Mental health assessment of transgender youth in a clinical paediatric setting; should standardised psychological measures be scored by norms of birth assigned sex or identified gender?

Worldwide there are increasing numbers of young people identifying as Transgender. There is not a great amount known about the mental health of transgender youth, possibly due to the relative recency of contemporary approaches... [ view full abstract ]

Worldwide there are increasing numbers of young people identifying as Transgender. There is not a great amount known about the mental health of transgender youth, possibly due to the relative recency of contemporary approaches to support this population. However, research indicates that the transgender population are at higher risk of mental health issues than the normal population and therefore accurate risk assessment is essential.   

Assessment of psychological and psychosocial functioning of transgender young people is important in a clinical paediatric setting as these assessment measures are used clinically to identify risk and to assess if difficulties are in the "clinical range." Our current practice is to score psychological assessment measure according to that Birth Assigned Sex (BAS) rather than the identified gender (IG), as assessment measures are typically normed on BAS. 

In the general population research has identified that there is a gender difference in the development of mental health issues. It is unclear how this relates to a transgender population, and how this may effect the outcomes on assessment measures to assess risk.

Therefore, the clinical question remains; which gender normative group is the appropriate and most relevant choice to assess risk.

This study aimed to determine if the assessment measures used in practice to assess psychological wellbeing and risk should be measured according to the Birth Assigned Sex (BAS) rather than the identified gender (IG). This... [ view full abstract ]

This study aimed to determine if the assessment measures used in practice to assess psychological wellbeing and risk should be measured according to the Birth Assigned Sex (BAS) rather than the identified gender (IG).
This study aimed to determine if scoring measures as the IG would influence the level of gender normed psychopathology.

Participants are adolescents (aged 11-17) attending the GDS in 2015 and 2016 (N= 44, M = 15 years, 4 months, SD = 1.52). Each participant and their family completed a battery of empirically-validated psychological assessment... [ view full abstract ]

Participants are adolescents (aged 11-17) attending the GDS in 2015 and 2016 (N= 44, M = 15 years, 4 months, SD = 1.52). Each participant and their family completed a battery of empirically-validated psychological assessment questionnaires at their first appointment with the GDS multidisciplinary team. These questionnaires asses behavioural problems, behaviour and peer relationships, child physical, psychological and psychosocial functioning, child psychological, gender dysphoria and body image/body dissatisfaction. The information gathered from these assessments is used for both clinical and research purposes. Young people are formally re-assessed at various times throughout their time with the service.

The assessment measure used for this study is the Beck Youth Inventory of Emotional and Social Impairment (BYI; Beck et al., 2001) questionnaire. The BYI assesses psychosocial functioning across five domains: four negative... [ view full abstract ]

The assessment measure used for this study is the Beck Youth Inventory of Emotional and Social Impairment (BYI; Beck et al., 2001) questionnaire. The BYI assesses psychosocial functioning across five domains: four negative symptom domains; depression, anxiety, anger, disruptive behaviour, and one positive symptom domain; self-concept. Each inventory domain takes approximately 10 minutes to complete, with 20 statements written at a second-grade reading level. Adolescents rate statements over the preceding 2 weeks, such as “I like my body”, from never (scored 0) to always (scored 3). This raw score for questions in each domain was converted to a T-score using the adolescents’ gender and age (either 11-14, or 15-18). T-scores indicate the severity of problems in that domain. Four groups were analysed, two Female to Male (FTM) age groups, 11-14, and 15-18, and two Male to Female (MTF) age groups, 11-14, and 15-18. Each BYI was initially scored as their BAS, then as their IG and analysed using a series of paired-samples t-tests.

FTM 11-14 There was a significant negative difference in the scores for BYI-BDBI-BAS level (M=51.22, SD=12.92) and BYI-BDBI-IG (M=47.56, SD=9.79) conditions; t(8)=3.14, p =.014. FTM 15-18 There was a significant positive... [ view full abstract ]

FTM 11-14
There was a significant negative difference in the scores for BYI-BDBI-BAS level (M=51.22, SD=12.92) and BYI-BDBI-IG (M=47.56, SD=9.79) conditions; t(8)=3.14, p =.014.
FTM 15-18
There was a significant positive difference in the scores for BYI-BSCI-BAS level (M=41.15, SD=12.50) and BYI-BSCI-IG (M=41.46, SD=11.70) conditions; t(25)=-2.86, p =.008.
There was a significant positive difference in the scores for BYI-BAI-BAS level (M=58.12, SD=12.92) and BYI-BAI- G (M=61.77, SD=12.78) conditions; t(25)=-29.30, p <.001.
There was a significant positive difference in the scores for BYI-BDI-BAS level (M=59.08, SD=10.95) and BYI-BDI-IG (M=61.58, SD=10.75) conditions; t(25)=-14.82, p <.001.
There was a significant negative difference in the scores for BYI- BDBI-BAS level (M=51.56, SD=9.42) and BYI-BDBI-IG (M=48.36, SD=8.33) conditions; t(25)=13.86, p <.001.
MTF 11-14
Only one participant fell into this group and therefore no comparisons could be made.
MTF 15-18
There was a significant negative difference in the scores for BYI-BSCI-BAS level (M=36.63, SD=11.41) and BYI-BSCI-IG (M=36.00, SD=11.25) conditions; t(7)=2.38, p =.049.
There was a significant negative difference in the scores for BYI-BAI-BAS level (M=61.63, SD=12.05) and BYI-BAI-IG (M=57.00, SD=12.05) conditions; t(7)=5.95, p =.001.
There was a significant negative difference in the scores for BYI-BDI-BAS level (M=65.63, SD=15.66) and BYI-BDI-IG (M=62.75, SD=15.75) conditions; t(7)=12.69, p <.001.

This study’s results highlight significant differences in psychopathology between adolescent groups attending a clinical paediatric gender service when scored as the adolescents IG. This may be evidence to indicate that... [ view full abstract ]

This study’s results highlight significant differences in psychopathology between adolescent groups attending a clinical paediatric gender service when scored as the adolescents IG. This may be evidence to indicate that scoring each individual according to their IG may represent a more accurate depiction of their current mental health functioning, which could be considered separate to their transgenderism.

Interestingly, not all domains function in an identical way, with the exception of the delinquent behaviour domain which indicated a decrease in psychopathology for all groups.

There is also a gender disparity in the results in this study. This may be due to the assessment measure used in this study. For example, in the literature some domains of the BYI are often associated as being potentially gender biased, i.e. the female gender typically scores higher on domains such as anxiety, thus when scoring from MTF, scores for this group of young people rise, indicating greater psychopathology, and therefore increased risk.

Lastly, there are important clinical implications posed by the results in this study. It may be more appropriate to score assessments in both forms, and be concerned if the young person falls into clinical range in one or the other sex norms.