Older Age of Gender-Affirming Care Initiation Associated with Poorer Mental Health, Canadian Study Finds

Symbol of a transgender and female and male gender symbols drawn with chalk on a black background
Does a relationship exist between the age of presentation to gender-affirming medical care and mental health difficulties?

Study data published in Pediatrics suggest that older age at initiation of gender-affirming medical care (GAMC) is associated with poorer psychiatric health. In a sample of youth with gender dysphoria who underwent GAMC, those who were ≥15 years of age reported significantly greater rates of depression, self-harm, suicide ideation, and suicide attempt than those who were <15 years of age.

This study was conducted at the Transgender Youth Clinic at The Hospital for Sick Children in Toronto, Canada. The clinic provides GAMC to youth with gender dysphoria who are <18 years of age. Patients with initial clinic visits between October 2013 and June 2016 or August 2017 and June 2018 were eligible for inclusion. Demographic and clinical data were extracted from medical records. Pubertal stage and gender history were also ascertained. The primary outcomes were mental health conditions determined by patient or caregiver reports. Psychoactive medication use, suicide ideation, self-harm, and suicide attempt were also recorded. In analyses, patients were stratified by age: younger presenting youth (YPY; <15 years) vs older presenting youth (OPY; ≥15 years). The cut-off age was selected to ensure that the majority of OPY had experienced pubertal development. Logistic regression was also performed to identify correlates of mental health outcomes.

The study cohort comprised 300 patients: 116 YPY and 184 OPY. YPY presented to the clinic at a median age of 13.9 years (interquartile range [IQR], 12.9-14.5). OPY presented to the clinic at a median age of 16.3 years (IQR, 15.6-16.8). Median (IQR) age of recognition of gender incongruence was significantly younger among YPY compared to OPY (5.8 [3.0-11.0] vs 9.0 [5.0-13.0] years; P <.001). Median (IQR) age of coming out about gender identity (12.0 [11.0-13.0] vs 15.0 [13.0-15.0] years) and undergoing social transition (13.0 [12.0-13.4] vs 15.0 [14.0-16.0] years) was also significantly younger with YPY compared to OPY (both P <.001). However, YPY and OPY waited a similar amount of time to come out (4.5 vs 4.3 years) and reported similar intervals between recognition of gender incongruence and first clinic visit (7.4 vs 6.8 years) (both P >.05).

At the first clinic visit, 78% of all youth reported ≥1 mental health problem. Depressive and anxiety disorders were reported by 40.0% and 44.3% of the total sample, respectively. A total of 14.0% had attempted suicide, and 31.3% were currently taking a psychoactive medication. In regression models, OPY were significantly more likely to experience depression (odds ratio [OR], 5.49; 95% CI, 1.14-26.32) and anxiety (OR, 4.18; 95% CI, 1.22-14.49) compared to YPY. Youth who were assigned female at birth were more likely to report self-harm compared to those who were assigned male at birth (OR, 3.41; 95% CI, 1.42-8.19). With each 1-year increase of age at clinic presentation, the odds of psychoactive medication use increased by 1.31 (95% CI, 1.05-1.63).

This study has some limitations. As a cross-sectional design was utilized, associations but not cause and-effect relationships were able to be identified. Also, some youth were unable to recall the timing of gender history events. In addition, the study included a small proportion of youth in early puberty, some of whom did not have documented pubertal examinations. Finally, the generalizability of the findings may be limited by the demographics of the population.

These data underscore an unmet need for mental health care among older youth and youth in later pubertal stage who seek GAMC. Study generalizability may be limited by clinic demographics; the majority of patients were white (72%) and assigned female at birth (75.0%). Additionally, these patients represent youth who are willing and able to seek help at a transgender health clinic, which likely represent only a fraction of those with gender dysphoria. Even so, data strongly suggest a correlation between older age at clinic presentation and risk for psychiatric symptoms. “Further study is required to better describe the mental health trajectories of transgender youth and determine if mental health status or age at initiation of GAMC is correlated with psychological well-being in adulthood,” the investigators wrote.


Sorbara JC, Chiniara LN, Thompson S, Palmert MR. Mental health and timing of gender-affirming care [published online September 21, 2020]. Pediatrics. doi: 10.1542/peds.2019-3600