Various sexual identities among a cohort of Italian adolescents: from their own perception of selves to social and healthcare acceptance

Various sexual identities among a cohort of Italian adolescents: from their own perception of selves to social and healthcare acceptance | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Various sexual identities among a cohort of Italian adolescents: from their own perception of selves to social and healthcare acceptance Pierluigi Diana, Anna Frugoni, Greta Ramundo, Cosimo Neglia, Maria Elisabeth Street, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4706981/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Gender incongruence (GI) is the conflict between the sex assigned at birth and the perceived gender identity, sometimes leading to significant distress (gender dysphoria). The WPATH Standards of Care (SOC) estimate that transgender youth make up approximately 3% of the global pediatric population, increasing to 8% when considering all gender-diverse identities. GI and perceived non-conforming sexual orientation can lead to reduced access to care and marginalization in non-inclusive socio-healthcare contexts. This study aims to overview the prevalence of different sexual identities among Italian adolescents, highlighting non-conforming gender identities and sexual orientations. Methods: A cross-sectional study used an online, anonymous questionnaire administered to adolescents aged 12 to 17 years at the Pediatric Clinic of the University Hospital of Parma, Italy, from January 2023 to April 2024. Informed consent was obtained from the adolescents and their parents. Results: Fifty-one adolescents [31 assigned female at birth (AFAB)] completed the questionnaire, with a mean age of 14.9 ± 1.4 years. Among them, 3.9% (all AFAB) reported GI causing significant distress. Among AFAB adolescents, 19.3% experienced gender-based discrimination, and about 13% desired to belong to a different gender at least once. Regarding sexual orientation, 13% identified as bisexual, 3.2% as asexual, and 16.1% were unsure. Among males assigned at birth (AMAB), 100% identified as cisgender, and 5% were homosexual. Sexual activity was reported by 41.9% of AFAB adolescents (3.2% homosexual, 38.7% heterosexual) and 15% of AMAB peers (all heterosexual). Most adolescents (68.6%) felt comfortable discussing sexual identity topics with their pediatrician/general practitioner. Conclusions: The study indicates that 3.9% of the adolescents experience GI and a notable percentage exhibit non-conforming sexual orientations. A significant proportion of adolescents wish to discuss their sexual orientation and gender identity with their healthcare providers, underscoring the need for medical competence and inclusive dialogue. adolescents gender dysphoria gender incongruence sexual identity sexual orientation transgender 1. Background Gender incongruence (GI) is defined as a condition where an individual's gender identity does not align with the gender assigned at birth [ 1 ]. The diagnosis of "transsexualism" was included in the International Classification of Diseases and Related Health Problems in 1978 (ICD-9) [ 2 ]. It was classified under the section "Sexual Deviations and Disorders" within the category of neurotic disorders, personality disorders, and other non-psychotic mental disorders, placing it alongside paraphilias and sexual deviations. In 1992, the tenth revision of the International Classification of Diseases (ICD-10) came into effect [ 3 ]. Unlike ICD-9, ICD-10 categorized gender identity disorders into a separate group of disorders of sexual preference and sexual dysfunctions, although they remained under the category of personality and behavioral disorders in adults (F60-F69). In 2018, with the publication of the updated ICD, the World Health Organization (WHO) led the process of depathologizing transsexuality. In ICD-11, the term "transsexualism" was replaced with "Gender Incongruence." This new entity was moved from the chapter on mental disorders to a newly created chapter titled "Conditions Related to Sexual Health" [ 4 ]. Gender dysphoria (GD) is a more complex phenomenon characterized by clinically significant distress resulting from the incongruence between an individual's gender assigned at birth and their actual gender identity or expression [ 5 ]. Various studies have demonstrated how transgender or non-binary children and adolescents are compelled to endure a disproportionate level of poor psychological health and are disadvantaged in development and academic performance compared to their cisgender peers [ 5 – 7 ]. International studies have reported an increase in referrals to gender identity care units. A study conducted in Spain from 2012 to 2021 observed a tenfold increase in the number of individuals referred to specialized gender care centers, rising from 18 subjects in 2012 to 189 in 2021 [ 8 ]. Although several studies have demonstrated the increase in cases and the relevance of the condition, the topic remains a taboo and continues to be subject to stigma. The direct consequence is a general lack of preparedness among doctors and pediatricians and the need for better networks among pediatricians and other medical professionals [ 7 , 9 ]. Research on gender identity development in adolescents is clearly lagging behind. Studies involving individuals with gender dysphoria and disorders of sexual development indicate that adolescence, with its changing social environment and the onset of physical puberty, appears to be the most critical period for the development of a non-conventional gender identity, as well as being the most stressful period [ 10 ]. Terms related to sexual identity are summarized in Table 1 . Table 1 Sexual identity’s related terms. Term Definition Gender Identity One’s inner perception of being male, female, both or neither Sex assigned at birth The sex assigned by a doctor at birth based on external anatomy, chromosomes, etc. AFAB is an abbreviation for “assigned female at birth”. AMAB is an abbreviation for “assigned male at birth” Transgender People who cross delineate categories of gender based on their assigned sex at birth. Cisgender People who identify themselves with a gender consistent with their sex assigned at birth Sexual orientation The romantic sentimental or sexual attraction to other individuals Gay A person emotionally or sexually attracted to people of the same gender Lesbian A woman emotionally or sexually attracted to other women Bisexual A person emotionally or sexually attracted to more than one sex or gender Asexual A person who experiences less or no sexual attraction or interest in sex Gender expression The way someone presents their gender Sexual Identity The complex result of sex assigned at birth, gender identity, gender expression and sexual orientation of one’s person In recent years, there has been a significant increase in the number of children and adolescents seeking support for GD and GI [ 11 ]. There has been a shift over time in the demographics of referrals to specialized facilities: previously, individuals assigned male at birth (AMAB) were more commonly involved. However, in the last decade, there has been a more significant number of individuals assigned female at birth (AFAB). A study conducted in the UK analyzed gender care referrals from 2017 to 2020. Out of a total of 9555 referrals, 5835 (62.3%) were AFAB, while the remaining 37.7% were AMAB [ 12 ]. Another study conducted in the United States aimed to determine the percentage of patients seeking gender affirmation surgery (GAS). Out of a total of 48019 patients, 7.7% were aged between 12 and 18 years old; 52.3% were between 19 and 30 years old; 21.8% were between 31 and 40 years old [ 13 ]. According to the most recent data available in the eighth edition of the WPATH Standards of Care (SOC 8), young transgender individuals represent approximately 3% of the global pediatric population (and up to 8% when including all gender-diverse identities) [ 14 ]. In recent years, the prevalence of GD and gender identity among adolescents has risen significantly, with a marked increase in referrals to gender identity services and a shift in demographic patterns (especially among AFAB). This growing visibility reflects a broader recognition of gender diversity but also underscores the psychological distress and social challenges that often accompany GD, particularly during puberty, a period known to amplify identity-related stress. Despite this upward trend, many healthcare systems remain ill-equipped to provide appropriate, inclusive, and informed support. In Italy, in particular, there is a scarcity of population-specific data on adolescents navigating gender identity questions, and a notable lack of comprehensive sexual and gender education in schools. Against this backdrop, the present study aims to fill a critical gap by investigating the prevalence and experiences of gender-diverse and non-conforming sexual identities among Italian adolescents, thereby informing more responsive and culturally sensitive healthcare and educational practices. 2. Methods This was a cross-sectional study. The study population was made up of adolescents aged 12–17 years who were hospitalized at the Pediatric Clinic of the University Hospital of Parma, Italy, between January 2023 and April 2024. The adolescent population who attended the clinic between September 2023 and April 2024 was directly invited to participate. Written consent of youth and their parents were obtained and collected. The adolescent population who attended the clinic before September 2023 was invited to participate via personal contacts (telephone number and/or email) after collecting parental consent. Participants were asked to complete an anonymous online survey through a link provided via email. A second consent were asked after clicking the link provided before starting the survey. A questionnaire was designed, assessing the following variables: age, sex assigned at birth (male, female, intersex), geographical area where they live (north, center, south), size of city ( 300,000 inhabitants), participation at lessons on gender identity at school (one time, more than one time, never), participation at lessons on sexual health at school (one time, more than one time, never), gender perception (male, female, non-binary, others), doubts about their gender perception (yes, no), doubts about gender identity being different from their assigned sex at birth (yes, no), sufferance from gender incongruence if any (yes, no), being discriminated because of their gender identity (yes one time, more than one time, never), place of discrimination if any (family and/or school and/or heath environment and/or others), sexual orientation (heterosexual, homosexual, bisexual, asexual, don’t know, others), having sexual intercourse (yes, no), gender of people they had sexual intercourse with (different gender, same gender, both genders), being discriminated because of their sexual orientation (yes once, yes more than once, no), place of discrimination if any (family and/or school and/or health environment and/or others), gender neutral language use (yes, sometimes, no, only when speaking English), substance use (tobacco, alcohol, other drugs, no substance), feel comfortable to talking about GI and/or sexual orientation with their family (yes, no, I don’t think they would understand), feel comfortable to talking about gender identity and/or sexual orientation with their pediatrician or other health provider (yes, no, I don’t think they would understand) ( Supplementary material 1). The questionnaire was standardized by drawing on validated items from existing literature and international guidelines on adolescent gender identity and sexual orientation, and was reviewed by a multidisciplinary team of pediatricians, psychologists, and endocrinologists to ensure its clarity, cultural appropriateness, and sensitivity to the target age group. The statistical analysis was performed using the STATA® software (version 12 College Station, TX). Quantitative variables are presented as mean and standard deviation, while dichotomous and categorical variables are presented as frequency and percentage. Group mean comparisons were conducted using the non-parametric Wilcoxon test. Group comparisons for dichotomous and categorical variables were carried out using the chi-square test (for frequencies equal to or greater than 5) and the Fisher's exact test (used for frequencies less than 5). A p-value less than 5% (p = 0.05) was considered statistically significant. The study was approved by the Ethics Committee for Research Protocols of the University of Parma (n. 4089 − 2023). 3. Results This cross-sectional study involved a total of 51 adolescents, of whom 31 (60.7%) were assigned female at birth and 20 (39.3%) were assigned male at birth. Table 2 summarizes sex assigned at birth in the study population, whereas Table 3 shows results on sexual orientation. The average age of the AFAB participants was 15.2 years (± 1.4), while for the AMAB participants, it was 14.5 years (± 1.4). Most participants were from northern Italy (48 out of 51, 94%), with only three participants from central Italy (6%). The distribution based on population density showed that 14 participants (27%) came from areas with less than 150,000 inhabitants, 32 participants (65%) from areas with a population between 150,000 and 300,000 inhabitants, and 4 participants (8%) from areas with more than 300,000 inhabitants. Table 2 Sex assigned at birth and gender identity among the study population. Woman Man Non-binary Female, n (%) 29 (93.6) 1 (3.2) 1 (3.2) Male, n (%) 0 20 (100) 0 Cisgender Transgender with gender dysphoria Overall, n (%) 49 (96.1) 2 (3.9) Table 3 Sexual orientation among among the study population. Orientation AFAB, n (%) AMAB, n (%) Heterosexual 21 (67.7) 18 (90) Gay, lesbian 0 1 (5) Bisexual 4 (13.0) 0 Asexual 1 (3.2) 0 Don’t know 5 (16.1) 1 (5) AFAB: assigned female at birth; AMAB: assigned male at birth. Regarding experiences of discrimination (Table 4 ), 19.3% of AFAB adolescents have experienced discrimination at least once due to their gender identity at school and in healthcare settings. In contrast, none of the AMAB participants have experienced discrimination due to their gender identity. Table 4 Discrimination due to sexual orientation and/or gender identity among the study population. Sexual identity, n (%) Discrimination due to GI, n (%) Discrimination due to SO, n (%) Heterosexual CG Once 0 More than once 4 (20) No 16 (80) Once 0 More than once 0 No 20 (100) Bisexual CG Once 0 More than once 0 No 5 (100) Once 0 More than once 2 (40) No 3 (60) Heterosexual CB Once 0 More than once 0 No 18 (100) Once 0 More than once 0 No 18 (100) Homosexual CB Once 0 More than once 0 No 1 (100) Once 0 More than once 1 (100) No 0 Undefined SO TB Once 0 More than once 1 (100) No 0 Once 0 More than once 0 No 1 (100) Undefined SO CG Once 0 More than once 0 No 4 (100) Once 0 More than once 0 No 4 (100) Undefined SO CB Once 0 More than once 0 No 1 (100) Once 0 More than once 0 No 1 (100) Asexual NBY Once 0 More than once 1 (100) No 0 Once 0 More than once 0 No 1 (100) CG: cisgender girl; CB: cisgender boy; TB: transgender boy; NBY: non-binary youth; GI: gender identity; SO: sexual orientation. In terms of sexual orientation, among AFAB adolescents, 13% identified as bisexual, 3.2% as asexual, and 16.1% were unsure of their orientation; 41.9% reported having had a sexual intercourse (3.2% homosexual, 38.7% heterosexual); two participants experienced multiple instances of discrimination due to their sexual orientation, while 29 never experienced discrimination; discrimination occurred at school, outside of school, and within their families. Among the AMAB participants, 18 were heterosexual (90%), one was homosexual (5%), and one felt unsure about their sexual orientation (5%); three of them (15%) had sexual intercourses, all with individuals of the opposite gender; one experienced multiple instances of discrimination due to their sexual orientation, with incidents occurring at school and within their family. Analyzing participation in meetings regarding sexual identity (Table 5 ), it was observed that among AFAB participants, three (10%) attended multiple meetings, 10 (32%) attended once, and 18 (58%) never attended. Regarding AMAB participants, 5 (25%) attended multiple meetings, 5 (25%) attended once, and 10 (50%) never attended. Regarding meetings on sexual health, 10 AFAB participants (32%) attended multiple meetings, 14 (45%) attended once, and seven (23%) never attended. Among AMAB participant, 8 (40%) attended multiple meetings, 6 (30%) attended once, and 6 (30%) never attended. When exploring awareness of sexual identity, it was found that 26 AFAB adolescents (84%) never had doubts about their sexual identity, while five out of 31 (16%) did. None of the AMAB adolescents ever had doubts about their sexual identity. From a gender perception perspective, 29 participants assigned female at birth (93.6%) perceive themselves as female, one as male (3.2%), and one as non-binary (3.2%). Both experienced distress associated with GI. Additionally, four AFAB participants expressed at least once in their lives the desire to have been born a different gender. Out of the total participating adolescents, 3.9% expressed GI and GD. It was found that 23 AFAB participants (74%) feel comfortable discussing gender identity and/or sexual orientation with their family, while 8 prefer not to. Additionally, 20 of them would feel comfortable discussing these topics with their pediatrician or another healthcare provider, while 11 prefer to avoid such discussions (of whom 3 believe they would not be understood). Among the AMAB participants, 14 (70%) feel comfortable discussing gender identity and/or sexual orientation with their family, while 6 prefer not to (with 1 believing their parents would not understand). Furthermore, 15 of them would feel comfortable discussing these topics with their pediatrician or another healthcare provider, while 5 prefer to avoid such discussions (with 1 believing they would not be understood). Overall, most adolescents (68.6%) expressed that they would feel comfortable discussing issues related to sexual identity with their pediatrician or primary care physician. Table 5 Sexual education among the study population. Type of education N (%) School classes/meetings focused on GI Only once More than once Never 15 (29.4) 8 (15.7) 28 (54.9) School classes/meetings focused on sexual health Only once More than once Never 20 (39.3) 18 (35.3) 13 (25.4) Feeling comfortable talking about GI and /or sexual orientation To family Yes No I don’t think they would understand 37 (72.5) 13 (25.5) 1 (2) To doctor Yes No I don’t think they would understand 35 (68.6) 12 (23.5) 4 (7.9) GI: gender identity. Regarding the use of gender-neutral language, 4 AFAB participants (12.9%) consistently use it, 9 (29%) use it sometimes, 4 (12.9%) only when speaking or writing in English, and 14 (45.2%) never use it. Among AMAB participants, 3 (15%) consistently use gender-neutral language, 3 (15%) use it sometimes, and 14 (70%) never use it. Examining substance abuse (Table 6 ), it was found that among AFAB participants, five (16%) habitually use tobacco, six (19%) alcohol, and two (6%) other drugs. Among AMAB peers, two (10%) habitually use tobacco, two (10%) alcohol, and one other (5%) drugs. Table 6 Sexual intercourse and abuse of substances among the study population. Sexual intercourse N (%) Substance abuse N (%) Heterosexual CG Yes, with same gender person Yes, with different gender person No 0 11 (55) 9 (45) Tobacco/Alcohol/other drugs No 8 (40) 12 (60) Bisexual CG Yes, with same gender person Yes, with different gender person No 1 (20) 1 (20) 3 (60) Tobacco/Alcohol/other drugs No 2 (40) 3 (60) Heterosexual CB Yes, with same gender person Yes, with different gender person No 0 3 (17) 15 (83) Tobacco/Alcohol/other drugs No 2 (11) 16 (89) Homosexual CB Yes, with same gender person Yes, with different gender person No 0 0 1 (100) Tobacco/Alcohol/other drugs No 1 (100) 0 Undefined SO TB Yes, with same gender person Yes, with different gender person No 0 0 1 (100) Tobacco/Alcohol/other drugs No 0 1 (100) Undefined SO CG Yes, with same gender person Yes, with different gender person No 0 0 4 (100) Tobacco/Alcohol/other drugs No 1 (25) 3 (75) Undefined SO CB Yes, with same gender person Yes, with different gender person No 0 0 1 (100) Tobacco/Alcohol/other drugs No 0 1 (100) Asexual NBY Yes, with same gender person Yes, with different gender person No 0 0 1 (100) Tobacco/Alcohol/other drugs No 0 1 (100) CG: cisgender girl; CB: cisgender boy; TB: transgender boy; NBY: non-binary youth. 4. Discussion Our study shows that a non-negligible proportion of adolescents in Italy present with GI and GD, emphasizing the need for appropriate settings and qualified health providers to assist and support this community. Among the study participants, six individuals expressed having doubts regarding their sexual identity. All six of these individuals are adolescents assigned female at birth. These data may suggest several considerations. Firstly, it could be that AFAB adolescents are more open to exploring and questioning their sexual identity. This may stem from greater social pressure on AMAB adolescents to conform to rigid gender norms, which could discourage the expression of doubts about sexual identity [ 15 ]. Furthermore, it could be that the contexts in which AFAB youth grow up offer a relatively more welcoming environment to discuss and explore such issues compared to what is available to AMAB peers. This underscores the importance of creating safe and supportive spaces for all adolescents, regardless of their assigned sex at birth, where they can feel free to explore and discuss their identity without fear of judgment or discrimination. However, it is important to note that AMAB adolescents who have doubts about their sexual identity may be less likely to participate in studies of this kind or to openly express their doubts due to social pressures or cultural biases. Of these six AFAB individuals, four have wished, at least once in their lives, to belong to the opposite gender. One participant, however, has never had doubts about their sexual identity but has nonetheless desired to be of the opposite sex. Two out of six AFAB adolescents perceive themselves as belonging to a gender different from that assigned at birth. One identifies as male, while the other perceives themselves as non-binary. These data align fully with that reported in the WPATH SOC8, which indicates a prevalence between 2.5% and 8.4% [ 14 ]. This lends validity to the findings and suggests that experiences of GI among adolescents in our sample reflect those observed in larger international studies. It is interesting to note that within the studied population, GI also manifests exclusively among individuals AFAB. This may indicate that AFAB adolescents are more inclined to recognize and report feelings of GI, perhaps due to specific social, cultural, or psychological factors as previously observed [ 15 ]. Further studies could help better understand the reasons behind this observation and develop targeted support strategies for all adolescents facing gender identity-related issues. Both AFAB adolescents with GI reported experiencing distress due to GI. It can therefore be stated that 100% of the adolescents who participated in the study with GI suffered from this condition. This figure is in line with previous international studies that have been conducted [ 14 ]. These data highlight the crucial importance of having adequately prepared health providers and institutions to support those living with GD. Despite this condition no longer being classified as a sexual deviation in the ICD manual, the issue continues to be considered taboo. Many individuals who suffer from GD prefer to isolate themselves rather than face possible social pressures and discrimination due to minority stress [ 5 , 7 , 16 – 17 ]. Recognition and understanding of this reality are fundamental to developing a supportive and inclusive environment. Health professionals, educators, and institutions as a whole need to adopt sensitive and informed approaches to reduce the stigma associated with GD [ 5 ]. Promoting education and awareness about gender diversity can help create a more welcoming and respectful society where people can express their identity without fear of judgment or discrimination. Increasing access to psychological and medical support resources can make a big difference for those suffering from gender dysphoria, improving their quality of life and overall well-being. Another interesting finding from our questionnaire is the lack of information young people receive about sexual health from educational institutions. Sexual education should not be an option offered only by more modern and open schools but a mandatory and responsibility that teachers and principals must take on. An effective approach to sexual education should involve experts such as gynecologists, urologists, and sexologists who can teach young people how to lead a healthy, aware, and risk-free sexual life. Sexually transmitted diseases are increasingly prevalent in our society. It is essential that sexual education be integrated into school curricula systematically and comprehensively to ensure that all students have access to accurate and complete knowledge [ 18 ]. Similarly, it can be observed that meetings on sexual identity were rarely attended by the adolescents who took part in the study. In particular, the percentage is even lower than that for sexual health meetings. During the study, it emerged that six participants reported experiencing discrimination at school or in healthcare settings due to their gender identity. All these participants are AFAB youth. Among them, four identify as female, one as male, and one as non-binary. These data are significant as it represents that 100% of the individuals who took part in the study and do not identify with the gender assigned at birth have experienced discrimination due to their sexual identity. This result reflects the current Italian society, which is not yet fully ready to address and accept such complex and sensitive issues [ 19 ]. However, it is evident that a change is necessary, both socially and from a medical and nursing perspective, considering that some adolescents experienced discrimination in healthcare settings. This latter place of prejudice is particularly concerning and underscores the importance of increased awareness and training for healthcare staff to ensure a safe and inclusive environment for everyone, regardless of gender identity. In our study, the presence of a significant percentage of young people undecided about their sexual orientation (11.7%) suggests that many adolescents go through a phase of exploration and uncertainty during this critical period of their lives. This phase is natural and reflects the complexity of sexual identity, which can evolve over time [ 11 ]. The distribution of GIs and sexual orientations also indicates the need for a more inclusive and sensitive school and healthcare environment. This is reinforced by the data collected regarding the discrimination experienced by participants due to their sexual orientation: two bisexual female participants received discrimination multiple times in both school and non-school settings; the homosexual boy experienced discrimination within his family, at school, and in healthcare settings. All heterosexual boys have never experienced discrimination based on their sexual orientation. A total of 40% of our study sample declared to use gender-neutral language. Global data support that gender-neutral language should be utilized whenever possible to provide a more inclusive and supportive environment [ 20 ]. Our findings suggest that adolescents, growing up in an era of increased awareness and access to information, more readily adopt inclusive terms and pronouns to respect and recognize diverse gender identities. In opposition with previous studies [ 17 , 21 – 23 ], we did not observe a higher propensity for individuals with GI/GD to develop substance abuse problems. The discrepancy between previous data and our results could be attributed to our small cohort of patients. As a final piece of data, we analyzed how many adolescents feel comfortable discussing topics such as sexual orientation and GI, first with their parents and then with their doctor or pediatrician. Overall, most adolescents are open to conversations on these topics both within the family and in a medical setting. Among those who avoid these discussions entirely, there is an equal distribution between genders. One participant with GD, a transgender boy, is in this group. Another participant with GD, a non-binary individual, is comfortable discussing their gender identity and sexual orientation with their family but not with medical professionals. Their reluctance to talk to medical staff may stem from feeling wrong or different, underscoring the need for greater sensitivity and inclusivity in healthcare. A similar issue is noted with a cisgender homosexual boy who reported experiencing discrimination due to his sexual orientation within his family, at school, and in the hospital. As already stated by literature, it is essential for family, schools, and healthcare services to become places of welcome and understanding, where young people can feel safe to openly discuss these topics without fear of judgment or discrimination. Offering adequate support can make a difference in their emotional and psychological well-being, helping them develop a sense of self-esteem and belonging [ 7 ]. It is important to clarify that the investigation of sexual orientation within this study serves an exploratory and descriptive purpose and does not carry a clinical implication. While GI and GD can lead adolescents to seek support and care within specialized gender-affirming pathways (often involving pediatric, psychological, and endocrinological evaluation), no such clinical care trajectories are established or indicated solely on the basis of sexual orientation. The inclusion of sexual orientation data aimed to capture a broader understanding of adolescents' identity experiences and social challenges, such as stigma or discrimination, rather than to inform any diagnostic or therapeutic approach. This distinction is essential to avoid conflating gender identity-related healthcare needs with the diverse, non-pathological spectrum of sexual orientations. This study has several limitations that should be acknowledged. First, the sample size was relatively small and geographically concentrated in northern Italy, which may limit the generalizability of the findings to the broader adolescent population across the country. Additionally, the study relied on self-reported data, which may be subject to reporting bias, particularly on sensitive topics such as gender identity and sexual orientation. The cross-sectional design also prevents the analysis of changes over time or causal relationships. We also acknowledge the methodological limitations related to the use of a self-administered questionnaire, particularly in assessing complex and subjective experiences such as discrimination based on gender identity. The finding that approximately 20% of cisgender participants reported experiencing such discrimination may reflect broader societal challenges, including gender expression that diverges from traditional norms, rather than GI per se . This underscores the need for future studies to more precisely differentiate between discrimination related to gender identity, gender expression, and perceived sexual orientation. Furthermore, we recognize that no formal statistical correlation was made between discrimination experiences and other potentially influential variables, such as prior exposure to educational programs on gender identity or the sociocultural characteristics of the participants’ area of residence. These aspects represent important avenues for future research to better contextualize and interpret adolescents’ experiences. Despite these limitations, the study has notable strengths. It is among the few to investigate GI and sexual orientation among adolescents in the Italian context using a structured and standardized questionnaire. The anonymity of the survey likely encouraged honest responses, and the multidisciplinary development of the tool ensured both clinical relevance and psychological sensitivity. Furthermore, the inclusion of experiences with healthcare providers adds practical insight into the current gaps in adolescent care and points toward areas for improvement in medical training and public health policy. In addition, our study provides an important initial insight into the lived realities of Italian adolescents and highlights the urgency of more comprehensive, multivariate approaches in future investigations. 5. Conclusions Our findings highlight a significant proportion of young people dealing with GI and GD in Italy, emphasizing the necessity for appropriate settings and qualified health providers to assist and support this community. Our data underscore the urgent need for targeted interventions to aid adolescents facing these conditions, ensuring they can live authentically and in alignment with their identity. GI and GD can significantly impact the psychological and physical well-being of adolescents. Awareness initiatives can help mitigate stigma and discrimination, fostering a more inclusive and welcoming environment for all. Abbreviations AFAB: assigned female at birth; AMAB: assigned male at birth; CB: cisgender boy; CG: cisgender girl; GI: gender incongruence; GD: gender dysphoria; NBY: non-binary youth; SO: sexual orientation; TB: transgender boy Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee for Research Protocols of the University of Parma (n. 4089-2023). Written consent was obtained by the study participants and both their parents. All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments. Consent for publication Written consent was obtained by the study participants and both their parents. Availability of data and materials All the data are included in the manuscript. Competing interests The authors declare that they have no competing interests. Funding The study was supported by a grant of the Pediatric Clinic, University of Parma, Italy (PED-2023-10). Authors’ contributions PD and SE contributed to the conception and design of the study and questionnaire. PD and AF collected data. GR and CN performed the statistical analysis. PD wrote the first draft of the manuscript. MES and SE critically reviewed and revised the final article before submission. Acknowledgments : None. References Claahsen-van der Grinten H, Verhaak C, Steensma T, Middelberg T, Roeffen J, Klink D. Gender incongruence and gender dysphoria in childhood and adolescence-current insights in diagnostics, management, and follow-up. Eur J Pediatr. 2021;180(5):1349–57. Salute M. Manuale ICD-9-CM versione italiana. 2007. https://www.salute.gov.it/portale/documentazione/p6_2_2_1.jsp?id=2251 Accessed 10 Jun 2024. 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Demographics of referrals to a specialist gender identity service in the UK between 2017 and 2020. Clin Child Psychol Psychiatry. 2024;29(2):624–36. Wright JD, Chen L, Suzuki Y, Matsuo K, Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022;23(Suppl 1):S1–259. Butler G, De Graaf N, Wren B, et al. Assessment and support of children and adolescents with gender dysphoria. Arch Dis Child. 2018;103(7):631–6. Marconi E, Monti L, Marfoli A, et al. A systematic review on gender dysphoria in adolescents and young adults: focus on suicidal and self-harming ideation and behaviours. Child Adolesc Psychiatry Ment Health. 2023;17(1):110. Reisner SL, Greytak EA, Parsons JT, et al. Gender minority social stress in adolescence: disparities in adolescent bullying and substance use by gender identity. J Sex Res. 2015;52(3):243–56. Diana P, Esposito S. Epidemiology, risk factors, and prevention strategies of HIV, HPV, and other sexually transmitted infections among cisgender and transgender youth: a narrative review. Front Public Health. 2024;12:1342532. Prunas A, Bandini E, Fisher AD, et al. Experiences of Discrimination, Harassment, and Violence in a Sample of Italian Transsexuals Who Have Undergone Sex-Reassignment Surgery. J Interpers Violence. 2018;33(14):2225–40. Bhatt N, Cannella J, Gentile JP. Gender-affirming Care for Transgender Patients. Innov Clin Neurosci 2022 Apr-Jun;19(4–6):23–32. Kameg BN, Nativio DG. Gender dysphoria in youth: An overview for primary care providers. J Am Assoc Nurse Pract. 2018;30(9):493–8. Garofalo R, Deleon J, Osmer E, Doll M, Harper GW. Overlooked, misunderstood and at- risk: Exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health. 2006;38:230–6. Russell ST, Ryan C, Toomey RB, Diaz RM, Sanchez J. Lesbian, gay, bisexual, and transgender adolescent school victimization: Implications for young adult health and adjustment. J Sch Health. 2011;81:223–30. Supplementary Files SupplementarymaterialpaperIG.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 17 Apr, 2025 Reviewers invited by journal 16 Apr, 2025 Editor assigned by journal 24 Mar, 2025 First submitted to journal 22 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4706981","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":443904869,"identity":"d9471a61-fc68-478b-a435-69739d38f487","order_by":0,"name":"Pierluigi Diana","email":"","orcid":"","institution":"University of Parma: Universita degli Studi di Parma","correspondingAuthor":false,"prefix":"","firstName":"Pierluigi","middleName":"","lastName":"Diana","suffix":""},{"id":443904870,"identity":"b2d43d66-48b4-4590-aea0-ed7acb0f3308","order_by":1,"name":"Anna Frugoni","email":"","orcid":"","institution":"University of Parma: Universita degli Studi di Parma","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Frugoni","suffix":""},{"id":443904871,"identity":"616abe57-f141-4f73-ab3c-5b5e8158ab90","order_by":2,"name":"Greta Ramundo","email":"","orcid":"","institution":"University of Parma: Universita degli Studi di Parma","correspondingAuthor":false,"prefix":"","firstName":"Greta","middleName":"","lastName":"Ramundo","suffix":""},{"id":443904872,"identity":"15164a2e-b6e6-4739-93bc-435f633cf94f","order_by":3,"name":"Cosimo Neglia","email":"","orcid":"","institution":"University of Parma: Universita degli Studi di Parma","correspondingAuthor":false,"prefix":"","firstName":"Cosimo","middleName":"","lastName":"Neglia","suffix":""},{"id":443904873,"identity":"a1b91dc0-b1d9-44b9-9969-8e783356702c","order_by":4,"name":"Maria Elisabeth Street","email":"","orcid":"","institution":"University of Parma: Universita degli Studi di Parma","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Elisabeth","lastName":"Street","suffix":""},{"id":443904874,"identity":"8cf4d027-5753-447f-95e7-0526286d3634","order_by":5,"name":"Susanna Esposito","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0003-4103-2837","institution":"University of Parma: Universita degli Studi di Parma","correspondingAuthor":true,"prefix":"","firstName":"Susanna","middleName":"","lastName":"Esposito","suffix":""}],"badges":[],"createdAt":"2024-07-08 16:27:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4706981/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4706981/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80825177,"identity":"83d69413-c67d-454e-9d1f-1c3ae424c5bb","added_by":"auto","created_at":"2025-04-17 13:04:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":818486,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4706981/v1/df46ede1-a458-4c3e-a880-76beb4889dfe.pdf"},{"id":80823962,"identity":"862a2e29-3bd6-41c8-8947-cded8cf64980","added_by":"auto","created_at":"2025-04-17 12:48:15","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":16905,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarymaterialpaperIG.docx","url":"https://assets-eu.researchsquare.com/files/rs-4706981/v1/19df96bb08bf8e95c304dde5.docx"}],"financialInterests":"","formattedTitle":"Various sexual identities among a cohort of Italian adolescents: from their own perception of selves to social and healthcare acceptance","fulltext":[{"header":"1. Background","content":"\u003cp\u003eGender incongruence (GI) is defined as a condition where an individual's gender identity does not align with the gender assigned at birth [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The diagnosis of \"transsexualism\" was included in the International Classification of Diseases and Related Health Problems in 1978 (ICD-9) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It was classified under the section \"Sexual Deviations and Disorders\" within the category of neurotic disorders, personality disorders, and other non-psychotic mental disorders, placing it alongside paraphilias and sexual deviations. In 1992, the tenth revision of the International Classification of Diseases (ICD-10) came into effect [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Unlike ICD-9, ICD-10 categorized gender identity disorders into a separate group of disorders of sexual preference and sexual dysfunctions, although they remained under the category of personality and behavioral disorders in adults (F60-F69). In 2018, with the publication of the updated ICD, the World Health Organization (WHO) led the process of depathologizing transsexuality. In ICD-11, the term \"transsexualism\" was replaced with \"Gender Incongruence.\" This new entity was moved from the chapter on mental disorders to a newly created chapter titled \"Conditions Related to Sexual Health\" [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGender dysphoria (GD) is a more complex phenomenon characterized by clinically significant distress resulting from the incongruence between an individual's gender assigned at birth and their actual gender identity or expression [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Various studies have demonstrated how transgender or non-binary children and adolescents are compelled to endure a disproportionate level of poor psychological health and are disadvantaged in development and academic performance compared to their cisgender peers [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. International studies have reported an increase in referrals to gender identity care units. A study conducted in Spain from 2012 to 2021 observed a tenfold increase in the number of individuals referred to specialized gender care centers, rising from 18 subjects in 2012 to 189 in 2021 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough several studies have demonstrated the increase in cases and the relevance of the condition, the topic remains a taboo and continues to be subject to stigma. The direct consequence is a general lack of preparedness among doctors and pediatricians and the need for better networks among pediatricians and other medical professionals [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch on gender identity development in adolescents is clearly lagging behind. Studies involving individuals with gender dysphoria and disorders of sexual development indicate that adolescence, with its changing social environment and the onset of physical puberty, appears to be the most critical period for the development of a non-conventional gender identity, as well as being the most stressful period [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Terms related to sexual identity are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSexual identity\u0026rsquo;s related terms.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTerm\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender Identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOne\u0026rsquo;s inner perception of being male, female, both or neither\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex assigned at birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe sex assigned by a doctor at birth based on external anatomy, chromosomes, etc.\u003c/p\u003e \u003cp\u003eAFAB is an abbreviation for \u0026ldquo;assigned female at birth\u0026rdquo;.\u003c/p\u003e \u003cp\u003eAMAB is an abbreviation for \u0026ldquo;assigned male at birth\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransgender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeople who cross delineate categories of gender based on their assigned sex at birth.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCisgender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeople who identify themselves with a gender consistent with their sex assigned at birth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual orientation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe romantic sentimental or sexual attraction to other individuals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA person emotionally or sexually attracted to people of the same gender\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLesbian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA woman emotionally or sexually attracted to other women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA person emotionally or sexually attracted to more than one sex or gender\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA person who experiences less or no sexual attraction or interest in sex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender expression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe way someone presents their gender\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual Identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe complex result of sex assigned at birth, gender identity, gender expression and sexual orientation of one\u0026rsquo;s person\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn recent years, there has been a significant increase in the number of children and adolescents seeking support for GD and GI [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. There has been a shift over time in the demographics of referrals to specialized facilities: previously, individuals assigned male at birth (AMAB) were more commonly involved. However, in the last decade, there has been a more significant number of individuals assigned female at birth (AFAB).\u003c/p\u003e \u003cp\u003eA study conducted in the UK analyzed gender care referrals from 2017 to 2020. Out of a total of 9555 referrals, 5835 (62.3%) were AFAB, while the remaining 37.7% were AMAB [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Another study conducted in the United States aimed to determine the percentage of patients seeking gender affirmation surgery (GAS). Out of a total of 48019 patients, 7.7% were aged between 12 and 18 years old; 52.3% were between 19 and 30 years old; 21.8% were between 31 and 40 years old [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the most recent data available in the eighth edition of the WPATH Standards of Care (SOC 8), young transgender individuals represent approximately 3% of the global pediatric population (and up to 8% when including all gender-diverse identities) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, the prevalence of GD and gender identity among adolescents has risen significantly, with a marked increase in referrals to gender identity services and a shift in demographic patterns (especially among AFAB). This growing visibility reflects a broader recognition of gender diversity but also underscores the psychological distress and social challenges that often accompany GD, particularly during puberty, a period known to amplify identity-related stress. Despite this upward trend, many healthcare systems remain ill-equipped to provide appropriate, inclusive, and informed support. In Italy, in particular, there is a scarcity of population-specific data on adolescents navigating gender identity questions, and a notable lack of comprehensive sexual and gender education in schools. Against this backdrop, the present study aims to fill a critical gap by investigating the prevalence and experiences of gender-diverse and non-conforming sexual identities among Italian adolescents, thereby informing more responsive and culturally sensitive healthcare and educational practices.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis was a cross-sectional study. The study population was made up of adolescents aged 12\u0026ndash;17 years who were hospitalized at the Pediatric Clinic of the University Hospital of Parma, Italy, between January 2023 and April 2024. The adolescent population who attended the clinic between September 2023 and April 2024 was directly invited to participate. Written consent of youth and their parents were obtained and collected. The adolescent population who attended the clinic before September 2023 was invited to participate via personal contacts (telephone number and/or email) after collecting parental consent. Participants were asked to complete an anonymous online survey through a link provided via email. A second consent were asked after clicking the link provided before starting the survey. A questionnaire was designed, assessing the following variables: age, sex assigned at birth (male, female, intersex), geographical area where they live (north, center, south), size of city (\u0026lt;\u0026thinsp;150,000 inhabitants, 150,000-300,000 inhabitants, \u0026gt;\u0026thinsp;300,000 inhabitants), participation at lessons on gender identity at school (one time, more than one time, never), participation at lessons on sexual health at school (one time, more than one time, never), gender perception (male, female, non-binary, others), doubts about their gender perception (yes, no), doubts about gender identity being different from their assigned sex at birth (yes, no), sufferance from gender incongruence if any (yes, no), being discriminated because of their gender identity (yes one time, more than one time, never), place of discrimination if any (family and/or school and/or heath environment and/or others), sexual orientation (heterosexual, homosexual, bisexual, asexual, don\u0026rsquo;t know, others), having sexual intercourse (yes, no), gender of people they had sexual intercourse with (different gender, same gender, both genders), being discriminated because of their sexual orientation (yes once, yes more than once, no), place of discrimination if any (family and/or school and/or health environment and/or others), gender neutral language use (yes, sometimes, no, only when speaking English), substance use (tobacco, alcohol, other drugs, no substance), feel comfortable to talking about GI and/or sexual orientation with their family (yes, no, I don\u0026rsquo;t think they would understand), feel comfortable to talking about gender identity and/or sexual orientation with their pediatrician or other health provider (yes, no, I don\u0026rsquo;t think they would understand) \u003cem\u003e(\u003c/em\u003eSupplementary material 1). The questionnaire was standardized by drawing on validated items from existing literature and international guidelines on adolescent gender identity and sexual orientation, and was reviewed by a multidisciplinary team of pediatricians, psychologists, and endocrinologists to ensure its clarity, cultural appropriateness, and sensitivity to the target age group.\u003c/p\u003e \u003cp\u003eThe statistical analysis was performed using the STATA\u0026reg; software (version 12 College Station, TX). Quantitative variables are presented as mean and standard deviation, while dichotomous and categorical variables are presented as frequency and percentage. Group mean comparisons were conducted using the non-parametric Wilcoxon test. Group comparisons for dichotomous and categorical variables were carried out using the chi-square test (for frequencies equal to or greater than 5) and the Fisher's exact test (used for frequencies less than 5). A p-value less than 5% (p\u0026thinsp;=\u0026thinsp;0.05) was considered statistically significant.\u003c/p\u003e \u003cp\u003e The study was approved by the Ethics Committee for Research Protocols of the University of Parma (n. 4089\u0026thinsp;\u0026minus;\u0026thinsp;2023).\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eThis cross-sectional study involved a total of 51 adolescents, of whom 31 (60.7%) were assigned female at birth and 20 (39.3%) were assigned male at birth. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes sex assigned at birth in the study population, whereas Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows results on sexual orientation. The average age of the AFAB participants was 15.2 years (\u0026plusmn;\u0026thinsp;1.4), while for the AMAB participants, it was 14.5 years (\u0026plusmn;\u0026thinsp;1.4). Most participants were from northern Italy (48 out of 51, 94%), with only three participants from central Italy (6%). The distribution based on population density showed that 14 participants (27%) came from areas with less than 150,000 inhabitants, 32 participants (65%) from areas with a population between 150,000 and 300,000 inhabitants, and 4 participants (8%) from areas with more than 300,000 inhabitants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSex assigned at birth and gender identity among the study population.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-binary\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (93.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCisgender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTransgender with gender dysphoria\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (96.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSexual orientation among among the study population.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrientation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAFAB, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMAB, n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeterosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (67.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGay, lesbian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAFAB: assigned female at birth; AMAB: assigned male at birth.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding experiences of discrimination (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), 19.3% of AFAB adolescents have experienced discrimination at least once due to their gender identity at school and in healthcare settings. In contrast, none of the AMAB participants have experienced discrimination due to their gender identity.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiscrimination due to sexual orientation and/or gender identity among the study population.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual identity, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscrimination due to GI, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiscrimination due to SO, n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeterosexual CG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 4 (20)\u003c/p\u003e \u003cp\u003eNo 16 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 0\u003c/p\u003e \u003cp\u003eNo 20 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBisexual CG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 0\u003c/p\u003e \u003cp\u003eNo 5 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 2 (40)\u003c/p\u003e \u003cp\u003eNo 3 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeterosexual CB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 0\u003c/p\u003e \u003cp\u003eNo 18 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 0\u003c/p\u003e \u003cp\u003eNo 18 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHomosexual CB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 0\u003c/p\u003e \u003cp\u003eNo 1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 1 (100)\u003c/p\u003e \u003cp\u003eNo 0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUndefined SO TB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 1 (100)\u003c/p\u003e \u003cp\u003eNo 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 0\u003c/p\u003e \u003cp\u003eNo 1 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUndefined SO CG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 0\u003c/p\u003e \u003cp\u003eNo 4 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 0\u003c/p\u003e \u003cp\u003eNo 4 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUndefined SO CB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 0\u003c/p\u003e \u003cp\u003eNo 1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 0\u003c/p\u003e \u003cp\u003eNo 1 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAsexual NBY\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 1 (100)\u003c/p\u003e \u003cp\u003eNo 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnce 0\u003c/p\u003e \u003cp\u003eMore than once 0\u003c/p\u003e \u003cp\u003eNo 1 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eCG: cisgender girl; CB: cisgender boy; TB: transgender boy; NBY: non-binary youth; GI: gender identity; SO: sexual orientation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn terms of sexual orientation, among AFAB adolescents, 13% identified as bisexual, 3.2% as asexual, and 16.1% were unsure of their orientation; 41.9% reported having had a sexual intercourse (3.2% homosexual, 38.7% heterosexual); two participants experienced multiple instances of discrimination due to their sexual orientation, while 29 never experienced discrimination; discrimination occurred at school, outside of school, and within their families. Among the AMAB participants, 18 were heterosexual (90%), one was homosexual (5%), and one felt unsure about their sexual orientation (5%); three of them (15%) had sexual intercourses, all with individuals of the opposite gender; one experienced multiple instances of discrimination due to their sexual orientation, with incidents occurring at school and within their family.\u003c/p\u003e \u003cp\u003eAnalyzing participation in meetings regarding sexual identity (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e), it was observed that among AFAB participants, three (10%) attended multiple meetings, 10 (32%) attended once, and 18 (58%) never attended. Regarding AMAB participants, 5 (25%) attended multiple meetings, 5 (25%) attended once, and 10 (50%) never attended. Regarding meetings on sexual health, 10 AFAB participants (32%) attended multiple meetings, 14 (45%) attended once, and seven (23%) never attended. Among AMAB participant, 8 (40%) attended multiple meetings, 6 (30%) attended once, and 6 (30%) never attended. When exploring awareness of sexual identity, it was found that 26 AFAB adolescents (84%) never had doubts about their sexual identity, while five out of 31 (16%) did. None of the AMAB adolescents ever had doubts about their sexual identity. From a gender perception perspective, 29 participants assigned female at birth (93.6%) perceive themselves as female, one as male (3.2%), and one as non-binary (3.2%). Both experienced distress associated with GI. Additionally, four AFAB participants expressed at least once in their lives the desire to have been born a different gender. Out of the total participating adolescents, 3.9% expressed GI and GD. It was found that 23 AFAB participants (74%) feel comfortable discussing gender identity and/or sexual orientation with their family, while 8 prefer not to. Additionally, 20 of them would feel comfortable discussing these topics with their pediatrician or another healthcare provider, while 11 prefer to avoid such discussions (of whom 3 believe they would not be understood). Among the AMAB participants, 14 (70%) feel comfortable discussing gender identity and/or sexual orientation with their family, while 6 prefer not to (with 1 believing their parents would not understand). Furthermore, 15 of them would feel comfortable discussing these topics with their pediatrician or another healthcare provider, while 5 prefer to avoid such discussions (with 1 believing they would not be understood). Overall, most adolescents (68.6%) expressed that they would feel comfortable discussing issues related to sexual identity with their pediatrician or primary care physician.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSexual education among the study population.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of education\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool classes/meetings focused on GI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnly once\u003c/p\u003e \u003cp\u003eMore than once\u003c/p\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (29.4)\u003c/p\u003e \u003cp\u003e8 (15.7)\u003c/p\u003e \u003cp\u003e28 (54.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool classes/meetings focused on sexual health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnly once\u003c/p\u003e \u003cp\u003eMore than once\u003c/p\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (39.3)\u003c/p\u003e \u003cp\u003e18 (35.3)\u003c/p\u003e \u003cp\u003e13 (25.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFeeling comfortable talking about GI and /or sexual orientation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eI don\u0026rsquo;t think they would understand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (72.5)\u003c/p\u003e \u003cp\u003e13 (25.5)\u003c/p\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo doctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eI don\u0026rsquo;t think they would understand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (68.6)\u003c/p\u003e \u003cp\u003e12 (23.5)\u003c/p\u003e \u003cp\u003e4 (7.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eGI: gender identity.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding the use of gender-neutral language, 4 AFAB participants (12.9%) consistently use it, 9 (29%) use it sometimes, 4 (12.9%) only when speaking or writing in English, and 14 (45.2%) never use it. Among AMAB participants, 3 (15%) consistently use gender-neutral language, 3 (15%) use it sometimes, and 14 (70%) never use it.\u003c/p\u003e \u003cp\u003eExamining substance abuse (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e), it was found that among AFAB participants, five (16%) habitually use tobacco, six (19%) alcohol, and two (6%) other drugs. Among AMAB peers, two (10%) habitually use tobacco, two (10%) alcohol, and one other (5%) drugs.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSexual intercourse and abuse of substances among the study population.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSexual intercourse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubstance abuse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeterosexual CG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, with same gender person\u003c/p\u003e \u003cp\u003eYes, with different gender person\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e11 (55)\u003c/p\u003e \u003cp\u003e9 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTobacco/Alcohol/other drugs\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (40)\u003c/p\u003e \u003cp\u003e12 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBisexual CG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, with same gender person\u003c/p\u003e \u003cp\u003eYes, with different gender person\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20)\u003c/p\u003e \u003cp\u003e1 (20)\u003c/p\u003e \u003cp\u003e3 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTobacco/Alcohol/other drugs\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (40)\u003c/p\u003e \u003cp\u003e3 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeterosexual CB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, with same gender person\u003c/p\u003e \u003cp\u003eYes, with different gender person\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e3 (17)\u003c/p\u003e \u003cp\u003e15 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTobacco/Alcohol/other drugs\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (11)\u003c/p\u003e \u003cp\u003e16 (89)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHomosexual CB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, with same gender person\u003c/p\u003e \u003cp\u003eYes, with different gender person\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTobacco/Alcohol/other drugs\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUndefined SO TB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, with same gender person\u003c/p\u003e \u003cp\u003eYes, with different gender person\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTobacco/Alcohol/other drugs\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUndefined SO CG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, with same gender person\u003c/p\u003e \u003cp\u003eYes, with different gender person\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e4 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTobacco/Alcohol/other drugs\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (25)\u003c/p\u003e \u003cp\u003e3 (75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUndefined SO CB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, with same gender person\u003c/p\u003e \u003cp\u003eYes, with different gender person\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTobacco/Alcohol/other drugs\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAsexual NBY\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes, with same gender person\u003c/p\u003e \u003cp\u003eYes, with different gender person\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTobacco/Alcohol/other drugs\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eCG: cisgender girl; CB: cisgender boy; TB: transgender boy; NBY: non-binary youth.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eOur study shows that a non-negligible proportion of adolescents in Italy present with GI and GD, emphasizing the need for appropriate settings and qualified health providers to assist and support this community. Among the study participants, six individuals expressed having doubts regarding their sexual identity. All six of these individuals are adolescents assigned female at birth. These data may suggest several considerations. Firstly, it could be that AFAB adolescents are more open to exploring and questioning their sexual identity. This may stem from greater social pressure on AMAB adolescents to conform to rigid gender norms, which could discourage the expression of doubts about sexual identity [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Furthermore, it could be that the contexts in which AFAB youth grow up offer a relatively more welcoming environment to discuss and explore such issues compared to what is available to AMAB peers. This underscores the importance of creating safe and supportive spaces for all adolescents, regardless of their assigned sex at birth, where they can feel free to explore and discuss their identity without fear of judgment or discrimination. However, it is important to note that AMAB adolescents who have doubts about their sexual identity may be less likely to participate in studies of this kind or to openly express their doubts due to social pressures or cultural biases. Of these six AFAB individuals, four have wished, at least once in their lives, to belong to the opposite gender. One participant, however, has never had doubts about their sexual identity but has nonetheless desired to be of the opposite sex.\u003c/p\u003e \u003cp\u003eTwo out of six AFAB adolescents perceive themselves as belonging to a gender different from that assigned at birth. One identifies as male, while the other perceives themselves as non-binary. These data align fully with that reported in the WPATH SOC8, which indicates a prevalence between 2.5% and 8.4% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This lends validity to the findings and suggests that experiences of GI among adolescents in our sample reflect those observed in larger international studies. It is interesting to note that within the studied population, GI also manifests exclusively among individuals AFAB. This may indicate that AFAB adolescents are more inclined to recognize and report feelings of GI, perhaps due to specific social, cultural, or psychological factors as previously observed [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Further studies could help better understand the reasons behind this observation and develop targeted support strategies for all adolescents facing gender identity-related issues.\u003c/p\u003e \u003cp\u003eBoth AFAB adolescents with GI reported experiencing distress due to GI. It can therefore be stated that 100% of the adolescents who participated in the study with GI suffered from this condition. This figure is in line with previous international studies that have been conducted [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These data highlight the crucial importance of having adequately prepared health providers and institutions to support those living with GD. Despite this condition no longer being classified as a sexual deviation in the ICD manual, the issue continues to be considered taboo. Many individuals who suffer from GD prefer to isolate themselves rather than face possible social pressures and discrimination due to minority stress [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Recognition and understanding of this reality are fundamental to developing a supportive and inclusive environment. Health professionals, educators, and institutions as a whole need to adopt sensitive and informed approaches to reduce the stigma associated with GD [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Promoting education and awareness about gender diversity can help create a more welcoming and respectful society where people can express their identity without fear of judgment or discrimination. Increasing access to psychological and medical support resources can make a big difference for those suffering from gender dysphoria, improving their quality of life and overall well-being.\u003c/p\u003e \u003cp\u003eAnother interesting finding from our questionnaire is the lack of information young people receive about sexual health from educational institutions. Sexual education should not be an option offered only by more modern and open schools but a mandatory and responsibility that teachers and principals must take on. An effective approach to sexual education should involve experts such as gynecologists, urologists, and sexologists who can teach young people how to lead a healthy, aware, and risk-free sexual life. Sexually transmitted diseases are increasingly prevalent in our society. It is essential that sexual education be integrated into school curricula systematically and comprehensively to ensure that all students have access to accurate and complete knowledge [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, it can be observed that meetings on sexual identity were rarely attended by the adolescents who took part in the study. In particular, the percentage is even lower than that for sexual health meetings.\u003c/p\u003e \u003cp\u003eDuring the study, it emerged that six participants reported experiencing discrimination at school or in healthcare settings due to their gender identity. All these participants are AFAB youth. Among them, four identify as female, one as male, and one as non-binary. These data are significant as it represents that 100% of the individuals who took part in the study and do not identify with the gender assigned at birth have experienced discrimination due to their sexual identity. This result reflects the current Italian society, which is not yet fully ready to address and accept such complex and sensitive issues [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, it is evident that a change is necessary, both socially and from a medical and nursing perspective, considering that some adolescents experienced discrimination in healthcare settings. This latter place of prejudice is particularly concerning and underscores the importance of increased awareness and training for healthcare staff to ensure a safe and inclusive environment for everyone, regardless of gender identity.\u003c/p\u003e \u003cp\u003eIn our study, the presence of a significant percentage of young people undecided about their sexual orientation (11.7%) suggests that many adolescents go through a phase of exploration and uncertainty during this critical period of their lives. This phase is natural and reflects the complexity of sexual identity, which can evolve over time [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe distribution of GIs and sexual orientations also indicates the need for a more inclusive and sensitive school and healthcare environment. This is reinforced by the data collected regarding the discrimination experienced by participants due to their sexual orientation: two bisexual female participants received discrimination multiple times in both school and non-school settings; the homosexual boy experienced discrimination within his family, at school, and in healthcare settings.\u003c/p\u003e \u003cp\u003eAll heterosexual boys have never experienced discrimination based on their sexual orientation.\u003c/p\u003e \u003cp\u003eA total of 40% of our study sample declared to use gender-neutral language. Global data support that gender-neutral language should be utilized whenever possible to provide a more inclusive and supportive environment [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Our findings suggest that adolescents, growing up in an era of increased awareness and access to information, more readily adopt inclusive terms and pronouns to respect and recognize diverse gender identities.\u003c/p\u003e \u003cp\u003eIn opposition with previous studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], we did not observe a higher propensity for individuals with GI/GD to develop substance abuse problems. The discrepancy between previous data and our results could be attributed to our small cohort of patients.\u003c/p\u003e \u003cp\u003eAs a final piece of data, we analyzed how many adolescents feel comfortable discussing topics such as sexual orientation and GI, first with their parents and then with their doctor or pediatrician. Overall, most adolescents are open to conversations on these topics both within the family and in a medical setting. Among those who avoid these discussions entirely, there is an equal distribution between genders. One participant with GD, a transgender boy, is in this group. Another participant with GD, a non-binary individual, is comfortable discussing their gender identity and sexual orientation with their family but not with medical professionals. Their reluctance to talk to medical staff may stem from feeling wrong or different, underscoring the need for greater sensitivity and inclusivity in healthcare. A similar issue is noted with a cisgender homosexual boy who reported experiencing discrimination due to his sexual orientation within his family, at school, and in the hospital. As already stated by literature, it is essential for family, schools, and healthcare services to become places of welcome and understanding, where young people can feel safe to openly discuss these topics without fear of judgment or discrimination. Offering adequate support can make a difference in their emotional and psychological well-being, helping them develop a sense of self-esteem and belonging [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is important to clarify that the investigation of sexual orientation within this study serves an exploratory and descriptive purpose and does not carry a clinical implication. While GI and GD can lead adolescents to seek support and care within specialized gender-affirming pathways (often involving pediatric, psychological, and endocrinological evaluation), no such clinical care trajectories are established or indicated solely on the basis of sexual orientation. The inclusion of sexual orientation data aimed to capture a broader understanding of adolescents' identity experiences and social challenges, such as stigma or discrimination, rather than to inform any diagnostic or therapeutic approach. This distinction is essential to avoid conflating gender identity-related healthcare needs with the diverse, non-pathological spectrum of sexual orientations.\u003c/p\u003e \u003cp\u003eThis study has several limitations that should be acknowledged. First, the sample size was relatively small and geographically concentrated in northern Italy, which may limit the generalizability of the findings to the broader adolescent population across the country. Additionally, the study relied on self-reported data, which may be subject to reporting bias, particularly on sensitive topics such as gender identity and sexual orientation. The cross-sectional design also prevents the analysis of changes over time or causal relationships. We also acknowledge the methodological limitations related to the use of a self-administered questionnaire, particularly in assessing complex and subjective experiences such as discrimination based on gender identity. The finding that approximately 20% of cisgender participants reported experiencing such discrimination may reflect broader societal challenges, including gender expression that diverges from traditional norms, rather than GI \u003cem\u003eper se\u003c/em\u003e. This underscores the need for future studies to more precisely differentiate between discrimination related to gender identity, gender expression, and perceived sexual orientation. Furthermore, we recognize that no formal statistical correlation was made between discrimination experiences and other potentially influential variables, such as prior exposure to educational programs on gender identity or the sociocultural characteristics of the participants\u0026rsquo; area of residence. These aspects represent important avenues for future research to better contextualize and interpret adolescents\u0026rsquo; experiences. Despite these limitations, the study has notable strengths. It is among the few to investigate GI and sexual orientation among adolescents in the Italian context using a structured and standardized questionnaire. The anonymity of the survey likely encouraged honest responses, and the multidisciplinary development of the tool ensured both clinical relevance and psychological sensitivity. Furthermore, the inclusion of experiences with healthcare providers adds practical insight into the current gaps in adolescent care and points toward areas for improvement in medical training and public health policy. In addition, our study provides an important initial insight into the lived realities of Italian adolescents and highlights the urgency of more comprehensive, multivariate approaches in future investigations.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eOur findings highlight a significant proportion of young people dealing with GI and GD in Italy, emphasizing the necessity for appropriate settings and qualified health providers to assist and support this community. Our data underscore the urgent need for targeted interventions to aid adolescents facing these conditions, ensuring they can live authentically and in alignment with their identity. GI and GD can significantly impact the psychological and physical well-being of adolescents. Awareness initiatives can help mitigate stigma and discrimination, fostering a more inclusive and welcoming environment for all.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAFAB: assigned female at birth; AMAB: assigned male at birth; CB: cisgender boy; CG: cisgender girl; GI: gender incongruence; GD: gender dysphoria; NBY: non-binary youth; SO: sexual orientation; TB: transgender boy\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee for Research Protocols of the University of Parma (n. 4089-2023). Written consent was obtained by the study participants and both their parents.\u0026nbsp;All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten consent was obtained by the study participants and both their parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data are included in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was supported by a grant of the Pediatric Clinic, University of Parma, Italy (PED-2023-10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePD and SE contributed to the conception and design of the study and questionnaire. PD and AF collected data. GR and CN performed the statistical analysis. PD wrote the first draft of the manuscript. MES and SE critically reviewed and revised the final article before submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: None.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eClaahsen-van der Grinten H, Verhaak C, Steensma T, Middelberg T, Roeffen J, Klink D. Gender incongruence and gender dysphoria in childhood and adolescence-current insights in diagnostics, management, and follow-up. Eur J Pediatr. 2021;180(5):1349\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalute M. 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LGBTQ\u0026thinsp;+\u0026thinsp;Youth Health: An Unmet Need in Pediatrics. Child (Basel). 2022;9(7):1027.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eExp\u0026oacute;sito-Campos P, G\u0026oacute;mez-Balaguer M, Hurtado-Murillo F, Morillas-Ari\u0026ntilde;o C. Evolution and trends in referrals to a specialist gender identity unit in Spain over 10 years (2012\u0026ndash;2021). J Sex Med. 2023;20(3):377\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiovanardi G, Fortunato A, Mirabella M, Speranza AM, Lingiardi V. Gender Diverse Children and Adolescents in Italy: A Qualitative Study on Specialized Centers' Model of Care and Network. Int J Environ Res Public Health. 2020;17(24):9536.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteensma TD, Kreukels BP, de Vries AL, Cohen-Kettenis PT. Gender identity development in adolescence. Horm Behav. 2013;64(2):288\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCalcaterra V, Tornese G, Zuccotti G, Staiano A, Cherubini V, Gaudino R, et al. Italian Academy of Pediatrics, Italian Society of Pediatrics, Italian Society for Pediatric Endocrinology and Diabetes, Italian Society of Adolescent Medicine, Italian Society of Child and Adolescent Neuropsychiatry. Adolescent gender dysphoria management: position paper from the Italian Academy of Pediatrics, the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, the Italian Society of Adolescent Medicine and the Italian Society of Child and Adolescent Neuropsychiatry. Ital J Pediatr. 2024;50(1):73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMasala B, Love A, Carmichael P, Masic U. Demographics of referrals to a specialist gender identity service in the UK between 2017 and 2020. Clin Child Psychol Psychiatry. 2024;29(2):624\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWright JD, Chen L, Suzuki Y, Matsuo K, Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColeman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022;23(Suppl 1):S1\u0026ndash;259.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButler G, De Graaf N, Wren B, et al. Assessment and support of children and adolescents with gender dysphoria. Arch Dis Child. 2018;103(7):631\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarconi E, Monti L, Marfoli A, et al. A systematic review on gender dysphoria in adolescents and young adults: focus on suicidal and self-harming ideation and behaviours. Child Adolesc Psychiatry Ment Health. 2023;17(1):110.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReisner SL, Greytak EA, Parsons JT, et al. Gender minority social stress in adolescence: disparities in adolescent bullying and substance use by gender identity. J Sex Res. 2015;52(3):243\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiana P, Esposito S. Epidemiology, risk factors, and prevention strategies of HIV, HPV, and other sexually transmitted infections among cisgender and transgender youth: a narrative review. Front Public Health. 2024;12:1342532.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrunas A, Bandini E, Fisher AD, et al. Experiences of Discrimination, Harassment, and Violence in a Sample of Italian Transsexuals Who Have Undergone Sex-Reassignment Surgery. J Interpers Violence. 2018;33(14):2225\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatt N, Cannella J, Gentile JP. Gender-affirming Care for Transgender Patients. Innov Clin Neurosci 2022 Apr-Jun;19(4\u0026ndash;6):23\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKameg BN, Nativio DG. Gender dysphoria in youth: An overview for primary care providers. J Am Assoc Nurse Pract. 2018;30(9):493\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarofalo R, Deleon J, Osmer E, Doll M, Harper GW. Overlooked, misunderstood and at- risk: Exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health. 2006;38:230\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRussell ST, Ryan C, Toomey RB, Diaz RM, Sanchez J. Lesbian, gay, bisexual, and transgender adolescent school victimization: Implications for young adult health and adjustment. J Sch Health. 2011;81:223\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"adolescents, gender dysphoria, gender incongruence, sexual identity, sexual orientation, transgender","lastPublishedDoi":"10.21203/rs.3.rs-4706981/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4706981/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eGender incongruence (GI) is the conflict between the sex assigned at birth and the perceived gender identity, sometimes leading to significant distress (gender dysphoria). The WPATH Standards of Care (SOC) estimate that transgender youth make up approximately 3% of the global pediatric population, increasing to 8% when considering all gender-diverse identities. GI and perceived non-conforming sexual orientation can lead to reduced access to care and marginalization in non-inclusive socio-healthcare contexts. This study aims to overview the prevalence of different sexual identities among Italian adolescents, highlighting non-conforming gender identities and sexual orientations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA cross-sectional study used an online, anonymous questionnaire administered to adolescents aged 12 to 17 years at the Pediatric Clinic of the University Hospital of Parma, Italy, from January 2023 to April 2024. Informed consent was obtained from the adolescents and their parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFifty-one adolescents [31 assigned female at birth (AFAB)] completed the questionnaire, with a mean age of 14.9 ± 1.4 years. Among them, 3.9% (all AFAB) reported GI causing significant distress. Among AFAB adolescents, 19.3% experienced gender-based discrimination, and about 13% desired to belong to a different gender at least once. Regarding sexual orientation, 13% identified as bisexual, 3.2% as asexual, and 16.1% were unsure. Among males assigned at birth (AMAB), 100% identified as cisgender, and 5% were homosexual. Sexual activity was reported by 41.9% of AFAB adolescents (3.2% homosexual, 38.7% heterosexual) and 15% of AMAB peers (all heterosexual). Most adolescents (68.6%) felt comfortable discussing sexual identity topics with their pediatrician/general practitioner.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe study indicates that 3.9% of the adolescents experience GI and a notable percentage exhibit non-conforming sexual orientations. A significant proportion of adolescents wish to discuss their sexual orientation and gender identity with their healthcare providers, underscoring the need for medical competence and inclusive dialogue.\u003c/p\u003e","manuscriptTitle":"Various sexual identities among a cohort of Italian adolescents: from their own perception of selves to social and healthcare acceptance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-17 12:48:11","doi":"10.21203/rs.3.rs-4706981/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-04-17T06:03:37+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-16T14:24:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-24T13:23:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Italian Journal of Pediatrics","date":"2025-03-22T04:57:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5b4e561c-bb4a-4ad0-92e6-de82d0360904","owner":[],"postedDate":"April 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-04-17T12:48:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-17 12:48:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4706981","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4706981","identity":"rs-4706981","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}