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Purpose: Transgender adolescents and adolescents with eating disorders (EDs) are known to have increased mental health comorbidity; however, little is understood about how gender dysphoria (GD), disordered eating and mental health disorders relate to each other. The purpose of this study was to examine associations between GD, ED, and mental health diagnoses among adolescents., Methods: Data were extracted from the electronic health records of 57,353 patients aged 9-18 seen at a single pediatric health system between 2009 and 2022. Adjusted logistic regression models tested for associations between GD, ED, and mental health diagnoses., Results: Youth with a GD diagnosis had significantly greater odds of also having an ED diagnosis compared to those without a GD diagnosis (adjusted odds ratio [aOR] = 3.72, 95% confidence interval [CI]: 2.98-4.64). Among those with an ED diagnosis, youth with a GD diagnosis had significantly lower odds of having an anorexia nervosa diagnosis (aOR = 0.34, 95% CI: 0.18-0.61) and significantly greater odds of having an unspecified or other specified ED diagnosis (aOR = 2.48, 95% CI: 1.56-3.93) compared to those without a GD diagnosis. Youth with both GD and ED diagnoses had significantly greater odds of also having a diagnosis of anxiety (aOR = 24.01, 95% CI: 14.85-38.83), depression (aOR = 48.41, 95% CI: 30.38-77.12), suicidality (aOR = 26.15, 95% CI: 16.65-41.05) and self-harm (aOR = 35.79, 95% CI: 22.48-56.98) as compared to those with neither a GD nor an ED diagnosis., Discussion: Adolescents with co-occurring GD and ED diagnoses are at greater risk for anxiety, depression, suicidality, and self-harm as compared to youth with neither diagnosis. Further research is essential to understand the complex interplay of mental health concerns and EDs among gender diverse adolescents and to inform appropriate interventions., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To understand if and why guardians access their adolescent child's electronic health record patient portal account., Methods: Guardians of transgender and gender-diverse adolescents completed a survey regarding patient portal use. Descriptive statistics were used to describe items related to guardian access to adolescent portal accounts., Results: Of 82 respondents, 37.8% indicated they had used their child's login to access the patient portal. Most indicated they accessed their adolescent's account because their child asked them to do so. Other common reasons included being worried they might miss important health information and not realizing there was a difference between patient and proxy accounts., Discussion: Results of this study provide a more detailed understanding regarding guardian access to adolescent patient portals. Findings can be used to inform adolescent patient portal design and enrollment practices that protect adolescent confidentiality., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

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 (

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., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Both affirming environments and access to gender-affirming medical care have a positive impact on the mental health of transgender and gender diverse (TGD) youth, however, many TGD youth experience barriers in accessing this care. Pediatric primary care providers (PCPs) can play an important role in expanding access to gender-affirming care for TGD youth; however, few currently provide this care. The purpose of this study was to explore pediatric PCPs' perspectives regarding barriers they experience to providing gender-affirming care in the primary care setting., Methods: Pediatric PCPs who had sought out support from the Seattle Children's Gender Clinic were recruited via email to participate in semistructured, one-hour Zoom interviews. All interviews were transcribed and then subsequently analyzed in Dedoose qualitative analysis software using a reflexive thematic analysis framework., Results: Provider participants (n = 15) represented a wide range of experiences with respect to years in practice, number of TGD youth seen, and practice location (urban, rural, suburban). PCPs identified both health system and community-level barriers to providing gender-affirming care to TGD youth. Health system-level barriers included: (1) lack of foundational knowledge and skills, (2) limited clinical decision-making support, and (3) health system design limitations. Community-level barriers included (1) community and institutional biases, (2) provider attitudes regarding gender-affirming care provision, and (3) challenges identifying community resources to support TGD youth., Discussion: A multitude of health system and community-level barriers must be overcome in the pediatric primary care setting to ensure that TGD youth receive timely, effective, and more equitable gender-affirming care., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To explore differences in healthcare experiences, healthcare avoidance, and well visit attendance between binary and nonbinary transgender adolescents; also, to explore the association between distinct healthcare experiences and healthcare avoidance and well visits., Methods: We surveyed transgender adolescents ages 12-26 (n = 156) recruited from a multidisciplinary gender clinic from July through November 2018. Differences in distinct healthcare experiences by demographics were assessed using multivariable linear regression. Multivariable logistic regression was used to examine independent associations between demographics and lifetime healthcare avoidance and past-year well visit and also, associations between distinct healthcare experiences and lifetime healthcare avoidance and past-year well visit., Results: Compared to transfeminine adolescents, more non-affirming healthcare experiences were reported by nonbinary (β = 1.41, 95% confidence interval [CI]: 0.49, 2.33) and transmasculine adolescents (β = 0.78, 95% CI: 0.02, 1.53). Gender-affirming healthcare experiences did not differ by demographics. Transmasculine adolescents had over three times the odds of lifetime healthcare avoidance (adjusted odds ratio [aOR] = 3.58, 95% CI: 1.41, 9.08) than transfeminine peers. Only younger age was associated with past-year well visit (aOR = 3.83, 95% CI: 1.44, 10.17). Non-affirming healthcare experiences were positively associated with healthcare avoidance (aOR = 1.85, 95% CI: 1.47, 2.34). Gender-affirming healthcare experiences were not associated with healthcare avoidance or past-year well visit., Discussion: Nonbinary and transmasculine adolescents experienced more non-affirming healthcare experiences than transfeminine adolescents. Non-affirming healthcare experiences were associated with healthcare avoidance, which was disproportionately more prevalent among transmasculine adolescents. Providers must be better equipped to provide inclusive, gender-affirming care to increase receipt of care for transgender adolescents beyond specialized gender clinics., (Published by Elsevier Inc.)

Background: Evidence-based strategies are needed to support appropriate use of telemedicine for initial outpatient subspecialty consultative visits. To inform such strategies we performed a survey of general pediatricians and pediatric subspecialists about use of telemedicine for patients newly referred for pediatric subspecialty care., Methods: We developed and fielded an e-mail and postal survey of a national sample of 840 general pediatricians and 840 pediatric subspecialists in May and June 2020., Results: Of 266 completed surveys (17% response rate), 204 (76%) thought telemedicine should be offered for some and 29 (11%) thought telemedicine should be offered for all initial subspecialist visits. Most respondents who indicated telemedicine should be offered for some initial consultations believed this decision should be made by subspecialty attendings (176/204, 86%). Respondents prioritized several data elements to inform this decision, including clinical information and family-based contextual information (e.g., barriers to in-person care, interest in telemedicine, potential communication barriers). Factors perceived to reduce appropriateness of telemedicine for subspecialty consultation included need for interpreter services and prior history of frequent no-shows. Responses from generalists and subspecialists rarely differed significantly., Conclusions: Survey results suggest potential opportunities to support the appropriate use of telemedicine for initial outpatient pediatric subspecialty visits through structured transfer of specific clinical and contextual information at the time of referral and through strategies to mitigate perceived communication or engagement barriers., Implication: Pediatric physician beliefs about telemedicine for initial outpatient subspecialty consultative visits may inform future interventions to support appropriate telemedicine use., Level of Evidence: Survey of a national sample of clinicians., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: We aimed to examine transgender youths' interest in receiving gender-affirming care via telemedicine or through primary care with telehealth support., Methods: We surveyed 12- to 26-year-old transgender youth receiving care in a multidisciplinary gender clinic. Descriptive statistics and bivariate analyses were used to assess relationships between demographic and gender-related characteristics and interest in receiving care via telemedicine., Results: Almost half (47%) of the 204 youth surveyed expressed interest in receiving gender care via telemedicine. Additionally, youth with lower levels of perceived parental support were more likely to express an interest in utilizing telemedicine (p = .001). Approximately half (45%) of youth were interested in receiving gender care in the primary care setting, with a majority expressing willingness to do so if their primary care provider had telehealth support., Conclusions: Many transgender youth expressed interest in receiving gender care via telehealth, particularly for ongoing care and monitoring. Increased interest in telemedicine was seen among youth with lower perceived parental support., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

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., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2020. Published by Elsevier B.V.)

Purpose: Transgender youth face significant health disparities and multiple barriers to receiving quality health care. Gender identity disclosure to health care providers (HCPs) is an important step in creating affirming relationships for transgender youth. The objectives of this study were to (1) determine the prevalence of voluntary disclosure and intentional avoidance to HCPs outside of gender clinics, (2) identify factors associated with voluntary disclosure and intentional avoidance, and (3) elucidate strategies to increase comfort with disclosure., Methods: A cross-sectional survey was administered to transgender youth aged 12-26 years. Bivariate analyses were conducted using χ 2 or Fisher's exact tests. Two logistic regression models for each outcome variable were used to examine factors associated with voluntary disclosure and intentional avoidance., Results: Two thirds (65%) of youth (N = 153) identified as transmasculine, and 57% were under 18 years. Three-quarters (78%) had voluntarily disclosed their gender identity to an HCP outside of gender clinic, whereas 46% had intentionally avoided disclosure. Odds ratios (ORs) of ever having disclosed were lower for participants ≥18 years (OR = .33; 95% confidence interval [CI]: .11-.98), those out to fewer people (OR = .12; 95% CI: .02-.81) and out for <1 year (OR = .03; 95% CI: .004-.31). Odds of intentional avoidance were lower among youth with higher perceived parental support (OR = .83; 95% CI: .70-.98)., Conclusion: A majority of transgender youth reported having voluntarily disclosed their gender identity to an HCP outside of gender clinic, but almost half reported having intentionally avoided disclosure when they felt it was important. Parental support may play a protective role in mitigating avoidance., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Increasing numbers of transgender youth are receiving hormone therapy in accordance with national and international guidelines. This study sought to determine the effect of testosterone on body mass index (BMI) z-score in transmasculine adolescents at 6 and 12 months after initiation., Methods: A retrospective chart review collected anthropomorphic data on transmasculine adolescents, aged 13 to 19 years, before and during testosterone use. These measurements were used to create a linear mixed model to explore the change in BMI z-score after initiating testosterone., Results: The increase in BMI z-score in transmasculine adolescents was significantly higher after six months of testosterone use, but there was no significant change between baseline and 12 months., Conclusions: Additional study is needed to understand the full short- and long-term impact of testosterone use on BMI z-score in transmasculine adolescents to provide appropriate informed consent and develop interventions to improve health outcomes., (Copyright © 2019 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)