Transmasculine Youth Research Articles

Mental health of Finnish cis- and transgender youth before, during and after the COVID-19 pandemic

Abstract Background Transgender youth report more mental health problems than their cisgender peers, but little is known about their mental health during and after the COVID-19 pandemic. We studied symptoms of anxiety and depression among cis- and transgender youth before, during, and after the pandemic using large nationwide samples. Methods Data from the Finnish School Health Promotion survey from years 2019, 2021 and 2023 (461,249 students in total; mean age 15.7, SD 1.3) were used. Self-reports covered official gender, gender identity, symptoms of anxiety (Generalized Anxiety Disorder Scale-7 ≥10) and depression (Patient Health Questionnaire-2 ≥3). Categories of cisgender boy (officially boy; gender identity boy; N = 214,423), transfeminine youth (officially boy; gender identity girl, both, neither, or it varies; N = 5,069), cisgender girl (officially girl; gender identity girl; N = 224,753), and transmasculine youth (officially girl; gender identity boy, both, neither, or it varies; N = 14,508) were formed. Results In all timepoints, proportion of those with anxiety or depression was higher among transfeminine youth compared with cisgender boys and among transmasculine youth compared with cisgender girls. In all groups anxiety and depression increased significantly from 2019 to 2021 (ORs 1.4-1.8, p < 0.0001), with no significant differences in these changes between cis- and transgender groups. From 2021 to 2023, anxiety (OR 0.91, p = 0.015) and depression (OR 0.77, p < 0.0001) decreased among transmasculine youth but increased among cisgender girls (ORs 1.11 [p < 0.0001] and 1.07 [p < 0.0001], interactions p < 0.0001). Among transfeminine youth, generalized anxiety symptoms decreased from 2021 to 2023, whereas they remained at the level observed in 2021 among cisgender boys (interaction p = 0.0025). Conclusions In Spring 2023, we found still increasing mental health problems among cisgender girls, while among transgender youth the post-pandemic developments were more positive. Key messages • Post-pandemic, we found further increases in mental health symptoms in cisgender youth, while among transgender youth the development seemed more promising. • Transgender youth experience more anxiety and depression than their cisgender peers, thus gender diversity deserves still more attention in educational, social, and health care services.

MyPEEPS Mobile App for HIV Prevention Among Transmasculine Youth: Adaptation Through Community-Based Feedback and Usability Evaluation.

Transgender men and transmasculine youth are at high risk for acquiring HIV. Growing research on transgender men demonstrates increased HIV risk and burden compared with the general US population. Despite biomedical advancements in HIV prevention, there remains a dearth of evidence-based, sexual health HIV prevention interventions for young transgender men. MyPEEPS (Male Youth Pursuing Empowerment, Education, and Prevention around Sexuality) Mobile is a web-based app that builds on extensive formative community-informed work to develop an evidence-based HIV prevention intervention. Our study team developed and tested the MyPEEPS Mobile intervention for 13- to 18-year-old cisgender young men in a national randomized controlled trial, which demonstrated efficacy to reduce sexual risk in the short term-at 3-month follow-up. Trans men and transmasculine youth resonated with basic HIV educational information and sexual scenarios of the original MyPEEPS app for cisgender men, but recognized the app's lack of transmasculine specificity. The purpose of this study is to detail the user-centered design methods to adapt, improve the user interface, and enhance the usability of the MyPEEPS Mobile app for young transgender men and transmasculine youth. The MyPEEPS Mobile app for young transgender men was adapted through a user-centered design approach, which included an iterative review of the adapted prototype by expert advisors and a youth advisory board. The app was then evaluated through a rigorous usability evaluation. MyPEEPS Mobile is among the first mobile health interventions developed to meet the specific needs of young transgender men and transmasculine youth to reduce HIV risk behaviors. While many of the activities in the original MyPEEPS Mobile were rigorously developed and tested, there was a need to adapt our intervention to meet the specific needs and risk factors among young transgender men and transmasculine youth. The findings from this study describe the adaptation of these activities through feedback from a youth advisory board and expert advisors. Following adaptation of the content, the app underwent a rigorous usability assessment through an evaluation with experts in human-computer interaction (n=5) and targeted end users (n=20). Usability and adaptation findings demonstrate that the MyPEEPS Mobile app is highly usable and perceived as potentially useful for targeting HIV risk behaviors in young transgender men and transmasculine youth.

Mental health after the COVID-19 pandemic among Finnish youth: a repeated, cross-sectional, population-based study

High levels of mental health problems among young people were reported during the COVID-19 pandemic, but studies of the post-pandemic period are scarce. We assessed mental health problems among Finnish youth before, during, and after the COVID-19 pandemic using nationwide population-based samples. Our aim was to examine in which direction the heightened levels of adolescent mental health problems have developed after the pandemic. In this national, repeated cross-sectional, population-based study in Finland, we recruited students at lower and upper secondary level (aged 13-20 years) who were taking part in the Finnish School Health Promotion (SHP) survey in 2015-23 (119 681-158 897 participants per round). The SHP is based on total sampling and conducted biennially between March and May. Self-reports covered the seven-item Generalized Anxiety Disorder Scale; the two-item Patient Health Questionnaire for depression; the Mini Social Phobia Inventory for social anxiety; the Short Warwick-Edinburgh Mental Wellbeing Scale for mental wellbeing; loneliness; the Sick, Control, One Stone, Fat, Food measure for disordered eating; and suicidality (suicidal ideation, deliberate self-harm, and suicide attempts). Scales were dichotomised using validated cutoffs. Presence of any and comorbid mental health problems was assessed. Logistic (for dichotomised outcomes) and linear (for Short Warwick-Edinburgh Mental Wellbeing Scale) mixed effects models were used to analyse the effect of survey year on mental health, controlling for sociodemographic background factors and stratified by gender and school level. Cisgender and transgender youth were compared. Between 2015 and 2023, the SHP study recruited 722 488 students (371 634 [51·6%] girls and 348 857 [48·4%] boys) with a mean age of 15·8 years (SD 1·3) who were either in the eighth and ninth grades of comprehensive school or the first and second years of general and vocational upper secondary schools in Finland. The proportion of participants with generalised anxiety, depression, and social anxiety symptoms above the cutoff increased from pre-COVID-19 levels to 2021 and remained at these higher levels in 2023 among all study groups. Among girls in lower secondary education, prevalence of generalised anxiety, depression, and social anxiety symptoms increased from 2021 to 2023, as did social anxiety among girls in upper secondary education. Among boys, the proportion with social anxiety symptoms decreased between 2021 and 2023. Mental wellbeing scores decreased in all groups between 2021 and 2023, and disordered eating increased in girls, and in boys in lower secondary education. Suicidality increased in girls but not in boys. Loneliness was the only measure to show improvement in all groups from 2021 to 2023. In 2023, 55 895 (72·6%) of 76 994 girls and 22 718 (32·8%) of 69 205 boys reported at least one mental health problem, and 37 250 (48·4%) girls and 9442 (13·6%) boys reported comorbid mental health problems. Among both transfeminine and transmasculine youth, the prevalence of generalised anxiety and depression symptoms decreased from 2021 to 2023, but compared with cisgender youth, the proportions were significantly higher throughout. The effects of the COVID-19 pandemic on youth mental health could be long lasting. In this study, the substantial change for the better among transgender youth was a positive exception. Providing adequate support and treatment for young people with poor mental health is essential, but solutions to the mental health crisis need to address a wider societal perspective and should be developed in partnership with young people. NordForsk, Research Council of Finland. For the Finnish and Swedish translations of the abstract see Supplementary Materials section.

Pubertal Suppression in Early Puberty Followed by Testosterone Mildly Increases Final Height in Transmasculine Youth.

Treatment for transmasculine youth (TMY) can involve testosterone treatment and is sometimes preceded by gonadotropin-releasing hormone agonist (GnRHa) treatment for puberty blockade. GnRHas can increase final height in birth-assigned females with central precocious puberty. Maximizing final adult height (FAH) is an important outcome for many TMY. Our objective was to determine how GnRHa treatment before testosterone impacts FAH. Retrospective cohort study at 5 US transgender health clinics. Participants were 32 TMY treated with GnRHas in early to midpuberty before testosterone (GnRHa + T group) and 62 late/postpubertal TMY treated with testosterone only (T-only group). The difference between FAH minus midparental target height (MPTH) was +2.3 ± 5.7 cm and -2.2 ± 5.6 cm in the GnRHa + T and T-only groups, respectively (P < .01). In the GnRHa + T group, FAH was 1.8 ± 3.4 cm greater than predicted adult height (PAH) (P < .05) and FAH vs initial height (IH) z-score was 0.5 ± 1.2 vs 0.16 ± 1.0 (P < .05). After adjusting for patient characteristics, each additional month of GnRHa monotherapy increased FAH by 0.59 cm (95% CI 0.31, 0.9 cm), stage 3 breast development at start of GnRHa was associated with 6.5 cm lower FAH compared with stage 2 (95% CI -10.43, -2.55), and FAH was 7.95 cm greater in the GnRHa + T group than in T-only group (95% CI -10.85, -5.06). Treatment with GnRHa in TMY in early puberty before testosterone increases FAH compared with MPTH, PAH, IH, and TMY who only received testosterone in late/postpuberty. TMY considering GnRHas should be counseled that GnRHas may mildly increase their FAH if started early.

Gendered Differences in Experiences of Bullying and Mental Health Among Transgender and Cisgender Youth

Even though previous studies have shown that transgender youth have poorer mental health and more experiences of being bullied than their cisgender counterparts, and that bullying associates with poorer mental health, knowledge on such associations in different gender identity groups is scarce. This study investigated how mental health problems and experiences of being bullied appear across different gender identity groups, and how bullying is associated with mental health among the groups in question. Data from the Finnish School Health Promotion 2021 study (n = 152,880, mean age 16.2 years (standard deviation 1.22)) was used and categorized into four gender identity groups: cisgender girls (n = 76,521), cisgender boys (n = 69,735), transfeminine youth (n = 1317), and transmasculine youth (n = 5307). Transgender youth experienced more bullying and reported poorer mental health than cisgender youth. While transfeminine youth faced the most bullying, transmasculine youth had the most mental health symptoms. In each group, bullying associated with poorer mental health. Compared to cisgender boys without bullying experiences, odds of poorer mental health were dozens-fold among transmasculine youth with weekly bullying experiences. In addition, compared to cisgender boys with bullying experiences, odds of poorer mental health were greater among all other gender identity groups with bullying experiences, and among transmasculine youth in particular (e.g., odds ratio of generalized anxiety = 8.36 (95% confidence interval, 6.59–10.6)). Bullying is associated with poorer mental health in all youth, but transgender youth, and especially transmasculine youth, may be in an even more vulnerable position for its implications. This suggests that there is a need for improving effective measures to decrease bullying in schools and to improve wellbeing of transgender youth.

Headache prevalence in transgender and gender diverse youth: A single-center case-control study.

Assess the prevalence of headache in transgender and gender-diverse adolescents, comparing prevalence with and without exposure to gender-affirming hormone therapy. Transgender and gender-diverse youth are an understudied group in whom we can study the effects of sex steroids on adolescents' development of headache. We hypothesized that transfeminine adolescents treated with estrogen would have higher odds of headache than those not treated, and that transmasculine adolescents treated with testosterone would have lower odds of headache than those not treated. This retrospective case-control study analyzed all patients seen at the Boston Children's Hospital Gender Multispecialty Service clinic from 2007 to 2017. Cases were defined as patients with headache, controls as those without headache, and exposure as treatment with gender-affirming hormone therapy (i.e., estrogen or testosterone). A computerized search identified cases that were then validated by chart review. Fifty-two of the 763 transgender and gender-diverse patients seen were confirmed to have headache. Of 273 transfeminine patients 45% (123/273) received estrogen treatment. Transfeminine patients receiving estrogen were more likely to have headache than those not receiving estrogen (7% [9/123] vs. 1% [2/150]; odd ratio [OR] 5.84 (95% confidence interval [CI] 1.24-27.6), p=0.026). Of 490 transmasculine patients, 46% (227/490) received testosterone. Transmasculine patients receiving testosterone were more likely to have headache than those not receiving testosterone (12% [28/227] vs. 5% (13/263); OR 2.71 (95% CI 1.37-5.4), p=0.005). Among transfeminine and transmasculine youth, those who received gender-affirming hormone therapy had higher odds of headache compared to those not taking gender-affirming hormone therapy. Further prospective studies to guide headache care of transgender and gender-diverse youth and adults are needed. Our results could be generalizable to other pediatric gender management clinics and may be worth discussing with patients considering treatment.

A mouse model mimicking gender-affirming treatment with pubertal suppression followed by testosterone in transmasculine youth.

Can mice serve as a translational model to examine the reproductive consequences of pubertal suppression with GnRH agonist (GnRHa) followed by testosterone (T) administration, a typical therapy in peripubertal transmasculine youth? An implanted depot with 3.6 mg of GnRHa followed by T enanthate at 0.45 mg weekly can be used in peripubertal female mice for investigating the impact of gender-affirming hormone therapy in transmasculine youth. There is limited knowledge available in transgender medicine to provide evidence-based fertility care, with the current guidelines being based on the assumption of fertility loss. We recently successfully developed a mouse model to investigate the reproductive consequences of T therapy given to transgender men. On the other hand, to our knowledge, there is no mouse model to assess the reproductive outcomes in peripubertal transmasculine youth. A total of 80 C57BL/6N female mice were used in this study, with n = 7 mice in each experimental group. We first assessed the effectiveness of GnRHa in arresting pubertal development in the female mice. In this experiment, 26-day-old female mice were subcutaneously implanted with a GnRHa (3.6 mg) depot. Controls underwent a sham surgery. Animals were euthanized at 3, 9, 21 and 28 days after the day of surgery. In the second experiment, we induced a transmasculine youth mouse model. C57BL/6N female mice were subcutaneously implanted with a 3.6 mg GnRHa depot on postnatal day 26 for 21 days and this was followed by weekly injections of 0.45 mg T enanthate for 6 weeks. The control for the GnRH treatment was sham surgery and the control for T treatment was sesame oil vehicle injections. Animals were sacrificed 0.5 weeks after the last injection. The data collected included the day of the vaginal opening and first estrus, daily vaginal cytology, weekly and terminal reproductive hormones levels, body/organ weights, ovarian follicular distribution and corpora lutea (CL) counts. GnRHa implanted animals remained in persistent diestrus and had reduced levels of FSH (P = 0.0013), LH (P = 0.0082) and estradiol (P = 0.0155), decreased uterine (P < 0.0001) and ovarian weights (P = 0.0002), and a lack of CL at 21 days after GnRHa implantation. T-only and GnRHa+T-treated animals were acyclic throughout the treatment period, had sustained elevated levels of T, suppressed LH levels (P < 0.0001), and an absence of CL compared to controls (P < 0.0001). Paired ovarian weights were reduced in the T-only and GnRHa+T groups compared with the control and GnRHa-only groups. N/A. Although it is an appropriate tool to provide relevant findings, precaution is needed to extrapolate mouse model results to mirror human reproductive physiology. To our knowledge, this study describes the first mouse model mimicking gender-affirming hormone therapy in peripubertal transmasculine youth. This model provides a tool for researchers studying the effects of GnRHa-T therapy on other aspects of reproduction, other organ systems and transgenerational effects. The model is supported by GnRHa suppressing puberty and maintaining acyclicity during T treatment, lower LH levels and absence of CL. The results also suggest GnRHa+T therapy in peripubertal female mice does not affect ovarian reserve, since the number of primordial follicles was not affected by treatment. This work was supported by the Michigan Institute for Clinical and Health Research grants KL2 TR 002241 and UL1 TR 002240 (C.D.C.); National Institutes of Health grants F30-HD100163 and T32-HD079342 (H.M.K.); University of Michigan Office of Research funding U058227 (A.S.); American Society for Reproductive Medicine/Society for Reproductive Endocrinology and Infertility grant (M.B.M.); and National Institutes of Health R01-HD098233 (M.B.M.). The University of Virginia Center for Research in Reproduction Ligand Assay and Analysis Core Facility was supported by the Eunice Kennedy Shriver NICHD/NIH grants P50-HD028934 and R24-HD102061. The authors declare that they have no competing interests.

A Trans Youth of Color Study to Measure Health and Wellness: Protocol for a Longitudinal Observation Study.

Growing research on transgender youth is accounting for the variety of ways in which young people define their genders and sexualities. Because of this growing representation, more research is needed to understand how intersectional identities and stigma affect risk for HIV acquisition along the HIV care continuum and engagement in mental and physical health care. Little is known about accessibility to HIV-related prevention services of nonbinary and transmasculine youth, and further understanding of the impacts on transfeminine people-those who have historically faced the highest prevalence of HIV positivity-is crucial. The overarching aims of the Trans Youth of Color Study are to conduct longitudinal research with a cohort of transgender minority youth (TGMY), explore factors that aid in the prevention of new HIV infection and transmission, and reduce HIV- and AIDS-related disparities by focusing on successful engagement in care. Findings from this research will be used to inform the development of new interventions designed to engage TGMY in the HIV prevention and care continua. Longitudinal research (baseline and follow-up assessments every 6 months for 3 waves of data collection) followed a cohort (N=108) of transgender youth of color recruited in Los Angeles, California, United States. Participants were recruited using multiple community-informed strategies, such as from local venues, social media, and participant referral. In addition to self-report surveys, urine was collected to assess recent use of illicit drugs, and blood, rectal, and throat swabs were collected to test for current sexually transmitted infection and HIV infection. Additional blood and plasma samples (10 mL for 4 aliquots and 1 pellet) were collected and stored for future research. Participants in the Trans Youth of Color Study were recruited between May 25, 2018, and December 7, 2018. Baseline and longitudinal data are being analyzed as of August 2022. The findings from this research will inform adaptations to existing evidence-based HIV prevention interventions and help to guide new interventions designed to engage TGMY, especially those who are Black, Indigenous, or people of color, in the HIV prevention and care continua. DERR1-10.2196/39207.

75. “Being Out” in a Pre- and Pandemic World: Does Sexual Orientation Disclosure to a Healthcare Provider Impact Receipt of Sexual and Reproductive Health Services in Youth Assigned Female Sex at Birth?

Sexual minority women and transmasculine youth in the U.S. experience disparities in sexual and reproductive health (SRH) outcomes and service receipt, including increased risk of unintended pregnancy. Limited research in predominantly non-Hispanic White (White) adult populations shows that disclosing one’s sexual orientation or behaviors to one’s healthcare provider (HCP disclosure) is associated with higher rates of HPV vaccination and PAP testing. No studies have evaluated disclosure and receipt of HIV testing or contraceptive services.

A Qualitative Study to Inform Adaptation of MyPEEPS Mobile for Transmasculine Youth

Transmasculine youth, ages 13-18 years, who reported attraction to or sex with cisgender men were recruited to participate in focus groups in four major cities in the United States. Overall, participants found MyPEEPS Mobile to be a useful educational platform for sexual health education. Participants discussed expansions of the MyPEEPS Mobile App to address interpersonal concerns and provision of a holistic approach to health promotion for transmasculine youth. Detailed suggestions for improvement included personalization; transmasculine inclusivity and relatability; expansion of population-specific educational components; and improvements to functionality, images, and graphics. While MyPEEPS Mobile has educational components, adaptations are needed to address specific needs of TMY and optimize user-centered design for feasibility and efficacy. If tailored to the lives of transmasculine youth, MyPEEPS has the potential to promote HIV preventive behavior.

Transgender Youth Referred to Clinics for Gender-Affirming Medical Care in Canada.

Referrals of transgender and gender-diverse (trans) youth to medical clinics for gender-affirming care have increased. We described characteristics of trans youth in Canada at first referral visit. Baseline clinical and survey data (2017-2019) were collected for Trans Youth CAN!, a 10-clinic prospective cohort of n = 174 pubertal and postpubertal youth <16 years with gender dysphoria, referred for hormonal suppression or hormone therapy, and 160 linked parent-participants. Measures assessed health, demographics, and visit outcome. Of youth, 137 were transmasculine (assigned female) and 37 transfeminine (assigned male); 69.0% were aged 14 to 15, 18.8% Indigenous, 6.6% visible minorities, 25.7% from immigrant families, and 27.1% low income. Most (66.0%) were gender-aware before age 12. Only 58.1% of transfeminine youth lived in their gender full-time versus 90.1% of transmasculine (P < .001). Although transmasculine youth were more likely than transfeminine youth to report depressive symptoms (21.2% vs 10.8%; P = .03) and anxiety (66.1% vs 33.3%; P < .001), suicidality was similarly high overall (past-year ideation: 34.5%, attempts: 16.8%). All were in school; 62.0% reported strong parental gender support, with parents the most common support persons (91.9%). Two-thirds of families reported external gender-related stressors. Youth had met with a range of providers (68.5% with a family physician). At clinic visit, 62.4% were prescribed hormonal suppression or hormone therapy, most commonly depot leuprolide acetate. Trans youth in Canada attending clinics for hormonal suppression or gender-affirming hormones were generally healthy but with depression, anxiety, and support needs.

Preliminary findings for adverse childhood experiences and associations with negative physical and mental health and victimization in transmasculine adults

IntroductionStudies highlight the impact of adverse childhood experiences (ACEs) on risk for negative health outcomes in adulthood, including cancer, cardiovascular disease, substance use, and mental health. Lesbian, gay, bisexual, and transgender (LGBT) people report higher rates of ACEs than non-LGBT people, with transgender people at greatest risk. ObjectiveThis study aims to comprehensively assess the prevalence of ACEs and association with health outcomes among transmasculine individuals. Participants and settingA sample of 131 transmasculine individuals enrolled in a clinical trial on preventive cervical cancer screening between March 2015 and September 2016 in the United States were surveyed about ACEs and health outcomes. MethodsPearson's chi-squared tests and logistic regression models were used to examine associations between self-reported ACEs prior to age 18 and the risk of various negative health outcomes in adulthood. ACEs were categorized as 0–1 ACEs, 2–3 ACEs, and 4+ ACEs. ResultsOver 90% of the sample (120/131) reported at least 1 ACE; 45% (59/131) reported 4+ ACEs. Report of 4 or more ACEs increased risk for negative health outcomes and risk factors compared to 0–1 ACEs, including: depression (AOR = 5.3, 95%CI = 1.7, 16.2), suicidality (AOR = 5.2, 95%CI = 1.4, 18.8), post-traumatic stress disorder (AOR = 6.0, 95%CI (1.6, 22.8)), intimate partner violence (AOR = 5.3, 95%CI = 1.4, 18.8), and obesity (AOR = 8.2, 95%CI = 1.8, 37.2). Report of 2–3 ACEs was also significantly associated with obesity (AOR = 5.9, 95%CI = 1.3, 26.2). ConclusionsACEs are highly prevalent in this sample, and more attention is needed for research and intervention. This exploratory study is the first to comprehensively highlight patterns of physical and mental health risk and victimization associated with report of ACEs among transmasculine individuals. Trauma-informed screening and intervention efforts tailored to the unique needs of this population are needed to provide appropriate and effective care. Clinicians should consider routinely screening for ACEs among transmasculine youth and engage in prevention strategies to reduce health disparities. Further research is warranted to validate these findings among larger, more representative samples to better reflect the diversity of experiences and identities of transmasculine individuals and produce more reliable findings.

Oxandrolone Use in Trans-Masculine Youth Appears to Increase Adult Height: Preliminary Evidence.

Purpose: Early use of oxandrolone and gonadotropin-releasing hormone analogs has been shown to increase adult height in patients at risk for short stature, but use in trans-masculine (TM) youth to augment height has not been explored. The purpose of this study was to identify the impact of oxandrolone on adult height in TM youth. Methods: This was a single-center, retrospective chart review of TM patients seen between 2013 and 2018. Hormone regimens, heights, mid-parental height, and bone ages were recorded. We examined correlations between adult height and age at the initiation of treatment or with the age of referral (in untreated patients). Results: Of TM patients, 154 had achieved adult height, including 34 who received oxandrolone, 42 who reached adult height before starting gender-affirming hormone therapy (GAHT), and 14 who received no treatment. Adult height correlated inversely with age at hormone initiation in oxandrolone-treated patients only (p = 0.001). Each earlier year of treatment yielded a 2.3 cm increase in adult height. Those who started oxandrolone younger than the median age achieved an adult height of 169.6 ± 6.4 cm compared to 162.1 ± 6.0 cm in those starting later than the median age (p < 0.001), 164.6 ± 4.8 cm in those receiving no treatment (p = 0.02), and 163.9 ± 6.5 cm in those receiving all other regimens (p < 0.001). Conclusions: Early use of oxandrolone may augment adult height in TM youth. Height discussions should be part of comprehensive GAHT counseling.

Recognizing the Importance of Chest Surgery for Transmasculine Youth.

Transmasculine youth and adults often report that masculinizing chest surgery (MCS) is an important step toward gender affirmation. In a sample of 133 transmasculine youth attending a pediatric gender clinic, 82% reported being dissatisfied with breasts and 93% reported a desire for MCS.1 However, most research in this area has been focused on adults. In this issue of Pediatrics, Mehringer et al2 elicit transmasculine youth’s descriptions of their experiences with chest dysphoria and MCS. Youth described improvements in mental health and quality of life after MCS. However, despite standards of care within transgender health considering MCS medically necessary,3 Mehringer et al2 identify important systemic barriers that often prevent transmasculine youth from accessing care. Although barriers to gender-affirming care remain widespread for transgender adults,4 barriers are particularly pronounced for youth. As youth in this study describe, lack of access to MCS prolongs unnecessary distress and difficulties in functioning.As Mehringer et al2 note, many youth have insurance that will not cover MCS and cannot afford to pay out of pocket. Insurance companies commonly use coverage guidelines that are not consistent with the field’s standards of care. Although standards of care do not recommend a specific age for considering MCS, many insurance companies will deny medical coverage for youth aged <18. Historically, some providers have recommended transmasculine individuals receive testosterone therapy for 1 year before surgery. Although this recommendation is no longer considered best practice, it is still a requirement for covering MCS under some insurance plans.5 These insurance coverage difficulties and high out-of-pocket costs are also common with puberty suppression and hormone therapy for transgender youth.6Barriers to care also exist on social, institutional, and cultural levels. Many transgender youth lack supportive parents, which often prevents them from accessing gender-affirming medical care altogether.7 Within the health care system, lack of available training needed to obtain the skill and techniques necessary to provide MCS (eg, incision, nipple placement, nipple sizing) contributes to a scarcity of providers. Although not successful to date, legislation to limit access to all gender-affirming medical care for youth aged <18 has been proposed in >12 states.2 Together, these barriers are manifestations of larger social stigma and transphobia that must be addressed. Transmasculine youth of color and youth from lower socioeconomic backgrounds are disproportionately impacted. In addition to structural practices that decrease access and quality of care for many people of color, Black youth tend to start breast development earlier than white youth,8 meaning they may experience more breast growth before obtaining MCS.In addition to advocating for youth’s access to MCS on a systemic level, providers can collaboratively assist youth in navigating insurance, preparing for surgery, and developing coping skills to manage chest dysphoria. This requires attunement to the diverse experiences transmasculine people have in relation to MCS. Although many transmasculine youth who are accessing hormone therapy desire MCS, not all do. Some youth desire MCS but not hormone therapy, and individuals who identify with other genders, such as agender and nonbinary, may also desire MCS.9 Goals and expectations surrounding outcomes vary both within and across these groups. Additionally, 2 common surgical approaches, double mastectomy and periareolar surgery, use different techniques and may be associated with unique experiences (eg, aftercare and recovery process and patient satisfaction).Attunement to the diversity and nuance of transgender youth’s experiences of their physical gender embodiment is also critical to providing gender-affirming care.10 Youth in the study conducted by Mehringer et al2 described internal (eg, distress, hopelessness) as well as situational (eg, limiting activities) and interpersonal (eg, avoiding interactions) manifestations of chest dysphoria. In addition to access to care, structural factors such as antidiscrimination policies and ability to legally change one’s name and gender marker may also impact dysphoria.11 Although often obscured by an overfocus on dysphoria, authors within the field highlight how experiences of gender euphoria and resiliency are equally as important.12 Providers should keep in mind that, although many transmasculine youth experience chest dysphoria, this is only one part of their overall experience. More holistic conceptualizations of physical embodiment are needed that better reflect the full spectrum of lived experiences.When referring to transgender people, writers should be cautious of using shorthand such as “pre- and post-MCS.” For a period, the terms “pre- and post-op transsexual” were commonly used. This convention was problematic because it violated privacy and conveyed a message that surgery defined the transgender person. Additionally, the specific terms used by Mehringer et al2 and this commentary may not reflect those used by individual youth. In general, language is actively evolving along with best practices in gender-affirming care. Maintaining cultural competency requires humility and regular engagement in continuing education that centers the experiences of transgender people from their own perspectives.We note that Drs Laura E. Kuper and G. Nic Rider use they/them pronouns, and Dr Colt M. St. Amand uses he/they pronouns.

Experience of Chest Dysphoria and Masculinizing Chest Surgery in Transmasculine Youth.

Transmasculine individuals, those assigned female sex at birth but who identify as masculine, have high rates of suicidal behavior and often suffer from chest dysphoria (discomfort and distress from unwanted breast development). Growing numbers of transmasculine youth are pursuing definitive treatment with masculinizing chest surgery (MCS), and adult studies reveal marked benefits of MCS, although little is known about the impact of chest dysphoria on transmasculine youth or the optimal timing of MCS. In this study, we aimed to explore youth experiences of chest dysphoria and the impact of MCS. Transmasculine youth aged 13 to 21 were recruited from a pediatric hospital-based gender clinic. Participants completed a semistructured qualitative interview exploring the experience of chest dysphoria and thoughts about or experiences with MCS. Interview transcripts were coded by 3 investigators employing modified grounded theory, with the median interrater reliability at κ = 0.92. Subjects (N = 30) were a mean age of 17.5 years, and 47% had undergone MCS. Youth reported that chest dysphoria triggered strong negative emotions and suicidal ideation, caused a myriad of functional limitations, and was inadequately relieved by testosterone therapy alone. All post-MCS youth reported near or total resolution of chest dysphoria, lack of regret, and improved quality of life and functioning. We observed consensus that chest dysphoria is a major source of distress and can be functionally disabling to transmasculine youth. MCS performed during adolescence, including before age 18, can alleviate suffering and improve functioning. Additional research is needed to develop patient-reported outcome measures to assess the impact of chest dysphoria and MCS.

Considerations for Providing Pediatric Gender-Affirmative Care During the COVID-19 Pandemic

Considerations for Providing Pediatric Gender-Affirmative Care During the COVID-19 Pandemic

Empowering Transmasculine Youth by Enhancing Reproductive Health Counseling in the Primary Care Setting

Empowering Transmasculine Youth by Enhancing Reproductive Health Counseling in the Primary Care Setting

Disordered Eating Among Trans-Masculine Youth: Considerations Through a Developmental Lens.

As with male populations more generally, eating disorder symptom expression among trans-masculine youth is understudied. Gender minority individuals are at increased risk for eating disorders; however, culturally responsive and developmentally tailored research is limited. Although all gender minority individuals may experience elevated risk for developing eating disorders, the focus of this article is trans-masculine youth. We provide a theoretical conceptualization of eating disorder symptom expression among this understudied group, and propose novel directions for research, particularly for youth at pubertal onset. Adolescence as a critical developmental period for intervention is highlighted.

51. Oxandrolone as an Alternative to Testosterone in Transmasculine Youth

Transmasculine (TM) youth (transgender and gender diverse youth assigned female at birth) are seeking medical therapy for gender transition in greater numbers and at earlier ages, requesting puberty blocking GnRH analogs and androgen-based masculinizing gender affirming hormone therapy (GAHT). One reason to delay use of testosterone in these patients is to allow time for long bone growth prior to hormonally mediated closure of the epiphyseal plates. Delaying the use of testosterone in TM youth who are psychosocially ready for puberty and hormonal transition could add to emotional distress. In addition, TM youth may desire to maximize adult height. As a non-aromatizable androgen, oxandrolone cannot advance the bone age. In Turner syndrome patients, oxandrolone has been shown to augment adult height. The goal of this study was to begin to evaluate the effects of oxandrolone use in TM youth on growth and final height.

5. Premature Height Deceleration: A Risk in Transmasculine Youth

Increasing numbers of transmasculine (TM) youth (transgender and gender diverse (TGD) youth assigned female at birth) are avoiding puberty with endogenous hormones and utilizing GnRH analogs followed by masculinizing gender affirming hormone therapy (GAHT). Clinicians providing early hormone care must monitor development, including growth. Growth spurts and final adult height are determined by numerous factors including parental heights, timing of puberty, and hormonal factors. We have noted anecdotally that a high percentage of TM youth attain their adult heights early. Few studies have systematically assessed growth variations in TGD youth, and little is known about the effects of therapies on height outcomes. The goal of this study is to assess growth patterns in TM youth before and after GnRH analog therapy and various types of GAHT.