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International Journal of Transgender Health logoLink to International Journal of Transgender Health
. 2024 Sep 2;27(2):647–661. doi: 10.1080/26895269.2024.2397720

The gender congruence and life satisfaction scale for transgender and gender-diverse youth (GCLS-Y): A validation study with samples from the UK and US

Bethany A Jones a, Alisha L Nguyen b,c, Gina M Sequeira d, Shane D Morrison c,e, Liam Cahill a,✉
PMCID: PMC13015035  PMID: 41891077

Abstract

Background

There are currently no good quality psychometric tools available to assess multi-dimensional outcomes for trans and gender diverse youth. A tool is needed to develop a stronger evidence base regarding the evaluation of gender-affirming healthcare for the population.

Aim

The current study aimed to adapt and validate the Gender Congruence and Life Satisfaction Scale for young trans and gender diverse people (GCLS-Y) with young trans and gender diverse people aged 14-19 living in the United Kingdom (UK) and the United States (US).

Method

Initially, the GCLS-Y was adapted through expert consultation and discussion with trans and gender diverse youth to ensure it is meaningful and relevant. A survey that included the GCLS-Y and other psychometric measures that assessed gender incongruence, mental health and wellbeing to determine convergent validity and social desirability to examine discriminant validity was completed by 307 trans and gender diverse youth (n = 175 in the US and n = 132 in the UK).

Findings

Exploratory Factor Analysis supported a 5-factor model that was assessed as conceptually accurate. The final version of the GCLS-Y included 38 items with the following subscales: Psychosocial Implications of Gender Distress, Incongruence and Dysphoria related to Chest, Incongruence and Distress related to Genitalia, Social Perceptions of Gender, and Life Satisfaction. The measure was also found to be valid and reliable.

Conclusions

The GCLS-Y is a psychometrically sound tool that can be used to assess multidimensional outcomes among trans and gender diverse youth (14-19 years) related to mental health and wellbeing, gender incongruence and distress, and social experiences of gender. The tool can support the development of evidence-based policy, which has implications for legislation, healthcare funding, and broader societal attitudes.

Keywords: Gender congruence, life satisfaction, mental health, wellbeing

Introduction

The demand for gender-affirming care that addresses gender dysphoria (i.e. distress associated with gender incongruence) from a medical and psychosocial perspective among trans and gender diverse youth is increasing (Coleman et al., 2022; Jessen et al., 2021; Lee & Rosenthal, 2023). When compared to cisgender youth, mental well-being is much poorer in young trans and gender diverse people (Price-Feeney et al., 2020). Originating from Minority Stress Theory (Hendricks & Testa, 2012; Testa et al., 2015), experiences of marginalization and oppression are most commonly cited as the catalyst for psychological distress in the trans and gender diverse community. In a recent study, discrimination was found to predict poor mental health through a lack of belonging and increased loneliness (Liss & Wilson, 2022). Lack of affirmative parental support (e.g. using correct pronouns and preferred names) has also been found to increase loneliness, anxiety, and depression, as well as reduce perceived well-being (Barras & Jones, 2024; Jones et al., 2023; 2024). To avoid negative social reactions, trans and gender diverse youth may choose to conceal their gender from immediate social groups such as their family and friends (e.g., Jones et al., 2023; 2024) or in broader social contexts (e.g. at school, healthcare settings) to avoid structural discrimination (Johns et al., 2021; McKay & Watson, 2020). The inability to live authentically among these important social groups and feel a sense of belongingness in society has been associated with significant psychological distress and poorer life satisfaction (Jones et al., 2023; 2024; Katz-Wise et al., 2018; Weinhardt et al., 2019).

Trans and gender diverse youth also often characterize their gender dysphoria with high levels of body dissatisfaction stemming from gender incongruence (Jessen et al., 2021; McGuire et al., 2016; Sequeira et al., 2017). Owing to the subjective nature of gender dysphoria (Jessen et al., 2021), some (but not all) trans and gender diverse youth may wish to access gender-affirming care, which may involve a reversible puberty blocker following a mental health assessment and care (Coleman et al., 2022). Older trans and gender diverse youth may wish to access gender-affirming hormones and, eventually, chest surgery, which is available in some countries before the age of 18 (Coleman et al., 2022). Genital surgery is not available until after a person’s 18th birthday in most countries. Gender-affirming medical interventions are associated with increased body satisfaction and a reduction in gender incongruence (Kuper et al., 2020; Sequeira et al., 2017), as well as a reduction in depressive symptoms and suicidality (Tordoff et al., 2022). However, trans and gender diverse youth report several barriers to accessing gender-affirming healthcare, which have included the requirement to come out to parents/carers and have a supportive relationship to enable consent to be obtained, extensive wait times and cost (for countries not in a national healthcare system) and discriminatory experiences from healthcare professionals (Kearns et al., 2021; Pullen Sansfacon et al., 2021). Several countries worldwide also impose legislation that can prevent or make access to gender-affirming care challenging.

Gender incongruence and dysphoria can also be felt in response to how others perceive and respond to one’s gender and expression and, consequently, validate their gender (Jessen et al., 2021). Similar to cisgender youth, research has found trans and gender diverse young people’s body image to be under sociocultural influence and susceptible to binary gendered body ideals (e.g. men are expected to have facial hair and a lower voice and women are not) (McGuire et al., 2016; Romito et al., 2021). Research has evidenced the significant psychological distress experienced in response to misgendering, deadnaming and questioning of gender in social contexts (e.g. Galupo et al., 2020). Androgenous gender expression has been found to liberate trans and gender diverse people from sociocultural notions of binary gender and body ideals (Galupo et al., 2021) and, therefore, may explain why trans and gender diverse people who identify outside the binary have been found to report more body satisfaction compared to trans and gender diverse people who identify within the binary (Jones et al., 2019a).

Although in recent years, research has explored trans and gender diverse youth’s health and well-being, current understanding is somewhat limited by the lack of specific measures available to use with youth (e.g. Bowman et al., 2022; Kamran et al., 2023; Sequeira et al., 2017). The evidence base concerned with gender-affirming medical interventions (GAMIs) in trans and gender diverse youth has also been hampered by methodological limitations, including a lack of robust outcome tools (Coleman et al., 2022). In a systematic review, Kamran et al. (2023) highlighted a dearth of measures created for the trans and gender diverse community to assess important outcomes and stakeholder work was needed to develop better-quality tools. The few measures available have been developed with adults and, therefore, do not capture the unique experiences of trans and gender diverse youth (e.g. parental rejection and school experiences). They also tend to focus solely on body dissatisfaction associated with gender-specific parts of the body, such as the Utrecht Gender Dysphoria Scale (Cohen-Kettenis & Van Goozen, 1997) and the Hamburg Body Drawing Scale (Becker et al., 2016). Also, most of these measures do not include non-binary identities, which limits their applicability across the entire trans and gender diverse population.

Concerning mental health, generic measures tend to be used (e.g. Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001) and Hospital Anxiety and Depression Scale (HADS-14; Zigmond & Snaith, 1983), which do not capture the unique roots of psychological distress trans and gender diverse youth experience (e.g. transgender prejudice; Hendricks & Testa, 2012). The lack of specific tools designed for and validated with trans and gender diverse youth also has clinical implications for gender services. Evaluating care can be time-consuming, and there is a lack of consistency in how this is done. Therefore, self-report measures consistently implemented across services can facilitate robust evaluation when developed with and for trans and gender diverse people (Coleman et al., 2022). This evidence base will also support the development of better policy and best practice recommendations for the care of trans and gender diverse youth (e.g. the Standards of Care; SOC). Additionally, tools that have a mental health component can support healthcare practitioners in gender services to identify problematic levels of psychological distress and make referrals to specialist services to ensure trans and gender diverse youth are appropriately supported. Within mental health services, such tools can improve care by facilitating an assessment for gender incongruence and measuring progress (concerning mental health outcomes) in a meaningful way across the treatment program.

The Gender Congruence and Life Satisfaction Scale (GCLS; Jones et al., 2019b) is a holistic measure that simultaneously assesses psychological well-being, gender and body incongruence, and life satisfaction. The tool was designed with and validated for use with trans and gender diverse adults and has been used widely in research (e.g. Cusack & Galupo, 2021; Goldbach et al., 2023; Julian et al., 2021; Lindley & Galupo, 2020) and clinical practice. It has seven subscales that capture psychological functioning, satisfaction with secondary sex characteristics, emotional intimacy, and life satisfaction. However, the GCLS is not currently validated in people under 17. Given this and the need for a holistic measure of trans and gender diverse youth’s well-being, this paper aimed to do the following:

  1. Adapt the GCLS for trans and gender diverse youth (GCLS-Y; aged 14-19) by ensuring items are meaningful and relevant to their experiences.

  2. Validate the GCLS with trans and gender diverse youth in US and UK samples (GCLS-Y).

Method

Phase 1: Adaption of the Gender Congruence and Life Satisfaction – Youth (GCLS-Y)

Expert panel adaptions

Initially, the authors reviewed the adult version of the GCLS-Y and based on their expertise in working with young trans and gender diverse individuals in research and practice, they edited or removed items that were not felt to be suitable for the youth version. Questions about intimate and sexual behavior were removed (“I have felt satisfied with my sex life”), and or reframed the item (“I have not been physically intimate with other people” was amended to “I have found it difficult to be physically close to people”). Given the high prevalence of self-harm behavior in this demographic (e.g. Butler et al., 2019; Rimes et al., 2020), questions relating to self-harming behavior were included (e.g. “I have thought about cutting or hurting my chest, genitals and/or surrounding areas”) instead of those asking directly about suicide. The item relating to suicidality was therefore removed (e.g. “I have thought about hurting myself or taking my own life”). The self-harm question, as well as those deemed as potentially sensitive given their focus on mental well-being, were moved to a subsection that was preceded with a content warning and signposts to relevant support if needed.

Similarly, we grouped questions assessing the same construct into separate subsections to enhance their readability and comprehension during the advisory panel discussions. Sub-section one included questions that related to life satisfaction (7 items). Sub-section two included items that related to gender dysphoria and how these impaired different aspects of life (e.g. relationships, school, hobbies; 9 items). Sub-section three was concerned with mental health and self-harm (4 items). Sub-section four assessed gender incongruence (7 items). Finally, sub-section five related to gender incongruence concerning the chest and genitalia specifically (10 items). Items in subsections three and five were deemed potentially sensitive and included a content warning and signposted to support.

Advisory panel findings

Young people who identified as trans and gender diverse and experts working in the field were then asked to provide feedback on the first draft of the adapted measure. To do this, we conducted a focus group with four young people from the US and collected survey responses from six US and seven UK young trans and gender diverse people. We also collected data from four UK and three US professionals (e.g. clinicians, surgeons, psychotherapists) via a survey.

Specifically, we provided a space for young trans and gender diverse people and professionals to comment on the initial draft of the measure. We specifically asked participants to comment on the content of the measure and their initial thoughts. This consisted of asking participants about the items and if they felt any should be removed, adapted or added. We also asked participants to comment on the language used. Specifically, we were interested in asking whether the participants felt that the language used was affirming, whether the language used in each item was understandable and whether the instructions were clear. We finally asked participants to comment on the structure of the measure. This comprised asking whether the items made sense in their current clusters or whether certain items needed moving around. We also asked about the length of the measure and whether participants felt this was appropriate. We concluded by giving the participants a space to provide any additional feedback. The exact questions we asked participants can be found in our open materials on the Open Science Framework: https://osf.io/pu5fh

Overall, the feedback from the advisory panel of young trans and gender diverse people and professionals was positive, the measure was affirmative, and the questions were easy to understand. They also felt the structure and signposting to support was appropriate. It was felt that the measure assessed all relevant constructs, but additional items could be added to represent trans and gender diverse youth’s experiences better. Young trans and gender diverse people commented that additional questions were needed to capture the support they receive from important social relation­ships (e.g. friends and family/caregivers). Given the significance of parental/caregiver relationships for mental health in trans and gender diverse youth (e.g., Barras & Jones 2024; Jones et al., 2024), we included the following questions: “I have felt satisfied with my friends/parents or caregivers” (Q3 & Q4), “I have felt satisfied with the support I have received from my friends/parents or caregivers”(Q7 & Q8).

Concerning mental health, the advisory panel of young trans and gender diverse people and professionals agreed with having a separate section and content warning. They commented, however, that they did not understand what “low mood” meant. We opted to change this to “low or depressed mood”, which they felt was more meaningful. Previously, there were not any items relating to hygiene practices, and young trans and gender diverse people and professionals felt this would be an important topic to include as some will avoid basic hygiene practices so they do not have to see or interact with parts of their body they feel extreme dysphoria with (e.g. genitalia). We, therefore, included the following question: “I have avoided basic hygiene practices such as showering or changing clothes because I am distressed about my gender”. Young trans and gender diverse people and professionals also commented on the lack of questions related to how other people perceived their gender and societal acceptance of their gender. We, therefore, included five questions (8-12) in section 4 of the questionnaire (e.g. “I have felt that there are aspects of my life in which I can present my gender authentically (e.g. at school, at work, at home”). In section 3, we also included an additional pronouns question to differentiate between pronouns used, whether talked about or talked to (questions 4 and 5). Finally, a question relating to genital surgery was removed from the questionnaire as we did not feel it was relevant given the age of participants and the inability to access this intervention for the majority of the target population (trans and gender diverse youth aged 14-19).

Phase 2: Validation of the Gender Congruence and Life Satisfaction – Youth (GCLS-Y)

Participants

Trans and gender diverse youth aged between 14-19 were recruited from either 1) the UK via support organizations or 2) the US by advertising to individuals under the care of a gender identity clinic. Participants were offered a $10 or £10 shopping voucher for participating. Participants were encouraged to pass the study information to other trans and gender diverse youth. The Social Sciences ethics committee at Nottingham Trent University granted a favorable ethical opinion.

Our sample comprised 317 participants. We removed ten participants as they did not meet our inclusion criteria (n = 9) or did not pass our attention checks (n = 1). Our final sample comprised 307 participants aged 14 to 19 (Mage = 16.89, SDage = 1.28). Of those, 175 participants reported living in the US and 132 in the UK. Table 1 displays further demographic information for our sample. As shown in Table 1, many participants did not use a valid ethnicity category (e.g. stating “British”) and were therefore categorized as”undefined”.

Table 1.

Demographic information for the total sample and divided by country.

Demographic Question UK US Total
  n (%) n (%) n (%)
Gender      
 Trans or Transgender 81 (61.36) 74 (42.29) 155 (50.49)
 Trans Man 3 (2.27) 22 (12.57) 25 (8.14)
 Woman 14 (10.61) 10 (5.71) 24 (7.82)
 Man 6 (4.55) 16 (9.14) 22 (7.17)
 Multi (Multiple) Genders 8 (6.06) 14 (8.00) 22 (7.17)
 Non-Binary 7 (5.30) 13 (7.43) 20 (6.51)
 Trans Masculine (Trans Masc) – 8 (4.57) 8 (2.61)
 Gender Queer 2 (1.52) 3 (1.71) 5 (1.63)
 Gender Questioning 2 (1.52) 3 (1.71) 5 (1.63)
 Gender Diverse 4 (3.03) – 4 (1.30)
 Trans Woman 1 (.76) 3 (1.71) 4 (1.30)
 Trans Feminine (Trans Fem) 2 (1.52) 1 (.57) 3 (.98)
 Demiboy – 3 (1.71) 3 (.98)
 Transsexual Man1 – 1 (.57) 1 (.33)
 Gender Fluid 1 (.76) – 1 (.33)
 Agender – 1 (.57) 1 (.33)
 Bigender – 1 (.57) 1 (.33)
 Demigirl – 1 (.57) 1 (.33)
 Xenogender 1 (.76) – 1 (.33)
 Unlabeled – 1 (.57) 1 (.33)
Ethnicity      
 White 31 (23.49) 112 (64.00) 143 (46.58)
 Undefined 68 (51.52) 13 (7.43) 81 (26.38)
 Mixed or Multiple Ethnic Groups 7 (5.30) 20 (11.43) 27 (8.79)
 Black/ African/Caribbean/Black British 24 (18.18) 1 (.57) 25 (8.14)
 African American – 19 (10.86) 19 (6.18)
 Asian 2 (1.51) 4 (2.29) 6 (1.95)
 Hispanic or Latino – 6 (3.43) 6 (1.95)
Living Situation      
 With Parents/Siblings in Family Home 114 (86.36) 169 (96.57) 283 (92.18)
 With Friends 12 (9.09) 3 (1.71) 15 (4.89)
 On my own 4 (3.03) 1 (.57) 5 (1.63)
 With Spouse (i.e. significant other) 1 (.76) 1 (.57) 2 (.65)
 Other 1 (.76) 1 (.57) 2 (.65)
Are you currently using gender-affirming hormones?      
 Yes 77 (58.33) 120 (68.57) 197 (64.17)
 No 55 (41.67) 55 (31.43) 110 (35.83)
Are you currently using hormone blockers?      
 Yes 58 (43.94) 71 (40.57) 129 (42.02)
 No 74 (56.06) 104 (59.43) 178 (57.98)
Have you undergone chest surgery?      
 Yes 6 (4.55) 26 (14.86) 32 (10.49)
 No 125 (94.70) 148 (84.57) 273 (89.51)
Are you satisfied with the stage of your medical transition (i.e. you do not wish to undergo further intervention)?      
 Yes 26 (19.70) 25 (14.29) 51 (16.72)
 No 105 (79.55) 149 (85.14) 254 (83.28)
Are you currently under the care of a gender identity service?      
 Yes 14 (10.61) 90 (51.43) 104 (33.88)
 No, I have not sought care from a gender identity clinic 66 (50.00) 41 (23.43) 107 (34.85)
 No, but I have previously 23 (17.42) 28 (16.00) 51 (16.61)
 No, I have been referred, but I am on a waiting list 29 (21.97) 16 (9.14) 45 (14.66)
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Notes. The total number of responses may not equal the number of participants due to missing responses. Only the demographic options used by our participants are included.

Materials and procedure

Interested participants were asked to read an information sheet and sign a consent form before taking part in a short online survey hosted on Gorilla (https://app.gorilla.sc/). Given the sensitive nature of some questions, participants were not obliged to answer questions they did not want to and could leave the survey at any stage. They were also periodically signposted to sources of support. Participants were asked to complete the following measures in randomized order.

Gender Congruence and Life Satisfaction was assessed using the the newly adapted GCLS-Y. Following the advisory panel, the adapted measure consisted of 39 items. These items were clustered into sub-sections to aid in readability and to allow us to provide content warnings and sources of support for subsections three and five. As mentioned, the measure was administered in several subsections, including life satisfaction (7 items; e.g. “I have felt satisfied with school/college/work”), gender dysphoria (9 items; e.g. “I have been unable to leave the house because I am distressed about my gender”), mental health and self-harm (4-items; e.g. “I have thought about cutting or hurting areas of my body because I am distressed about my gender”), gender incongruence (7 items; e.g. “I have felt comfortable with how others have perceived my gender”) and gender incongruence with respects to the chest and genitalia (10-items; e.g. “I have felt like my chest does not match my gender identity”).

Participants were asked to respond to each statement, thinking about how frequently they felt what was described in each statement in the past six months. They responded on a five-point rating scale ranging from 1 (never) to 5 (always). Several items across the measure were reverse-scored (see Table 2). Higher scores on the measure reflected greater gender congruence and life satisfaction. Scores were calculated by creating a mean score for each participant.

Table 2.

Factor loadings, proportion of explained variance and McDonald’s omega values final five factor 38-item GCLS-Y.

Item Factor 1 Factor 2 Factor 3 Factor 4 Factor 5
Factor 1: Psychosocial Implications of Gender Distress          
9. I have avoided social situations and/or social interactions because I am distressed about my gender (R) .53 .16 −0.04 .06 .17
10. I have not gone to school, college or work because I am distressed about my gender (R) .63 −0.03 .09 −0.01 −0.17
11. I have not been able to have close relationships with other people (e.g. friends and family) because I am distressed about my gender (R) .60 −0.04 .12 .03 −0.01
12. I have been unable to leave the house because I am distressed about my gender (R) .61 .05 .12 .04 −0.14
13. I have found it difficult to make friends because I am distressed about my gender (R) .71 −0.04 −0.06 −0.05 .16
14. I have felt that life is meaningless because I am distressed about my gender (R) .63 −0.09 .15 .08 .12
15. I have not enjoyed life because I am distressed about my gender (R) .53 .16 .08 .12 .16
16. I have not engaged in any of my usual hobbies because I am distressed about my gender (R) .69 −0.09 −0.02 .03 −0.12
17. I have avoided basic hygiene practices such as showering or changing clothes because I am distressed about my gender (R) .52 .11 .05 −0.05 −0.09
18. I have thought about cutting or hurting areas of my body because I am distressed about my gender (R) .58 .13 .06 .02 −0.08
19. I have suffered from anxiety because I am distressed about my gender (†) (R) .45 .26 −0.11 .08 .34
20. I have suffered from low or depressed mood because I am distressed about my gender (R) .46 .21 .10 .15 .20
28. I have felt that I do not belong in society because of my gender identity (R) .35 .09 .22 .06 .23
32. I have felt comfortable disclosing my gender identity to others .31 −0.13 .29 .02 .09
Factor 2: Incongruence and Dysphoria related to Chest          
34. I have felt so distressed about my chest that I have not been able to have a fulfilling life (R) .28 .58 −0.03 .10 −0.20
35. I have felt like my chest does not match my gender identity (R) −0.13 .77 – – .17
38. I have felt extremely distressed when looking at my chest (R) .10 .71 −0.01 .07 −0.13
Factor 3: Life Satisfaction          
1. I have felt satisfied at school, college or work (†) −0.06 .26 .38 .13 −0.14
2. I have felt satisfied with my hobbies .17 −0.11 .36 .09 −0.32
3. I have felt satisfied with my friends .23 −0.09 .45 −0.06 −0.21
4. I have felt satisfied with the support I have received from my friends .18 −0.17 .54 −0.05 −0.15
5. I have felt satisfied with my general health .08 .25 .35 – −0.12
6. I have felt satisfied with life .08 .12 .39 .14 −0.11
7. I have felt satisfied with the relationship I have with my parents or caregivers −0.03 .05 .53 – .02
8. I have felt satisfied with the support I have received from my parents or caregivers .04 −0.11 .58 .07 .10
24. I have felt satisfied with the pronouns that others use when talking about me −0.02 .06 .64 – .07
25. I have felt satisfied with the pronouns that others use when talking to me −0.02 −0.07 .61 −0.06 .02
30. I have felt that there are aspects of my life in which I can present my gender authentically (e.g. at school, at work, at home) .12 −0.08 .51 −0.03 −0.04
Factor 4: Incongruence and Dysphoria related to Genitalia          
33. I have felt distressed when touching my genitals as they do not match my gender identity (R) −0.01 −0.04 −0.08 .84 .08
36. I have felt unhappy about my genitalia since they do not match my gender identity (R) −0.12 .02 – .78 .06
37. I have been unable to have a fulfilling life because of the distress relating to my genitalia (R) .19 .03 .05 .58 −0.23
39. I have felt extremely distressed when looking at my genitals (R) .05 .03 .01 .70 −0.12
Factor 5: Social Perceptions of Gender          
22. I have felt that my body hair conflicts with my gender identity, either because I have it and do not like it or because I would like to have it (R) .18 −0.12 .16 .15 .43
26. I have felt that my voice has affected the way other people have perceived my gender identity, which has been distressing for me (R) .09 .17 .13 .13 .46
27. I have felt that my facial hair conflicts with my gender identity, either because I have it and do not like it or because I would like to have it (R) .04 .02 .31 .24 .34
29. I have felt that other people close to me (e.g. friends and family) do not understand my gender identity (†) (R) .14 .09 .30 .05 .39
21. I have felt comfortable with how others have perceived my gender – .17 .58 −0.12 .22
23. I have found it distressing that others do not address me according to my gender identity (†) (R) −0.02 .41 −0.02 .05 .38
Variance Explained (%) 33 25 16 15 11
McDonald’s Omega .90 [.87, .91] .76 [.72, .81] .81 [.78, .85] .81 [.77, .84] .81,
[.77, .84]
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Notes. Item 31 was removed during the initial stages. Cross-loaded items were retained in their respective factors for conceptual reasons. Salient factors are in bold. (R) indicates reverse-scored items. (†) indicates items that cross-load onto more than one factor. Values contained within square brackets represent the 95% confidence interval.

Gender Incongruence was assessed using the Transgender Congruence Scale (TCS; Kozee et al., 2012). This measure has 12 questions, of which nine correspond with “appearance congruence” (e.g. “I do not feel that my appearance reflects my gender identity”; “I am generally comfortable with how others perceive my gender identity when they look at me”) and three relating to “gender identity acceptance” (e.g. “I am not proud of my gender identity”). Participants responded on a five-point rating scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree). The measure was used to assess convergent validity, and a mean score was calculated for each subscale and global score. Higher scores reflected greater congruence overall and for each subscale. Internal consistency overall (ω = .84, 95% CI: .80, .87) and for both subscales (appearance congruence: ω = .88, 95% CI: .85, .90; gender identity acceptance: ω = .76, 95% CI: .70, .81) was good.

Anxiety was measured using the GAD-7 (Spitzer et al., 2006). Seven items (e.g. “How often have you been bothered by: Feeling nervous, anxious or on edge”) assess anxiety during the preceding two weeks on a four-point rating scale from 0 (Not at all) to 4 (Nearly every day). The sum was calculated, and a higher score indicated higher levels of anxiety. The measure was found to previously be reliable with a sample of trans and gender diverse youth (e.g. Moyer et al., 2019). Internal consistency for this measure was good (ω = .82, 95% CI: .78, .85).

Depression was measured using the PHQ-9 (Kroenke et al. 2001). Participants rated nine statements based on their feelings over the previous two weeks (e.g. “How often have you been bothered by having little interest or pleasure in doing things?”) on a four-point rating scale ranging from 0 (Not at all) to 4 (Nearly every day). The sum was calculated, and a higher score was indicative of higher levels of depression. The measure has been used previously with young trans and gender diverse people and is reliable (e.g. Moyer et al., 2019). Internal consistency among the current sample was good (ω = .79, 95% CI: .74, .83).

Well-being was measured using the Warwick Edinburgh Mental Well-being Scale (WEMWBS; Tennant et al. 2007). The measure includes 14 items (e.g. “I’ve been feeling optimistic about the future” on a five-point rating scale from 1 (None of the time) to 5 (All of the time). The sum was, and a higher score was representative of greater perceived well-being. The measure has been used previously with young trans and gender diverse people and is reliable. Internal consistency for the current sample was good (ω = .83, 95% CI: .79, .87).

Social desirability was used to assess discriminate validity using the Children’s Social Desirability Short Scale (Baxter et al., 2004). There are 14 items (e.g. Are you always polite, even to people who are not very nice?). Participants are asked to respond “Yes” or “No” to each item.

Demographic questions: participants were asked to report their age, gender identity, ethnic group, education or working status. They were also asked about their living conditions (i.e. who else they lived with) and whether they were residing in the UK or US. In terms of gender, they were asked about their social and medical transition and whether they were currently under the care of a gender identity service. Responses to these questions are outlined in Table 1.

Analytical process

We conducted our analysis in R. The data and analysis code that support our results can be found here: https://osf.io/pu5fh

For our primary analyses, we began by exploring the factor structure of the newly adapted GCLS-Y. We used an exploratory factor analysis employing a direct oblimin rotation, as we expected the items in the adapted GCLS-Y to be related. This is the same procedure used when evaluating the factor structure of the original GCLS. We used several methods to determine how many factors to retain. These are as follows. We initially assessed the (1) eigenvalues and (2) scree-plot. However, there are several limitations to using eigenvalues and scree-plots when determining the number of factors to retain (Courtney, 2013). As such, we also used (3) parallel analysis and (4) minimum average partial test, which are more accurate (Crawford et al., 2010). Our decision on how many factors to retain was based on evaluating each of these methods and making an informed decision.

After determining the number of factors to retain, we explored each item individually. We examined whether each item loaded sufficiently onto a single factor or whether an item loaded onto more than one factor (cross-loaded). Generally, items should have a factor loading of .30 or higher on a single factor (Stevens, 2002). If an item does not meet this threshold, it is a candidate for deletion. If an item cross-loaded onto multiple factors, then the authors examined the face validity of that item and determined which factor it conceptually and theoretically fit into best. This is the same procedure used when evaluating the factor structure of the original GCLS. We next evaluated the internal consistency and validity of the final measure. Internal consistency for each measure represents Omega (ω) calculated across 1000 iterations. For clarity, we also used this method to calculate the internal consistency for each of the measures used in this study (presented above). To assess the validity of the final GCLS-Y measure, we explored the zero-order Pearson correlations between the total GCLS-Y scores and each subscale and each of our measures mentioned above as per common practice (Bishop & Morrison, 2024). We assessed the construct validity of the final GCLS measure by evaluating the correlations between it and measures it should (i.e. convergent validity) and should not (i.e. discriminant validity) correlate with.

The final GCLS-Y measure is freely available to use and can be found on the OSF. If you use the measure in practice or research, please contact us using the details listed on the OSF so we can track its use. This also includes if you want to translate the GCLS-Y into a different language.

Results

Preliminary analyses

Before conducting our analyses, we identified a small number of missing responses (6; .05%) on the GCLS-Y measure. To ensure valid responses were not lost, we decided to impute those missing values using predictive mean matching across five imputations using the mice package in R. We checked and determined that these imputed values were plausible. We then assessed the appropriateness of our data for exploratory factor analysis (EFA). We determined that the assumptions of multicollinearity and sphericity were not violated and that our items displayed a good level of common variance. Owning to this, we proceeded with our analysis as planned.

Exploratory factor analysis (EFA)

Assessing the eigenvalues revealed that an 8-factor structure was the most appropriate. Contrastingly, evaluating the scree-plot indicated that a 3-factor structure was the most appropriate. Parallel analysis and the minimum average partial test revealed that a four to six-factor structure was the most appropriate. Given this, we evaluated whether a four, five or six-factor structure would most accurately represent our data. Neither a four or six-factor structure created conceptually or theoretically logical factors. In contrast, a five-factor structure created five distinct and conceptually accurate factors. As such, we decided to proceed with this five-factor structure (see Table 2).

We used several criteria to determine whether to retain specific items outlined above. One item (31; “I have avoided public bathrooms due to how other people might perceive my gender”) did not load onto any factor sufficiently (<.30). The authors felt that this item, while important, did not conceptually fit with the other items. We removed the item on those grounds. We then evaluated cross-loading (loading onto more than one factor at .30 or greater) items, and each of the authors determined whether the items made conceptual sense based on the factors with which they were aligned. Item two loaded highest with factor three (.37) but also had a high loading with factor five (-0.33). Conceptually, the authors felt that the item (“I have felt satisfied with my hobbies”) best aligned with factor three (life satisfaction). Item 19, “I have suffered from anxiety because I am distressed about my gender”, loaded highest with factor one (.43) but also loaded highly with factor five (.34). Conceptually, the authors felt the item was a better fit with factor one (psychological implications of gender). Item 23, “I have found it distressing that others do not address me according to my gender identity”, cross-loaded highly onto factor two (.40) and factor five (.39). As this item was related to social perceptions of gender, it was included within factor five. Item 29, “I have felt that other people close to me (e.g. friends and family) do not understand my gender identity”, loaded highest with factor five (.39). We felt it conceptually fit better with factor 3, which also loaded highly (.30) and, therefore, was placed in this factor. Finally, item 21, “I have felt comfortable with how others have perceived my gender”, loaded highest with factor three (.56) and factor five. Although the item loaded below the recommended threshold of .30 for factor five (.24), we felt it conceptually aligned best with factor five and, therefore, was included in this factor.

The final measure comprised 38 items. We re-ran our EFA, removing item 31. All items were conceptually and theoretically practical within their respective factors (Table 2). The five subscales were labeled as follows: Factor 1 - Psychosocial Implications of Gender Distress (n = 14), Factor 2 - Incongruence and Dysphoria related to Chest (n = 3), Factor 3—Life Satisfaction (n = 11), Factor 4 - Incongruence and Dysphoria related to Genitalia (n = 4), Factor 5 - Social Perceptions of Gender (n = 5). Internal consistency metrics for each subscale were good. Internal consistency for the overall measure was also good (ω = .92, 95% CI: .89, .93).

Validity

Next, we assessed the construct validity of the GCLS-Y. First, we assessed the univariate normality of each measure used in this study. We determined that the normality assumption was not violated as most measures have a skew or kurtosis between ±2 (George & Mallery, 2010). The well-being variable (measured using the WEMWBS) did exhibit a slight kurtosis (2.20). However, as this violation was minor and a visual inspection of the distribution indicated no substantial departure from normality, we proceeded with the analysis as planned per best practice (Kim, 2013).

Table 3 presents the zero-order correlations between each of our measures. For the GCLS-Y to demonstrate convergent validity, we expect the total score and the scores for each of the five factors (or subscales) to correlate highly and positively with measures that it should theoretically relate to. For instance, we expect higher scores on the GCLS-Y to correlate with more positive well-being (WEMWBS). We first examined the correlation between the GCLS-Y and the TCS scale (and its subscales). As expected, the GCLS-Y total and most factors were significantly positively correlated with the TCS total score and the TCS appearance congruence subscale. However, factor two (Incongruence and Dysphoria related to Chest) did not significantly correlate with the TCS gender identity acceptance subscale. This lack of association is theoretically logical, considering the TCS is concerned with identity pride and the GCLS-Y chest, which is related to satisfaction with this body area. Next, we examined the correlation between the GCLS-Y and each factor regarding well-being (WEMWBS) scores. Again, we found a moderate to strong correlation between GCLS-Y total and factor scores and well-being (WEMWBS).

Table 3.

Zero-order correlations.

Measure 1 2 3 4 5 6 7 8 9 10 11 12 13
1. GCLS-Y: Total – .91*** .50*** .70*** .57*** .69*** .56*** .45*** .45*** −0.37*** −0.48*** .50*** .10
2. GCLS-Y Factor One .89, .93 – .36*** .59*** .42*** .51*** .44*** .31*** .48*** −0.36*** −0.45*** .46*** .11
3. GCLS-Y Factor Two .41, .58 .26, .45 – .07*** .36*** .37*** .39*** .42*** .04 −0.30*** −0.22*** .16** −0.04
4. GCLS-Y Factor Three .64, .76 .51, .66 −0.05, .18 – .15** .36*** .38*** .23*** .51*** −0.27*** −0.46*** .58*** .10
5. GCLS-Y Factor Four .49, .64 .32, .51 .26, .45 .04, .26 – .30*** .24*** .19*** .20*** −0.14* −0.20*** .21*** −0.04
6. GCLS-Y Factor Five .63, .75 .42, .59 .27, .46 .26, .46 .19, .40 – .53*** .55*** .08*** −0.22*** −0.24*** .22*** .14*
7. TCS: Total .47, .63 .35, .53 .29, .48 .28, .47 .13, .34 .44, .60 – .94*** .44*** −0.26*** −0.27*** .37*** .11
8. TCS: Appearance .36, .54 .21, .41 .32, .50 .13, .34 .08, .29 .47, .63 .93, .95 – .12* −0.23*** −0.21*** .26*** .13*
9. TCS: Acceptance .35, .53 .39, .56 −0.07, .15 .42, .59 .09, .30 −0.03, .19 .35, .53 .01, .23 – −0.15* −0.23*** .39*** −0.03
10. Anxiety (PHQ-9) −0.47, −0.27 −0.46, −0.26 −0.40, −0.19 −0.37, −0.16 −0.25, −0.03 −0.32, −0.11 −0.36, −0.15 −0.33, −0.12 −0.26, −0.04 – .75*** −0.41*** −0.23***
11. Depression (GAD-7) −0.56, −0.39 −0.54, −0.36 −0.32, −0.11 −0.54, −0.36 −0.31, −0.09 −0.35, −0.14 −0.37, −0.16 −0.32, .10 −0.33, −0.12 .70, .80 – −0.53*** −0.26***
12. Well-being (WEMWBS) .42, .58 .36, .54 .05, .26 .50, .65 .1, .31 .11, .32 .27, .46 .15, .36 .30, .49 −0.5, −0.32 −0.60, −0.44 – −0.02
13. Social Des −0.01, .21 0, .22 −0.16, .07 −0.01, .21 −0.15, .08 .03, .25 −0.01, .22 .01, .23 −0.14, .09 −0.34, −0.12 −0.36, −0.15 −0.13, .10 –
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Notes. Pearson’s r above the diagonal, 95% CIs below the diagonal. *** p < .001, ** p < .01, * p < .05. GCLS-Y Factor One = Psychosocial Implications of Gender Distress, GCLS-Y Factor Two = Incongruence and Dysphoria related to Chest, GCLS-Y Factor Three = Life Satisfaction, GCLS-Y Factor Four = Incongruence and Dysphoria related to Genitalia, GCLS-Y Factor Five = Social Perceptions of Gender. TCS Appearance = TCS Appearance Congruence. Social Des = Social Desirability.

We also assessed whether the GCLS-Y was associated with psychological health and well-being measures. We expected that the GCLS-Y total and each factor would correlate negatively with anxiety (PHQ-9) and depression (GAD-7). That is, as GCLS-Y scores increase, self-reported anxiety and depression decrease. We found a moderate to strong negative correlation between the GCLS-Y total and each factor score with anxiety and depression. The correlation between factor four (Incongruence and Dysphoria related to Genitalia) and anxiety was the weakest.

We finally examined discriminant validity. We examined whether the GCLS-Y did not (or weakly) correlate with theoretically unrelated measures. As such, we compared the correlations between the total GCLS-Y scores and each factor to the participant’s social desirability scores. We found that the GCLS-Y, or factors one to four, did not significantly correlate with social desirability scores. We found that factor five (Social Perceptions of Gender) correlated significantly (albeit weakly) with social desirability. However, examining the lower confidence interval limit suggests that this finding should be interpreted cautiously.

Discussion

This study aimed to adapt and validate the GCLS-Y for young trans and gender diverse people (14-19 years). Before the current study, no measure was available that encompassed all of the requirements of such a measure simultaneously for adolescent populations. Measures used in clinical practice and research tended to have been developed with trans and gender diverse individuals over the age of 18, primarily assessing body and gender dysphoria from a binary perspective, and to assess mental health, generic measures validated with cisgender people were adopted. The current study presents a new measure, the GCLS-Y, that assesses the multidimensional nature of gender dysphoria and incongruence. This measure is inclusive of gender diversity and is validated with trans and gender diverse youth aged 11-19. Our analysis identified five subscales in the GCLS-Y: Psychosocial Implications of Gender Distress, Incongruence and Dysphoria related to Chest, Incongruence and Dysphoria related to Genitalia, Social Perceptions of Gender and Life Satisfaction. These subscales assessed the multidimensional experiences of trans and gender diverse youth as identified in previous research (Jessen et al., 2021) and were informed and affirmed by the young trans and gender diverse people in this study who supported the development of the GCLS-Y. The current study also affirms the GCLS-Y as a robust, valid and reliable measure that can be utilized both in research and clinical practice.

While there is an emerging evidence base regarding the evaluation of GAMIs for trans and gender diverse youth, this research has methodological flaws that affect the certainty of conclusions (Coleman et al., 2022). This is especially problematic given that legislative recommendations and decisions are often based on these findings (e.g. the UK CASS report). Nevertheless, this evidence base suggests that GAMIs do alleviate gender dysphoria and incongruence, and this is associated with improved psychological well-being in trans and gender diverse youth (e.g. Kuper et al., 2020; Tordoff et al., 2022). One way to achieve high-quality research in this area or overcome these methodological issues is to employ outcome measures, like the GCLS-Y, developed and validated for trans and gender diverse youth. Utilizing the GCLS-Y would enable uniformity of outcomes assessed and support with more conclusive findings, which is currently lacking. Additionally, we encourage the GCLS-Y to be used internationally to allow for more consistent and comparable data collection across different regions. This will help better shape best practice guidelines in future versions of the Standards of Care for trans and gender diverse people (SOC).

For practitioners, the GCLS-Y can be used to support assessment and treatment. During the initial assessment stage, scores either overall or across the GCLS-Y subscales can support healthcare professionals. For instance, overall or subscale scores on the GCLS-Y could be used by clinicians to spur conversations with patients concerning their care, prompt additional assessments, or determine if other services or support are warranted. While it is important to note that the GCLS-Y is useful in supporting healthcare professionals, it does not account for individualized care needs. As such, it should be used to support clinicians in providing gender-affirming care.

Limitations and directions for future research

The GCLS-Y is only validated in English; therefore, future research should validate the tool in different languages, like the adult version has been, to support the equality of high-quality trans and gender diverse healthcare for youth across the globe. While the GCLS-Y is valid and reliable in this study, readers should be mindful of the cross-sectional nature of the data. Therefore, future research should aim to implement a longitudinal design to support a robust evaluation of gender-affirming care.

We removed a single item during phase two as it did not load sufficiently onto any factor (“I have avoided public bathrooms due to how other people might perceive my gender”). Public bathroom access continues to be a source of stress for many trans and gender diverse people and a discussion point for policymakers (Harrison & Michelson, 2019). Likely, this item did not load onto a distinct factor as other items relating to how trans and gender diverse people navigate public spaces were not included. Other public spaces (e.g. changing rooms and hospital appointments) are also a source of stress for many trans and gender diverse people (Linander et al., 2019). While the GCLS-Y does not capture these experiences directly, future research may wish to develop a parallel measure which does.

Similarly, we did not collect data about the length of time young trans and gender diverse people in this study had been using blockers or hormones. Given their age, the length of time is likely to be short, but as in an adult population, we would expect to see a dose-response relationship for gender-affirming hormones. We also note that our sample largely reported living at home. Youth living at home likely have access to different sources of support, resources and safety systems relative to those who do not. However, while most of our sample reported living at home, this does not necessarily mean their home environment is supportive (Shelton & Bond, 2017).

We also note that despite our sampling approach being designed to recruit a range of identities across the trans and gender diverse umbrella, our sample identified as predominantly trans or transgender, with only a small percentage of our sample (6.51%) identifying as non-binary. While the GCLS-Y was designed to assess gender congruence and life satisfaction across trans and gender diverse populations, future research should explore this measure with a larger sample of non-binary youth to confirm its applicability.

Conclusion

In conclusion, the GCLS-Y is a multidimensional tool that can assess holistic outcomes in trans and gender diverse youth. The measure has been developed for and with trans and gender diverse youth and has proven to be psychometrically sound. This tool will support healthcare professionals in their care of trans and gender diverse youth, facilitate building a robust evidence base regarding the treatment outcomes of GAMIs for trans and gender diverse youth, and inform best practice guidelines. This will ensure high-quality care for trans and gender diverse youth around the globe.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Note

1

We acknowledge that the term transexual is outdated. However, consistent with APA recommendations, we use this term only to refer to our participants who explicitly used this to refer to themselves (American Psychological Association, 2015).

Funding Statement

The authors report receiving internal funding from Nottingham Trent University to support this research.

Disclosure statement

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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