Functional Tic-Like Behaviors in Youth With Gender Dysphoria: A Case Series

Functional tic-like behaviors (FTLBs) are increasingly recognized as distinct from Tourette syndrome, characterized by abrupt onset, complex and atypical motor and vocal phenomena, and the absence of premonitory urges or suppressibility. During the severe acute respiratory syndrome coronavirus 2 pandemic, there was a marked rise in FTLB cases, disproportionately affecting adolescents assigned female at birth and individuals with gender dysphoria. Data describing FTLBs in adolescents with coexisting gender dysphoria remain limited.

We conducted a retrospective review of patients younger than 18 years presenting to the Tourette Centers of Excellence at Arkansas Children's Hospital between January 2022 and December 2023 with sudden onset complex tic-like behaviors and coexisting gender dysphoria. Demographic characteristics, clinical phenomenology, psychiatric comorbidities, treatments, and outcomes were abstracted from the medical record.

Nine patients met inclusion criteria (median age 15 years, range 9-18 years); 89% were assigned female at birth, and all were White/Caucasian. Tic onset occurred within six months before or after the diagnosis of gender dysphoria. FTLB phenomenology included context-dependent motor behaviors (self-injury, object throwing, copropraxia, freezing, and drop episodes) and socially inappropriate or situationally triggered vocalizations, with symptom fluctuation and frequent emergence of new movements or sounds. Psychiatric comorbidity was universal: anxiety and depression were present in 100%, attention-deficit/hyperactivity disorder in 44%, suicidal ideation in 44%, and prior suicide attempts in 33%. Additional diagnoses included post-traumatic stress disorder (22%), obsessive-compulsive disorder (22%), eating disorder (11%), and autism spectrum disorder (11%). All patients received psychotherapy, and 78% received pharmacologic treatment, most commonly selective serotonin reuptake inhibitors and alpha-2 agonists. At follow-up of at least 12 months, all patients demonstrated complete or near-complete resolution of FTLBs, accompanied by improved psychiatric stability and functional recovery.

This case series highlights the intersection of FTLBs and gender dysphoria in adolescents and underscores the importance of multidisciplinary, integrated mental health care. Early recognition and comprehensive psychiatric treatment are associated with favorable long-term outcomes in this population.