Gender-Affirming Pharmacological Interventions for Youth With Gender Dysphoria: When Treatment Guidelines Are Not Enough.

Youth with gender dysphoria, also known as transgender youth, are increasingly presenting to multidisciplinary clinics within academic pediatric centers across the United States. Gender-affirming pharmacological interventions for adolescents with gender dysphoria may be used to promote positive psychological well-being and mental health outcomes. Interventions range from completely reversible to partially irreversible, based on the age and sexual maturity of the adolescent. For each intervention, dilemmas and controversies exist regarding age at treatment initiation, treatment duration, safety, and cost. Pharmacists' awareness of these considerations and interventions is important when providing evidence-based gender-affirming care to this underserved population.

Healthcare Barriers and Utilization Among Adolescents and Young Adults Accessing Services for Homeless and Runaway Youth.

Homeless and runaway youth are at disproportionate risk for adverse health outcomes. Many barriers to accessing healthcare have been documented; however, the relative impact of discrete barriers on homeless youth healthcare utilization behavior is not firmly established. We administered a survey examining reported barriers and healthcare utilization among adolescents and young adults accessing services at three community centers for homeless and runaway youth. Of 180 respondents, 57 % were male, 80 % non-White, and 21 % identified as a sexual minority. Stepwise logistic regression models, controlling for age and study site, explored associations between barriers and 3 healthcare utilization outcomes (doctor visit in past 12 months; regular care provider; frequent emergency department (ED) visits). The most commonly reported barriers were "don't have a ride" (27.2 %), "no insurance" (23.3 %), and "costs too much" (22.8 %). All fear-based barriers (e.g., "I don't trust the doctors") were reported by <5 % of surveyed youth. Significant predictors of having seen a doctor in the past 12 months included sexual minority status (OR 2.8, p = 0.04) and possession of health insurance (OR 4.9, p < 0.001). Female sex (OR 5.2, p < 0.001) and reported external barriers other than health insurance (OR 0.2, p < 0.001) were associated with having a regular care provider. Fear-based concerns were associated (OR 3.8, p = 0.02) with frequent ED visits, as was being insured (OR 2.2, p = 0.03). These results underscore the need to clearly define healthcare outcomes when investigating barriers to care among homeless and runaway youth as the impact of discrete barriers varies depending on outcome of focus.

Polycystic ovary syndrome in adolescents: a review of past year evidence.

PURPOSE OF REVIEW: Despite the fact that polycystic ovary syndrome (PCOS) is a common disorder, much remains unknown or controversial regarding the cause, diagnosis, and management of this disorder, particularly in adolescents where normal pubertal events can overlap with the PCOS phenotype. RECENT FINDINGS: We put forth a critical assessment of recent literature on PCOS in adolescents, with particular focus on new information regarding the pathogenesis, diagnosis, associated morbidities, and management. SUMMARY: Although the evidence is increasing, there is still a critical need for large, prospective studies of adolescents with PCOS. Given the current level of evidence, a definitive diagnosis of PCOS is not necessary to effectively identify and treat manifestations of this syndrome in adolescents. Currently, ovarian imaging is not recommended in the diagnostic evaluation of PCOS in adolescents until high-quality data for defining polycystic ovarian morphology are available in this age group. Weight loss remains the safest and most effective treatment option for obese or overweight adolescents with PCOS. Clinicians should be mindful of the significant associated psychological morbidity and effectively screen and manage these conditions in adolescents with manifestations of PCOS.

Decision Support Needs for Transgender and Gender-Diverse Youth and Families: A Patient-Centered Needs Assessment.

PURPOSE: Due to the intertwining of medical and social decision-making, new approaches to shared decision-making are likely needed for supporting decisions related to the care of transgender and gender-diverse (TGD) adolescents. Prior to developing decision support interventions for TGD youth, a decision support needs assessment must be completed. METHODS: Self-identified TGD youth, family members of TGD youth, clinicians caring for this population, and community advocates participated in one of six group level assessments (GLAs). GLA is a structured, participatory qualitative method that engages diverse groups of stakeholders in generating and evaluating ideas on the topic of interest. Upon completion of all GLAs, a survey was developed and distributed to GLA participants inviting them to rank ideas generated during the GLAs. RESULTS: Six major themes emerged from the GLAs regarding decision support needs, including: improving healthcare provider skills and education, increasing access to support outside the healthcare system, strengthening community and societal support, developing special information resources, supporting youth in leading decision-making about transition, and modifying the healthcare system. In the follow-up survey, improving healthcare provider skills and education was the most commonly chosen top priority. DISCUSSION: Participants identified decision support needs for TGD youth and their families that were mostly distinct from traditional decision support approaches. Participants' focus on the need to improve healthcare provider skills and education provides an opportunity to couple gender-focused education with shared decision-making skills, an approach that may be more sustainable than tools for specific decisions.

Associations Among Gender-Affirming Hormonal Interventions, Social Support, and Transgender Adolescents' Mental Health.

PURPOSE: We aimed to examine the concurrent associations of gender-affirming hormonal interventions (i.e., puberty blockers, testosterone, estrogen), as well as family and friend social support, on transgender and nonbinary (TNB) adolescents' reports of anxiety symptoms, depressive symptoms, nonsuicidal self-injury (NSSI), and suicidality. We hypothesized that gender-affirming hormonal interventions and greater social support would be associated with lower levels of mental health concerns. METHODS: Participants (n = 75; aged 11-18; Mage = 16.39 years) were recruited for this cross-sectional study from a gender-affirming multidisciplinary clinic. Fifty-two percent were receiving gender-affirming hormonal interventions. Surveys assessed anxiety and depressive symptoms, NSSI and suicidality in the past year, and social support from family, friends, and significant others. Hierarchical linear regression models examined associations between gender-affirming hormonal interventions and social support (i.e., family, friend) with mental health while accounting for nonbinary gender identity. RESULTS: Regression models explained 15%-23% of variance in TNB adolescents' mental health outcomes. Gender-affirming hormonal interventions were associated with fewer anxiety symptoms (ß = -0.23; p < .05). Family support was associated with fewer depressive symptoms (ß = -0.33; p = .003) and less NSSI (ß = -0.27; p = .02). Friend support was associated with fewer anxiety symptoms (ß = -0.32; p = .007) and less suicidality (ß = -0.25; p = .03). DISCUSSION: TNB adolescents had better mental health outcomes in the context of receiving gender-affirming hormonal interventions and having greater support from family and friends. Findings highlight the important role of quality family and friend support for TNB mental health. Providers should aim to address both medical and social factors to optimize TNB mental health outcomes.

Care of Gender Diverse Youth with Obesity.

PURPOSE OF REVIEW: The relationships between gender identity, body image, and gender expression are complex, requiring a gender affirming approach to address weight management. This purpose of this review is to describe the essentials to caring for gender diverse youth, as well as the differences and intersections among those with obesity. RECENT FINDINGS: Gender-affirming hormone therapy may lead to abnormal weight gain and increased body mass index, or worsen obesity and exacerbate weight-related complications. Moreover, given the high prevalence of victimization, marginalization, and stigmatization among gender diverse people and youth with obesity, care guidelines and treatment goals should also include reducing the negative impact of social-related complications. Despite the overlap in clinical care and lived experiences that impact the health of gender diverse youth with obesity, there is very little research to help guide clinicians. Careful attention to medical and behavioral comorbidities, barriers to care, and health disparities can inform clinical practice. Future research that specifically addresses nuances to care for gender diverse youth with obesity can help to establish standards of care to address their unmet needs and further support clinicians, patients and their families.

Cardiometabolic Parameters Among Transgender Adolescent Males on Testosterone Therapy and Body Mass Index-Matched Cisgender Females.

Limited data are available on changes in metabolic parameters in transgender youth on testosterone therapy in comparison with cisgender females. Data from 42 transgender males on testosterone therapy were retrospectively analyzed. Body mass index (BMI) and lipid profile changes were compared with BMI-matched females. There was a significant increase in BMI over time in the transgender males as compared with the cisgender females, and a decrease in high-density lipoprotein in the transgender males after starting testosterone therapy. Longitudinal prospective studies with cisgender controls are needed to better define effects of testosterone therapy in adolescents.

The Stamp-in-Safety programme, an intervention to promote better supervision of children on childcare centre playgrounds: an evaluation in an urban setting.

Using a non-equivalent control group design, this report evaluated a previously studied behavioural intervention, the Stamp-in-Safety programme, which is designed to reduce the injury risk for young children on playgrounds at childcare centres by increasing the quality of adult supervision and rewarding children for safe play. In an urban, commercial childcare centre, 71 children aged 3-5 years and 15 teachers participated. Primary outcome measures were teacher verbalisations (warnings, explanations, redirects), teacher location (core, outskirt, or fringe of playground), child risk-taking behaviours (using equipment appropriately) and the number of injuries on the playground. Analyses revealed that the intervention had a modest positive effect in promoting safer teacher and child playground behaviours. This study reaffirms previous results that the Stamp-in-Safety programme is an effective method to decrease the risk of playground injuries at childcare centres.

Experiences of Gender Minority Youth With the Intrauterine System.

PURPOSE: The aim of the study was to evaluate the experience of menstruating adolescents identifying as male or gender nonconforming with the levonorgestrel-releasing intrauterine system (LNG-IUS) as a method of menstrual suppression and compare to that of cisgender youth (CGY) using the LNG-IUS for noncontraceptive indications. METHODS: A retrospective chart review of gender minority youth (GMY), aged 12-22 years, who self-selected the 52 mg LNG-IUS for menstrual suppression between June 2014 and January 2018. GMY were then matched for age and time of insertion with CGY. Subjects were contacted by telephone to further explore LNG-IUS experience such as if the device was still in place, method satisfaction, current bleeding patterns, and for GMY improvement in menstrual distress. RESULTS: Thirty GMY had the LNG-IUS inserted during the study period, and 20 GMY were matched with CGY for age and time of insertion. GMY were significantly more likely to receive sedation for LNG-IUS insertion (50% vs. 15%, p = .04). Otherwise, the LNG-IUS experience was similar between groups, including mean number of telephone/office visit encounters for an LNG-IUS concern, expulsion and reinsertion rates, and need for additional medications to control bleeding. On average, the mean months of use was 14.5 ± 8.6 months in GMY and 14.6±11.5 in CGY (p = .97). LNG-IUS removal was documented in three (15%) of GMY and five (25%) of CGY. Improvement in menstrual distress was reported by 80% of GMY after the insertion of the LNG-IUS. CONCLUSIONS: Overall experience with the LNG-IUS was similar for GMY and CGY, and menstrual distress and bleeding pattern improved in the majority of GMY who self-selected this method for menstrual suppression.

Caring for the transgender adolescent and young adult: Current concepts of an evolving process in the 21st century.

The term transgender youth commonly refers to those whose gender identity, or personal core sense of self as a particular gender, differs from their assigned sex at birth; this is often designated by what external genitalia are present. These youths are presenting to multidisciplinary clinics worldwide at exponentially higher rates than in decades past, and clinics themselves have grown in number to meet the specialized demands of these youth. Additionally, the scientific and medical community has moved towards understanding the construct of gender dimensionally (i.e., across a spectrum from male to female) as opposed to dichotomous or binary "male or female" categories. This is reflected in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5); in this publication, the diagnostic classification of gender dysphoria, GD, (which has two subtypes: childhood and adolescence/adulthood) provides a set of criteria that many transgender people meet. GD describes the affective distress that arises as a result of the incongruence between gender identity and sex anatomy. The DSM uses language to indicate that a person may identify as another gender instead of the other gender, which further captures the complexity of the human experience of gender. Also, research regarding how current adolescents are describing their identity development and experience along this spectrum within today's society is only now being addressed in the literature. Therefore, the clinical needs of the transgender population have outpaced medical training and scientific advancement, which has opened up gaps on how to define best practices. This article provides current concepts of evaluation and management for transgender persons with emphasis on hormonal therapy (i.e., puberty blockers and gender affirming hormone therapy). Other management issues are briefly considered including gender confirming surgery and changes in the face as well as voice.

Long Curriculum in Resident Education: Comprehensive Curriculum in Pediatric and Adolescent Gynecology for Postgraduate Trainees in Obstetrics/Gynecology, Pediatrics, and Adolescent Medicine.

In 2015 the Resident Education Committee published the Long Curriculum in Resident Education to provide educators with a comprehensive document to be used in post-graduate medical education. The original curriculum was designed to meet the resident learning objectives for CREOG, RCPSC and ABP and to provide a more intensive, broader learning experience. This Committee Document is an updated version of the 2015 Long Curriculum.

Improving Resident Knowledge in Pediatric and Adolescent Gynecology: An Evaluation of the North American Society for Pediatric and Adolescent Gynecology Short Curriculum.

STUDY OBJECTIVE: Resident education in pediatric and adolescent gynecology (PAG) is challenging. It encompasses patients from neonates to young adults with different disorders involving multiple subspecialties. Residents have inadequate exposure to PAG topics and report lack of knowledge in this area. The objective of this study was to determine if the North American Society for Pediatric and Adolescent Gynecology (NASPAG) Short Curriculum improves self-reported knowledge in PAG among obstetrics and gynecology (ObGyn), family medicine, and pediatric residents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Participants were 47 US ObGyn, family medicine, and pediatric residency training programs across a 4-month study window, from September to December 2016. The NASPAG Short Curriculum was distributed to them with a request to complete a retrospective pre- and post-test survey. Primary outcome measure was improvement in self-perceived knowledge after exposure to the curriculum. RESULTS: Forty-eight programs responded to the study comprising a total of 1130 residents. One program was excluded because of logistical barriers to the distribution of study incentive. In total, 1080 residents were invited and 103 chose to participate (10% response rate); 68 residents completed all survey questions to be included in the final analysis. After completing the curriculum, self-reported knowledge improved in all 10 learning objectives, across all 3 specialties (47% [32/68] to 82% [56/68]; P < .01). Pre-test knowledge correlated with previous clinical exposure to PAG patients, but did not correlate with year of residency training, type of residency, or previous PAG lectures. CONCLUSION: Significant deficiencies exist regarding self-reported knowledge of core PAG topics among ObGyn, family medicine, and pediatric residents. Use of the NASPAG Short Curriculum improves self-reported knowledge in PAG trainees across all 3 specialties.