, Age when youth started living in identified gender. Data for 2 missing, 2 youth were not living in their gender. C. Age at clinic visit for medication.

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TABLE 1

Demographic and Gender Characteristics: Transgender and Gender-Diverse Youth <16 Years Referred to Canadian Medical Clinics

Total (N = 174)Transfemininea (n = 37)Transmasculineb (n = 137)Pc
nWeighted %nWeighted %nWeighted %
Age       .23 
 10–13 y 54 31.0 14 40.6 40 28.7  
 14–15 y 120 69.0 23 59.4 97 71.3  
Ethnoracial backgroundd       .51 
 Indigenous 34 18.8 10.7 30 20.7  
 Non-Indigenous visible minoritye 10 6.6 7.4 6.4  
 Non-Indigenous white 128 74.6 31 81.9 97 72.9  
Immigration background       .49 
 1 or more immigrant parent 44 28.6 12 34.2 32 27.3  
 No immigrant parents 127 71.4 23 65.8 104 72.7  
Living environment       .08 
 City 88 55.4 16 55.4 72 55.4  
 Suburb 59 33.7 11 23.8 48 36.0  
 Rural 27 10.9 10 20.8 17 8.6  
Province of residencef       .80g 
 Alberta 32 15.1 16.6 25 14.8  
 British Columbia 11 9.0 13.0 8.0  
 Manitoba 1.3 0.0 1.6  
 Nova Scotia 11 5.0 2.4 10 5.6  
 Ontario 96 58.7 21 55.4 75 59.5  
 Prince Edward Island 0.5 0.0 0.6  
 Quebec 20 10.4 12.6 15 9.9  
Gender identity       <.001g 
 Male or primarily a boy 126 75.8 2.4 125 92.2  
 Female or primarily a girl 32 15.9 32 87.1 0.0  
 Nonbinaryg 14 8.3 10.5 11 7.8  
Time since first aware of gender issues       .76 
 <1 y 1.7 3.1 1.4  
 1 y 22 12.7 18.9 17 11.3  
 2 y 29 17.4 17.8 24 17.3  
 3-4 y 62 38.4 11 30.9 51 40.1  
 5+ y 57 29.9 14 29.3 43 30.0  
Living in their identified gender       <.001h 
 All the time 146 84.0 24 58.1 122 90.1  
 Some of the time 24 15.2 11 37.8 13 9.9  
 Not at all 0.8 4.1 0.0  
Legal name changed       .79 
 Yes 3.5 3.6 3.5  
 In process 21 13.6 10.2 17 14.4  
 No 143 82.9 31 86.2 112 82.1  
Changed birth certificate gender       .99 
 Yes 12 5.4 5.4 5.4  
 In process 16 11.3 10.4 12 11.3  
 No 142 83.3 19 84.2 113 83.3  
Discussed gender, before clinici        
 Family physician 108 68.5 23 68.2 85 68.6 .97 
 Pediatrician or adolescent medicine 52 31.0 13 33.4 39 30.5 .76 
 Endocrinologist 10 4.6 7.2 3.9 .38 
 Nurse practitioner 3.5 0.0 4.4 .59g 
 Psychologist or psychiatrist 82 45.6 18 46.2 64 45.4 .94 
 Counselor, elder, religious leader 81 46.5 17 50.7 64 45.6 .62 
 Community group 28 16.6 17.2 20 16.5 .91 
Total (N = 174)Transfemininea (n = 37)Transmasculineb (n = 137)Pc
nWeighted %nWeighted %nWeighted %
Age       .23 
 10–13 y 54 31.0 14 40.6 40 28.7  
 14–15 y 120 69.0 23 59.4 97 71.3  
Ethnoracial backgroundd       .51 
 Indigenous 34 18.8 10.7 30 20.7  
 Non-Indigenous visible minoritye 10 6.6 7.4 6.4  
 Non-Indigenous white 128 74.6 31 81.9 97 72.9  
Immigration background       .49 
 1 or more immigrant parent 44 28.6 12 34.2 32 27.3  
 No immigrant parents 127 71.4 23 65.8 104 72.7  
Living environment       .08 
 City 88 55.4 16 55.4 72 55.4  
 Suburb 59 33.7 11 23.8 48 36.0  
 Rural 27 10.9 10 20.8 17 8.6  
Province of residencef       .80g 
 Alberta 32 15.1 16.6 25 14.8  
 British Columbia 11 9.0 13.0 8.0  
 Manitoba 1.3 0.0 1.6  
 Nova Scotia 11 5.0 2.4 10 5.6  
 Ontario 96 58.7 21 55.4 75 59.5  
 Prince Edward Island 0.5 0.0 0.6  
 Quebec 20 10.4 12.6 15 9.9  
Gender identity       <.001g 
 Male or primarily a boy 126 75.8 2.4 125 92.2  
 Female or primarily a girl 32 15.9 32 87.1 0.0  
 Nonbinaryg 14 8.3 10.5 11 7.8  
Time since first aware of gender issues       .76 
 <1 y 1.7 3.1 1.4  
 1 y 22 12.7 18.9 17 11.3  
 2 y 29 17.4 17.8 24 17.3  
 3-4 y 62 38.4 11 30.9 51 40.1  
 5+ y 57 29.9 14 29.3 43 30.0  
Living in their identified gender       <.001h 
 All the time 146 84.0 24 58.1 122 90.1  
 Some of the time 24 15.2 11 37.8 13 9.9  
 Not at all 0.8 4.1 0.0  
Legal name changed       .79 
 Yes 3.5 3.6 3.5  
 In process 21 13.6 10.2 17 14.4  
 No 143 82.9 31 86.2 112 82.1  
Changed birth certificate gender       .99 
 Yes 12 5.4 5.4 5.4  
 In process 16 11.3 10.4 12 11.3  
 No 142 83.3 19 84.2 113 83.3  
Discussed gender, before clinici        
 Family physician 108 68.5 23 68.2 85 68.6 .97 
 Pediatrician or adolescent medicine 52 31.0 13 33.4 39 30.5 .76 
 Endocrinologist 10 4.6 7.2 3.9 .38 
 Nurse practitioner 3.5 0.0 4.4 .59g 
 Psychologist or psychiatrist 82 45.6 18 46.2 64 45.4 .94 
 Counselor, elder, religious leader 81 46.5 17 50.7 64 45.6 .62 
 Community group 28 16.6 17.2 20 16.5 .91 
a

Includes those assigned male at birth and who identify as girls or a nonbinary identity.

b

Includes those assigned female at birth and who identify as boys or a nonbinary identity.

c

Unless otherwise specified, P values are for differences between transfeminine and transmasculine patients, using Rao-Scott χ2 tests on weighted data.

d

Coded to match Statistics Canada categories of Indigenous, visible minority, and white. Non-white, Non-Indigenous ethnoracial backgrounds were indicated by the following numbers of participants: 7 Black Canadian or African-American, 2 Black African, 4 Latin American, 4 East Asian, 1 Indo-Caribbean, 4 Black Caribbean, 2 Middle Eastern, and 1 Southeast Asian (participants could indicate more than one).

e

The Canadian government defines visible minorities as “persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour.”82 

f

No participants were from other provinces or territories.

g

Response option was “non-binary or something other than male or female.”

h

Unable to produce valid χ2 tests due to expected cell counts <5. Fisher exact tests for unweighted data substituted.

i

Most clinics also require youth to meet in-clinic with other providers (eg, psychologist or psychiatrist) before referral for hormones, and these providers are likely not included in these numbers. Data are derived from parent report (n = 160 biological, step, foster, or other parent type).

Health findings are presented in Table 2. Growth parameters reflected sex assigned at birth, with puberty effects apparent in comparisons with identified-gender standards; when analyzed on the female standard, mean height-for-age z score for transfeminine youth was 1.40 (SD = 0.85). Of youth, 74.9% reported good to excellent physical health, in contrast with 45.5% for mental health. Anxiety was the most common previous diagnosis (40.2%), and 65.2% had OASIS scores consistent with a probable anxiety disorder. Past-year self-harm (67.6%) and suicidal ideation (34.5%) were common, whereas physical health diagnoses were not. Most youth did not use substances. Although transmasculine youth were more likely to report symptoms consistent with depression (21.2% vs 10.8%; P = .03) and anxiety (66.1% vs 33.3%; P < .001), lifetime and past-year suicidal ideation or attempts were common regardless of gender. Transmasculine youth were more likely to report past-year “other” drug use, but gender groups did not differ statistically significantly for other substances. Past diagnoses differed significantly only for attention-deficit/hyperactivity disorder (ADHD) and autism.

TABLE 2

Health Characteristics: Transgender and Gender-Diverse Youth <16 Years Referred to Canadian Medical Clinics

Total (N = 174)Transfemininea (n = 37)Transmasculineb (n = 137)Pc
Growth parameters, for sex at birth,d weighted mean (SD)     
 Height-for-age z score — 0.49 (0.69) 0.31 (0.81) .28 
 BMI-for-age z score — 0.45 (1.01) 0.71 (2.00) .29 
 Wt-for-age z score — 0.57 (0.88) 0.66 (1.16) .71 
Growth parameters, for gender,e weighted mean (SD)     
 Height-for-age z score — 1.40 (0.85) −0.41 (0.93) <.001 
 BMI-for-age z score — 0.29 (0.96) 0.89 (1.25) .02 
 Wt-for-age z score — 0.84 (0.88) 0.43 (1.22) .07 
Self-assessed physical health, n (weighted %)    .37 
 Excellent or very good (1 or 2) 78 (40.5) 18 (49.9) 60 (38.3)  
 Good 61 (34.4) 13 (35.0) 48 (34.3)  
 Fair or poor 33 (25.2) 5 (15.1) 28 (27.5)  
Self-assessed mental health, n (weighted %)    .06 
 Excellent or very good (1 or 2) 43 (22.8) 16 (38.8) 27 (19.0)  
 Good 42 (22.7) 8 (23.4) 34 (22.6)  
 Fair or poor 88 (54.5) 13 (37.7) 75 (58.4)  
Depression (MDS often or always ≥4), n (weighted %) 33 (19.3) 4 (7.6) 29 (22.0) .03 
Probably anxiety (OASIS ≥ 8),fn (weighted %) 94 (65.2) 10 (35.0) 84 (71.4) <.001 
Self-harm, past year, n (weighted %) 110 (67.6) 18 (61.5) 92 (69.0) .43 
Suicidal ideation, ever, n (weighted %) 95 (58.1) 19 (58.8) 76 (58.0) .93 
Suicidal ideation, past year, n (weighted %) 56 (34.5) 11 (35.1) 45 (34.4) .95 
Suicide attempt, ever, n (weighted %) 53 (36.0) 9 (30.8) 44 (37.3) .55 
Suicide attempt, past year, n (weighted %) 24 (16.8) 4 (12.4) 20 (17.9) .52 
Substance use, n (weighted %)     
 Smoking, sometimes or daily 14 (12.2) 1 (6.5) 13 (13.5) .44 
 Vaping, sometimes or daily 15 (20.2) 2 (4.1) 13 (13.7) .08 
 Binge drinking, weekly or more 4 (2.9) 1 (2.3) 3 (3.0) .81 
 Marijuana, any past year 29 (19.9) 2 (8.8) 27 (22.5) .18 
 Other drug, any past year 15 (10.5) 0 (0.0) 15 (13.0) .04g 
Diagnoses,hn (weighted %)     
 Anxiety 75 (40.2) 11 (25.9) 64 (43.5) .06 
 Depression 58 (32.0) 7 (19.4) 51 (34.9) .12 
 ADHD 39 (23.3) 12 (38.7) 27 (19.8) .04 
 Autism spectrum 10 (6.0) 7 (23.4) 3 (1.9) <.001 
 Learning disability 7 (4.8) 1 (6.5) 6 (4.4) .72 
 OCD 5 (4.2) 0 (0.0) 5 (5.1) .59g 
 PTSD 3 (1.9) 0 (0.0) 3 (2.4) 1.00g 
 Otheri 42 (25.2) 10 (30.9) 32 (23.9) .47 
Total (N = 174)Transfemininea (n = 37)Transmasculineb (n = 137)Pc
Growth parameters, for sex at birth,d weighted mean (SD)     
 Height-for-age z score — 0.49 (0.69) 0.31 (0.81) .28 
 BMI-for-age z score — 0.45 (1.01) 0.71 (2.00) .29 
 Wt-for-age z score — 0.57 (0.88) 0.66 (1.16) .71 
Growth parameters, for gender,e weighted mean (SD)     
 Height-for-age z score — 1.40 (0.85) −0.41 (0.93) <.001 
 BMI-for-age z score — 0.29 (0.96) 0.89 (1.25) .02 
 Wt-for-age z score — 0.84 (0.88) 0.43 (1.22) .07 
Self-assessed physical health, n (weighted %)    .37 
 Excellent or very good (1 or 2) 78 (40.5) 18 (49.9) 60 (38.3)  
 Good 61 (34.4) 13 (35.0) 48 (34.3)  
 Fair or poor 33 (25.2) 5 (15.1) 28 (27.5)  
Self-assessed mental health, n (weighted %)    .06 
 Excellent or very good (1 or 2) 43 (22.8) 16 (38.8) 27 (19.0)  
 Good 42 (22.7) 8 (23.4) 34 (22.6)  
 Fair or poor 88 (54.5) 13 (37.7) 75 (58.4)  
Depression (MDS often or always ≥4), n (weighted %) 33 (19.3) 4 (7.6) 29 (22.0) .03 
Probably anxiety (OASIS ≥ 8),fn (weighted %) 94 (65.2) 10 (35.0) 84 (71.4) <.001 
Self-harm, past year, n (weighted %) 110 (67.6) 18 (61.5) 92 (69.0) .43 
Suicidal ideation, ever, n (weighted %) 95 (58.1) 19 (58.8) 76 (58.0) .93 
Suicidal ideation, past year, n (weighted %) 56 (34.5) 11 (35.1) 45 (34.4) .95 
Suicide attempt, ever, n (weighted %) 53 (36.0) 9 (30.8) 44 (37.3) .55 
Suicide attempt, past year, n (weighted %) 24 (16.8) 4 (12.4) 20 (17.9) .52 
Substance use, n (weighted %)     
 Smoking, sometimes or daily 14 (12.2) 1 (6.5) 13 (13.5) .44 
 Vaping, sometimes or daily 15 (20.2) 2 (4.1) 13 (13.7) .08 
 Binge drinking, weekly or more 4 (2.9) 1 (2.3) 3 (3.0) .81 
 Marijuana, any past year 29 (19.9) 2 (8.8) 27 (22.5) .18 
 Other drug, any past year 15 (10.5) 0 (0.0) 15 (13.0) .04g 
Diagnoses,hn (weighted %)     
 Anxiety 75 (40.2) 11 (25.9) 64 (43.5) .06 
 Depression 58 (32.0) 7 (19.4) 51 (34.9) .12 
 ADHD 39 (23.3) 12 (38.7) 27 (19.8) .04 
 Autism spectrum 10 (6.0) 7 (23.4) 3 (1.9) <.001 
 Learning disability 7 (4.8) 1 (6.5) 6 (4.4) .72 
 OCD 5 (4.2) 0 (0.0) 5 (5.1) .59g 
 PTSD 3 (1.9) 0 (0.0) 3 (2.4) 1.00g 
 Otheri 42 (25.2) 10 (30.9) 32 (23.9) .47 

MDS, Modified Depression Scale; OCD, obsessive compulsive disorder; PTSD, posttraumatic stress disorder; —, not applicable.

a

Includes those assigned male at birth and who identify as girls or a nonbinary identity.

b

Includes those assigned female at birth and who identify as boys or a nonbinary identity.

c

Unless otherwise specified, P values for continuous variables are from weighted t tests and for categorical variables are from Rao-Scott χ2 tests using weighted data. Tests are for differences between transfeminine and transmasculine participants.

d

Based on the WHO Growth Charts for Canada, 2014 revision. Based on data from 31 transfeminine and 108 transmasculine youth.

e

Growth parameters also shown by identified gender, because one goal of hormonal suppression at puberty is to bring adult height and size closer to distributions for the identified gender.

f

Asked only of participants aged 12 y and older.

g

Unable to produce valid χ2 tests due to expected cell counts <5. Fisher exact tests for unweighted data substituted.

h

Diagnosis specifically extracted, but with fewer than 3 reports were not shown: polycystic ovary disease (1 case), personality disorder (1), eating disorder (0), and intersex or differences in sex development (0).

i

Other diagnoses included those not specifically coded in our case report form, eg, gastrointestinal condition, atopic conditions (eg, eczema), oppositional defiant disorder, parent-child relationship issues, musculoskeletal condition, substance use disorder, and endocrine disorder.

Social context results are presented in Table 3. All youth were in school, with 3.2% homeschooled; 12.9% attended religious school. Household income was below Statistics Canada’s LIM for 27.2%, as reflected in proportions without access to essential resources or food security. Almost two-thirds (62.0%) reported strong support for their gender identity and expression from all parents, and 96.0% lived with parents. Of families, 64.3% experienced at least one external stressor related to the youth’s gender, most commonly school involvement (41.0%), unwanted parenting advice from friends and family (31.2%), and friends’ parents barring them spending time with the youth (22.7%). Most youth reported avoiding group spaces. Common sources of support included parents (91.9%), real-life (off-line) friends (85.8%), and nontrans friends (80.5%). Social context differed for gender groups. Transfeminine youth were more likely to attend a religious school, less likely to experience food insecurity or avoid group spaces, and had families less likely to experience trans-specific external stressors.

TABLE 3

Social Context: Transgender and Gender-Diverse Youth <16 Years Referred to Canadian Medical Clinics

Total (N = 174)Transfemininea (n = 37)Transmasculineb (n = 137)Pc
nWeighted %nWeighted %nWeighted %
School, funding type       .23 
 Public school 162 91.6 32 83.8 130 93.4  
 Private school 5.2 11.6 3.8  
 Homeschooled 3.2 4.6 2.8  
 Not in school 0.0 0.0 0.0  
School, religious-affiliated 21 12.9 30.4 13 8.9 .005 
Living situation       .62d 
 With birth/adoptive parents 166 96.0 36 97.7 130 95.6  
 With foster parents 1.7 2.3 1.5  
 Group home 0.3 0.0 0.4  
 With other relatives 2.0 0.0 2.5  
 By self or with friends 0.0 0.0 0.0  
Had to move because others had problem with their gender 4.4 1.8 5.0 .32 
Avoidance of group spaces       <.001 
 Not avoiding 28 14.5 14 38.8 14 8.9  
 Avoiding 1-2 types of spaces 26 13.7 22.7 18 11.6  
 Avoiding 3+ types of spaces 119 71.8 15 38.5 104 79.5  
Food insecurity 23 13.7 3.8 21 15.8 .03 
Low-income household (LIM)e 40 27.1 31.4 32 26.1 .61 
Deprivation, No. essential resources availablef       .96d 
 5 91 46.5 20 50.5 71 45.5  
 4 30 17.4 14.0 23 18.2  
 3 28 18.6 14.0 23 19.7  
 2 14 10.7 14.9 10 9.7  
 1 5.0 6.5 4.6  
 0 1.8 0.0 2.2  
Parental support for genderg       .23 
High for all parents 110 62.0 26 72.2 84 59.6  
Moderate or mixed 57 38.0 10 27.8 47 40.4  
External stressors on the familyh       .04d 
 No stressors reported 60 35.7 18 50.9 42 32.1  
 1 39 23.1 13.6 34 25.3  
 2-4 43 22.3 12 30.9 31 20.3  
 5-9 27 17.4 4.6 25 20.4  
 10+ 1.5 0.0 1.9  
Sources of support        
 Parent(s) 160 91.9 36 98.2 124 90.4 .06 
 Real-life (off-line) friends 149 85.8 31 82.0 118 86.7 .55 
 Nontrans friends 132 80.5 25 69.7 107 83.0 .09 
 Trans friends 93 56.0 15 41.4 78 59.4 .08 
 Sibling(s) 91 55.0 25 67.2 66 52.2 .16 
 Online friends 80 49.6 20 53.1 60 48.8 .68 
 Teacher(s) 79 48.0 16 46.0 63 48.5 .81 
 Mental health provider 81 48.0 15 35.0 66 51.0 .11 
 Extended family 76 44.1 17 47.1 59 43.4 .72 
 Classmates 70 41.7 21 59.3 49 37.6 .04 
 LGBT2Q community 70 41.5 15 35.7 55 42.8 .48 
 Regular doctor 66 37.1 13 36.8 53 37.2 .97 
 Extracurricular leaders 28 18.6 14.2 22 19.6 .46 
 Cultural of ethnic community 6.9 4.6 7.4 .55 
 Faith community 2.6 4.6 2.2 .42 
 Otheri 18 9.4 1.8 17 11.2 .04 
Total (N = 174)Transfemininea (n = 37)Transmasculineb (n = 137)Pc
nWeighted %nWeighted %nWeighted %
School, funding type       .23 
 Public school 162 91.6 32 83.8 130 93.4  
 Private school 5.2 11.6 3.8  
 Homeschooled 3.2 4.6 2.8  
 Not in school 0.0 0.0 0.0  
School, religious-affiliated 21 12.9 30.4 13 8.9 .005 
Living situation       .62d 
 With birth/adoptive parents 166 96.0 36 97.7 130 95.6  
 With foster parents 1.7 2.3 1.5  
 Group home 0.3 0.0 0.4  
 With other relatives 2.0 0.0 2.5  
 By self or with friends 0.0 0.0 0.0  
Had to move because others had problem with their gender 4.4 1.8 5.0 .32 
Avoidance of group spaces       <.001 
 Not avoiding 28 14.5 14 38.8 14 8.9  
 Avoiding 1-2 types of spaces 26 13.7 22.7 18 11.6  
 Avoiding 3+ types of spaces 119 71.8 15 38.5 104 79.5  
Food insecurity 23 13.7 3.8 21 15.8 .03 
Low-income household (LIM)e 40 27.1 31.4 32 26.1 .61 
Deprivation, No. essential resources availablef       .96d 
 5 91 46.5 20 50.5 71 45.5  
 4 30 17.4 14.0 23 18.2  
 3 28 18.6 14.0 23 19.7  
 2 14 10.7 14.9 10 9.7  
 1 5.0 6.5 4.6  
 0 1.8 0.0 2.2  
Parental support for genderg       .23 
High for all parents 110 62.0 26 72.2 84 59.6  
Moderate or mixed 57 38.0 10 27.8 47 40.4  
External stressors on the familyh       .04d 
 No stressors reported 60 35.7 18 50.9 42 32.1  
 1 39 23.1 13.6 34 25.3  
 2-4 43 22.3 12 30.9 31 20.3  
 5-9 27 17.4 4.6 25 20.4  
 10+ 1.5 0.0 1.9  
Sources of support        
 Parent(s) 160 91.9 36 98.2 124 90.4 .06 
 Real-life (off-line) friends 149 85.8 31 82.0 118 86.7 .55 
 Nontrans friends 132 80.5 25 69.7 107 83.0 .09 
 Trans friends 93 56.0 15 41.4 78 59.4 .08 
 Sibling(s) 91 55.0 25 67.2 66 52.2 .16 
 Online friends 80 49.6 20 53.1 60 48.8 .68 
 Teacher(s) 79 48.0 16 46.0 63 48.5 .81 
 Mental health provider 81 48.0 15 35.0 66 51.0 .11 
 Extended family 76 44.1 17 47.1 59 43.4 .72 
 Classmates 70 41.7 21 59.3 49 37.6 .04 
 LGBT2Q community 70 41.5 15 35.7 55 42.8 .48 
 Regular doctor 66 37.1 13 36.8 53 37.2 .97 
 Extracurricular leaders 28 18.6 14.2 22 19.6 .46 
 Cultural of ethnic community 6.9 4.6 7.4 .55 
 Faith community 2.6 4.6 2.2 .42 
 Otheri 18 9.4 1.8 17 11.2 .04 
a

Includes those assigned male at birth and who identify as girls or a nonbinary identity.

b

Includes those assigned female at birth and who identify as boys or a nonbinary identity.

c

Unless otherwise specified, P values are from Rao-Scott χ2 tests using weighted data. Tests are for differences between transfeminine and transmasculine participants.

d

Unable to produce valid χ2 tests due to expected cell counts <5. Fisher exact tests for unweighted data substituted.

e

Coded using Statistics Canada’s LIM, using parent/caregiver-report data.

f

Number of essential resources to which youth always had access (of 5).

g

Youth could report on up to 4 parents, stepparents, foster parents, or guardians. No youth had low parental support, although data were missing for 7.

h

Stressors on Families of Trans Youth Checklist. Of 16 possible stressors, the maximum reported by youth was 13.

i

Other sources of support included primarily pets and romantic partners.

Table 4 presents medications prescribed. An estimated 62.4% received a prescription, with no difference by gender group (P = .45). Depot leuprolide acetate was the most common, given alone to 53.0% of transfeminine and 45.2% of transmasculine patients, or prescribed with testosterone (1.7% of transmasculine) or estrogen (6.6% of transfeminine). Of 46 participants not prescribed hormones at this visit, physician’s reason was included in 36 records. The most common reason was the clinic protocol of not prescribing at first visit. Additional reasons included being younger than the clinic’s age limit for estrogen or testosterone, unconfirmed gender dysphoria, waiting for information (bloodwork, pregnancy test, psychiatric assessment), waiting for parental consent, no desire for medical transition, and current medication working well (eg, continuous oral contraceptives suppressing menstruation). Youth’s reasons included fear of needles, not interested or uncertain on timing, waiting for additional medical care (eg, psychiatric, fertility preservation), and wanting time to consider options or discuss with family doctor. Parent’s reasons included disagreement with therapy, existing medications working, belief that gender dysphoria is a phase, and needing to confirm another parent’s consent. No physician, youth, or parent indicated cost as a reason for not starting medication.

TABLE 4

Medications Prescribed: Transgender and Gender-Diverse Youth <16 Years Referred to Canadian Medical Clinics

Total (N = 174)Transfemininea (n = 37)Transmasculineb (n = 137)Pc
nWeighted %nWeighted %nWeighted %
Were medications prescribed at visit       .45 
 Yes 128 62.4 29 69.2 99 60.8  
 No 46 37.6 30.8 38 39.2  
Medications prescribedd        
 Leuprolide acetate — — 25 53.0 76 45.2 — 
 Testosterone — — — — 16 11.7 — 
 Leuprolide acetate + testosterone — — — — 1.7 — 
 Leuprolide acetate + estrogen — — 6.6 — — — 
 Spironolactone — — 9.5 — — — 
 Continuous oral contraceptives — — — — 1.0 — 
 Medroxyprogesterone acetate — — — — 1.3 — 
 IUD — — — — 0.0 — 
Total (N = 174)Transfemininea (n = 37)Transmasculineb (n = 137)Pc
nWeighted %nWeighted %nWeighted %
Were medications prescribed at visit       .45 
 Yes 128 62.4 29 69.2 99 60.8  
 No 46 37.6 30.8 38 39.2  
Medications prescribedd        
 Leuprolide acetate — — 25 53.0 76 45.2 — 
 Testosterone — — — — 16 11.7 — 
 Leuprolide acetate + testosterone — — — — 1.7 — 
 Leuprolide acetate + estrogen — — 6.6 — — — 
 Spironolactone — — 9.5 — — — 
 Continuous oral contraceptives — — — — 1.0 — 
 Medroxyprogesterone acetate — — — — 1.3 — 
 IUD — — — — 0.0 — 

IUD, intrauterine device; —, not applicable.

a

Includes those assigned male at birth and who identify as girls or a nonbinary identity.

b

Includes those assigned female at birth and who identify as boys or a nonbinary identity.

c

Unless otherwise indicated, P values are from Rao-Scott χ2 tests using weighted data. Tests are for differences between transfeminine and transmasculine participants.

d

All medication combinations listed separately, eg, “testosterone” indicates testosterone only.

An estimated 18.8% of clinic youth under 16 were transfeminine, similar to 18% observed for 14- to 18-year-olds in a national community survey56  and 23% in a single-clinic records review,24  but different from the higher transfeminine proportions among older youth56  and approximately equal proportions among older youth and adults.57  This may be in part explained by earlier puberty for transmasculine youth. Prepubertal nonnormative gender expression in assigned-female children is often supported,58,59  and pressure to rapidly conform to feminine norms may contribute to urgent need for clinical services at puberty. In contrast, transfeminine nonconforming youth are often disapproved of, victimized, or unsupported60,61 ; transmisogyny (which penalizes perceived femininity in those assigned male) may underlie such findings,62  delaying coming out and acceptance.

Indigenous identities were indicated by 18.8%; as with trans community surveys in Canada,56,63  this is higher than the 4.9% in the general population.64  In contrast, 6.6% were classified as visible minorities, versus 27.2% among Canada’s school-aged population,65  raising questions for further exploration regarding study participation, timing of identity development, parental disclosure, pathways of care seeking, or access to care. Our findings also raise questions regarding access to care at younger ages, as youth had higher levels of parental gender support than community samples.37  Youth from low-income families were well-represented, with 27.1% in households below the LIM, versus 17.0% of Canadians under age 18.66  Low income in our study was not associated with ethnoracial group (P = .35) but was associated with urban residence (P = .01).

Consistent with existing reports,67  mental health diagnoses were common. Highest were depression and anxiety, with prevalence similar to clinical data published on trans youth ages 10 to 17.68  Personality disorders were not found to be relevant comorbidities, consistent with existing clinical samples.69  Prevalences of self-harm, suicidal ideation, and suicide attempts observed were elevated compared with published estimates for cisgender youth.6,68  Past-year suicide attempt (16.8%) was similar to findings for Ontario trans youth age 16-24 (19%; 95% confidence interval: 10–30)70  but lower than the 36.1% observed in a national trans youth survey.6  These findings highlight the need for ongoing mental health supports to address psychological distress in younger patient populations; such supports differ from the psychological assessment process often required to access care. Community samples show lower suicide risk in older trans youth and adults,6,70  with reductions associated with social, legal, and medical gender affirmation.5,71 

Validated self-report symptom indicators of anxiety (71.4% vs 35.0%; P < .001) and depression (22.0% vs 7.6%; P = .03) were statistically higher among transmasculine youth, and diagnoses approached significance. Conversely, ADHD and autism spectrum disorder diagnoses were more likely in transfeminine youth (38.7% vs 19.8%; P = .04 and 23.4% vs 1.9%; P < .001). Findings mirror observations of a higher prevalence of neurodevelopmental disorders in clinical samples of trans youth, especially transfeminine youth.7275  and align with existing gender norms favoring ADHD and autism being diagnosed earlier and more often in those assigned male. The proportions of transmasculine and transfeminine youth who indicated a nonbinary identity did not differ (P = .68). Our findings of transmasculine disadvantage on some social context and mental health factors may be partially explained by the higher proportion of transmasculine youth living in their gender (90.1% vs 58.1%), thus experiencing others’ responses and negotiating access to gendered spaces and activities.

Hormonal suppression is most effective if initiated during puberty. Although youth identified gender issues at young ages, 69.0% were not seen for medications until age 14 or 15, and in clinics many youth are older at referral. This represents a missed opportunity to achieve the physiologic and psychological advantages hormonal suppression was designed to provide.23  Our finding of high height-for-age z scores for transfeminine youth relative to female reference ranges suggests missed intervention opportunities for youth who may desire shorter stature. Estimates that 0.6% of the adult population is transgender,76  76% will need gender-affirming medical care,77  and ∼80% recognized their gender before age 14,57,78  suggest that at age 14 ∼1 in every 277 youth is aware they are trans and will need gender-affirming care, although few are accessing care.

Finally, the high proportion of youth from low-income households, with food insecurity, or lacking access to essential resources indicates that these youth do access care in Canada. Although no participant gave cost as a reason for not starting medication, Canada’s “universal” health care system has cross-provincial variability in pharmacare (universal versus age-limited) with gaps in coverage. If needed at older ages, gender-affirming chest and genital surgeries would be publicly funded, although some may need additional supports for travel or aftercare costs. These findings support the need for administrative and financial supports to help patients and their families navigate care.

The study population is likely representative of youth <16 years of age referred for hormonal suppression or hormone therapy to specialized medical clinics in Canada. We included all major clinics providing such care during the study period. Although recruitment period varied by clinic, we weighted results to remove this potential bias. Some community clinics, family doctors, and general pediatricians have begun providing hormonal suppression for younger youth, including those in rural areas, often in consultation with subspecialists; such youth are not represented in this study.

Findings are from medical clinic-referred pubertal and postpubertal trans youth under age 16, and interpretation should be limited to this group. The majority of youth receiving gender-affirming medical care are older21,22,24,25  and may attend without parents or be treated under adult protocols. Our study population differs from two more frequently studied groups: broader trans and gender-diverse communities and psychology clinic samples of gender-diverse children. The former includes those not needing gender-affirming medical care, or who identify as trans at later ages,56,57  whereas the latter includes a more heterogeneous group of generally prepubertal children, including many who do not meet diagnostic criteria or will not later seek or be referred for gender-affirming medical care.7981 

Because some REBs did not allow eligibility prescreening, we were unable to calculate participation rate or examine differential participation across subgroups. Sample frequencies for assigned sex were comparable to those from a single-clinic records review,24  but we were unable to similarly compare ethnoracial background. Although strategies to reduce participation barriers were implemented (parking, honoraria), participants may underrepresent rural patients. Responses to survey items regarding providers seen “prior to being seen at this clinic” may exclude those within the same clinic. One clinic may have less complete data on previous diagnoses, because an extended mental health waitlist resulted in high-risk patients being seen for hormonal suppression first. Finally, small subgroups limited statistical power (eg, (n = 37 transfeminine; n = 10 visible minority), although based on previous research and treatment differences we did make gender group comparisons.

We presented baseline youth characteristics from Trans Youth CAN!, the first prospective cohort study of trans and gender-diverse youth referred to medical clinics for hormonal suppression or gender-affirming hormone care in Canada. Findings are from patients under age 16, a group for whom hormonal suppression is a common therapy and outcomes are rarely studied. Future analyses will present follow-up data over a two-year period.

The Trans Youth CAN! Study Team would like to thank the trans youth and their families who have generously shared their time and experience with us. The authors acknowledge the contributions of the local site teams to participant recruitment, including site leads Ashley Vandermorris, Robert Stein, Natasha Johnson, and Jennifer Ducharme.

Dr Bauer conceptualized and designed the study, designed the data collection instruments, conducted the statistical analyses, drafted the majority of the initial manuscript, and reviewed and revised the manuscript; Drs Pacaud and Ghosh conceptualized and designed the study, collected data, contributed to manuscript drafting, and reviewed and revised the manuscript; Drs Feder, Metzger, and Lawson conceptualized and designed the study, designed the data collection instruments, collected data, and reviewed and revised the manuscript; Drs Couch and Mokashi conceptualized and designed the study, collected data, and reviewed and revised the manuscript; Ms Gale conceptualized and designed the study and reviewed and revised the manuscript; Dr Gotovac designed the data collection instruments, contributed to manuscript drafting, and reviewed and revised the manuscript; Dr Speechley conceptualized and designed the study, designed the data collection instruments, contributed to manuscript drafting, and reviewed and revised the manuscript; Dr Temple Newhook designed the data collection instruments, and reviewed and revised the manuscript; Drs Raiche, Pullen Sansfaçon, and Susset conceptualized and designed the study, contributed to manuscript drafting, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Canadian Institutes for Health Research (MOP-148641). Canadian Institutes of Health Research played no role in the design or conduct of the study.

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Competing Interests

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Supplementary data