Gender and Sexual Health-Related Knowledge Gaps and Educational Needs of Parents of Transgender and Non-Binary Youth.

Parents can have a substantial impact on adolescent sexual decision-making, but few studies have explored the role of parents in providing sexual health information to transgender and non-binary (TNB) youth, a population that experiences significant sexual and mental health disparities and lower levels of perceived family support compared with other youth. This study aimed to elucidate existing knowledge gaps and content deemed important for a sexual health curriculum and educational materials for parents of TNB youth. We conducted 21 qualitative interviews with five parents of TNB youth, 11 TNB youth aged 18+, and five healthcare affiliates to identify parents' educational needs. We analyzed the data using theoretical thematic analysis and consensus coding. Parents self-reported multiple knowledge deficits regarding gender/sexual health for TNB individuals and were primarily concerned with long-term impacts of medical interventions. Youth goals for parents included greater understanding of gender/sexuality and sufficient knowledge to support youth through social transition to their affirmed gender identity. Content areas suggested for a future curriculum for parents of TNB youth included: basics of gender/sexuality, diverse narratives of TNB experiences/identities, gender dysphoria, non-medical gender-affirming interventions, medical gender-affirming interventions, and resources for peer support. Parents desired access to accurate information and wanted to feel equipped to facilitate affirming conversations with their child, something that could combat health disparities among TNB youth. An educational curriculum for parents has the potential to provide a trusted information source, expose parents to positive representations of TNB individuals, and help parents support their TNB child through decisions about potential gender-affirming interventions.

Sex Education for Transgender and Non-Binary Youth: Previous Experiences and Recommended Content.

BACKGROUND: Transgender and non-binary (TNB) youth face disparities in sexual health risks compared with cisgender peers. Comprehensive sex education programs have the potential to result in delayed sexual debut, increased condom and contraceptive use, and reduced sexual risk-taking; however, little research has explored the specific sex education needs of TNB youth. AIM: To use insights from TNB youth, parents of TNB youth, and healthcare affiliates to understand deficits in sex education experienced by TNB youth, and to elicit recommended content for a comprehensive and trans-inclusive sex education curriculum. METHODS: We conducted 21 in-depth interviews with non-minor TNB youth (n = 11) and with parents (n = 5) and healthcare affiliates (n = 5) of TNB youth recruited from Seattle Children's Gender Clinic and local TNB community listerv readerships. Data was analyzed using theoretical thematic analysis. OUTCOMES: Participants described prior sex education experiences and content needs of TNB youth. RESULTS: Participants described 5 key sources where TNB youth received sexual health information: school curricula, medical practitioners, peers, romantic partners, and online media. Inapplicability of school curricula and variable interactions with medical practitioners led youth to favor the latter sources. 8 content areas were recommended as important in sex education for TNB youth: puberty-related gender dysphoria, non-medical gender-affirming interventions, medical gender-affirming interventions, consent and relationships, sex and desire, sexually transmitted infection prevention, fertility and contraception, and healthcare access. CLINICAL IMPLICATIONS: Dependence on potentially inaccurate sex education sources leaves TNB youth vulnerable to negative outcomes, including sexually transmitted infections, pregnancy, unsanitary/unsafe sex toy use, and shame about their body or sexual desires. STRENGTHS & LIMITATIONS: Strengths included capturing perspectives of an underserved population using open-ended interview questions, which allowed topics of greatest importance to participants to arise organically. Limitations included a sample size of 21 participants, and racial and geographic homogeneity of youth and parent participants. Only 1 author identifies as TNB. One-on-one interview methods may have omitted participants who would otherwise have been willing to share their perspective in a more impersonal format. CONCLUSION: This study demonstrates that TNB youth have unique sex education needs that are not well covered in most sexual health curricula. Recommended content for this population includes standard sex education topics that require trans-inclusive framing (eg, contraception), topics specific to TNB youth (eg, gender-affirming medical interventions), and topics absent from standard curricula that warrant universal teaching (eg, information on consent as it relates to sex acts aside from penile-vaginal sex). Haley SG, Tordoff DM, Kantor AZ, et al. Sex Education for Transgender and Non-Binary Youth: Previous Experiences and Recommended Content. J Sex Med 2019;16:1834-1848.

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.

My46: a Web-based tool for self-guided management of genomic test results in research and clinical settings.

A major challenge to implementing precision medicine is the need for an efficient and cost-effective strategy for returning individual genomic test results that is easily scalable and can be incorporated into multiple models of clinical practice. My46 is a Web-based tool for managing the return of genetic results that was designed and developed to support a wide range of approaches to disclosing results, ranging from traditional face-to-face disclosure to self-guided models. My46 has five key functions: set and modify results-return preferences, return results, educate, manage the return of results, and assess the return of results. These key functions are supported by six distinct modules and a suite of features that enhance the user experience, ease site navigation, facilitate knowledge sharing, and enable results-return tracking. My46 is a potentially effective solution for returning results and supports current trends toward shared decision making between patients and providers and patient-driven health management.Genet Med 19 4, 467-475.

Use of metaphors about exome and whole genome sequencing.

Clinical and research uses of exome and whole genome sequencing (ES/WGS) are growing rapidly. An enhanced understanding of how individuals conceptualize and communicate about sequencing results is needed to ensure effective, mutual exchange of information between care providers and patients and between researchers and participants. Focus groups and interviews participants were recruited to discuss their attitudes and preferences for receiving hypothetical results from ES/WGS. African Americans were intentionally oversampled. We qualitatively analyzed participants' speech to identify unsolicited metaphorical language pertaining to genes and health, and grouped these occurrences into metaphorical concepts. Participants compared genetic information to physical objects including tools, weapons, contents of boxes, and formal documents or reports. These metaphorical concepts centered on several key themes, including locus of control; containment versus release of information; and desirability, usability, interpretability, and ownership of genetic results. Metaphorical language is often used intentionally or unintentionally in discussions about receiving results from ES/WGS in both clinical and research settings. Awareness of the use of metaphorical language and attention to its varied meanings facilitates effective communication about return of ES/WGS results. In turn, both should foster shared and informed decision-making and improve the translation of genetic information by clinicians and researchers.

Understanding the Complex Relationship Between One's Body, Eating, Exercise, and Gender-Affirming Medical Care Among Transgender and Nonbinary Adolescents and Young Adults.

Purpose: Gender dysphoria has been linked to body dissatisfaction, which can affect an individual's eating and exercise habits and increase their risk for disordered eating. The prevalence of eating disorders among transgender and nonbinary (TGNB) adolescents and young adults (AYA) ranges from 5% to 18% and studies have found a higher risk of disordered eating among these AYA in comparison to their cisgender peers. However, there is minimal research on why TGNB AYA are at higher risk. The aim of this study is to understand unique factors that define a TGNB AYA's relationship between their body and food, how this relationship may be affected by gender-affirming medical care, and how these relationships may contribute to disordered eating. Methods: A total of 23 TGNB AYA were recruited from a multidisciplinary gender-affirming clinic to participate in semistructured interviews. Transcripts were analyzed using Braun and Clarke's theory of thematic analysis (2006). Results: The average age of participants was 16.9 years. Forty-four percent of participants identified as having a transfeminine gender identity, 39% transmasculine, and 17% nonbinary/gender fluid. Five themes emerged regarding TGNB participants' relationship to food and exercise: gender dysphoria and control over one's body, societal expectations of gender, mental health and safety concerns, emotional and physical changes with gender-affirming medical care, and recommended resources for TGNB AYA. Conclusion: By understanding these unique factors, clinicians can provide targeted and sensitive care when screening and managing disordered eating among TGNB AYA.

Strategies for Providing Gender-Affirming Care for Adolescents in the Primary Care Setting.

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

Gender Diverse Youth on Fertility and Future Family: A Qualitative Analysis.

PURPOSE: Gender-affirming treatment for transgender and nonbinary adolescents has been shown to decrease anxiety, depression, and suicidality, but treatments have medical consequences. Specifically, hormone replacement and pubertal blocking may impact patients' fertility and childbearing capabilities. We interviewed gender diverse adolescents regarding their thoughts on family and fertility. METHODS: We completed semistructured interviews with 23 gender diverse adolescents recruited from the Seattle Children's Gender Clinic. Interviewees included transfeminine, transmasculine, and nonbinary youth. Interviews were recorded, transcribed, and analyzed using Braun and Clarke's theory of thematic analysis, a flexible framework for qualitative analysis. RESULTS: Gender diverse adolescents have myriad views on fertility, but four main themes were identified: (1) an interest in future family, including ideas regarding adoption and biological children; (2) barriers to fertility, including cost and procedure-related dysphoria; (3) factors unique to the developmental stage of adolescents, including the age discordance of making fertility decisions as a teenager and parental influence on decision-making; and (4) suggestions for clinicians approaching fertility counseling with adolescents considering hormone therapy. CONCLUSIONS: Many gender diverse youth asserted an interest in building families, although the process of fertility preservation remains fraught. Relative to other studies, our participants were hopeful, imaginative, and interested in having children. Participants wanted to receive specific counseling on fertility, to receive help navigating the logistics of fertility preservation, and to be listened to when their hopes for children (or no children) were stated. Further research is needed to create care paradigms that address fertility of transgender youth in an affirming, developmentally appropriate manner.

Developing Resources for American Indian/Alaska Native Transgender and Two-Spirit Youth, Their Relatives, and Healthcare Providers.

American Indian and Alaska Native (AI/AN) youth disproportionately face barriers accessing healthcare, including lack of access to culturally specific resources. This article details the creation of a culturally-specific Toolkit for AI/AN transgender and Two-Spirit youth, their relatives, and their healthcare providers across the United States. The Toolkit aims to 1) deliver culturally grounded resources to youth with diverse gender identities, 2) provide resources for families, and 3) increase healthcare provider awareness. A culturally appropriate Toolkit, "Celebrating Our Magic," was created from continual engagement with community partners over a 6-month period to address identified needs. The Toolkit has been shared regionally with partners who helped with its creation and nationally with Indian Health Service, Tribal, and Urban clinics serving AI/AN youth. This Toolkit creation process could be applied to manuals or guides for work in other underserved communities.

How Are Transgender and Gender Nonconforming Youth Affected by the News? A Qualitative Study.

PURPOSE: News stories about transgender and gender nonconforming (TGNC) people have become more common in recent years and TGNC youth may be disparately affected by this information compared with their cisgender peers. The aim of this study was to understand how TGNC youth react to news stories about TGNC and other gender and sexual minority (GSM) identifying persons. METHODS: As part of a larger study, 23 TGNC youth were recruited from the Seattle Children's Gender Clinic to participate in a semistructured interview. Interviews were audio recorded, transcribed, and thematically analyzed. RESULTS: Participating youth ranged in age from 13 to 19 years (mean = 16.9 years). Of the 23 participants, 43% identified as having a transfeminine gender identity, 39% transmasculine, and 17% nonbinary/gender fluid. Four main themes were identified: (1) news coverage of current political climate affects gender transition; (2) negative news coverage of GSM people contributes to concerns about mental well-being and safety; (3) geographical location affects perception of news; and (4) positive news coverage of TGNC people increases visibility and hope. CONCLUSIONS: Exposure to negative news about GSM people may contribute to increased levels of stress among TGNC youth. With increased visibility, participants described frustration associated with inaccurate portrayals of the TGNC community in the news; however, with increased visibility, there is also a growing sense of shared community and opportunity for acceptance of TGNC people. Given the scope of responses to negative and positive news on GSM people, TGNC youth may benefit from increased support to promote resilience when interpreting the news.

Youth and Parent Experiences in a Multidisciplinary Gender Clinic.

Purpose: To assess youth and parent/caregiver satisfaction with care at a pediatric multidisciplinary gender clinic. Methods: Transgender/gender nonconforming youth (n=33) and their parent/caregiver (n=29) completed self-report questionnaires and individual interviews (n=20) about experiences and satisfaction with care. Results: Quantitatively, participants reported being extremely satisfied with care experiences (parents 97%; youth 94%). Qualitatively, main themes included (1) affirmation due to use of preferred name/pronouns, (2) access barriers due to scheduling and readiness assessments, and (3) positive interactions with Care Navigator. Conclusion: Youth and parents/caregivers are highly satisfied with multidisciplinary, coordinated health care for transgender/gender nonconforming youth; however, some challenges remain.

Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth.

PURPOSE: Few transgender youth eligible for gender-affirming treatments actually receive them. Multidisciplinary gender clinics improve access and care coordination but are rare. Although experts support use of pubertal blockers and cross-sex hormones for youth who meet criteria, these are uncommonly offered. This study's aim was to understand barriers that transgender youth and their caregivers face in accessing gender-affirming health care. METHODS: Transgender youth (age 14-22 years) and caregivers of transgender youth were recruited from Seattle-based clinics, and readerships from a blog and support group listserv. Through individual interviews, focus groups, or an online survey, participants described their experiences accessing gender-affirming health care. We then used theoretical thematic analysis to analyze data. RESULTS: Sixty-five participants (15 youth, 50 caregivers) described barriers spanning six themes: (1) few accessible pediatric providers are trained in gender-affirming health care; (2) lack of consistently applied protocols; (3) inconsistent use of chosen name/pronoun; (4) uncoordinated care and gatekeeping; (5) limited/delayed access to pubertal blockers and cross-sex hormones; and (6) insurance exclusions. CONCLUSIONS: This is the first study aimed at understanding perceived barriers to care among transgender youth and their caregivers. Themed barriers to care led to the following recommendations: (1) mandatory training on gender-affirming health care and cultural humility for providers/staff; (2) development of protocols for the care of young transgender patients, as well as roadmaps for families; (3) asking and recording of chosen name/pronoun; (4) increased number of multidisciplinary gender clinics; (5) providing cross-sex hormones at an age that permits peer-congruent development; and (6) designating a navigator for transgender patients in clinics.