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Gender diverse individuals are those whose sex assigned at birth does not correspond with their gender identity. Gender dysphoria, or the distress associated with the incongruence between an individual's gender identity and sex assigned at birth, is associated with adverse psychosocial and health outcomes. We hypothesize that puberty intensifies this distress, in effect exacerbating mental health symptoms and increasing healthcare utilization across all services. Our study seeks to investigate the influence that puberty has on mental health symptoms and service utilization for a cohort of gender diverse youth at a multidisciplinary care clinic. This is a retrospective chart review of all gender diverse patients seen at the Nemours Gender Wellness Program from 2015-2020. Abstracted data include demographics, pubertal status, symptoms of depression, anxiety and gender dysphoria, body image concerns, self-harm related thoughts and behaviors, and clinic service utilization. Comparisons were made according to pubertal status defined as the onset of secondary sex characteristics. Descriptive statistical analysis was performed using frequency counts, percentages, means and standard deviations. Categorical variables were compared using chi-square and Fisher exact tests. 199 patients were included. Most were White (83%) and non-Hispanic (91%). Participant ages ranged from 5-18 years, with a median of 15 years. 136 (68%) individuals identified as transgender male, 35 (18%) as transgender female, 17 (9%) as non-binary, and 11 (6%) as another gender. Among all participants, 75% reported depressive symptoms, 74% reported anxiety symptoms, and 96% reported gender dysphoria. Prepubertal individuals were less likely than pubertal patients to report symptoms of depression (40% vs. 90%, p< 0.01) and gender dysphoria (94% vs. 99%, p=0.05). There were no differences in anxiety symptoms, body image concerns, suicidal ideation, suicide attempts, or self-harm by pubertal status. The Gynecology service was utilized by pubertal patients more than prepubertal patients (73% vs. 24%, p< 0.001). There were no significant differences in Psychology, Psychiatry, or Endocrinology utilization based on pubertal status. We found high rates of psychological symptoms in gender diverse youth, especially in pubertal patients. However, except for Gynecology, service utilization was not correlated with pubertal status. Understanding how psychological symptoms change around the time of puberty in this population may help families, providers, and policymakers improve on current outreach and treatment strategies for gender diverse youth. [ABSTRACT FROM AUTHOR]