Adolescent gender diversity: sociodemographic correlates & mental health outcomes

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In this podcast, we are joined by Akhgar Ghassabian, Assistant Professor at the Departments of Pediatrics, Population Health, and Environmental Medicine at NYU School of Medicine, and Dr. Tonya White, Professor at the Department of Child and Adolescent Psychiatry at Erasmus University Medical Center, Rotterdam.

The focus of this podcast is on the JCPP paper ‘Adolescent gender diversity: sociodemographic correlates and mental health outcomes in the general population’ (

Akhgar and Tonya set the scene by detailing what their study looked at, providing us with a summary of the paper, plus insight into what methodology they used, before sharing some of the key findings from the research.

In their paper, Akhgar and Tonya point to an association between gender diversity and mental health symptoms in adolescents, and in this podcast, Tonya elaborates on the relationship between the two.

Akhgar and Tonya then comment on their finding that more females were likely to have a gender-variant experience than males, and that adolescents with gender-variant experience appear to have higher autistic trait scores in the study. Akhgar and Tonya also highlight what implications, if any, can be drawn from these findings.

With this study showing that, whilst less than 1% of parents reported that their children had gender-variant experience, 4% of children reported this, Akhgar and Tonya discuss why parents may often be unaware of gender diverse feelings in their adolescence and how parental awareness or attitudes make a difference in terms of mental health outcomes, before exploring what the implications are of their findings for CAMH professionals.

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If you are interested in hearing more about adolescent gender diversity: sociodemographic correlates and mental health outcomes in the general population, Assistant Professor Akhgar Ghassabian will be speaking at the FREE online event ‘CAMHS around the Campfire journal club – Adolescent gender diversity: sociodemographic correlates and mental health outcomes in the general population’ on 28 June 2022, 5pm.

Assistant Professor Dr. Akhgar Ghassabian
Assistant Professor Dr. Akhgar Ghassabian

Akhgar Ghassabian, MD, PhD is an investigator and Assistant Professor at Departments of Pediatrics, Population Health, and Environmental Medicine, NYU School of Medicine. Her research interests center on identifying environmental exposures that contribute to the etiology of developmental disabilities in childhood. Prior to joining NYU School of Medicine, Dr. Ghassabian was the Intramural Research Training Award (IRTA) fellow at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Dr. Ghassabian obtained her Medical Degree from Tehran University of Medical Sciences and completed a Master’s and a PhD in epidemiology at Erasmus University Rotterdam, the Netherlands (2013). During her doctoral and postdoctoral training, Dr. Ghassabian has been actively involved in birth cohort studies in Europe and in the U.S., i.e., Generation R, Upstate KIDS, the New York University Children’s Health and Environment Study (NYU CHES). She was a collaborator on European epidemiological consortia examining the effect of nutrition (NUTRIMENTHE) and air pollution (ESCAPE) on children’s neurodevelopment. Dr. Ghassabian is the recipient of the Rubicon Award from the Netherlands Organisation for Scientific Research (NWO) in 2014 and the Robin/Guze Young Investigator Award from the American Psychopathological Association in 2019. (bio via NYU Langone Health)

Dr. Tonya White
Dr. Tonya White

Pediatric population neuroimaging lies at the interface between the disciplines of child psychiatry, radiology, pediatrics, and epidemiology. While there are certain challenges in being at the interface of four different disciplines, there are also tremendous opportunities to address specific questions that lie at this interface. My group works as a team focusing on five different research domains, including: 1.) Effects of prenatal and early life experience on downstream brain development 2.) Psychopathology along the continuum 3.) The neurobiology of emerging psychopathology 4.) Pediatric imaging genetics and 5.) Typical development and pediatric neuroimaging methodologies.

I moved from the University of Minnesota in 2009 to set up a neuroimaging program (KNICR) within the Department of Child and Adolescent Psychiatry and the Generation R Study. I currently direct the neuroimaging program in the Generation R Study and via collaborative work with the departments of Radiology, Epidemiology, Bioinformatics, and Pediatrics we have one of the largest pediatric neuroimaging cohorts in the world. The tenets for our work are that developmental and psychiatric disorders emerge within the context of brain development, yet little is known about the developmental trajectory of many of the major psychiatric disorders and their point of divergence from typical developmental trajectories. It is thus the goal of my research team to carefully map normal neurodevelopment and to map neurodevelopment of individuals with, or at high-risk for developing serious psychiatric disorders. In addition, my team explores environmental factors associated with later neurodevelopment. With nearly 7,000 active participants in the Generation R Study, it is extremely well suited to pursue these research questions. (bio via Erasmus MC)


[00:00:32] Jo Carlowe: Hello, welcome to In Conversation podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. And I have with me Akhgar Ghassabian, Assistant Professor at the Departments of Pediatrics, Population Health, and Environmental Medicine at NYU School of Medicine, and Dr. Tonya White, Professor at the Department of Child and Adolescent Psychiatry at Erasmus University Medical Center, Rotterdam.

Akhgar and Tonya are co-authors of the paper ‘Adolescent gender diversity: sociodemographic correlates and mental health outcomes in the general population’ recently published in the Journal of Child Psychology and Psychiatry.

The JCPP is one of the three journals produced by the Association for Child and Adolescent Mental Health. ACAMH also produces JCPP Advances and the CAMH. If you’re a fan of In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with a rating or review, and do share with friends and colleagues.

Akhgar and Tonya, welcome. Can you start with a brief introduction about yourselves.

[00:01:43] Assistant Professor Akhgar Ghassabian: Hi, thank you, Jo. I’m delighted to be here. I’m Akhgar Ghassabian. I’m an epidemiologist Assistant Professor of Pediatrics and Population Health at New York University at New York City. And my research is about environmental determinants of child neurodevelopment. We basically follow up children and their families from very early stages of life through childhood, adolescence, and young adulthood. And we study how life experiences shaped the development of brain and influence children’s mental health.

[00:02:12] Jo Carlowe: Brilliant. Tonya?

[00:02:13] Dr. Tonya White: Yes, I’m also delighted to be here. I’m Tonya White. I am a pediatrician and a child and adolescent psychiatrist. And I moved from the US about 12 years ago to set up a pediatric population neuroimaging program with the Generation R study, Erasmus University Medical Center here in Rotterdam. And my area of research involves really this intersection between epidemiology and developmental neuroscience, encompassing the interplay between brain, cognition and behavior.

[00:02:42] Jo Carlowe: Great. Thank you very much. Let’s turn to the paper, ‘Adolescent gender diversity: sociodemographic correlates and mental health outcomes in the general population’ published in the JCPP. What did you look at in this study? Can you give us a summary of the paper?

[00:03:00] Assistant Professor Akhgar Ghassabian: It’s about gender diversity in young adolescents within the general population. Current data show that the number of youths who are referred to gender clinics because of gender dysphoria has increased over the past decade. Overall, we know that about 1% to 3% of youth self-identify as transgender or gender nonconforming. But gender diversity has a broad definition including, but not limited to varying gender identity, gender expression, and exists in the general population.

And another important point to consider is that gender diversity can be present at very young age. But how to measure gender diversity in young adolescents has been a challenge for researchers. Some researchers ask parents about gender-variant behaviours and some others frame the question in a way that adolescents can understand and can answer themselves. So in this project, our goal was to estimate the prevalence of gender-varied experiences as reported by both young adolescents and their parents, and also to find stability over time and the agreement between parents and children. We also examined the association of gender-variant experiences with sociodemographic factors as you mentioned and mental health outcomes in children.

[00:04:11] Jo Carlowe: And what methodology did you use for the research?

[00:04:15] Dr. Tonya White: I can address that. But I want to give a little bit of background first because I think it’s helpful to understand the methodology when you also understand the context of the study. So between 2002 and 2006, about 10,000 women were recruited into the Generation R study, which is an epidemiological study with the goals of assessing child development over time and multiple aspects of child development as well. The only inclusion criteria for this study were women needed to be pregnant and they needed to live within certain zip codes. And so it is truly a population-based epidemiological study.

Rotterdam in the Netherlands is quite ethnically diverse. Its largest port city in Europe. And approximately 60% of the families are still participating from the initial recruitment. So it’s one of the nice aspects of having these large population-based studies in Northern Europe, is that they’re well conducted on this side of the pond, so to speak, being an American living in the Netherlands.
So what we did was we surveyed adolescents, actually starting between age 9, so older school age children and adolescents about gender-variant experiences and also mental health outcomes.
We did that via questionnaires, but we not only asked the adolescents themselves, but we also asked the parents. And we asked two specific questions for this study. Yes, adolescents and their parents, they wished to be of the opposite sex or would like to be treated as someone from the opposite sex. Actually, the parents survey was done at 10 and the adolescent survey was done at 13 to 15 age range.

[00:06:04] Jo Carlowe: Can you share some of the key findings from the research?

[00:06:07] Assistant Professor Akhgar Ghassabian: Tonya gave an overview of the Generation R study, which gave us a nice, large sample of over 5,700 children who were born between 2002 and 2006 in the city of Rotterdam in the Netherlands. When we looked at this survey, we found out about 4% of these adolescents express some sort of discontentedness with their assigned sex at some point at around age 13 to 14 years, but even less than 1% of parents could actually report the same thing in their children. So in other words, we found that parents may not be aware of gender diversity feelings in their adolescence.

We also found that adolescents assigned female adverse reported more gender-variant experiences than those assigned male. And when we looked at mental health outcomes in these children, we found positive associations between report of gender-varied experiences and mental health outcomes such as anxiety, depression, and autistic traits. These findings did not differ between those who were assigned male or female at birth. So very similar.

[00:07:11] Jo Carlowe: Let’s pick the findings a bit further. You point to an association between gender dysphoria and mental health symptoms in adolescents. Can you elaborate on the relationship between the two?

[00:07:23] Dr. Tonya White: Yes. First, I want to clarify that we did not, actually unfortunately, in this study, we were not able to study gender dysphoria. We rather studied gender diversity. So gender dysphoria really is a clinically significant distress or impairment. It’s related to a strong desire to live as the other gender or the one that is incongruent with the sex they were assigned.

What we did is we asked adolescents to express whether they wished to be the opposite sex, and at the time, asking if they felt distressed by this sex that they were assigned. So several studies have shown associations between gender dysphoria and mental health problems. What our study does is really extend this to the general population, and that’s one of the advantages of these large population-based studies rather than just having the clinically referred samples.

You also have the full spectrum of the gender spectrum, but also the full spectrum of the behaviour as well. So the thought, for example, I’ve worked quite a bit in studies looking at autism spectrum disorder, where also the thought is that symptoms of autism also extend into the general population where you have children who are very severe, who would have met the criteria when I was a medical student, which was 2 to 5 per 20,000, now it’s one in 68. So at one time, it was very severe. Now it’s become more of a broader spectrum. So you have these groups that might have subclinical symptoms and aren’t help-seeking, and also in this gender spectrum as well. So we’re looking at the relationship, not only in the help-seeking group, but also across the entire population.

[00:09:20] Jo Carlowe: I’m just going to ask whether that confounds things, because some of the mental health symptoms may relate to autistic traits rather than gender diversity, is that possible?

[00:09:33] Dr. Tonya White: So we’re not looking at a causal relationship. We’re defining an association. So the fact that a child can have autistic symptoms along a spectrum and gender diversity along a spectrum, we showed that those two are related, but that doesn’t mean that the underlying mechanism is the same. It may be. There might be factors that occur during prenatal life or early life that has similar mechanisms, especially when you think that autism, for example, has in itself occurs 4 to 1 males versus females.

So there’s something interacting in the brain with possible gender dimorphic features that are occurring. I just want to come back, we’re showing a relationship and we’re not defining causality. Other studies would have to look more closely to look at causal mechanisms for this relationship. It could be that the psychopathology is related to state modernization and the negative consequences in certain societies of being different, having gender diverse experiences that I think is fortunately becoming less over time.

[00:10:40] Jo Carlowe: Well, you’ve mentioned two things, you’ve mentioned the fact that more females were likely to have gender-variant experience than males, and then you also talked about higher autistic trait scores in the study. Let’s focus on females first. What do you make of that finding, that more females were likely to have gender-variant experience than males?

[00:11:00] Assistant Professor Akhgar Ghassabian: It was not a surprising finding specifically based on what we see from clinical data that comes from transgender clinic, because in transgender clinic, when investigating the youth who come for transitioning there, we see that those who were assigned female at birth they have an overrepresentation in those samples. So that’s why our data is just a confirmation that in this regard also, the same pattern exists in the general population. Why is that? We did not really study the underlying reason, is just, well, we observed that also in the general population, those assigned female, they also express more gender diversity across the spectrum.

[00:11:41] Jo Carlowe: And adolescents with gender-variant experience at higher autistic trait scores as you mentioned. What implications, if any, can be drawn from that?

[00:11:52] Dr. Tonya White: This is a topic that when I’ve attended meetings directed towards the autism that it’s a topic that’s had a lot of– I don’t want to say publicity. But it’s a topic that is commonly spoken about now at these conferences and tried to understand why there’s relationships because this isn’t a relationship that– I think what we’ve shown is that this relationship extends into the general population.

Other studies have really highlighted that within samples of children with autism, they have higher rates of gender dysphoria. And in samples of children with gender dysphoria, there’s higher rates of autism spectrum disorder. I have an ongoing study of eating disorders, and we’re also looking at autism symptoms. And so it may be not all that specific because we’re seeing higher rates in that group as well. So what does it mean? I think is a great question.

So does it mean that there’s– again, we’re not looking at causality. We could understand that more, but there could be different biological mechanisms, whether it’s related to hormonal influences during early gestation or fetal brain development, oestrogen signalling pathways. Those are questions that our study didn’t address. We’re looking at relationships within the broader population but the fact that we’re looking within a larger population-based study, and that we see it not only on the extremes but also in the children with different levels of features suggests that there are some levelling difference.

[00:13:35] Jo Carlowe: Thank you. I want to return to something you highlighted earlier. The paper shows that while less than 1% of parents reported that their children had gender-variant experience, 4% of children reported this. Why, in your view, are parents often unaware of gender diverse feelings in their adolescence? And does parental awareness or attitudes make a difference in terms of mental health outcomes?

[00:14:04] Assistant Professor Akhgar Ghassabian: That’s a good question. Well, our data suggest that parents might not always be aware of the gender diverse feeling in their adolescence. That’s what the observation we had. Does parental awareness or attitude make a difference in terms of mental health outcomes? Well, we did not study that directly. But if you think about it within the context of the minority stress framework, which is discussed for mental health outcome in the context of mental health outcomes in gender diverse youth, we know that the experience of gender diverse children in general in their social environment, including their family can contribute to their mental health outcome because of this distress. So if you think about in that framework, you can argue that parents awareness can make a difference in terms of mental health outcomes. What we can do is that’s the basis for several approaches while children are navigating their path through understanding their gender identity. The best is to listen to children.

[00:15:04] Jo Carlowe: Great. Thank you. Your study shows that parents with low or medium educational levels reported more gender-variant experience in their children than those with higher education. I found that quite surprising. How do you account for that difference?

[00:15:20] Assistant Professor Akhgar Ghassabian: Well, for us, it was we account for these differences when we were looking at, for example, the relationship between gender diversity and mental health symptoms by adjusting for those factors in our analysis. We found differences in gender, in child self-reported event experiences by maternal education not by paternal education. That was interesting. Also, something that I want to add that we found negligible differences among ethnic group or income level. That was something that we also saw on reports from Canada and the Netherlands. Again, this is a study that we did not really investigate the reasons for those differences. But I think those differences are informative and, as you said, we accounted for those when we are looking at, for example, why these kids are at high risk of mental health outcomes in the future.

[00:16:13] Jo Carlowe: Akhgar and Tonya, is there anything else in the paper that you’d like to highlight?

[00:16:18] Dr. Tonya White: The one thing that I brought up before, I think, is the strength of the study is the large sample size and the population-based recruitment of the study. And when we’ve looked at how well the current cohort, because there’s been some attrition over time, but how well the current cohort reflects the existing population, it actually reflects it quite well in spite of the attrition. I think we feel fairly confident that we’ve captured a multi-ethnic population base for a Rotterdam– and Rotterdam might not necessarily be reflective of all of the Netherlands or definitely. But in terms of a large city that captures many different aspects of multicultural, that’s a strength of the study.

[00:17:02] Jo Carlowe: What are the implications of your findings for CAMH professionals?

[00:17:07] Dr. Tonya White: So I think the implications for those who are of Child and Adolescent Mental Health professionals are, when you see children with psychiatric disorders, it’s good to ask also about gender diverse experience as well and vice versa to explore those relationships. Your question really relates to implications for findings for child mental health professionals. But since it’s a population-based study, you could also say that what are the implications for public health, which also could be a possibility from this study, because there are children who may not be help-seeking, who have maybe subclinical mental health issues that could benefit and whether that’s via education, via the school, via other mechanisms to reach out to these children could also be helpful.

[00:18:02] Jo Carlowe: It’s a really important point to make. Are you planning some follow up research that you can share with us?

[00:18:08] Dr. Tonya White: So you’re asking researchers if they’re planning to do follow up research? {LAUGH} That’s like a knee jerk reflex. Sorry. So yes, we are. One of the limitations of our study is that we really relied on two questions that didn’t really capture the spectrum. There were actually more binary questions about, do you feel like you would rather be born as the opposite sex? And would you rather be treated as the opposite of sex? So we have an ongoing wave, so we have a longitudinal population-based study. And in our current wave which is ongoing, we’ve added a measure that captures more of the full spectrum of gender diversity. So we also would like to look more closely at the MRI features of these experience, and not only at the time that we’re assessing them, at 13 to 15 and then later at 17 to 19, COVID has put a delay in all of that. But also we have the opportunity to look back, because we have almost 4,000 scans that were collected from 9 to 11 years of age, and we also have over 1,000 in our first wave from 6 to 9 years of age. So we’ll have the opportunity to look really longitudinal. Unfortunately, we don’t have early measures of gender diversity.

[00:19:32] Jo Carlowe: Nonetheless, it would be really interesting to see that–

[00:19:35] Dr. Tonya White: It would be very interesting.

[00:19:37] Jo Carlowe: Is there anything else in the pipeline for either of you that you would like to mention?

[00:19:43] Assistant Professor Akhgar Ghassabian: I would like to add that, Tonya, talked about future direction for research and what we’re doing. But at the same time, we are building connection with the community. We talk about the community that has been historically marginalized in the United States, in Europe, and many other countries. And for us, it’s important, if you’re doing research, should be in constant communication and contact with the community to get feedback from them, to have their involvement, and also we want to make sure that we disseminate defining back to the community because we want the community to benefit from the findings of our research as well.

[00:20:24] Jo Carlowe: And by the community, do you mean young people or also their family?

[00:20:28] Assistant Professor Akhgar Ghassabian: Oh, family. And when you are talking about the LGBT and in particular in this case, gender diverse children usually families, parents are also involved. So that would be both children and their parents.

[00:20:41] Jo Carlowe: Anything in terms of anything coming up in the pipeline that you also that you want to add?

[00:20:47] Assistant Professor Akhgar Ghassabian: For me, the highlight of this research was that others have done this research in Canada, the US, or Germany. And finding similar results in different countries suggest that despite the impact of societal factors, cultural factors, we know that the recognition of gender-variant experiences in adolescents are quite stable across these cultures– –and that is very important to know. And as researchers and health care providers, for us understanding the contributing factors and also providing support when children and families are navigating through gender and sexual identity, our role is essential to be there and to support them.

[00:21:28] Jo Carlowe: Is support lacking at the moment in terms of [inaudible] younger people and their parents and families are getting.

Assistant Professor Akhgar Ghassabian: I believe so despite all the fact– I mean, we can talk about advancements, but we can do better.

Dr. Tonya White: And I just want to say that Akhgar has a Brain Behavior Research Foundation grant in order to explore this question further together with me and Xavier Castellanos at NYU, and we have a postdoc Yllza Xerxa who is also working on this project. So we have some pilot funding to move the project forward and we hope to get additional funding.

[00:22:07] Jo Carlowe: And finally Akhgar and Tonya, what is your take-home message for those listening to our conversation?

[00:22:13] Assistant Professor Akhgar Ghassabian: I think I just want to repeat the same thing that I said. I think gender-variant experiences in adolescents are quite a staple across culture, and that’s probably the most important message from this paper, the similarities of our findings with others.

[00:22:27] Jo Carlowe: Tonya, anything to add?

[00:22:30] Dr. Tonya White: I just want to add that the discrepancy between youth reports and parents’ knowledge of their youth, I think that also is quite interesting and it would be important to follow up to see why that discrepancy does exist between the youth and parent report.

[00:22:50] Jo Carlowe: Thank you both ever so much. For more details on Assistant Professor Akhgar Ghassabian and Professor Tonya White, please visit the ACAMH website,, and Twitter @acamh. ACAMH is spelt A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoy the podcast with a rating or review, and do share with friends and colleagues.

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