Limited health insurance coverage of injectable neurotoxins and fillers for gender affirmation: a cross-sectional study of Affordable Care Act silver and Medicaid plans.

Background: Injectable neurotoxins and fillers are potential options for facial gender affirmation for transgender/nonbinary patients. However, the largest barrier to access is cost/insurance coverage. Objective: The purpose of this article is to assess the extent to which Affordable Care Act (ACA) silver plans and Medicaid policies cover gender-affirming injectable neurotoxin and filler procedures. Methods: A cross-sectional study of all ACA silver plans and Medicaid policies was performed from June 22 to August 15, 2021. Plan-specific certificates of coverage, clinical policies of insurance providers, and Medicaid documents were evaluated. Results: A total of 915 plans were reviewed (864 ACA silver plans and all 51 Medicaid policies). None potentially covered neurotoxins. Only 72 (71 ACA and 1 Medicaid) potentially covered fillers, specifically collagen injections and lipofilling. Coverage required demonstration of medical necessity or significant variation of physical appearance from the patient's experienced gender. However, of the 71 ACA plans, 69 outlined cosmetic exclusions, possibly nullifying this coverage. Limitations: Data were sourced from publicly available online information in 2021. Additionally, we were unable to confirm explicit coverage of these procedures with insurance companies. Conclusion: The majority of ACA silver and Medicaid plans did not cover gender-affirming neurotoxin or filler procedures, limiting access to this gender-affirming care.

Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement.

Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.

Transgender Youths' Sexual Health and Education: A Qualitative Analysis.

STUDY OBJECTIVE: To characterize transgender adolescents' sexual behaviors, identities, and their perceived experiences with sex education. DESIGN: Semi-structured interviews were conducted and addressed sexual experiences and perceptions of sex education received from family, school educators, and healthcare providers. Interviews were audio recorded, transcribed, and analyzed utilizing NVivo 12 software for thematic analysis. SETTING: Child and adolescent gender services clinic at a Midwestern university-based medical center in the United States. PARTICIPANTS: 30 transgender adolescents between the ages of 15 to 20. INTERVENTIONS AND MAIN OUTCOME MEASURES: Themes generated during semi-structured interviews. RESULTS: Sexual orientations were inclusive of attractions to a spectrum of gender identities. Libido was perceived to be impacted by gender-affirming hormone therapy, which was unanticipated for some adolescents. Family and school-based sex education was perceived to be relevant only for heterosexual and cisgender adolescents. Inclusive education for transgender adolescents was desired. Counseling provided by gender-affirming providers on sexual health was trusted and other healthcare providers were perceived to lack training on gender-inclusive care. CONCLUSION: This study demonstrated that families and school educators did not provide sex education perceived to be applicable to transgender adolescents. Similarly, healthcare providers of transgender adolescents were perceived to not provide inclusive or comprehensive medical care in comparison to physicians who routinely provide gender-affirming care. Gaps in education and healthcare could be improved with sex education outreach or training for families and school educators as well as the development and implementation of professional competencies for pediatricians on transgender adolescent healthcare.

Romantic Relationships in Transgender Adolescents: A Qualitative Study.

BACKGROUND: Identity formation and exploration of interpersonal relationships are important tasks that occur during adolescence. Transgender, gender diverse, and gender-nonconforming (TGNC) individuals must face these developmental milestones in the context of their transgender identity. Our aim with this article is to describe adolescents' history and experiences with romantic partners. METHODS: We conducted phenomenological, qualitative semistructured interviews with transgender adolescents. Questions were focused on romantic experiences, thoughts, and perceptions. All interviews were coded by 2 members of the research team, with disagreements resolved by discussion and, if needed, with a third member of the research team. Thematic analysis was used to analyze the data, as well as descriptive categorization. RESULTS: In total, 30 adolescents (18 transmasculine and 12 transfeminine) between the ages of 15 and 20 years were interviewed. Themes included (1) engagement in romantic relationships, (2) disclosure of gender identity and romantic relationships, (3) experience with abusive relationships, and (4) perceived impact of gender-affirming hormone care on romantic experiences. CONCLUSIONS: TGNC adolescents are engaged in romantic experiences before and during social and/or medical transitioning and are cultivating relationships through both proximal peers and online connections. There is perceived benefit of gender-affirming hormone care on romantic experiences. Risk of transphobia in romantic relationships impacts the approach that transgender adolescents take toward romance and influences decisions of identity disclosure. TGNC adolescents have experience with relationship abuse in different forms. Providers can incorporate these findings in their approach to counseling and screening when caring for TGNC youth.

Transgender Adolescents' Uses of Social Media for Social Support.

PURPOSE: Transgender adolescents are at higher risk for negative mental health outcomes, such as depression, anxiety, and suicidality, compared with cisgender adolescents. Social media may be an effective venue for addressing these health disparities because most adolescents have access to online information and socialization. This study used qualitative inquiry to explore transgender adolescents' uses of social media for social support. METHODS: Transgender adolescents between the ages of 15 and 18 years with a social media profile were recruited from a pediatric gender clinic in the Midwestern U.S. A 30- to 60-minute semistructured interview assessed ways participants used social media to access transgender-related support. Thematic analysis was used to develop categories and code the transcripts. Coding discrepancies were resolved by two researchers following initial coding. RESULTS: Results represent data from 25 interviews comprising 13 transmasculine, 11 transfeminine, and one nonbinary participant(s), with 68% of the sample identifying as white, non-Hispanic. Categories emerged regarding forms of support participants received from transgender-related online communities including emotional support through peers and role models, appraisal support for validating their experiences, and informational support for navigating health decisions and educating family and friends. Participants also referenced negative experiences, including harassment and exclusionary behavior online. CONCLUSIONS: Social media platforms represent hubs of community for transgender adolescents. These communities provide emotional, appraisal, and informational support that transgender youth may not otherwise be able to access. Future research should use the affordances of social media to identify approaches to addressing health disparities and improving the well-being of transgender adolescents.

Childhood adiposity and adolescent sex steroids in the Exploring Perinatal Outcomes among Children study.

OBJECTIVE: It is unclear how childhood adipose tissue deposition influences sex hormone profiles in later adolescence. DESIGN: Prospective cohort study. PARTICIPANTS: Children (n = 418) with a mean age of 10.5 (1.5) years at visit 1 and 16.7 (1.2) at visit 2 in the Exploring Perinatal Outcomes among Children (EPOCH) Study. MEASUREMENTS: We used reverse-scale Cox proportional hazard models to assess associations between pubertal dehydroepiandrosterone (DHEA), testosterone (T), and oestradiol (E2) and childhood-to-puberty rate of change in visceral (VAT) and subcutaneous adipose tissue (SAT). Models stratified by sex and adjusted for childhood adiposity, maternal factors, birthweight and pubertal onset, and then further adjusted for insulin, luteinizing hormone (LH), leptin and hepatic fat fraction. RESULTS: Among boys, more rapid accumulation of either VAT or SAT was associated with lower testosterone at visit 2 (HR 0.86, and .96, respectively, both P < .0001), independently of race/ethnicity, LH, leptin and hepatic fat fraction. Among boys, more childhood VAT was associated with lower testosterone in adolescence (HR 0.98, P = .003), but this association did not persist after adjustment for leptin or insulin. No associations were observed between either fat measure and oestradiol or DHEA in boys. In girls, no associations between childhood fat or fat accumulation and sex hormones were observed. CONCLUSIONS: More rapid accumulation of fat is associated with lower testosterone in boys. These associations suggest that fat growth influences androgen profiles in adolescent boys. Since fat accumulation is a modifiable risk factor, the study results provide a possible intervention target and time period for improving adult health.

Revisiting the Link: Evidence of the Rates of Autism in Studies of Gender Diverse Individuals.

Turban and van Schalkwyk assert in their Translations article, "'Gender Dysphoria' and Autism Spectrum Disorder: Is the Link Real?" that an over-representation of autism spectrum disorder (ASD) in gender dysphoria is unsupported based on current evidence. Turban and van Schalkwyk discuss 7 of the currently 19 available empirical studies (excluding reviews and case reports) of the over-occurrence of ASD and/or autism traits with gender dysphoria/diversity. They are correct to note that some ASD screeners may lack specificity; that is, a clinical-range total score could indicate non-ASD-related mental health conditions or other developmental difference. However, they do not account for the 7 available studies which specifically report rates of clinical diagnoses of ASD among unselected gender-diverse samples. We suggest also that many of the studies that assess ASD-symptoms in gender-diverse groups are more convincing than suggested by Turban and van Schalkwyk because they employ measures assessing the multi-dimensionality of ASD symptoms and report significant elevations not only for socially-related symptoms but also for the various components of restricted and repetitive behaviors and interests (RRBI) core to ASD. We come together to write this response as gender clinicians and researchers, autism clinicians and researchers, and key stakeholders, including autistic and autistic transgender self-advocates. We work and live with the co-occurrence of autism and gender diversity on a daily basis, and we are concerned that perpetuating misunderstanding about the co-occurrence places individuals at risk.

Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents.

Evidence indicates an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD). The clinical assessment and treatment of adolescents with this co-occurrence is often complex, related to the developmental aspects of ASD. There are no guidelines for clinical care when ASD and GD co-occur; however, there are clinicians and researchers experienced in this co-occurrence. This study develops initial clinical consensus guidelines for the assessment and care of adolescents with co-occurring ASD and GD, from the best clinical practices of current experts in the field. Expert participants were identified through a comprehensive international search process and invited to participate in a two-stage Delphi procedure to form clinical consensus statements. The Delphi Method is a well-studied research methodology for obtaining consensus among experts to define appropriate clinical care. Of 30 potential experts identified, 22 met criteria as expert in co-occurring ASD and GD youth and participated. Textual data divided into the following data nodes: guidelines for assessment; guidelines for treatment; six primary clinical/psychosocial challenges: social functioning, medical treatments and medical safety, risk of victimization/safety, school, and transition to adulthood issues (i.e., employment and romantic relationships). With a cutoff of 75% consensus for inclusion, identified experts produced a set of initial guidelines for clinical care. Primary themes include the importance of assessment for GD in ASD, and vice versa, as well as an extended diagnostic period, often with overlap/blurring of treatment and assessment.

Overrepresentation of Adopted Adolescents at a Hospital-Based Gender Dysphoria Clinic.

Purpose: We have noted a greater than expected prevalence of adopted children presenting to our multidisciplinary gender program for evaluation of gender dysphoria. Methods: A retrospective review of 184 patient charts was conducted to assess the prevalence of adopted children presenting to gender clinic. Results: Fifteen of 184 patients seen were living with adoptive families (8.2%). This is significantly higher than expected based on U.S. census data. Conclusion: Adopted children are referred to our gender program more than would be expected based on the percentage of adopted children in our state and the United States at large. This may be due to a true increased risk of gender dysphoria in adopted children, or could represent presentation bias. Gender programs should be prepared to provide assessments for adopted children. Further work is needed to understand the relationship between adopted status and gender development.

Disorders of Sex Development: Pediatric Psychology and the Genital Exam.

Objective: To provide suggestions for clinical care of youth with disorders of sex development (DSD) and their families, by drawing on preexisting pediatric psychology literature with a particular focus on child sexual abuse (CSA) genital exams. Method: Relevant peer-reviewed papers published since 1990 in the CSA literature were systematically reviewed, as well as an illustrative sample of general pediatric psychology papers. Results: Empirical research from the CSA literature provided information on prevalence of distress and the impact of provider behavior, the importance of preparation, and proposed interventions. Expert recommendations from CSA literature and general findings gleaned from pediatric psychology also address these issues. Conclusions: Psychological findings in the CSA pediatric population suggest that fears and anxieties are not universal and can be linked to a number of variables. Based on this review, we make a number of recommendations for potential interventions for youth with DSD and their families, emphasizing the need for further clinical research.

Evaluation of Asperger Syndrome in Youth Presenting to a Gender Dysphoria Clinic.

PURPOSE: There is evolving evidence that children and adolescents with gender dysphoria have higher-than-expected rates of autism spectrum disorder (ASD), yet clinical data on ASD among youth with gender dysphoria remain limited, particularly in North America. This report aims to fill this gap. METHODS: We conducted a retrospective review of patient chart data from 39 consecutive youth ages 8 to 20 years (mean age 15.8 years, natal male: n = 22, natal female: n = 17) presenting for evaluation at a multidisciplinary gender clinic in a large U.S. pediatric hospital from 2007 to 2011 to evaluate the prevalence of ASD in this patient population. RESULTS: Overall, 23.1% of patients (9/39) presenting with gender dysphoria had possible, likely, or very likely Asperger syndrome as measured by the Asperger Syndrome Diagnostic Scale (ASDS). CONCLUSION: These findings are consistent with growing evidence supporting increased prevalence of ASD in gender dysphoric children. To guide provision of optimal clinical care and therapeutic intervention, routine assessment of ASD is recommended in youth presenting for gender dysphoria.

Transgender and gender nonconforming adolescent care: psychosocial and medical considerations.

PURPOSE OF REVIEW: Transgender individuals display incongruence between their assigned birth sex and their current gender identity, and may identify as male, female, or being elsewhere on the gender spectrum. Gender nonconformity describes an individual whose gender identity, role, or expression is not typical for individuals in a given assigned sex category. This update highlights recent literature pertaining to the psychosocial and medical care of transgender and gender nonconforming (TGN) adolescents with applications for the general practitioner. RECENT FINDINGS: The psychological risks and outcomes of TGN adolescents are being more widely recognized. Moreover, there is increasing evidence that social and medical gender transition reduces gender dysphoria, defined as distress that accompanies the incongruence between one's birth sex and identified gender. Unfortunately, lack of education about TGN adolescents in medical training persists. SUMMARY: Recent literature highlights increased health risks in TGN adolescents and improved outcomes following gender dysphoria treatment. It is important for clinicians to become familiar with the range of treatment options and referral resources available to TGN adolescents in order to provide optimal and welcoming care to all adolescents.

Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study.

PURPOSE: Transgender youth represent a vulnerable population at risk for negative mental health outcomes including depression, anxiety, self-harm, and suicidality. Limited data exist to compare the mental health of transgender adolescents and emerging adults to cisgender youth accessing community-based clinical services; the present study aimed to fill this gap. METHODS: A retrospective cohort study of electronic health record data from 180 transgender patients aged 12-29 years seen between 2002 and 2011 at a Boston-based community health center was performed. The 106 female-to-male (FTM) and 74 male-to-female (MTF) patients were matched on gender identity, age, visit date, and race/ethnicity to cisgender controls. Mental health outcomes were extracted and analyzed using conditional logistic regression models. Logistic regression models compared FTM with MTF youth on mental health outcomes. RESULTS: The sample (N = 360) had a mean age of 19.6 years (standard deviation, 3.0); 43% white, 33% racial/ethnic minority, and 24% race/ethnicity unknown. Compared with cisgender matched controls, transgender youth had a twofold to threefold increased risk of depression, anxiety disorder, suicidal ideation, suicide attempt, self-harm without lethal intent, and both inpatient and outpatient mental health treatment (all p < .05). No statistically significant differences in mental health outcomes were observed comparing FTM and MTF patients, adjusting for age, race/ethnicity, and hormone use. CONCLUSIONS: Transgender youth were found to have a disparity in negative mental health outcomes compared with cisgender youth, with equally high burden in FTM and MTF patients. Identifying gender identity differences in clinical settings and providing appropriate services and supports are important steps in addressing this disparity.

Brief Report: Autistic Traits in Mothers and Children Associated with Child's Gender Nonconformity.

We examined relationships between autistic traits in children, mothers, and fathers and gender nonconformity (GNC) in children using data from the Nurses' Health Study II and the Growing Up Today Study 1. Autistic traits of mothers, fathers and children were measured using the Social Responsiveness Scale (SRS). GNC in children was measured using questions from the Recalled Childhood Gender Identity/Gender Role Questionnaire. In multivariable analyses increase in child's SRS score was associated with increased odds (OR 1.35; p = 0.03) of being in a higher GNC category. Increase in maternal SRS score was also associated with increased odds (OR 1.46; p = 0.005) of the child being in a higher GNC category. Paternal SRS scores were not related to child's GNC category.