Healthcare Experiences of Gender Diverse Youth Across Clinical Settings

Pubertal Suppression in Early Puberty Followed by Testosterone Mildly Increases Final Height in Transmasculine Youth

Context

Treatment for transmasculine youth (TMY) can involve testosterone treatment and is sometimes preceded by gonadotropin-releasing hormone agonist (GnRHa) treatment for puberty blockade. GnRHas can increase final height in birth-assigned females with central precocious puberty. Maximizing final adult height (FAH) is an important outcome for many TMY.

Objective

Our objective was to determine how GnRHa treatment before testosterone impacts FAH.

Methods

Retrospective cohort study at 5 US transgender health clinics. Participants were 32 TMY treated with GnRHas in early to midpuberty before testosterone (GnRHa + T group) and 62 late/postpubertal TMY treated with testosterone only (T-only group).

Results

The difference between FAH minus midparental target height (MPTH) was +2.3 ± 5.7 cm and -2.2 ± 5.6 cm in the GnRHa + T and T-only groups, respectively (P < .01). In the GnRHa + T group, FAH was 1.8 ± 3.4 cm greater than predicted adult height (PAH) (P < .05) and FAH vs initial height (IH) z-score was 0.5 ± 1.2 vs 0.16 ± 1.0 (P < .05). After adjusting for patient characteristics, each additional month of GnRHa monotherapy increased FAH by 0.59 cm (95% CI 0.31, 0.9 cm), stage 3 breast development at start of GnRHa was associated with 6.5 cm lower FAH compared with stage 2 (95% CI -10.43, -2.55), and FAH was 7.95 cm greater in the GnRHa + T group than in T-only group (95% CI -10.85, -5.06).

Conclusion

Treatment with GnRHa in TMY in early puberty before testosterone increases FAH compared with MPTH, PAH, IH, and TMY who only received testosterone in late/postpuberty. TMY considering GnRHas should be counseled that GnRHas may mildly increase their FAH if started early.

Demographic Differences in Gender Dysphoria Diagnosis and Access to Gender-Affirming Care Among Adolescents

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.

Mental Health of Youth With Autism Spectrum Disorder and Gender Dysphoria

BACKGROUND AND OBJECTIVES

Youth with either autism spectrum disorder (ASD) or gender dysphoria (GD) alone have also been shown to be at greater risk for mental health (MH) concerns; however, very little research has considered how cooccurring ASD and GD may exacerbate MH concerns. The purpose of this study was to examine associations between ASD, GD, and MH diagnoses (anxiety, depression, eating disorder, suicidality, and self-harm) among US adolescent populations.

METHODS

This is a secondary analysis of a large administrative dataset formed by 8 pediatric health system members of the PEDSnet learning health system network. Analyses included descriptive statistics and adjusted mixed logistic regression models testing for associations between combinations of ASD and GD diagnoses and MH diagnoses as recorded in the patient's electronic medical record.

RESULTS

Based on data from 919 898 patients aged 9 to 18 years, adjusted mixed logistic regression indicated significantly greater odds of each MH diagnosis among those with ASD alone, GD alone, and cooccurring ASD/GD diagnoses compared with those with neither diagnosis. Youth with cooccurring ASD/GD were at significantly greater risk of also having anxiety (average predicted probability, 0.75; 95% confidence interval, 0.68-0.81) or depression diagnoses (average predicted probability, 0.33; 95% confidence interval, 0.24-0.43) compared with youth with ASD alone, GD alone, or neither diagnosis.

CONCLUSIONS

Youth with cooccurring ASD/GD are more likely to also be diagnosed with MH concerns, particularly anxiety and depression. This study highlights the need to implement developmentally appropriate, gender-affirming MH services and interventions for youth with cooccurring ASD/GD.

Adolescent and Caregiver Perspectives on Receiving Gender-Affirming Care in Primary Care

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.

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.

Increasing Frequency of Affirmed Name and Pronoun Documentation in a Pediatric Emergency Department

BACKGROUND AND OBJECTIVES

In a previous study of 204 transgender and gender diverse youth in our region, 44% reported being made to feel uncomfortable in the emergency department (ED) because of their gender identity. The objective of our study was to conduct a 2 year quality improvement project to increase affirmed name and pronoun documentation in the pediatric ED.

METHODS

Using process mapping, we identified 5 key drivers and change ideas. The key driver diagram was updated as interventions were implemented over 3 Plan-Do-Study-Act cycles. Our primary outcome, the percentage of ED visits per month with pronouns documented, was plotted on a run chart with the goal of seeing a 50% increase in form completion from a baseline median of ∼14% over the 2 year study period.

RESULTS

The frequency of pronoun documentation increased from a baseline median of 13.8% to a median of 47.8%. The most significant increase in pronoun documentation occurred in Plan-Do-Study-Act cycle 3, immediately after ED-wide dissemination of a near-miss case and subsequent call for improvement by ED leadership. Roughly 1.7% of all encounters during the study period involved patients whose pronouns were discordant from the sex listed in their electronic health record.

CONCLUSIONS

This quality-improvement project increased the frequency of pronoun documentation in the ED. This has the potential to improve the quality of care provided to transgender and gender diverse youth in the ED setting and identify patients who may benefit from receiving a referral to a pediatric gender clinic for additional support.

Binary and Nonbinary Transgender Adolescents' Healthcare Experiences, Avoidance, and Well Visits

PURPOSE

To explore differences in healthcare experiences, healthcare avoidance, and well visit attendance between binary and nonbinary transgender adolescents; also, to explore the association between distinct healthcare experiences and healthcare avoidance and well visits.

METHODS

We surveyed transgender adolescents ages 12-26 (n = 156) recruited from a multidisciplinary gender clinic from July through November 2018. Differences in distinct healthcare experiences by demographics were assessed using multivariable linear regression. Multivariable logistic regression was used to examine independent associations between demographics and lifetime healthcare avoidance and past-year well visit and also, associations between distinct healthcare experiences and lifetime healthcare avoidance and past-year well visit.

RESULTS

Compared to transfeminine adolescents, more non-affirming healthcare experiences were reported by nonbinary (β = 1.41, 95% confidence interval [CI]: 0.49, 2.33) and transmasculine adolescents (β = 0.78, 95% CI: 0.02, 1.53). Gender-affirming healthcare experiences did not differ by demographics. Transmasculine adolescents had over three times the odds of lifetime healthcare avoidance (adjusted odds ratio [aOR] = 3.58, 95% CI: 1.41, 9.08) than transfeminine peers. Only younger age was associated with past-year well visit (aOR = 3.83, 95% CI: 1.44, 10.17). Non-affirming healthcare experiences were positively associated with healthcare avoidance (aOR = 1.85, 95% CI: 1.47, 2.34). Gender-affirming healthcare experiences were not associated with healthcare avoidance or past-year well visit.

DISCUSSION

Nonbinary and transmasculine adolescents experienced more non-affirming healthcare experiences than transfeminine adolescents. Non-affirming healthcare experiences were associated with healthcare avoidance, which was disproportionately more prevalent among transmasculine adolescents. Providers must be better equipped to provide inclusive, gender-affirming care to increase receipt of care for transgender adolescents beyond specialized gender clinics.