{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,13]],"date-time":"2026-09-13T04:55:00Z","timestamp":1789275300340,"version":"build-2803163510"},"reference-count":50,"publisher":"American Medical Association (AMA)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"Importance<\/jats:title>Transgender and gender-diverse (TGD) children and adolescents may experience not only gender dysphoria but also depression and anxiety, all of which are likely to be associated with reduced quality of life (QOL). Despite this, little is known about QOL in this population.<\/jats:p><\/jats:sec>Objectives<\/jats:title>To identify demographic, social, and clinical characteristics associated with reduced QOL in TGD children and adolescents; compare their QOL with age-matched population-based norms and that of young people with common mental health problems; and evaluate the association between gender dysphoria and QOL.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>In this cohort study, baseline data were derived from questionnaires completed in a prospective cohort study (Trans20) of TGD children aged 6 to 12 years and adolescents aged 13 to 17 years first seen at the Royal Children\u2019s Hospital Gender Service (Melbourne, Australia) between February 2017 and February 2020.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>The main outcome was QOL, measured using the Child Health Utility 9D instrument (CHU-9D). Data collection included demographic information, social factors (eg, bullying, lack of support, and social transition), and clinical characteristics (eg, gender identity, gender dysphoria, and mental health difficulties). Population norms and CHU-9D data for Australian youths with mental health diagnoses were derived from published literature.<\/jats:p><\/jats:sec>Results<\/jats:title>The TGD cohort comprised 525 children and adolescents aged 6 to 17 years (median age, 14 years [IQR, 12-16 years]; 364 [69.33%] presumed female at birth). The mean (SD) CHU-9D score was 0.46 (0.26). Compared with population norms, TGD children (0.58 [0.27] vs 0.81 [0.16]; P<\/jats:italic>\u2009&amp;lt;\u2009.001) and adolescents (0.41 [0.25] vs 0.80 [0.14]; P<\/jats:italic>\u2009&amp;lt;\u2009.001) had significantly lower scores. Within the TGD cohort, mean (SD) scores were significantly lower in adolescents (0.41 [0.24] vs 0.62 [0.25]; P<\/jats:italic>\u2009&amp;lt;\u2009.001), those assigned female at birth (0.43 [0.26] vs 0.55 [0.25]; P<\/jats:italic>\u2009&amp;lt;\u2009.001), those reporting mental health problems (0.37 [0.23] vs 0.57 [0.25]; P<\/jats:italic>\u2009&amp;lt;\u2009.001) and physical health problems (0.41 [0.26] vs 0.48 [0.26]; P<\/jats:italic>\u2009=\u2009.04), and those who were bullied (0.38 [0.24] vs 0.52 [0.25]; P<\/jats:italic>\u2009&amp;lt;\u2009.001). Gender dysphoria alone was associated with a lower mean (SD) CHU-9D score (0.51 [0.23]) than that in control adolescents with serious mental health conditions such as depression (0.64 [0.26]) and anxiety (0.70 [0.24]) and was an independent factor associated with QOL.<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>In this cohort study of TGD children and adolescents in Australia, QOL was worse in this population than in age-matched, population-based peers. Quality of life associated with gender dysphoria was substantially worse than that seen in young people with common mental health conditions. These findings emphasize the risk of poor QOL among TGD young people and the need to better support them.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2022.54292","type":"journal-article","created":{"date-parts":[[2023,2,2]],"date-time":"2023-02-02T16:11:17Z","timestamp":1675354277000},"page":"e2254292","source":"Crossref","is-referenced-by-count":19,"title":["Assessment of Quality of Life of Transgender and Gender-Diverse Children and Adolescents in Melbourne, Australia, 2017-2020"],"prefix":"10.1001","volume":"6","author":[{"given":"Lidia","family":"Engel","sequence":"first","affiliation":[{"name":"School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ishani","family":"Majmudar","sequence":"additional","affiliation":[{"name":"Deakin Health Economics, Deakin University, Burwood, Victoria, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cathrine","family":"Mihalopoulos","sequence":"additional","affiliation":[{"name":"School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia"},{"name":"Deakin Health Economics, Deakin University, Burwood, Victoria, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michelle A.","family":"Tollit","sequence":"additional","affiliation":[{"name":"The Royal Children\u2019s Hospital, Parkville, Victoria, Australia"},{"name":"Murdoch Children\u2019s Research Institute, Parkville, Victoria, Australia"},{"name":"Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ken C.","family":"Pang","sequence":"additional","affiliation":[{"name":"The Royal Children\u2019s Hospital, Parkville, Victoria, Australia"},{"name":"Murdoch Children\u2019s Research Institute, Parkville, Victoria, Australia"},{"name":"Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2023,2,2]]},"reference":[{"issue":"10042","key":"zoi221534r1","doi-asserted-by":"publisher","first-page":"390","DOI":"10.1016\/S0140-6736(16)00683-8","article-title":"Transgender people: health at the margins of society.","volume":"388","author":"Winter","year":"2016","journal-title":"Lancet"},{"issue":"1","key":"zoi221534r2","doi-asserted-by":"publisher","first-page":"93","DOI":"10.1016\/j.jadohealth.2013.11.008","article-title":"The health and well-being of transgender high school students: results from the New Zealand Adolescent Health Survey (Youth\u201912).","volume":"55","author":"Clark","year":"2014","journal-title":"J Adolesc Health"},{"issue":"5","key":"zoi221534r3","doi-asserted-by":"publisher","first-page":"312","DOI":"10.1089\/lgbt.2017.0176","article-title":"Perceived gender presentation among transgender and gender diverse youth: approaches to analysis and associations with bullying victimization and emotional distress.","volume":"5","author":"Gower","year":"2018","journal-title":"LGBT Health"},{"issue":"3","key":"zoi221534r4","doi-asserted-by":"publisher","first-page":"67","DOI":"10.15585\/mmwr.mm6803a3","article-title":"Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students\u201419 states and large urban school districts, 2017.","volume":"68","author":"Johns","year":"2019","journal-title":"MMWR Morb Mortal Wkly Rep"},{"issue":"3","key":"zoi221534r6","doi-asserted-by":"publisher","first-page":"418","DOI":"10.1542\/peds.2011-0907","article-title":"Children and adolescents with gender identity disorder referred to a pediatric medical center.","volume":"129","author":"Spack","year":"2012","journal-title":"Pediatrics"},{"issue":"4","key":"zoi221534r7","doi-asserted-by":"publisher","first-page":"906","DOI":"10.1016\/j.jpeds.2013.10.068","article-title":"Clinical management of youth with gender dysphoria in Vancouver.","volume":"164","author":"Khatchadourian","year":"2014","journal-title":"J Pediatr"},{"issue":"5","key":"zoi221534r8","doi-asserted-by":"publisher","first-page":"808","DOI":"10.1017\/S0033291719000643","article-title":"Associations between negative life experiences and the mental health of trans and gender diverse young people in Australia: findings from Trans Pathways.","volume":"50","author":"Strauss","year":"2020","journal-title":"Psychol Med"},{"issue":"10","key":"zoi221534r10","doi-asserted-by":"publisher","first-page":"1403","DOI":"10.1016\/0277-9536(95)00112-K","article-title":"The World Health Organization Quality of Life assessment (WHOQOL): position paper from the World Health Organization.","volume":"41","author":"The WHOQOL Group","year":"1995","journal-title":"Soc Sci Med"},{"issue":"3","key":"zoi221534r11","doi-asserted-by":"publisher","first-page":"199","DOI":"10.1007\/s11154-018-9459-y","article-title":"Quality of life of treatment-seeking transgender adults: a systematic review and meta-analysis.","volume":"19","author":"Nobili","year":"2018","journal-title":"Rev Endocr Metab Disord"},{"issue":"4","key":"zoi221534r12","doi-asserted-by":"publisher","first-page":"696","DOI":"10.1542\/peds.2013-2958","article-title":"Young adult psychological outcome after puberty suppression and gender reassignment.","volume":"134","author":"de Vries","year":"2014","journal-title":"Pediatrics"},{"issue":"6","key":"zoi221534r13","doi-asserted-by":"publisher","first-page":"1597","DOI":"10.1007\/s11136-020-02430-8","article-title":"Health-related quality of life among transgender and gender expansive youth at a rural gender wellness clinic.","volume":"29","author":"O\u2019Bryan","year":"2020","journal-title":"Qual Life Res"},{"issue":"1","key":"zoi221534r14","doi-asserted-by":"publisher","first-page":"78","DOI":"10.1080\/15532739.2018.1425649","article-title":"Health-related quality of life in transgender adolescents: associations with body image and emotional and behavioral problems.","volume":"19","author":"R\u00f6der","year":"2018","journal-title":"Int J Transgenderism"},{"issue":"6","key":"zoi221534r15","doi-asserted-by":"publisher","first-page":"791","DOI":"10.1016\/j.jadohealth.2013.07.019","article-title":"Parental support and mental health among transgender adolescents.","volume":"53","author":"Simons","year":"2013","journal-title":"J Adolesc Health"},{"issue":"8","key":"zoi221534r16","doi-asserted-by":"publisher","first-page":"2107","DOI":"10.1007\/s11136-018-1839-y","article-title":"Documenting an epidemic of suffering: low health-related quality of life among transgender youth.","volume":"27","author":"Zou","year":"2018","journal-title":"Qual Life Res"},{"issue":"10","key":"zoi221534r17","doi-asserted-by":"publisher","first-page":"1503","DOI":"10.3390\/jcm8101503","article-title":"Mental health correlates of autism spectrum disorder in gender diverse young people: evidence from a specialised child and adolescent gender clinic in Australia.","volume":"8","author":"Mahfouda","year":"2019","journal-title":"J Clin Med"},{"issue":"11","key":"zoi221534r18","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2019-032151","article-title":"What are the health outcomes of trans and gender diverse young people in Australia? study protocol for the Trans20 longitudinal cohort study.","volume":"9","author":"Tollit","year":"2019","journal-title":"BMJ Open"},{"issue":"8","key":"zoi221534r19","doi-asserted-by":"publisher","first-page":"713","DOI":"10.2165\/11597900-000000000-00000","article-title":"Developing adolescent-specific health state values for economic evaluation: an application of profile case best-worst scaling to the Child Health Utility 9D.","volume":"30","author":"Ratcliffe","year":"2012","journal-title":"Pharmacoeconomics"},{"issue":"8","key":"zoi221534r20","doi-asserted-by":"publisher","first-page":"1092","DOI":"10.1016\/j.jval.2012.07.011","article-title":"Measuring and valuing health benefits for economic evaluation in adolescence: an assessment of the practicality and validity of the child health utility 9D in the Australian adolescent population.","volume":"15","author":"Stevens","year":"2012","journal-title":"Value Health"},{"issue":"8","key":"zoi221534r21","doi-asserted-by":"publisher","first-page":"1105","DOI":"10.1007\/s11136-009-9524-9","article-title":"Developing a descriptive system for a new preference-based measure of health-related quality of life for children.","volume":"18","author":"Stevens","year":"2009","journal-title":"Qual Life Res"},{"key":"zoi221534r22","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1186\/s12955-015-0218-4","article-title":"The validity of the Child Health Utility instrument (CHU9D) as a routine outcome measure for use in child and adolescent mental health services.","volume":"13","author":"Furber","year":"2015","journal-title":"Health Qual Life Outcomes"},{"issue":"1","key":"zoi221534r23","doi-asserted-by":"publisher","first-page":"173","DOI":"10.1007\/s11136-012-0119-5","article-title":"Measuring preference-based quality of life in children aged 6-7 years: a comparison of the performance of the CHU-9D and EQ-5D-Y\u2014the WAVES pilot study.","volume":"22","author":"Canaway","year":"2013","journal-title":"Qual Life Res"},{"issue":"4","key":"zoi221534r24","doi-asserted-by":"publisher","first-page":"432","DOI":"10.1016\/j.jval.2015.02.014","article-title":"Assessing the health-related quality of life of Australian adolescents: an empirical comparison of the Child Health Utility 9D and EQ-5D-Y instruments.","volume":"18","author":"Chen","year":"2015","journal-title":"Value Health"},{"key":"zoi221534r25","doi-asserted-by":"publisher","first-page":"211","DOI":"10.1186\/s12887-015-0526-1","article-title":"Is utility-based quality of life associated with overweight in children? evidence from the UK WAVES randomised controlled study.","volume":"15","author":"Frew","year":"2015","journal-title":"BMC Pediatr"},{"key":"zoi221534r26","doi-asserted-by":"publisher","DOI":"10.1007\/s40271-017-0265-5","article-title":"Measuring health-related quality of life in adolescent populations: an empirical comparison of the CHU9D and the PedsQLTM 4.0 Short Form 15.","author":"Petersen","year":"2018","journal-title":"Patient"},{"issue":"4","key":"zoi221534r27","doi-asserted-by":"publisher","first-page":"717","DOI":"10.1007\/s11136-011-9971-y","article-title":"An assessment of the construct validity of the CHU9D in the Australian adolescent general population.","volume":"21","author":"Ratcliffe","year":"2012","journal-title":"Qual Life Res"},{"issue":"2","key":"zoi221534r28","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0089222","article-title":"Measuring and valuing health-related quality of life among children and adolescents in mainland China\u2014a pilot study.","volume":"9","author":"Xu","year":"2014","journal-title":"PLoS One"},{"issue":"3","key":"zoi221534r29","doi-asserted-by":"publisher","first-page":"443","DOI":"10.1016\/j.jval.2020.09.012","article-title":"A review of the psychometric performance of selected child and adolescent preference-based measures used to produce utilities for child and adolescent health.","volume":"24","author":"Rowen","year":"2021","journal-title":"Value Health"},{"key":"zoi221534r30","doi-asserted-by":"publisher","first-page":"48","DOI":"10.1016\/j.socscimed.2016.03.042","article-title":"Valuing the Child Health Utility 9D: using profile case best worst scaling methods to develop a new adolescent specific scoring algorithm.","volume":"157","author":"Ratcliffe","year":"2016","journal-title":"Soc Sci Med"},{"key":"zoi221534r32","doi-asserted-by":"publisher","first-page":"e4","DOI":"10.1016\/j.puhe.2021.09.012","article-title":"Challenges in measuring gender identity among transgender, gender diverse, and non-binary young people.","volume":"200","author":"Blacklock","year":"2021","journal-title":"Public Health"},{"issue":"3-4","key":"zoi221534r33","doi-asserted-by":"publisher","first-page":"131","DOI":"10.1080\/15532739.2016.1217812","article-title":"Development and validation of a measure for assessing gender dysphoria in adults: the Gender Preoccupation and Stability Questionnaire.","volume":"17","author":"Hakeem","year":"2016","journal-title":"Int J Transgenderism"},{"issue":"12","key":"zoi221534r36","doi-asserted-by":"publisher","first-page":"1266","DOI":"10.1176\/appi.ajp.2011.10111704","article-title":"The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults.","volume":"168","author":"Posner","year":"2011","journal-title":"Am J Psychiatry"},{"issue":"2","key":"zoi221534r37","doi-asserted-by":"publisher","first-page":"75","DOI":"10.1111\/josh.2007.77.issue-2","article-title":"A comparison of the Gatehouse Bullying Scale and the peer relations questionnaire for students in secondary school.","volume":"77","author":"Bond","year":"2007","journal-title":"J Sch Health"},{"issue":"2","key":"zoi221534r38","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2020-042762","article-title":"A waitlist intervention for transgender young people and psychosocial outcomes.","volume":"148","author":"Dahlgren Allen","year":"2021","journal-title":"Pediatrics"},{"key":"zoi221534r39","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1136\/bmjopen-2018-022398","article-title":"Health-related quality of life: population epidemiology and concordance in Australian children aged 11-12 years and their parents.","volume":"9","author":"Catchpool","year":"2019","journal-title":"BMJ Open"},{"issue":"10","key":"zoi221534r40","doi-asserted-by":"publisher","first-page":"2895","DOI":"10.1007\/s11136-021-02864-8","article-title":"Australian adolescent population norms for the Child Health Utility Index 9D\u2014results from the Young Minds Matter survey.","volume":"30","author":"Le","year":"2021","journal-title":"Qual Life Res"},{"issue":"4","key":"zoi221534r43","doi-asserted-by":"publisher","first-page":"499","DOI":"10.1177\/1359104510378303","article-title":"Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study.","volume":"16","author":"Steensma","year":"2011","journal-title":"Clin Child Psychol Psychiatry"},{"issue":"2-3","key":"zoi221534r45","doi-asserted-by":"publisher","first-page":"230","DOI":"10.1080\/15532739.2017.1370627","article-title":"Non-binary and binary transgender youth: comparison of mental health, self-harm, suicidality, substance use and victimization experiences.","volume":"20","author":"Rimes","year":"2017","journal-title":"Int J Transgend"},{"issue":"6","key":"zoi221534r46","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2018-2902","article-title":"School restroom and locker room restrictions and sexual assault risk among transgender youth.","volume":"143","author":"Murchison","year":"2019","journal-title":"Pediatrics"},{"issue":"6","key":"zoi221534r47","doi-asserted-by":"publisher","first-page":"991","DOI":"10.1016\/j.jadohealth.2021.06.001","article-title":"Timing of social transition for transgender and gender diverse youth, K-12 harassment, and adult mental health outcomes.","volume":"69","author":"Turban","year":"2021","journal-title":"J Adolesc Health"},{"issue":"5","key":"zoi221534r48","doi-asserted-by":"publisher","first-page":"344","DOI":"10.3109\/07853890109002088","article-title":"Introducing economic and quality of life measurements into clinical studies.","volume":"33","author":"Drummond","year":"2001","journal-title":"Ann Med"},{"issue":"6","key":"zoi221534r49","doi-asserted-by":"publisher","first-page":"948","DOI":"10.1016\/j.jsxm.2019.03.407","article-title":"Shifts in assigned sex ratios at gender identity clinics likely reflect changes in referral patterns.","volume":"16","author":"Ashley","year":"2019","journal-title":"J Sex Med"},{"issue":"3","key":"zoi221534r50","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2022-056567","article-title":"Sex assigned at birth ratio among transgender and gender diverse adolescents in the United States.","volume":"150","author":"Turban","year":"2022","journal-title":"Pediatrics"},{"key":"zoi221534r9","volume-title":"Diagnostic and Statistical Manual of Mental Disorders","year":"2022","edition":"5th ed, text re"},{"key":"zoi221534r34","volume-title":"Manual for the ASEBA Preschool Forms & Profiles","author":"Achenbach","year":"2000"},{"key":"zoi221534r35","volume-title":"Manual for the ASEBA School-Age Forms & Profiles","author":"Achenbach","year":"2001"},{"key":"zoi221534r41","volume-title":"Statistical Power Analysis for the Behavioural Sciences","author":"Cohen","year":"1988"},{"key":"zoi221534r42","volume-title":"Release 1","author":"Stata Statistical Software","year":"2017"},{"key":"zoi221534r5","unstructured":"Strauss? P, Cook? A, Winter? S, Watson? V, Wright Toussaint? D, Lin? A. Trans Pathways: the mental health experiences and care pathways of trans young people\u2014summary of results. Telethon Kids Institute. Accessed August 8, 2022. https:\/\/www.telethonkids.org.au\/globalassets\/media\/documents\/brain--behaviour\/trans-pathways_easy-print.pdf"},{"key":"zoi221534r31","unstructured":"Australian Bureau of Statistics. Socio-Economic Indexes for Areas. Accessed January 4, 2023. https:\/\/www.abs.gov.au\/websitedbs\/censushome.nsf\/home\/seifa"},{"key":"zoi221534r44","unstructured":"Australian Institute of Health and Welfare. Australia\u2019s youth: mental illness. Accessed December 6, 2022. https:\/\/www.aihw.gov.au\/reports\/children-youth\/mental-illness"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2800899\/engel_2023_oi_221534_1678202149.69554.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,3,13]],"date-time":"2023-03-13T15:09:29Z","timestamp":1678720169000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2800899"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,2,2]]},"references-count":50,"journal-issue":{"issue":"2","published-print":{"date-parts":[[2023,2,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2022.54292","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,2,2]]}}}