Increasing numbers of transgender and nonbinary youth are now accessing gender-affirming medical interventions, which have been demonstrated to improve health and well-being. This Perspective addresses how the needs of transgender and nonbinary youth, up to age 18, can be addressed through individualized gender-embodiment care. We first review standard medical therapies, including gonadotropin-releasing hormone analogues, 17β-oestradiol, testosterone, steroidal antiandrogens and progestins, followed by presenting novel approaches to individualizing gender healthcare for transgender and nonbinary youth, consisting of selective oestrogen receptor modulators, 5α-reductase inhibitors, aromatase inhibitors and non-steroidal antiandrogens. Ethical guidance for off-label prescribing is provided, grounded in the principles of evidence, benefit, safety, respect, care, communication, transparency, equity and innovation. These ethical principles are applied in three clinical scenarios in which off-label therapies are considered. We conclude that standard medical therapies are ethically justified and that novel therapies can be ethically acceptable when carefully considered in the context of an individual youth's care plan and taking into account the available theoretical, clinical and research evidence as well as the potential benefits and potential risks. In keeping with the principle of innovation, we encourage clinicians and researchers to share evidence of medical innovations that support the gender health of transgender and nonbinary youth.

Attention deficit hyperactivity disorder (ADHD) turns into a common neuro progressional disorder. Although gender identity has obtained increasing attention in ADHD researches, its role in ADHD presentation and treatment response remains underexplored. Our review seeks to mainly delve into the effect of gender identity on ADHD, exploring the unique needs of individuals with various gender identities in the context of ADHD symptoms, diagnostic assessment, and treatment, with the goal of supplying theoretical support and practical recommendations for future research and clinical practice. The primary content includes, specifically: (1) Symptom expression differences: Gender identity significantly affects ADHD symptoms; male-identified individuals commonly perform worse in task orientation and attention stability, while female-identified individuals may demonstrate more variability in attention control and executive functions; (2) Diagnosis and treatment: Clinical practice generally neglects the impact of gender identity on ADHD management, with personalized needs of gender-identified individuals frequently not adequately addressed, potentially, affecting treatment outcomes; and (3) Future research directions: Future studies should further assess how gender identity affects the specific mechanisms of ADHD, conduct researches in multicultural contexts, and engage in long-term follow-up studies to evaluate the long-term impact of gender identity on ADHD progression. Besides, enhanced funding and public education on the relationship between gender identity and ADHD are needed to advance the field.

This retrospective study of 1101 children and adolescents examines differences in psychiatric admissions between cisgender and transgender/gender nonconforming (TGNC) youth between June 2018 and November 2021. Sociodemographic and clinical characteristics for each admission were extracted from medical records. We compared proportion of total admissions and clinical characteristics between cisgender and TGNC youth, during specified time frames of pre-COVID-19, during quarantine, and post-quarantine. During quarantine, 294 (89.9%) youth identified as cisgender and 33 (10.1%) youth identified as TGNC. Post-quarantine, 205 (88.4%) youth identified as cisgender and 27 (11.6%) identified as TGNC. TGNC patients had more history of mood disorders (p < 0.001), self-injurious behavior (p < 0.001), and suicide attempt (p = 0.007), whereas cisgender patients had more history of Attention-deficit/Hyperactivity Disorder (ADHD) (p = 0.011) and violence (p < 0.001) across each time frame of the study. TGNC patients were more likely to be admitted due to suicidal ideation (p = 0.003), whereas cisgender patients were more often admitted for aggression (p < 0.001). There was no change across COVID-19 time periods in terms of any psychiatric history variable among patients identifying as TGNC. The proportion of admitted youth identifying as TGNC increased by 8.1% from pre-COVID-19 to post-quarantine (p < 0.001). These findings suggest that TGNC youth might be particularly vulnerable to mental health crises when faced with pandemic-related stressors. Further research on the vulnerabilities of TGNC youth during sudden and extreme social changes and how this can impact their mental health is necessary, as global pandemics could and are anticipated to repeat.

This historical narrative presents a comprehensive historical journey delving into the diverse facets of gender identity and expression across ancient cultures. It explores these civilizations' perspectives on gender diversity, highlighting instances that challenged conventional gender norms. Transitioning to the modern era, the narrative examines the dynamic landscape of LGBTQ+ and trans movements, spotlighting influential figures whose advocacy has significantly influenced societal perceptions and advanced the rights of gender diverse individuals. Their contributions continue to shape contemporary affirming care practices. Exploring the emergence of gender-affirming surgery, the narrative highlights pioneering surgeons and original techniques employed in these transformative procedures. It shows the courage and innovation of early surgeons who laid the groundwork for contemporary practices. At the core of this historical narrative lies the pivotal role of plastic surgeons in gender-affirming care. It emphasizes the significance of a collaborative multidisciplinary approach among medical professionals to ensure comprehensive and patient-centered care for transgender individuals seeking affirming interventions. However, intertwined with this narrative are legislative barriers that have hindered progress in gender-affirming care. The narrative navigates these obstacles, highlighting their complexities and emphasizing the urgent need for sustained medical advocacy and legislative reforms to foster an inclusive healthcare landscape. Ultimately, this narrative stands as a testament to the ongoing struggle and resilience within the realm of gender-affirming care, shedding light on its profound impact on individuals' lives, emphasizing the ongoing need for compassionate, comprehensive, and inclusive healthcare practices.

Youth who identify as transgender and gender diverse (TGD) are increasingly presenting to pediatric providers. Gender-affirming surgery is often delayed until after a patient reaches the age of majority; however, patients may desire surgery at a younger age.

We explore the specific clinical needs of this vulnerable population, including surgical requests.

We present a cross-sectional study of patient intake interviews at time of presentation to our gender health program from 2017 to 2020. We summarize patient demographics, medical histories, and gender-affirming care needs by gender identity and age of presentation.

Of 92 patients analyzed, those included were 19 trans girls, 55 trans boys, and 18 non-binary individuals. The median age of our sample was 15 (range 5-17). The median age (IQR) while first questioning gender was 10 (7-12). Sexual orientation was variable with 28 (43%) not sure/unknown. The majority of patients present for primary care services (grade schoolers 75%, early teens 78%, and late teens 77%, p = 0.97) and hormone management (grade schoolers 42%, early teens 62%, and late teens 77%, p = 0.06). Late teens were more likely to present for surgical services (49%) compared to grade schoolers (25%) and early teens (11%), p = 0.001. Prior psychiatric diagnoses were common in all age groups. Trans girls were interested in a variety of affirming procedures whereas trans boys and non-binary individuals primarily sought chest surgery (see summary figure).

Pediatric gender affirming care needs are varied and multidisciplinary within our center. By age 16, about half of TGD individuals are seeking surgical services. On average, there was a 4-5 year delay from age at first questioning one's gender and presenting to our gender health program. Primary care physicians in particular may prepare to serve this complex population by familiarizing themselves with treatment needs, including developing a network of competent surgical referrals.

Over the last 6 years, there has been a change in the demographics of people presenting to gender services in Ireland. This is in line with international trends describing a higher number of transgender men (Female-Male, FTM, AFAB) presenting to gender services as compared to transgender women (Male-Female, MTF, AMAB), and lower ages at referral. Given the changes in demographics, it would be anticipated that clinical needs may have changed. This study describes the demographics of a young Irish sample (participants aged 18-30 years old) and explores the referral pathways and clinical needs of this cohort.

The study was performed as a retrospective chart review of 167 charts at The National Gender Service in Ireland over a five-month period.

Transgender men represented 62.3% of the sample, transgender women 35.3%, and transmasculine/non-binary individuals represented 2.4%. Over two-thirds of participants were on gender affirming hormone therapy or GnRH antagonists and 16.1% had undergone surgical interventions. The median time from referral received to being seen at the clinic was 450 days (481 mean). Mental health comorbidities remain high with 49.1% of youth experiencing depression, a further 15.6% low mood and 26.3% anxiety.

This is the first study to show increasing referrals of people who were assigned female at birth (AFAB) over assigned male at birth (AMAB) individuals in Ireland, and to document the clinical needs of this cohort. By understanding the changing demographics and clinical needs, we can better plan for care and service improvements.

Transgender and gender-diverse (TGD) individuals and their families face numerous challenging decisions. To better understand their decision processes, we conducted a scoping review of the existing literature and of decision-support tools in use at pediatric gender-care clinics.

We searched PubMed, EMBASE, Scopus CINAHL, PsychINFO, and EBM Reviews for studies that were original research focused on decisions, decision making, or decision support for TGD individuals and/or their families. All studies were reviewed for inclusion by at least two researchers. Additionally, we reviewed clinical tools used to support decision making by TGD youth and their families.

We retrieved 3306 articles. Thirty-two met criteria for data extraction. Studies focused on three major decisions: gender-confirming surgery, fertility preservation, and gender-affirming hormone therapy. Several themes that cut across clinical topics emerged: decision-making processes, decision-making roles, and sources of decision support. Only three articles focused on decision-support interventions, two of which discussed development of support tools and one evaluated a class designed to help with surgical decision making. None of the clinical tools reviewed met criteria for a decision aid.

There is a dearth of studies related to decision support interventions, an absence validated by the resources currently in clinical use. This scoping review suggests an opportunity for the development of tools to aid in the decision-making processes for TGD youth and their families.

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.

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.

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).

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.

Contemporary transgender youth in the U.S. today face increasing stigmatization as extraordinary legislative attacks intensify discrimination and exclusion of these young people in healthcare, recreation, and school life. These attacks reflect broader political, religious, and cultural ideologies embedded in systems of power that regulate the provision of healthcare for American transgender youth. We apply Foucauldian discourse analysis and a theory-driven conceptual framework for structural analysis of transgender health inequities-Intersectionality Research for Transgender Health Justice-to identify discourses youth encounter within healthcare practice. We analyzed data from interviews conducted in Western Washington State with youth ages 13-17 (n =11) and asked how transgender subjectivity was constructed in their accounts and in what ways youth made use of the discursive resources available to them when navigating systems of care. Three sets of discourses-discourses of normativity, discourses of temporality, and discourse of access-characterized participants' narratives. We discuss how participants negotiated discursively situated systems of power in order to ensure their safety and access to care.

Purpose:We sought to expand telehealth at an academic multidisciplinary pediatric gender center to increase access to gender-affirming care without compromising communication, privacy, or patient satisfaction.Materials and Methods:Patient needs assessments were performed from January 2019 to March 2020. The severe acute respiratory syndrome coronavirus 2 pandemic accelerated implementation of the quality improvement project, and clinically appropriate patients were scheduled for video visits starting March 16, 2020. From September 8, 2020 to October 2, 2020, caregivers of transgender and gender diverse (TGD) minors or TGD young adults pursuing gender-affirming medications completed 9-item surveys evaluating communication quality and privacy, access to care, and quality of services for video and clinic visits. Answers were rated via Likert scales (1 = strongly agree, 5 = strongly disagree; 1 = less travel time, 4 = more travel time).Results:Needs assessment (n = 69) showed that 63.8% felt that video visits would improve follow-up. Survey participants (n = 91) reported statistically significant differences (p < 0.05) in several areas. Compared with clinic visits, video visits were more convenient, 1.21 ± 0.435 versus 2.36 ± 1.207, took less time from other activities, 4.55 ± 0.522 versus 2.93 ± 1.281, required less travel time, 1.03 ± 0.180 versus 2.63 ± 0.901, and were more acceptable, 1.35 ± 0.545 versus 1.65 ± 0.736. Participants were more likely to choose video visits in the future, 1.32 ± 0.555 versus 1.57 ± 0.732. There were no statistically significant differences in communication quality, privacy, or overall satisfaction.Conclusion:An integrated clinic-video visit model increases access to gender-affirming care for TGD youth while maintaining excellent communication, privacy, and patient satisfaction.

To characterize transgender adolescents' sexual behaviors, identities, and their perceived experiences with sex education.

Semi-structured interviews were conducted and addressed sexual experiences and perceptions of sex education received from family, school educators, and healthcare providers. Interviews were audio recorded, transcribed, and analyzed utilizing NVivo 12 software for thematic analysis.

Child and adolescent gender services clinic at a Midwestern university-based medical center in the United States.

30 transgender adolescents between the ages of 15 to 20.

Themes generated during semi-structured interviews.

Sexual orientations were inclusive of attractions to a spectrum of gender identities. Libido was perceived to be impacted by gender-affirming hormone therapy, which was unanticipated for some adolescents. Family and school-based sex education was perceived to be relevant only for heterosexual and cisgender adolescents. Inclusive education for transgender adolescents was desired. Counseling provided by gender-affirming providers on sexual health was trusted and other healthcare providers were perceived to lack training on gender-inclusive care.

This study demonstrated that families and school educators did not provide sex education perceived to be applicable to transgender adolescents. Similarly, healthcare providers of transgender adolescents were perceived to not provide inclusive or comprehensive medical care in comparison to physicians who routinely provide gender-affirming care. Gaps in education and healthcare could be improved with sex education outreach or training for families and school educators as well as the development and implementation of professional competencies for pediatricians on transgender adolescent healthcare.

Growing data on suicidal behavior among members of the lesbian, gay, bisexual, transgender, queer, questioning, and other sexual/gender minority (LGBTQ+) communities, particularly in the transgender subgroup, demonstrate that there is a stark elevation in suicidality compared with rates in their cisgender counterparts. Among the available theories of suicide, the interpersonal theory of suicide (IPTS) is a plausible explanation for the increased suicidal behaviors among transgender youths.

The objective of this study was to examine the pathologic basis of treatment-resistant suicidality in transgender youth despite favorable environments using the theoretical framework of the IPTS, supported by a literature review and case series.

We conducted a literature review using PubMed and PsycInfo with key words suicidal ideation, suicidality, transgender, transgender youth, gender dysphoria, and interpersonal theory of suicide. Seventy-eight articles were retrieved, which were then narrowed down to 30 articles after non-English articles and irrelevant topics were excluded. The clinical presentations of 5 transgender youths, 11 to 17 years of age, were found to be correlated with relevant reports in the research literature, implying a plausible rationale for elevated rates of suicide. All patients and families supplied verbal consent for these case reports to be published.

Reasons for suicidal behavior among the patients included thwarted belongingness and perceived burdensomeness leading to perpetual suicidal behavior. The presence in these cases of the following contributing factors in the IPTS-thwarted belongingness, perceived burdensomeness, and acquired capability for suicide-suggests that such a basis exists. Perceived burdensomeness appears to have a greater correlation with developing suicidal behavior than thwarted belongingness alone, but the presence of both demonstrates the highest risk of suicidality in transgender youth. Transgender children and adolescents are at extremely high risk of suicidal behavior, but little research has been devoted to the etiology and plausible explanations for this elevated risk, despite growing awareness of and support for the problem. This review suggests further research is required on the triadic factor interactions of the IPTS model that could help us to better understand and intervene with this high-risk population.

To examine the impact of standardized patient encounters (SPEs) on gender-affirming communication skills and self-efficacy of pediatrics learners.

Fourth-year medical students, pediatrics interns, psychiatry interns, and nurse practitioner trainees on 1-month adolescent medicine blocks completed a curriculum with e-learning activities that was expanded to include SPEs. Following e-learning, learners completed 2 SPEs featuring transgender adolescent cases. Faculty observers and standardized patients completed checklists focused on history-taking, counseling, and interpersonal communication, and provided learner feedback after each case. The curriculum was evaluated by comparing skills checklists scores from case 1 to case 2 via Wilcoxon signed-rank tests. Self-efficacy was assessed precurriculum (Assessment 1), post-e-learning (Assessment 2), and post-SPE (Assessment 3) using a previously developed instrument. Changes in self-efficacy scores were assessed via linear regression models with generalized estimating equations.

Forty-three eligible learners participated in the study. The majority were pediatrics interns, and 5 learners had worked in a transgender clinic prior to the curriculum participation. Learners increased median total checklist scores between cases from 22 to 28 (P < .001) (maximum score of 34). Learners' overall self-efficacy scores improved by 3.4 (confidence interval [CI]: 2.9-3.9; P < .001) between Assessments 1 and 2 and by 1.5 (CI: 1.2-1.7; P < .001) from Assessment 2 to 3. Similar improvements in checklist scores and self-efficacy occurred within stratified learner types.

The combination of SPEs with e-learning is effective at improving self-efficacy and gender-affirming communication skills for a multidisciplinary pediatrics learners. The comprehensive curriculum allowed learners inexperienced with transgender youth to apply knowledge and practice skills.

This descriptive study reports caregiver experiences with GnRH agonist implants among a cohort of youth followed in a pediatric hospital-based gender clinic. We administered a survey to 36 of 55 eligible caregivers ascertaining demographics and satisfaction, with a medical record review of any surgical complications. The overwhelming majority (97.1%) reported satisfaction with the procedure and would undergo the implant procedure again (94.4%). The most frequent challenges noted were about affordability (39.8%) and insurance denials (39.8%). Implantable GnRH agonist can be used successfully in pediatric patients with gender dysphoria. Future policy should seek to address concerns regarding insurance approval and reimbursement.

This study aimed to pilot systematic gender identity screening during adolescent well checks and examine perceptions of feasibility and acceptability of screening from adolescents, parents/guardians, and clinicians.

Adolescents aged 12-18 years with a well visit between July 1, 2018, and June 30, 2019 (n = 134,114; 817 pilot and 133,297 usual care) in Kaiser Permanente Northern California (KPNC) pediatric primary care clinics. "What is your gender?" was added to the previsit questionnaire in pilot clinics; all other KPNC clinics provided usual care. Additional anonymous surveys were administered to adolescents and parents/guardians in the pilot clinics and to all KPNC pediatric clinicians. Multivariable logistic regression examined associations between clinics and patients reporting as transgender and gender diverse (TGD). Descriptive statistics summarized patient, parent/guardian, and clinician perceptions of gender identity screening.

Adjusting for age and race/ethnicity, adolescents had higher odds of reporting as TGD in pilot clinics than in usual care (odds ratio = 6.91, 95% confidence interval = 3.76-12.74). Two thirds of adolescents, 75.5% of parents/guardians, and 92.5% of clinicians felt it was important to screen for gender identity in primary care. Less than 2% of adolescents found the question confusing, offensive, or uncomfortable, and 2.8% of parents/guardians felt it was offensive. In addition, 36.4% of clinicians and 3.6% of parents/guardians were concerned it would affect visit workflow/time.

Most adolescents, parents/guardians, and pediatric clinicians viewed systematic gender identity screening as both feasible and acceptable. Standardized gender identity screening during adolescent well checks could facilitate and increase identification of TGD adolescents and the delivery of gender-affirming care for adolescents and families in need.

There is a growing number of youth and their parents seeking assistance from care providers related to gender dysphoria and transitional care for transgender and gender-nonconforming (TGNC) youth. The purpose of this study was to determine pediatric nurse practitioners' (PNP) attitudes/beliefs and knowledge/competence in caring for TGNC youth.

This cross-sectional descriptive study surveyed PNPs (N = 93) from eight states using two survey instruments to measure attitudes and beliefs and knowledge and perceived competence related to caring for TGNC youth.

Eighty-one percent of PNPs reported caring for TGNC youth in their practice. Despite this, only 15% of the PNPs received education related to transgender patients during their advanced practice education. Results showed that attending continuing education offerings related to caring for TGNC patients increases PNP perceived competence as well as knowledge. Attitudes and behaviors towards the transgender population were also more positive if the PNP had attended continuing nursing education offerings. Three themes emerged from a qualitative portion of the survey, asking the participant to share thoughts related to caring for transgender youth: lack of education for healthcare providers, the need to refer patients to comprehensive gender services, and the need for support for transgender patients and their families.

Education plays an important part in nurses' attitudes, beliefs, and perceived competence in caring for transgender patients. Because the PNP is likely to be exposed to patients with TGNC, it is imperative they seek out opportunities to learn about transgender issues and caring for transgender patients.

In recent years, Italy, similar to many other countries, has witnessed an increase in children and adolescents presenting gender incongruence. This trend has led to the development and implementation of specialized centers providing care and support for these youths and their families. The present study aimed at investigating the functioning of agencies specialized in working with transgender and gender non-conforming youths in the Italian territory. Professionals in these agencies were interviewed about their perspectives on their agency's functioning, networks with other services, and work with trans* youths and their families. A semi-structured interview was developed and administered to professionals in specialized centers and associations dedicated to trans * youths, and deductive thematic analysis was applied to the transcripts. Eight professionals were interviewed: six working in specialized centers and two working in associations. The qualitative analyses of transcripts revealed four main themes, pertaining to service referrals, assessment protocols and intervention models, psychological support for youths and families, and agency shortcomings. The study explored the functioning of Italian agencies specialized in caring for transgender and gender non-conforming youths, from the perspective of professionals working in these agencies. While several positive aspects of the work emerged, the study highlighted a lack of uniformity across the Italian territory and the need for better networks between agencies and other medical professionals.

Evidence suggests that psychosexuality in humans is modulated by both organizational effects of prenatal and peripubertal sex steroid hormones, and by activational effects of circulating hormones in adulthood. Experimental work in male rodents indicates that sensitivity to androgen-driven organization of sexual motivation decreases across the pubertal window, such that earlier puberty leads to greater sex-typicality. We test this hypothesis in typically developing men (n = 231) and women (n = 648), and in men (n = 72) and women (n = 32) with isolated GnRH deficiency (IGD), in whom the precise timing of peripubertal hormone exposure can be ascertained via the age at which hormone replacement therapy (HRT) was initiated. Psychosexuality was measured with the Sexual Desire Inventory-2 (SDI-2) and Sociosexual Orientation Inventory-Revised (SOI-R). In both sexes, earlier recalled absolute pubertal timing predicted higher psychosexuality in adulthood, although the magnitude of these associations varied with psychosexuality type and group (i.e., typically developing and IGD). Results were robust when controlling for circulating steroid hormones in typically developing participants. Age of initiation of HRT in men with IGD negatively predicted SOI-R. We discuss the clinical implications of our findings for conditions in which pubertal timing is medically altered.

Experiments in male rodents demonstrate that sensitivity to the organizational effects of steroid hormones decreases across the pubertal window, with earlier androgen exposure leading to greater masculinization of the brain and behavior. Similarly, some research suggests the timing of peripubertal exposure to sex steroids influences aspects of human psychology, including visuospatial cognition. However, prior studies have been limited by small samples and/or imprecise measures of pubertal timing. We conducted 4 studies to clarify whether the timing of peripubertal hormone exposure predicts performance on male-typed tests of spatial cognition in adulthood. In Studies 1 (n = 1095) and 2 (n = 173), we investigated associations between recalled pubertal age and spatial cognition in typically developing men, controlling for current testosterone levels in Study 2. In Study 3 (n = 51), we examined the relationship between spatial performance and the age at which peripubertal hormone replacement therapy was initiated in a sample of men with Isolated GnRH Deficiency. Across Studies 1-3, effect size estimates for the relationship between spatial performance and pubertal timing ranged from. -0.04 and -0.27, and spatial performance was unrelated to salivary testosterone in Study 2. In Study 4, we conducted two meta-analyses of Studies 1-3 and four previously published studies. The first meta-analysis was conducted on correlations between spatial performance and measures of the absolute age of pubertal timing, and the second replaced those correlations with correlations between spatial performance and measures of relative pubertal timing where available. Point estimates for correlations between pubertal timing and spatial cognition were -0.15 and -0.12 (both p < 0.001) in the first and second meta-analyses, respectively. These associations were robust to the exclusion of any individual study. Our results suggest that, for some aspects of neural development, sensitivity to gonadal hormones declines across puberty, with earlier pubertal hormone exposure predicting greater sex-typicality in psychological phenotypes in adulthood. These results shed light on the processes of behavioral and brain organization and have implications for the treatment of IGD and other conditions wherein pubertal timing is pharmacologically manipulated.

Transgender and gender nonconforming (TGNC) populations are disproportionately affected by limited health care access and poor health outcomes and commonly report discrimination and mistreatment in health care settings. Despite these disparities, comprehensive approaches to improve the quality of health care of TGNC patient populations are currently lacking.

The Vanderbilt Program for LGBTQ Health has developed a multifaceted, community-engaged approach to improve the quality of health care of TGNC patients, which includes the creation of a transgender patient advocacy program, a community advisory board, and a transgender health clinic. To support the continuous quality improvement of transgender health care, the program is currently piloting a novel multilevel monitoring and evaluation (M&E) system to collect information at the individual patient visit and health systems levels.

The next steps for Vanderbilt's community-engaged M&E system are to identify the clinics and health services most used by TGNC patients and assess the level of patient satisfaction in each area. This process will support the identification of high- and low-performing clinics and health services and allow for targeted delivery of trainings to improve the quality of culturally competent health care TGNC patients receive systemwide.

In collaboration with TGNC patient populations and community stakeholders, Vanderbilt has created a model to improve the quality of both transition- and non-transition-related health care at the systems level that can be adopted by other health care systems nationally.

This article analyzes the relevance of the comprehensive definition of sexual and reproductive health and rights (SRHR) to adolescents and identifies adolescent-specific implications for the implementation of an essential package of SRHR interventions. The delivery of a comprehensive approach to SRHR targeting adolescents is underpinned by five principles-equity, quality, accountability, multisectorality, and meaningful engagement. All SRHR interventions included in the package are relevant to adolescents, given the diversity of adolescents' SRHR needs and considering their specific attributes, circumstances, and experiences. Ensuring that this package is available, accessible, and acceptable to adolescents requires an approach that looks at adolescents as being biologically and socially distinct from other age groups and acknowledges that they face some specific barriers when accessing SRHR services. This article provides cross-cutting strategies for the implementation of a comprehensive approach to SRHR for adolescents and specific considerations in delivering each intervention in the package of essential SRHR interventions. To further implement the International Conference on Population and Development Programme of Action, a prerequisite for achieving the Sustainable Development Goals, SRHR interventions must be adolescent responsive, delivered through multiple platforms, leveraging multisectoral collaboration, and strengthening accountability and participation.

Transgender and non-binary (TNB) youth face disparities in sexual health risks compared with cisgender peers. Comprehensive sex education programs have the potential to result in delayed sexual debut, increased condom and contraceptive use, and reduced sexual risk-taking; however, little research has explored the specific sex education needs of TNB youth.

To use insights from TNB youth, parents of TNB youth, and healthcare affiliates to understand deficits in sex education experienced by TNB youth, and to elicit recommended content for a comprehensive and trans-inclusive sex education curriculum.

We conducted 21 in-depth interviews with non-minor TNB youth (n = 11) and with parents (n = 5) and healthcare affiliates (n = 5) of TNB youth recruited from Seattle Children's Gender Clinic and local TNB community listerv readerships. Data was analyzed using theoretical thematic analysis.

Participants described prior sex education experiences and content needs of TNB youth.

Participants described 5 key sources where TNB youth received sexual health information: school curricula, medical practitioners, peers, romantic partners, and online media. Inapplicability of school curricula and variable interactions with medical practitioners led youth to favor the latter sources. 8 content areas were recommended as important in sex education for TNB youth: puberty-related gender dysphoria, non-medical gender-affirming interventions, medical gender-affirming interventions, consent and relationships, sex and desire, sexually transmitted infection prevention, fertility and contraception, and healthcare access.

Dependence on potentially inaccurate sex education sources leaves TNB youth vulnerable to negative outcomes, including sexually transmitted infections, pregnancy, unsanitary/unsafe sex toy use, and shame about their body or sexual desires.

Strengths included capturing perspectives of an underserved population using open-ended interview questions, which allowed topics of greatest importance to participants to arise organically. Limitations included a sample size of 21 participants, and racial and geographic homogeneity of youth and parent participants. Only 1 author identifies as TNB. One-on-one interview methods may have omitted participants who would otherwise have been willing to share their perspective in a more impersonal format.

This study demonstrates that TNB youth have unique sex education needs that are not well covered in most sexual health curricula. Recommended content for this population includes standard sex education topics that require trans-inclusive framing (eg, contraception), topics specific to TNB youth (eg, gender-affirming medical interventions), and topics absent from standard curricula that warrant universal teaching (eg, information on consent as it relates to sex acts aside from penile-vaginal sex). Haley SG, Tordoff DM, Kantor AZ, et al. Sex Education for Transgender and Non-Binary Youth: Previous Experiences and Recommended Content. J Sex Med 2019;16:1834-1848.

The aim of the article was to understand adolescents' and parents' decision-making process related to gender-affirming hormone therapy (GAHT).

We conducted qualitative semistructured interviews with transgender adolescents who began testosterone for GAHT in the prior year and the parents of such adolescents. Questions focused on decision-making roles, steps in the decision process, and factors considered in the decision. Participants used pie charts to describe the division of responsibility for the decision. All interviews were coded by at least two members of the research team with disagreements resolved through discussion. Thematic analysis was used to analyze the data.

Seventeen adolescents and 13 parents were interviewed (12 dyads). The process of deciding about GAHT involves a series of small conversations, typically with the adolescent advocating to start treatment and the parent feeling hesitant. In most cases, after seeking information from the Internet, healthcare providers and personal contacts move toward acceptance and agree to start treatment. Although adolescents have some short-term concerns, such as about needles, parents' concerns relate more to long-term risks. Ultimately, for both parents and adolescents, the benefits of treatment outweigh any concerns, and they are in agreement about the goals of personal confidence, comfort in one's body and happiness.

To the extent that the decision about GAHT is a medical decision, the decision process is similar to others. However, decisions about GAHT are much more about gender identity than medical risks, suggesting that interventions based in a medical framework may not aid in supporting decision-making.

Gender diverse people are individuals who define their gender as different from the sex they were assigned as birth. This incongruence leads to a sense of discomfort within oneself, which according to the DSM-V is called gender dysphoria. The combination of dysphoria, ongoing stress, as outlined in the Minority Stress Theory (Meyer, 2003, Dohrenwend, 2000) and the stigma related to living in a society which traditionally defines gender as binary and rejects the notion of gender as fluid, is associated with psycho-social, mental, and physical health problems. Gender diverse children and young people require support from health practitioner to assist them not only in transitioning, if this is what they choose, but also to manage ongoing and preventive health care in a system which is not always welcoming and frequently hostile to them. In 2012 the United Nations General Assembly called for universal health coverage as a goal in the post-2015 Millennium Development Goal Framework. One step in attaining this goal is universal health access which is not currently being met for gender diverse individuals. Hence, we need to work together, with those that we serve, to develop appropriate, sensitive and accessible health care for all.

The measurement of puberty is an intricate and precise task, requiring a match between participants' developmental age and appropriate techniques to identify and capture variations in maturation. Much of the foundational work on puberty and its psychosocial correlates was conducted several decades ago. In this article, we review the biological foundation of puberty; the operationalization of puberty in statistical analyses; and strategies for considering diversity and social context in research to help researchers align measurement with meaningful conceptual questions. These three areas are particularly important, given new statistical techniques, greater awareness of individual variations in development, and key differences between past cohorts and youth coming of age today.

Youth programs and policies provide opportunities for institutions and societies to support healthy adolescent development. Puberty education programs are universally important, as they provide crucial knowledge and skills to help youth and their caregivers navigate the physical, emotional, and interpersonal changes of puberty with positive outcomes. However, few puberty programs have been rigorously evaluated, resulting in a lack of evidence-based knowledge and practice in this area. This review examines the status of research on puberty education and related programs and draws on the broader intervention literature and recent research findings on adolescence to identify program features that might improve program effectiveness. Implications for policy are also discussed. The need for rigorous program evaluation is emphasized throughout.

Decades of puberty research have yielded key scientific discoveries. Building on the field's rich history, we highlight four understudied populations: youth of color, boys, sexual minority youth, and gender minority youth. We explore why scientific study has been slow to evolve in these groups and propose paths forward for exciting new work. For ethnically racially diverse youth, we discuss the need to incorporate culture and context. For boys, we highlight methodological issues and challenges of mapping existing conceptual models onto boys. For sexual and gender minority youth, we discuss unique challenges during puberty and suggest ways to better capture their experiences. With an eye toward a new era, we make recommendations for next steps and underscore the importance of transdisciplinary research.

To compare experiences for adverse events, especially sexual abuse, and mental health in a group of high school students in out-of-home care with a representative sample of peers of the same age and similar educational attainment living with their parents.

A sample of 5839 students in the third year of Swedish high school, corresponding to a response rate of 59.7%, answered a study specific questionnaire. Data from 41 students living in out-of-home care were compared with data from peers not in out-of-home care in a cross-sectional analyze.

Students in out-of-home care had more often an immigrant background and a non-heterosexual orientation, had more often experienced physical and penetrative sexual abuse, and more often sought healthcare for mental problems. Disclosure of sexual abuse was less common, and acts of persuasion or adults' use of their social position was more common among students in out-of-home care.

Even where the protective factor 'senior educational attainment' is present, risks for abuse and poor mental health are evident for adolescents in out-of-home care. Disclosure of adversity, when it has occurred, ought to be higher among these adolescents with regular contact with social services, but our findings indicate tendencies for the opposite. We therefore suggest routines to be established to screen for adverse life events and mental health actively, along with general and systematic assessments of adversity and mental health during care.

As a traditionally underserved population that faces numerous health disparities, youth who identify as transgender and gender diverse (TGD) and their families are increasingly presenting to pediatric providers for education, care, and referrals. The need for more formal training, standardized treatment, and research on safety and medical outcomes often leaves providers feeling ill equipped to support and care for patients that identify as TGD and families. In this policy statement, we review relevant concepts and challenges and provide suggestions for pediatric providers that are focused on promoting the health and positive development of youth that identify as TGD while eliminating discrimination and stigma.

Venous thromboembolism can be precipitated by both genetic and acquired factors, but the role of testosterone therapy is less clear. Here, we present a 17-year-old transgender adolescent, transitioning from female to male, receiving both estrogen and testosterone therapy, who developed a pulmonary embolism without an underlying genetic thrombophilic condition. As transgender medical care evolves, the use of testosterone as cross-sex hormone therapy in adolescents is likely to increase. Our review suggests that care must be taken when initiating treatment with testosterone, and modification of other thrombophilic risks should be explored before starting therapy in this population.

Research in disorders of sex development (DSD) is hindered by a lack of standardized measures sensitive to the experiences of affected children and families. We developed and evaluated parent proxy (children 2-6 years) and parent self-report (children ≤6 years) health-related quality of life (HRQoL) instruments for DSD.

Items were derived from focus groups and open-ended interviews. Clarity and comprehensiveness were assessed with cognitive interviews. Psychometric properties were examined in a field survey of 94 families.

Measures demonstrated adequate to good psychometrics, including internal consistency, test-retest reliability, convergent validity, and ability to detect known-group differences. Parents reported greatest stress on Early Experiences , Surgery , and Future Concerns scales.

These instruments identify patients' and families' needs, monitor health and quality of life status, and can evaluate clinical interventions. Findings highlight the need for improved psychosocial support during the diagnostic period, better parent-provider communication, and shared decision-making. HRQoL measures are needed for older youth.

There is often a gap between politics and science, but the influence across the gap is bidirectional. This editorial considers a longitudinal, community-based sample of children and adolescents and asks about risks from early childhood gender non-conformity and adolescent reported sexual minority status for subsequent anxiety disorders. It is especially valuable to have longitudinal data from a non-referred sample to address questions of risk, and the investigators must be complemented for having foresight about these questions twenty years ago. The topics of our investigations are informed and motivated by cultural assumptions, pressures and conflicts. In the example discussed, transgender people are not new, but research on their development is fairly recent, as they are culturally now more accepted as different rather than pathological. Research findings also matter to the culture. Dropping homosexuality as a mental disorder in formal nosologies occurred with significant scientific substantiation. The value of this research to enhance clinical care and offer informed parental guidance about children of a minority status cannot be overemphasized.

College students are at high risk for mental health problems, yet many do not receive treatment even when services are available. Treatment needs may be even higher among sexual minority students, but little is known about how these students differ from heterosexual peers in terms of mental health needs and service utilization.

A total of 33,220 California college students completed an online survey on mental health needs (e.g., current serious psychological distress and mental health-related academic impairment) and service utilization. Using logistic regressions, we examined differences in student characteristics, mental health service use, and perceived barriers to using on-campus services by sexual minority status.

Approximately 7% of students self-identified as sexual minorities. Compared with heterosexual students, sexual minority students endorsed higher rates of psychological distress (18% vs. 26%, p < .001) and mental health-related academic impairment (11% vs. 17%, p < .001) but were 1.87 (95% confidence interval: 1.50-2.34) times more likely to use any mental health services. Sexual minority students were also more likely to report using off-campus services and to endorse barriers to on-campus service use (e.g., embarrassed to use services and uncertainty over eligibility for services).

Sexual minority individuals represent a sizeable minority of college students; these students use mental health services at higher rates than heterosexual peers but have high rates of unmet treatment need. Efforts to address commonly reported barriers to on-campus service use, foster sexual minority-affirmative campus environments, and promote awareness of campus services may help reduce unmet treatment need in this population.

The purpose of this Position Statement is to emphasize the importance of an affirmative approach to the health care of transgender individuals, as well as to improve the understanding of the rights of transgender youth.

Transgender youth have optimal outcomes when affirmed in their gender identity, through support by their families and their environment, as well as appropriate mental health and medical care.

The Pediatric Endocrine Society Special Interest Group on Transgender Health joins other academic societies involved in the care of children and adolescents in supporting policies that promote a safe and accepting environment for gender nonconforming/transgender youth, as well as adequate mental health and medical care. This document provides a summary of relevant definitions, information and current literature on which the medical management and affirmative approach to care of transgender youth are based.

Prevalence of suicide attempts, self-injurious behaviors, and associated psychosocial factors were examined in a clinical sample of transgender (TG) adolescents and emerging adults (n = 96). Twenty-seven (30.3%) TG youth reported a history of at least one suicide attempt and 40 (41.8%) reported a history of self-injurious behaviors. There was a higher frequency of suicide attempts in TG youth with a desire for weight change, and more female-to-male youth reported a history of suicide attempts and self-harm behaviors than male-to-female youth. Findings indicate that this population is at a high risk for psychiatric comorbidities and life-threatening behaviors.

Transgender is an umbrella term used to describe individuals who identify with a gender incongruent to or variant from their sex recorded at birth. Affirming gender identity through a variety of social, medical, and surgical interventions is critical to the mental health of transgender individuals. In recent years, awareness surrounding transgender identities has increased, which has highlighted the health disparities that parallel this demographic. These disparities are reflected in the experience of transgender patients and their providers when seeking clinical laboratory services.

Little is known about the effect of gender-affirming hormone therapy and surgery on optimal laboratory test interpretation. Efforts to diminish health disparities encountered by transgender individuals and their providers can be accomplished by increasing social and clinical awareness regarding sex/gender incongruence and gaining insight into the physiological manifestations and laboratory interpretations of gender-affirming strategies. This review summarizes knowledge required to understand transgender healthcare including current clinical interventions for gender dysphoria. Particular attention is paid to the subsequent impact of these interventions on laboratory test utilization and interpretation. Common nomenclature and system barriers are also discussed.

Understanding gender incongruence, the clinical changes associated with gender transition, and systemic barriers that maintain a gender/sex binary are key to providing adequate healthcare to transgender community. Transgender appropriate reference interval studies are virtually absent within the medical literature and should be explored. The laboratory has an important role in improving the physiological understanding, electronic medical system recognition, and overall social awareness of the transgender community.