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

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

First- and Second-Hand Experiences of Enacted Stigma Among LGBTQ Youth.

Research on enacted stigma, or stigma- and bias-based victimization, including bullying and harassment, among lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth often focuses on one context (e.g., school) or one form (e.g., bullying or microaggressions), which limits our understanding of these experiences. We conducted qualitative go-along interviews with 66 LGBTQ adolescents (14-19 years) in urban, suburban, town, and rural locations in the United States and Canada identified through purposive and snowball sampling. Forty-six participants (70%) described at least one instance of enacted stigma. Three primary themes emerged: (1) enacted stigma occurred in many contexts; (2) enacted stigma restricted movement; and (3) second-hand accounts of enacted stigma shaped perceptions of safety. Efforts to improve well-being among LGBTQ youth must address the diverse forms and contexts of enacted stigma that youth experience, which limit freedom of movement and potential access to opportunities that encourage positive youth development. School nurses can play a critical role in reducing enacted stigma in schools and in collaboration with community partners.

The link between LGBTQ-supportive communities, progressive political climate, and suicidality among sexual minority adolescents in Canada.

Despite supportive structural changes to reduce stigma towards lesbian, gay, and bisexual, transgender, queer, and questioning (LGBTQ) Canadian residents, sexual minority youth still face disparities compared to heterosexual peers. We aimed to characterize LGBTQ-supportive environments and political climates, and examine their links to suicidal behavior among sexual minority adolescents in western Canada. Data were from the 2013 British Columbia Adolescent Health Survey, a cluster-stratified random cross-sectional survey of public school students in BC, Canada; We sampled 2678 self-identified LGB and mostly heterosexual students (69% girls) from 274 schools, representing an estimated provincial population of 24,624 sexual minority students in weighted models. Student reports of past-year suicidal ideation, suicidal attempts, and self-harm behaviors were merged with community-level data assessing diverse aspects of LGBTQ-supportive resources and progressive political climates in communities surrounding the schools. Adjusted multilevel models showed that for sexual minority adolescent girls, higher community LGBTQ-supportiveness predicted marginally significant lower suicidal ideation (aOR = 0.94, 95% CI [0.88, 1.01]) and suicidal attempts (aOR = 0.91, 95% CI [0.83, 1.00]) and significantly lower self-harm behaviors (aOR = 0.91, 95% CI [0.85, 0.98]). Further, progressive political climates predicted marginally significant lower suicidal ideation (aOR = 0.89, 95% CI [0.78, 1.02]) and significantly lower self-harm behaviors (aOR = 0.87, 95% CI [0.77, 0.99]). For sexual minority adolescent boys, no community-level variables were associated with suicidal behavior in adjusted models. Thus, LGBTQ-supportive communities and progressive political climates appear to be protective against suicidal behavior among sexual minority adolescent girls, but not sexual minority adolescent boys.

Hormone therapy decision-making processes: Transgender youth and parents.

INTRODUCTION: This study explored how transgender (trans) youth and parents of trans youth made decisions around hormone therapy initiation as well as trans youth experiences of barriers to care. METHODS: Participants included 21 trans youth (ages 14-18) and 15 parents of trans youth who resided in British Columbia, Canada. Data for this grounded theory research consisted of transcripts and lifeline drawings collected through semi-structured interviews conducted August 2016 through February 2017. RESULTS: The decision-making processes of youth and of parents are illustrated in three-phase temporal models, starting with discovery, leading to (inter)action while seeking care, and reflection after hormone therapy initiation. Youth who sought hormone therapy were clear about their decision to access this care. Throughout these processes, youth experienced numerous parent- and system-related barriers to care. Youth with the lowest levels of parent support experienced more system barriers, with non-binary/genderfluid youth experiencing greater barriers and less support for hormone therapy than youth with binary genders. A new barrier identified in this study was health care provider imposed requirements for parental involvement and/or approval, which rendered some youth unable access to hormone therapy. CONCLUSIONS: Health care providers should be aware of the deliberation and information-seeking in which youth engage prior to seeking care as well as the temporally misaligned decision-making processes of youth and parents. Understanding the challenges trans youth experience due to insufficient parental support and system barriers can provide important context for health care providers striving to provide accessible, gender-affirming care and decision-making support for trans youth.

Supportive Community Resources Are Associated with Lower Risk of Substance Use among Lesbian, Gay, Bisexual, and Questioning Adolescents in Minnesota.

Research has indicated that lesbian, gay, bisexual, and queer/questioning (LGBQ) adolescents have disproportionately high rates of substance use compared to heterosexual peers; yet certain features of schools and communities have been associated with lower substance use rates in this population. To advance this field, research examining multiple levels of influence using measures developed with youth input is needed. With community, school, and student data, this study tested hypotheses that LGBQ students attending high schools and living in communities with more LGBQ-supportive environments (assessed with a novel inventory tool) have lower odds of substance use behaviors (cigarette smoking, alcohol use, marijuana use, prescription drug misuse, and other drug use) than their peers in less supportive LGBQ environments. Multilevel models using data from 2454 LGBQ students (54.0% female, 63.9% non-Hispanic white) in 81 communities and adjusting for student and school covariates found that LGBQ adolescents who lived in areas with more community support had lower odds of frequent substance use, particularly among females. Expanding and strengthening community resources (e.g., LGBQ youth-serving organizations, LGBQ events such as a Pride parade, and LGBQ-friendly services) is recommended to further support LGBQ adolescents and reduce substance use disparities.

Population-level sexual behaviours in adolescent girls before and after introduction of the human papillomavirus vaccine (2003-2013).

BACKGROUND: The human papillomavirus (HPV) vaccine is delivered widely through school-based immunization programs. Some groups have expressed concern that HPV vaccination programs will result in an increase in sexual risk-taking behaviours among adolescents. We aimed to evaluate population-level changes in sexual behaviours before and after implementation of the school-based HPV vaccination program in British Columbia. METHODS: In 2008, a school-based HPV vaccination program for girls was introduced in British Columbia. Using data from the BC Adolescent Health Survey - a longitudinal provincial survey administered in schools to capture adolescent physical and emotional health indicators, we conducted a linear trend analysis on sexual health behaviours and risk factors in adolescent girls before and after the implementation of vaccination for HPV (2003, 2008 and 2013). RESULTS: We analyzed data for 298 265 girls who self-identified as heterosexual. The proportion of girls reporting ever having sexual intercourse decreased from 21.3% (2003) to 18.3% (2013; adjusted odds ratio [OR] 0.79). Self-report of sexual intercourse before the age of 14 years decreased significantly from 2008 to 2013 (adjusted OR 0.76), as did reported substance use before intercourse (adjusted OR for 2003-2013 0.69). There was no significant change in the number of sexual partners reported (2003-2013). Between 2003 and 2013, girls' reported use of contraception and condoms increased, while pregnancy rates decreased. INTERPRETATION: Since the implementation of school-based HPV vaccination program in BC, sexual risk behaviours reported by adolescent girls either reduced or stayed the same. These findings contribute evidence against any association between HPV vaccination and risky sexual behaviours.

Love and Dating Patterns for Same- and Both-Gender Attracted Adolescents Across Europe.

Sexual orientation is a multidimensional phenomenon, which includes identity, behavior, and attraction. The attraction component, however, is less studied than the other two. In this article, we present the development of a two-item measure to identify adolescents who prefer same- and both-gender partners for love and dating. The questions were administered to nationally representative samples of 15-year-old adolescents in eight European countries and regions participating in the Health Behaviour in School-aged Children (HBSC) cross-national study. The distribution of attraction, as operationalized by preference for the gender of love and dating partners, was similar across countries. These questions offer an alternative or supplementary approach to identify same- and both-gender attracted youth, without administering questions related to sexual identity.

Assessing the impacts and outcomes of youth driven mental health promotion: A mixed-methods assessment of the Social Networking Action for Resilience study.

Mental health challenges are the leading health issue facing youth globally. To better respond to this health challenge, experts advocate for a population health approach inclusive of mental health promotion; yet this area remains underdeveloped. Further, while there is growing emphasis on youth-engaged research and intervention design, evidence of the outcomes and impacts are lacking. The purpose of this paper is to contribute to addressing these gaps, presenting findings from the Social Networking Action for Resilience (SONAR) study, an exploration of youth-driven mental health promotion in a rural community in British Columbia, Canada. Mixed methods including pre- and post-intervention surveys (n = 175) and qualitative interviews (n = 10) captured the outcomes and impacts of the intervention on indicators of mental health, the relationship between level of engagement and benefit, and community perceptions of impact. Findings demonstrate the feasibility and benefits of youth engaged research and intervention at an individual and community-level.

Disordered eating behaviors among transgender youth: Probability profiles from risk and protective factors.

PURPOSE: Research has documented high rates of disordered eating for lesbian, gay, and bisexual youth, but prevalence and patterns of disordered eating among transgender youth remain unexplored. This is despite unique challenges faced by this group, including gender-related body image and the use of hormones. We explore the relationship between disordered eating and risk and protective factors for transgender youth. METHODS: An online survey of 923 transgender youth (aged 14-25) across Canada was conducted, primarily using measures from existing youth health surveys. Analyses were stratified by gender identity and included logistic regressions with probability profiles to illustrate combinations of risk and protective factors for eating disordered behaviors. RESULTS: Enacted stigma (the higher rates of harassment and discrimination sexual minority youth experience) was linked to higher odds of reported past year binge eating and fasting or vomiting to lose weight, while protective factors, including family connectedness, school connectedness, caring friends, and social support, were linked to lower odds of past year disordered eating. Youth with the highest levels of enacted stigma and no protective factors had high probabilities of past year eating disordered behaviors. DISCUSSION: Our study found high prevalence of disorders. Risk for these behaviors was linked to stigma and violence exposure, but offset by social supports. Health professionals should assess transgender youth for disordered eating behaviors and supportive resources. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:515-522).

Chasing the rainbow: lesbian, gay, bisexual, transgender and queer youth and pride semiotics.

While the pride rainbow has been part of political and social intervention for decades, few have researched how lesbian, gay, bisexual, transgender and queer young people perceive and use the symbol. How do lesbian, gay, bisexual, transgender and queer youth who experience greater feelings of isolation and discrimination than heterosexual youth recognise and deploy the symbol? As part of a larger study on supportive lesbian, gay, bisexual, transgender and queer youth environments, we conducted 66 go-along interviews with lesbian, gay, bisexual, transgender and queer youth people from Massachusetts, Minnesota and British Columbia. During interviews, young people identified visible symbols of support, including recognition and the use of the pride rainbow. A semiotic analysis reveals that young people use the rainbow to construct meanings related to affiliation and positive feelings about themselves, different communities and their futures. Constructed and shared meanings help make the symbol a useful tool for navigating social and physical surroundings. As part of this process, however, young people also recognize that there are limits to the symbolism; it is useful for navigation but its display does not always guarantee supportive places and people. Thus, the pride rainbow connotes safety and support, but using it as a tool for navigation is a learned activity that requires caution.

"Kicked out": LGBTQ youths' bathroom experiences and preferences.

Attention toward who can use which gender binary, multi-stall bathroom has brought to the forefront, once again, the ways in which youth are supported or marginalized. No study has documented sexual and gender minority youths' experiences with and perspectives about bathrooms. We collected qualitative data in 2014-2015. Participants were 25 lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) youth, aged 14-19, in the United States and Canada. Their comments describe first- and second-hand bathroom experiences, identify advocacy efforts, and highlight the roles of peers and adults in making bathrooms safe (or not). Youth emphasized the importance of gender-neutral bathrooms in fostering a sense of safety and inclusivity. Adult support and gay-straight alliances (GSAs) were important contributors to a welcoming environment and fostered advocacy efforts for gender-neutral bathrooms. We encourage purposeful inclusivity of youths' voices when enacting bathroom-specific policies and legislation that directly influence their health and well-being.

Respecting variations in embodiment as well as gender: Beyond the presumed 'binary' of sex.

Although societies and health care systems are increasingly recognizing gender outside traditional binary categories, the notion persists of two, and only two sexes, 'naturally' aligned between chromosomes and phenotypic body. Yet there are more than a dozen documented genetic or phenotypic variations that do not completely fit the two simplistic categories, and together, they may comprise 1%-2% of the population worldwide. In this commentary, I consider how adherence to binary notions of sex has created and maintained social and health care structures that perpetuate health care inequities, and may well violate our nursing codes of ethics. I provide some current examples in law and health care systems that create difficulties for people with variations in sex development. I describe our responsibility to challenge the societally promoted but scientifically inaccurate perspective of sex as a binary. I conclude by briefly suggesting a few implications for action within nursing research, nursing education, nursing practice, and in advocacy as a profession.

"I would have preferred more options": accounting for non-binary youth in health research.

As a research team focused on vulnerable youth, we increasingly need to find ways to acknowledge non-binary genders in health research. Youth have become more vocal about expanding notions of gender beyond traditional categories of boy/man and girl/woman. Integrating non-binary identities into established research processes is a complex undertaking in a culture that often assumes gender is a binary variable. In this article, we present the challenges at every stage of the research process and questions we have asked ourselves to consider non-binary genders in our work. As researchers, how do we interrogate the assumptions that have made non-binary lives invisible? What challenges arise when attempting to transform research practices to incorporate non-binary genders? Why is it crucial that researchers consider these questions at each step of the research process? We draw on our own research experiences to highlight points of tensions and possibilities for change. Improving access to inclusive health-care for non-binary people, and non-binary youth in particular, is part of creating a more equitable healthcare system. We argue that increased and improved access to inclusive health-care can be supported by research that acknowledges and includes people of all genders.

Sexual Health questions included in the Health Behaviour in School-aged Children (HBSC) Study: an international methodological pilot investigation.

BACKGROUND: This paper describes the methodological developments of the sexual health items included in the Health Behaviour in School-aged Children (HBSC) study since their mandatory inclusion in the study in 2002. The current methodological, ethical and pedagogical challenges in measuring young people's sexual health behaviours are discussed along with the issues associated with the sexual health items introduced to the HBSC study in 2002. The development and piloting of new cross-national items for use in the 2013/14 HBSC data collection are presented and discussed. METHODS: An international pilot study was undertaken to determine the impact of these proposed changes. Questionnaires and classroom discussion groups were conducted in five pilot countries in 2012/2013 (France, Hungary, Ireland, Portugal and Romania) with a total of 612 school-aged children (age M = 15.55 years, SD = 0.95). RESULTS: The majority of participants in each country provided positive feedback about the appropriateness of the questions. Some small cross-national differences were found in the self-reported quantitative data relating to the appropriateness of the questions (χ2 = 22.831, df = 9, p = .007, V = .117). Qualitative feedback suggests that for the vast majority of students the phrasing and age-targeting of the questions were considered appropriate. With the exception of a small number of respondents who commented on the clarity and/or personal nature of the content, no specific issues with the questions were identified. CONCLUSIONS: These findings provide guidance on the answerability (including the extent of missing and inconsistent data), understandability, acceptability (including in different cultures) and relevance of questions to potential participants. The findings from the pilot study suggest that in general, the questions are understandable, acceptable, and of a high priority to the target population, and that the simplification has significantly reduced the proportion of missing data. The new developments thus enhance the capacity of the questions to measure cross-nationally, sensitive aspects of young people's sexual behaviour. These questions were included in the 2013/2014 round of the HBSC survey and will continue to be used to monitor trends in adolescent sexual health and behaviours, and to inform and influence health services and health education policy and practice at local, national and international levels.

Living for the moment: men situating risk-taking after the death of a friend.

The primary cause of death for men under the age of 30 is unintentional injury and, despite health-promotion efforts and programme interventions, male injury and death rates have not decreased in recent years. Drawing on 22 interviews from a study of men, risk and grief, we describe how a risk-related tragedy shaped the participants' understandings of and practices of risk-taking. The findings indicate that most participants did not alter their perceptions and engagement in risky practices, which reflected their alignment to masculine ideals within specific communities of practice where risk-taking was normalised and valorised. Continued reliance on risky practices following the death of a friend was predominantly expressed as 'living for the moment,' where caution and safety were framed as conservative practices that undermined and diluted the robustness ideally embodied by this subgroup of young men. Two main themes: living life, accepting death and upping the ante illustrate how risk-taking can persist following a death. A smaller group of participants articulated a different viewpoint; reining in risk practices, to describe their risk management approaches after the death of a male friend. This novel study confirms the ongoing challenge of reducing men's risk-taking practices, even after the death of a friend.

Adolescent reactions to icon-driven response modes in a tablet-based health screening tool.

Increasingly popular touch-screen electronic tablets offer clinics a new medium for collecting adolescent health screening data in the waiting area before visits, but there has been limited evaluation of interactive response modes. This study investigated the clarity, comprehensibility, and utility of icon-driven and gestural response functions employed in one such screening tool, TickiT. We conducted cognitive processing interviews with 30 adolescents from Vancouver (aged 14-20 years, 60% female, 30% English as a second language) as they completed the TickiT survey. Participants used seven different interactive functions to respond to questions across 30 slides, while being prompted to articulate their thoughts and reactions. The audio-recorded, transcribed interviews were analyzed for evidence of comprehension, nuances in response choices, and youth interest in the modes. Participants were quite receptive to the icon response modes. Across demographics and cultural backgrounds, they indicated question prompts were clear, response choices appropriate, and response modes intuitive. Most said they found the format engaging and would be more inclined to fill out such a screening tool than a paper-and-pencil form in a clinical setting. Given the positive responses and ready understanding of these modes among youth, clinicians may want to consider interactive icon-driven approaches for screening.

Associations between the school food environment, student consumption and body mass index of Canadian adolescents.

BACKGROUND: Increasing attention has been paid to the school food environment as a strategy to reduce childhood obesity. The purpose of this study was to examine associations between the school food environment, students' dietary intake, and obesity in British Columbia (BC), Canada. METHODS: In 2007/08, principal responses about the school environment (N=174) were linked to grades 7-12 students (N=11,385) from corresponding schools, who participated in the BC Adolescent Health Survey. Hierarchical mixed-effect regression analyses examined the association between the school food environment and student's intake of sugar-sweetened beverages (SSBs), food consumption, and body mass index. Analyses controlled for school setting, neighborhood education level and student's age and sex. RESULTS: School availability of SSBs was positively associated with moderate (Odds Ratio (OR)=1.15, 95% Confidence Interval (CI)=1.02-1.30) and high (OR=1.43, 95% CI=1.13-1.80) SSB intake as were less healthful school nutrition guidelines for moderate SSB consumers only (OR=0.65, 95% CI=0.48-0.88). Availability of SSBs at school and its consumption were positively associated with student obesity (OR=1.50, 95% CI=1.12-2.01 and OR=1.66, 95% CI=1.19-2.34, respectively) but not with overweight. In contrast, consumption of less healthful food was positively associated with overweight (OR=1.03, 95% CI=1.01-1.06). CONCLUSIONS: The results of this study provide further evidence to support the important role of schools in shaping adolescents' dietary habits. Availability and consumption of SSBs, but not less healthful foods, at school were associated with higher adolescent obesity highlighting that other environments also contribute to adolescent obesity.

Trends in substance use among sexual minority adolescents in South Korea.

PURPOSE: Substance use, that is of cigarettes, alcohol and chemical inhalants, is a major contributor to health-compromising behaviors and the related consequences among adolescents around the world. The purpose of this paper is to examine trends in this phenomenon in South Korea among sexually active adolescents who reported sexual minority behaviors as compared to their heterosexual (HS) peers. DESIGN AND METHODS: This study used data from the annual web-based survey called Korea Youth Risk Behavior Survey in 5-year intervals: 2006, 2011, and 2016. From 2017, the questions regarding the gender of sex partners were excluded from the survey, thus no data is available for sexual minorities after 2016. Selected data (Unweighted n = 10,029) was used to assess whether substance use increased, decreased, or remained unchanged among adolescents who reported same-sex (SS) behaviors and bisexual (BS) behaviors compared to their peers reporting HS behaviors. Demographic variables included age and assigned gender. Substances referred to are cigarettes, alcohol, and chemical inhalants. Logistic regression models were sex-stratified according to assigned gender. Trend analyses were carried out to examine disparities in substance use among sexually active adolescents across the three survey years. RESULTS: Across the three survey years, cigarette use, alcohol use, and problematic drinking declined among all sexually active youths, but there were some differences among the subgroups. In 2016, SS girls were more likely to use cigarettes than HS girls. The prevalence of alcohol use and problematic drinking among BS girls was relatively higher than among girls who exhibited either HS or SS behaviors. Inhalant use was very high among both boys and girls with SS and BS behaviors. PRACTICE IMPLICATIONS: The findings of the study reveal disparities in substance use between sexual minority and heterosexual adolescents in South Korea. This creates an alarm for collecting data separately for sexually diverse youth in future Korean national surveys with a goal of reducing substance use among all adolescents.

Indicators to Measure Adolescent Health at the Country, Regional, and Global Levels: Results of a Five-Year Selection Process by the Global Action for the Measurement of Adolescent Health.

PURPOSE: To improve adolescent health measurement, the Global Action for the Measurement of Adolescent health (GAMA) Advisory Group was formed in 2018 and published a draft list of 52 indicators across six adolescent health domains in 2022. We describe the process and results of selecting the adolescent health indicators recommended by GAMA (hereafter, "GAMA-recommended indicators"). METHODS: Each indicator in the draft list was assessed using the following inputs: (1) availability of data and stakeholders' perceptions on their relevance, acceptability, and feasibility across selected countries; (2) alignment with current measurement recommendations and practices; and (3) data in global databases. Topic-specific working groups comprised of GAMA experts and representatives of United Nations partner agencies reviewed results and provided preliminary recommendations, which were appraised by all GAMA members and finalized. RESULTS: There are 47 GAMA-recommended indicators (36 core and 11 additional) for adolescent health measurement across six domains: policies, programs, and laws (4 indicators); systems performance and interventions (4); health determinants (7); health behaviors and risks (20); subjective well-being (2); and health outcomes and conditions (10). DISCUSSION: These indicators are the result of a robust and structured five-year process to identify a priority set of indicators with relevance to adolescent health globally. This inclusive and participatory approach incorporated inputs from a broad range of stakeholders, including adolescents and young people themselves. The GAMA-recommended indicators are now ready to be used to measure adolescent health at the country, regional, and global levels.