Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study

Increase in Functional Tic Presentations in Sexual Orientation and Gender Identity Minority Youth During Coronavirus Disease 2019

BACKGROUND

Functional tic disorders are among the least common functional movement disorders, but their prevalence rose during the coronavirus disease 2019 (COVID-19) pandemic. Although female adolescents develop functional neurological disorders at higher rates than males, investigations into sexual orientation and gender identity (SOGI) status of these patients are limited.

METHODS

We completed a retrospective, cross-sectional time series examining the incidence of new-onset functional tic disorders in youth presenting to the Massachusetts General Hospital Movement Disorder clinics before and during the COVID-19 pandemic. Data were collected by searching for relevant International Classification of Diseases (ICD)-10 diagnostic codes in youth aged nine to 26 years using a hospital-wide data repository. Individual cases were reviewed for inclusion based on clinical criteria and expert consensus.

RESULTS

The prevalence of functional tic presentations in youth rose 8.6-fold from pre- to postpandemic levels (Fisher exact test P < 0.001), whereas the prevalence of developmental tic presentations pre- and postpandemic remained stable (114 vs 112). SOGI minority youth comprised 37% of those with functional tics (total n = 19). Ninety five percent of patients with functional tics identified as female, with 10% of these identifying as transgender.

CONCLUSIONS

Our data confirm previously demonstrated dramatic rises in functional tic presentations during the COVID-19 pandemic and, more notably, reveal a strong association with SOGI minority status. We highlight the potential link between functional tic disorders and SOGI minority status. Providing a safe and supportive clinical environment and addressing stress linked to SOGI minority status may help to improve patient prognosis.

Access to healthcare among transgender and non-binary youth in Sweden and Spain: A qualitative analysis and comparison

BACKGROUND

Transgender and non-binary (TGNB) people tend to report worse health than cis people, however, despite an increased need for care, they face several barriers when trying to access healthcare. These barriers might be exacerbated when young age intersects with a trans identity, and so there is a need for studies highlighting the experiences of TGNB youth.

AIMS

To explore and compare how TGNB youth (15-26 years old) in Sweden and Spain experienced their access to healthcare, in order to shed light on the strengths and limitations of different kinds of healthcare systems and improve healthcare provision and policy development.

METHODS

This study was based on a qualitative analysis of semi-structured interviews with TGNB youth living in Sweden (n = 16) and Spain (n = 18). Of these, 22 identified as male or transmasculine, six as non-binary, and six as women or transfeminine; 25 had undergone some type of gender-affirming care, and the rest were on the waiting list or undergoing preparatory visits and had not started hormonal treatment. The interviews were analyzed using reflexive thematic analysis. An abductive approach was applied, and the Levesque conceptual framework was used to compare the analyses of each set of materials.

RESULTS

We present our findings using the structure of the accessibility framework, focusing on approachability, acceptability, availability, affordability, and appropriateness. The conceptualization of accessibility in combination with the concept of cisnormativity illustrates how specific ideals and normative expectations affect access to healthcare for TGNB people across contexts, with most barriers arising from the appropriateness of the services.

DISCUSSION

Young TGNB people experience barriers to accessing healthcare both in the Spanish and the Swedish contexts. Strategies to reduce these barriers should be framed within the critique of and resistance to cisnormativity and should focus on users with intersecting marginalized identities to promote health equity.

Mental Health Needs, Barriers, and Receipt of Care Among Transgender and Nonbinary Adolescents

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.

Systematic Review of Gender and Sex Terminology Use in Arthroplasty Research: There is Room for Improvement

BACKGROUND

There is increasing appreciation of the distinction between gender and sex as well as the importance of accurately reporting these constructs. Given recent attention regarding transgender and gender nonconforming (TGNC) and intersex identities, it is more necessary than ever to understand how to describe these identities in research. This study sought to investigate the use of gender- and sex-based terminology in arthroplasty research.

METHODS

The five leading orthopaedic journals publishing arthroplasty research were reviewed to identify the first twenty primary clinical research articles on an arthroplasty topic published after January 1, 2022. Use of gender- or sex-based terminology, whether use was discriminate, and whether stratification or adjustment based on gender or sex was performed, were recorded.

RESULTS

There were 98 of 100 articles that measured a construct of gender or sex. Of these, 15 articles used gender-based terminology, 45 used sex-based terminology, and 38 used a combination of gender- and sex-based terminology. Of the 38 articles using a combination of terminology, none did so discriminately. All articles presented gender and sex as binary variables, and two attempted to explicitly define how gender or sex were defined. Of the 98 articles, 31 used these variables for statistical adjustments, though only six reported stratified results.

CONCLUSIONS

Arthroplasty articles infrequently describe how gender or sex was measured, and frequently use this terminology interchangeably. Additionally, these articles rarely offer more than two options for capturing variation in sex and gender. Future research should be more precise in the treatment of these variables to improve the quality of results and ensure findings are patient-centered and inclusive.

Epidemiology of Gender Diversity

In the United States, approximately 1.6 million individuals identify as transgender and gender diverse (TGD), encompassing a wide range of identities and experiences. Despite progress in visibility and acceptance, TGD people continue to face health care and societal disparities, especially affecting racial minorities. Although legal advancements have been achieved, the key to addressing these persistent health care disparities lies in implementing comprehensive and culturally sensitive health care practices and supportive policies. With a growing number of TGD people seeking gender-affirming care, it is imperative that health care practitioners understand the unique challenges faced by this community and provide tailored services with sensitivity and expertise.

Demographics of referrals to a specialist gender identity service in the UK between 2017 and 2020

Trends in clinical referrals to specialist gender services historically comprised more assigned male at birth young people. In the last decade, this has shifted in adolescent samples to more assigned female young people. An updated review of the current patterns of referrals is important to better understand the potential changing needs of clinically referred gender-diverse children and adolescents. We assessed the demographics of referrals to the Gender Identity Development Service (GIDS) and their attendance patterns from 2017 to 2020. During this period, 9555 referrals were received in total, most were in adolescence (n = 7901, 82.7%), and more assigned female (age range = 1-18 years; M = 14.05; SD = 2.5) were referred than assigned male young people overall (n = 6823, 71.4%). A larger proportion of assigned female adolescents (assigned female: n = 5835, 62.3%, assigned male: n = 1897, 20.3%) and assigned female children (n = 988, 10.6%, assigned male: n = 640, 6.8%) were referred. For 2%, sex assigned at birth was unrecorded, 83.4% were White British and 36.6% had an unidentified ethnicity. Only 4% did not attend a first appointment, indicating the need for care from this specialist service. With more young people presenting to gender services, understanding the demographics of young people seeking gender care is vital for service provision. Future research should explore how to increase access to gender care for ethnic minorities, and how to support those accessing services.

Mental health outcomes and suicidality in hospitalized transgender adolescents: A propensity score-matched Cross-sectional analysis of the National inpatient sample 2016-2018

Transgender adolescents have unique mental health needs. This demographic has increased rates of mood disorders, anxiety, and depression compared to their cisgender peers. Large-scale studies focused on mental health outcomes, including suicidality, in the transgender adolescent population remain unknown. This study tries to fill these gaps in the literature. Data for this study was taken from the National Inpatient Sample 2016-2018. Transgender adolescents were identified using the ICD-10 codes related to transsexualism diagnoses. These individuals were compared to adolescents without transsexualism diagnoses. To mitigate imbalances in baseline characteristics, we utilized a 1:2 nearest neighbor propensity score matching with a caliper width of 0.0001, considering variables such as age, year of hospitalization, and psychiatric disorders. Following propensity score matching, the study cohort comprised 2635 transgender and 5270 non-transgender adolescents (Mean age 15.2 years). The transgender group demonstrated a notably higher prevalence of mood disorders (91%) and anxiety disorders (65%). Furthermore, the prevalence of suicidal ideation was significantly higher in the transgender group (52.4% vs. 39.2%, p < 0.001). However, there was no significant difference in the prevalence of suicide attempts between the groups. After controlling for psychiatric comorbidities, age, and gender, the odds ratio for the composite outcome of suicidal ideation or attempt was 1.99 (95% CI 1.58-2.12, p < 0.001). Our study identifies elevated mood and anxiety disorders and suicidality rates in hospitalized transgender adolescents compared to cisgender peers. Mood disorders notably amplify the risk of suicidal attempts. These findings urgently call for targeted mental health interventions and policy changes to serve this vulnerable population in healthcare settings better.

Sexual Orientation/Gender Identity Discrimination and Chronic Pain in Children: A National Study

INTRODUCTION

This study provides national estimates of parental perceived child sexual orientation or gender minority (SGM) discrimination and examines associations between SGM discrimination and chronic pain in children.

METHODS

Cross-sectional analysis of the 2020 and 2021 National Survey of Children's Health (N=47,213). Caregivers of children ages 6-17 years old reported whether their child had ever been treated or judged unfairly (i.e., discrimination) because of their SGM identity. Chronic pain in children was defined as frequent or chronic difficulty with repeated or chronic physical pain during the past 12 months, as reported by caregivers. Weighted prevalence estimates for discrimination were calculated for the whole sample and sociodemographic subgroups. Associations between SGM discrimination and chronic pain were estimated using multivariable Poisson regression models adjusting for sociodemographic factors. Analyses were conducted 2022-2023.

RESULTS

Within this nationally representative sample, parents reported 1.4% (95% CI 1.2%-1.6%) of children have experienced SGM-related discrimination. The prevalence was higher among adolescents, females at birth, and those living in suburban areas. Children who experienced discrimination had a higher prevalence of chronic pain (20.2%) compared to those who did not (7.0%, p<0.0001), with an adjusted prevalence rate ratio of 2.0 (95% CI 1.5-2.5, p<0.0001).

CONCLUSIONS

Based on parent report, about 0.6 million children in the U.S. have experienced SGM-based discrimination; these children are twice as likely to have chronic pain. Findings highlight the importance of assessment and intervention for chronic pain in children who may experience marginalization and discrimination due to their sexual orientation and gender identity.

Integrating perspectives of transgender and gender-diverse youth, family members, and professionals to support their health and wellbeing - a mixed-method study protocol

BACKGROUND

The current literature highlights a strong link between the poor health outcomes of transgender and gender diverse (TGD) individuals and their negative experiences in various areas of life. Most of these publications rely on adults' memories, lacking a focus on the current experiences and needs of young transgender and gender-diverse individuals. Furthermore, previous studies on support for these young people often solely consider the perspectives of TGD adults or professionals and rarely involve parents' viewpoints.

METHODS

This study will use a mixed sequential method with a participatory approach. Firstly, the qualitative phase will explore the difficulties and needs of TGD (15-20 years old) and of the families and professionals who support them. Results from this part will be used to develop the questionnaire for the quantitative phase, with the help of a community board. Secondly, based on participatory epidemiological research, the quantitative phase will use an intersectional perspective to measure the impact of individual and structural factors on the quality of life and well-being of transgender and gender-diverse young people. Finally, a co-creation phase will be undertaken to formulate recommendations based on the results of the first two phases.

DISCUSSION

This research aims at better understanding the influence of gender identity on the quality of life and health of TGD young people and their families and to identify protective and risk factors that affect their vulnerabilities.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of the Erasme Faculty Hospital (CCB B4062023000140). As this research is participatory and part of a PhD dissertation, we aim to disseminate the results through our partners' networks and structures locally, and internationally through conferences and peer-reviewed journals.

Gender diversity is correlated with dimensional neurodivergent traits but not categorical neurodevelopmental diagnoses in children

BACKGROUND

Gender clinic and single-item questionnaire-based data report increased co-occurrence of gender diversity and neurodevelopmental conditions. The nuances of these associations are under-studied. We used a transdiagnostic approach, combining categorical and dimensional characterization of neurodiversity, to further the understanding of its associations with gender diversity in identity and expression in children.

METHODS

Data from 291 children (Autism N = 104, ADHD N = 104, Autism + ADHD N = 17, neurotypical N = 66) aged 4-12 years enrolled in the Province of Ontario Neurodevelopmental Network were analyzed. Gender diversity was measured multi-dimensionally using a well-validated parent-report instrument, the Gender Identity Questionnaire for Children (GIQC). We used gamma regression models to determine the significant correlates of gender diversity among age, puberty, sex-assigned-at-birth, categorical neurodevelopmental diagnoses, and dimensional neurodivergent traits (using the Social Communication Questionnaire and the Strengths and Weaknesses of ADHD Symptoms and Normal Behavior Rating Scales). Internalizing and externalizing problems were included as covariates.

RESULTS

Neither a categorical diagnosis of autism nor ADHD significantly correlated with current GIQC-derived scores. Instead, higher early-childhood dimensional autistic social-communication traits correlated with higher current overall gender incongruence (as defined by GIQC-14 score). This correlation was potentially moderated by sex-assigned-at-birth: greater early-childhood autistic social-communication traits were associated with higher current overall gender incongruence in assigned-males-at-birth, but not assigned-females-at-birth. For fine-grained gender diversity domains, greater autistic restricted-repetitive behavior traits were associated with greater diversity in gender identity across sexes-assigned-at-birth; greater autistic social-communication traits were associated with lower stereotypical male expression across sexes-assigned-at-birth.

CONCLUSIONS

Dimensional autistic traits, rather than ADHD traits or categorical neurodevelopmental diagnoses, were associated with gender diversity domains across neurodivergent and neurotypical children. The association between early-childhood autistic social-communication traits and overall current gender diversity was most evident in assigned-males-at-birth. Nuanced interrelationships between neurodivergence and gender diversity should be better understood to clarify developmental links and to offer tailored support for neurodivergent and gender-diverse populations.

Facilitators and barriers to using telemedicine for gender-affirming care in gender-diverse youth: A qualitative study

INTRODUCTION

Access to gender-affirming care (GAC) is limited for gender-diverse (GD) youth, with the potential for further limitations given the current political climate. GAC has been shown to improve the mental health of GD youth and telemedicine (TM) could increase access to GAC. With limited data on the acceptability and feasibility of TM for GAC among GD youth, we sought to further explore their perspectives on the use of TM in their care.

METHODS

We used a semi-structured interview guide, with prompts developed to explore participants' knowledge of TM, identify factors that influenced use, and advantages or disadvantages of use.

RESULTS

Thirty GD participants aged 13-21 years old participated in TM. While TM was not the preferred option for medical visits, it was recognized as a practical option for providing GAC. Various actual and perceived disadvantages noted by youth included, technical issues interrupting the visit, not receiving care equivalent to that of an in-person visit, having to see themselves on the screen, family members interrupting visits, and meeting new staff while connecting to a TM visit. The advantages, however, were an increased autonomy and convenience of TM, especially when used for specific aspects of GAC.

DISCUSSION

The use of TM in GAC could be optimized by limiting camera use, eliminating/reducing staff involvement, being sensitive to privacy issues, and alternating TM with in-person visits. Clinicians should be cognizant of patient preferences and concerns and be flexible with visit types.

Experiences of hereditary cancer care among transgender and gender diverse people: "It's gender. It's cancer risk…it's everything"

Transgender and gender diverse (TGD) individuals are a significant yet underrepresented population within genetic counseling research and broader LGBTQI+ health studies. This underrepresentation perpetuates a cycle of exclusion from the production of medical knowledge, impacting the quality and equity of care received by TGD individuals. This issue is particularly poignant in cancer genetic counseling, where TGD individuals with elevated cancer risk receive risk assessment, counseling, and referral to support based on risk figures and standards of care developed for cisgender individuals. The experiences of TGD individuals navigating inherited cancer syndromes remain largely undocumented in medical literature, posing challenges to the provision of inclusive care by genetics providers. To bridge this knowledge gap, we conducted a cross-sectional qualitative study. Nineteen semi-structured interviews were held with gender diverse adults having hereditary cancer syndromes, family histories of such syndromes, or personal histories of chest cancer. Our study employed thematic analysis using combined inductive and deductive methods to illuminate how hereditary cancer care intersects with participants' gender identities, gender expression, and gender-affirming care experiences. Participants reflected on care experiences that felt affirming or triggered gender dysphoria. Participants also discussed the interplay between risk-reducing mastectomy and top surgery, exploring co-emergent dynamics between cancer risk management and gender expression. Significantly, participants identified actionable strategies for healthcare providers to enhance support for gender diverse patients, including the mindful use of gendered language, collaborative decision-making, and conveying allyship. These findings offer valuable insights into tailoring genetic counseling to meet the unique needs of TGD individuals, advancing the path toward inclusive and appropriate care for LGBTQI+ individuals with hereditary cancer syndromes.

Minority stressors, traumatic events, and associations with mental health and school climate among gender and sexuality diverse young people in Australia: Findings from a nationally representative cohort study

INTRODUCTION

Population-level, nationally representative data on the prevalence of minority stressors and traumatic events, mental ill-health effects, and the preventative utility of school climate, among gender and sexuality diverse young people in Australia, is significantly lacking. In this study, we estimated the prevalence and distribution of minority stressors and traumatic events among young people by sexuality identity (gay/lesbian, bisexual, other sexuality, heterosexual), sexuality diversity (sexuality diverse, not sexuality diverse), and gender identity (transgender, cisgender) and assessed associations with mental ill-health and the moderating role of school climate factors.

METHODS

Using Wave 8 (2018) follow-up data from a population-level, nationally representative longitudinal cohort study, the sample comprised 3037 young people aged 17-19 years in Australia. Prevalence ratios for minority stressors and traumatic events were calculated for gender and sexuality diverse categories using logistic regression models. Linear regression models were used to test associations between traumatic events and minority stressors, and mental ill-health. Multivariate linear regression tested school climate factors as effect modifier between minority stressors and mental ill-health among sexuality diverse young people.

RESULTS

Rates of traumatic events and minority stressors were highest among bisexual and gay/lesbian young people and were significantly associated with mental ill-health among all gender and sexuality diverse young people. Highest mental ill-health effects were observed among trans young people. Among sexuality diverse young people, positive and negative feelings toward school climate were associated with decreased and increased mental ill-health, respectively. After accounting for sexuality diversity, positive overall school climate appeared protective of mental ill-health effects of sexuality-based discrimination.

DISCUSSION

Minority stressors, traumatic events, and associated mental ill-health are prevalent among gender and sexuality diverse young people in Australia, especially trans, bisexual, and gay/lesbian young people. Promotion of affirmative, safe, and inclusive school climate demonstrates significant promise for the prevention and early intervention of mental ill-health among gender and sexuality diverse young people.

Masculinizing Chest Reconstruction in Adolescents and Young Adults: An Analysis of National Surgical Quality Improvement Program Data

BACKGROUND

Masculinizing chest reconstruction (MCR) has been shown to improve quality of life and gender dysphoria in transmasculine adult patients. As nationwide access to gender-affirming care expands, more adolescents are seeking MCR. However, there is a paucity of literature examining patient characteristics, safety, and disparities among this population.

METHODS

Cases of MCR were selected from the pediatric and adult American College of Surgeons and National Surgical Quality Improvement Program. Adolescent (18 years and older) and young adult (aged 19-25 years) transgender patients were analyzed for differences in demographics, comorbidities, surgical characteristics, and postoperative complications.

RESULTS

A total of 1287 cases were identified, with an adolescent cohort of 189 patients. The proportion of White patients to other races was greater among adolescents than young adults (91.2% vs 82.4%, P = 0.007). Of adolescents and young adults, 6.0% and 11.1% identified as Hispanic/Latino, respectively (P = 0.059). Rates of all-cause postoperative complications were similar between adolescents (4.2%) and young adults (4.1%). Multivariate binary logistic regression showed that Black or African American patients experienced more all-cause postoperative complications than other races after controlling for American Society of Anesthesiologists classification, age group, and body mass index (odds ratio, 2.8; 95% confidence interval, 1.3-5.9; P = 0.008).

CONCLUSIONS

Masculinizing chest reconstruction is equally safe for transmasculine adolescent and young adult patients. However, our data point to racial disparities in access to care and postoperative outcomes. An intersectional approach is needed to better understand the unique health care needs and barriers to care of minority transgender youth.

Gender Diversity Among Youth Attending an Intensive Interdisciplinary Pain Treatment Program

Transgender and gender diverse (TGD) youth with chronic pain may be at unique risk for psychological distress and associated functional impairment, yet research on the intersection of chronic pain and gender identity is lacking. In a retrospective chart review of 491 participants admitted to a pediatric intensive interdisciplinary pain treatment (IIPT) program in the midwestern United States over an approximately 4-year period, 6.11% were TGD. TGD participants who completed the IIPT program reported significant and large improvements in anxiety, depression, pain catastrophizing, and functional ability. At baseline, TGD participants presented as more emotionally distressed and functionally impaired compared to age-matched, cisgender peers. When accounting for baseline scores, TGD participants who completed the IIPT program reported similar scores to cisgender peers at discharge, yet TGD youth were significantly less likely than cisgender peers to complete the IIPT program. Future directions and implications for clinical practice are discussed.

Transgender and gender diverse youths' experiences of healthcare: A systematic review of qualitative studies

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.

Topical Review: Acute and Chronic Pain Experiences in Transgender and Gender-Diverse Youth

OBJECTIVE

To provide an overview of the existing literature on gender diversity in pediatric acute and chronic pain, propose an ecological systems model of understanding pain in transgender and gender-diverse (TGD) youth, and identify a direction for future work that will address the key knowledge gaps identified.

METHODS

Relevant literature on pain and gender diversity was reviewed, drawing from adult literature where there was insufficient evidence in pediatric populations. Existing relevant models for understanding minority stress, gender and pain, and pain experiences within marginalized groups were considered with the reviewed literature to develop a pain model in TGD youth.

RESULTS

While there is an abundance of literature pointing to increased risk for pain experiences amongst TGD youth, there is comparably little empirical evidence of the rates of pain amongst TGD youth, prevalence of TGD identities in pain care settings, effective pain treatments for TGD youth and unique considerations for their care, and the role intersectional factors in understanding TGD youth identities and pain.

CONCLUSION

Pediatric psychologists are well-positioned to advance the research on acute and chronic pain in TGD youth, make evidence-based adaptations to clinical care for TGD youth with pain, including pain related to gender affirmation, and support colleagues within the medical system to provide more inclusive care.

Knowledge and perceived competence with sexual and gender minority healthcare topics among medical students and medical school faculty

BACKGROUND

Despite changes in social attitudes in the United States over the last decade, sexual and gender minority (SGM) individuals continue to face significant health disparities, driven partly by disproportionately higher rates of self-reported discrimination and harassment when seeking healthcare. Historically, physicians have received little to no required training on how to provide sensitive, competent care to SGM patients, and continue to demonstrate poor competency with SGM topics despite calls for increased education and published guidelines to promote competency. The present study aimed to investigate competency with SGM topics among both faculty and medical students at one institution.

METHODS

The authors distributed an anonymous online survey (2020-2021) to medical students and student-facing faculty at one allopathic medical school in the United States. The objective of the study was to evaluate knowledge, clinical skills, and self-reported competence with SGM topics.

RESULTS

Of survey respondents, 223 medical students and 111 faculty were included in final analysis. On average, medical students were significantly more likely to answer General Knowledge questions correctly (97.2%) compared to faculty (89.9%). There were no significant differences in responses to Clinical Knowledge questions between medical students and faculty. however medical students were significantly more likely to report competence with eliciting a thorough sexual history, and faculty were significantly more likely to report receiving adequate clinical training and supervision to work with lesbian, gay, and bisexual patients.

CONCLUSIONS

Medical students demonstrated significantly higher general knowledge about SGM topics compared to faculty. Medical students and faculty demonstrated similarly low average clinical knowledge, with percent correct 65.6% for students and 62.7% for faculty. Despite significant differences in general knowledge and low clinical knowledge, medical students and faculty self-reported similar levels of competence with these topics. This indicates insufficient curricular preparation to achieve the AAMC competencies necessary to care for SGM patients.

Demographic factors associated with healthcare avoidance and delay in the transgender population: Findings from a systematic review

Purpose

Healthcare avoidance and delay (HAD) in the transgender population has been well documented, and research has explored a range of associated factors that help to identify those most at risk of HAD. This review addresses a gap in the research by synthesizing research exploring associations between HAD and demographic factors.

Methods

A systematic search of literature published at any time up to December 2021 was conducted, using five databases (EBSCO, EMBASE, PubMed, Scopus, and Web of Science) and manually searching reference lists of included studies. After exclusion of duplicates, 608 unique records were subjected to double screening. Papers reporting statistical analyses of HAD in association with any sociodemographic variables were included in this review. Papers consisted of nineteen cross-sectional studies. Narrative synthesis was used to address findings.

Results

Nineteen studies met inclusion criteria, exploring HAD in association with a wide range of demographic factors, including sex and gender, social transition factors, age, race and ethnicity, socioeconomic factors, veteran status, education, sexuality, relationship status, citizenship, place of residence, and state demographics. Findings identified intra-community demographic risk factors, with consistent evidence for increased HAD among transmasculine, and younger, participants. Lower income and higher educational attainment were also associated with increased HAD, while remaining areas had weak or little evidence for association with HAD.

Conclusion

This review expands knowledge in this area by highlighting demographic factors associated with increased HAD in research literature, and exploring how these may be further investigated to address substantial gaps in the body of research.

Supporting the Mental Health of Transgender and Gender-Diverse Youth

Increasing numbers of youth are identifying as transgender or gender diverse (TGD), meaning their gender identity or expression do not conform to culturally defined expectations for their designated sex at birth. The mental health needs of TGD youth are diverse, and to effectively address these needs requires knowledgeable general pediatric providers, who often are families' first resource for education and support around gender diversity. To help general pediatric providers work more effectively with TGD youth, we describe the role of mental health providers working with TGD youth and how best to support TGD youth's access to gender-affirming mental health and medical interventions. [Pediatr Ann. 2023;52(12):e456-e461.].

Gender identity and expression in relation to depression and anxiety in racial and ethnic minority youth: Evaluations of intersectionality in a population-based study

INTRODUCTION

Transgender and gender non-conforming (TGNC) youth experience higher rates of depression and anxiety. Risk for these outcomes in racial and ethnic minority populations remains unclear. This study aimed to examine disparities in depression and anxiety at the intersection of race and ethnicity and TGNC status in a population-based sample.

METHODS

Data were from the 2019 Minnesota Student Survey. Students (n = 119,648) completed questions about their race, ethnicity, gender identity and expression, depression, and anxiety.

RESULTS

Within racial and ethnic groups, TGNC youth generally had greater risk for depression and anxiety. Significant associations for gender minority identity ranged from ORDepression = 2.25 for Black youth who do not identify as male to ORDepression = 5.08 for non-minority ethnicity youth who do not identify as female. For perceived gender expression in cisgender youth, significant associations ranged from ORDepression = 1.17 for Black youth assigned female at birth and ORAnxiety = 1.17 for other-minority ethnicity youth assigned female at birth to ORDepression = 1.46 for non-minority ethnicity youth assigned female at birth and ORAnxiety = 1.46 for American Indian/Alaskan Native youth assigned male at birth. Within-TGNC-youth comparisons yielded a few racial/ethnic differences relative to White peers. Significant differences ranged from ORAnxiety = 0.53 to ORAnxiety = 1.41 for cisgender females.

LIMITATIONS

The cross-sectional data limits our ability to test causation.

CONCLUSIONS

Multiple-minority youth were not universally at increased risk for depression and anxiety, indicating an intersectional framework is important for understanding risk for these outcomes in TGNC youth. Future research identifying potential risk and protective factors is needed to advance screening and treatment strategies for multiple-minority TGNC youth populations.

"Bridging the Gap": School Nurse Experiences Providing Care for Transgender and Gender Diverse Students and Their Parents/Guardians

School systems are often not set up to support transgender and gender diverse (TGD) students, which results in unsafe and unsupportive environments and other institutional barriers to helping TGD students thrive. An important factor to students' feeling safe and supported in schools may be their relationship with school nurses. The purpose of this study was to describe school nurses' experiences working with TGD students and their parents/guardians, their role in working with this community, and the challenges nurses face when trying to serve TGD students. Semistructured interviews were conducted with 23 school nurses across a Midwestern state. Thematic analysis was used to identify themes: gender-affirming education and interpersonal collaboration, bridging the gap between TGD youth and parents/guardians, gender-affirming care and confidentiality, and navigating parental acceptance and gender-affirmation. School nurses expressed a strong desire to support TGD students but lack the structure and training within schools.

Supporting Transgender Youth Across Psychosocial Systems

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.

Puberty Suppression Followed by Testosterone Therapy Does Not Impair Reproductive Potential in Female Mice

More adolescents are coming out as transgender each year and are put on puberty blockers to suppress natal puberty, which is then followed by cross-hormone treatment to achieve puberty of the desired gender. Studies to examine the effects of puberty suppression and virilizing therapy on future reproductive potential among transgender males are lacking. This study used a translational murine in vitro fertilization model to examine the effects of female puberty suppression with depot leuprolide acetate (LA), followed by virilizing therapy with testosterone cypionate (T), on embryologic and pregnancy outcomes. LA effectively inhibited puberty when mice were treated beginning at 3 weeks of age. LA treatment was associated with higher mouse weight but lower ovarian weight. LA-treated mice ovulated developmentally competent eggs in response to gonadotropin administration, albeit at a higher dose than controls. Ovaries from mice treated with LA and T produced oocytes that had morphologically normal meiotic spindles after in vitro maturation and responded to gonadotropin stimulation. Eggs from mice treated with LA and T were fertilizable and produced developmentally competent embryos that led to births of fertile pups. These results suggest that fertility may not be impaired after puberty suppression and cross-hormone therapy for transgender males.

Evidence-based sexual healthcare for the LGBTQIA2+ patient across the lifespan

ABSTRACT

People who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, two-spirit, or other minority sexual and gender identities (LGBTQIA2+) often avoid seeking healthcare due to social discrimination and stigma. Clinical education in LGBTQIA2+-affirming care is essential but often lacking across disciplines. Provider acceptance, awareness of personal biases, and understanding of microaggressions affecting LGBTQIA2+ people can improve access, outcomes, and survival for this population. Expertise in caring for LGBTQIA2+ people in rural and suburban communities, for people who are transgender, and for people who have undergone or are in the process of undergoing gender-affirming surgeries is essential to offer best-practice healthcare.

Exploring the Impact of Legislation Aiming to Ban Gender-Affirming Care on Pediatric Endocrine Providers: A Mixed-Methods Analysis

Context

Access to gender-affirming medical care is associated with better mental health outcomes in transgender and gender diverse youth. In 2021 and 2022, legislation aiming to ban gender-affirming medical care for youth was proposed in 24 states.

Objective

This study aimed to (1) assess the impact of this legislation on pediatric providers based on legislative status of their state of practice and (2) identify the themes of concerns reported by them.

Methods

A mixed-methods study was conducted via an anonymous survey distributed to pediatric endocrinology providers. Survey responses were stratified based on US state of practice, with attention to whether legislation aiming to ban gender-affirming care had been considered. Data were analyzed both quantitatively and qualitatively.

Results

Of 223 respondents, 125 (56.0%) were currently providing gender-affirming medical care. A total of 103 (45.7%) respondents practiced in a state where legislation aiming to ban gender-affirming care had been proposed and/or passed between January 2021 to June 2022. Practicing in legislation-affected states was associated with negative experiences for providers including (1) institutional pressure that would limit the ability to provide care, (2) threats to personal safety, (3) concerns about legal action being taken against them, (4) concerns about their career, and (5) institutional concerns about engagement with media. Major qualitative themes emerging for providers in legislation-affected states included safety concerns and the impact of laws on medical practice.

Conclusion

This study suggests that legislation aiming to ban health care for transgender youth may decrease access to qualified providers in affected states.

Adolescent Perspectives on the Use of Telemedicine for Confidential Health Care: An Exploratory Mixed-Methods Study

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.

State-Level Policies and Health Outcomes in U.S. Transgender Adolescents: Findings from the 2019 Youth Risk Behavior Survey

Purpose: Policies have been shown to bear a considerable influence on transgender health. The few studies that have examined policy-related health outcomes in adolescent transgender populations have rarely included policies that directly affect them. Our study explores associations between four state-level policies and six health outcomes in a sample of transgender adolescents. Methods: Our analytic sample consisted of adolescents residing in 14 states that used the 2019 Youth Risk Behavior Survey's optional gender identity question in their surveys (n = 107,558). Chi-square analyses were performed to examine differences between transgender and cisgender adolescents in demographic variables and suicidal ideation, depression status, cigarette use, binge drinking, grades in school, and perceptions of school safety. Multivariable logistic regression models were run for transgender adolescents only to examine associations between policies and health outcomes, adjusting for demographics. Results: Transgender adolescents comprised 1.7% (n = 1790) of our sample. Compared with cisgender adolescents, transgender adolescents were more likely to experience adverse health outcomes in chi-square analyses. Multivariable models indicated that transgender adolescents who lived in a state that had explicit transgender guidance in their antidiscrimination laws were less likely to experience depressive symptoms, and those who lived in a state with positive or neutral athlete guidance were less likely to report past 30-day cigarette use. Conclusion: Our study is one of the first to show protective associations between affirming transgender-specific policies and health outcomes in transgender adolescents. Findings could have important implications for policymakers and school administrators.

Achieving Health Equity for Sexual and Gender-Diverse Youth

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.

Barriers Pediatric PCP's Identify To Providing Gender-Affirming Care For Adolescents

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.

Differences in Health Care Experiences among Transgender and Gender Diverse Youth by Gender Identity and Race/Ethnicity

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.

A self-guided curriculum on endocrinology standard of care for gender diverse youth, including ethical considerations

Objective

While the field of pediatric endocrinology, and the American Board of Pediatrics, continues expanding training to include gender-affirming care, many pediatric endocrinology fellowship programs do not have formal curriculum for this patient population. Members of the Pediatric Endocrine Society (PES) that have a special interest in transgender health designed a curriculum based on Endocrine Society practice guidelines to expand the knowledge of gender affirming care for medical trainees' and faculty.

Methods

PES members designed a 5-part self-guided educational module series with embedded knowledge questions. Uniquely, medical ethical reflections were included within each module. Participants completed baseline demographic and baseline and follow-up knowledge surveys.

Results

Most participants were pediatric endocrinology fellows and 44 % percent (n = 21) completed all study components, including the follow up knowledge survey. Knowledge question data analysis demonstrated knowledge gained in medical management of pubertal youth and surgical interventions.

Conclusion

This is the first medical education curriculum in gender-affirming care created by pediatric endocrinologists grounded in the Endocrine Society practice guidelines. This study demonstrates medical knowledge gained in caring for gender diverse youth and is the first to incorporate ethical considerations for this patient population. While initially designed for pediatric endocrinology trainees and faculty, this curriculum may be of great utility for any provider interested in caring for gender diverse youth.

Efficacy of the Outsmart HPV Intervention: A Randomized Controlled Trial to Increase HPV Vaccination among Young Gay, Bisexual, and Other Men Who Have Sex with Men

BACKGROUND

Routine human papillomavirus (HPV) vaccination is recommended for young adults, yet many young gay, bisexual, and other men who have sex with men (YGBMSM) remain unvaccinated. We report the efficacy of Outsmart HPV, a web-based HPV vaccination intervention for YGBMSM.

METHODS

From 2019 to 2021, we recruited YGBMSM in the United States who were ages 18-25 and unvaccinated against HPV (n = 1,227). Participants were randomized to receive either: (i) Outsmart HPV content online and monthly interactive text reminders (interactive group); (ii) Outsmart HPV content online and monthly unidirectional text reminders (unidirectional group); or (iii) standard information online about HPV vaccine (control group). Regression models compared study groups on HPV vaccination outcomes.

RESULTS

Overall, 33% of participants reported initiating the HPV vaccine series and 7% reported series completion. Initiation was more common among participants in the interactive group compared with the control group [odds ratio (OR) = 1.47, 98.3% confidence interval (CI): 1.03-2.11]. Completion was more common among participants in both the interactive group (OR = 3.70, 98.3% CI: 1.75-7.83) and unidirectional group (OR = 2.26, 98.3% CI: 1.02-5.00) compared with the control group. Participants who received Outsmart HPV content reported higher levels of satisfaction with online content compared with the control group.

CONCLUSIONS

Outsmart HPV is an efficacious and acceptable HPV vaccination intervention for YGBMSM. Future efforts are needed to determine how to optimize the intervention and disseminate it to settings that provide services to YGBMSM.

IMPACT

Outsmart HPV is a promising tool for increasing HPV vaccination among YGBMSM with the potential for wide dissemination.

Reproductive endocrinologist and infertility specialists' knowledge, skills, behaviors, and attitudes regarding the care for transgender and gender-diverse individuals

Objective

To investigate associations between reproductive endocrinology and infertility (REI) providers' prior training and current knowledge, skills, attitudes, and behaviors regarding fertility preservation and family building for transgender and gender-diverse (T/GD) patients.

Design

The survey was distributed to members of the Society for Reproductive Endocrinology and Infertility, the REI-physician-focused professional body within the American Society for Reproductive Medicine, with additional participants recruited through snowball sampling.

Results

Participants (n = 206) reported on training in T/GD care; 51% endorsed prior training. Most participants (93%) believed T/GD individuals were as fit for parenthood as cisgender individuals. Prior training was associated with an increased likelihood of offering T/GD health resources and more frequent consultations with specialist colleagues.Common barriers to providing care indicated by respondents included cost, delays in gender-affirming care, and lack of knowledge of the potential impact of hormonal interventions. Common facilitators included education and training, prior experience, and affordability of services.

Conclusions

Most REI providers believed T/GD individuals are fit for parenthood and agreed that prior training facilitates care for T/GD patients. The lack of provider knowledge emerged as a barrier to care. Although training helped facilitate some components of care, systemic barriers such as the cost and variability of patient population characteristics/experiences are important considerations when serving T/GD individuals.

Telemedicine Utilization Among Transgender and Gender-Diverse Adolescents Before and After the COVID-19 Pandemic

Introduction: Little is known about how expansion of telemedicine services during the COVID-19 pandemic has affected access to gender-affirming care for transgender and gender-diverse (TGD) youth. The purpose of this study was to explore differences in demographic characteristics and visit completion rates at a multidisciplinary gender clinic before and after telemedicine implementation in March 2020 and among telemedicine users and nonusers. Methods: Data were from electronic health records of Seattle Children's Gender Clinic (SCGC) patients seen between April 2019 and February 2021. We assessed differences in demographic characteristics and care utilization (i.e., encounter type and status) between April 2019 and February 2020 (pre-telemedicine) and April 2020 and February 2021 (post-telemedicine). Results: Of the 1,051 unique patients seen at SCGC during this time period, majority groups were as follows: 62% identified as transmasculine/male, 68% were non-Hispanic White, and 76% resided within 50 miles of the clinic. Statistically significant differences were observed in patient pronouns and insurance type when comparing the pre- and post-telemedicine periods (p < 0.01). Half (52%) of post-telemedicine period encounters were conducted through telemedicine, and telemedicine encounters were significantly more likely to be completed (72% vs. 50%) and less likely to be canceled (21% vs. 46%) compared with in-person encounters. Conclusions: Telemedicine services facilitated continued access to gender-affirming care services for TGD youth during the COVID-19 pandemic. Although the introduction of telemedicine did not exacerbate demographic disparities in access to this care, further research and interventions are warranted to address the ongoing disparities in access to gender-affirming care for youth of color and rural youth.

Outcomes Research on Telemedicine-Delivered Gender-Affirming Health Care for Transgender Youth Is Needed Now: A Call to Action

This article is a call to action for outcomes research on telemedicine-delivered gender-affirming health care (GAH) for transgender youth. Transgender youth, especially rural youth, are severely underserved and face many obstacles to GAH. Telemedicine reduces access barriers for underserved populations, but telemedicine for this population can be complex. Our literature search identified only five studies exploring the use of telemedicine for GAH for transgender youth. Coronavirus disease 2019 (COVID-19)-related regulatory and reimbursement changes for telemedicine may have increased transgender youths' access to such care. Research is urgently needed to increase understanding regarding access, satisfaction, safety, and health-related outcomes of telemedicine-delivered GAH for transgender youth.

Gender-Affirming Care of Transgender and Gender-Diverse Youth: Current Concepts

Increasing numbers of transgender and gender-diverse (TGD) youth, from early puberty through late adolescence, are seeking medical services to bring their physical sex characteristics into alignment with their gender identity-their inner sense of self as male or female or elsewhere on the gender spectrum. Numerous studies, primarily of short- and medium-term duration (up to 6 years), demonstrate the clearly beneficial-even lifesaving-mental health impact of gender-affirming medical care in TGD youth. However, there are significant gaps in knowledge and challenges to such care. Long-term safety and efficacy studies are needed to optimize medical care for TGD youth.

Psychosocial Functioning in Transgender Youth after 2 Years of Hormones

BACKGROUND

Limited prospective outcome data exist regarding transgender and nonbinary youth receiving gender-affirming hormones (GAH; testosterone or estradiol).

METHODS

We characterized the longitudinal course of psychosocial functioning during the 2 years after GAH initiation in a prospective cohort of transgender and nonbinary youth in the United States. Participants were enrolled in a four-site prospective, observational study of physical and psychosocial outcomes. Participants completed the Transgender Congruence Scale, the Beck Depression Inventory-II, the Revised Children's Manifest Anxiety Scale (Second Edition), and the Positive Affect and Life Satisfaction measures from the NIH (National Institutes of Health) Toolbox Emotion Battery at baseline and at 6, 12, 18, and 24 months after GAH initiation. We used latent growth curve modeling to examine individual trajectories of appearance congruence, depression, anxiety, positive affect, and life satisfaction over a period of 2 years. We also examined how initial levels of and rates of change in appearance congruence correlated with those of each psychosocial outcome.

RESULTS

A total of 315 transgender and nonbinary participants 12 to 20 years of age (mean [±SD], 16±1.9) were enrolled in the study. A total of 190 participants (60.3%) were transmasculine (i.e., persons designated female at birth who identify along the masculine spectrum), 185 (58.7%) were non-Latinx or non-Latine White, and 25 (7.9%) had received previous pubertal suppression treatment. During the study period, appearance congruence, positive affect, and life satisfaction increased, and depression and anxiety symptoms decreased. Increases in appearance congruence were associated with concurrent increases in positive affect and life satisfaction and decreases in depression and anxiety symptoms. The most common adverse event was suicidal ideation (in 11 participants [3.5%]); death by suicide occurred in 2 participants.

CONCLUSIONS

In this 2-year study involving transgender and nonbinary youth, GAH improved appearance congruence and psychosocial functioning. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.).

Greater gender diversity among autistic children by self-report and parent-report

LAY ABSTRACT

Gender diversity broadly refers to the way in which an individual experiences (expressions and/or identities) their gender distinctly to that which would be expected based upon social norms for their gender assigned at birth. Recent research has shown a higher representation of gender diversity among autistic youth. Previous research in this area has relied on parent-report based on a single question from the Child Behavior Checklist Item-110, asking whether their child "Wishes to be the opposite sex." The Gender Diversity Screening Questionnaire Self-Report and Parent-Report were used to assess the experience of gender diversity in 244 children (140 autism spectrum disorder and 104 typically developing) between 10 and 13 years. The Item-110 was also collected. Results showed that autistic children endorsed much higher rates of Binary Gender Diversity (less identification with their designated sex and more with the other binary sex) and Nonbinary Gender Diversity (identification as neither male nor female) than typically developing children. Similarly, parents of autistic children reported significantly more gender-body incongruence experienced by their child than parents of typically developing children. Specifically, parents of autistic females-assigned-at-birth reported significantly more gender-body incongruence than autistic males-assigned-at-birth. Parent- and self-report measures were largely related. Moreover, statistical comparisons between and within the groups revealed associations between gender profiles and symptoms of anxiety, depression, and suicidality. Results extend previous reports showing increased rates of gender diversity in autistic children, now based on both self-report and parent-report, and highlight the need to better understand and support the unique and complex needs of autistic children who experience gender diversity.

Understanding access to healthcare for gender diverse young people: a critical review of the literature

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.

Gender Dysphoria: Optimizing Healthcare for Transgender and Gender Diverse Youth with a Multidisciplinary Approach

Transgender and gender diverse (TGD) youth and their families are seeking medical and mental health care at increasing rates. As the number of multidisciplinary pediatric gender programs expands, we consider the history and evidence base for gender affirmative care and highlight existing models of care that can flexibly accommodate the diverse needs of TGD youth and their families. Comprehensive multidisciplinary care includes both medical and mental health providers who work collaboratively with TGD youth and their caregivers to assess gender-related support needs and facilitate access to developmentally appropriate medical and mental health interventions. In addition to direct health-care services, multidisciplinary care for TGD youth and their families extends into community training, education, community outreach, nonmedical programming, and advocacy for TGD youth.

Sports Medicine Physicians Comfort and Competence in Caring for Transgender and Gender Nonconforming Patients and Athletes

OBJECTIVE

The purpose of this study was to explore primary care sports medicine physicians' comfort, competence, education, and scope of training in caring for transgender and gender nonconforming (TGNC) patients/athletes.

DESIGN

Mixed-methods, cross-sectional survey.

SETTING

Online.

PATIENTS OR PARTICIPANTS

In total, 4300 e-mails were successfully sent with 252 eligible responses received from the American Medical Society for Sports Medicine members.

INDEPENDENT VARIABLES

Previous relationships with TGNC persons; previous relationships with TGNC patients/athletes; frequency of care for TGNC patients/athletes.

MAIN OUTCOME MEASURES

The participants completed a 38-item tool used to assess perceived comfort and competence treating TGNC patients/athletes. Physicians defined "transgender" and described their thoughts on unfair competitive advantage of transgender athletes.

RESULTS

Most participants had worked with a TGNC patient (70.2%, n = 177), but far fewer worked with a TGNC athlete (n = 26.6%, n = 67). Among the participants who provided a definition of transgender (n = 183), only 28.4% (n = 52) of participants were able to correctly define the term, whereas most were able to partially (57.9%, n = 106) characterize the term. The most common mechanisms identified for learning about TGNC patients were reading peer-reviewed journal articles (44.8%, n = 113) and CME (41.3%, n = 104). Those with previous TGNC friend/family, patient, and athlete relationships had a significantly different level of comfort and competence treating TGNC patients/athletes.

CONCLUSIONS

Previous care relationships with TGNC strongly influences comfort and perceived competence of primary care sports medicine physicians. Training, from unbiased peer-reviewed sources of data, is critical to improve care for TGNC patients/athletes.

Health and service utilization among a sample of gender-diverse youth of color: the TRUTH study

BACKGROUND

While there is growing research considering the experiences of transgender youth whose identities align with the gender binary, especially among young trans women, there are significantly fewer studies that accurately capture data about nonbinary youth, and even fewer studies capturing the experiences of transgender and gender diverse (TGD) youth of color. The purpose of this research was to assess the prevalence of sexual health behaviors, mental health challenges, substance use, and healthcare utilization among Black/African American, Latinx, Asian/Pacific Islander, indigenous and multi-racial/ethnic TGD youth, who have been largely underrepresented in research.

METHODS

A total of 108 TGD youth ages 16-24 were recruited into the Trans Youth of Color Study (TRUTH). Each participant completed a 90-min survey administered by a research assistant with more sensitive information collected using ACASI. In addition to a completing a survey administered by research staff, participants also participated in specimen collection, which included urine sampling to assess recent substance use without a prescription, self-collected rectal/frontal and throat swabs to test for gonorrhea and chlamydia, and a blood draw to test for recent use of drugs, gonorrhea and chlamydia, and syphilis. The sample was recruited at public venues, community outreach and referral, through social media outreach, and via participant referral. Cross-sectional analyses were from a single study visit.

RESULTS

Compared to rates among their cisgender peers, participants reported experiencing adverse social and structural determinants of health-e.g. food insecurity (61%), housing instability (30%), and limited access to healthcare (26% had no place to go for healthcare)-and elevated rates of illicit drug use (19-85%), mental health problems (e.g. 60% self-reported depression), and involvement in sexual risk-related behaviors (e.g. among those reporting penetrative sex 57-67% reported sex without a condom).

CONCLUSIONS

This study adds descriptions of both mental and sexual health outcomes of a non-clinical sample of TGD youth to the literature, particularly among young transgender men and gender nonbinary youth, who have frequently been excluded from previous studies of sexual health. The findings document experiences and behaviors among TGD youth that contribute to mental and sexual health concerns, including rates of substance use, and healthcare utilization.

Geographic Distribution of Clinical Care for Transgender and Gender-Diverse Youth

OBJECTIVES

Geographic barriers limit access to clinical care in the United States for transgender and gender-diverse (TGD) youth. Some factors differentiating access to care are variability in state laws/policies, the number of available clinical care programs and mental health providers for TGD youth.

METHODS

We aggregated data from the Human Rights Campaign for pediatric clinical care programs for TGD youth, the Movement Advancement Project for state-by-state assessment of gender identity laws and policies, and Psychology Today for mental health providers for TGD youth by state. Current prevalence rates for TGD youth were applied by state with 2020 Census data. Findings were summarized as a whole and per capita by state, region, and country overall.

RESULTS

The South has the highest number of TGD youth per clinic (36 465-186 377), and the lowest average equality score in gender identity laws and policies (1.96). The Midwest has the highest number of TGD youth per mental health provider (278-1422). The Northeast has the lowest number of TGD youth per clinic (11 094-56 703), the highest average equality score in laws and policies per state (17.75), and the highest average number of TGD youth per mental health providers (87-444).

CONCLUSIONS

Findings support there are barriers to TGD youth care throughout the United States, especially the South and Midwest. Increasing medical and mental health care for TGD youth is likely to improve their health and well-being. Enacting gender identity protective laws/policies would allow for equal treatment and access to care among TGD youth.

Syndemic relationship of depressive symptoms, substance use, and suicidality in transgender youth: a cross-sectional study using the U.S. youth risk behavior surveillance system

PURPOSE

Syndemics are co-occurring epidemics that cluster within populations due to shared socio-structural factors and are often in populations with intersecting forms of vulnerability. Suicide, depression, and substance use all disproportionately affect transgender and gender diverse (TGD) youth. In this study, we test a syndemic model of the relationship between these three mental health conditions in the context of economic deprivation and interpersonal discrimination.

METHODS

We used data on substance use, depressive symptoms, suicidality, and social-structural factors from 2680 TGD youth captured in the 2017 and 2019 survey waves of the Youth Risk Behavior Surveillance System. We used a latent class analysis (LCA) to identify groups with distinct patterns of self-reported substance use and depressive symptoms, and regression models to characterize the relationship between substance-use, depressive symptoms, class membership, social-structural factors, and suicidality.

RESULTS

A three-class LCA solution identified a subset of student respondents in a "high use" latent class characterized by high self-reported substance use frequency and depressive symptoms compared with other classes. Online bullying (aOR: 1.58; 95% CI: 1.28-1.95) and housing insecurity (aOR: 8.78; 95% CI: 4.35-17.71) were associated with increased odds of "high use" class membership relative to the "no use" class membership. "High use" class membership was associated with increased odds of suicidal ideation (aOR: 2.26; 95% CI: 1.75-2.94), plans (aOR: 2.59; 95% CI: 2.01-3.36), and attempts (aOR: 6.85; 95% CI: 3.17-15.68).

CONCLUSION

The co-occurrence of substance use and depressive symptoms is associated with socio-structural factors and may drive risk for suicidality among TGD youth. Meaningful suicide prevention efforts that address disproportionate risk in this population must be attentive to and mitigate the shared determinants of mood symptoms and substance use behavior.

Gender identity and transition: relationships with sleep disorders in US youth

STUDY OBJECTIVES

Transgender or gender-nonconforming (TGNC) identity is associated with higher burden of sleep disorders relative to cisgender identity. However, the role of gender-affirming therapy (GAT) in sleep disorders is poorly understood. This study examined relationships between TGNC identity, transition, and sleep disorders among TGNC and cisgender youth.

METHODS

This retrospective cross-sectional study utilized a large US-based administrative claims database (deidentified Optum Clinformatics Data Mart Database) to identify youth aged 12-25 years who obtained a diagnosis of TGNC identity and those who pursued GAT. Descriptive statistics estimated distributions of demographic and health characteristics by gender identity. Unadjusted and age-adjusted logistic regression models were used to examine associations between TGNC identity, GAT, and sleep disorders.

RESULTS

This study included 1,216,044 youth, of which 2,603 (0.2%) were identified as TGNC. Among the 1,387 TGNC who pursued GAT, 868 and 519 were identified as transmasculine and transfeminine, respectively. Adjusted analysis showed increased odds of insomnia (odds ratio = 5.4, 95% confidence interval 4.7, 6.2), sleep apnea (odds ratio = 3.0, 95% confidence interval 2.3, 4.0), and other sleep disorders (odds ratio = 3.1, 95% confidence interval 2.5, 3.9) in TGNC relative to cisgender youth. Decreased odds of any sleep disorder were observed in the TGNC youth on GAT (odds ratio = 0.5, 95% confidence interval 0.4, 0.7) relative to those not on GAT.

CONCLUSIONS

This study demonstrated a high burden of sleep disorders in TGNC youth in comparison to cisgender. However, GAT may confer a protective effect on sleep disorders among TGNC youth. Longitudinal assessments of sleep disorders prior to and post-GAT are needed to uncover their temporal relationships.

CITATION

Gavidia R, Whitney DG, Hershner S, Selkie EM, Tauman R, Dunietz GL. Gender identity and transition: relationships with sleep disorders in US youth. J Clin Sleep Med. 2022;18(11):2553-2559.

Review of Health Insurance Policy Inclusivity of Gender Nonconforming and Nonbinary Individuals Seeking Gender-Affirming Health Care

Background

An increasing number of individuals who present to health care professionals identify as transgender, gender nonconforming (GNC), and gender nonbinary (NB). GNC/NB individuals experience higher rates of discrimination in health care settings compared with their binary (e.g., trans male and trans female) counterparts. Outdated language excludes the nuances of gender identity. The goal of this study was to evaluate whether current terminology found in health insurance policies may be a barrier to gender-affirming health care for GNC/NB individuals.

Methods

Health insurance policies for a diverse subset of government (n=4) and private (n=6) payers were obtained in May 2020. Policies were reviewed independently by two members of the research team to determine whether each was supportive or unsupportive to GNC/NB individuals. An arbitrary scoring system was designed that allowed the reviewers to assign a specific number of points to each policy based on the aggregation of mention, coverage, and inclusivity.

Results

Most policies performed poorly as indicated by a support score less than zero. It was also noted that most policies used binary, gendered language, and terminology that excludes the unique gender identities of many GNC/NB individuals.

Conclusions

Most policies currently failed to provide clear, inclusive coverage to GNC/NB individuals for relevant and important aspects of their care. In their current state, these policies are a source of confusion, uncertainty, and discouragement for these individuals, which can present as a barrier to accessing quality, inclusive, gender-affirming health care.

Lesbian, gay, bisexual, transgender and gender diverse and queer (LGBTQ) community members' perspectives on palliative care in New South Wales (NSW), Australia

Lesbian, gay, bisexual, transgender and gender diverse people, and queer people (LGBTQ people) are at increased risk of some chronic diseases and cancers. NSW Health palliative care health policy prioritises equitable access to quality care, however, little is known about community members' perspectives on palliative care. This study aimed to understand LGBTQ community views and preferences in palliative care in NSW. A community survey and follow-up interviews with LGBTQ people in NSW were conducted in mid-2020. A total of 419 people responded to the survey, with 222 completing it. Six semi-structured phone interviews were conducted with participants who volunteered for follow-up. The sample included LGBTQ people with varied levels of experience in palliative care. Thematic analysis was conducted on survey and interview data, to identify perceived barriers and enablers, and situate these factors in the socio-ecological model of health. Some perceived barriers from community members related to considering whether to be 'out' (i.e., making one's sexual orientation and gender known to services), knowledge and attitudes of staff, concern about potential substandard care or mistreatment (particularly for transgender health), decision making, biological family as a source of tension, and loneliness and isolation. Perceived enablers related to developing and distributing inclusive palliative care information, engaging with community(ies), fostering inclusive and non-discriminatory service delivery, ensuring respectful approaches to person-centred care, and staff training on and awareness building of LGBTQ needs and issues. Most of the participants who had experienced palliative care recounted positive interactions, however, we identified that LGBTQ people require better access to knowledgeable and supportive services. Palliative care information should be inclusive and services respectful and welcoming. Particular consideration should be given to how services respond to and engage with people from diverse population groups. These insights can support ongoing policy and service development activities to further enhance palliative care.

Concepts and issues related to adolescent health in nursing education

OBJECTIVE

analyze the structure of teaching programs and contents of the adolescent health and its development in nursing education.

METHOD

descriptive observational study conducted in Colombia, Ecuador and Peru. Data was collected by the Instrument for (self-)evaluation of the adolescent health and development component in undergraduate nursing programs, and investigated using descriptive statistics.

RESULTS

A total of 95 nursing schools participated in the study (84.1% of the total). Of the faculty responsible for teaching contents relating to adolescent health, 31.6% had no specific training on the topic and 18.9% had no educational/pedagogical training. Behavior, gender identity and sexual orientation, bullying and cyberbullying, use of digital technologies, partner violence, parenting, and pubertal delay were the main topics which could be incorporated into nursing education.

CONCLUSION

the faculty of the schools analyzed have limited education in pedagogical/educational topics and specific adolescent health issues. Curricula should be updated, including knowledge of laws and policies, thus expanding nurses' ability to generate, analyze and use data for decision making.

(1) 31.6% of faculty have no specific education in adolescent health. (2) 18.9% of faculty have no educational/pedagogical training. (3) Progress is needed in the use of active methodologies and interactive multimedia. (4) Knowledge of laws and policies for the adolescent population must be expanded. (5) Current and relevant adolescent health issues need to be addressed in nursing education.