Table 2

Intervention characteristics

Study ID, countryIntervention and goalsIntervention content and structureMode of deliveryModifications/adaptations
Allen et al,33
Australia
First Assessment Single-Session Triage (FAAST) individual triage clinic for specialist gender service
Aims to decrease wait time into service by providing initial assessment and triage, and to deliver information, education and support to gender questioning young people and their families.
Thirty-minute biopsychosocial assessment with young person using (Home, Education, Activities, Drugs, Sexuality and Suicide (HEADSS) framework.
Followed by a joint consultation with the young person and primary caregiver(s) to provide information, education and support. Topics for discussion tailored to individual need. May involve onward referrals to relevant local community support services including mental health services, school support and peer support groups.
Individual format delivered face-to-face in single 90 min consultation session.
Delivered by specialist nurse at specialist gender service.
Developed specifically for children and adolescents referred to specialist gender service.
Austin et al,34
Canada
AFFIRM—Affirmative cognitive behavioural coping skills group intervention
Aims to improve coping and reduce emotional distress using cognitive behavioural therapy (CBT) techniques that target underlying, problematic cognitions, and by promoting positive change and healthy coping via the creation of a safe, affirming and collaborative therapeutic experience.
Manualised intervention comprising eight modules that covered;
  1. Introduction to CBT and understanding minority stress

  2. Understanding the effect of anti-transgender attitudes and behaviours on stress

  3. Understanding how thoughts affect feelings

  4. Using thoughts to change feelings

  5. Exploring how activities affect feelings

  6. Planning to overcome counterproductive thoughts and negative feelings by building hope

  7. Understanding the impact of minority stress and homo/transphobia on social relationships

  8. Developing safe, supportive and identity-affirming social networks.

Group format (10 young people and two co-facilitators) delivered face-to-face over eight sessions (duration/frequency not reported).
Facilitators had minimum 1 year of experience working with sexual and gender minority youth, with some history of using CBT-based interventions. Facilitators received 5 hours of training.
Designed for delivery in a variety of community settings. Pilot delivered as weekend group retreat format.
CBT was adapted for youth with sexual and/or gender-minority identities. Intervention developed in partnership with a transgender-identified intern with expertise in developing identity-affirming and inclusive materials. Feedback from stakeholders also informed adaptations.
Examples included using real-world examples relevant to the unique experiences of transgender youth to illustrate CBT strategies, addressing impact of transphobia and cisgenderism, creating affirming environment by using community centre with gender-neutral restrooms, gender-diverse staff, displaying events for gender-diverse people, etc.
Bluth et al,35
USA
Mindful Self-Compassion for Teens (MSC-T) group intervention
Aims to improve mental health and psychosocial outcomes using self-compassion training and mindfulness techniques.
Each session began with a brief mindfulness art activity to allow participants to settle in and orient themselves. The intervention included hands-on exercises, videos, games, mindful movement and music meditation. Home practice was encouraged to reinforce techniques.
Eight sessions covered;
  1. Introduction to concepts of mindfulness and self-compassion.

  2. Paying attention on purpose—concept of mindfulness and wandering mind; mindful eating.

  3. Loving kindness practice is introduced; adolescent brain development.

  4. Self-compassion exercise to encourage young people to challenge the inner critic with a compassionate voice.

  5. Self-compassion vs self-esteem—exploring differences between these and perils of social comparison.

  6. Living deeply—core values exercise; giving and receiving meditation.

  7. Managing difficult emotions—soften, soothe, allow practice introduced; tools to contend with anger and unmet needs are practiced; two developing systems of the adolescent brain explained.

  8. Embracing your life with gratitude—gratitude and self-appreciation practices; wrap-up of course via writing an online letter to oneself to be delivered a month later.

Group format delivered online via Zoom over 8 sessions of 90 min in duration.
First cohort delivered over 8 days (one session per day) in the summer holiday, second cohort twice weekly in the evenings for 4 weeks.
Delivered by two trained MSC-T instructors.
Modifications to MSC-T, which was developed for all teenagers, were made to accommodate needs of transgender adolescents. An example reported was omitting the body scan in case bringing attention to body parts was triggering. No other information was provided.
Costa et al,36
UK
Psychosocial support is provided within specialist gender services for children and adolescents
Aims to improve psychosocial functioning.
Starts with standardised psychological assessment of gender dysphoria and identity, and psychosocial difficulties.
Individual needs are met using various psychotherapeutic interventions ranging from individual to family and group therapy. Social and educational interventions are also provided if necessary.
Individual, family or group format delivered face-to-face depending on need. Carried out regularly (at least once a month). Provided for duration of study (up to 18 months). No other details provided.
Delivered by staff working in specialist gender service (no other details provided).
Developed specifically for children and adolescents referred to specialist gender service.
Davidson et al,37
UK
Structured therapeutic peer-support group for young people attending specialist gender service
Aims to explore young people’s difficulties in the context of their social systems and to provide concrete strategies to help them in their interpersonal relationships, prepare them for gender transitions, sustain hope and manage challenging emotions.
Multiple therapeutic techniques were used—CBT and systemic therapy were predominant approaches. Nine didactic and interactive sessions covered;
  1. Establishing safety and a connection.

  2. Managing worry and anxiety.

  3. Managing low mood (including managing self-harm and suicidal feelings).

  4. Dealing with frustration and anger.

  5. Considering peer relationships (including responding to bullying).

  6. Considering family relationships.

  7. Considering intimate relationships and sexual health.

  8. Considering different identities: perspectives from a transman, a transwoman and someone identified as non-binary/gender fluid.

  9. Consolidating the learning.


Each theme was problem oriented, with members encouraged to provide real-life examples from their own experiences in pairs, before feeding back to the larger group, where connections between experiences were made. Later in the session emphasis shifted to participants sharing solution focused strategies they found useful in addressing the issues.
Group format delivered face-to-face over 9 weekly sessions of 90 min in duration.
Co-facilitated by three staff from the gender service (consultant clinical psychologist, trainee clinical psychologist, research psychologist). Specialist gender service setting—details not reported.
Developed specifically for young people referred to specialist gender service.
Hollinsaid et al,38
USA
Standard and modular empirically supported psychotherapy treatments (ESTs)
Aims to treat depression, anxiety, trauma or conduct problems using a range of therapeutic approaches matched to a child’s primary problems.
Modular ESTs utilised a multidiagnostic framework—The Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH) that included treatment procedures from various ESTs, including CBT and behavioural parent training to individualised treatment for a young person’s main problems over time. MATCH therapists chose and sequenced intervention components from 33 modules grouped across protocols for anxiety, depression, trauma and conduct problems. Examples include psychoeducation for anxiety or behavioural activation for depression.
Standard ESTs used the same content but intervention components were delivered sequentially based on the young person’s primary problems.
Individual format delivered face-to-face. Intervention duration and session numbers varied depending on treatment modules offered. Duration ranged from 8 to 589 days. Number of sessions ranged from 1 to 87.
Delivered by trained therapists in community-based mental health clinics.
No modifications for gender diverse/incongruent participants.
Lucassen et al,39
New Zealand
SPARX—Video game-based e-therapy
Aims to provide a computerised cognitive behavioural therapy programme for the treatment of depression in adolescents.
Self-help cognitive behavioural therapy online game which involved participants joining a virtual fantasy world with a personalised avatar and embarking on a mission to rid the world of gloom.
Completed over seven modules, each comprising a challenge to complete and including a direct teaching component where a core CBT skill is applied to the user’s real-life context. Users aim to gain six ‘gem stones’ for their shield against depression, which correspond to CBT techniques taught in the modules. Homework tasks allow practice and facilitate skill generalisation. A 'Guide' or 'virtual therapist' introduces each module and reviews the content covered when completed. CBT techniques included relaxation training, behavioural activation, social skills training, naming cognitive distortions, problem-solving and cognitive restructuring.
Each of the seven modules designed to take around 30 min to complete.No modifications for gender diverse/incongruent participants.
Russon et al,32
USA
Attachment-Based Family Therapy (ABFT)
Aims to repair damage in the adolescent-caregiver attachment relationship and establish or resuscitate a secure, family-based environment.
Provides an interpersonal, process-oriented, trauma-focused approach to treat depression, suicidality and trauma in LGBTQ+ youth.
Manualised therapy consisted of five treatment tasks that encouraged young person to take developmentally appropriate responsibility and challenged parents to find the right balance of support and encouragement.
  1. Relational reframe (one session) helps move family from a focus on young person’s symptoms to improvement in parent(s)–child relationship.

  2. Adolescent alliance-building task (two to four sessions), exploring adolescent’s strengths and interests, ruptures in attachment security that impact mental health and inhibit the adolescent from turning to parents for support.

  3. Build alliance with the parents (two to four sessions)—discussion of parents’ own history of attachment ruptures and current stressors that may impact parenting.

  4. Attachment task (one to four sessions)—the central mechanism of therapy is to generate a ‘corrective attachment experience’ in which the young person expresses grievances in a more regulated manner and receives empathy and understanding from parents.

  5. Autonomy-promoting task (one to ten sessions)—helping family members practice new relational skills, consolidating newly formed secure base. Attention shifts to promoting the adolescent’s autonomy and/or focus on other causes of depression/suicide.

Individual format delivered face-to-face over 16 weeks with weekly sessions (three participants continued to 20–24 weeks). Session duration not reported.
Delivered by trained ABFT therapists who were supervised by the lead therapist.
Delivered within LGBTQ+ focused community organisations.
Modified for LGBTQ+ adolescents and young adults based on interviews with key stakeholders. The following changes were reported:
  1. More individual sessions with young person before family therapy to build alliance.

  2. Increased number of meetings with caregivers who showed rejecting behaviours to reduce anxiety and anger before family sessions.

  3. Advocacy role for therapists with external systems of care (eg, schools and clinicians) about the needs of LGBTQ+ young people.

  4. Discussed minority stressors and discrimination with parents to increase empathy for child’s struggles.

Silveri et al,40
USA
Acute residential treatment (ART) insurance-based programme
Aims to reduce clinical psychiatric symptoms in young people.
Milieu-based treatment, comprised of cognitive behavioural therapy, dialectical behavioural therapy, motivational interviewing and individual, group and family therapy.
Assessment by a psychiatrist twice a week and medical interventions introduced if deemed necessary.
Individual, family or group format delivered face-to-face over approximately 2 weeks (no other details provided).
Delivered in residential setting (no other details provided).
No modifications for gender diverse/incongruent participants.
Stevens et al,41
USA
iTEAM—Affirming system of care community intervention
Aims to promote affirming forms of self-acceptance, increase self-esteem, lower psychological distress and mediate negative effects of discrimination in LGBTQ+ youth.
Used a system-of-care framework involving a co-ordinated network of multiple relevant agencies. Following an intake assessment, young people were assigned a case manager who provided on-going support and introduced iTEAM affirming services and provided referrals to other community-based services.
iTEAM services included:
Strength-based case management.
Motivational Enhancement Therapy and Cognitive Behavioural Therapy.
Street Smart (sexual health education intervention).
Crisis and mental health counselling/therapy.
Education and employment services.
Direct enrolment in local housing programmes.
Group-based services and activities.
Case management delivered individually face-to-face at least three times weekly during first 3 months and then reduced based on clinical need for additional 3–4 months.
Delivered by case managers at the iTEAM programme site.
Other intervention components also delivered at iTEAM programme site. Mode of delivery, duration and frequency of other elements not reported.
System-of-care framework model was adapted for LGBTQ+ youth. Adaptations included a welcoming space, LGBTQ+ pro-social activities; staff who were representative of multiple identities; on-going training provided for staff and volunteers with regard to affirming care for this population.
Services involved in providing care were also adapted to address specific needs of LGBTQ+ youth, for example, family rejection, work-place discrimination.
  • CBT, cognitive behavioural therapy; LGBTQ+, lesbian, gay, bisexual, transgender, queer or questioning.