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Foo MM, Roberts Z, Roden RC. Use of Telemedicine Services Is Associated with Longer Time to Initiation of Hormone Therapy in Transgender Teens and Young Adults. Telemed J E Health 2024. [PMID: 39291313 DOI: 10.1089/tmj.2024.0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2024] Open
Abstract
Purpose: This is a retrospective chart review examining factors, which may contribute to timing of receipt of prescription for testosterone or estrogen-based interventions for transgender adolescents and young adults who do not receive such a prescription at their first medical appointment. Methods: A total of 176 patient records were available; of this a minority received a prescription for hormone therapy at first medical appointment. Of the remaining 108 unique individuals, 49 received a prescription at a subsequent medical. Results: Participants seen through virtual health care had a significantly longer time in care prior to receipt of estrogen or testosterone prescription (331 days vs. 220 days, p = 0.046). No other significant relationships were found. Conclusion: Patients who utilize telemedicine services for gender-related health care purposes and who did not receive a prescription for estrogen or testosterone at their initial medical encounter have a longer lead time to receipt of hormone therapy.
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Affiliation(s)
- Megan Mia Foo
- Division of Adolescent Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Zaine Roberts
- Division of Adolescent Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Rosemary Claire Roden
- Division of Adolescent Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
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2
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Abernathey L, Kahn NF, Sequeira GM, Richardson LP, Ahrens K. Associations Between Gender Dysphoria, Eating Disorders, and Mental Health Diagnoses Among Adolescents. J Adolesc Health 2024:S1054-139X(24)00306-9. [PMID: 39217528 DOI: 10.1016/j.jadohealth.2024.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 06/17/2024] [Accepted: 06/17/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Transgender adolescents and adolescents with eating disorders (EDs) are known to have increased mental health comorbidity; however, little is understood about how gender dysphoria (GD), disordered eating and mental health disorders relate to each other. The purpose of this study was to examine associations between GD, ED, and mental health diagnoses among adolescents. METHODS Data were extracted from the electronic health records of 57,353 patients aged 9-18 seen at a single pediatric health system between 2009 and 2022. Adjusted logistic regression models tested for associations between GD, ED, and mental health diagnoses. RESULTS Youth with a GD diagnosis had significantly greater odds of also having an ED diagnosis compared to those without a GD diagnosis (adjusted odds ratio [aOR] = 3.72, 95% confidence interval [CI]: 2.98-4.64). Among those with an ED diagnosis, youth with a GD diagnosis had significantly lower odds of having an anorexia nervosa diagnosis (aOR = 0.34, 95% CI: 0.18-0.61) and significantly greater odds of having an unspecified or other specified ED diagnosis (aOR = 2.48, 95% CI: 1.56-3.93) compared to those without a GD diagnosis. Youth with both GD and ED diagnoses had significantly greater odds of also having a diagnosis of anxiety (aOR = 24.01, 95% CI: 14.85-38.83), depression (aOR = 48.41, 95% CI: 30.38-77.12), suicidality (aOR = 26.15, 95% CI: 16.65-41.05) and self-harm (aOR = 35.79, 95% CI: 22.48-56.98) as compared to those with neither a GD nor an ED diagnosis. DISCUSSION Adolescents with co-occurring GD and ED diagnoses are at greater risk for anxiety, depression, suicidality, and self-harm as compared to youth with neither diagnosis. Further research is essential to understand the complex interplay of mental health concerns and EDs among gender diverse adolescents and to inform appropriate interventions.
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Affiliation(s)
- Liz Abernathey
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington.
| | - Nicole F Kahn
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Gina M Sequeira
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Laura P Richardson
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Kym Ahrens
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington
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3
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Calzo JP, Andrzejewski J, Torres C, Silverstein S, Lopez E, Gordon AR. "There is a paywall to my happiness": the influence of socioeconomic determinants on transgender and gender diverse young adults' experiences with eating disorders. Eat Disord 2024:1-20. [PMID: 39102353 DOI: 10.1080/10640266.2024.2381908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
Transgender and gender diverse (TGD) young adults experience elevated risk for eating disorders (ED), partially due to cissexist discrimination and victimization; less is understood about how socioeconomic determinants contribute to their ED risk. Qualitative data collected from 66 TGD young adults (18-30 years old; 29% self-identified as transgender women, 29% as transgender men, 39% as nonbinary people, and 3% as another gender identity (e.g., māhū)) in eight asynchronous online focus groups explored how socioeconomic determinants in conjunction with other dimensions of identity and lived experience shape disordered eating behavior (DEB) and ED risk. Participants described how economic barriers-including poverty and dependency on others (e.g. parents for health insurance)-and challenges produced by insurance and healthcare systems impeded healthcare access to the detriment of their overall mental health and risk for ED. In addition, participants shared different ways they leveraged financial resources to cope with stress, sometimes in ways that impelled disordered eating behaviors. Finally, participants described how poverty, socioeconomic advantage and disadvantage, and classism compound other systems of oppression (e.g. racism, ableism, weight bias) to adversely impact their general health and ED risk.
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Affiliation(s)
- Jerel P Calzo
- School of Public Health, San Diego State University, San Diego, California, USA
- Action Research on Community Health Equity and Stigma Lab, Institute for Behavioral and Community Health, San Diego, California, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jack Andrzejewski
- Action Research on Community Health Equity and Stigma Lab, Institute for Behavioral and Community Health, San Diego, California, USA
- Joint Doctoral Program in Public Health, San Diego State University and University of California, San Diego, CA, USA
| | - Catalina Torres
- Action Research on Community Health Equity and Stigma Lab, Institute for Behavioral and Community Health, San Diego, California, USA
| | - Scout Silverstein
- Program Director, Fighting Eating Disorders in Underrepresented Populations: A Trans+ & Intersex Collective, San Diego, CA, USA
- Program Development, EQUIP Health
| | - Ethan Lopez
- Program Director, Fighting Eating Disorders in Underrepresented Populations: A Trans+ & Intersex Collective, San Diego, CA, USA
- Program Development, EQUIP Health
| | - Allegra R Gordon
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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4
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Lucas R, Geierstanger S, Soleimanpour S. Mental Health Needs, Barriers, and Receipt of Care Among Transgender and Nonbinary Adolescents. J Adolesc Health 2024; 75:267-274. [PMID: 38739056 DOI: 10.1016/j.jadohealth.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/02/2024] [Accepted: 03/19/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE Transgender and nonbinary youth disproportionately experience adverse mental health outcomes compared to cisgender youth. This study examined differences in their mental health needs and supports, barriers to care, and receipt of mental health care. METHODS This study examined cross-sectional data from 43,339 adolescents who completed the California Healthy Kids Survey, 4% (n = 1,876) of whom identified as transgender and/or nonbinary. Chi-square test and t-test were used to compare mental health needs and supports, resilience, and barriers to and receipt of care experienced by transgender and nonbinary youth compared to cisgender youth. RESULTS Transgender and nonbinary youth were significantly more likely to experience chronic sadness/hopelessness (74% vs. 35%) and consider suicide (53% vs. 14%) and less likely to report resilience factors (school connectedness: mean score 3.12 vs. 3.52). Transgender and nonbinary youth were significantly less likely to be willing to talk to teachers/adults from school (12% vs. 18%) or parents/family members (21% vs. 43%), but more willing to talk to counselors (25% vs. 19%) regarding mental health concerns. Transgender and nonbinary youth were significantly more likely to select being afraid (48% vs. 20%), not knowing how to get help (44% vs. 30%), or concern their parents would find out (61% vs. 36%) as barriers to seeking mental health care, yet reported slightly higher odds of receiving care when needed (odds ratio: 1.2). DISCUSSION Transgender and nonbinary youth are more likely to report mental health concerns and barriers to seeking care than cisgender youth. Increasing access to care is critical for this population.
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Affiliation(s)
- Ruby Lucas
- Department of Epidemiology, University of Washington, Seattle, Washington; School of Medicine, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California.
| | - Sara Geierstanger
- School of Medicine, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California
| | - Samira Soleimanpour
- School of Medicine, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California
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5
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MacMullin LN, Sorbara JC, Coome LA, VanderLaan DP, Palmert MR. Characteristics of Youth Presenting for Gender Care Compared to Background Populations: Examination of Social Determinants of Health. LGBT Health 2024. [PMID: 39077808 DOI: 10.1089/lgbt.2023.0271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Abstract
Purpose: Transgender and gender diverse (TGD) youth in North American clinical reports are predominantly White with relatively high socioeconomic status suggesting that access to gender-affirming care is inequitable. This study examined whether socioeconomic and social determinant of health discrepancies exist between a clinical population of TGD youth and surrounding communities. Methods: Patient postal codes were used to link the Ontario Marginalization Index (ON-MARG) to a clinic-based TGD youth cohort (n = 298). Using ON-MARG, each patient was assigned a quintile score from 1 (least marginalized) to 5 (most marginalized) on four marginalization measures. Mean quintile scores were compared to background populations. Census-based Toronto neighborhood-level data on ethnic diversity and educational status were also examined. Neighborhoods were categorized as highly represented, less represented, or unrepresented based on representation in the clinic cohort. One-way analysis of covariance was used to determine associations between neighborhood-level variables and the degree of neighborhood representation. Results: ON-MARG data demonstrated that clinic patients hailed from areas with more individuals having paid employment. Patients from Toronto and surrounding areas came, in general, from communities with fewer recent immigrants and visible minorities. Highly represented Toronto neighborhoods had smaller proportions of visible minorities and immigrants compared with less and unrepresented neighborhoods. Educational status, represented by adults with bachelor's degrees, was lower among unrepresented neighborhoods. Conclusion: TGD youth seen in clinic, particularly those from Toronto, are disproportionally White and socioeconomically advantaged. Further research is needed to better understand the underrepresentation of racialized and low-socioeconomic status youth and to inform strategies to improve access to care.
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Affiliation(s)
- Laura N MacMullin
- Department of Psychology, University of Toronto, Mississauga, Canada
| | - Julia C Sorbara
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Lindsay A Coome
- Department of Psychology, University of Toronto, Mississauga, Canada
| | - Doug P VanderLaan
- Department of Psychology, University of Toronto, Mississauga, Canada
- Child and Youth Psychiatry, Centre for Addiction and Mental Health, Toronto, Canada
| | - Mark R Palmert
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Canada
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6
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McNamara M, Gentry KR, Sequeira GM, Kidd KM. State-Level Bans on the Care of Transgender and Gender Diverse Youth in the United States: Implications for Ethics and Advocacy. J Pediatr 2024; 274:114182. [PMID: 38964438 DOI: 10.1016/j.jpeds.2024.114182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 05/26/2024] [Accepted: 06/26/2024] [Indexed: 07/06/2024]
Affiliation(s)
| | - Katherine R Gentry
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, WA; Seattle Children's Hospital, Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle, WA
| | - Gina M Sequeira
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Kacie M Kidd
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV
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7
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Kahn NF, Asante PG, Coker TR, Kidd KM, Christakis DA, Richardson LP, Sequeira GM. Demographic Differences in Gender Dysphoria Diagnosis and Access to Gender-Affirming Care Among Adolescents. LGBT Health 2024; 11:348-358. [PMID: 38190267 DOI: 10.1089/lgbt.2023.0273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024] Open
Abstract
Purpose: The goal of this article was to identify demographic differences in receipt of gender dysphoria (GD) diagnosis and access to gender-affirming care (GAC) among adolescents whose gender identity and/or pronouns differed from their sex assigned at birth. Methods: Data were from 2444 patients who were 13-17 years old and had a documented gender identity and/or pronouns that differed from their sex assigned at birth in the electronic health record. Adjusted logistic regression models explored associations between demographic characteristics (sex assigned at birth, gender identity, race and ethnicity, language, insurance type, rural status) and presence of GD diagnosis and having accessed GAC. Results: The average predicted probability (Pr) of having received a GD diagnosis was 0.62 (95% confidence interval [CI] = 0.60-0.63) and of having accessed GAC was 0.48 (95% CI = 0.46-0.50). Various significant demographic differences emerged. Notably, Black/African American youth were the least likely to have received a GD diagnosis (Pr = 0.43, 95% CI = 0.33-0.54) and accessed GAC (Pr = 0.32, 95% CI = 0.22-0.43). Although there were no significant differences in GD diagnosis by insurance type, youth using Medicaid, other government insurance, or self-pay/charity care were less likely to have accessed GAC compared with youth using commercial/private insurance. Conclusion: Results indicate significant differences in both receipt of GD diagnosis and accessing GAC by various demographic characteristics, particularly among Black/African American youth. Identification of these differences provides an opportunity to further understand potential barriers and promote more equitable access to GAC among adolescents who desire this care.
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Affiliation(s)
- Nicole F Kahn
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
- Seattle Children's Hospital, Seattle, Washington, USA
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Peter G Asante
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Tumaini R Coker
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
- Seattle Children's Hospital, Seattle, Washington, USA
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Kacie M Kidd
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Dimitri A Christakis
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
- Seattle Children's Hospital, Seattle, Washington, USA
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Laura P Richardson
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
- Seattle Children's Hospital, Seattle, Washington, USA
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Gina M Sequeira
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
- Seattle Children's Hospital, Seattle, Washington, USA
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA
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8
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Lava CX, Snee IA, Li KR, O’Hara GL, Bhatt NP, Manrique OJ, Fan KL, Del Corral GA. Perioperative Patient-Initiated Communication in Gender-Affirming Mastectomy. J Clin Med 2024; 13:3368. [PMID: 38929897 PMCID: PMC11204160 DOI: 10.3390/jcm13123368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/14/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Gender-affirming mastectomy (GAM) improves the psychosocial functioning and quality of life of transgender and non-binary (TGNB) individuals. However, the perioperative period is often marked by emotional stress, concerns about surgical outcomes, and physical discomfort. While inpatient procedures provide multiple opportunities to engage with and educate patients, outpatient surgeries, such as GAM, pose a unique challenge as patients are followed for <24 h postoperatively. Given the heightened emotional and psychological distress related to gender dysphoria TGNB individuals often experience, addressing these gaps can significantly improve outcomes. This study aims to characterize patient and surgical characteristics associated with patient-initiated communication (PIC) frequency in this population. Methods: A single-center retrospective review of TGNB patients undergoing GAM from February 2018 to November 2022 was conducted. Demographics, surgical characteristics, and frequency of and reasons for perioperative PIC (30 days before and after surgery) were recorded. The primary outcome was the incidence of perioperative PIC. The secondary outcomes included (1) the rationale for PIC and (2) patient and surgical characteristics associated with PIC. Results: A total of 352 patients were included. Of these, 285 (74.6%) initiated communication in the perioperative period, totaling 659 PICs. The median age was 25.0 (interquartile range [IQR]: 9.0) years. The median body mass index (BMI) was 28.5 (IQR: 8.5) kg/m2. The mean number of PICs was 0.7 ± 1.3 preoperatively and 1.3 ± 1.7 postoperatively (p < 0.001). The most frequent preoperative PIC subjects were administrative issues (AI; n = 66, 30.7%), preoperative requirements (n = 43, 20.0%), and cost and insurance (n = 33, 15.0%). The most frequent postoperative PIC subjects were wound care (n = 77, 17.3%), AI (n = 70, 15.0%), activity restrictions (n = 60, 13.5%), drainage (n = 56, 12.6%), and swelling (n = 37, 8.3%). Collectively, older patients (β = 0.234, p = 0.001), those with a history of major depressive disorder or generalized anxiety disorder (2.4 ± 3.0 vs. 1.7 ± 1.9; p = 0.019), and those without postoperative drains (n = 16/17, 94.1% vs. n = 236/334, 70.7%; p = 0.025) engaged in higher levels of PIC. There were no significant associations between other patient characteristics, perioperative details, or complications and PIC frequency. Conclusions: Perioperative PIC is prevalent among the majority of GAM patients at our institution, with age, psychiatric diagnosis, and postoperative drain use identified as significant predictors. To mitigate PIC frequency, it is crucial to ensure adequate support staffing and provide comprehensive postoperative instructions, particularly concerning activity restrictions and drainage management. These interventions may reduce PICs in high-volume centers. Further research should investigate targeted interventions to further support TGNB patients during the perioperative period.
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Affiliation(s)
- Christian X. Lava
- Georgetown University School of Medicine, Washington, DC 20007, USA; (C.X.L.); (I.A.S.); (K.R.L.); (G.L.O.); (N.P.B.)
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC 20007, USA;
| | - Isabel A. Snee
- Georgetown University School of Medicine, Washington, DC 20007, USA; (C.X.L.); (I.A.S.); (K.R.L.); (G.L.O.); (N.P.B.)
| | - Karen R. Li
- Georgetown University School of Medicine, Washington, DC 20007, USA; (C.X.L.); (I.A.S.); (K.R.L.); (G.L.O.); (N.P.B.)
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC 20007, USA;
| | - George L. O’Hara
- Georgetown University School of Medicine, Washington, DC 20007, USA; (C.X.L.); (I.A.S.); (K.R.L.); (G.L.O.); (N.P.B.)
| | - Niyati P. Bhatt
- Georgetown University School of Medicine, Washington, DC 20007, USA; (C.X.L.); (I.A.S.); (K.R.L.); (G.L.O.); (N.P.B.)
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive Surgery, University of Rochester Medical Center, New York, NY 14627, USA;
| | - Kenneth L. Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC 20007, USA;
| | - Gabriel A. Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Franklin Square Medical Center, Baltimore, MD 21237, USA
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Kidd KM, Didden E, Harman H, Sequeira GM, Faeder M, Inwards-Breland DJ, Voss RV, Katz-Wise SL. Parents of Gender Diverse Youth: Support Sought, Received, and Still Needed. J Adolesc Health 2024; 74:1078-1087. [PMID: 37715763 PMCID: PMC10947309 DOI: 10.1016/j.jadohealth.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/14/2023] [Accepted: 08/01/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE Gender diverse youth (GDY) have improved mental health when affirmed by parents, but little is known about the support parents of GDY seek, receive, and still need. This qualitative study explored experiences of parents of GDY to better understand their support needs. METHODS Parents of GDY submitted videos and were interviewed about their journey supporting their GDY. Data collection continued until thematic saturation was reached. Audio recordings from videos and interviews were transcribed and analyzed via an inductive thematic analysis using the rigorous and accelerated data reduction technique. RESULTS In total, 25 parents of GDY (mean age 15 years, range 6-21 years) from 12 states provided video recordings and interviews; 36% were People of Color and 28% were fathers. We identified four themes and 12 subthemes. Theme 1: support through education included acknowledging ignorance about gender diversity and remedying ignorance. Theme 2: engaging community noted that support was multilayered and based around the family unit and pre-existing community. Theme 3: expanding community included acknowledgement that seeking new community was important for many to reduce feelings of isolation. It also highlighted that "safe spaces" for parents of GDY were not always safe for those of other marginalized groups, particularly People of Color. Theme 4: support in healthcare spaces centered experiences navigating medical and mental healthcare for GDY and feeling supported and unsupported in those spaces. DISCUSSION Parents identified numerous ways they sought, received, and needed support to understand and affirm their GDY. These findings will aid development of targeted support interventions for parents of GDY. Further research is needed to evaluate the impact of these interventions on GDY health.
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Affiliation(s)
- Kacie M Kidd
- Department of Pediatrics, Division of Adolescent Medicine, West Virginia University School of Medicine, WVU Medicine Children's Hospital, Morgantown, West Virginia.
| | - El Didden
- West Virginia University School of Medicine, WVU Medicine Children's Hospital, Morgantown, West Virginia
| | - Hayley Harman
- West Virginia University School of Medicine, WVU Medicine Children's Hospital, Morgantown, West Virginia
| | - Gina M Sequeira
- Department of Pediatrics, Division of Adolescent Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Morgan Faeder
- Department of Psychiatry, University of Pittsburgh School of Medicine, UPMC Western Psychiatric Hospital, Pittsburgh, Pennsylvania
| | | | - Raina V Voss
- Department of Pediatrics, Divison of Adolescent and Young Adult Medicine, Northwestern University Feinburg School of Medicine, Lurie Children's Hospital, Chicago, Illinois
| | - Sabra L Katz-Wise
- Harvard TH Chan School of Public Health, Boston Children's Hospital, Boston, Massachusetts
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10
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Kahn NF, Sequeira GM, Asante PG, Kidd KM, Coker TR, Christakis DA, Karrington B, Aye T, Conard LAE, Dowshen N, Kazak AE, Nahata L, Nokoff NJ, Voss RV, Richardson LP. Estimating Transgender and Gender-Diverse Youth Populations in Health Systems and Survey Data. Pediatrics 2024; 153:e2023065197. [PMID: 38752289 DOI: 10.1542/peds.2023-065197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/22/2024] [Accepted: 02/08/2024] [Indexed: 06/02/2024] Open
Abstract
OBJECTIVES To identify and examine demographic variation in estimates of gender-diverse youth (GDY) populations from the PEDSnet learning health system network and the Youth Risk Behavior Survey (YRBS). METHODS The PEDSnet sample included 14- to 17-years-old patients who had ≥2 encounters at a member institution before March 2022, with at least 1 encounter in the previous 18 months. The YRBS sample included pooled data from 14- to 17-year-old in-school youth from the 2017, 2019, and 2021 survey years. Adjusted logistic regression models tested for associations between demographic characteristics and gender dysphoria (GD) diagnosis (PEDSnet) or self-reported transgender identity (YRBS). RESULTS The PEDSnet sample included 392 348 patients and the YRBS sample included 270 177 youth. A total of 3453 (0.9%) patients in PEDSnet had a GD diagnosis and 5262 (1.9%) youth in YRBS self-identified as transgender. In PEDSnet, adjusted logistic regression indicated significantly lower likelihood of GD diagnosis among patients whose electronic medical record-reported sex was male and among patients who identified as Asian, Black/African American, and Hispanic/Latino/a/x/e. In contrast, in the YRBS sample, only youth whose sex was male had a lower likelihood of transgender identity. CONCLUSIONS GDY are underrepresented in health system data, particularly those whose electronic medical record-reported sex is male, and Asian, Black/African American, and Hispanic/Latino/a/x/e youth. Collecting more accurate gender identity information in health systems and surveys may help better understand the health-related needs and experiences of GDY and support the development of targeted interventions to promote more equitable care provision.
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Affiliation(s)
- Nicole F Kahn
- Seattle Children's Hospital & Research Institute, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Gina M Sequeira
- Seattle Children's Hospital & Research Institute, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Peter G Asante
- University of Washington School of Medicine, Seattle, Washington
| | - Kacie M Kidd
- West Virginia University School of Medicine, Morgantown, West Virginia
| | - Tumaini R Coker
- Seattle Children's Hospital & Research Institute, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Dimitri A Christakis
- Seattle Children's Hospital & Research Institute, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Baer Karrington
- Seattle Children's Hospital & Research Institute, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Tandy Aye
- Stanford School of Medicine, Stanford, California
| | | | - Nadia Dowshen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Natalie J Nokoff
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Raina V Voss
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Laura P Richardson
- Seattle Children's Hospital & Research Institute, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
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11
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Kahn NF, Kidd KM, Hodax JK, Goldenberg ME, Asante PG, Kyweluk MA, Christakis DA, Pratt W, Richardson LP, Sequeira GM. Telemedicine-Based Provision of Adolescent Gender-Affirming Medical Care to Promote Equitable Access. Telemed J E Health 2024; 30:1896-1900. [PMID: 38597959 PMCID: PMC11296150 DOI: 10.1089/tmj.2023.0575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/05/2024] [Indexed: 04/11/2024] Open
Abstract
Purpose: To explore transgender and nonbinary (TNB) young adults' (1) interest in receiving gender-affirming medications through telemedicine before age 18 years and (2) willingness to initiate this care with primary care providers (PCPs). Methods: Data were from a survey of TNB young adults who had not received gender-affirming medications before age 18 years. Chi-square and Wald tests identified demographic differences in telemedicine interest and willingness to initiate medications with their PCP as minors. Results: Among 280 respondents, 82.5% indicated interest in telemedicine and 42.0% were willing to initiate medications with their PCP. Black/African American respondents were more likely to indicate interest in telemedicine than White and multiracial respondents. Respondents from rural areas were more likely to indicate willingness to initiate medications with their PCP than those from urban areas. Conclusions: Telemedicine expansion and further support for PCPs may represent critical opportunities to promote equitable access to adolescent gender-affirming care.
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Affiliation(s)
- Nicole F. Kahn
- Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
- University of Washington School of Medicine, Department of Pediatrics, Seattle, Washington, USA
| | - Kacie M. Kidd
- West Virginia University School of Medicine, Department of Pediatrics, Morgantown, West Virginia, USA
| | - Juanita K. Hodax
- Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
- University of Washington School of Medicine, Department of Pediatrics, Seattle, Washington, USA
| | | | - Peter G. Asante
- Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
| | | | - Dimitri A. Christakis
- Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
- University of Washington School of Medicine, Department of Pediatrics, Seattle, Washington, USA
| | - Wanda Pratt
- University of Washington School of Medicine, Department of Pediatrics, Seattle, Washington, USA
| | - Laura P. Richardson
- Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
- University of Washington School of Medicine, Department of Pediatrics, Seattle, Washington, USA
| | - Gina M. Sequeira
- Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
- University of Washington School of Medicine, Department of Pediatrics, Seattle, Washington, USA
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12
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Sequeira GM, Kahn NF, Kyweluk MA, Kidd KM, Asante PG, Karrington B, Bocek K, Lucas R, Christakis D, Pratt W, Richardson LP. Desire for Gender-Affirming Medical Care Before Age 18 in Transgender and Nonbinary Young Adults. LGBT Health 2024. [PMID: 38800949 DOI: 10.1089/lgbt.2023.0436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Purpose: We aimed to understand transgender and nonbinary (TNB) young adults' desire to receive gender-affirming medical care (GAMC) before age 18 and identify barriers and facilitators to receiving this care in adolescence. Methods: A cross-sectional survey was administered to TNB young adults presenting for care between ages 18 and 20 in 2023. Descriptive statistics characterized the sample, χ2 tests with post hoc pairwise comparisons identified differences in desire for gender-affirming medications, outness, and parental consent by gender identity and sex assigned at birth, and t-tests evaluated differences in barriers and facilitators to receiving care by outness to parents. Results: A total of 230 TNB respondents had complete data. Nearly all (94.3%) indicated they desired GAMC before age 18. Half (55.7%) of the respondents reported being out about their gender identity to a parent before age 18. Outness, discussing desire for GAMC, and asking for consent to receive GAMC from a parent were significantly more common among participants who identified as men compared to those who identified as women and among those assigned female at birth compared to those assigned male at birth. No such differences emerged when comparing nonbinary individuals to those who identified as men or women. Lack of parental willingness to consent for GAMC was cited as the primary contributor of not having received care in adolescence. Conclusions: Many TNB young adults desire GAMC in adolescence; however, lack of parental support is a key barrier to receiving this care, suggesting a need for more readily available resources for parents to support TNB adolescents.
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Affiliation(s)
- Gina M Sequeira
- Seattle Children's Hospital, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Nicole F Kahn
- Seattle Children's Hospital, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | | | - Kacie M Kidd
- School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Peter G Asante
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Baer Karrington
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Kevin Bocek
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Ruby Lucas
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Dimitri Christakis
- Seattle Children's Hospital, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Wanda Pratt
- Information School, University of Washington, Seattle, Washington, USA
| | - Laura P Richardson
- Seattle Children's Hospital, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
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13
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Chen D, Shen E, Kolbuck VD, Sajwani A, Finlayson C, Gordon EJ. Co-design and usability of an interactive web-based fertility decision aid for transgender youth and young adults. J Pediatr Psychol 2024:jsae032. [PMID: 38722239 DOI: 10.1093/jpepsy/jsae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/26/2024] [Accepted: 04/16/2024] [Indexed: 05/22/2024] Open
Abstract
OBJECTIVE To develop a patient- and family-centered Aid For Fertility-Related Medical Decisions (AFFRMED) interactive website targeted for transgender and nonbinary (TNB) youth/young adults and their parents to facilitate shared decision-making about fertility preservation interventions through user-centered participatory design. METHOD TNB youth/young adults interested in or currently receiving pubertal suppression or gender-affirming hormone treatment and parents of eligible TNB youth/young adults were recruited to participate in a series of iterative human-centered co-design sessions to develop an initial AFFRMED prototype. Subsequently, TNB youth/young adults and parents of TNB youth/young adults were recruited for usability testing interviews, involving measures of usability (i.e., After Scenario Questionnaire, Net Promotor Score, System Usability Scale). RESULTS Twenty-seven participants completed 18 iterative co-design sessions and provided feedback on 10 versions of AFFRMED (16 TNB youth/young adults and 11 parents). Nine TNB youth/young adults and six parents completed individual usability testing interviews. Overall, participants rated AFFRMED highly on measures of acceptability, appropriateness, usability, and satisfaction. However, scores varied by treatment cohort, with TNB youth interested in or currently receiving pubertal suppression treatment reporting the lowest usability scores. CONCLUSIONS We co-created a youth- and family-centered fertility decision aid prototype that provides education and decision support in an online, interactive format. Future directions include testing the efficacy of the decision aid in improving fertility and fertility preservation knowledge, decisional self-efficacy, and decision satisfaction.
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Affiliation(s)
- Diane Chen
- Potocsnak Family Division of Adolescent and Young Adult Medicine, Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Elaine Shen
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Victoria D Kolbuck
- Potocsnak Family Division of Adolescent and Young Adult Medicine, Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Afiya Sajwani
- Potocsnak Family Division of Adolescent and Young Adult Medicine, Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Courtney Finlayson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
- Division of Endocrinology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Elisa J Gordon
- Department of Surgery and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, United States
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14
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Speechley M, Stuart J, Scott RA, Barber BL, Zimmer-Gembeck MJ. Provision of gender affirming care among medical and allied health practitioners: The influence of transnormative beliefs in working with gender diverse patients. Soc Sci Med 2024; 348:116876. [PMID: 38615615 DOI: 10.1016/j.socscimed.2024.116876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/04/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
Gender diverse patients (including gender diverse, transgender, and non-binary people) deserve quality health care, which has been referred to as gender affirming care. Given that practitioners' attitudes and competence can influence their provision of gender affirming care, this study used a lens of transnormativity (Bradford & Syed, 2019; Johnson, 2016) to develop a measure of practitioners' transnormative beliefs. The aim of the study was to determine if these beliefs were related to practitioners' gender affirming attitudes and perceptions of competence in gender affirming practice. Survey data were collected from Australian medical and allied health practitioners (N = 95). Exploratory factor analysis was applied to items measuring transnormative beliefs, with the results supporting three higher order factors; conditional approval, narrative, and gender role beliefs. Conditional approval reflected belief in gender diverse identity as authentic and worthy of intervention. Narrative beliefs reflected understanding of common developmental experiences among gender diverse populations, specifically experiences of victimisation and nascence. Gender role beliefs reflected belief in the existence of gender roles. In models that regressed gender affirming attitudes and self-perceived competency on all transnormative beliefs, controlling for demographics and work history, practitioners higher in conditional approval were lower in gender affirming attitudes and practitioners higher in narrative beliefs were higher in gender affirming attitudes and competency. Conditional approval was not significantly associated with competency, and gender role beliefs were not significantly associated with attitudes or competency. Results indicate that practitioners' transnormative beliefs are related to their gender affirming attitudes and suggest that targeting these beliefs through training opportunities could bridge the gap between gender diverse people's healthcare needs and the ability of healthcare practitioners to provide high quality care.
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Jecke L, Zepf FD. Delivering transgender-specific knowledge and skills into health and allied health studies and training: a systematic review. Eur Child Adolesc Psychiatry 2024; 33:1327-1354. [PMID: 37115277 PMCID: PMC11098887 DOI: 10.1007/s00787-023-02195-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 03/11/2023] [Indexed: 04/29/2023]
Abstract
Many transgender individuals face inequities, discrimination, and sometimes even a lack of transgender-specific knowledge in health care settings. Educational curricula can address such disparities and help future health professionals to become more knowledgeable, confident, and well-prepared for addressing the needs of transgender individuals. This systematic review aims to summarize current training interventions about care of transgender individuals for health and allied health students, and to analyse the effects of the respective intervention. A total of six databases (Pubmed, MEDLINE, Scopus, Web of Science, Embase and SciSearch) were screened for original articles published between 2017 and June 2021. Search terms and eligibility criteria were pre-specified, and after a structured selection process 21 studies were included into further analysis. Extracted data contained information on general study properties, population, design, program format and outcomes of interest. A narrative synthesis was used to summarize detected results. Study quality was assessed for each individual study. A self-developed 18-item checklist combining criteria of two prior published tools was used to assess overall quality of quantitative studies. For qualitative studies a 10-item checklist by Kmet et al. [HTA Initiat, 2004] was applied. Eligible studies were designed for multiple health or allied health profession students, and varied widely regarding program format, duration, content, and assessed outcomes. Almost all (N = 19) interventions indicated improvements in knowledge, attitude, confidence and comfort levels or practical skills concerning care for transgender clients. Major limitations included the lack of long-term data, validated assessment tools, control groups and comparative studies. Training interventions contribute to prepare future health professionals to deliver competent and sensitive care and which may improve the prospective experienced health care reality of transgender individuals. However, currently there is no common consensus about best practice of education. Additionally, little is known about whether detected effects of training interventions translate into noticeable improvements for transgender clients. Further studies are warranted to assess the direct impact of specific interventions in the light of the respective target populations.
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Affiliation(s)
- L Jecke
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - F D Zepf
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany.
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany.
- Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health (C-I-R-C), Jena-Magdeburg-Halle, Jena, Germany.
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16
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Christiano JG, Punekar I, Patel A, McGregor HA, Moskow M, Anson E. Qualitative Assessment of the Experiences of Transgender Individuals Assigned Female at Birth Undergoing Gender-Affirming Mastectomy for the Treatment of Gender Dysphoria. Transgend Health 2024; 9:143-150. [PMID: 38585246 PMCID: PMC10998022 DOI: 10.1089/trgh.2022.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose Evaluation and comparison of outcomes following gender-affirming mastectomy have been hindered by the lack of a validated population- and surgery-specific patient-reported outcome measure (PROM). The purpose of this study was to explore the lived experiences of transgender individuals assigned female at birth (AFAB) from before-to-after gender-affirming mastectomy to identify key qualitative themes that might inform the creation of a quantitative PROM in the future. Methods Identified candidates were transgender men AFAB, 18-65 years of age (mean±standard deviation: 30.3±12.2), who had undergone gender-affirming mastectomy from 2015 through 2017 (n=53). Twelve individuals participated in either focus groups (6) or phone interviews (6), carried out in a semistructured fashion. Verbatim transcriptions were anonymized. Conventional content analysis was used to code all transcripts. Results Content analysis identified six key themes experienced by transgender men undergoing gender-affirming mastectomy. In contrast to their experiences before surgery, participant reported that after surgery they experienced fewer symptoms of gender dysphoria, lower anxiety associated with gender dysphoria, less fear about physical safety, no need to hide a female chest shape, and that they passed as male. Also explored were themes about experiences with the health care team. Conclusion This study presents the first qualitative data based on the lived experiences of transgender individuals AFAB who underwent gender-affirming mastectomy. These qualitative themes should be heavily considered when creating a quantitative PROM that will fully capture the changes transgender individuals AFAB experience from before-to-after gender-affirming mastectomy.
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Affiliation(s)
- Jose G. Christiano
- Division of Plastic Surgery, Department of Surgery, University of Rochester, Rochester, New York, USA
| | - Imran Punekar
- Division of Plastic Surgery, Department of Surgery, University of Rochester, Rochester, New York, USA
| | - Alap Patel
- Division of Plastic Surgery, Department of Surgery, University of Rochester, Rochester, New York, USA
| | | | - Marian Moskow
- University of Rochester School of Nursing, Rochester, New York, USA
| | - Elizabeth Anson
- University of Rochester School of Nursing, Rochester, New York, USA
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17
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Tsai MV, Kuper LE, Lau M. Transgender Youth Readiness for Health Care Transition: A Survey of Youth, Parents, and Providers. Transgend Health 2024; 9:53-60. [PMID: 38312455 PMCID: PMC10835149 DOI: 10.1089/trgh.2022.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose The purpose of this study was to identify health care transition (HCT) readiness and skills among transgender youth transitioning gender-affirming care from pediatric to adult providers. Methods A convenience sample of youth, 14-21 years old, their parents, and health care providers recruited from a multidisciplinary transgender youth clinic in 2019 completed a modified version of the Got Transition readiness assessment with elements specific to gender-affirming care. Youth assessed their own readiness, parents assessed their child's readiness, and providers assessed their transgender patients' readiness overall. Results Twenty-nine youth (mean age 17.0 years), 26 parents, and 5 health care providers participated. Ratings of the overall importance of preparing for HCT were similar across all participant groups, and there were few disagreements on the importance of individual skills included in the readiness assessment. Ratings of overall HCT readiness were similar for youth regardless of age, while parents of younger youth (<18 years old) reported lower readiness than did parents of older youth. Youth rated their own competence in several skills higher compared with parents or providers, including knowledge of hormone therapy side effects. All groups of participants reported that youth most frequently needed assistance with scheduling appointments and keeping records of health information. Conclusions Survey of youth, parents, and providers suggests that youth and parents require additional support to navigate the HCT process, highlighting the importance of ongoing skills assessment and planning.
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Affiliation(s)
- Michelle V Tsai
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Laura E Kuper
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Endocrinology, Children's Health System of Texas, Dallas, Texas, USA
| | - May Lau
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Developmental and Behavioral Pediatrics, Children's Health System of Texas, Dallas, Texas, USA
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18
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Sequeira GM, Asante PG, Bocek K, Kahn NF, Sethness JL, Hodax JK, Kidd KM, Pratt W, Christakis DA, Richardson LP. Evaluating an Electronic Consultation Platform to Support Pediatric Primary Care Providers in Caring for Transgender and Nonbinary Adolescents. Telemed J E Health 2024; 30:595-600. [PMID: 37624647 PMCID: PMC10877380 DOI: 10.1089/tmj.2023.0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 08/27/2023] Open
Abstract
Background: An electronic consultation (e-consult) platform was implemented to support pediatric primary care providers (PCPs) in providing gender-affirming care to transgender and nonbinary (TNB) adolescents. Following implementation, a study was conducted to (1) explore how access to this e-consult platform impacts PCP confidence and referral patterns, (2) describe the content of questions, and (3) evaluate PCP's perspectives regarding platform usability. Methods: Following each submission, providers completed a 17-item survey. A total of 20 providers submitted 38 e-consults and 26 follow-up surveys between October 2021 and December 2022. Results: All PCPs reported a high overall value and increased confidence caring for TNB adolescents. Nearly one in five (19%) felt it allowed them to avoid submitting a specialty referral. Mean System Usability Scale score was 78.2 indicating good usability. Conclusion: This e-consult platform shows great promise in increasing PCP confidence providing gender-affirming care adolescents. More widespread utilization could help improve access to care and decrease specialty care referrals.
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Affiliation(s)
- Gina M. Sequeira
- Seattle Children's Hospital, Seattle, Washington, USA
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Peter G. Asante
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kevin Bocek
- Seattle Children's Hospital, Seattle, Washington, USA
| | | | - Janis L. Sethness
- Seattle Children's Hospital, Seattle, Washington, USA
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Juanita K. Hodax
- Seattle Children's Hospital, Seattle, Washington, USA
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kacie M. Kidd
- West Virginia University, Morgantown, West Virginia, USA
| | - Wanda Pratt
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Dimitri A. Christakis
- Seattle Children's Hospital, Seattle, Washington, USA
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Laura P. Richardson
- Seattle Children's Hospital, Seattle, Washington, USA
- Division of Adolescent Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Marra EE, Mabel H, Feldman S, Mercer MB, Altinay M, Ferrando CA. Transgender women's perspectives on mental health care related to vaginoplasty for gender affirmation. BMC Womens Health 2024; 24:14. [PMID: 38172910 PMCID: PMC10765568 DOI: 10.1186/s12905-023-02681-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/30/2023] [Indexed: 01/05/2024] Open
Abstract
PURPOSE This study aimed to describe patient experiences and attitudes about the role of the mental health professional as it relates to pursuing gender affirmation surgery. METHODS This was a mixed-models study with semi-structured interviews. Participants who presented for gender affirming vaginoplasty and had completed pre-surgical requirements but had not yet had the procedure were invited to participate in the study. Semi-structured phone interviews were conducted from November 2019 and December 2020 until saturation of themes was achieved at a sample size of 14. Interviews were then transcribed verbatim and coded by theme. Qualitative analysis was performed using a grounded theory approach. RESULTS Almost half of the patients did not identify any barriers to obtaining mental health care, but a majority brought up concerns for less advantaged peers, with less access to resources. Some patients also felt that there was benefit to be obtained from the mental health care required before going through with surgery, while others felt the requirements were discriminatory. Finally, a large proportion of our participants reported concerns with the role of mental health care and the requirements set forth by the World Professional Association for Transgender Health (WPATH), and patients gave suggestions for future improvements including decreasing barriers to care while rethinking how guidelines impact patients. CONCLUSION There are many competing goals to balance when it comes to the guidelines for gender affirmation surgery, and patients had differing and complex relationships with mental health care and the pre-surgical process.
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Affiliation(s)
- Emily E Marra
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Hilary Mabel
- Clinical Ethics, Wellstar Health System, Marietta, GA, USA
| | | | - Mary Beth Mercer
- Center for Bioethics, Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Murat Altinay
- Department of Psychiatry and Psychology, Center for Behavioral Health, Center for LGBT Care, Cleveland Clinic, Cleveland, OH, USA
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Obstetrics & Gynecology Institute, Cleveland, OH, USA.
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20
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Lawson ML, Gotovac S, Couch B, Gale L, Vandermorris A, Ghosh S, Bauer GR. Pathways to Care for Adolescents Attending a First Hormone Appointment at Canadian Gender Affirming Medical Clinics: A Cross-Sectional Analysis From the Trans Youth CAN! Study. J Adolesc Health 2024; 74:140-147. [PMID: 37791927 DOI: 10.1016/j.jadohealth.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 06/17/2023] [Accepted: 07/17/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE Limited research has examined adolescents' pathways to gender-affirming medical care. METHODS Enrollment in Trans Youth CAN! was at an initial appointment for hormone suppression or gender-affirming hormones, if pubertal or postpubertal, and < 16 years old. Adolescent/parent surveys and clinical records were obtained for 174 adolescents and 160 matched parents at 10 medical clinics across Canada. RESULTS Participants' mean age was 14.3 years, 95% confidence interval (CI) [14.1-14.6]; 126 (75.8%) identified as boys, 32 (15.9%) girls, and 14 (8.3%) nonbinary. Average wait time after referral was 269 days (95% CI [244, 294]). Adolescents reported 13.5 months seeking gender-affirming medical care, longer than reported by their parents (p = .0001). Family physicians or pediatricians provided 68% of referrals. Prior to clinic, adolescents saw an average of 2.7 (maximum eight) different types of providers (95% CI [2.4, 2.9]). Indigenous background and greater number of types of providers seen were associated with longer time seeking care. The majority of adolescents had ever engaged in self-harm (67.6%), with 58.1% ever seriously considering suicide and 36.0% attempting. Previous self-harm and suicidal thoughts were associated with longer wait times and older age. Seventeen point seven percent of parents/caregivers reported their adolescents had participated in conversion therapy or that parents had considered it. DISCUSSION The majority of participants were referred by family physicians or pediatricians, seeing multiple types of providers regarding their gender prior to referral. Adolescents experienced significant wait times. Indigenous adolescents reported longer times seeking care. Adolescents with longer wait times were more likely to have ever engaged in self-harm or had suicidal ideation.
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Affiliation(s)
| | - Sandra Gotovac
- Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Bob Couch
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Lorraine Gale
- Trans Youth CAN! Research Team, Toronto, Ontario, Canada
| | - Ashley Vandermorris
- Division of Adolescent Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shuvo Ghosh
- Child Development Program, Department of Pediatrics, McGill University Montréal Children's Hospital/Meraki Health Centre, Montréal, Quebec, Canada; Eli Coleman Institute for Sexual and Gender Health, University of Minnesota, Minneapolis, Minnesota
| | - Greta R Bauer
- Eli Coleman Institute for Sexual and Gender Health, University of Minnesota, Minneapolis, Minnesota
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21
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Sitas Z, Peters K, Luck L, Einboden R. Erasure of the young trans person: A critical discursive review of contemporary health care literature. J Nurs Scholarsh 2024; 56:103-118. [PMID: 37393606 DOI: 10.1111/jnu.12922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 05/03/2023] [Accepted: 05/23/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Trans youth experience significantly higher rates of societal violence and ill-health compared to their cisgender peers. Although recent clinical guidelines for trans young people in health have paved the way for revolutionizing care, many trans young people still experience adversity in clinical settings. This discursive literature review provides a novel approach in exploring why trans young people experience violence in health care despite the availability of evidence-based resources and guidelines. DESIGN Databases (CINAHL and Scopus) were systematically searched to identify qualitative literature on the experiences of trans young people (<18 years) in health care settings. METHOD Rather than synthesizing and presenting the literature, Fairclough's (2001) CDA methodology was used to critically analyze the literature as texts in a data corpus. The authors engaged with the data from a critical social theory perspective. RESULTS Fifteen qualitative articles and one report (n = 16) on the experiences of trans young people (3-24 years) in health care settings were included. Two key discourses were identified in the literature. First, discourses that constituted the trans young person were identified in the definitions of 'trans' as a pathological incongruence and as alternate, self-determined ways of being. Further discourses were identified in the constitution of trans young people as victims, extra-pathological, and alternatively problematised as socially dysphoric. Second, discourses in health provider responses were identified in dismissive, gatekeeping, regulatory, and respectful practices. DISCUSSION The discursive constitution of the trans young person as incongruent, vulnerable, and pathological is constituted and generated by dismissive, gatekeeping, and regulatory practices of health care providers. The analysis reveals how trans young people are considered pathological and deemed treatable (at the site of the body), in the interest of 'protecting' them from a perceived abject future of trans adulthood. The logic and violence of cisgenderism is uncovered as the foundation of these dominant discourses, whereby growing up cisgender is often presented as the only option in health care settings. The dominant discourses that constitute the trans young person in health care as incongruent, pathological, and vulnerable, alongside the reifying health care responses of dismissal, gatekeeping, and regulation contribute to the erasure of the young trans person. CONCLUSION This paper identified key discourses in the literature in how trans young people are constituted and regulated in health care. This review highlights an urgent need for further critical scholarship in trans health by trans researchers, from critical perspectives. Furthermore, it provides a starting point for critical reflection of health care provider and researcher practices and the re-imagination of trans-futurity for all young people in health care. CLINICAL RELEVANCE Nurses are situated at the forefront of health care delivery and play a crucial role in the advocacy and provision of culturally safe care. With this ideal proximity to clients, nurses can powerfully affect change through better understanding and reflecting on how regulatory practices constitute and position trans young people in health care. Nursing knowledge, such as cultural safety, can offer novel approaches in working towards safer ways of meeting the needs of trans young people.
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Affiliation(s)
- Zoë Sitas
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Kath Peters
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Lauretta Luck
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
- Nepean Blue Mountains Local Health District, Penrith, New South Wales, Australia
| | - Rochelle Einboden
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
- School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario (CHEO) and CHEO Research Institute, Ottawa, Ontario, Canada
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22
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Saadat M, Keramat A, Jahanfar S, Nazari AM, Ranjbar H, Motaghi Z. Barriers and Facilitators to Accessing Sexual and Reproductive Health Services Among Transgender People: A Meta-Synthesis. INTERNATIONAL JOURNAL OF SOCIAL DETERMINANTS OF HEALTH AND HEALTH SERVICES 2024; 54:40-51. [PMID: 37470127 DOI: 10.1177/27551938231187863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
The availability and accessibility of sexual and reproductive health (SRH) services for transgender individuals are crucial. This population is deprived of health care due to rejection, stigma, gender-based discrimination, confidentiality, and violence. This review attempts to provide readers with an account of the fundamental problems that the transgender population faces regarding experiences of SRH. This meta-synthesis review applied the Social-Ecological Model (SEM) to address trans individuals' SRH factors. The databases were searched using "SRH" and "transgender" keywords. Fifty studies were finally selected. All studies were qualitative, including 36 semi-structured/ in-depth interviews, two focus group studies, and 12 interviews and focus group studies. The Social-Ecological Model application illustrates the impact of individual, interpersonal, institutional, and social factors on the condition of SRH among transgender individuals. This meta-synthesis reinforces multiple levels of factors that influence the SRH of transgender individuals. These include limited information, lack of awareness, low socioeconomic status, stigma and discrimination, and social deprivation. Interventions are urgently needed to provide better sexual and reproductive well-being for transgender individuals.
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Affiliation(s)
- Mina Saadat
- Student Research Committee, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Afsaneh Keramat
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Shayesteh Jahanfar
- Tufts School of Medicine, Department of Public Health and Community Medicine, Boston, MA, USA
| | - Ali Mohammad Nazari
- School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Hadi Ranjbar
- Mental Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Motaghi
- School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
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23
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Kearns S, O'Shea D, Neff K. Factors that help and hinder transgender and nonbinary youth accessing gender care in Ireland: A multistakeholder exploration. J Nurs Scholarsh 2024; 56:60-75. [PMID: 38228566 DOI: 10.1111/jnu.12907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 04/26/2023] [Accepted: 05/01/2023] [Indexed: 01/18/2024]
Abstract
INTRODUCTION The purpose of this study was to identify the common factors that help and hinder transgender and nonbinary youth accessing gender-specific health care in Ireland and to identify how these factors may be perceived differently by young people seeking gender-affirming care, their parents, and health-care providers. DESIGN Qualitative investigation utilizing framework analysis (FA). METHODS In-depth one-one interviews were conducted with transgender and nonbinary youth (n = 10), parents of youth (n = 10), and gender-specific health-care providers (n = 10). Maximum variation and snowball sampling were used to recruit participants across Ireland. An interview guide codesigned with an expert panel of gender-diverse youth was utilized. Interviews were audio-recorded and transcribed verbatim. FA was used to code the data and identify key issues and recommendations. RESULTS Four themes were derived: (1) "Needing bricks to build" (structural factors); (2) "Enduring and convincing" (diagnostic factors); (3) "Being me, hiding me"; (personal factors); and (4) "It takes a tribe" (interpersonal factors). Each stakeholder group perceived different factors as help or hindrance in accessing care with varying intensities. CONCLUSIONS Paramount to the future of gender services in Ireland is the investment of resources for children and young adults. Assessment is likely to remain a component of gender care, but youth recommend distinct revisions to the assessment process. Additional research would be useful in exploring the intersection of neurodiversity and gender as it pertains to health-care navigation. Family and peer support is a strong protective factor and enabler of health-care access among youth. CLINICAL RELEVANCE Access to gender-specific health care remains difficult for transgender and non-binary youth. An understanding of the complexity of this healthcare navigation by healthcare professionals may help to mitigate future negative experiences. This study explores some of the clinical considerations that arise for this population from provider perspectives while elucidating the experiences of youth and parents attempting to access care. Further research is needed on longitudinal outcomes following medical and surgical interventions for transgender youth, including nonbinary identities.
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Affiliation(s)
- Seán Kearns
- University College Dublin, School of Medicine, Dublin, Ireland
- National Gender Service, St Columcille's Hospital, Dublin, Ireland
| | - Donal O'Shea
- University College Dublin, School of Medicine, Dublin, Ireland
- National Gender Service, St Columcille's Hospital, Dublin, Ireland
| | - Karl Neff
- University College Dublin, School of Medicine, Dublin, Ireland
- National Gender Service, St Columcille's Hospital, Dublin, Ireland
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24
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Goulding R, Goodwin J, O'Donovan A, Saab MM. Transgender and gender diverse youths' experiences of healthcare: A systematic review of qualitative studies. J Child Health Care 2023:13674935231222054. [PMID: 38131632 DOI: 10.1177/13674935231222054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Transgender and gender-diverse (TGD) populations are identified as high-risk for negative healthcare outcomes. Limited data exists on experiences of TGD youths in healthcare. The review aim is to systematically review literature on healthcare experiences of TGD youths. Seven electronic databases were systematically searched for relevant studies. Pre-determined eligibility criteria were used for inclusion with a double-screening approach. Sixteen studies were included. Studies included were quality appraised, data were extracted, and findings were synthesized narratively. Four narratives were identified including experiences of: accessing care, healthcare settings and services, healthcare providers, and healthcare interventions. Long waiting times, lack of competent providers, and fear were reported as challenges to accessing gender-affirming care. Negative experiences occurred in mental health services and primary care, while school counseling and gender clinics were affirming. Puberty blockers and hormone-replacement therapy were identified as protective factors. TGD youths are at risk of negative health outcomes due to an under resourced healthcare system. Further research is needed to assess interventions implemented to improve TGD youth's experiences.
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Affiliation(s)
- Ryan Goulding
- Catherine McAuley School of Nursing & Midwifery, University College Cork, Cork, Ireland
| | - John Goodwin
- Catherine McAuley School of Nursing & Midwifery, University College Cork, Cork, Ireland
| | - Aine O'Donovan
- Catherine McAuley School of Nursing & Midwifery, University College Cork, Cork, Ireland
| | - Mohamad M Saab
- Catherine McAuley School of Nursing & Midwifery, University College Cork, Cork, Ireland
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25
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Roden RC, Billman MG, Mullin R, Francesco A, Essayli JH. Rural Location of Residence is Not Associated With Use of Telemedicine for Initial Medical Contact for Gender-Related Healthcare. J Adolesc Health 2023; 73:940-945. [PMID: 37610385 DOI: 10.1016/j.jadohealth.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
PURPOSE There is very little information available regarding the health needs of transgender and gender diverse adolescents and young adults with gender dysphoria who reside in rural areas of the United States. This study aims to determine if residing in a rural area is associated with the use of telemedicine services, such as synchronous voice-video appointments, for initial contact for medical interventions for gender-related reasons in adolescents and young adults with gender incongruence. METHODS This study is a retrospective chart review of patients (N = 176) ages 10-24 years who had an initial medical appointment for gender-related concerns between July 1, 2020 and June 30, 2022. Participants were determined to be rural or not based on address eligibility for rural-related health care services by the Centers for Medicare and Medicaid Services Rural Health Clinics Program or the Federal Office of Rural Health Policy grant programs. The use of telemedicine versus in-person appointments were compared, as were initial medical prescriptions (hormones, psychotropic medications, contraceptives, etc.) and recommendations for medical follow-ups made at this initial appointment. RESULTS Most participants did not reside in a rural location (N = 130). There was no statistically significant difference in the use of telemedicine versus in-person care in rural patients (22% vs. 78%) as compared to nonrural patients (21% vs. 79%), nor any statistically significant differences in the medical decisions made at the initial appointment with respect to rurality or modality of care. DISCUSSION Residing in a rural area is not associated with either choice of in-person care versus telemedicine services for initial medical appointments or medical decision-making.
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Affiliation(s)
- Rosemary Claire Roden
- Division of Adolescent Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania.
| | - Marley G Billman
- Division of Adolescent Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Robert Mullin
- Internal Medicine/Pediatrics Residency Program, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Angelea Francesco
- Rehabilitation and Human Services, Penn State University, Abington, Pennsylvania
| | - Jamal H Essayli
- Division of Adolescent Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania
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26
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Kidd KM, Sequeira GM, Katz-Wise SL, Fechter-Leggett M, Gandy M, Herring N, Miller E, Dowshen NL. "Difficult to Find, Stressful to Navigate": Parents' Experiences Accessing Affirming Care for Gender-Diverse Youth. LGBT Health 2023; 10:496-504. [PMID: 37184531 PMCID: PMC10552142 DOI: 10.1089/lgbt.2021.0468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Purpose: Gender-diverse youth (GDY) face significant health disparities, which can be mitigated by gender-affirming medical care. Understanding parents' experiences seeking care for their GDY can identify barriers to care and improve access. This study sought to understand parents' experiences accessing gender-affirming medical care with their GDY. Methods: We asked parents of GDY in the United States to describe their experiences with gender-affirming medical care through a single open-ended item on an online survey disseminated through social media in February of 2020. Open-ended survey responses were analyzed through inductive thematic analysis by two authors using an iteratively developed codebook adjudicated by consensus. This codebook was used to identify key themes. Results: We analyzed 277 responses from majority White (93.9%) parents from 41 U.S. states. Themes included (1) Experiences accessing care: finding a provider, financial and insurance-related considerations, the impact of geography on care access; (2) Experiences receiving care: factors in successful or unsuccessful patient-provider interactions, differing approaches to initiating care, sense of community with other families; and (3) Outcomes related to receiving care: how care for their child was perceived to be lifesaving or helped their child thrive. Conclusions: Parents highlighted how access to gender-affirming medical care improved their GDY's health and wellbeing, and described numerous barriers they experienced with finding and receiving this care. Given the evidence that gender-affirming medical care mitigates health disparities, providers, policymakers, insurance companies, and health systems leaders should urgently address these challenges to ensure equitable receipt of care for all GDY.
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Affiliation(s)
- Kacie M. Kidd
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Gina M. Sequeira
- Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Sabra L. Katz-Wise
- Boston Children's Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Molly Fechter-Leggett
- West Virginia University Medicine, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Megan Gandy
- School of Social Work, West Virginia University, Morgantown, West Virginia, USA
| | - Nadeen Herring
- blaq noyz, LLC, Rowan University, Glassboro, New Jersey, USA
| | - Elizabeth Miller
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Nadia L. Dowshen
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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27
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Canavera KE, Bjornard KL, Cost NG, Grady A, Irving H, Kaye EC, Ketterl T, Levine J, Reinecke J, Rios J, Roth M, Sawyer K, Thomas SM, Unguru Y, Johnson LM. Disparate Access to Fertility Preservation in Youth: A Call for Advocacy to Close the Gap. J Pediatr 2023; 261:113496. [PMID: 37211206 DOI: 10.1016/j.jpeds.2023.113496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 04/07/2023] [Accepted: 05/14/2023] [Indexed: 05/23/2023]
Affiliation(s)
| | - Kari L Bjornard
- Department of Pediatrics, Division of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, IN; Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Nicholas G Cost
- Department of Pediatric Urology and the Surgical Oncology Program, Children's Hospital Colorado, Aurora, CO
| | - Allison Grady
- Department of Pediatrics, Oncology Section, Medical College of Wisconsin, Milwaukee, WI; University of Wisconsin-Milwaukee College of Nursing, Milwaukee, WI
| | - Helen Irving
- Department of Oncology, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Erica C Kaye
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Tyler Ketterl
- Department of Pediatric Hematology/Oncology, Seattle Children's Hospital, Seattle, WA
| | - Jennifer Levine
- Division of Pediatric Hematology and Oncology, Weill Cornell Medicine, New York, NY
| | | | - Julie Rios
- Department of Obstetrics, Gynecology, and Reproductive Science, The University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael Roth
- Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kimberly Sawyer
- Department of Pediatrics, Section of Palliative Care, Baylor College of Medicine, Houston, TX
| | - Stefanie M Thomas
- Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Cleveland Clinic Children's, Cleveland, OH
| | - Yoram Unguru
- Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, MD; Johns Hopkins Berman Institute of Bioethics, Baltimore, MD
| | - Liza-Marie Johnson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN.
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28
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Hughes LD, Gamarel KE, Restar AJ, Sequeira GM, Dowshen N, Regan K, Kidd KM. Adolescent Providers' Experiences of Harassment Related to Delivering Gender-Affirming Care. J Adolesc Health 2023; 73:672-678. [PMID: 37589604 PMCID: PMC10568537 DOI: 10.1016/j.jadohealth.2023.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE The politicization of adolescent gender-affirming care has occurred alongside targeted harassment (e.g., threats of violence, doxing, bomb threats) of adolescent gender-affirming care providers across the United States. This study sought to explore their experiences of targeted harassment. METHODS From October to December 2022, mental and physical health gender-affirming care providers from across the United States completed a survey including open-ended questions about the kinds of harassment they experienced (i.e., method and messages of harassment) and its impact on their lives and practices. Thematic analyses were used to analyze their responses. RESULTS In total, 117 providers completed the survey and 70% shared that either they, their practice, or their institution had received threats specific to delivering gender-affirming care. The most common experiences were threats via social media or mailed letters. Several received death threats. Providers described how targeted harassment impacted their psychological well-being and required them to reassess clinic safety. Additionally, providers expressed the need for a more accurate representation of gender-affirming care in media and stronger advocacy from institutions and organizations emphasizing the importance of this care. DISCUSSION Adolescent gender-affirming care providers are experiencing targeted harassment, significantly affecting their ability to deliver care to transgender and gender-diverse adolescents and their families. Providers stressed the importance of receiving support from their institutions to ensure their safety. The ongoing sociopolitical climate related to gender-affirming care coupled with targeted harassment of those providing it will further limit access to this care.
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Affiliation(s)
- Landon D Hughes
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
| | - Kristi E Gamarel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan; Population Studies Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan
| | - Arjee J Restar
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington; Department of Behavioral and Social Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Gina M Sequeira
- Department of Pediatrics, University of Washington, Seattle, Washington; Craig-Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nadia Dowshen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Gender & Sexual Development Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katelyn Regan
- Gender & Sexual Development Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kacie M Kidd
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
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29
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Tordoff DM, Sequeira GM, Shook AG, Williams F, Hayden L, Kasenic A, Inwards-Breland D, Ahrens K. Factors Associated with Time to Receiving Gender-Affirming Hormones and Puberty Blockers at a Pediatric Clinic Serving Transgender and Nonbinary Youth. Transgend Health 2023; 8:420-428. [PMID: 37810940 PMCID: PMC10551760 DOI: 10.1089/trgh.2021.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose To describe barriers to care for a cohort of transgender and nonbinary (TNB) youth and examine factors associated with delays in receiving puberty blockers (PBs) or gender-affirming hormones (GAHs). Methods We used longitudinal data from a prospective cohort of TNB youth seeking care at a multidisciplinary pediatric gender clinic between August 2017 and June 2018. We calculated the time between (i) initial clinic contact, (ii) phone intake, (iii) first medical appointment, and (iv) initiating PBs/GAHs. We estimated Kaplan-Meier curves for each time-to-care interval and used Cox regression models to estimate hazard ratios (HRs) for factors hypothesized to be barriers and facilitators of care. Results Our cohort included 104 youth aged 13-20 years. The median time from contacting the clinic to initiating PBs/GAHs was 307 days (range, 54-807). Lower income level, Medicaid insurance, and lack of family support were associated with longer times from contacting the clinic to completing the first medical appointment. In addition, older youth experienced longer times to first medical appointment relative to youth aged 13-14 years. Youth younger than 18 years of age who did not complete a mental health assessment before their first medical appointment experienced delays from first medical appointment to initiating PBs/GAHs (HR=0.44, 95% confidence interval, 0.22-0.88). Conclusion Certain subsets of youth disproportionately experienced delays in receiving gender-affirming medications, and these factors varied by stage of care engagement. Given the association between gender-affirming care and improved mental health, identifying sociostructural and clinic-level barriers to care is critically important to facilitating more equitable access.
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Affiliation(s)
- Diana M. Tordoff
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Gina M. Sequeira
- Seattle Children's Research Institute, Seattle, Washington, USA
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Alic G. Shook
- Seattle University, College of Nursing, Seattle, Washington, USA
- Seattle Children's Center for Pediatric Nursing Research, Seattle, Washington, USA
| | | | - Lara Hayden
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Ash Kasenic
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - David Inwards-Breland
- Rady Children's Hospital, San Diego, California, USA
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UC San Diego, San Diego, California, USA
| | - Kym Ahrens
- Seattle Children's Research Institute, Seattle, Washington, USA
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
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30
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Johnson B, Szilagyi N. Supporting Transgender Youth Across Psychosocial Systems. Child Adolesc Psychiatr Clin N Am 2023; 32:815-837. [PMID: 37739637 DOI: 10.1016/j.chc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
Transgender children and adolescents are at an elevated risk for negative mental health outcomes due to exposure to stigma and discrimination regarding their identity. While various environments may perpetuate this stigma, many supports also exist that can bolster safety, affirmation, and resilience in this population. Opportunities for support exist within schools, broader communities, religious organizations, and with medical professionals who practice gender-affirming care. Clinicians who are familiar with resources in their communities can effectively guide transgender youth and their families to these affirming spaces.
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Affiliation(s)
- Brandon Johnson
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, 1090 Amsterdam Avenue 16th Floor, New York, NY 10025, USA.
| | - Nathalie Szilagyi
- Yale Child Study Center, Yale School of Medicine, New Haven, CT, USA; Aurora Psychiatric Associates, Greenwich, CT, USA
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31
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Stevens J. Transgender and Gender Diverse Youth in Inpatient and Other Residential Care. Child Adolesc Psychiatr Clin N Am 2023; 32:849-866. [PMID: 37739639 DOI: 10.1016/j.chc.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
Inpatient and other residential care environments require special considerations for safety and unique opportunities to provide affirming care to TGD youth. Gender-positive policies, staff training, communication, placement, programming, and discharge planning are imperative; however, data and literature are limited in regard to affirming the care of TGD youth in such environments. This chapter draws from published research and best practice to support the wellness of TGD individuals in inpatient and similar settings. It offers clinical guidance for an organization's clinicians, administrators, educators, and advocates to provide safer and more effective care for TGD youth in such facilities to best support their mental and physical health.
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Affiliation(s)
- Jaime Stevens
- Affirming Psychiatry LLC, University of Hawai'i, PO Box 22148, Honolulu, HI 96823, USA.
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32
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Sequeria GM, Guler J, Reyes V, Asante PG, Kahn N, Anan Y, Bocek K, Kidd K, Christakis D, Pratt W, Richardson LP. Adolescent and Caregiver Perspectives on Receiving Gender-Affirming Care in Primary Care. Pediatrics 2023; 152:e2023062210. [PMID: 37697934 PMCID: PMC10698727 DOI: 10.1542/peds.2023-062210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Transgender and gender-diverse (TGD) adolescents experience barriers to receiving gender-affirming care. Delivering services in the pediatric primary care setting may help facilitate improved access. With this study, we aimed to explore TGD adolescents' and caregivers' experiences receiving primary care services and their perspectives regarding gender-affirming care delivery in pediatric primary care. METHODS TGD adolescents aged 14 to 17 and caregivers of TGD adolescents currently receiving gender-affirming medical care participated in 1-hour-long, semi-structured, individual, virtual interviews. Each interview was recorded and transcribed. Transcripts were then individually coded, and themes were generated iteratively by using a reflexive thematic analysis framework. Recruitment of each group continued until thematic saturation was reached. RESULTS A total of 33 participants (15 adolescents and 18 caregivers) completed interviews. Adolescent participants (mean age of 15.7 years) predominantly identified as transmasculine or trans male (73%), and caregiver participants were predominantly mothers (83.3%). Four themes were identified, which included (1) barriers, such as microaggressions and poor psychosocial support, (2) benefits, such as existing trusted relationships with primary care providers (PCPs) and convenience, (3) improvement strategies, such as training and interdisciplinary collaboration, and (4) opportunities for integrating primary care and specialty gender-affirming care. CONCLUSIONS TGD adolescents and their caregivers reported previous negative interactions with PCPs; however, some desired to receive gender-affirming care in this setting, citing increased convenience, efficiency, and availability. Participants highlighted an ongoing need for further work to provide resources, education, and training to PCPs and their staff and improve PCP-to-specialist communication and collaboration.
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Affiliation(s)
- Gina M Sequeria
- Seattle Children's Hospital, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Jessy Guler
- Seattle Children's Hospital, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | | | - Peter G Asante
- University of Washington School of Medicine, Seattle, Washington
| | - Nicole Kahn
- Seattle Children's Hospital, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Yomna Anan
- Seattle Children's Hospital, Seattle, Washington
| | - Kevin Bocek
- Seattle Children's Hospital, Seattle, Washington
| | - Kacie Kidd
- West Virginia University, Morgantown, West Virginia
| | - Dimitri Christakis
- Seattle Children's Hospital, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Wanda Pratt
- University of Washington School of Medicine, Seattle, Washington
| | - Laura P Richardson
- Seattle Children's Hospital, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
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Karakılıç Özturan E, Öztürk AP, Baş F, Erdoğdu AB, Kaptan S, Kardelen Al AD, Poyrazoğlu Ş, Yıldız M, Direk N, Yüksel Ş, Darendeliler F. Endocrinological Approach to Adolescents with Gender Dysphoria: Experience of a Pediatric Endocrinology Department in a Tertiary Center in Turkey. J Clin Res Pediatr Endocrinol 2023; 15:276-284. [PMID: 36987788 PMCID: PMC10448553 DOI: 10.4274/jcrpe.galenos.2023.2023-1-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/27/2023] [Indexed: 03/30/2023] Open
Abstract
Objective A significant rise in the number of trans adolescents seeking medical interventions has been reported in recent years. The aim of this study was to report the clinical features, treatment, and follow-up of adolescents with gender dysphoria (GD) with our increased experience. Methods Twenty-six male-to-female (MTF) and twenty-seven female-to-male (FTM) adolescents who were referred to the GD-outpatient clinic between 2016 and 2022 were reviewed. The clinical and laboratory findings of thirty transgender adolescents (15 FTM /15 MTF) who received medical intervention were evaluated retrospectively. Results Most individuals (60.4%) were admitted between 2020 and 2022, and the remaining (39.6%) were admitted between 2016 and 2019. At the time of referral, median age was 16.3 years [interquartile range (IQR) 1.53; range 13.2-19.4] in 26 MTF, and 16.4 years (IQR 1.74; range 11.7-21.6) in 27 FTM adolescents. The median age at pubertal blockage with gonadotropin-releasing hormone analog and androgen receptor blocker was 16.4 years (IQR 1.4; range 11.7-17.8) in 22 adolescents (9 MTF, 13 FTM), and 17.4 years (IQR 1.4; range 15.5-19.4) in 6 MTF individuals, respectively. Cross-sex hormone therapy was commenced in 21 adolescents (12 MTF, 9 FTM) at the median age of 17.7 years (IQR 0.61; range 16-19.5). Fifteen individuals (8 MTF, 7 FTM) have been transferred to the adult endocrinology department in transition clinics. Conclusion All treatments were generally well tolerated and effective, including bicalutamide, and no significant side effects were observed. Transition clinics played an important role in the better management of gender reassignment processes.
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Affiliation(s)
- Esin Karakılıç Özturan
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Ayşe Pınar Öztürk
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Firdevs Baş
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Ayşe Burcu Erdoğdu
- Marmara University, Pendik Training and Research Hospital, Clinic of Child and Adolescent Psychiatry, İstanbul, Turkey
| | - Seven Kaptan
- Psychiatrists in Private Practice, İstanbul, Turkey
| | - Aslı Derya Kardelen Al
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Şükran Poyrazoğlu
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Melek Yıldız
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
| | - Neşe Direk
- İstanbul University, İstanbul Faculty of Medicine, Department of Psychiatry, İstanbul, Turkey
| | - Şahika Yüksel
- İstanbul University, İstanbul Faculty of Medicine, Department of Psychiatry, Psychiatrist in Private Practice, Emeritus Professor, İstanbul, Turkey
| | - Feyza Darendeliler
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İstanbul, Turkey
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Rankine J, Kidd KM, Sequeira GM, Miller E, Ray KN. Adolescent Perspectives on the Use of Telemedicine for Confidential Health Care: An Exploratory Mixed-Methods Study. J Adolesc Health 2023; 73:360-366. [PMID: 37227338 PMCID: PMC10524174 DOI: 10.1016/j.jadohealth.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 03/16/2023] [Accepted: 04/04/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE Telemedicine can improve access to adolescent health care, but adolescents may experience barriers to accessing this care confidentially. Gender-diverse youth (GDY) may especially benefit from telemedicine through increased access to geographically limited adolescent medicine subspecialty care but may have unique confidentiality needs. In an exploratory analysis, we examined adolescents' perceived acceptability, preferences, and self-efficacy related to using telemedicine for confidential care. METHODS We surveyed 12- to 17-year-olds following a telemedicine visit with an adolescent medicine subspecialist. Open-ended questions assessing acceptability of telemedicine for confidential care and opportunities to enhance confidentiality were qualitatively analyzed. Likert-type questions assessing preference for future use of telemedicine for confidential care and self-efficacy to complete components of telemedicine visits confidentially were summarized and compared across cisgender versus GDY. RESULTS Participants (n = 88) included 57 GDY and 28 cisgender females. Factors affecting the acceptability of telemedicine for confidential care related to patient location, telehealth technology, adolescent-clinician relationships, and quality or experience of care. Perceived opportunities to protect confidentiality included using headphones, secure messaging, and prompting from clinicians. Most participants (53/88) were likely or very likely to use telemedicine for future confidential care, but self-efficacy for completing components of telemedicine visits confidentially varied by component. DISCUSSION Adolescents in our sample were interested in using telemedicine for confidential care, but cisgender and GDY recognized threats to confidentiality that may reduce acceptability of telemedicine for these services. Clinicians and health systems should carefully consider youth's preferences and unique confidentiality needs to ensure equitable access, uptake, and outcomes of telemedicine.
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Affiliation(s)
- Jacquelin Rankine
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Kacie M Kidd
- WVU Medicine Children's, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Gina M Sequeira
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Elizabeth Miller
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kristin N Ray
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Terrizzi BF, Lambert AS, Conard LAE, Vaughn LM, Lipstein EL. Providers' Perspectives on Decision-Making About Care for Transgender Youth. Transgend Health 2023; 8:337-343. [PMID: 37525837 PMCID: PMC10387150 DOI: 10.1089/trgh.2021.0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Transgender and gender-diverse (TGD) youth face health care decisions that are complicated by both social and medical aspects of gender care. Little is known about how providers support decision-making in this context or the gaps they perceive in decision support. Objective To explore health care providers' perspectives on the decision-making processes in youth gender care. Methods We interviewed health care providers (n=17) caring for TGD youth and asked about the nature of families' decision-making, providers' role in this process, and potential improvements to existing support systems. Two independent coders coded all responses which were analyzed using thematic analysis. Results From providers' perspectives, they serve as "guides" to families through a challenging decision-making process. Youth arrive educated and eager to begin treatment, but caregivers are more hesitant. Providers lack data to address parents' concerns, and struggle to support families through interpersonal conflict. All providers recognized a need to improve decision support for families. Conclusions Providers described decision-making in this context as a multistep process where interpersonal conflict and limited data slow progress. Practice Implications There is ample opportunity to leverage insights from adult and pediatric medical decision-making research to improve decision support for providers, TGD youth, and families.
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Affiliation(s)
- Brandon F. Terrizzi
- Division of General & Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Amy Sue Lambert
- Clinical Psychology, Gallaudet University, Washington, District of Columbia, USA
| | - Lee Ann E. Conard
- Adolescent Medicine, Transgender Health Clinic, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Lisa M. Vaughn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ellen L. Lipstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Fields EL. Achieving Health Equity for Sexual and Gender-Diverse Youth. Pediatr Clin North Am 2023; 70:813-835. [PMID: 37422316 DOI: 10.1016/j.pcl.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
Compared to their heterosexual and cisgender peers, sexual and gender diverse (SGD) youth, especially those from minoritized racial/ethnic groups, experience significant disparities in health, health care, and social conditions that can threaten their health and well-being. This article describes the disparities impacting SGD youth, their differential exposure to the stigma and discrimination that foster these disparities, and the protective factors that can mitigate or disrupt the impact of these exposures. On the final point, the article specifically focuses on pediatric providers and inclusive, affirming, medical homes as critical protective factors for SGD youth and their families.
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Affiliation(s)
- Errol L Fields
- Division of Adolescent/Young Adult Medicine, Department of Pediatrics Johns Hopkins School of Medicine, 200 North Wolfe Street, Room 2015, Baltimore, MD 21287, USA.
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Sequeira GM, Kahn NF, Ricklefs C, Collin A, Asante PG, Pratt W, Christakis D, Richardson LP. Barriers Pediatric PCP's Identify To Providing Gender-Affirming Care For Adolescents. J Adolesc Health 2023; 73:367-374. [PMID: 37294258 PMCID: PMC10802986 DOI: 10.1016/j.jadohealth.2023.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE Both affirming environments and access to gender-affirming medical care have a positive impact on the mental health of transgender and gender diverse (TGD) youth, however, many TGD youth experience barriers in accessing this care. Pediatric primary care providers (PCPs) can play an important role in expanding access to gender-affirming care for TGD youth; however, few currently provide this care. The purpose of this study was to explore pediatric PCPs' perspectives regarding barriers they experience to providing gender-affirming care in the primary care setting. METHODS Pediatric PCPs who had sought out support from the Seattle Children's Gender Clinic were recruited via email to participate in semistructured, one-hour Zoom interviews. All interviews were transcribed and then subsequently analyzed in Dedoose qualitative analysis software using a reflexive thematic analysis framework. RESULTS Provider participants (n = 15) represented a wide range of experiences with respect to years in practice, number of TGD youth seen, and practice location (urban, rural, suburban). PCPs identified both health system and community-level barriers to providing gender-affirming care to TGD youth. Health system-level barriers included: (1) lack of foundational knowledge and skills, (2) limited clinical decision-making support, and (3) health system design limitations. Community-level barriers included (1) community and institutional biases, (2) provider attitudes regarding gender-affirming care provision, and (3) challenges identifying community resources to support TGD youth. DISCUSSION A multitude of health system and community-level barriers must be overcome in the pediatric primary care setting to ensure that TGD youth receive timely, effective, and more equitable gender-affirming care.
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Affiliation(s)
- Gina M Sequeira
- Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington.
| | - Nicole F Kahn
- Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
| | - Colbey Ricklefs
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Arin Collin
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Peter G Asante
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Wanda Pratt
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Dimitri Christakis
- Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
| | - Laura P Richardson
- Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
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Johns MM, Gordon AR, Andrzejewski J, Harper CR, Michaels S, Hansen C, Fordyce E, Dunville R. Differences in Health Care Experiences among Transgender and Gender Diverse Youth by Gender Identity and Race/Ethnicity. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2023; 24:1128-1141. [PMID: 37086334 DOI: 10.1007/s11121-023-01521-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 04/23/2023]
Abstract
Transgender and gender diverse (TGD) youth experience significant risk for negative health outcomes, yet few studies exist that address TGD youth's experiences of health care. This paper explores the equitable access and utilization of health care in a sample of TGD youth of diverse gender and racial/ethnic identities. Data for this analysis are from the TGD subsample (n = 1415) of the 2018 Survey of Today's Adolescent Relationships and Transitions (START) Project. We assessed five health care experiences: being insured, having a current health care provider, being out to one's provider, believing your provider was knowledgeable about transgender issues, and barriers to accessing care due to gender identity/expression. We examined the proportion of TGD youth who reported each of these outcomes and within-group differences by gender identity and race/ethnicity using descriptive statistics, logistic regression, and predicted probabilities. When differences were examined by gender identity, barriers to equitable care were consistently more present among transgender females than youth of other gender identities. There were few significant differences by race/ethnicity; however, dual referent models demonstrated barriers to equitable care were particularly evident among Black and Hispanic transgender women. We discuss these findings through the lens of intersectionality and highlight the importance of research and intervention work focused on reducing barriers to equitable care for TGD youth.
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Affiliation(s)
- Michelle M Johns
- Division of Adolescent and School Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
- NORC at the University of Chicago, 1447 Peachtree Street NE, Suite 700, Atlanta, GA, 30309, USA.
| | - Allegra R Gordon
- Boston University School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jack Andrzejewski
- San Diego Joint Doctoral Program in Public Health, San Diego State University, University of California, San Diego, CA, USA
| | - Christopher R Harper
- Division of Violence Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Stuart Michaels
- NORC at the University of Chicago, 1447 Peachtree Street NE, Suite 700, Atlanta, GA, 30309, USA
| | - Christopher Hansen
- NORC at the University of Chicago, 1447 Peachtree Street NE, Suite 700, Atlanta, GA, 30309, USA
| | - Erin Fordyce
- NORC at the University of Chicago, 1447 Peachtree Street NE, Suite 700, Atlanta, GA, 30309, USA
| | - Richard Dunville
- NORC at the University of Chicago, 1447 Peachtree Street NE, Suite 700, Atlanta, GA, 30309, USA
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Ross MB, Jahouh H, Mullender MG, Kreukels BPC, van de Grift TC. Voices from a Multidisciplinary Healthcare Center: Understanding Barriers in Gender-Affirming Care-A Qualitative Exploration. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6367. [PMID: 37510602 PMCID: PMC10379025 DOI: 10.3390/ijerph20146367] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/17/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023]
Abstract
When seeking gender-affirming care, trans* and gender-diverse individuals often describe experiencing barriers. However, a deeper understanding of what constitutes such barriers is generally lacking. The present research sought to better understand the barriers trans* and gender-diverse individuals experienced, and their effects, when seeking gender-affirming care in the Netherlands. Qualitative interviews were conducted with trans* and gender-diverse individuals who sought care at a Dutch multidisciplinary medical center. Twenty-one participants were included, of which 12 identified as (trans) male, six identified as (trans) female, one as trans*, and one as gender-nonconforming (GNC)/non-binary. The interviews were mostly conducted at the homes of the participants and lasted between 55 min and 156 min (mean = 85 min). Following data collection and transcription, the interviews were analyzed using axial coding and thematic analysis. A total of 1361 codes were extracted, which could be classified into four themes describing barriers: lack of continuity: organizational and institutional factors (ncodes = 546), patient-staff dynamics (ncodes = 480), inadequate information and support (ncodes = 210), and lack of autonomy in decision making (ncodes = 125). Within our study, trans* and gender-diverse individuals described encountering multiple and diverse barriers when seeking gender-affirming care in the Netherlands. Future studies are needed to evaluate whether individualized care, the decentralization of care, and the use of decision aids can improve the experienced barriers of trans* and gender-diverse individuals seeking gender-affirming care within the Dutch healthcare system.
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Affiliation(s)
- Maeghan B Ross
- Department of Plastic Reconstructive and Hand Surgery, Amsterdam University Medical Centers, Location VUmc, 1081 HV Amsterdam, The Netherlands
- Amsterdam Public Health Institute, 1081 BT Amsterdam, The Netherlands
| | - Hiba Jahouh
- Department of Plastic Reconstructive and Hand Surgery, Amsterdam University Medical Centers, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Margriet G Mullender
- Department of Plastic Reconstructive and Hand Surgery, Amsterdam University Medical Centers, Location VUmc, 1081 HV Amsterdam, The Netherlands
- Amsterdam Public Health Institute, 1081 BT Amsterdam, The Netherlands
| | - Baudewijntje P C Kreukels
- Amsterdam Public Health Institute, 1081 BT Amsterdam, The Netherlands
- Department of Medical Psychology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Tim C van de Grift
- Department of Plastic Reconstructive and Hand Surgery, Amsterdam University Medical Centers, Location VUmc, 1081 HV Amsterdam, The Netherlands
- Amsterdam Public Health Institute, 1081 BT Amsterdam, The Netherlands
- Department of Medical Psychology and Psychiatry, Zaans Medisch Centrum, 1502 DV Zaandam, The Netherlands
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Carroll R, Sepulveda B, McLeod L, Stephenson C, Carroll RW. Characteristics and gender affirming healthcare needs of transgender and non-binary students starting hormone therapy in a student health service in Aotearoa New Zealand. J Prim Health Care 2023; 15:106-111. [PMID: 37390028 DOI: 10.1071/hc23040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/26/2023] [Indexed: 07/02/2023] Open
Abstract
Introduction Traditionally, gender-affirming hormonal therapy (GAHT) is initiated in secondary care, but a primary care based approach has been developed to reduce access barriers. Aim We aim to describe the demographics, hormone choices, and additional referrals made for young people initiating GAHT in a primary care setting in Aotearoa New Zealand. Methods Clinical notes were reviewed for all patients who commenced GAHT between 1 July 2020 to the end of 2022 at a tertiary education health service. Data were collected on age, ethnicity, gender, type of hormones prescribed, and any additional referrals. Results Eighty five patients commenced GAHT during the review period (64% assigned male at birth and starting oestrogen-based GAHT, 36% assigned female at birth and commencing testosterone-based GAHT). Fourty seven percent of patients identified as transgender female, 38% as non-binary, and 15% as transgender male. Spironolactone was the most common choice of testosterone blocker (81%). The choice of oestrogen formulation was fairly equal between patches (54%) and tablets (46%). Eighty percent of those assigned male at birth chose to preserve fertility, 54% requested voice therapy, and 87% of those assigned female at birth requested top surgery. Discussion There is a need for improved understanding of non-binary gender-affirmation needs, in particular those of Māori and Pasifika youth. An informed consent approach in primary care can reduce barriers and distress for transgender youth seeking GAHT. The high unmet need for top surgery for transgender people assigned female at birth requires attention.
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Affiliation(s)
- Rona Carroll
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand; and Mauri Ora Student Health and Counselling Service, Victoria University of Wellington, New Zealand
| | - Bianca Sepulveda
- Mauri Ora Student Health and Counselling Service, Victoria University of Wellington, New Zealand
| | - Lane McLeod
- University of Otago Medical School, Wellington, New Zealand
| | | | - Richard W Carroll
- Endocrine, Diabetes and Research Centre, Te Whatu Ora Capital, Coast and Hutt Valley
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Falck F, Bränström R. The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes. BMC Public Health 2023; 23:1031. [PMID: 37259082 DOI: 10.1186/s12889-023-15856-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 05/09/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND According to the minority stress theory, stigma affects the health of marginalized populations. Previous stigma research has focused on the health effects of individual and interpersonal stigma, paying less attention to structural factors. Laws on legal gender recognition affect the lives of transgender individuals in unique ways. The fact that these laws and population attitudes vary greatly between European countries, offer a unique opportunity to study the role of structural stigma in the lives of transgender individuals. Little is known about how transgender specific structural stigma relates to individual health determinants. Consequently, the aim of this study was to explore the association between structural stigma and access to gender affirming care, gender identity disclosure in health care, and experiences of discrimination in health care across 28 European countries. METHODS By using multilevel regression, we combined data on health seeking behavior, transgender identity disclosure to health care providers, and experiences of discrimination in health care from 6,771 transgender individuals participating in the 2012 European Union Lesbian, Gay, Bisexual and Transgender survey with a structural stigma measure, consisting of population attitudes towards transgender individuals as well as national legislation on gender recognition. Reasons to refrain from seeking care and discrimination in health care were assessed by categorizing countries as low or high in structural stigma and using Chi-square statistics. RESULTS Country-level structural stigma was negatively associated experiences of seeking gender affirming care and positively associated with concealment of being transgender to health care providers. Identity concealment was associated with a lower likelihood of exposure to discrimination in the health care setting across countries regardless of their level of structural stigma. The most prevalent reasons to forgo gender affirming care were shared between low and high structural stigma country groups and centered around fear. CONCLUSION The results highlight the importance of changing stigmatizing legislation and population attitudes to promote access to gender affirming care as well as openness of being transgender towards providers. Measures to decrease discrimination in the health care setting are warranted in high as well as in low structural stigma countries.
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Affiliation(s)
- Felicitas Falck
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, CAP Research Centre, Stockholm, Sweden.
- ANOVA Clinic, Karolinska University Hospital Stockholm, Norra Stationsgatan 69, 171 76, Stockholm, Sweden.
| | - Richard Bränström
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Nobels väg 9, 17177, Stockholm, Sweden
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DeZure C. Gender-Affirming Care in Children. Pediatr Ann 2023; 52:e160-e163. [PMID: 37159060 DOI: 10.3928/19382359-20230307-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Cast into the spotlight because of recent legislative actions, gender-affirming care is a hot topic of discussion across the country when it comes to pediatric health care. And yet there is a great deal of misinformation being perpetuated about gender-affirming care that may be harmful to youth who identify as transgender and gender diverse (TGD). In addition, TGD youth continue to be an underserved and marginalized group that receive disparate health care at baseline. It is our role as pediatricians to understand the current landscape of evidence and guidance available to promote the health of TGD youth while reducing discrimination through education, nonjudgmental holistic treatment, and advocacy at local and national levels. [Pediatr Ann. 2023;52(5):e160-e163.].
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Bisno DI, Lubitz S, Marshall I, Cohen DA. A National Survey of United States-based Endocrinologists who Prescribe Gender-Affirming Hormone Therapy. Endocr Pract 2023:S1530-891X(23)00063-0. [PMID: 36906069 DOI: 10.1016/j.eprac.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVE The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) Version 7 recommended that before initiating gender-affirming hormone therapy (GAHT), patients should seek a psychosocial evaluation from a mental health professional documenting a diagnosis of persistent gender dysphoria. The Endocrine Society published guidelines in 2017 recommending against an obligatory psychosocial evaluation, which was affirmed in the recently published WPATH SOC Version 8 from 2022. Little is known about how endocrinologists ensure appropriate psychosocial assessment for their patients. This study assessed the protocols and characteristics of United States-based adult endocrinology clinics that prescribe GAHT. METHODS An anonymous electronic survey sent to members of a professional organization and the "Endocrinologists" Facebook group was responded to by 91 practicing board-certified adult endocrinologists who prescribe GAHT. RESULTS Thirty-one states were represented by the respondents. Overall, 83.1% of GAHT-prescribing endocrinologists reported accepting Medicaid. They reported working in university practices (28.4%), community practices (22.7%), private practices (27.3%), and other practice settings (21.6%). Overall, 42.9% of the respondents reported that their practice required documentation of a psychosocial evaluation from a mental health professional before initiating GAHT. CONCLUSION Endocrinologists who prescribe GAHT are divided about requiring a baseline psychosocial evaluation before prescribing GAHT. Further work is needed to understand the impact of psychosocial assessment on patient care and facilitate the uptake of new guidelines into clinical practice.
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Affiliation(s)
- Daniel I Bisno
- Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, United States
| | - Sara Lubitz
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States; PROUD Gender Center of New Jersey, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, United States
| | - Ian Marshall
- PROUD Gender Center of New Jersey, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, United States; Division of Pediatric Endocrinology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - David A Cohen
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States; PROUD Gender Center of New Jersey, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, United States.
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Thoma BC, Jardas EJ, Choukas-Bradley S, Salk RH. Perceived Gender Transition Progress, Gender Congruence, and Mental Health Symptoms Among Transgender Adolescents. J Adolesc Health 2023; 72:444-451. [PMID: 36528514 PMCID: PMC10107849 DOI: 10.1016/j.jadohealth.2022.09.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/20/2022] [Accepted: 09/25/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Transgender adolescents (TGAs) have high risk for experiencing mental health problems, but little is known about how aspects of gender identity relate to their mental health symptoms. Evidence from child and adult samples of transgender individuals indicates making progress in gender transition milestones and higher levels of congruence between gender identity and gender expression are related to fewer mental health problems. We examined associations between perceived transition progress, gender congruence, and mental health symptoms in a diverse, nationwide sample of TGAs. METHODS TGAs (n = 1,943) participated in a cross-sectional online survey. Perceived gender transition progress, gender congruence, and depressive and anxiety symptoms were assessed. Path analysis was conducted to examine whether transition progress was related to mental health symptoms via higher levels of gender congruence. RESULTS Most TGAs had undertaken at least one social transition step (98%), but only 11% had taken medical transition steps. Higher gender congruence was associated with lower mental health symptoms. Greater transition progress was associated with higher gender congruence, and perceived transition progress evidenced negative indirect associations with mental health symptoms. TGAs identifying with binary identities (transmasculine and transfeminine youth) reported lower levels of transition progress and gender congruence compared to other subgroups of TGAs. DISCUSSION Higher levels of perceived transition progress and gender congruence are related to lower mental health symptoms among TGAs. Mental health interventions tailored to the unique developmental needs of TGAs are needed given high risk for mental health problems within this population, and interventions addressing transition progress and gender congruence should be examined.
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Affiliation(s)
- Brian C Thoma
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - E J Jardas
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Rachel H Salk
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
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Wall CSJ, Patev AJ, Benotsch EG. Trans broken arm syndrome: A mixed-methods exploration of gender-related medical misattribution and invasive questioning. Soc Sci Med 2023; 320:115748. [PMID: 36736052 DOI: 10.1016/j.socscimed.2023.115748] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023]
Abstract
RATIONALE Gender-related medical misattribution and invasive questioning (GRMMIQ), colloquially known as "trans broken arm syndrome," is a form of medical discrimination faced by transgender and gender diverse (TGD) patients wherein a provider incorrectly assumes that a medical condition results from a patient's gender identity or medical transition. This phenomenon may take one of two forms: (1) the incorrect and explicit misattribution of gender identity or medical transition as being the cause of an acute complaint, or (2) invasive and unnecessary questions regarding a patient's gender identity or gender transition status. OBJECTIVE Using mixed-methods procedures, this study aims to explore the incidence, some common correlates, and manifestations of GRMMIQ. METHODS American TGD participants (N = 147), recruited through an online recruitment platform, completed questions assessing their experiences in the healthcare system including lifetime incidence of GRMMIQ, outness to healthcare providers, and additional experiences of gender-related discrimination in a medical setting. Participants who indicated experiences of GRMMIQ were asked open-ended questions about one such experience. RESULTS Nearly one-third of participants reported experiencing GRMMIQ. Experiences were associated with outness to acute care providers and other types of gender-related discrimination in healthcare settings. Analysis of qualitative data revealed four primary themes: (1) assumptions of disordered thinking and being, (2) hyperfocus on aspects of medical transition, (3) cultural ignorance and incompetence, and (4) dismissiveness of the patient. CONCLUSION Together, these results enhance the understanding of an underexplored aspect of medical discrimination faced by TGD individuals while highlighting commonalities across different experiences.
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Affiliation(s)
- Catherine S J Wall
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA.
| | - Alison J Patev
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA.
| | - Eric G Benotsch
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA.
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Chaplyn G, Saunders LA, Lin A, Cook A, Winter S, Gasson N, Watson V, Wright Toussaint D, Strauss P. Experiences of parents of trans young people accessing Australian health services for their child: Findings from Trans Pathways. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2023; 25:19-35. [PMID: 38328587 PMCID: PMC10846451 DOI: 10.1080/26895269.2023.2177921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Background Many trans young people seek mental health support and gender-affirming medical interventions including puberty suppression, gender-affirming hormones and/or surgeries. Trans young people and their parents face multiple barriers in accessing gender-affirming care and mental health support, however little is known about the parent perspective on accessing services for their trans child. Aims This study aimed to understand the experiences of parents accessing medical and mental health services with and for their trans children within Australia. Methods Using data from Trans Pathways, a large mixed-methods cross-sectional study, we examined the experiences of parents (N = 194) in Australia accessing primary care, psychiatry, therapy/counseling, mental health inpatient, and gender-affirming medical services with/for their trans children (aged 25 years or younger). Qualitative data on service experiences were thematically analyzed. Quantitative analyses included frequency of access to services, wait times, service satisfaction, and mental health diagnoses of the parents' trans child. Results Services were mostly first accessed when the young person was between 12 and 17 years of age, with primary care physicians being the most accessed service. Parents reported that some practitioners were respectful and knowledgeable about gender-affirming care, and others lacked experience in trans health. Across all services, common barriers included long wait times, complicated pathways to navigate to access support, as well as systemic barriers such as sparsity of gender speciality services. Across services, parents reported feeling as though they do not have the necessary tools to best support their child in their gender affirmation. Discussion This study highlights the crucial need for systemic changes in the processes of accessing gender-affirming care and mental health support to enable access to appropriate and timely care. These findings also indicate the importance of improving individual practitioner knowledge around trans health, to enhance the support provided to trans young people and their parents.
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Affiliation(s)
- Georgia Chaplyn
- School of Population Health, Curtin University, Perth, Australia
- Telethon Kids Institute, Nedlands, Australia
| | - Liz A. Saunders
- Gender Diversity Service, Perth Children’s Hospital, Nedlands, Australia
- School of Human Science (Exercise and Sports Science), The University of Western Australia, Perth, Australia
| | | | - Angus Cook
- School of Population and Global Health, The University of Western Australia, Perth, Australia
| | - Sam Winter
- School of Population Health, Curtin University, Perth, Australia
| | - Natalie Gasson
- School of Population Health, Curtin University, Perth, Australia
| | - Vanessa Watson
- School of Population and Global Health, The University of Western Australia, Perth, Australia
| | | | - Penelope Strauss
- Telethon Kids Institute, Nedlands, Australia
- School of Population and Global Health, The University of Western Australia, Perth, Australia
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Sequeira GM, Kahn NF, Bocek KM, Shafii T, Asante PG, Christakis DA, Pratt W, Richardson LP. Pediatric Primary Care Providers' Perspectives on Telehealth Platforms to Support Care for Transgender and Gender-Diverse Youths: Exploratory Qualitative Study. JMIR Hum Factors 2023; 10:e39118. [PMID: 36719714 PMCID: PMC9929719 DOI: 10.2196/39118] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 10/20/2022] [Accepted: 11/07/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Access to gender-affirming care services for transgender and gender-diverse youths is limited, in part because this care is currently provided primarily by specialists. Telehealth platforms that enable primary care providers (PCPs) to receive education from and consult specialists may help improve the access to such services. However, little is known about PCPs' preferences regarding receiving this support. OBJECTIVE This study aimed to explore pediatric PCPs' perspectives regarding optimal ways to provide telehealth-based support to facilitate gender-affirming care provision in the primary care setting. METHODS PCPs who had previously requested support from the Seattle Children's Gender Clinic were recruited to participate in semistructured, 1-hour web-based interviews. Overall, 3 specialist-to-PCP telehealth modalities (tele-education, electronic consultation, and telephonic consultation) were described, and the participants were invited to share their perspectives on the benefits and drawbacks of each modality, which modality would be the most effective, and the most important characteristics or outcomes of a successful platform. Interviews were transcribed and analyzed using a reflexive thematic analysis framework. RESULTS The interviews were completed with 15 pediatric PCPs. The benefits of the tele-education platform were developing a network with other PCPs to facilitate shared learning, receiving comprehensive didactic and case-based education, having scheduled education sessions, and increasing provider confidence. The drawbacks were requiring a substantial time commitment and not allowing for real-time, patient-specific consultation. The benefits of the electronic consultation platform were convenient and efficient communication, documentation in the electronic health record, the ability to bill for provider time, and sufficient time to synthesize information. The drawbacks of this platform were electronic health record-related difficulties, text-based communication challenges, inability to receive an answer in real time, forced conversations with patients about billing, and limitations for providers who lack baseline knowledge. With respect to telephonic consultation, the benefits were having a dialogue with a specialist, receiving compensation for PCP's time, and helping with high acuity or complex cases. The drawbacks were challenges associated with using the phone for communication, the limited expertise of the responding providers, and the lack of utility for nonemergent issues. Regarding the most effective platform, the responses were mixed, with 27% (4/15) preferring the electronic consultation, 27% (4/15) preferring tele-education, 20% (3/15) preferring telephonic consultation, and the remaining 27% (4/15) suggesting a hybrid of the 3 models. CONCLUSIONS A diverse suite of telehealth-based training and consultation services must be developed to meet the needs of PCPs with different levels of experience and training in gender-affirming care. Beyond the widely used telephonic consultation model, electronic consultation and tele-education may provide important alternative training and consultation opportunities to facilitate greater PCP independence and promote wider access to gender-affirming care.
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Affiliation(s)
- Gina M Sequeira
- Seattle Children's Research Institute, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Nicole F Kahn
- Seattle Children's Research Institute, Seattle, WA, United States
| | - Kevin M Bocek
- Seattle Children's Research Institute, Seattle, WA, United States
| | - Taraneh Shafii
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Peter G Asante
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Dimitri A Christakis
- Seattle Children's Research Institute, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Wanda Pratt
- Information School, University of Washington, Seattle, WA, United States
| | - Laura P Richardson
- Seattle Children's Research Institute, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
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Lovejoy C, Fitzgerald L, Mutch A. Understanding access to healthcare for gender diverse young people: a critical review of the literature. CULTURE, HEALTH & SEXUALITY 2023; 25:18-32. [PMID: 35000558 DOI: 10.1080/13691058.2021.2017486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 12/08/2021] [Indexed: 06/14/2023]
Abstract
Gender diverse young people face well-documented physical, mental and sexual health disparities compared to the general population. Differential access to healthcare is a key driver of these inequities and literature highlights high unmet healthcare need among members of this group. Healthcare access has been described through a model that defines five dimensions of health services: approachability; acceptability; availability and accommodation; affordability; and appropriateness; and five abilities of health service consumers that interact with these dimensions: the abilities to perceive, seek, reach, pay and engage. This comprehensive literature review examined barriers to and facilitators of healthcare access among gender diverse young people using the lens provided by this model as it relates to dimensions of access at the health service level and/or the abilities of health service users. We advocate expansion of this model to incorporate demand- and supply-side barriers and facilitators of access, and important structural factors including the gender binary health system framework, intersectionality and stigma. Findings highlight the need for improvements to healthcare provider education and the participatory redesign of health services with a focus on intersectionality, individually-tailored service provision and healthcare that is responsive to the unique needs of gender diverse young people.
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Affiliation(s)
- Charlotte Lovejoy
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Lisa Fitzgerald
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Allyson Mutch
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia
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Hodax JK, DiVall S. Gender-affirming endocrine care for youth with a nonbinary gender identity. Ther Adv Endocrinol Metab 2023; 14:20420188231160405. [PMID: 37006780 PMCID: PMC10064168 DOI: 10.1177/20420188231160405] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/11/2023] [Indexed: 04/04/2023] Open
Abstract
Nonbinary individuals, or those who identify outside of the traditional gender binary, are currently present in up to 9% of the general population of youth or up to 55% of gender-diverse youth. Despite the high numbers of nonbinary individuals, this population continues to experience barriers to healthcare due to providers' inability to see beyond the transgender binary and lack of competence in providing nonbinary care. In this narrative review, we discuss using embodiment goals to individualize care of nonbinary individuals, and review hormonal and nonhormonal treatment options for gender affirmation. Hormonal treatments include those often used in binary transgender individuals, such as testosterone, estradiol, and anti-androgens, but with adjustments to dosing or timeline to best meet a nonbinary individual's embodiment goals. Less commonly used medications such as selective estrogen receptor antagonists are also discussed. For nonhormonal options, alterations in gender expression such as chest binding, tucking and packing genitalia, and voice training may be beneficial, as well as gender-affirming surgeries. Many of these treatments lack research specific to nonbinary individuals and especially nonbinary youth, and future research is needed to ensure safety and efficacy of gender-affirming care in this population.
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Tyler TR, Huddleston BS, Barton TN, Thornton MH, Calloway ET, Martin KG, Morgan AL, Munoz V. Qualitative metasummary: Parents seeking support related to their TGNC children. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2023; 24:132-148. [PMID: 37114113 PMCID: PMC10128398 DOI: 10.1080/26895269.2022.2068724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Background: Parents seek support on behalf of their transgender and gender nonconforming (TGNC) children. Previous qualitative studies explore the types of support parents seek inside and outside of healthcare settings. Healthcare providers often remain unprepared to effectively provide gender-affirming services to TGNC children and their accompanying parents and may benefit from learning about the support seeking experiences of parents with TGNC children. Aims: This paper summarized qualitative research studies that address the topic of parents seeking support on behalf of their TGNC children. We produced this report for healthcare providers to review to enhance gender-affirming services for parents and TGNC children. Methods: This paper outlines a qualitative metasummary of studies from the United States or Canada with data collected from parents of TGNC children. Data collection included the steps of journal runs, database searches, reference checks, and area scans. Data analysis involved the steps of extracting, editing, grouping, abstracting, and calculating the intensity and frequency effect sizes for finding statements from qualitative research study articles. Results: The results of this metasummary yielded two primary themes, six subthemes, and 24 total findings. The first primary theme of seeking guidance had three subthemes: educational resources, community networks, and advocacy efforts. The second primary theme of seeking healthcare had three subthemes: healthcare providers, mental healthcare, and general healthcare. Discussion: These findings provide information healthcare providers can use to inform their practice. These findings also highlight the importance of providers working collaboratively with parents when serving TGNC children. This article concludes with practical tips for providers.
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Affiliation(s)
- Tee R. Tyler
- Texas Christian University, Fort Worth, Texas, USA
- CONTACT Tee R. Tyler Texas Christian University, TCU Box 298750, Fort Worth, TX76129, USA
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