Pathways to Care for Adolescents Attending a First Hormone Appointment at Canadian Gender Affirming Medical Clinics: A Cross-Sectional Analysis From the Trans Youth CAN! Study.

PURPOSE: Limited research has examined adolescents' pathways to gender-affirming medical care. METHODS: Enrollment in Trans Youth CAN! was at an initial appointment for hormone suppression or gender-affirming hormones, if pubertal or postpubertal, and < 16 years old. Adolescent/parent surveys and clinical records were obtained for 174 adolescents and 160 matched parents at 10 medical clinics across Canada. RESULTS: Participants' mean age was 14.3 years, 95% confidence interval (CI) [14.1-14.6]; 126 (75.8%) identified as boys, 32 (15.9%) girls, and 14 (8.3%) nonbinary. Average wait time after referral was 269 days (95% CI [244, 294]). Adolescents reported 13.5 months seeking gender-affirming medical care, longer than reported by their parents (p = .0001). Family physicians or pediatricians provided 68% of referrals. Prior to clinic, adolescents saw an average of 2.7 (maximum eight) different types of providers (95% CI [2.4, 2.9]). Indigenous background and greater number of types of providers seen were associated with longer time seeking care. The majority of adolescents had ever engaged in self-harm (67.6%), with 58.1% ever seriously considering suicide and 36.0% attempting. Previous self-harm and suicidal thoughts were associated with longer wait times and older age. Seventeen point seven percent of parents/caregivers reported their adolescents had participated in conversion therapy or that parents had considered it. DISCUSSION: The majority of participants were referred by family physicians or pediatricians, seeing multiple types of providers regarding their gender prior to referral. Adolescents experienced significant wait times. Indigenous adolescents reported longer times seeking care. Adolescents with longer wait times were more likely to have ever engaged in self-harm or had suicidal ideation.

Gynecological concerns and vaginal practices and exposures among transfeminine individuals who have undergone vaginoplasty.

BACKGROUND: Vaginoplasty is a gender-affirming surgery that is medically necessary for some transfeminine individuals. Little research exists describing vaginal health after the initial recovery from surgery, and evidence-based guidelines for vaginal care practices are unavailable. AIM: The study sought to describe self-reported gynecological concerns and vaginal care practices among transfeminine persons who have undergone vaginoplasty. METHODS: A total of 60 transfeminine participants 18+ years of age, living in Canada, and who had undergone vaginoplasty at least 1 year prior were recruited through social media, community groups, healthcare provider referrals, and study recontact. Participants completed a cross-sectional, online questionnaire detailing demographics, gynecological concerns, and genital practices and exposures. Hierarchical clustering was used to group participants based on behavioral practices and exposures. Associations between clusters and gynecological concerns were assessed. OUTCOMES: Outcomes included self-reported gynecological concerns within the past year, recent vulvar or vaginal symptoms (past 30 days), and behavioral practices/exposures, including douching with varied products and dilating. RESULTS: Participants reported a variety of concerns in the past year, including urinary tract infection (13%) and internal hair regrowth (23%). More than half (57%) had experienced at least 1 recent vaginal symptom, most commonly malodor (27%) and vaginal bleeding (21%). Of participants, 48% were dilating weekly and 52% reported douching in the past 30 days. Four distinct clusters of vaginal practices/exposures were identified: limited exposures; dilating, no douching; dilating and douching; and diverse exposures. No significant associations between cluster membership and gynecological concerns were identified, though cluster membership was significantly associated with surgical center (P = .03). Open-text write-ins provided descriptions of symptoms and symptom management strategies. CLINICAL IMPLICATIONS: The results provide insight for clinicians on common patient-reported gynecological concerns and current vaginal care practices and exposures, including symptom management strategies. STRENGTHS AND LIMITATIONS: This was the first study to investigate vaginal health and genital practices/exposures among a community sample of transfeminine individuals. As participants self-enrolled for a detailed survey and swab collection, individuals experiencing concerns were likely overrepresented. CONCLUSION: Transfeminine individuals reported a range of gynecological concerns outside of the surgical healing period. Genital practices/exposures varied across clusters, but no clear associations between clusters and symptoms were identified; instead, practice/exposure clusters were dependent on where the individual underwent vaginoplasty. There is a need for evidence to inform diagnostics, treatments, and vaginal care guidelines to support vaginal health.

Correlates of hazardous alcohol drinking among trans and non-binary people in Canada: A community-based cross-sectional study.

PURPOSE: Transgender and non-binary people (TGNB) have a higher rate of heavy episodic drinking than cisgender people; however, extant knowledge about predictors of hazardous alcohol drinking (HAD) among different TGNB groups is limited. This study examined predictors of HAD in a national sample of TGNB people in Canada. METHODS: Logistic regression models were fit to examine the effects of 1) minority stressors and 2) stress-buffering factors on the likelihood of HAD, stratified by gender, among 2324 TGNB individuals from the Trans PULSE Canada survey, a cross-sectional survey conducted in 2019 among trans and non-binary people aged 14+ in Canada. RESULTS: Almost 17% of participants reported past-year HAD. Lifetime day-to-day and lifetime major discrimination were associated with higher odds of HAD in the full sample [(AOR=1.37, 95% CI: 1.30, 1.44) and (AOR=1.69, 95% CI: 1.55, 1.86) respectively], and across all gender groups. Social support was associated with lower odds of HAD in trans men, non-binary people assigned female at birth (NB-AFAB), and non-binary people assigned male at birth (NB-AMAB) groups, but with higher odds of HAD in the trans women group. Misgendering was associated with lower odds of HAD in trans men and NB-AFAB, but higher odds of HAD in trans women and NB-AMAB. Mixed effects of gender distress, gender positivity, and gender-affirming medical care were also reported across groups. CONCLUSION: The study provided a more detailed understanding of the predictors of HAD across four TGNB groups. Public health interventions should focus on structural discrimination and social support for TGNB people.

Change in Finances, Peer Access, and Mental Health Among Trans and Nonbinary People During the COVID-19 Pandemic.

Purpose: Due to structural transphobia, trans and nonbinary (TNB) individuals were particularly vulnerable to the negative effects of social isolation and financial instability resulting from COVID-19. The present study examined the effect of change in finances and access to TNB peer gatherings on anxiety and depression during the COVID-19 pandemic. Methods: Participants were 18 years and older (mean = 30) and completed prepandemic baseline (Fall 2019) and pandemic follow-up (Fall 2020) surveys. Multivariable regressions examined associations between mental health and change in (1) finances and (2) access to TNB peer gatherings (in person or online). Results: Of 780 participants, 50% reported that the COVID-19 pandemic had a negative impact on personal income and 58.3% reported negative impact on access to TNB peer gatherings. Depression and anxiety symptoms increased from prepandemic to follow-up, and most participants were above measurement cutoffs for clinical levels at both time points. Change in finances and access to TNB peer gatherings interacted with prepandemic depression scores to predict depression symptoms during the COVID-19 pandemic. For participants with high prepandemic depression scores, financial stability predicted pandemic depression scores comparable to that predicted by negative financial change. No interaction was found between these variables when predicting anxiety symptoms during the COVID-19 pandemic. Conclusion: Findings underscore the influence of inequality and prepandemic mental health when considering the impact of COVID-19 on wellbeing. Results suggest need for multifaceted programs and services, including financial support and meaningful TNB community engagement, to address barriers to health equity posed by systematic gender oppression.

Gynecological Care Among Brazilian Women Who Have Sex with Women: A Respondent-Driven Sampling Study.

Purpose: This study aimed to describe the gynecological care provided to Brazilian women who have sex with women (WSW). Methods: Respondent-driven sampling was used to recruit Brazilian WSW. The survey questions, concerning gynecological care, were designed in Portuguese by medical professionals, medical students, and LGBTQIA+ community members, including the authors. The statistical analyses were weighted to account for the likelihood of recruitment. Results: From January to August of 2018, 299 participants were recruited in 14 recruitment waves. The mean age of the WSW was 25.3 years. Most (54.9%) identified as lesbian and had been involved in past-year sexual intercourse mainly with cisgender women (86.1%). The WSW also reported having sex with cisgender men (22.2%), transgender men (5.3%), nonbinary people (2.3%), and transgender women (5.3%) in the last year. More than a quarter of the WSW did not have regular appointments with a gynecologist: 8.0% (95% confidence interval [CI] = 4.2-11.6) and 19% (95% CI = 12.8-25.2) stated that they had never gone to the gynecologist or they had only gone for emergencies, respectively. Almost one-third had never had cervical cancer screening (cervical cytology, Pap test or Pap smear). Most women justified avoiding the test because they felt healthy, thought it would hurt, or feared a health professional might mistreat them. Conclusion: Gynecologists should avoid heteronormative assumptions, inquire about sexual practices, orientation, and identity separately, and provide Pap tests as advised to WSW.

Rare exemplars and missed opportunities: Intersectionality within current sexual and gender diversity research and scholarship in psychology.

Using intersectionality as our critical analytical framework, we examined 22 articles on sexual and gender diversity (SGD) published in peer-reviewed psychology journals between January and June 2022 to: (1) identify their engagement with intersectionality's core themes; and (2) highlight key findings and directions for future intersectional SGD research. Our review includes 12 theoretical and empirical articles that addressed a breadth of topics such as intersectional stigma/discrimination, gendered racism, minority stress, and intersectional ableism. This review highlights opportunities within intersectional SGD research in psychology to provide a needed corrective to the discipline's tradition of individualistic, single-axis research focused on predominantly White, cisgender and heterosexual people, and attend to intersectionality's focus on intersecting power relations and commitments to social justice.

Sex and Gender Multidimensionality in Epidemiologic Research.

Along with age and race, sex has historically been a core stratification and control variable in epidemiologic research. While in recent decades research guidelines and institutionalized requirements have incorporated an approach differentiating biological sex from social gender, neither sex nor gender is itself a unidimensional construct. The conflation of dimensions within and between sex and gender presents a validity issue wherein proxy measures are used for dimensions of interest, often without explicit acknowledgement or evaluation. Here, individual-level dimensions of sex and gender are outlined as a guide for epidemiologists, and 2 case studies are presented. The first case study demonstrates how unacknowledged use of a sex/gender proxy for a sexed dimension of interest (uterine status) resulted in decades of cancer research misestimating risks, racial disparities, and age trends. The second illustrates how a multidimensional sex and gender framework may be applied to strengthen research on coronavirus disease 2019 incidence, diagnosis, morbidity, and mortality. Considerations are outlined, including: 1) addressing the match between measures and theory, and explicitly acknowledging and evaluating proxy use; 2) improving measurement across dimensions and social ecological levels; 3) incorporating multidimensionality into research objectives; and 4) interpreting sex, gender, and their effects as biopsychosocial.

The Preferences of Transgender and Nonbinary People for Virtual Health Care After the COVID-19 Pandemic in Canada: Cross-sectional Study.

BACKGROUND: Virtual health care use has dramatically increased in response to the COVID-19 pandemic, raising the question of its potential role after the pandemic. For transgender (trans) and nonbinary (TNB) people, virtual care is promising because it may expand access to appropriate health care providers. However, emerging research indicates potential disparities in virtual care access related to sociodemographic, health, and social factors. There is a paucity of research on the factors affecting patient preferences for virtual versus in-person care, particularly in TNB communities. OBJECTIVE: This study aimed to identify the sociodemographic, health, and social factors associated with postpandemic virtual care preferences in TNB communities. METHODS: The 2020 Trans PULSE Canada COVID survey examined the health, social, and economic impacts of the COVID-19 pandemic among 820 TNB participants who previously completed the prepandemic 2019 Trans PULSE Canada survey (n=2783). Data were weighted to the demographics of the 2019 sample. Chi-square tests were used to compare postpandemic preferences for virtual versus in-person care across sociodemographic, health, and social characteristics. Participants provided open-text responses explaining their preferences, which were used to contextualize quantitative findings. RESULTS: Among 812 participants who indicated whether they would prefer virtual or in-person care after the pandemic, a weighted 32.7% (n=275) would prefer virtual care and 67.3% (n=537) would prefer in-person care. Preference for in-person over virtual care was associated with being in the 14-19 (49/56, weighted 85.0%), 50-64 (51/62, weighted 80.0%), and ≥65 (9/10, weighted 90.7%) age groups (χ25=19.0; P=.002). Preference for virtual over in-person care was associated with having a chronic health condition (125/317, weighted 37.7% versus 150/495, weighted 29.9%; χ21=4.7; P=.03) and having probable anxiety (229/645, weighted 34.7% versus 46/167, weighted 25.7%; χ21=4.3; P=.04). Among participants with romantic partners, preferences varied based on the partner's level of support for gender identity or expression (χ23=13.3; P=.004). Participants with moderately supportive partners were more likely than participants with very supportive partners to prefer in-person care (36/43, weighted 85.1% versus 275/445, weighted 62.3%). Care preferences did not vary significantly based on the indicators of socioeconomic status. Open-text responses showed that multiple factors often interacted to influence participant preferences, and that some factors, such as having a chronic condition, simultaneously led some participants to prefer virtual care and others to prefer in-person care. CONCLUSIONS: TNB people may have differential interest in virtual care based on factors including age, chronic and mental health conditions, and gender-unsupportive home environments. Future research examining virtual care preferences would benefit from mixed methods intersectional approaches across these factors, to explore complexity in the barriers and facilitators of virtual care access and quality. These observed differences support flexibility with options to choose between in-person and virtual health care to meet TNB patients' specific health needs.

Impacts of COVID-19 on trans and non-binary people in Canada: a qualitative analysis of responses to a national survey.

BACKGROUND: Emerging international evidence indicates the COVID-19 pandemic has exacerbated socioeconomic and health challenges faced by transgender (trans) and non-binary populations globally. This qualitative study is among the first to characterize impacts of the pandemic on these groups in Canada. METHODS: Drawing on data from the Trans PULSE Canada survey (N = 820), we used thematic analysis to examine the free-form responses of 697 participants to one open-ended question on impacts of the pandemic. We first organized responses into descriptive themes, and then used this preliminary analytical process to construct more refined, higher order themes that provided a rich account of the pandemic's impacts. RESULTS: Our results are organized into five themes that highlight the pandemic's impacts on trans and non-binary populations in Canada. These include: (1) reduced access to both gender-affirming and other healthcare, (2) heightened financial, employment, and housing precarity, (3) strained social networks in an era of physical distancing and virtual communication, (4) an intensification of safety concerns, and (5) changes in experiences of gender affirmation. CONCLUSION: Our findings highlight the pandemic's systemic impacts on the lives of trans and non-binary people in domains such as healthcare, employment, and housing, and on the social networks of these groups, many of which reflect an exacerbation of pre-existing inequities. Based on our analysis, we recommend that public health researchers, policymakers, and practitioners attend to the structural impacts of the pandemic on these groups as primary sites of inquiry and intervention.

Methods in HIV-Related Intersectional Stigma Research: Core Elements and Opportunities.

Researchers are increasingly recognizing the importance of studying and addressing intersectional stigma within the field of HIV. Yet, researchers have, arguably, struggled to operationalize intersectional stigma. To ensure that future research and methodological innovation is guided by frameworks from which this area of inquiry has arisen, we propose a series of core elements for future HIV-related intersectional stigma research. These core elements include multidimensional, multilevel, multidirectional, and action-oriented methods that sharpen focus on, and aim to transform, interlocking and reinforcing systems of oppression. We further identify opportunities for advancing HIV-related intersectional stigma research, including reducing barriers to and strengthening investments in resources, building capacity to engage in research and implementation of interventions, and creating meaningful pathways for HIV-related intersectional stigma research to produce structural change. Ultimately, the expected payoff for incorporating these core elements is a body of HIV-related intersectional stigma research that is both better aligned with the transformative potential of intersectionality and better positioned to achieve the goals of Ending the HIV Epidemic in the United States and globally. (Am J Public Health. 2022;112(S4):S413-S419. https://doi.org/10.2105/AJPH.2021.306710).

Avoidance of primary healthcare among transgender and non-binary people in Canada during the COVID-19 pandemic.

Transgender (trans) and non-binary people experience barriers to culturally competent healthcare and many have reported avoiding care. COVID-19 and related mitigation strategies may have exacerbated avoidance, and poor mental health may be bidirectionally related to avoiding care. This study estimated the prevalence of primary care avoidance during the pandemic in a national sample of trans and non-binary people in Canada with a primary care provider and examined the association between poorer self-rated mental health and avoidance. In Fall 2019, Trans PULSE Canada collected multi-mode survey data from trans and non-binary people. In September to October 2020, 820 participants completed a COVID-19-focused survey. In this cross-sectional analysis, multivariable logistic regression models estimated odds ratios adjusted for confounders and weighted to the 2019 sample. The analysis included 689 individuals with a primary healthcare provider, of whom 61.2% (95% CI: 57.2, 65.2) reported fair or poor mental health and 25.7% (95% CI: 22.3, 29.2) reported care avoidance during the pandemic. The most common reason for avoidance was having a non-urgent health concern (72.7%, 95% CI: 65.9, 79.5). In adjusted analyses, those with fair or poor mental health had higher odds of avoiding primary care as compared to those with good to excellent mental health (adjusted odds ratio [AOR] = 2.37; 95% CI: 1.50, 3.77). This relationship was similar when excluding COVID-related reasons for avoidance (AOR = 2.52; 95% CI: 1.52, 4.17). Expansion of virtual communication may enhance primary care accessibility, and proactively assessing mental health symptoms may facilitate connections to gender-affirming mental health services.

Experiences and Stressors of Parents of Trans and Gender-Diverse Youth in Clinical Care from Trans Youth CAN!

Parents of trans and gender-diverse youth can experience challenges navigating gender-affirming (GA) care such as stigma, transphobia, and lack of support. There is little information available about stressors, worries, and positive feelings of parents as they try to support their youth accessing GA care. This article presents baseline survey data on experiences and stressors of 160 parents/caregivers in the Trans Youth CAN! cohort study, which examined medical, social, and family outcomes in youth age 16 years or younger considering puberty blockers or GA hormones. Data were collected at 10 Canadian gender clinics. Authors report on participating parents' characteristics, levels of support toward youth, stressors, worries, concerns, and positive feelings related to youth's gender. Most parent participants were White (85.1 percent), female (85.1 percent), birth or adoptive parents (96.1 percent), and reported strong support for youth's gender. Participants' concerns included their youth facing rejection (81.9 percent), generalized transphobia (74.6 percent), or encountering violence (76.4 percent). Parents also reported positive feelings about seeing their youth grow more confident. Most parental worries and stressors were situated outside the family, reflecting the systemic discrimination faced by youth and their families. Social workers could address these by developing systems-focused interventions and by further taking into account intersectional health disparities.

Describing Intersectional Health Outcomes: An Evaluation of Data Analysis Methods.

BACKGROUND: Intersectionality theoretical frameworks have been increasingly incorporated into quantitative research. A range of methods have been applied to describing outcomes and disparities across large numbers of intersections of social identities or positions, with limited evaluation. METHODS: Using data simulated to reflect plausible epidemiologic data scenarios, we evaluated methods for intercategorical intersectional analysis of continuous outcomes, including cross-classification, regression with interactions, multilevel analysis of individual heterogeneity (MAIHDA), and decision-tree methods (classification and regression trees [CART], conditional inference trees [CTree], random forest). The primary outcome was estimation accuracy of intersection-specific means. We applied each method to an illustrative example using National Health and Nutrition Examination Study (NHANES) systolic blood pressure data. RESULTS: When studying high-dimensional intersections at smaller sample sizes, MAIHDA, CTree, and random forest produced more accurate estimates. In large samples, all methods performed similarly except CART, which produced less accurate estimates. For variable selection, CART performed poorly across sample sizes, although random forest performed best. The NHANES example demonstrated that different methods resulted in meaningful differences in systolic blood pressure estimates, highlighting the importance of selecting appropriate methods. CONCLUSIONS: This study evaluates some of a growing toolbox of methods for describing intersectional health outcomes and disparities. We identified more accurate methods for estimating outcomes for high-dimensional intersections across different sample sizes. As estimation is rarely the only objective for epidemiologists, we highlight different outputs each method creates, and suggest the sequential pairing of methods as a strategy for overcoming certain technical challenges.

Quantitative methods for descriptive intersectional analysis with binary health outcomes.

Intersectionality recognizes that in the context of sociohistorically shaped structural power relations, an individual's multiple social positions or identities (e.g., gender, ethnicity) can interact to affect health-related outcomes. Despite limited methodological guidance, intersectionality frameworks have increasingly been incorporated into epidemiological studies, both to describe health disparities and to examine their causes. This study aimed to advance methods in intersectional estimation of binary outcomes in descriptive health disparities research through evaluation of 7 potentially intersectional data analysis methods: cross-classification, regression with interactions, multilevel analysis of individual heterogeneity (MAIHDA), and decision trees (CART, CTree, CHAID, random forest). Accuracy of estimated intersection-specific outcome prevalence was evaluated across 192 intersections using simulated data scenarios. For comparison we included a non-intersectional main effects regression. We additionally assessed variable selection performance amongst decision trees. Example analyses using National Health and Nutrition Examination Study data illustrated differences in results between methods. At larger sample sizes, all methods except for CART performed better than non-intersectional main effects regression. In smaller samples, MAIHDA was the most accurate method but showed no advantage over main effects regression, while random forest, cross-classification, and saturated regression were the least accurate, and CTree and CHAID performed moderately well. CART performed poorly for estimation and variable selection. Sensitivity analyses examining the bias-variance tradeoff suggest MAIHDA as the preferred unbiased method for accurate estimation of high-dimensional intersections at smaller sample sizes. Larger sample sizes are more imperative for other methods. Results support the adoption of an intersectional approach to descriptive epidemiology.

Latent variable and clustering methods in intersectionality research: systematic review of methods applications.

PURPOSE: An intersectionality framework has been increasingly incorporated into quantitative study of health inequity, to incorporate social power in meaningful ways. Researchers have identified "person-centered" methods that cluster within-individual characteristics as appropriate to intersectionality. We aimed to review their use and match with theory. METHODS: We conducted a multidisciplinary systematic review of English-language quantitative studies wherein authors explicitly stated an intersectional approach, and used clustering methods. We extracted study characteristics and applications of intersectionality. RESULTS: 782 studies with quantitative applications of intersectionality were identified, of which 16 were eligible: eight using latent class analysis, two latent profile analysis, and six clustering methods. Papers used cross-sectional data (100.0%) primarily had U.S. lead authors (68.8%) and were published within psychology, social sciences, and health journals. While 87.5% of papers defined intersectionality and 93.8% cited foundational authors, engagement with intersectionality method literature was more limited. Clustering variables were based on social identities/positions (e.g., gender), dimensions of identity (e.g., race centrality), or processes (e.g., stigma). Results most commonly included four classes/clusters (60.0%), which were frequently used in additional analyses. These described sociodemographic differences across classes/clusters, or used classes/clusters as an exposure variable to predict outcomes in regression analysis, structural equation modeling, mediation, or survival analysis. Author rationales for method choice included both theoretical/intersectional and statistical arguments. CONCLUSION: Latent variable and clustering methods were used in varied ways in intersectional approaches, and reflected differing matches between theory and methods. We highlight situations in which these methods may be advantageous, and missed opportunities for additional uses.

Do Clinical Data from Transgender Adolescents Support the Phenomenon of "Rapid Onset Gender Dysphoria"?

Although emergence of gender dysphoria at puberty is long established, a distinct pathway of rapid onset gender dysphoria was recently hypothesized based on parental data. Using adolescent clinical data, we tested a series of associations that would be consistent with this pathway, however, our results did not support the rapid onset gender dysphoria hypothesis.

Health care access among transgender and nonbinary people in Canada, 2019: a cross-sectional survey.

BACKGROUND: Previous Canadian studies have identified problems regarding health care access for transgender (trans) and nonbinary people, but all-ages national data have been lacking. This study describes access to care among trans and nonbinary people in Canada, and compares health care access across provinces or regions. METHODS: We conducted a bilingual, multimode cross-sectional survey (Trans PULSE Canada) from July 26 to Oct. 1, 2019. We recruited trans and nonbinary people aged 14 years and older using convenience sampling. We assessed 5 outcomes: having a primary care provider, having a primary care provider with whom the respondent was comfortable discussing trans health issues, past-year unmet health care need, medical gender affirmation status, and being on a wait-list to access gender-affirming medical care. Average marginal predictions were estimated from multivariable logistic regression models with multiply imputed data. RESULTS: The survey included 2873 participants, and 2217 surveys were analyzed after exclusions. Of the 2217 trans and nonbinary respondents, most had a primary care provider (n = 1803; 81.4%, 95% confidence interval [CI] 79.8%-83.0%), with model-predicted probabilities from 52.1% (95% CI 20.2%-84.1%) in the territories to 92.9% (95% CI 83.5%-100.0%) in Newfoundland and Labrador. Of the respondents, 52.3% (n = 1150; 95% CI 50.3%-54.2%) had a primary care provider with whom they were comfortable discussing trans health issues, and 44.4% (n = 978; 95% CI 42.3%-46.4%) reported an unmet health care need. Among participants who needed gender-affirming medical treatment (n = 1627), self-defined treatment completion ranged from an estimated 16.8% (95% CI 0.6%-32.5%) in Newfoundland and Labrador to 59.1% (95% CI 52.5%-65.6%) in Quebec. Of those who needed but had not completed gender-affirming care at the time of the study (n = 1046), 40.7% (n = 416; 95% CI 37.8%-43.6%) were on a wait-list, most often for surgery. These outcomes, with the exception of having a provider with whom one is comfortable discussing trans issues, varied significantly by province or region (p < 0.05). INTERPRETATION: Participants reported considerable unmet needs or delays in primary, general and gender-affirming care, with significant regional variation. Our results indicate that, despite efforts toward equity in access to care for trans and nonbinary people in Canada, inequities persist.

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

BACKGROUND AND OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: Trans youth in Canada attending clinics for hormonal suppression or gender-affirming hormones were generally healthy but with depression, anxiety, and support needs.