Care Of Transgender Youth Research Articles

The Role of Sex and Gender in Transgender Bone and Other Musculoskeletal Health.

Musculoskeletal changes occur with gender-affirming hormonal therapy (GAHT) and gender-affirming surgery (GAS) used in the care of transgender adolescents and adults. Survey results have shown that orthopaedic surgeons desire to care for transgender individuals but express concern over a knowledge deficit. This article reviews the physiology and pathophysiology that may occur with GAHT and GAS. Transgender women have lower bone mineral density (BMD) prior to GAHT than cisgender men. Limited fracture data would suggest that transgender women >50 years of age have fracture rates similar to those of cisgender women. Transgender men have normal BMD prior to GAHT and are not at an increased risk for fracture compared with cisgender women. The use of puberty-blocking medications in the care of transgender youth does result in a decline in BMD, which returns to baseline with GAHT, but the effect of delaying puberty on maximal BMD and the lifetime fracture risk are unknown. At present, dual x-ray absorptiometry (DXA) is used to measure BMD and assess fracture risk. Attention should be paid to using the appropriate reference group in the interpretation of DXA for transgender individuals. Promote musculoskeletal health by ensuring appropriate calcium, vitamin D, weight-bearing activity, and a healthy lifestyle. Adherence to GAHT needs to be encouraged to avoid bone loss. Data with regard to therapy for osteoporosis in transgender patients have been lacking, but, at present, use of available therapies is expected to be effective. Information with regard to differences in other musculoskeletal health issues such as joint injuries has been lacking in transgender individuals.

Sex non-specific growth charts and potential clinical implications in the care of transgender youth.

The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) created separate growth charts for girls and boys because growth patterns and rates differ between sexes. However, scenarios exist in which this dichotomizing "girls versus boys" approach may not be ideal, including the care of non-binary youth or transgender youth undergoing transitions consistent with their gender identity. There is therefore a need for growth charts that age smooth differences in pubertal timing between sexes to determine how youth are growing as "children" versus "girls or boys" (e.g., age- and sex-neutral, compared to age- and sex-specific, growth charts). Employing similar statistical techniques and datasets used to create the CDC 2000 growth charts, we developed age-adjusted, sex non-specific growth charts for height, weight, and body mass index (BMI), and z-score calculators for these parameters. Specifically, these were created using anthropometric data from five US cross-sectional studies including National Health Examination Surveys II-III and National Health and Nutrition Examination Surveys I-III. To illustrate contemporary clinical practice, we overlaid our charts on CDC 2000 girls and boys growth charts. 39,119 youth 2-20 years old (49.5% female; 66.7% non-Hispanic White; 21.7% non-Hispanic Black) were included in the development of our growth charts, reference ranges, and z-score calculators. Respective curves were largely superimposable through around 10 years of age after which, coinciding with pubertal onset timing, differences became more apparent. We conclude that age-adjusted, sex non-specific growth charts may be used in clinical situations such as transgender youth in which standard "girls versus boys" growth charts are not ideal. Until longitudinal auxological data are available in these populations, our growth charts may help to assess a transgender youth's growth trajectory and weight classification, and expectations surrounding these.

Caught in the Middle: The Care of Transgender Youth in Texas.

In the US, approximately 0.7% of adolescents identify as transgender or gender fluid.1 Many pediatric centers now provide multidisciplinary care to assist in the transition from a child's or adolescent's assigned sex at birth (or natal sex) to their affirmed (or preferred) gender. During early puberty, therapy is available that results in the suppression of sex steroid production and secretion, followed later in adolescence by the administration of supraphysiologic doses of sex hormones appropriate for their gender identity.1-3 The duration of pubertal suppression with gonadotropin hormone releasing hormone agonists (GnRHa) varies, but can extend up to 4 years for younger patients who are not able to provide consent until age 16 for receipt of gender-affirming therapy. Puberty blockers represent an invaluable intervention for these children and adolescents, to reduce anxiety and "buy time" until final decisions can be made about gender assignment.

Providers' Perspectives on Decision-Making About Care for Transgender Youth.

Transgender and gender-diverse (TGD) youth face health care decisions that are complicated by both social and medical aspects of gender care. Little is known about how providers support decision-making in this context or the gaps they perceive in decision support. To explore health care providers' perspectives on the decision-making processes in youth gender care. We interviewed health care providers (n=17) caring for TGD youth and asked about the nature of families' decision-making, providers' role in this process, and potential improvements to existing support systems. Two independent coders coded all responses which were analyzed using thematic analysis. From providers' perspectives, they serve as "guides" to families through a challenging decision-making process. Youth arrive educated and eager to begin treatment, but caregivers are more hesitant. Providers lack data to address parents' concerns, and struggle to support families through interpersonal conflict. All providers recognized a need to improve decision support for families. Providers described decision-making in this context as a multistep process where interpersonal conflict and limited data slow progress. There is ample opportunity to leverage insights from adult and pediatric medical decision-making research to improve decision support for providers, TGD youth, and families.

Conditions for shared decision making in the care of transgender youth in Canada.

Information is lacking on the role shared decision making plays in the care of transgender (trans) youth. This qualitative, descriptive study explored how trans youth, parents and health care providers engaged or did not engage in shared decision-making practices around hormone therapy initiation and what conditions supported shared decision-making approaches in clinical practice. Semi-structured interviews were conducted with 47 participants in British Columbia, Canada, and analyzed using a constructivist grounded theory approach. While formal shared decision-making models were not used in practice, many participants described elements of such approaches when asked about their health care decision-making processes. Others described health care interactions that were not conducive to a shared decision-making approach. The key finding that emerged through this analysis was a set of five conditions for supporting shared decision making when making decisions surrounding initiation of hormone therapy with trans youth. Both supportive relationships and open communication were necessary among participants to support shared decision making. All parties needed to agree regarding what decisions were to be made and what role each person would play in the process. Finally, adequate time was needed for decision-making processes to unfold. When stakeholders meet these five conditions, a gender-affirming and culturally safer shared decision-making approach may be used to support decision making about gender-affirming care. Implications for clinical practice and future research are discussed.

A Pediatric Transgender Medicine Curriculum for Multidisciplinary Trainees.

While pediatricians should receive training in the care of transgender youth, a paucity of formal educational curricula have been developed to train learners to care for this vulnerable population. We developed a curriculum including six online modules and an in-person afternoon session observing clinic visits in a pediatric gender clinic. Learners-fourth-year medical students, interns, and nurse practitioner trainees-received protected time during an adolescent medicine rotation to complete the online modules (total duration: 77 minutes). For 20 learners, we assessed the impact of the entire curriculum-online modules and in-person observation-on self-perceived knowledge of considerations for transgender youth. For 31 learners, we assessed the effect of the online modules alone on knowledge and self-efficacy. Descriptive analyses illustrated changes in educational domains by learner group. On evaluations of the entire curriculum (modules and observation), median self-perceived knowledge scores (1 = not at all knowledgeable/aware, 5 = extremely knowledgeable/aware) increased within learner groups: pediatric interns (from 2.3 to 4.0), nurse practitioner trainees (from 2.9 to 4.7), fourth-year medical students (from 3.3 to 4.9), and psychiatry interns (from 2.8 to 4.4). Assessment of learners completing only the online modules demonstrated increases in median knowledge and self-efficacy scores within learner groups. All learner groups highly valued the curriculum. Our curriculum for multidisciplinary learners in the care of transgender youth was successful and well received. Increasing learner knowledge and self-efficacy is an important step towards skill development in patient care for the transgender youth population.

Ethical and legal issues in the care of transgender youth in the juvenile justice system

Summary The juvenile justice system faces ethical and legal issues in dealing with transgender youth. They are entitled to the same legal rights and protections while in state custody as other youth. Within the juvenile justice system, they are at risk for abuse and sexual assault by other youth. This article provides an overview of the issues regarding transgender youth in the juvenile justice system. Transgender youth are at risk for involvement in the juvenile justice system for several reasons, including rejection by families, schools and social networks that lead to contact with law enforcement. A number of legal cases have established some standards for their care and protection, but correctional facilities are often unable or do not know how to meet their needs. It is important for clinicians working with transgender youth to be aware of the risks they face with the juvenile justice system and the protections and treatment they are entitled to receive.

Fertility preservation for a transgender teenager

In this article, we discuss a case in which a 16-year-old birth-assigned male came out to her parents as transgender. She is referred to the gender management program at a large pediatric academic center to discuss hormone therapy. She was initially evaluated by a psychiatrist, diagnosed with gender dysphoria and anxiety, and treated with medication and psychotherapy. When her anxiety was well controlled and she met eligibility and readiness criteria, she was referred to 1 of 2 pediatric endocrinologists in the gender management program to discuss hormone therapy. As part of the discussion about the risks/benefits of estrogen therapy, the pediatric endocrinologist discussed options for fertility preservation (FP) before potentially gonadotoxic therapy. The patient stated that she was not interested in FP. Her mother requested procedures to preserve the possibility that the daughter could have biological children someday. We asked experts in the care of transgender youth to discuss ways in which the doctor could respond to this disagreement between parents and a teenager about FP.

“The edge of harm and help”: ethical considerations in the care of transgender youth with complex family situations

Health-care providers frequently face clinical ethical dilemmas when working with transgender youth who require hormone therapy but lack parental support for this intervention. Through semi-structured interviews and grounded theory analysis, we explored ethical and clinical decision-making processes of health-care providers, as well as the health care experiences of trans youth with family discordance. We analyzed responses in relation to North American bioethics principles, best interests standard, and the harm principle, exploring issues of autonomy, evidence, and anti-trans bias. We propose an ethically acceptable clinical approach termed parallel process hormone therapy initiation to address the needs of transgender youth with complex family situations.

Review of Current Care Models for Transgender Youth and Application to the Development of a Multidisciplinary Clinic - The Seattle Children's Hospital Experience.

Care of transgender and gender diverse youth is complex and requires a multidisciplinary approach. Many transgender patients and providers feel the limited availability of affirming, knowledgeable professionals is a barrier to obtaining care. Such care can be provided through a clinic with providers from different disciplines who are trained in the unique care of transgender youth. In this paper, we discuss the care guidelines for transgender youth and the unresolved challenges that need to be addressed during the development of a transgender clinic. We describe our experience at Seattle Children's Hospital in the development of a multidisciplinary Gender Clinic which incorporates the expertise of social work, mental health professionals, pediatric endocrinology, adolescent medicine, and bioethics. Other institutions may build from our experience, with the ultimate goal of further decreasing health disparities for young transgender patients.

To Refer or Not to Refer: General Pediatricians' Perspectives on Their Role in Caring for Transgender Youth.

Little is known about general pediatricians' experience and knowledge regarding the care of transgender youth. We surveyed N=50 general pediatricians practicing in an integrated Midwest health system. Few respondents had participated in medical management care for transgender patients, but one-third were willing to do so if training opportunities were made available. Notably, <60% of respondents were comfortable providing routine care for transgender youth. At a minimum, pediatricians need the training to feel capable of providing routine care for transgender pediatric patients. In addition, opportunities for training should be offered to those who are willing to learn about medical management of transgender youth.

A Call for Fertility and Sexual Function Counseling in Pediatrics.

* Abbreviation: AAP — : American Academy of Pediatrics During a pediatric endocrinology clinic visit, a 16-year-old boy presented with his family for evaluation of his endocrine axes due to history of bone marrow transplantation. He had previously been followed elsewhere; transfer records stated his family had been told that his fertility was likely to be impaired, but his parents had not shared this with him. It was also unclear from review of the notes whether any discussions regarding sexual function had occurred. Historically, reproductive health in pediatrics has focused primarily on contraception and prevention of sexually transmitted infections. However, there is now a growing body of literature discussing the long-term impact of many pediatric conditions and treatments on fertility and sexual function, such as oncologic therapy, hematologic or autoimmune conditions requiring bone marrow transplantation, renal and rheumatologic disorders in which alkylators are used, cross-sex hormonal therapy used in the care of transgender youth, disorders of sex development, and other genetic syndromes such as galactosemia. Pediatric providers face dilemmas about the optimal approaches for assessing and discussing fertility and sexual function with patients and families, the type of guidance to give to parents about related communications with their children at each developmental stage, and ethical obligations regarding disclosure when parents are opposed to sharing sensitive information with their children. Decades ago, the nondisclosure approach to sensitive … Address correspondence to Leena Nahata, MD, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205. E-mail: leena.nahata{at}nationwidechildrens.org

Improving transgender health by building safe clinical environments that promote existing resilience: Results from a qualitative analysis of providers.

BackgroundTransgender (TG) individuals experience discordance between their sex at birth and their gender identity. To better understand the health care needs and characteristics of TG youth that contribute to resilience, we conducted a qualitative study with clinical and non-clinical providers.MethodsIn-depth interviews were conducted of providers (n = 11) of TG youth (ages 13–21). Convenience and purposive sampling were used to recruit participants in the Boston area. All interviews were audio-recorded and transcribed verbatim. An interview guide of 14 open-ended questions was used to guide the discussion. A grounded theory approach was utilized to code and analyze the data, including double-coding to address issues of inter-rater reliability.ResultsFive primary themes emerged: 1) resilience of TG youth 2) lack of access to services that influence health, 3) the critical role of social support, 4) challenges in navigating the health care system, and 5) the need for trans-affirming competency training for providers and frontline staff.ConclusionThe findings of this study show that providers recognize multiple barriers and challenges in the care of TG youth. However, they also identify the resilience exhibited by many youth. We propose that providers can further enhance the resilience of TG youth and help them flourish by offering them necessary resources via the creation of safe and welcoming clinical environments.