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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.)

Competing Interests: Declaration of Competing Interest Dr. Sequeira has received compensation for Pivotal Ventures for participation in an advisory board. Dr. McNamara has received expert witness payments from Human Rights Campaign and GLBTQ Defenders. The other authors have no relevant disclosures. No sources of funding.

Adolescent transgender medicine is a growing clinical field. Gender-affirming medications for transgender youth may include gonadotropin-releasing hormone (GnRH) agonists, gender-affirming hormones or both. To evaluate the potential effects of GnRH agonists (puberty suppression) on pharmacokinetic processes for transgender youth, we searched PubMed from inception to May 2024 for publications on the effects of GnRH agonists on drug absorption, distribution, metabolism or excretion for transgender adolescents or effects on hormones (including gonadotropins, adrenal androgens, sex steroids) that are associated with changes in drug metabolism during puberty in the general adolescent population. No publications discussed the effects of GnRH agonist treatment on pharmacokinetic processes for adolescent transgender people. Sixteen publications observed marked decreases in gonadotropins and sex steroids for both adolescent transgender men and adolescent transgender women and slight effects on adrenal androgens. During GnRH agonist treatment, changes in body composition and body shape were greater for adolescent transgender people than for cisgender adolescent people. Further research is needed to better understand the effects of GnRH agonists on drug metabolism and other pharmacokinetic processes for transgender adolescents receiving GnRH agonists and other gender-affirming medications., (© 2024 The Author(s). British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Background: Family support (FS) is a key social determinant of health for transgender and gender-diverse (TGD) young adults. We examined the association between FS and health outcomes in young adults seeking gender-affirming hormone therapy (GAHT) from a US telehealth service. Methods: Cross-sectional data from TGD young adults ages 18-24 ( n = 7,740) who provided demographic information and information on FS at intake were analyzed. Relationships between FS, geography, insurance status, rates of depression, and smoking status were examined. Results: Less than half of respondents reported having FS. Patients with FS reported lower rates of depression and higher incidence of previous gender-affirming medical care (e.g., hormone therapy, surgeries), had lower rates of being uninsured, and were more likely to reside in the Northeast or Western United States. Young adults assigned female at birth had higher rates of FS. Conclusion: FS may mitigate mental health disparities in TGD young adults including rates of depression. FS and insurance status are closely related in a geographically diverse population seeking telehealth services. The finding underscores the importance of FS as a social determinant of health and the unique characteristics of patients seeking telehealth services.

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: The purpose of this analysis is to: 1) describe the most common mental health diagnoses in the emergency department (ED) and inpatient hospital settings among transgender and gender diverse (TGD) youth vs. matched controls and 2) evaluate if a gender-affirming hormone therapy (GAHT) or gonadotropin-releasing hormone agonist (GnRHa) prescription decreased the risk of suicidality within these settings. Methods: Using the PEDSnet dataset (years 2009-2019), TGD youth aged 8-18 ( n = 3414, with a median age at last visit of 16.2 [14.4, 17.7] years, were propensity-score matched to controls ( n = 13,628, age 16.6 [14.2, 18.3] years). Relative risks of the most common mental health diagnoses within ED and inpatient settings were calculated for TGD youth compared with controls. Recurrent time-to-event analysis was used to examine whether GAHT or GnRHa attenuated the risk of suicidality among subsamples of TGD youth. Results: TGD youth had a higher relative risk (95% confidence interval [CI]) of mental health diagnoses and suicidality in the ED (5.46 [4.71-6.33]) and inpatient settings (6.61 [5.28-8.28]) than matched controls. TGD youth prescribed GAHT had a 43.6% lower risk of suicidality (hazard ratio [HR] = 0.564 [95% CI 0.36-0.89]) compared with those never prescribed GAHT during our study period or before GAHT initiation. TGD youth who were prescribed GnRHa therapy had a nonstatistically significant reduction in ED or inpatient suicidality diagnoses compared with those never prescribed GnRHa (HR = 0.79 [0.47-1.31]). Conclusion: Although risk of mental health diagnoses and suicidality in ED and inpatient settings was high among TGD youth, a GAHT prescription was associated with a significant reduction in suicidality risk.

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.

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 (

Objectives: To identify and examine demographic variation in estimates of gender-diverse youth (GDY) populations from the PEDSnet learning health system network and the Youth Risk Behavior Survey (YRBS)., Methods: The PEDSnet sample included 14- to 17-years-old patients who had ≥2 encounters at a member institution before March 2022, with at least 1 encounter in the previous 18 months. The YRBS sample included pooled data from 14- to 17-year-old in-school youth from the 2017, 2019, and 2021 survey years. Adjusted logistic regression models tested for associations between demographic characteristics and gender dysphoria (GD) diagnosis (PEDSnet) or self-reported transgender identity (YRBS)., Results: The PEDSnet sample included 392 348 patients and the YRBS sample included 270 177 youth. A total of 3453 (0.9%) patients in PEDSnet had a GD diagnosis and 5262 (1.9%) youth in YRBS self-identified as transgender. In PEDSnet, adjusted logistic regression indicated significantly lower likelihood of GD diagnosis among patients whose electronic medical record-reported sex was male and among patients who identified as Asian, Black/African American, and Hispanic/Latino/a/x/e. In contrast, in the YRBS sample, only youth whose sex was male had a lower likelihood of transgender identity., Conclusions: GDY are underrepresented in health system data, particularly those whose electronic medical record-reported sex is male, and Asian, Black/African American, and Hispanic/Latino/a/x/e youth. Collecting more accurate gender identity information in health systems and surveys may help better understand the health-related needs and experiences of GDY and support the development of targeted interventions to promote more equitable care provision., (Copyright © 2024 by the American Academy of Pediatrics.)

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.

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.

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: We aimed to understand transgender and nonbinary (TNB) young adults' desire to receive gender-affirming medical care (GAMC) before age 18 and identify barriers and facilitators to receiving this care in adolescence. Methods: A cross-sectional survey was administered to TNB young adults presenting for care between ages 18 and 20 in 2023. Descriptive statistics characterized the sample, χ 2 tests with post hoc pairwise comparisons identified differences in desire for gender-affirming medications, outness, and parental consent by gender identity and sex assigned at birth, and t -tests evaluated differences in barriers and facilitators to receiving care by outness to parents. Results: A total of 230 TNB respondents had complete data. Nearly all (94.3%) indicated they desired GAMC before age 18. Half (55.7%) of the respondents reported being out about their gender identity to a parent before age 18. Outness, discussing desire for GAMC, and asking for consent to receive GAMC from a parent were significantly more common among participants who identified as men compared to those who identified as women and among those assigned female at birth compared to those assigned male at birth. No such differences emerged when comparing nonbinary individuals to those who identified as men or women. Lack of parental willingness to consent for GAMC was cited as the primary contributor of not having received care in adolescence. Conclusions: Many TNB young adults desire GAMC in adolescence; however, lack of parental support is a key barrier to receiving this care, suggesting a need for more readily available resources for parents to support TNB 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.

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., Competing Interests: No competing financial interests exist., (Copyright 2024, Mary Ann Liebert, Inc., publishers.)

Telemedicine may help improve access to gender-affirming care for transgender and gender diverse (TGD) adolescents. Parents or guardians (i.e., caregivers) of TGD adolescents play a critical role in supporting TGD adolescents in accessing this care. The purpose of this study was to explore caregivers' perspectives regarding their adolescent receiving pediatric gender-affirming care via telemedicine to help providers and health systems optimize this modality for future care delivery. Caregivers (n=18) of TGD adolescents ages 14-17 participated in semi-structured, individual interviews that were transcribed and analyzed qualitatively. Caregivers cited participating in visits from their home environment, decreased anxiety, COVID safety, ability to have more family members attend, no transportation demands, and effective delivery of care as advantages of telemedicine. Disadvantages included dysphoria or discomfort with self-image, impersonal provider-patient interactions, video teleconferencing fatigue, difficulty with portal navigation, connectivity issues, and lack of privacy. Caregivers largely deferred to their child's preference regarding the choice of visit modality, but many reported a preference for the first to be conducted in-person, and follow-up and less complex visits via telemedicine. Health systems should consider these perspectives as they adapt telemedicine infrastructure to better meet the needs of patients and their families., Competing Interests: Declaration of Interests Statement Dr. Sequeira is a consultant for Pivotal Ventures and the Fenway Institute. The authors have no other interests to disclose.

Background and Objectives: Youth with either autism spectrum disorder (ASD) or gender dysphoria (GD) alone have also been shown to be at greater risk for mental health (MH) concerns; however, very little research has considered how cooccurring ASD and GD may exacerbate MH concerns. The purpose of this study was to examine associations between ASD, GD, and MH diagnoses (anxiety, depression, eating disorder, suicidality, and self-harm) among US adolescent populations., Methods: This is a secondary analysis of a large administrative dataset formed by 8 pediatric health system members of the PEDSnet learning health system network. Analyses included descriptive statistics and adjusted mixed logistic regression models testing for associations between combinations of ASD and GD diagnoses and MH diagnoses as recorded in the patient's electronic medical record., Results: Based on data from 919 898 patients aged 9 to 18 years, adjusted mixed logistic regression indicated significantly greater odds of each MH diagnosis among those with ASD alone, GD alone, and cooccurring ASD/GD diagnoses compared with those with neither diagnosis. Youth with cooccurring ASD/GD were at significantly greater risk of also having anxiety (average predicted probability, 0.75; 95% confidence interval, 0.68-0.81) or depression diagnoses (average predicted probability, 0.33; 95% confidence interval, 0.24-0.43) compared with youth with ASD alone, GD alone, or neither diagnosis., Conclusions: Youth with cooccurring ASD/GD are more likely to also be diagnosed with MH concerns, particularly anxiety and depression. This study highlights the need to implement developmentally appropriate, gender-affirming MH services and interventions for youth with cooccurring ASD/GD., (Copyright © 2023 by the American Academy of Pediatrics.)

Transgender and gender diverse (TGD) youth have high rates of health disparities and face significant barriers to accessing medical care. Primary care providers (PCPs) are often the first health care providers that TGD youth seek out to discuss gender identity and find support. Thus, it is crucial for PCPs to have an understanding of gender diversity and knowledge to support TGD youth with gender-affirming care. The purpose of this article is to offer strategies PCPs can implement to increase their comfort and capacity in providing care for TGD people. Key steps to support TGD youth in the primary care setting include creating affirming clinical environments, discussing gender identity at routine visits, supporting parents and families, supporting social transition, and providing menstrual suppression for those who desire it. Multidisciplinary gender clinics can partner with PCPs to support adolescents in accessing gender-affirming medical care and to provide additional education and support. [ Pediatr Ann . 2023;52(12):e442-e449.] .

Purpose: To describe barriers to care for a cohort of transgender and nonbinary (TNB) youth and examine factors associated with delays in receiving puberty blockers (PBs) or gender-affirming hormones (GAHs)., Methods: We used longitudinal data from a prospective cohort of TNB youth seeking care at a multidisciplinary pediatric gender clinic between August 2017 and June 2018. We calculated the time between (i) initial clinic contact, (ii) phone intake, (iii) first medical appointment, and (iv) initiating PBs/GAHs. We estimated Kaplan-Meier curves for each time-to-care interval and used Cox regression models to estimate hazard ratios (HRs) for factors hypothesized to be barriers and facilitators of care., Results: Our cohort included 104 youth aged 13-20 years. The median time from contacting the clinic to initiating PBs/GAHs was 307 days (range, 54-807). Lower income level, Medicaid insurance, and lack of family support were associated with longer times from contacting the clinic to completing the first medical appointment. In addition, older youth experienced longer times to first medical appointment relative to youth aged 13-14 years. Youth younger than 18 years of age who did not complete a mental health assessment before their first medical appointment experienced delays from first medical appointment to initiating PBs/GAHs (HR=0.44, 95% confidence interval, 0.22-0.88)., Conclusion: Certain subsets of youth disproportionately experienced delays in receiving gender-affirming medications, and these factors varied by stage of care engagement. Given the association between gender-affirming care and improved mental health, identifying sociostructural and clinic-level barriers to care is critically important to facilitating more equitable access., Competing Interests: D.M.T. receives support unrelated to this work from National Institutes of Health National Institute of Allergy and Infectious Diseases (Grant No. F31AI152542). The authors have no conflicts of interest to report., (Copyright 2023, Mary Ann Liebert, Inc., publishers.)

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.

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.)

Background and Objectives: Autism spectrum disorder (ASD) and gender dysphoria (GD) frequently cooccur. However, existing research has primarily used smaller samples, limiting generalizability and the ability to assess further demographic variation. The purpose of this study was to (1) examine the prevalence of cooccurring ASD and GD diagnoses among US adolescents aged 9 to 18 and (2) identify demographic differences in the prevalence of cooccurring ASD and GD diagnoses., Methods: This secondary analysis used data from the PEDSnet learning health system network of 8 pediatric hospital institutions. Analyses included descriptive statistics and adjusted mixed logistic regression testing for associations between ASD and GD diagnoses and interactions between ASD diagnosis and demographic characteristics in the association with GD diagnosis., Results: Among 919 898 patients, GD diagnosis was more prevalent among youth with an ASD diagnosis compared with youth without an ASD diagnosis (1.1% vs 0.6%), and adjusted regression revealed significantly greater odds of GD diagnosis among youth with an ASD diagnosis (adjusted odds ratio = 3.00, 95% confidence interval: 2.72-3.31). Cooccurring ASD/GD diagnoses were more prevalent among youth whose electronic medical record-reported sex was female and those using private insurance, and less prevalent among youth of color, particularly Black and Asian youth., Conclusions: Results indicate that youth whose electronic medical record-reported sex was female and those using private insurance are more likely, and youth of color are less likely, to have cooccurring ASD/GD diagnoses. This represents an important step toward building services and supports that reduce disparities in access to care and improve outcomes for youth with cooccurring ASD/GD and their families., (Copyright © 2023 by the American Academy of Pediatrics.)

Introduction: Little is known about how expansion of telemedicine services during the COVID-19 pandemic has affected access to gender-affirming care for transgender and gender-diverse (TGD) youth. The purpose of this study was to explore differences in demographic characteristics and visit completion rates at a multidisciplinary gender clinic before and after telemedicine implementation in March 2020 and among telemedicine users and nonusers. Methods: Data were from electronic health records of Seattle Children's Gender Clinic (SCGC) patients seen between April 2019 and February 2021. We assessed differences in demographic characteristics and care utilization (i.e., encounter type and status) between April 2019 and February 2020 (pre-telemedicine) and April 2020 and February 2021 (post-telemedicine). Results: Of the 1,051 unique patients seen at SCGC during this time period, majority groups were as follows: 62% identified as transmasculine/male, 68% were non-Hispanic White, and 76% resided within 50 miles of the clinic. Statistically significant differences were observed in patient pronouns and insurance type when comparing the pre- and post-telemedicine periods ( p < 0.01). Half (52%) of post-telemedicine period encounters were conducted through telemedicine, and telemedicine encounters were significantly more likely to be completed (72% vs. 50%) and less likely to be canceled (21% vs. 46%) compared with in-person encounters. Conclusions: Telemedicine services facilitated continued access to gender-affirming care services for TGD youth during the COVID-19 pandemic. Although the introduction of telemedicine did not exacerbate demographic disparities in access to this care, further research and interventions are warranted to address the ongoing disparities in access to gender-affirming care for youth of color and rural youth.

Background: Access to virtual care has increased since the beginning of the COVID-19 pandemic, yet little is known about transgender and gender-diverse (TGD) youth's experiences and perspectives on receiving care via telemedicine., Objective: The purpose of this study was to explore these experiences to (1) inform necessary changes to the provision of pediatric gender-affirming care and (2) help providers and health systems determine if and how telemedicine should be made available post pandemic., Methods: Youth (aged 14-17 years) who completed a telemedicine visit in the Seattle Children's Gender Clinic were invited to participate in a semistructured interview exploring perceived advantages or disadvantages of telemedicine and preferred visit modalities. Interview transcriptions were analyzed by 2 research team members using an inductive thematic analysis framework., Results: A total of 15 TGD youth completed an interview. Commonly cited advantages of telemedicine were convenience and comfort with having visits in their own environments. Reported disadvantages included technical issues, discomfort with the impersonal nature, lack of familiarity with the platform, and privacy concerns. Overall, slightly more youth preferred in-person visits over telemedicine, referencing both specific characteristics of the clinical visit (ie, initial vs return and complexity) and proximity to the clinic as reasons for this preference. Although a plurality of TGD youth preferred in-person visits, they also recognized the value of telemedicine and the impact it may have in facilitating access to care., Conclusions: Given the variations in needs and visit complexity, our study supports the provision of both in-person and telemedicine modalities as options for pediatric gender-affirming care., (©Nicole F Kahn, Yomna H Anan, Kevin M Bocek, Dimitri A Christakis, Laura P Richardson, Wanda Pratt, Gina M Sequeira. Originally published in JMIR Pediatrics and Parenting (https://pediatrics.jmir.org), 14.02.2023.)

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.)

Background: Access to gender-affirming care services for transgender and gender-diverse youths is limited, in part because this care is currently provided primarily by specialists. Telehealth platforms that enable primary care providers (PCPs) to receive education from and consult specialists may help improve the access to such services. However, little is known about PCPs' preferences regarding receiving this support., Objective: This study aimed to explore pediatric PCPs' perspectives regarding optimal ways to provide telehealth-based support to facilitate gender-affirming care provision in the primary care setting., Methods: PCPs who had previously requested support from the Seattle Children's Gender Clinic were recruited to participate in semistructured, 1-hour web-based interviews. Overall, 3 specialist-to-PCP telehealth modalities (tele-education, electronic consultation, and telephonic consultation) were described, and the participants were invited to share their perspectives on the benefits and drawbacks of each modality, which modality would be the most effective, and the most important characteristics or outcomes of a successful platform. Interviews were transcribed and analyzed using a reflexive thematic analysis framework., Results: The interviews were completed with 15 pediatric PCPs. The benefits of the tele-education platform were developing a network with other PCPs to facilitate shared learning, receiving comprehensive didactic and case-based education, having scheduled education sessions, and increasing provider confidence. The drawbacks were requiring a substantial time commitment and not allowing for real-time, patient-specific consultation. The benefits of the electronic consultation platform were convenient and efficient communication, documentation in the electronic health record, the ability to bill for provider time, and sufficient time to synthesize information. The drawbacks of this platform were electronic health record-related difficulties, text-based communication challenges, inability to receive an answer in real time, forced conversations with patients about billing, and limitations for providers who lack baseline knowledge. With respect to telephonic consultation, the benefits were having a dialogue with a specialist, receiving compensation for PCP's time, and helping with high acuity or complex cases. The drawbacks were challenges associated with using the phone for communication, the limited expertise of the responding providers, and the lack of utility for nonemergent issues. Regarding the most effective platform, the responses were mixed, with 27% (4/15) preferring the electronic consultation, 27% (4/15) preferring tele-education, 20% (3/15) preferring telephonic consultation, and the remaining 27% (4/15) suggesting a hybrid of the 3 models., Conclusions: A diverse suite of telehealth-based training and consultation services must be developed to meet the needs of PCPs with different levels of experience and training in gender-affirming care. Beyond the widely used telephonic consultation model, electronic consultation and tele-education may provide important alternative training and consultation opportunities to facilitate greater PCP independence and promote wider access to gender-affirming care., (©Gina M Sequeira, Nicole F Kahn, Kevin M Bocek, Taraneh Shafii, Peter G Asante, Dimitri A Christakis, Wanda Pratt, Laura P Richardson. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 31.01.2023.)

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.)

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., (Copyright © 2022 by the American Academy of Pediatrics.)

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.)

Context: Studies on cardiometabolic health in transgender and gender-diverse youth (TGDY) are limited to small cohorts., Objective: This work aimed to determine the odds of cardiometabolic-related diagnoses in TGDY compared to matched controls in a cross-sectional analysis, using a large, multisite database (PEDSnet)., Methods: Electronic health record data (2009-2019) were used to determine odds of cardiometabolic-related outcomes based on diagnosis, anthropometric, and laboratory data using logistic regression among TGDY youth vs controls. The association of gender-affirming hormone therapy (GAHT) with these outcomes was examined separately among TGDY. TGDY (n = 4172) were extracted from 6 PEDSnet sites and propensity-score matched on 8 variables to controls (n = 16 648). Main outcomes measures included odds of having cardiometabolic-related diagnoses among TGDY compared to matched controls, and among TGDY prescribed GAHT compared to those not prescribed GAHT., Results: In adjusted analyses, TGDY had higher odds of overweight/obesity (1.2; 95% CI, 1.1-1.3) than controls. TGDY with a testosterone prescription alone or in combination with a gonadotropin-releasing hormone agonist (GnRHa) had higher odds of dyslipidemia (1.7; 95% CI, 1.3-2.3 and 3.7; 95% CI, 2.1-6.7, respectively) and liver dysfunction (1.5; 95% CI, 1.1-1.9 and 2.5; 95% CI, 1.4-4.3) than TGDY not prescribed GAHT. TGDY with a testosterone prescription alone had higher odds of overweight/obesity (1.8; 95% CI, 1.5-2.1) and hypertension (1.6 95% CI, 1.2-2.2) than those not prescribed testosterone. Estradiol and GnRHa alone were not associated with greater odds of cardiometabolic-related diagnoses., Conclusion: TGDY have increased odds of overweight/obesity compared to matched controls. Screening and tailored weight management, sensitive to the needs of TGDY, are needed., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

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., Competing Interests: The authors have nothing to disclose and no conflicts of interest to report., (Copyright 2022, Mary Ann Liebert, Inc., publishers.)

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.)

Objective: To assess the odds of a psychiatric or neurodevelopmental diagnosis among youth with a diagnosis of gender dysphoria compared with matched controls in a large electronic health record dataset from 6 pediatric health systems, PEDSnet. We hypothesized that youth with gender dysphoria would have higher odds of having psychiatric and neurodevelopmental diagnoses than controls., Study Design: All youth with a diagnosis of gender dysphoria (n = 4173 age at last visit 16.2 ± 3.4) and at least 1 outpatient encounter were extracted from the PEDSnet database and propensity-score matched on 8 variables to controls without gender dysphoria (n = 16 648, age at last visit 16.2 ± 4.8) using multivariable logistic regression. The odds of having psychiatric and neurodevelopmental diagnoses were examined using generalized estimating equations., Results: Youth with gender dysphoria had higher odds of psychiatric (OR 4.0 [95% CI 3.8, 4.3] P < .0001) and neurodevelopmental diagnoses (1.9 [1.7, 2.0], P < .0001). Youth with gender dysphoria were more likely to have a diagnosis across all psychiatric disorder subcategories, with particularly high odds of mood disorder (7.3 [6.8, 7.9], P < .0001) and anxiety (5.5 [5.1, 5.9], P < .0001). Youth with gender dysphoria had a greater odds of autism spectrum disorder (2.6, [2.2, 3.0], P < .0001)., Conclusions: Youth with gender dysphoria at large pediatric health systems have greater odds of psychiatric and several neurodevelopmental diagnoses compared with youth without gender dysphoria. Further studies are needed to evaluate changes in mental health over time with access to gender affirming care., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: e-Consultations between primary care physicians and specialists are a valuable means of improving access to specialty care. Adolescents and young adults (AYAs) face unique challenges in accessing limited adolescent medicine specialty care resources, which contributes to delayed or forgone care. e-Consultations between general pediatricians and adolescent medicine specialists may alleviate these barriers to care. However, the optimal application of this model in adolescent medicine requires careful attention to the nuances of AYA care., Objective: This study aims to qualitatively analyze feedback obtained during the iterative development of an e-consultation system for communication between general pediatricians and adolescent medicine specialists tailored to the specific health care needs of AYAs., Methods: We conducted an iterative user-centered design and evaluation process in two phases. In the first phase, we created a static e-consultation prototype and storyboards and evaluated them with target users (general pediatricians and adolescent medicine specialists). In the second phase, we incorporated feedback to develop a functional prototype within the electronic health record and again evaluated this with general pediatricians and adolescent medicine specialists. In each phase, general pediatricians and adolescent medicine specialists provided think-aloud feedback during the use of the prototypes and semistructured exit interviews, which was qualitatively analyzed to identify perspectives related to the usefulness and usability of the e-consultation system., Results: Both general pediatricians (n=12) and adolescent medicine specialists (n=12) perceived the usefulness of e-consultations for AYA patients, with more varied perceptions of potential usefulness for generalist and adolescent medicine clinicians. General pediatricians and adolescent medicine specialists discussed ways to maximize the usability of e-consultations for AYAs, primarily by improving efficiency (eg, reducing documentation, emphasizing critical information, using autopopulated data fields, and balancing specificity and efficiency through text prompts) and reducing the potential for errors (eg, prompting a review of autopopulated data fields, requiring physician contact information, and prompting explicit discussion of patient communication and confidentiality expectations). Through iterative design, patient history documentation was streamlined, whereas documentation of communication and confidentiality expectations were enhanced., Conclusions: Through an iterative user-centered design process, we identified user perspectives to guide the refinement of an e-consultation system based on general pediatrician and adolescent medicine specialist feedback on usefulness and usability related to the care of AYAs. Qualitative analysis of this feedback revealed both opportunities and risks related to confidentiality, communication, and the use of tailored documentation prompts that should be considered in the development and use of e-consultations with AYAs., (©Jacquelin Rankine, Deepika Yeramosu, Loreta Matheo, Gina M Sequeira, Elizabeth Miller, Kristin N Ray. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 05.08.2021.)

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.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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.)