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PurposeThe aim of this study is to compare substance use and school-based stressors among Black and Latinx transgender youth (trans BLY), White transgender youth (trans WY), and Black and Latinx cisgender youth (cis BLY) and identify associations between substance use and stressors among trans BLY.MethodsWe analyzed 2015-2017 Biennial California Healthy Kids Survey data with a weighted sample of the state's secondary school population. The analytic sample included 9th and 11th grade trans BLY, trans WY, and cis BLY. Past 30-day and lifetime substance use (cigarettes, e-cigarettes/vaping, marijuana, and alcohol) and school-based stressors (victimization, race-, gender-, and sexuality-based harassment) were compared between cohorts via logistic regression. For trans BLY, associations between substance use and stressors were assessed via logistic regression.ResultsThe analytic sample (n= 19,780) included 252 trans BLY, 104 trans WY, and 19,424 cis BLY. Among trans BLY, estimated prevalence of 30-day (and lifetime) use of cigarettes, e-cigarette/vaping, marijuana, and alcohol were 13% (23%), 19% (39%), 27% (42%), and 29% (48%), respectively. Trans BLY had similar odds of 30-day and lifetime use of all substances compared to trans WY but higher odds of use compared to cis BLY. For trans BLY, race- and gender-based harassment and higher victimization levels were associated with higher odds of 30-day and lifetime use of all substances. Sexuality-based harassment was associated with higher odds of 30-day and lifetime marijuana and alcohol use.DiscussionTrans BLY have high prevalence of substance use, comparable with trans WY but higher than cis BLY. Substance use among trans BLY is associated with school-based stressors.

Despite the high prevalence of eating disorders in gender diverse adolescents, little is known about the characteristics of gender diverse youth with eating disorders who require inpatient medical stabilization. The primary objective of this study was to describe the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents hospitalized for eating disorders and compare these characteristics to cisgender peers hospitalized for eating disorders. The secondary objective was to evaluate percent median body mass index as one marker of malnutrition and treatment goal body mass index as a recovery metric between patients' birth-assigned sex and affirmed gender using standardized clinical growth charts.A retrospective chart review was conducted of 463 patients admitted to an inpatient eating disorders medical unit between 2012 and 2020. To compare medical, anthropometric, and psychiatric data between gender diverse and cisgender patients, chi-square/Fisher's exact and t-tests were used. Clinical growth charts matching the patients' birth-assigned sex and affirmed gender identity were used to assess percent of median body mass index and treatment goal body mass index.Ten patients (2.2%) identified as gender diverse and were younger than cisgender patients [13.6 (1.5) years vs. 15.6 (2.7) years, p = 0.017]. Gender diverse patients were hospitalized with a higher percent median body mass index compared to cisgender peers [97.1% (14.8) vs. 87.9% (13.7), p = 0.037], yet demonstrated equally severe vital sign instability such as bradycardia [44 (8.8) beats per minute vs. 46 (10.6) beats per minute, p = 0.501], systolic hypotension [84 (7.1) mmHg vs. 84 (9.7) mmHg, p = 0.995], and diastolic hypotension [46 (5.8) mmHg vs. 45 (7.3) mmHg, p = 0.884]. Gender diverse patients had a higher prevalence of reported anxiety symptoms compared to cisgender patients (60% vs. 28%, p = 0.037).Gender diverse patients demonstrated complications of malnutrition including vital sign instability despite presenting with a higher weight. This is consistent with a greater proportion of gender diverse patients diagnosed with atypical anorexia nervosa compared to cisgender peers. Additionally, psychiatric comorbidities were present among both groups, with a larger percentage of gender diverse patients endorsing anxiety compared to cisgender patients.Gender diverse is a term that includes gender identities such as (but not limited to) transgender, non-binary, and gender fluid. Eating disorders are becoming increasingly recognized among this population. In recent years there has been a better understanding of the risk factors and screening for eating disorders in the outpatient setting for gender diverse adolescents. However, the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents with eating disorders requiring inpatient medical stabilization are poorly understood. This study examines these characteristics in gender diverse adolescents hospitalized for eating disorder-related medical complications from 2012 to 2020. Gender diverse adolescents presented for medical hospitalization with signs of malnutrition, including vital sign instability and laboratory abnormalities, as well as additional psychiatric diagnoses such as depression and anxiety. Understanding the medical, anthropometric, and psychiatric presentation of this population can lead to more tailored and comprehensive care with the potential to reduce the risks of adverse health outcomes.

To examine the impact of standardized patient encounters (SPEs) on gender-affirming communication skills and self-efficacy of pediatrics learners.Fourth-year medical students, pediatrics interns, psychiatry interns, and nurse practitioner trainees on 1-month adolescent medicine blocks completed a curriculum with e-learning activities that was expanded to include SPEs. Following e-learning, learners completed 2 SPEs featuring transgender adolescent cases. Faculty observers and standardized patients completed checklists focused on history-taking, counseling, and interpersonal communication, and provided learner feedback after each case. The curriculum was evaluated by comparing skills checklists scores from case 1 to case 2 via Wilcoxon signed-rank tests. Self-efficacy was assessed precurriculum (Assessment 1), post-e-learning (Assessment 2), and post-SPE (Assessment 3) using a previously developed instrument. Changes in self-efficacy scores were assessed via linear regression models with generalized estimating equations.Forty-three eligible learners participated in the study. The majority were pediatrics interns, and 5 learners had worked in a transgender clinic prior to the curriculum participation. Learners increased median total checklist scores between cases from 22 to 28 (P.001) (maximum score of 34). Learners' overall self-efficacy scores improved by 3.4 (confidence interval [CI]: 2.9-3.9; P.001) between Assessments 1 and 2 and by 1.5 (CI: 1.2-1.7; P.001) from Assessment 2 to 3. Similar improvements in checklist scores and self-efficacy occurred within stratified learner types.The combination of SPEs with e-learning is effective at improving self-efficacy and gender-affirming communication skills for a multidisciplinary pediatrics learners. The comprehensive curriculum allowed learners inexperienced with transgender youth to apply knowledge and practice skills.

Purpose To determine the prevalence of disordered eating behaviors (DEBs) and body image dissatisfaction (BID) according to sexual minority youth (SMY) status and describe healthcare utilization patterns by SMY status. Methods Retrospective data from 107,528 adolescents, who had a Well Check in Kaiser Permanente Northern California in 2016, were used to compare DEB and BID by SMY status. Multivariate logistic models were used to examine the associations of SMY, birth-assigned sex, age, race/ethnicity, and body mass index on DEB and BID. The utilization of specialized eating disorder (ED) medical and mental health services and general mental health services was described at one Kaiser Permanente Northern California facility. Results BID was reported in 20,763 (19.3%) adolescents, DEB in 1,458 (1.7%) adolescents, and 5,363 (5%) adolescents identified as SMY. SMY had higher odds of having DEB and BID than non-SMY, respectively (adjusted odds ratio 2.0 95% confidence interval [1.9–2.2] and adjusted odds ratio 3.8 [3.4–4.2]). Regardless of SMY status, adolescents with older age, female sex, nonwhite race, and elevated body mass index had higher odds of ED risk factors. SMY with ED risk factors had higher ED medical utilization than non-SMY with ED risk factors (4.6% vs. 1.6%). However, SMY status was not associated with utilization of specialized ED mental health services. Conclusions SMY had increased rates of DEB and BID but had underutilization of specialized ED mental health services. Future targeted efforts to prevent eating disorder-related mortality and morbidity for SMY should include targeted eating disorder screening and referral to specialized ED medical and mental health services.

Key Points Question Do Black and Latinx transgender youth experience greater mental health symptoms than their White transgender and Black and Latinx cisgender peers? Findings In this survey study of 19 780 participants, analyses of a statewide school-based survey data set indicated that Black and Latinx transgender youth had high rates of depressive symptoms and suicidality, similar to those among White transgender youth but higher than those among Black and Latinx cisgender youth. Meaning These findings suggest that Black and Latinx transgender youth are susceptible to mental health symptoms that should be addressed through clinical services that consider both race/ethnicity and gender identity., This survey study compares past-year mental health symptoms and psychosocial factors among Black and Latinx transgender youth, White transgender youth, and Black and Latinx cisgender youth., Importance Black and Latinx transgender youth experience stigma that may increase their susceptibility to mental health symptoms. Objective To compare past-year mental health symptoms and psychosocial factors among Black and Latinx transgender youth, White transgender youth, and Black and Latinx cisgender youth. Design, Setting, and Participants This survey study used data from the 2015-2017 Biennial California Healthy Kids Survey with a weighted sample (N = 45 269) representative of California’s secondary school population. The analytic sample (n = 19 780) included Black and Latinx transgender youth, White transgender youth, and Black and Latinx cisgender youth in the 9th and 11th grades. Data analysis was conducted from July 2020 to February 2021. Main Outcomes and Measures Outcomes include past-year depressive symptoms and suicidality. Psychosocial risk factors include school-based victimization, gender-based harassment, sexuality-based harassment, and race-based harassment; protective factors include school connectedness and caring adult relationships. Results The analytic sample of 19 780 participants (in 9th grade: weighted percentage, 51% [95% CI, 50% to 52%]; female participants: weighted percentage, 50% [95% CI, 49% to 51%]) included 252 Black and Latinx transgender youth (weighted percentage, 1.3% [95% CI, 1.1% to 1.5%]), 104 White transgender youth (weighted percentage, 0.7% [95% CI, 0.6% to 0.8%]), and 19 424 Black and Latinx cisgender youth (weighted percentage, 98.0% [95% CI, 97.8% to 98.2%]). For Black and Latinx transgender youth, estimated prevalence of depressive symptoms and suicidality were 50% (95% CI, 44% to 57%) and 46% (95% CI, 39% to 52%), respectively. Logistic regression models adjusted for grade, living arrangement, and reported sex indicated that compared with White transgender youth, Black and Latinx transgender youth had similar odds of depressive symptoms (adjusted odds ratio, 0.6; 95% CI, 0.4 to 1.1) and suicidality (adjusted odds ratio, 1.1; 95% CI, 0.6 to 1.8) and similar odds of all forms of harassment (eg, race-based harassment: adjusted odds ratio, 1.5; 95% CI, 0.8 to 2.6). Regression models indicated that compared with White transgender youth, Black and Latinx transgender youth had similar levels of victimization (adjusted linear regression coefficient, 0.5; 95% CI, −0.3 to 1.3) and caring adult relationships (adjusted linear regression coefficient, −0.6; 95% CI, −1.4 to 0.09) but lower levels of school connectedness (adjusted linear regression coefficient, −1.6; 95% CI, −2.9 to −0.4). With similar analyses, compared with Black and Latinx cisgender youth, Black and Latinx transgender youth had higher odds of depressive symptoms (adjusted odds ratio, 2.7; 95% CI, 2.0 to 3.7) and suicidality (adjusted odds ratio, 5.9; 95% CI, 4.3 to 8.0), higher odds and levels of all forms of harassment and victimization (eg, race-based harassment: adjusted odds ratio, 3.2; 95% CI, 2.4 to 4.5), and lower levels of school connectedness (adjusted linear regression coefficient, −2.6; 95% CI −3.3 to −1.8) and caring adult relationships (adjusted linear regression coefficient, −0.9; 95% CI −1.3 to −0.5). Conclusions and Relevance In this study, Black and Latinx transgender youth had high rates of mental health symptoms, with rates comparable with White transgender youth but higher than Black and Latinx cisgender youth. Their unique pattern of psychosocial risk and protective factors for these mental health symptoms should be factored in clinical preventive services and school-based interventions to support them.

BACKGROUND We aimed to evaluate the effect of online modules - as stand-alone training - on paediatric transgender-related self-perceived knowledge, objective knowledge, and clinical self-efficacy of learners. We previously evaluated the online modules as part of a larger curriculum that included observation in a paediatric transgender clinic, and assessed change in self-perceived knowledge. METHODS Paediatric interns, psychiatry interns, fourth-year medical students and nurse practitioner students were administered assessments before and after the completion of six online modules focused on medical and psychosocial considerations for transgender youth. The assessments queried learner demographics and transgender clinical exposure. Nine items tested transgender-related objective knowledge. Twenty-four items asked learners to rate self-perceived transgender-specific knowledge (1, not at all knowledgeable; 5, completely knowledgeable). Thirteen self-efficacy items asked learners to rate confidence in their ability to evaluate and counsel these youth (0, not at all confident; 10, completely confident). Overall and subscores were calculated for each domain. Wilcoxon signed-rank tests were used to compare the pre- and post-module scores. RESULTS Thirty-six learners were eligible to join the study and 86% (n = 31) participated. Among the participants, 90% (n = 28) completed both assessments. The median number of transgender patients seen before the curriculum was one, and 10% had past experience in a transgender clinic. Comparing pre- and post-module scores, the overall objective knowledge scores increased from 22 to 56% (p

Purpose To enhance pediatric trainees' and students' knowledge of the psychosocial and medical issues facing transgender youth through a comprehensive curriculum. Methods During the 2015–2016 academic year, we administered a transgender youth curriculum to fourth-year medical students, pediatric interns, psychiatry interns, and nurse practitioner students on their 1-month adolescent and young adult medicine rotation. The curriculum included six interactive, online modules and an observational experience in a multidisciplinary pediatric gender clinic. The online modules had a primary care focus with topics of general transgender terminology, taking a gender history, taking a psychosocial history, performing a sensitive physical examination, and formulating an assessment, psychosocial plan, and medical plan. At the completion of the curriculum, learners completed an evaluation that assessed change in perceived awareness and knowledge of transgender-related issues and learner satisfaction with the curriculum. Results Twenty learners participated in the curriculum with 100% completing the curriculum evaluations, 100% reporting completing all six online modules, and 90% attending the gender clinic. Learners demonstrated a statistically significant improvement in all pre-post knowledge/awareness measures. On a Likert scale where 5 indicated very satisfied, learners' mean rating of the quality of the curriculum was 4.5 ± .7; quality of the modules was 4.4 ± .7; and satisfaction with the observational experience was 4.5 ± .8. Conclusions A comprehensive curriculum comprised interactive online modules and an observational experience in a pediatric gender clinic was effective at improving pediatric learners' perceived knowledge of the medical and psychosocial issues facing transgender youth. Learners also highly valued the curriculum.

Purpose To determine how the seven Maternal and Child Health Bureau funded Leadership and Education in Adolescent Health (LEAH) programs currently obtain information on gender identity from their patients. Methods A computerized survey was sent to all LEAH site directors with questions to identify if and how programs documented youth's gender identity and barriers to implementation. Results With response rate of 100%, seven LEAH programs reported a total of 43 primary care and specialty clinics. For clinics with Electronic Health Records, 67% of clinics had a standardized gender identity question. Barriers to implementing a standardized question included concerns about confidentiality, lack of trained providers, low numbers of transgender patients, and no validated gender identity question. Conclusions Incorporation of inquiry of gender identity is possible in numerous clinical settings that serve adolescents. Future research is needed to determine how this information affects conversations with providers and necessary referrals to treatment.

Purpose The aim of the study was to estimate the prevalence of sexual minority youth (SMY) within an integrated health care system using a standardized questionnaire. Methods This study assessed SMY status in youth aged 12.5–18 years using a previsit Well Check questionnaire at Kaiser Permanente Northern California facilities in 2016. SMY was defined as self-reported attraction to the same sex or both sexes. Results A total of 93,817 youth (87.3%) self-reported sexual attraction, and 5% (n = 5,329) of respondents (N = 107,532) identified as SMY: 1.7% were attracted to same sex, and 3.2% were attracted to both sexes. There were youth who responded neither (1.5%) and unsure (2.4%). Females were 2.8 times (95% confidence interval 2.6–2.94) more likely to be SMY than males. SMY status significantly increased with age. Nonwhite youth were significantly less likely to be SMY compared with white youth. Conclusions This is the first study to examine SMY prevalence in pediatric primary care. Primary care providers can use previsit screening before preventive visits to identify and support sexual minority adolescents, facilitate family acceptance, and promote healthy behaviors with care coordination.

* Abbreviation: LGBTQ — : lesbian, gay, bisexual, transgender, and questioning This month’s issue of Pediatrics features studies from Baams1 and Becerra-Culqui et al,2 in which they contribute to the ever-growing body of literature that characterizes psychosocial disparities faced by lesbian, gay, bisexual, transgender, questioning (LGBTQ), and gender nonconforming youth. Authors of several studies have previously described the psychosocial realities of these youth that include, but are not limited to, depression, anxiety, nonsuicidal self-injury, suicidality, homelessness, and substance use.3–5 However, in 2 studies in this issue, both with the strength of describing large population-based samples, authors confirm the dismal psychosocial disparities experienced by these youth and provide novel information that should embolden health care providers to better identify such youth in their practices, assess risk factors, and offer support options that may not only promote resilience but may also be lifesaving. There has been growing evidence in which stress associated with cumulative adverse childhood … Address correspondence to Stanley Ray Vance Jr, MD, Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, 3333 California St, Suite 245, Box 0503, San Francisco, CA 94143. E-mail: stanley.vance{at}ucsf.edu

Gender nonconforming (GN) children and adolescents, collectively referred to as GN youth, may seek care to understand their internal gender identities, socially transition to their affirmed genders, and/or physically transition to their affirmed genders. Because general pediatricians are often the first point of contact with the health care system for GN youth, familiarity with the psychological and medical approaches to providing care for this population is crucial. The objective of this review is to provide an overview of existing clinical practice guidelines for GN youth. Such guidelines emphasize a multidisciplinary approach with collaboration of medical, mental health, and social services/advocacy providers. Appropriate training needs to be provided to promote comprehensive, culturally competent care to GN youth, a population that has traditionally been underserved and at risk for negative psychosocial outcomes.

Purpose To determine if changing electronic health record (EHR) note templates can increase documentation of gender identity in an adolescent and young adult clinic. Methods A two-step gender question was added to EHR note templates for physicals in February 2016. A retrospective chart review was performed 3 months before and after this addition. The primary measure was whether answers to the two-step question were documented. Gender identity/birth-assigned sex discordance, age, and use of the appropriate note template post-template change were also measured. Results One hundred twenty-five pretemplate change and 106 post-template change physicals were reviewed with an inter-rater reliability of 97%. Documentation of answers to the two-step gender identity question increased from 11% to 84% ( p Conclusions This study suggests that incorporating a standardized question into EHR note templates is effective at improving the documentation of gender identity in youth presenting for annual physicals.

OBJECTIVES: To describe the patients with gender identity disorder referred to a pediatric medical center. We identify changes in patients after creation of the multidisciplinary Gender Management Service by expanding the Disorders of Sex Development clinic to include transgender patients. METHODS: Data gathered on 97 consecutive patients RESULTS: Genotypic male:female ratio was 43:54 (0.8:1); there was a slight preponderance of female patients but not significant from 1:1. Age of presentation was 14.8 ± 3.4 years (mean ± SD) without sex difference (P = .11). Tanner stage at presentation was 4.1 ± 1.4 for genotypic female patients and 3.6 ± 1.5 for genotypic male patients (P = .02). Age at start of medical treatment was 15.6 ± 2.8 years. Forty-three patients (44.3%) presented with significant psychiatric history, including 20 reporting self-mutilation (20.6%) and suicide attempts (9.3%). CONCLUSIONS: After establishment of a multidisciplinary gender clinic, the gender identity disorder population increased fourfold. Complex clinical presentations required additional mental health support as the patient population grew. Mean age and Tanner Stage were too advanced for pubertal suppressive therapy to be an affordable option for most patients. Two-thirds of patients were started on cross-sex hormone therapy. Greater awareness of the benefit of early medical intervention is needed. Psychological and physical effects of pubertal suppression and/or cross-sex hormones in our patients require further investigation.

Purpose To explore providers' clinical experiences, comfort, and confidence with and barriers to providing care to transgender youth. Methods An online survey was administered to members of the Society for Adolescent Health and Medicine and the Pediatric Endocrine Society with items querying about clinical exposure to transgender youth, familiarity with and adherence to existing clinical practice guidelines, perceived barriers to providing transgender-related care, and comfort and confidence with providing transgender-related care. The response rate was 21.9% (n = 475). Results Of the respondents, 66.5% had provided care to transgender youth, 62.4% felt comfortable with providing transgender medical therapy, and 47.1% felt confident in doing so. Principal barriers to provision of transgender-related care were lack of the following: training, exposure to transgender patients, available qualified mental health providers, and insurance reimbursement. Conclusions This study suggests that more training in transgender-related care, available qualified mental health providers, and insurance reimbursement for transgender-related care are needed.

A survey on various issues related to the DSM-IV-TR gender identity disorder diagnosis was conducted among 201 organizations concerned with the welfare of transgender people from North America, Europe, Africa, Asia, Oceania, and Latin America. Forty-three organizations from all continents completed the survey. A majority of 55.8% believed the diagnosis should be excluded from the 2013 edition. The major reason for wanting to keep the diagnosis in the DSM was health care reimbursement. Regardless of whether groups were for or against the removal of the diagnosis, the survey revealed a broad consensus that if the diagnosis remains in the DSM, there needs to be an overhaul of the name, criteria, and language to minimize stigmatization of transgender individuals.