Telemedicine-Based Provision of Adolescent Gender-Affirming Medical Care to Promote Equitable Access

Purpose: To explore transgender and nonbinary (TNB) young adults' (1) interest in receiving gender-affirming medications through telemedicine before age 18 years and (2) willingness to initiate this care with primary care providers (PCPs). Methods: Data were from a survey of TNB young adults who had not received gender-affirming medications before age 18 years. Chi-square and Wald tests identified demographic differences in telemedicine interest and willingness to initiate medications with their PCP as minors. Results: Among 280 respondents, 82.5% indicated interest in telemedicine and 42.0% were willing to initiate medications with their PCP. Black/African American respondents were more likely to indicate interest in telemedicine than White and multiracial respondents. Respondents from rural areas were more likely to indicate willingness to initiate medications with their PCP than those from urban areas. Conclusions: Telemedicine expansion and further support for PCPs may represent critical opportunities to promote equitable access to adolescent gender-affirming care.

Comfort Providing Gender-Affirming Care and Preferences for Consultative Support Among Rural Pediatric Primary Care Providers

Objective: To examine how specialist-to-pediatric primary care provider (PPCP) consultative support may impact PPCP comfort in providing gender-affirming care. Methods: PPCPs in West Virginia completed an electronic survey. T-tests compared comfort providing gender-affirming care and rank-sum tests compared the practicality of four consultative support modalities by time in practice and specialty. Results: Of 51 participants, 47.1% had been in practice for <10 years and 59.6% were trained in pediatrics. PPCPs with <10 years in practice and those trained in pediatrics were more comfortable providing gender-affirming care than those in practice >10 years and those trained in family medicine. PPCPs felt that telemedicine was more practical than tele-education, although they reported all consultative support modalities would increase comfort providing this care. Conclusions: Access to consultative support can increase PPCP comfort providing gender-affirming care, although certain modalities may be more effective for PPCPs with varying levels of experience and specialty training.

Pediatric Gender Care in Primary Care Settings in West Virginia: Provider Knowledge, Attitudes, and Educational Experiences

PURPOSE

Pediatric primary care providers (PPCPs) often care for gender diverse youth (GDY), particularly in rural areas, but little is known about their relevant knowledge, attitudes, or educational experiences regarding caring for this population.

METHODS

This study surveyed PPCPs throughout the rural state of West Virginia using an online survey assessing 1) demographics, 2) knowledge, 3) attitudes, and 4) educational experiences. Knowledge and attitude scores were calculated and proportion-tests and t-tests were used to compare these scores by PPCP characteristics including age, time in practice, and training background.

RESULTS

In total, 51 PPCPs from throughout the state completed the survey and 82% had cared for GDY in the prior year. Younger providers (

DISCUSSION

PPCPs in a rural state reported caring for GDY, but knowledge and attitudes related to this care varied by age, time in practice, and relevant educational experiences. More research is needed to determine best strategies for providing education to PPCPs, particularly those who are older and have been in practice longer, and to better understand the impacts of legislation limiting evidence-based gender-affirming care on PPCP knowledge, attitudes, and access to educational experiences.

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Key Words

• LGBTQ
• Pediatrics
• Primary care
• Rural health

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Affiliation(s)

Kacie M Kidd Division of Adolescent Medicine, Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia.
Alana Slekar West Virginia University, Morgantown, West Virginia
Gina M Sequeira Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
Nicole F Kahn Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
Lisa M Costello Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
Isabela Negrin Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
Sara Farjo WVU Urgent Care, West Virginia University School of Medicine, Morgantown, West Virginia
Savannah Lusk Department of Family Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
Snehalata Huzurbazar Department of Mathematics and Data Science, West Virginia University, Morgantown, West Virginia
Janani Narumanchi Department of Pediatrics, University of Tennessee School of Medicine, Memphis, Tennessee

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Nine Ways Parents Can Support Their Gender Diverse Children

Parental support is associated with improved mental health outcomes for gender diverse youth (GDY). Parents often seek guidance from pediatric providers, but few studies explore what actions make GDY feel supported. Using a qualitative analysis of open-ended survey responses, we aimed to identify ways in which GDY want to be supported by their parents or caregivers. Nine key themes were identified, including using affirming language at home and other settings as desired by GDY, seeking education, and aiding in accessing affirming items and care. Findings from this study can help pediatric medical and mental health providers help parents to support their GDY.

Evaluating an Electronic Consultation Platform to Support Pediatric Primary Care Providers in Caring for Transgender and Nonbinary Adolescents

Background: An electronic consultation (e-consult) platform was implemented to support pediatric primary care providers (PCPs) in providing gender-affirming care to transgender and nonbinary (TNB) adolescents. Following implementation, a study was conducted to (1) explore how access to this e-consult platform impacts PCP confidence and referral patterns, (2) describe the content of questions, and (3) evaluate PCP's perspectives regarding platform usability. Methods: Following each submission, providers completed a 17-item survey. A total of 20 providers submitted 38 e-consults and 26 follow-up surveys between October 2021 and December 2022. Results: All PCPs reported a high overall value and increased confidence caring for TNB adolescents. Nearly one in five (19%) felt it allowed them to avoid submitting a specialty referral. Mean System Usability Scale score was 78.2 indicating good usability. Conclusion: This e-consult platform shows great promise in increasing PCP confidence providing gender-affirming care adolescents. More widespread utilization could help improve access to care and decrease specialty care referrals.

Awareness and utilization of pre-exposure prophylaxis and HIV prevention services among transgender and non-binary adolescent and young adults

Introduction

Transgender and gender non-binary (TGNB) individuals are disproportionally affected by HIV and face high rates of discrimination and stigmatization, resulting in limited access to HIV prevention services. Pre-exposure prophylaxis (PrEP) is highly efficacious for reducing the risk of HIV transmission. However, little research is available regarding PrEP awareness and utilization among TGNB adolescents and young adults (AYA).

Methods

TGNB AYA ages 15-24 years old were recruited between December 2021 and November 2022 for participation in a one-time, anonymous online survey study to assess PrEP awareness and perceptions, as well as barriers to its use. Participants were recruited from seven academic centers offering gender-affirming care to TGNB AYA across the United States.

Results

Of the 156 TGNB AYA individuals who completed the survey, most (67%) were aware of PrEP; however, few (7%) had been prescribed PrEP. Many (60%) had not spoken to a medical provider and, even if the medication was free and obtained confidentially, most participants did not plan to take PrEP due to low perceived HIV risk, lack of PrEP knowledge, and concern about interactions between their hormone therapy and PrEP.

Discussion

These findings underscore the need for broad PrEP educational efforts for both TGNB AYA and their providers to improve knowledge, identify potential PrEP candidates among TGNB AYA and improve access by addressing identified barriers.

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.

Social Support for Rural Gender Diverse Youth Compared to Cisgender Peers

PURPOSE

Gender diverse youth (GDY) experience higher rates of mental health concerns than their cisgender peers, but these can be ameliorated by feeling support from family, school, and community. Little is known about how youth perceptions of support vary by gender identity, especially for younger adolescents and those living in rural areas.

METHODS

Youth ages 12-19 years completed anonymous surveys including measures of perceived support and a two-step gender identity question. GDY (n = 206) were further categorized into binary and nonbinary gender identities. An additional 500 randomly selected cisgender youth were included for comparison. Multivariate analyses of variance with Tukey post hoc tests were employed to test GDY group differences while accounting for the interaction between scaled measures.

RESULTS

Cisgender youth had the highest perceived support across all support measures while youth who shared both binary and nonbinary aspects of their gender identity had the lowest rates of perceived support. The F tests for between-subject effects were statistically significant (p <.001) for all six support measures, and multivariate group testing was statistically significant with Wilks' λ 6.38(18,1621.17) = 0.82; p <.001.

DISCUSSION

Despite research demonstrating a strong association between perceived support and improved mental health outcomes, GDY in our sample had lower rates of perceived support at the family, school, and community levels. GDY with both binary and nonbinary gender identities had the lowest levels of perceived support. Further research is needed to see if this finding is consistent in other populations and to develop targeted interventions to improve perceived support for this population.

"Difficult to Find, Stressful to Navigate": Parents' Experiences Accessing Affirming Care for Gender-Diverse Youth

Purpose: Gender-diverse youth (GDY) face significant health disparities, which can be mitigated by gender-affirming medical care. Understanding parents' experiences seeking care for their GDY can identify barriers to care and improve access. This study sought to understand parents' experiences accessing gender-affirming medical care with their GDY. Methods: We asked parents of GDY in the United States to describe their experiences with gender-affirming medical care through a single open-ended item on an online survey disseminated through social media in February of 2020. Open-ended survey responses were analyzed through inductive thematic analysis by two authors using an iteratively developed codebook adjudicated by consensus. This codebook was used to identify key themes. Results: We analyzed 277 responses from majority White (93.9%) parents from 41 U.S. states. Themes included (1) Experiences accessing care: finding a provider, financial and insurance-related considerations, the impact of geography on care access; (2) Experiences receiving care: factors in successful or unsuccessful patient-provider interactions, differing approaches to initiating care, sense of community with other families; and (3) Outcomes related to receiving care: how care for their child was perceived to be lifesaving or helped their child thrive. Conclusions: Parents highlighted how access to gender-affirming medical care improved their GDY's health and wellbeing, and described numerous barriers they experienced with finding and receiving this care. Given the evidence that gender-affirming medical care mitigates health disparities, providers, policymakers, insurance companies, and health systems leaders should urgently address these challenges to ensure equitable receipt of care for all GDY.

Adolescent Providers' Experiences of Harassment Related to Delivering Gender-Affirming Care

PURPOSE

The politicization of adolescent gender-affirming care has occurred alongside targeted harassment (e.g., threats of violence, doxing, bomb threats) of adolescent gender-affirming care providers across the United States. This study sought to explore their experiences of targeted harassment.

METHODS

From October to December 2022, mental and physical health gender-affirming care providers from across the United States completed a survey including open-ended questions about the kinds of harassment they experienced (i.e., method and messages of harassment) and its impact on their lives and practices. Thematic analyses were used to analyze their responses.

RESULTS

In total, 117 providers completed the survey and 70% shared that either they, their practice, or their institution had received threats specific to delivering gender-affirming care. The most common experiences were threats via social media or mailed letters. Several received death threats. Providers described how targeted harassment impacted their psychological well-being and required them to reassess clinic safety. Additionally, providers expressed the need for a more accurate representation of gender-affirming care in media and stronger advocacy from institutions and organizations emphasizing the importance of this care.

DISCUSSION

Adolescent gender-affirming care providers are experiencing targeted harassment, significantly affecting their ability to deliver care to transgender and gender-diverse adolescents and their families. Providers stressed the importance of receiving support from their institutions to ensure their safety. The ongoing sociopolitical climate related to gender-affirming care coupled with targeted harassment of those providing it will further limit access to this care.

Parents of Gender Diverse Youth: Support Sought, Received, and Still Needed

PURPOSE

Gender diverse youth (GDY) have improved mental health when affirmed by parents, but little is known about the support parents of GDY seek, receive, and still need. This qualitative study explored experiences of parents of GDY to better understand their support needs.

METHODS

Parents of GDY submitted videos and were interviewed about their journey supporting their GDY. Data collection continued until thematic saturation was reached. Audio recordings from videos and interviews were transcribed and analyzed via an inductive thematic analysis using the rigorous and accelerated data reduction technique.

RESULTS

In total, 25 parents of GDY (mean age 15 years, range 6-21 years) from 12 states provided video recordings and interviews; 36% were People of Color and 28% were fathers. We identified four themes and 12 subthemes. Theme 1: support through education included acknowledging ignorance about gender diversity and remedying ignorance. Theme 2: engaging community noted that support was multilayered and based around the family unit and pre-existing community. Theme 3: expanding community included acknowledgement that seeking new community was important for many to reduce feelings of isolation. It also highlighted that "safe spaces" for parents of GDY were not always safe for those of other marginalized groups, particularly People of Color. Theme 4: support in healthcare spaces centered experiences navigating medical and mental healthcare for GDY and feeling supported and unsupported in those spaces.

DISCUSSION

Parents identified numerous ways they sought, received, and needed support to understand and affirm their GDY. These findings will aid development of targeted support interventions for parents of GDY. Further research is needed to evaluate the impact of these interventions on GDY health.

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.

Leuprolide Acetate for Puberty Suppression in Transgender and Gender Diverse Youth: A Comparison of Subcutaneous Eligard Versus Intramuscular Lupron

PURPOSE

To compare the efficacy of intramuscular Lupron and subcutaneous Eligard, two formulations of leuprolide, for puberty suppression in transgender and gender diverse (TGD) youth.

METHODS

A retrospective chart review of TGD youth receiving Lupron or Eligard 22.5 mg every 3 months was conducted to determine hormone levels obtained 1 hour after an injection (1hrPost) and patient-reported clinical puberty suppression.

RESULTS

Forty eight patients were analyzed: 33% assigned female at birth of which 25% were premenarchal, mean age at first injection 13.7 years, and 50% received concurrent gender affirming hormones. Of these, 13% received Lupron, 52% Eligard, and 35% initially received Lupron then transitioned to Eligard due to drug shortages. There were 55 incidents of 1hrPost levels, 42 after Eligard and 13 after Lupron. Clinical puberty suppression occurred in all patients; however, biochemical suppression occurred in 90% of Eligard and 69% of Lupron (p = .06).

DISCUSSION

Eligard and Lupron were both effective in suppressing clinical puberty progression in our population of TGD youth, of which 50% were receiving concurrent gender affirming hormones.

Sexual Orientation Among Gender Diverse Youth

PURPOSE

Many youth are gender diverse, but our understanding of sexual orientation among gender diverse youth (GDY) is limited. We sought to compare sexual identity, attraction, and contact between cisgender youth and GDY and to describe these characteristics across GDY subgroups.

METHODS

We analyzed cross-sectional data from school-based surveys of 4,207 adolescents. Two-sample t-tests or chi-squared tests compared characteristics between GDY and cisgender youth. Sexual attraction/contact was summarized with frequencies/proportions and stratified by transmasculine, transfeminine, and nonbinary identities.

RESULTS

Two hundred eighty-one (9.1%) youth were GDY. Compared to cisgender peers, GDY were more likely to identify as sexual minority youth. In total, 29.9% of GDY were transmasculine, 36.7% transfeminine, and 33.5% nonbinary. Many transmasculine (45%) and transfeminine (58%) youth identified as heterosexual; most nonbinary youth (91%) identified as sexual minority youth. For transgender youth identifying as heterosexual, sexual attraction/contact varied.

DISCUSSION

Aspects of sexuality among GDY remain complex, warranting individualized approaches to sexual/reproductive healthcare.

The Prevalence of Gender-Diverse Youth in a Rural Appalachian Region

This study discusses a survey that explores youth gender identity in the Appalachian region.

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.

Pediatric Provider Perspectives on Laws and Policies Impacting Sports Participation for Transgender Youth

Purpose: Since May 2021, numerous state legislatures in the United States have introduced bills to restrict the participation of transgender and gender diverse (trans) youth in gender-segregated sports in a manner consistent with their gender identity. The purpose of this study was to understand how medical providers of pediatric gender-affirming care for trans youth view these legislative efforts and how they believe these bills will affect their practice and patients. Methods: In March 2021, we recruited participants using listservs known to be frequented by providers of gender-affirming medical care to complete a survey about bills that restrict trans youths' participation in sex-segregated sports. Eligible participants were over the age of 18, currently worked as a physician, nurse practitioner, or physician's assistant, and provided gender-affirming care to trans youth under the age of 18 in the United States. Results: We analyzed the responses of 103 providers from all 50 states and the District of Columbia. Most participants identified as White (77%), cisgender women (70%), and specialized in pediatric care (52%). The most salient theme, described by nearly all participants, was that legislation banning trans youth from sports participation would lead to worsening discrimination and stigmatization. Other themes included worsening mental and physical health of trans youth, forced changes to clinical practice, politicization of trans youth, and efforts required to stop these bills. Conclusions: Providers of gender-affirming care in this study overwhelmingly opposed legislation that bans trans youth from sports participation citing the severe consequences to the well-being of trans youth. More research is needed to examine stakeholder's opinions regarding legislation that does not ban but otherwise restricts sports participation by trans youth.

Operationalizing and analyzing 2-step gender identity questions: Methodological and ethical considerations

OBJECTIVE

Two-step questions to assess gender identity are recommended for optimizing care delivery for gender-diverse individuals. As gender identity fields are increasingly integrated into electronic health records, guidance is needed on how to analyze these data. The goal of this study was to assess potential approaches for analyzing 2-step gender identity questions and the impact of each on suicidal ideation.

MATERIALS AND METHODS

A regional Youth Risk Behavior Survey in one Northeastern school district used a 2-step question to assess gender identity. Three gender measurement strategies (GMSs) were used to operationalize gender identity, (1) combining all gender-diverse youth (GDY) into one category, (2) grouping GDY based on sex assigned at birth, and (3) categorizing GDY based on binary and nonbinary identities. Mixed-effects logistic regression was used to compare odds of suicidal ideation between gender identity categories for each GMS.

RESULTS

Of the 3010 participants, 8.3% were GDY. Subcategories of GDY had significantly higher odds (odds ratio range, 1.6-2.9) of suicidal ideation than cisgender girls regardless of GMS, while every category of GDY had significantly higher odds (odds ratio range, 2.1-5.0) of suicidal ideation than cisgender boys.

CONCLUSIONS

The field of clinical informatics has an opportunity to incorporate inclusive items like the 2-step gender identity question into electronic health records to optimize care and strengthen clinical research. Analysis of the 2-step gender identity question impacts study results and interpretation. Attention to how data about GDY are captured will support for more nuanced, tailored analyses that better reflect unique experiences within this population.

"These Laws Will Be Devastating": Provider Perspectives on Legislation Banning Gender-Affirming Care for Transgender Adolescents

PURPOSE

The standards of care for transgender and gender diverse youth (TGDY) experiencing gender dysphoria are well-established and include gender-affirming medical interventions. As of July 2021, 22 states have introduced or passed legislation that bans the provision of gender-affirming medical care to anyone under the age of 18 even with parent or guardian consent. The purpose of this study is to understand what providers who deliver gender-affirming medical care to TGDY think about this legislation.

METHODS

In March 2021, we recruited participants via listservs known to be frequented by providers of gender-affirming medical care. Eligible participants were over the age of 18, currently working as a physician, nurse practitioner, or physician's assistant, and providing gender-affirming care to TGDY under the age of 18 in the U.S.

RESULTS

We analyzed the responses of 103 providers from all 50 states and DC. Most participants identified as white (77%), cisgender women (70%), specializing in pediatric care (52%). The most salient theme, described by nearly all participants, was the fear that legislation banning gender-affirming care would lead to worsening mental health including increased risk for suicides among TGDY. Other themes included the politicization of medical care, legislation that defies the current standards of care for TGDY, worsening discrimination toward TGDY, and adverse effects on the providers.

CONCLUSIONS

Providers of gender-affirming care overwhelmingly opposed legislation that bans gender-affirming care for TGDY citing the severe consequences to the health and well-being of TGDY along with the need to practice evidence-based medicine without fear.

Development and Psychometric Analysis of the Transgender Family Acceptance To Empowerment (TransFATE) Scale

PURPOSE

Parent and caregiver support can reduce health disparities experienced by gender diverse youth (GDY). Parent and caregiver empowerment improves health outcomes for children with medical and mental health diagnoses, but no existing scale measures this construct in families of GDY. We aimed to develop a scale measuring empowerment in parents and caregivers of GDY.

METHODS

We adapted two existing scales and added investigator-derived items to create a survey instrument. We revised using input from focus groups and experts assessing face and content validity. Using the revised scale, we surveyed parents and caregivers of GDY from across the U.S. to assess the construct validity through exploratory and confirmatory factor analyses, internal consistency, and convergent validity.

RESULTS

The initial 67 items were reduced to 42 items after face and content validity analyses. Parents and caregivers (n = 309) from 31 states completed the revised measure. Most participants were white (81.4%), mothers (69.3%), and parenting a gender diverse child who identifies on the binary (transmasculine, male, transfeminine, or female; 91.3%). Exploratory factor analyses showed a two-factor solution: Factor 1 having 10 items (Cronbach's alpha = .86) and Factor 2 having six items (Cronbach's alpha = .86). Our confirmatory factor analysis demonstrated good fit (Comparative Factor Index = .972, Tucker-Lewis Index = .968, Root Mean Square Error of Approximation = .060 [90% confidence interval = .410-.078], and Standardized Root Mean Square Residual = .062).

CONCLUSIONS

The Transgender Family Acceptance To Empowerment (TransFATE) scale demonstrates face, content, and construct validity among a geographically diverse sample of GDY's parents and caregivers. This scale has the potential to aid in developing and evaluating programs focused on building stronger social supports for GDY through increased family empowerment.

"This Could Mean Death for My Child": Parent Perspectives on Laws Banning Gender-Affirming Care for Transgender Adolescents

OBJECTIVES

Numerous U.S. state legislatures have proposed bills to ban gender-affirming medical interventions for minors. Parents and caregivers play a critical role in advocating for and supporting their transgender and gender-diverse youth (TGDY). We aimed to understand parent and caregiver perspectives about this potential legislation and perceived effects on their TGDY's mental health.

METHODS

We developed and launched a social-media based, anonymous online survey in February 2020 to assess parent and caregiver perspectives on proposed laws to ban gender-affirming medical interventions for minors. Participants were asked to respond to two open-ended questions about these laws; responses were coded to identify key themes.

RESULTS

We analyzed responses from 273 participants from 43 states. Most identified as white (86.4%) female (90.0%) mothers (93.8%), and 83.6% of their TGDY had received gender-affirming medical interventions before age 18 years. The most salient theme, which appeared in the majority of responses, described parent and caregiver fears that these laws would lead to worsening mental health and suicide for their TGDY. Additional themes included a fear that their TGDY would face increased discrimination, lose access to gender-affirming medical interventions, and lose autonomy over medical decision-making due to government overreach.

CONCLUSIONS

In this convenience sample, parents and caregivers overwhelmingly expressed fear that the proposed legislation will lead to worsening mental health and increased suicidal ideation for their TGDY. They implored lawmakers to hear their stories and to leave critical decisions about gender-affirming medical interventions to families and their medical providers.

Gender-Diverse Youth's Experiences and Satisfaction with Telemedicine for Gender-Affirming Care During the COVID-19 Pandemic

Purpose

Telemedicine holds potential to improve access to gender-affirming care for gender-diverse youth (GDY), but little is known about youth's perspectives regarding its use. The purpose of this study was to explore GDY's experiences and satisfaction with telemedicine for gender-affirming care during the COVID-19 pandemic.

Methods

An online, cross-sectional survey was completed by 12-17-year-old GDY after a telemedicine gender clinic visit. Demographic characteristics, responses to a 12-item telemedicine satisfaction scale, and items assessing interest in future telemedicine use were analyzed using descriptive statistics. Open-ended items exploring GDY's experiences were coded qualitatively to identify key themes.

Results

Participants' (n=57) mean age was 15.6 years. A majority were satisfied with telemedicine (85%) and willing to use it in the future (88%). Most GDY preferred in-person visits for their first gender care visit (79%), with fewer preferring in-person for follow-up visits (47%). Three key themes emerged from the open-ended comments: (1) benefits of telemedicine including saving time and feeling safe; (2) usability of telemedicine such as privacy concerns and technological difficulties; and (3) telemedicine acceptability, which included comfort, impact on anxiety, camera use, and patient preference.

Conclusions

Despite their preference for in-person visits, a majority of GDY were satisfied and comfortable with telemedicine, and expressed their interest in continuing to have telemedicine as an option for care. Pediatric gender care providers should continue services through telemedicine while implementing protocols related to privacy and hesitation regarding camera use. While adolescents may find telemedicine acceptable, it remains unclear whether telemedicine can improve access to gender-affirming care.

Caring for gender diverse youth with cystic fibrosis

Gender diverse youth with cystic fibrosis have unique health needs. Providers should be aware of existing health disparities in this population as well as aspects of gender-affirming care including hormone therapy, chest binding, and use of affirming language. This communication provides an introduction to these concerns.

Providing Care for Transgender and Gender Diverse Youth

Transgender and gender diverse youth (TGDY) experience modifiable health disparities and difficulty accessing the physical and mental health care systems. Providers and staff should understand the unique needs of this population and provide affirming spaces where these resilient young people can thrive. In addition to addressing social, setting, and system level barriers to access, providers should consider offering comprehensive gender care because this reduces barriers to medical services and can improve health outcomes. This article educates providers about TGDY, reviews the role of mental health care, and provides an overview of medical interventions for gender affirmation.

Gendered Body Mass Index Percentile Charts and Transgender Youth: Making the Case to Change Charts

Body mass index (BMI) is defined as weight (kg)/height2 (m2). Differences in BMI percentiles between sexes confound the diagnosis of weight-related disorders in transgender youth because choosing the appropriate chart is challenging. Data on BMI measures are needed for transgender youth, but there are no guidelines on how to collect or report this data. We use two theoretical cases to assert that health care providers and researchers should consider use of both male and female growth charts for transgender youth, particularly for individuals at the extremes of weight.

Knowledge and Attitudes of Health Care Providers Toward Transgender Patients Within a Rural Tertiary Care Center

Purpose: Members of the transgender community face significant health disparities within our society, especially within the state of West Virginia, which is primarily rural. We sought to examine and compare existing attitudes and knowledge of resident and faculty physician medical professionals at our institution about treating transgender individuals within a rural tertiary care center.

Methods: The Medical Practitioner Attitudes Towards Transgender Patients (MP-ATTS) survey and the Medical Practitioner Beliefs and Knowledge about Treating Transgender Patients (MP-BKTTP) survey were sent to all faculty and resident physicians at West Virginia University Hospitals. Demographics included information about gender, rurality of hometown, race, and description of medical practitioner status (i.e., years out of residency, residency status).

Findings: In general, there were positive attitudes and reception of the survey among residents and faculty physicians. 76.45% of providers assumed that their patients were not transgender. More than 40% of respondents believed that they would need further education about transgender patients to provide appropriate health care. Male health care providers had significantly higher negative perceptions of the transgender community (N=85, M=4.46, standard deviation [SD]=0.55, p<0.0001) and perceived fewer barriers due to personnel (N=80, M=3.24, SD=0.96, p<0.0001).

Conclusion: A clear need exists for increased training in transgender health care among physicians taking care of this patient population. A gender divide exists among health care providers within West Virginia over attitudes regarding the transgender community. Further studies are needed to fully understand the health care needs and barriers of the transgender population.