Mental Health of Youth With Autism Spectrum Disorder and Gender Dysphoria.

BACKGROUND AND OBJECTIVES: Youth with either autism spectrum disorder (ASD) or gender dysphoria (GD) alone have also been shown to be at greater risk for mental health (MH) concerns; however, very little research has considered how cooccurring ASD and GD may exacerbate MH concerns. The purpose of this study was to examine associations between ASD, GD, and MH diagnoses (anxiety, depression, eating disorder, suicidality, and self-harm) among US adolescent populations. METHODS: This is a secondary analysis of a large administrative dataset formed by 8 pediatric health system members of the PEDSnet learning health system network. Analyses included descriptive statistics and adjusted mixed logistic regression models testing for associations between combinations of ASD and GD diagnoses and MH diagnoses as recorded in the patient's electronic medical record. RESULTS: Based on data from 919 898 patients aged 9 to 18 years, adjusted mixed logistic regression indicated significantly greater odds of each MH diagnosis among those with ASD alone, GD alone, and cooccurring ASD/GD diagnoses compared with those with neither diagnosis. Youth with cooccurring ASD/GD were at significantly greater risk of also having anxiety (average predicted probability, 0.75; 95% confidence interval, 0.68-0.81) or depression diagnoses (average predicted probability, 0.33; 95% confidence interval, 0.24-0.43) compared with youth with ASD alone, GD alone, or neither diagnosis. CONCLUSIONS: Youth with cooccurring ASD/GD are more likely to also be diagnosed with MH concerns, particularly anxiety and depression. This study highlights the need to implement developmentally appropriate, gender-affirming MH services and interventions for youth with cooccurring ASD/GD.

Providers' Perspectives on Decision-Making About Care for Transgender Youth.

Background: Transgender and gender-diverse (TGD) youth face health care decisions that are complicated by both social and medical aspects of gender care. Little is known about how providers support decision-making in this context or the gaps they perceive in decision support. Objective: To explore health care providers' perspectives on the decision-making processes in youth gender care. Methods: We interviewed health care providers (n=17) caring for TGD youth and asked about the nature of families' decision-making, providers' role in this process, and potential improvements to existing support systems. Two independent coders coded all responses which were analyzed using thematic analysis. Results: From providers' perspectives, they serve as "guides" to families through a challenging decision-making process. Youth arrive educated and eager to begin treatment, but caregivers are more hesitant. Providers lack data to address parents' concerns, and struggle to support families through interpersonal conflict. All providers recognized a need to improve decision support for families. Conclusions: Providers described decision-making in this context as a multistep process where interpersonal conflict and limited data slow progress. Practice Implications: There is ample opportunity to leverage insights from adult and pediatric medical decision-making research to improve decision support for providers, TGD youth, and families.

Co-occurring Autism Spectrum Disorder and Gender Dysphoria in Adolescents.

BACKGROUND AND OBJECTIVES: Autism spectrum disorder (ASD) and gender dysphoria (GD) frequently cooccur. However, existing research has primarily used smaller samples, limiting generalizability and the ability to assess further demographic variation. The purpose of this study was to (1) examine the prevalence of cooccurring ASD and GD diagnoses among US adolescents aged 9 to 18 and (2) identify demographic differences in the prevalence of cooccurring ASD and GD diagnoses. METHODS: This secondary analysis used data from the PEDSnet learning health system network of 8 pediatric hospital institutions. Analyses included descriptive statistics and adjusted mixed logistic regression testing for associations between ASD and GD diagnoses and interactions between ASD diagnosis and demographic characteristics in the association with GD diagnosis. RESULTS: Among 919 898 patients, GD diagnosis was more prevalent among youth with an ASD diagnosis compared with youth without an ASD diagnosis (1.1% vs 0.6%), and adjusted regression revealed significantly greater odds of GD diagnosis among youth with an ASD diagnosis (adjusted odds ratio = 3.00, 95% confidence interval: 2.72-3.31). Cooccurring ASD/GD diagnoses were more prevalent among youth whose electronic medical record-reported sex was female and those using private insurance, and less prevalent among youth of color, particularly Black and Asian youth. CONCLUSIONS: Results indicate that youth whose electronic medical record-reported sex was female and those using private insurance are more likely, and youth of color are less likely, to have cooccurring ASD/GD diagnoses. This represents an important step toward building services and supports that reduce disparities in access to care and improve outcomes for youth with cooccurring ASD/GD and their families.

Preferences for Rectal Sexually Transmitted Infection Sample Collection and Sexual Behaviors Among Adolescent and Young Adult Women Accessing Primary Care Services.

BACKGROUND: High prevalence of asymptomatic rectal chlamydia and gonorrhea among women is increasingly recognized. Screening is controversial because of lack of natural history data. Barriers to screening may include reluctance to discuss anal sex and collect rectal samples. This study describes the prevalence of sexual contact exposing adolescent and young adult women to extragenital sexually transmitted infections and acceptability of self-collection and clinician collection of rectal samples, preference for self- versus clinician-collected rectal samples, and preference for home or doctor's office for sample collection. METHODS: Participants were recruited from a primary care office and completed structured interviews assessing types of sexual contact and attitudes about rectal sampling. Differences were tested using χ2 and 2-sided Fisher exact test. RESULTS: Of 110 cisgender women (aged 14-22 years) enrolled, the average age was 18.4 years (SD, 1.7 years), 83% reported a history of extragenital contact, 22% reported history of receptive anal intercourse. A majority of participants reported self- and clinician-collected rectal samples to be acceptable (86% and 73%, respectively), with preferences for self-collection (71%) over clinician collection (29%, P < 0.001) and collection at the doctor's office (85%) over home (15%, P < 0.001). CONCLUSIONS: Adolescent and young adult (AYA) women engage in behaviors that increase the risk of rectal sexually transmitted infection (STI). Self- and clinician-collected rectal samples were acceptable. A majority of AYA women preferred to collect rectal samples in the doctor's office rather than at home. This may reduce adolescents' access to direct-to-consumer STI services. Offering in-clinic, self-collected rectal samples may improve uptake of rectal STI screening in adolescent girls.

Supporting Gender-Related Medical Decision Making for Transgender and Gender-Diverse Individuals: A Scoping Review.

Purpose: Transgender and gender-diverse (TGD) individuals and their families face numerous challenging decisions. To better understand their decision processes, we conducted a scoping review of the existing literature and of decision-support tools in use at pediatric gender-care clinics. Methods: We searched PubMed, EMBASE, Scopus CINAHL, PsychINFO, and EBM Reviews for studies that were original research focused on decisions, decision making, or decision support for TGD individuals and/or their families. All studies were reviewed for inclusion by at least two researchers. Additionally, we reviewed clinical tools used to support decision making by TGD youth and their families. Results: We retrieved 3306 articles. Thirty-two met criteria for data extraction. Studies focused on three major decisions: gender-confirming surgery, fertility preservation, and gender-affirming hormone therapy. Several themes that cut across clinical topics emerged: decision-making processes, decision-making roles, and sources of decision support. Only three articles focused on decision-support interventions, two of which discussed development of support tools and one evaluated a class designed to help with surgical decision making. None of the clinical tools reviewed met criteria for a decision aid. Conclusions: There is a dearth of studies related to decision support interventions, an absence validated by the resources currently in clinical use. This scoping review suggests an opportunity for the development of tools to aid in the decision-making processes for TGD youth and their families.

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.

Thrombosis Risk in Transgender Adolescents Receiving Gender-Affirming Hormone Therapy.

BACKGROUND AND OBJECTIVES: Many transgender youth experience gender dysphoria, a risk factor for suicide. Gender-affirming hormone therapy (GAHT) ameliorates this risk but may increase the risk for thrombosis, as seen from studies in adults. The aim with this study was to examine thrombosis and thrombosis risk factors among an exclusively adolescent and young adult transgender population. METHODS: This retrospective chart review was conducted at a pediatric hospital-associated transgender health clinic. The primary outcome was incidence of arterial or venous thrombosis during GAHT. Secondary measures included the prevalence of thrombosis risk factors. RESULTS: Among 611 participants, 28.8% were transgender women and 68.1% were transgender men. Median age was 17 years at GAHT initiation. Median follow-up time was 554 and 577 days for estrogen and testosterone users, respectively. Individuals starting GAHT had estradiol and testosterone levels titrated to physiologic normal. Multiple thrombotic risk factors were noted among the cohort, including obesity, tobacco use, and personal and family history of thrombosis. Seventeen youth with risk factors for thrombosis were referred for hematologic evaluation. Five individuals were treated with anticoagulation during GAHT: 2 with a previous thrombosis and 3 for thromboprophylaxis. No participant developed thrombosis while on GAHT. CONCLUSIONS: In this study, we examined thrombosis and thrombosis risk factors in an exclusively adolescent and young adult population of transgender people receiving GAHT. These data suggest that GAHT in youth, titrated within physiologic range, does not carry a significant risk of thrombosis in the short-term, even with the presence of preexisting thrombosis risk factors.

The relationship of the UPPS model of impulsivity on bulimic symptoms and non-suicidal self-injury in transgender youth.

OBJECTIVE: This brief report examined the relationship of negative urgency (the tendency to act rashly in response to negative emotional states), (lack of) perseverance, (lack of) premeditation, and sensation seeking in association with non-suicidal self-injury (NSSI) and symptoms of bulimia nervosa (BN) in a sample of treatment-seeking transgender (TG) youth. METHOD: Eighty-six TG youth with a mean age of 17 (sd = 3.2) agreed to participate in the study. The majority of our sample identified as TG male (n = 60) with 20 participants identifying as TG female and 6 identifying as non-binary. The racial ethnic breakdown of our sample was 8.2% Black, 8.2% Multi-racial, 1.2% Native American, and 82.4% White. Over » of our sample endorsed at least one episode of objective binge eating in the last 28 days and 62% endorsed a history of NSSI. RESULTS: Negative urgency was significantly associated with the odds of NSSI, objective binge eating, and general eating disorder symptoms. Lack of premeditation was significantly related to the odds of NSSI only. No other factors were significantly associated with NSSI or symptoms of BN. CONCLUSIONS: Negative urgency appears to be an important personality construct in understanding increased risk for NSSI and BN symptoms in transgender youth.

Supporting and Caring for Transgender and Gender-Expansive Individuals in the Dental Practice.

Transgender and gender nonconforming youth are rapidly gaining visibility and acceptance. Nevertheless, this group still experiences a variety of health disparities and is often at high risk for negative health outcomes. To improve cultural competence and provide the best possible care to this vulnerable population, health care professionals, including dentists, need to have a broader understanding of their issues. The purposes of this paper are to (1) summarize the prevalence, etiology, treatment, and common health risks associated with a transgender or gender nonconforming identity; and (2) discuss strategies to create a safe and welcoming environment for this population in the dental practice. (J Dent Child 2019;86(3):173-9).

Hormonal contraceptive choices in a clinic-based series of transgender adolescents and young adults.

Aims: To describe the use of hormonal contraceptives for menstrual management and/or pregnancy prevention in a clinic-based series of transgender adolescents and young adults who were assigned female at birth (transmasculine identity). Methods: We performed a chart review of post-menarchal transgender assigned-female-at-birth (AFAB) patients, age 10-25 years, seen at CCHMC Transgender Health Clinic for at least 2 visits between July 1, 2013 and September 17, 2016, and who were not on a puberty suppression method. We collected data including choice of hormonal contraceptive and indication (menstrual suppression, pregnancy prevention, or both), duration of use, initiation of sexual activity, reported sexual partners, and use of gender-affirming hormone therapy (i.e., testosterone). We present simple descriptive statistics. Results: A total of 231 patients met inclusion criteria, with ages from 11 to 25 years. Of those, 135 (59%) were using a hormonal contraceptive method. Most patients (67%) used hormonal contraception for the indication of menstrual suppression. Most commonly used method was depot medroxyprogesterone (DMPA) (49 patients), followed by combined oral contraceptives (COC) and norethindrone (progestin-only pill, POP) (34 patients each). Thirteen patients used 52 mg levonorgestrel IUD (LNG-IUD). Of the total sample (n = 231), 82 (36%) reported sexual activity, 35 of whom (43% of sexually active patients) reported sexual intercourse with assigned-male-at-birth (AMAB) partners and/or penile-vaginal intercourse. Among 35 patients at risk for pregnancy, only 21 (60%) were using hormonal contraception. Over half (54%) of sexually active patients taking testosterone discontinued their hormonal contraceptive method once they stopped having menses. Discussion: Within a sample of transgender AFAB adolescents, half of whom were taking testosterone, a variety of contraceptives were used, including depot medroxyprogesterone, combined oral contraceptives, and levonorgestrel IUD. Among those taking testosterone, many patients discontinued contraception once they stopped having menses.

Documenting an epidemic of suffering: low health-related quality of life among transgender youth.

PURPOSE: To quantify HRQOL of TGN patients using the PedsQL 4.0 generic core scales, and to compare reported HRQOL of TGN adolescents with published data from comparison populations. METHODS: Transgender children and adolescents (N = 142; 68% natal females) ages 6-23 years (M = 15.9, SD = 3.7) attending an outpatient clinic for TGN care at an academic pediatric hospital and caregivers of children and adolescents (N = 95) completed the PedsQL 4.0 generic core scales. Scores were compared with published scores for healthy adolescents and adolescents with 10 chronic diseases. RESULTS: TGN youth reported significantly lower overall HRQOL (more than twice the clinically meaningful difference) compared to youth without chronic disease. Total self-reported TGN HRQOL (M(SD), 65.72(17.40)) was lower than all chronic disease comparison groups except for rheumatology and cerebral palsy. TGN youth reported physical functioning (M(SD), 75.33(22.87)) lower than or similar to chronically ill comparisons, but higher than rheumatology and cerebral palsy groups. Psychosocial functioning (M(SD), 59.87(17.83)) was lower than all comparison samples and similar to youth with cerebral palsy. Results were similar for parent proxy-reports of TGN youth HRQOL (LS means: 68.75; 95% CI 65.87-71.61 vs 66.16; 95% CI 62.87-69.45; p = 0.12). CONCLUSIONS: TGN youth reported low HRQOL across all domains; most were significantly lower than healthy peers or peers with chronic diseases. Clinicians should understand the magnitude of TGN youth's low HRQOL and offer them and their caregivers resources to maximize their ability to achieve their full potential for healthy and productive lives.

Health Concerns of Transgender and Gender Nonconforming Youth and Their Parents Upon Presentation to a Transgender Clinic.

PURPOSE: The purpose of the study was to determine the frequency of specific health concerns identified by transgender and gender nonconforming patients and their parents at initial clinic visit. METHODS: Checklists were developed in an iterative process and distributed to both patients and parents at their initial visit to a transgender clinic. Retrospective chart review and secondary data analyses were performed to determine the number of items endorsed, frequency with which each item was endorsed, and provider domain of each item endorsed: physician, social work, or both physician and social work. RESULTS: Checklists were collected from 118 patients and 103 parents. Patients endorsed a mean of 8.4 concerns (range 0-22) and parents 7.9 concerns (range 0-20). The most commonly endorsed patient concerns included use of gender-affirming hormones, steps for transition, gender-affirming surgery, restroom/dressing room use, and legal issues. Common parent concerns included general resources, child safety at school, acute mental health concerns, restroom/dressing room use, and steps for transition. Of the concerns endorsed by patients, 44% were in the social work domain, 37% in the physician domain, and 19% in both the social work and physician domain. Of the concerns endorsed by parents, 40% were in the social work domain, 31% in the physician domain, and 29% in the social work and physician domain. CONCLUSIONS: Although patients and parents had similar numbers of concerns, they primarily focused on different topics. Youth were more interested in hormones and transition, while parents were more interested with transition and acceptance. Many concerns for both patients and parents fell within the social work domain.

Screening for Spiritual Struggle in an Adolescent Transgender Clinic: Feasibility and Acceptability.

Spiritual struggles are associated with poorer health outcomes, including depression, which has higher prevalence among transgender individuals than the general population. This study's objective was to improve the quality of care in an outpatient transgender clinic by screening patients and caregivers for spiritual struggle and future intervention. The quality improvement questions addressed were whether screening for spiritual struggle was feasible and acceptable; and whether the sensitivity and specificity of the Rush Protocol were acceptable. Revision of the screening was based on cognitive interviews with the 115 adolescents and caregivers who were screened. Prevalence of spiritual struggle was 38-47%. Compared to the Negative R-COPE, the Rush Protocol screener had sensitivities of 44-80% and specificities of 60-74%. The Rush Protocol was acceptable to adolescents seen in a transgender clinic, caregivers, and clinic staff; was feasible to deliver during outpatient clinic visits, and offers a straightforward means of identifying transgender persons and caregivers experiencing spiritual struggle.

Emergency contraception.

Emergency contraception is increasing in use and has become a universal standard of care in the United States. This article reviews available forms of emergency contraception, their indications, contraindications, adverse effects and efficacy at preventing pregnancy. This article describes the mechanism of action of different forms of emergency contraception and provides recommendations on when to start or restart an ongoing method of contraceptive after emergency contraception use. Literature on the impact of the advance provision of emergency contraception on contracepting behaviors is reviewed, and behavior change counseling related to emergency contraception is described.

Emergency contraceptive pills: a review of the recent literature.

PURPOSE OF REVIEW: The purpose of this review is to inform the reader of new information published since early 2003 about emergency contraception, with a particular focus on issues of access. RECENT FINDINGS: Research continues to document low but increasing levels of knowledge about emergency contraception, increasing use, and more positive attitudes towards emergency contraception by both patients and healthcare providers. Additional information is available about efficacy and mechanisms of action. More reports of side-effects have been published, as have studies relating to the impact of emergency contraception on sexual and contracepting behaviors. Advance provision, provision by pharmacists, and over-the-counter status have been studied as ways to improve access to emergency contraception. SUMMARY: Knowledge about the efficacy, safety, types and use of emergency contraception continues to increase. Although patients have greater awareness of and more access to emergency contraception, there are still numerous barriers to its use even in countries where it is available over the counter. Healthcare providers must continue to educate themselves and their patients about emergency contraception even when it becomes available over the counter. In countries where emergency contraception is only available by prescription, providers should offer an advance prescription or supply (where available), and use newer dosing regimens for levonorgestrel-only emergency contraception to increase adherence and efficacy. Developing collaborative practice agreements with pharmacists to increase access is also recommended. Patients should be counseled to seek follow-up if no menses occurs within 3 weeks of taking emergency contraception or if symptoms such as lower abdominal pain occur after the use of emergency contraception.

Sexual function, sexual abuse and sexually transmitted diseases in adolescence.

As adolescents progress through puberty, many biological changes occur and, for young women, this includes the onset of menses and the capability for reproduction. During this time, sexual identity is developed and expressions of sexuality become more frequent. Adolescent women engage in a variety of sexual behaviours, both non-coital and coital. As teens begin dating relationships, they are at risk for dating violence and sexual abuse. Some may even be raped after sedation with a 'date rape' drug. As adolescents attempt to develop intimate sexual relationships, they may be at high risk for health consequences associated with sexual activity, such as pregnancy and sexually transmitted diseases (STDs). Providers, such as physicians, nurse practitioners, physician assistants and nurses, must know current STD diagnosis and treatment recommendations to decrease morbidity caused by these infections. By knowing how to interview, understanding legal issues and anticipating concerns pertinent to teens, providers have the opportunity to decrease barriers to health care for adolescents.

Pharmacists' attitudes toward and practices with adolescents.

BACKGROUND: Adolescents often face barriers to health care. As pharmacists' scope of practice expands, they may be in positions to decrease barriers to care for adolescents. OBJECTIVE: To describe pharmacists' attitudes toward and practices with adolescents. DESIGN: Cross-sectional self-administered survey of chief pharmacists at 1361 Indiana pharmacies. Survey items inquired about sociodemographic variables, adolescent-specific pharmacy practices, and training in adolescent health issues. SETTING: All active, licensed pharmacies in Indiana were surveyed. PARTICIPANTS: Nine hundred forty-eight surveys (70%) were returned. Sixty-five percent of responding pharmacists were male, 54% were younger than 45 years, and 58% had been practicing for more than 15 years; 47% practiced in areas with fewer than 30 000 people. MAIN OUTCOME MEASURES: Pharmacists' attitudes toward and practices with adolescents. RESULTS: The majority of pharmacists (94%) dispensed prescriptions for adolescents, but 57% felt inadequately trained in adolescent-specific issues. Forty-eight percent of pharmacies did not dispense emergency contraception. Pharmacists were more likely to report dispensing contraceptives directly to 17-year-olds than to 14-year-olds, and were more likely to report contacting a parent or provider before dispensing contraceptives to 14-year-olds. CONCLUSIONS: Adolescents often require pharmacy services, but many pharmacists feel inadequately trained in adolescent-specific issues. Confidentiality may not be maintained by all members of the health care team, and a prescription may be refused by the receiving pharmacist. Younger adolescents may face more barriers to care than older adolescents. Increasing pharmacists' knowledge and skills in adolescent issues, especially confidentiality, may decrease barriers to care and improve adolescent health outcomes.