Clinical Validity, Strengths, and Limitations of Tools Used with Adolescents with Gender Dysphoria

Most Tools in Use Are Outdated: New Metrics Needed

Over the past twenty years, members of the LGBTQ+ community have become more visible in our society. We see this as a positive development. It reflects a gradual trend towards openness, acceptance, and respect for the way each individual experiences their own identity and determines their own path through life. However, as our society becomes more open toward non-traditional viewpoints and lifestyles, our institutions are often slow to respond.

As our citizens move forward on social and cultural issues, the structures they operate within lag. For instance, in the 1960s, public polling indicated support for civil rights and voting rights before the Civil Rights Act and Voting Rights Act became law. In the 70s, the work of attorneys like Ruth Bader Ginsburg gave women access to credit cards, bank loans, property ownership, and many other basic rights years after the majority of the population felt women should have those rights.

With regards to LGBTQ+ issues, we observe the same phenomenon. Public acceptance of the LGBTQ+ community began to expand in the 1980s, grew through the 1990s and 2000s. Then, in 2011, the U.S. military ended its “Don’t ask, don’t tell” policy (DADT). This is a perfect example of the dissonance between public opinion and institutional progress in our society. DADT prevented military personnel from discriminating against closeted LGBTQ+ people, but banned out and open LGBTQ+ people from serving in the military. Finally, in 2014, the Supreme Court legalized gay marriage. Again, years after most people in the U.S. felt like any two consenting adults should be allowed to marry whomever they pleased.

This article is about an analogous trend in mental health.

Although most mental health professionals welcome LGBTQ+ people, the institutions and structures related to the LGBTQ+ community, and the transgender community in particular, lag behind.

Assessing Gender and Gender Dysphoria in Children and Adolescents

The structures we refer to here are the metrics used to assess gender-related issues in children and adolescents. The authors of a paper published in The Lancet Child & Adolescent Health in August 2021 observed a problem. Among the metrics used to assess gender related issues in children and adolescents, most contain outdated language and questions that reflect attitudes and opinions on the LGBTQ+ community that are at best outdated and at worst clinically irrelevant, misleading, and inappropriate in our current social and cultural climate.

To determine which metrics are valid for the 21^st century population, researchers collected known metrics that assess the following important aspects of personal experience in transgender, non-binary, and gender-diverse children and adolescents:

1. Their gender identity
2. Their gender expression
3. The presence of absence of gender dysphoria

Let’s take a moment to discuss why it’s important to examine the validity of our current assessments for these categories. The following information comes from the 2017 Youth Risk Behavior Survey (2017 YRBS) by way of The Trevor Project:

Prevalence of Gender Minority Youth

• 2% of youth in the U.S. identify as transgender
  • That’s over half a million children and adolescents

Prevalence Of Suicide and Depression Among Gender Minority Youth

• Attempted suicide in the past year:
  • 7% of gender majority youth
  • 35% of trans, non-binary, or agender youth
• Seriously considered suicide in the past year:
  • 16% of the gender majority
  • 44% of trans, non-binary, or agender youth
• Reported symptoms of major depressive disorder (MDD):
  • 30% of gender majority youth
  • 53% of trans, non-binary, or agender youth

Teens and youth in the gender minority need a specific type of support that supersedes everything that follows: they need to be seen and heard as they are, for who they are and what they are, without judgment and without any confusion about who or what they are. The suicide and depression statistics we see above are directly related to the complex emotions that arise when a trans, non-binary, or agender youth experiences exclusion, isolation, judgment, and non-acceptance from family, peers, and society at large.

That’s why we need evidence-based metrics that offer an objective assessment of gender expression, gender identity, and gender dysphoria for youth and teens: when we have metrics that align with our current knowledge and trend toward openness and acceptance, we can better support our youth and teens in the gender minority.

The State of Our Assessments Now

As we mention above, the words we use in transgender mental health have changed – albeit slowly – to reflect our evolving understanding of gender and the trans experience. But although our language has changed, many of our structures have not. For instance, many of the metrics we use still employ the phrase gender role rather than gender expression and gender identity disorder rather than gender dysphoria. These phrases are relics of the 20^th century, when many people considered being trans or being gender diverse as a psychiatric disorder, rather than a simple manifestation of an individual’s inner sense of self and identity.

The authors of the Lancet paper we cite above describe the limitations of our existing tools. Most were created before the year 2000. They include language that reflects attitudes and language that do not reflect the current cultural moment or our contemporary scientific understanding of gender and gender diversity.

Tools in common use today that were created before the year 2000 include:

• Child and Adolescent Questionnaires/Assessments:

  • Body Image Scale (BIS)
  • Draw-a-Person (DAP)
  • Sex-Typed Free Play Task (FPT)
  • Rorschach
  • Make-a-Picture-Story test (MAPS)
  • Brown IT Scale for Children

• Parent Report Questionnaires/Assessments:

  • Play and Games Questionnaire (PGQ)
  • Parent Evaluation of Child Behavior (PECB)
  • Revised Gender Behavior Inventory for Boys (GBIB)
  • The Gender Identity Questionnaire for Children (GIQC)
  • Playmate and Play Style Preferences Structured Interview (PPPSI)
  • Gender Identity/Gender Role Questionnaire for Adolescents (GIGRQ-A)

Tools that were created after 2000 include:

• The Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA)
• Recalled Childhood Gender Identity/Gender Role Questionnaire (RCGI)
• Body Uneasiness Test (BUT)
• Gender Diversity Questionnaire (GDQ)
• Gender Feeling Amplitude (GFA)
• Similarity Test
• Gender-Preference and Gender-Identity Implicit Association Test (IAT)
• Explicit Gender Peer Preferences Test

Of all the assessments reviewed, including those created pre- and post- 200, only three include rigorous psychometric analysis:

• The Gender Identity Questionnaire for Children (GIQC)
• Gender Identity Interview for Children (GIIC)
• Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA)

And only one tool formally recognized non-binary and agender identities:

• Gender Diversity Questionnaire (GDQ)

Let’s review that information.

Researcher reviewed a total of 24 tools and identified 20 in common use today. Among the 20 in use today, they determined that a total of four (4) align with our current scientific knowledge and cultural perspective on gender minority youth and teens.

That means – obviously – there is room for improvement in this area of adolescent mental health.

The Current Assessments: Shortcomings

It’s clear that the assessments we use to explore gender-related mental health issues in youth and adolescents need an upgrade. This will require research, testing, and retesting to ensure viability and accuracy – and that will take time.

We’d prefer it were as simple as clicking “update now” on a software update for our computers or phones., Unfortunately, it’s not. It’s complex. The shortcomings are significant, and what we need most is nuance, as opposed to generic changes to certain words and phrases. What we need are assessments that reflect the latest knowledge and understanding of gender, gender identity, and gender dysphoria in the youth and adolescent population.

Here’s a summary of why mental health researchers and professionals need to devote time and energy to bringing these metrics up to date.

Gender Identity, Gender Expression, and Gender Dysphoria: How to Improve Assessments

1. Bring Them Up to Date

Many of the current assessment in use employ outdated language. This language reflects outdated ideas. For instance, one assessment asks parents about the types of dolls their children play with, referring to them as boy-type GI Joe or Ken dolls. To improve, we need to eliminate gender-normative language from these questions.

2. Gather More Data

The tools in current use, for the most part, have only been verified for accuracy and efficacy using small groups of transgender individuals. To improve, we need to expand the size of our data pool and include more trans and gender minority youth and teens.

3. Develop Tests Designed to Assess Gender

At least two of tools used to assess gender in gender minority populations – the Rorschach and the DAP – were neither designed to assess gender nor reviewed for effectiveness in the transgender population. This casts doubt on their validity as measure of gender issues for gender minority teens. To improve, we need to use tools that were designed to assess gender issues trans, non-binary, and agender teens.

4. Develop Tests for Adolescents.

Most of the tools currently in use to assess gender identity, gender expression, and gender dysphoria, were not designed for use in children and adolescents. To improve, we need to create tools designed to assess gender issues in adolescents, rather than adults.

5. Include All Gender Permutations.

Most of the tools currently in use do not include opportunities for teens to express non-binary, gender fluid, or agender elements of gender identity. Since these three aspects of gender are very important to gender minority teens, in order to improve, we need to create assessments that include opportunities for non-binary, gender fluid, or agender teens to both identify themselves and feel recognized in the assessment process.

6. Update, Evaluate, and Confirm the Tests

Only a small number of assessments include mention of gender dysphoria as defined in the Diagnostic and Statistical Manual of Mental Disorders Volume 5 (DSM-V) in combination with valid psychometric evaluation. To improve, we need to develop assessments that keep pace with the DSM-V – the gold standard diagnostic reference in mental health – and also apply rigorous evaluation techniques to the assessments themselves.

We’ll end this article by talking about a phrase we’ve used twice without any good explanation: valid psychometric evaluation. This means the tests we use must be tested. We need to verify that the tests actually measure what we want them to measure. We need to know the results of these tests are objectively accurate in varying contexts and for different groups of people. Finally, we need to know they align with our current knowledge of the subjects they measure.

In an ideal world, mental health professionals will design tests that are scientifically sound, include all aspects of gender – including non-binary, agender, and gender fluid components – and use gender-affirming language. When we do this, we’ll be able to offer teens who seek support for gender-related issues the best help they can get, based on the latest evidence, and guided by data that directly measures their experience and anticipates their needs.