Clinical and socio-demographic factors influencing social adaptation in individuals with gender incongruence

Introduction

In recent years, the problem of persons with gender incongruence (GI) has taken a significant place in the professional community both in the Russian Federation and abroad. The global healthcare sector is actively developing strategies and activities to increase knowledge about GI issues and improve the health and well-being of persons with gender disorders, who, according to WHO, constitute 0.3–0.5% (25 million) of the world's population.

The ICD-11 defines GI as "a pronounced and persistent discrepancy between an individual's perceived gender and assigned sex" without requiring significant distress or mental impairment to make a diagnosis. The range of medical care measures includes activities aimed at social adaptation in a gender role, as well as social, psychological, behavioral, or medical measures (including hormonal treatment or surgery) aimed at supporting and confirming a person's gender identity.

GI leading to symptoms of gender dysphoria is not amenable to change if desired, does not undergo changes during educational activities and attempts by patients to "remake themselves" and is the result of currently insufficiently studied mechanisms affecting the sexual differentiation of brain structures associated with genetic factors and changes in metabolism sex steroids [1]. The technique used in some foreign countries to suppress puberty is still going through the stages of study and is not applicable in the Russian Federation [2]. In this regard, from the moment of the first symptoms of GI and dysphoria to the opportunity to start a social transition, the patient goes through a period in which he or she is vulnerable to the development of comorbid mental and eating disorders, addictions, has a high risk of autoaggression and suicidal activity, especially at the peak of puberty and rejection of external changes. Patients often resort to self-prescribed hormonal therapy in search of an opportunity to reduce their dysphoria, which is associated with the risks of adverse effects of therapy in the absence of medical supervision [2].

The life of gender nonconforming people is associated with a high degree of discomfort and distress caused both by the discrepancy between the sex assigned at birth and the person's gender identity, and by the pressure of society that dictates a certain social, behavioral model of functioning. The systematic struggle between one's needs and the requirements of the environment since childhood disrupts socialization and, according to the theory of "minority stress", increases the prevalence of mental disorders [3].

 A high incidence of clinically significant anxiety, depression, reduced social contacts, self-injurious behavior, and suicidal attempts has been proven [4][5].

According to Petrova (2013), people with gender identity disorders are more likely to have moderate and severe depressive disorders with a higher risk of suicide in this group (67%) compared to the group of patients without gender disorders (34%) [6].

According to Peterson et al. (2017), 58% of patients aged 12–22 years with a gender dysphoria diagnosis had an additional psychiatric diagnosis, and 39.3% of patients had at least one suicide attempt [4].

Practice in Russia demonstrates a high comorbidity of transsexualism with other mental disorders that aggravate the course of both gender dysphoria and the mental disorder itself, which limits the therapeutic effect when one of the comorbid processes is ignored (Starostina, 2020) [7].

With a high demand of patients with gender disorders for medical support, there are no comprehensive practical skills and theoretical knowledge among both Russian and foreign colleagues. The study by Johnston et al. (2017) demonstrated that 47% of the students surveyed had fragmentary knowledge on this issue, and 97% considered it necessary to obtain information on working with transgender patients [8].

The research by Shires et al. (2018) on awareness of general practitioners on this issue showed that 48% noted their lack of competence and training, and 31% reported that they did not consider themselves prepared to provide elective care to transgender patients [9].

The maximum effect in reducing gender dysphoria from the moment of the first symptoms (usually in the prepubertal period) can be expected from a favorable social environment at all stages of growing up (family, school, educational institutions) until a decision is made on social transition and medical interventions [10]. A study of children with gender disorders conducted in Washington, DC showed no difference in the mental health of transchildren and a group of cisgender children with family support during gender transition [11]. The authors demonstrate the positive impact of social support (family, school) in reducing symptoms of depression and greater life satisfaction and prevention of comorbid mental disorders. (Simons et al. [12], Parodi et al. [13]).

The study was aimed at identifying potentially reversible clinical and socio-demographic factors influencing the social adaptation of patients with GI.

Materials and methods

A retrospective analysis of 926 patient records with gender identity disorder (GI) of MtF (male-to-female, transgender women) and FtM (female-to-male, transgender men) who applied to the Scientific Center for Personalized Medicine (SCPM) in Moscow with a request for gender- affirmative events from January 2014 to April 2021 was performed.

The study had retrospective cross-sectional design.

Variables

The following variables were studied: history of life, demographic characteristics (sex, place of residence before the onset of GI symptoms, age at the time of the initial visit to doctor, educational level, work activity, experience of marital relations, the presence of children, support from relatives); dynamics of GI symptoms (age when the first symptoms emerged, age when accepting oneself as a transperson, experience of "remaking oneself" and biological adaptation; steps to reduce gender dysphoria before seeking medical help); experience with hormone replacement therapy; appearance data of those who applied in terms of appearance correspondence to the associated sex (the authors’ scale of appearance congruence to the associated sex (ACAS), where 1 was no incongruence, 3 – androgynous or unisexual appearance, 5 – complete appearance congruence); comorbid psychiatric disorder (according to anamnesis, catamnesis, and assessment of mental status at the time of treatment); the frequency of suicidal activity in groups depending on the studied positions.

For a more detailed assessment of clinical and demographic factors affecting the quality of life, the data were analyzed in terms of the age when GI first emerged according to the stages of psychosexual development by Vasilchenko (parapubertal (up to 6 years), prepubertal (7–13 years), pubertal (14–17 years old), and the period of sexuality development (over 18 years old)).

Population

The data of 926 patients with complaints of GI were analyzed taking into account the diagnosis codes of the ICD-10: F64/ ICD-11: HA60. Of the 926 people, 40 (4.3%) did not meet the criteria for the diagnosis of "Transsexualism" and "Gender Incongruence" and were represented by a heterogeneous group of patients with psychotic symptoms, the leading symptom of which was the desire to "reassign gender". The ratio of FtM and MtF groups was 515 (55.7%) and 411 (44.3%) people. The median age of applicants was 24 years (13 to 65 years).

Statistical data processing was performed in the Statistica 10 (StatSoft Russia) program for Microsoft using parametric and nonparametric tests. In the case of a representative sample, the values ​​were given as mean and standard deviation M+m. In the case of a nonrepresentative sample, the values ​​were given as the median and the 25th and 75th quartiles – Me [Q1; Q3]. A  comparison of intergroup differences was performed using Student's T test or Mann-Whitney U test. In order to compare qualitative traits, Pearson's chi-square (χ²) was used. When testing statistical hypotheses, the critical significance level was taken equal to 0.05.

Results

Patients were divided by gender into two groups: MtF, n=411 (44.38%) and FtM, n=515 (55.62%). The average age at the time of applying to the SCPM was 24.0 years (from 13 to 65 years). For MtF, the average age was 27.9 years (from 15 to 65 years), and for FtM – 24.85 years (from 13 to 47 years). Prior to accepting themselves as a transperson, 43% of patients lived in rural areas, and 57% – in urban areas. Most of those living in rural areas began their steps toward socialization in the desired gender after moving to large cities due to the intolerant environment and the need to protect families from negative comments (Table 1).

As a rule, the majority of patients grew up in a two-parent family: 82.02% of people had two parents; 15.08% had one parent; and 2.09% were orphans. In a third of patients, parents were divorced while maintaining formal communication with former family members. Refusal to communicate on the part of parents was revealed in 15% of those who applied for medical help due to the family's rejection of the situation. Fifteen percent (n=139/926) of patients deprived of family support in serious life situations received efficient help from friends and activists of the transcommunity (assistance in providing housing, adaptation to society, employment, psychological support).

The educational level of patients who applied for medical help was mainly represented by higher and secondary vocational education: higher education (44.2%, n=410) and secondary vocational education (22.3%, n=206). Of the entire sample, 15.5% (n=143) were students of higher educational institutions, 2.3% (n=21) were schoolchildren, and 15.7% (n=128) had only secondary vocational education and did not start further education or stopped studying in educational institutions due to the impossibility of adapting to a team when using passport data before changing documents to the desired ones.

It was noted that 6.3% (n=58/926) of patients had the experience of changing their documents to gender-neutral ones under the age of 18, before seeking medical help. The presence of gender-neutral passport data in adolescents under the age of 18 significantly improved socialization and allowed reducing the degree of dysphoria for passport data until the moment of official admission to gender-affirmative activities.

Of the entire group of transgender patients, 94.0% of people (n=870) worked. In the selected areas of professional activity, those who were allowed to work remotely with a minimum of social contacts and without the requirement to demonstrate passport data at work prevailed. Transgender people with a high level of education were often engaged in low-skilled types of work caused by the difficulty of employment due to appearance incongruence and fear of intolerant attitudes from potential employers and colleagues.

The first manifestations of GI in MtF and FtM emerged in 61.6% (n=571) in the prepubertal period (from 7 to 13 years), in 26.4% (n=246) – in the parapubertal period (up to 6 years), in 10.3% (n=96) – in the pubertal period (from 14 to 17 years old, the mean age was 14.6±0.85 years), in 1.4% (n=13) – in adulthood (from 18 years and older, the mean age of the first symptoms of GI in this group was 25.7±9.2 years).

The average age of accepting oneself as a transgender person was 17.0 years [ 15;20]. Steps to reduce gender dysphoria and receive specialized care were usually taken after the age of 20. The average age of seeking medical help to access gender-affirmative activities was 24 years.

 FtM individuals showed earlier emergence of GI symptoms than MtF patients (9.3+3.7 years versus 10.6+4.5 years, respectively, p=0.000), which led to earlier self-acceptance as transgender persons (17.2+4.02 years versus 19.9+6.8 years, respectively, p=0.000) and earlier medical care seeking (24.8+6.9 years versus 27.9+9.1 years, respectively, p =0.000).

The group with late access to medical care was dominated by MtF persons, as well as persons living in rural areas without the possibility of access to specialists who had information on the procedures and rules for providing assistance to transgender people.

The vast majority of patients with gender disorders (87.4%, n=797 out of 911) had already lived in the desired gender and social role from six months to 30 years at the time of applying for medical help (median 2.0 [1.0; 4.0] years), wore appropriate clothes, accessories, hairstyles, spoke about themselves in the appropriate gender, which somewhat reduced the severity of gender dysphoria, but made it impossible to use documents for social interaction.

Appearance congruence with the desired gender on a scale from 1 to 5 (points) averaged 4.0 points [ 3;5]. The share of MtF and FtM with a convincing appearance congruence was 41.51% and 58.49%, respectively. In the group with the early emergence of the first GI symptoms (up to 6 years), the indicator of appearance congruence was 4.2+0.81 points on the ACAS scale. When the first GI symptoms emerged in an older period (from puberty (14–17 years) and older), the appearance congruence to the associated gender was lower and constituted 3.2+1.06 points. Patients with earlier emergence of gender disorders had a more harmonious appearance.

The maximum problem for people with GI at the stage of social transition (congruence of appearance with the desired gender) was receiving elective and emergency medical care due to the difference in appearance and passport data. The outcome of seeking medical help depended on the awareness of specialists in this field and their individual tolerance.

According to the survey data, 490 (63%) patients refused to undergo routine medical examinations. Most of them (73%) were FtM individuals, often against the background of self-prescribed hormone therapy and achieved external masculinization. When hospitalized for emergency reasons in hospitals, many patients were forced to stay in wards that corresponded to their passport data, experiencing additional distress, getting into the center of public attention and, often, criticism, which forced them to interrupt beforehand the prescribed treatment courses.

Many of the patients with GI had the experience of "adapting" to prescribed social and gender roles. Attempts to "remake themselves" were noted by 66.8% of the entire population. So, at the emergence of the first symptoms of GI in parapubertal age (up to 6 years), 58.1% of persons (n=143) tried to "become like everyone else"; in prepubertal age (up to 13 years old) – 71.6% (n=409); in pubertal age (14–17 years old) –70.8% (n=68); in adulthood (over the age of 18) – 23% (n=3).

This experience was necessary for patients to understand their characteristics and assess the possibilities of adapting to the demands of society against the GI background. The duration of these stages was different, but in all cases, it stopped due to an increase in dysphoria for a social role, an increase in suicidal thoughts due to the progression of undesirable external changes in the body and figure, or the elimination of the reason for postponing the gender transition (acceptance by parents, having financial independence, obtaining adequate information, change of residence, etc.).

Attempts to adapt to a biological role, "adapt to the demands of society" were accompanied by episodes of autoaggression, depressive experiences and suicidal attempts (72% (n=83 out of 116)). Analysis of suicidal activity showed that the frequency of suicidal attempts was higher in persons who passed the stage of biological adaptation than in persons who did not make these attempts. The frequency of suicide attempts was higher in MtF and constituted 15.2% (n=62 of 406) against 10.6% in FtM (n=54 of 509).

During periods of attempting to live the social role assigned at birth, some individuals with GI got married. Marriages were made "out of necessity", at the insistence of parents during periods of remaking themselves, "to try to live like everyone else", "in the hope of finding an understanding of a partner and not being lonely." The minimum rate of marriage in groups with GI emergence in the parapubertal (up to 6 years) and prepubertal (from 7 to 13 years) period was 12.1% (n=30) and 12.2% (n=70), respectively. In the group with GI emergence at the age of 14–17 years, the frequency of marriage was 35.4% (n=34). The maximum marriage rate was observed in individuals with the emergence of the first GI symptoms over the age of 18 years (23%, n=3). In total, 102 children were born in marriages. Suicidal experience in individuals with GI was the highest in the unmarried persons: 76.7% (n=89 out of 116) – in single persons, 87.0% (n=101 out of 116) – in persons without children. In both groups, MtF persons significantly predominated (88.2% among singles and 53% among those who had children).

Social reasons that are frequent triggers for autoaggression and suicidal activity, according to patient questionnaires, were induced by parents' refusal to accept the situation and "educational measures", bullying in the school environment, including the attitude of teachers, a feeling of loneliness and hopelessness in the period of lack of adequate information about similar people, refusal of therapy for comorbid mental disorder due to fear of rejection of the situation or unpreparedness of specialists.

Most transgender patients had depressive episodes in the past or at the time of treatment (83.1% in the general group), and about a third (38.5%) had autoaggression (self-harm, cauterization, risky behavior, etc.). There were 1.3 suicide attempts per one patient with suicidal experience (from 1 to 5). Suicide attempts were recorded in 12.5% of patients (n=116 out of 926), while the number of suicide attempts was 125, which was more than one attempt per person.

 A high rate of suicidal activity was revealed in the group with a pronounced clinical syndrome of gender dysphoria, previously described as "nuclear transsexualism", and amounted to 50% (n=58 out of 116) in this group. "Marginal", milder GI was defined in 45% of patients (n=55 out of 116), and in three patients (2.6%) who were not included in the "Transsexualism"/"Gender Incongruence" group according to the diagnostic criteria, suicidal activity was revealed.

Additional psychiatric diagnoses in medical history and at the time of examination (comorbid psychiatric disorder) were found in 24.5% (n=229 out of 926) of patients and represented by three groups of diseases.

The first group of diseases (6.2%, n=58/926) was represented by potentially reversible neurotic, stress-related, and somatoform disorders which significantly decreased against the background of social transition, medical support, and pharmacotherapy.

The second group of diseases (14.1%, n=131/926) included underlying mental disorders that did not cause GI but aggravated the social adaptation of patients with GI. Many patients went through treatment by psychologists and psychotherapists, received long courses of therapy with antipsychotics and antidepressants with a reduction in the symptoms of comorbid disorder but the symptoms of gender dysphoria persisted, which allowed patients making informed decisions as their mental state stabilized. Most of these patients were committed to long-term therapy and had been observed by psychiatrists for years.

The third group of diseases (4.3%, n=40/926) included other mental states with "ideas of gender reassignment". It was mainly represented among patients with a late, often spontaneous, emergence of GI symptoms at the age of 18 or more (92.3%), and it was significantly more common in the group of biological males (p=0.01). In a more detailed examination, i.e., during a clinical and experimental psychological examination, as a rule, potentially reversible operational mental disorders, or productive symptoms that required pharmacological correction and subsequent assessment of GI symptoms, came to the fore.

Analysis of the impact of comorbid and other psychiatric disorders on suicidal activity revealed the following: 51.3% of patients who had suicidal experience (n=59/116) had an additional psychiatric diagnosis or were in a psychotic state at the time of treatment.

Patients with earlier emergence of GI symptoms more often had support from others (family, friends, loved ones). So, 71.6% of patients got support when GI emerged in the parapubertal period (up to 6 years), 70.8% (7–13 years) – in the prepubertal period, 41.6% (14–17 years) – in the pubertal period, and 15.3% (n=2) got the support of loved ones at the GI emergence after 18 years.

Married people with children (8.3%, n=48 out of 573) committed suicide more than 2 times less often than single patients (19.9%, n=68 out of 341).

Suicidal activity was noted less often in patients with appearance data corresponding to the desired gender, with a high score on the ACAS scale. With 4–5 points of appearance congruence, 10.7% (n=67 out of 622) of patients made suicide attempts, with appearance congruence from 1 to 3 points – 16.7% (n=49 out of 292), p=0.001 according to Pearson's χ².

A high percentage of people (50%; 463/926) was noted who started self-prescribed hormone therapy before applying for admission to gender-affirmative activities. Hormone replacement therapy was revealed in 73.7% (n=303/411) of MtF and 31.1% (n=160/515) of FtM. Therapy with hormones of the desired sex contributed to the emergence of the appearance features of the desired gender, reduced the degree of dysphoria, improved socialization, but often led to undesirable effects without medical support.

Low suicidal activity was determined when patients got early access to medical help, as well as when earlier steps to adapt to the desired gender were taken.

The reasons that affected the age of seeking medical attention (from 13 to 65 years in this study) at the standard stages of GI development were as follows: access to the information space (Internet, mass media), which became possible for consumers from the moment they received personal access to a computer connected to the Internet, or when watching TV shows on these topics. Patients often received information in a negative context before the advent of computer technology, which made it difficult to understand the situation and prolonged periods of "living between genders" or forced them to start risky self-prescribed hormone therapy on the advice of casual acquaintances or postpone steps to reduce gender dysphoria until real information was received. Thus, the results of this study showed that people who sought medical help after the age of 40 first learned about their characteristics and opportunities for access to activities to reduce dysphoria against the background of GI at the age of 23 years, during the completion of the stage of formation of the external genitalia and secondary sex characteristics, often in the presence of a family, work that required strict adherence to the external feminine or masculine framework of behavior. Many of those seeking medical help described the stages before receiving adequate information as "forced play", "survival", "waiting for the child to understand the situation", "a period of manipulation by loved ones and the risk of losing family support or parental rights".

The low quality of social life of patients with GI (difficulties in obtaining medical care, employment, socialization) is the reason for migration to countries with more loyal living conditions for transpeople. Twelve percent of patients with a high educational qualification and work experience were at the stage of preparation for leaving the Russian Federation, and 5% (n=46/926) lived and worked in other countries.

Discussion

Among the 926 patients, transmen predominated (FtM). Patients with gender disorders have a high level of education, but are forced to get low-skilled jobs, the level of professional and social adaptation depends on the social environment. Early symptoms of GI impede learning and obtaining professional skills before changing documents.

Access to timely medical care is possible in the central cities of Russia, but difficult in peripheral cities, and practically inaccessible in rural areas.

During socialization, there are no teachers in school groups who are informed about GI issues, which complicates the adaptation of children with GI and provokes sociophobic and neurotic reactions. Patients with GI that first emerged in the para- and prepubertal period often do not continue their education until the change of passport data to the desired ones. Some patients, in order to alleviate social dysphoria before receiving medical help on GI issues, resort to changing their passport data to gender-neutral ones.

About 80% of patients had the experience of life in a conscious field, and 50% were on hormone replacement therapy, which allowed them obtaining the desired appearance features, reduced the degree of gender dysphoria, and improved socialization.

 High suicidal activity (72%) was demonstrated in patients trying to socialize in the biological field, "remake oneselves", as well as having pronounced symptoms of gender dysphoria (up to 50% of cases, despite understanding one's own characteristics). The minimum percentage of suicidal activity was revealed in the group of patients who did not meet the F64/HA6 criteria.

Considering the obtained data on the predominance of the GI first symptoms in the studied group of people in the prepubertal period, the fact that there is no significant influence of upbringing, the role of society, and Internet resources on the development of sexual identity disorders in children in the period preceding puberty should be accepted. During this period (up to 13 years of age), children, as a rule, are under the influence of their parents, do not have the opportunity to make meaningful decisions for themselves, but feel discomfort from the role they play, not understanding the reasons for this. These states are often also associated with ideas of "ugliness, insanity", which makes the child control his/her steps and more demonstratively show the qualities of peers of his/her gender.

Taking into account the above-mentioned data and in order to improve social adaptation and prevent emotional and psychological suffering in individuals with GI, assistance to them is possible at the following levels:

1. Parents should be attentive to the non-standard behavior of the child, strive to create a trusting relationship and identify the causes of discomfort or non-standard behavioral and emotional reactions, get advice from a GI specialist in a timely manner, without resorting to severe restrictions and punishments for atypical behavior. If early GI symptoms are suspected, parents should carefully and amiably communicate with the child; it is advisable to use gender-neutral names, playful pseudonyms that will be comfortable for both the child and the whole family. It is recommended to buy clothes and accessories that are as neutral in style as possible, if the child does not want to look like other children of the same sex. Parents should try to protect the child from inappropriate comments and questions from the lay public. It is mandatory to make teachers aware of the characteristics of the child and methods to reduce stress in specific situations. In case of difficulties in learning against the background of gender dysphoria at school (using one’s name, difficulties when going to the toilet, embarrassment when using locker rooms, bullying), it is advisable to take measures to minimize stress for the child (transfer to mixed attendance mode, individual learning, distance learning, home education). With severe dysphoria to appearance changes, refusal to communicate, an increase in depressive experiences, the issue of medical care under the supervision of a psychotherapist or psychiatrist should be considered until the symptoms are eliminated. When children reject their passport gender, it is recommended to change their passport data to gender-neutral ones to facilitate social communication. When the difficulties of socialization are revealed during the period of choosing a profession and planning future professional activity, it is advisable to prefer a specialty making it possible to minimize the use of personalized data during face-to-face communication.
2. Educational institutions. Teachers should be aware of the peculiarities of children and adolescents with GI, which will allow avoiding difficult situations for a child in a peer group. It is advisable to use the "strengths" and abilities of the child, even if they are not typical for the biological sex (boys with GI could be involved in theatrical and creative activities, girls with GI could be engaged in tasks requiring responsibility, control, guardianship over the weak). The importance of a child with GI in a particular area will help raise self-esteem and reduce the risks of social exclusion.
3. Medical community. The task of specialists with practical experience in working with people with GI is to competently and methodically inform the medical community about the characteristics of this group of people, the risks of stigmatization, iatrogenicity, and suicidal behavior in case of incorrect treatment of a patient with GI. A special task of medical workers is to competently convey information to teachers and psychologists about the characteristics of children with early, often unconscious, symptoms of GI in children's groups. When obvious symptoms of GI are detected during childhood and adolescence, measures for social adaptation of a child in the desired gender (unisexual appearance) are recommended for reducing the risk of developing adaptation disorders, depression, autoaggressive and suicidal tendencies. If a comorbid chronic mental disorder is revealed that makes learning and socialization even more difficult, measures to select a planned therapy for the comorbid condition should be taken. When a patient presents with acute psychotic symptoms, in the structure of which ideas of gender reassignment are revealed, it is necessary to try to achieve compliance and cooperation for the period of therapy and observation, followed by the mental state examination and identification of GI symptoms. When addressing a patient with GI of the older age group, the peculiarities of this group should be considered: previously experienced stresses and possible risks for this category associated with late informing, a formed social circle, often not ready to accept changes, the difficulty in achieving the appearance of a perceived gender induced by the completed stage of formation of external genitalia and secondary sex characteristics, frequent somatic and mental burden.
4. Patient organizations. Currently, patient organizations are becoming full participants in the dialogue with the medical community and the state on the healthcare system development when considering this specific problem both in terms of somatic and mental health. A feature of transgender patient organizations is peer-to-peer consultations, which allows people obtaining timely support and information about their problem from a person with comparable experience (assistance in self-acceptance, adaptation of the environment, the possibility of obtaining affordable medical care for people with GI in a particular region). Obtaining first-hand information with a description of the optimal strategies, problems, and risks of the trans transition allows reducing social deprivation and social phobia and providing a more successful solution to personal problems.

Conclusion

Among those who applied for gender-affirmative medical care, 44.38% of patients were MtF, and 55.62% were FtM. The average age at the time of applying for medical help was 24.0 years (from 13 to 65 years). The educational level of patients was mainly represented by higher (44.2%) and secondary vocational education (22.3%); 43% of persons lived in the village, and 57% – in urban areas. The majority of those who sought medical care grew up in a two-parent family (82.02%).

The first manifestations of GI in transpatients emerged mainly in the prepubertal (26.4%) and parapubertal (61.6%) periods (up to 13 years). The average age of self-acceptance for a transgender person was 17.0 years. Steps to reduce gender dysphoria and receive specialized care were mainly taken after the age of 20. The average age of seeking medical help to access gender-affirmative activities was 24 years. The vast majority of patients with gender disorders (87.4%) at the moment of applying to medical care had already lived in the desired gender and social role from six months to 30 years. The proportion of MtF and FtM with convincing appearance congruence with the desired gender was 41.51% and 58.49%, respectively.

Most of the transgender patients had depressive episodes (83.1%), and a third (38.5%) of patients had autoaggression. Additional psychiatric diagnoses (comorbid psychiatric disorder) were present in 24.5% of patients and were represented by three groups of diseases: the first group (6.2%) – potentially reversible neurotic disorders associated with stress and somatoform disorders; the second group (14.1%) – background mental disorders that did not the induce GI but aggravated the social adaptation of patients with GI; the third group (4.3%) – other mental states with "ideas of gender reassignment" represented mostly among patients with late emergence of GI symptoms at 18 years of age or older (92.3%).

In order to improve social adaptation and prevent emotional and psychological suffering in people with GI, assistance at several levels should be provided (family, educational institutions, medical community, patient organizations).