Military Family Physicians' Readiness to Provide Gender-Affirming Care: A Serial Cross-Sectional Study.

PURPOSE: Family physicians are increasingly more likely to encounter transgender and gender-diverse (TGD) patients requesting gender-affirming care. Given the significant health inequities faced by the TGD community, this study aimed to assess changes in military-affiliated clinicians' perspectives toward gender-affirming care over time. METHODS: Using a serial cross-sectional survey design of physicians at the 2016 and 2023 Uniformed Services Academy of Family Physicians conferences, we studied participants' perception of, comfort with, and education on gender-affirming care using Fisher's Exact tests and logistic regression. RESULTS: Response rates were 68% (n = 180) and 69% (n = 386) in 2016 and 2023, respectively. Compared to 2016, clinicians in 2023 were significantly more likely to report receiving relevant education during training, providing care to >1 patient with gender dysphoria, and being able to provide nonjudgmental care. In 2023, 26% reported an unwillingness to prescribe gender-affirming hormones (GAH) to adults due to ethical concerns. In univariable analysis, female-identifying participants were more likely to report willingness to prescribe GAH (OR = 2.6, 95%CI = 1.7-4.1) than male-identifying participants. Willingness to prescribe was also associated with ≥4 h of education (OR = 2.2, 95%CI = 1.1-4.2) compared to those with fewer than 4 h, and those who reported the ability to provide nonjudgmental care compared to those who were neutral (OR = 0.09, 95%CI = 0.04-0.2) or disagreed (OR = 0.11, 95%CI = 0.03-0.39). Female-identifying clinicians were more likely to agree additional training would benefit their practice (OR = 5.3, 95%CI = 3.3-8.5). CONCLUSIONS: Although military-affiliated family physicians endorsed more experience with and willingness to provide nonjudgmental gender-affirming care in 2023 than 2016, profound gaps in patient experience may remain based on the assigned clinician. Additional training opportunities should be available, and clinicians unable to provide gender-affirming care should ensure timely referrals. Future research should explore trends across clinical specialties.

Incidence and prevalence of eating disorders among U.S. military service members, 2016-2021.

OBJECTIVE: Despite unique experiences that may increase eating disorder risk, U.S. military service members are an understudied population. The current study examined incidence and prevalence of eating disorder diagnoses in U.S. military personnel. METHOD: This retrospective cohort study utilized Military Health System Data Repository (MDR) data on eating disorder diagnoses (2016-2021). Active duty, Reserve, and National Guard U.S. military service members who received care via TRICARE Prime insurance were identified by ICD-10 eating disorder diagnostic codes. RESULTS: During the 6-year surveillance period, 5189 Service members received incident eating disorders diagnoses, with a crude overall incidence rate of 6.2 cases per 10,000 person-years. The most common diagnosis was other/unspecified specified eating disorders, followed by binge-eating disorder, bulimia nervosa, and anorexia nervosa. There was an 18.5% overall rise in total incident cases across the surveillance period, but this trend was not statistically significant (p = 0.09). Point prevalence significantly increased across the 6-year timeframe for total eating disorders (p < 0.001). Period prevalence for 6-year surveillance period was 0.244% for total eating disorders, 0.149% for other/unspecified eating disorder, 0.043% for bulimia nervosa, 0.038% for binge-eating disorder, and 0.013% for anorexia nervosa. DISCUSSION: Overall crude incidence estimates for total eating disorders were higher than reported in prior research that included only active duty Service members and required an eating disorder diagnosis code in the first or second diagnostic position of the medical record. Comprehensive and confidential studies are needed to more thoroughly characterize the nature and scope of eating disorder symptomatology within U.S. military personnel. PUBLIC SIGNIFICANCE: U.S. military service members are a vulnerable population with regard to eating disorder symptoms. Previously reported incidence and prevalence estimates using data from the Military Health System may have been underestimated due to overly stringent case definitions. Given personal and occupational barriers (e.g., career consequences), confidential studies of military personnel may provide more complete data on the scope of eating disorders to inform screening and clinical practice guidelines for military populations.

Variation in Time-to-Gender-Affirming Hormone Therapy in US Active Duty Service Members.

BACKGROUND: Beginning in July 2016, transgender service members in the US military were allowed to receive gender-affirming medical care, if so desired. OBJECTIVE: This study aimed to evaluate variation in time-to-hormone therapy initiation in active duty Service members after the receipt of a diagnosis indicative of gender dysphoria in the Military Health System. RESEARCH DESIGN: This retrospective cohort study included data from those enrolled in TRICARE Prime between July 2016 and December 2021 and extracted from the Military Health System Data Repository. PARTICIPANTS: A population-based sample of US Service members who had an encounter with a relevant International Classification of Diseases 9/10 diagnosis code. MEASURES: Time-to-gender-affirming hormone initiation after diagnosis receipt. RESULTS: A total of 2439 Service members were included (M age 24 y; 62% white, 16% Black; 12% Latine; 65% Junior Enlisted; 37% Army, 29% Navy, 25% Air Force, 7% Marine Corps; 46% first recorded administrative assigned gender marker female). Overall, 41% and 52% initiated gender-affirming hormone therapy within 1 and 3 years of diagnosis, respectively. In the generalized additive model, time-to-gender-affirming hormone initiation was longer for Service members with a first administrative assigned gender marker of male relative to female ( P <0.001), and Asian and Pacific Islander ( P =0.02) and Black ( P =0.047) relative to white Service members. In time-varying interactions, junior enlisted members had longer time-to-initiation, relative to senior enlisted members and junior officers, until about 2-years postinitial diagnosis. CONCLUSION: The significant variation and documented inequities indicate that institutional data-driven policy modifications are needed to ensure timely access for those desiring care.

Emotional dysregulation moderates the relation between perceived stress and emotional eating in adolescent military dependents.

OBJECTIVE: Adolescent children of US service members (i.e., military-dependent youth) face unique stressors that increase risk for various forms of disinhibited eating, including emotional eating. Difficulties with adaptively responding to stress and aversive emotions may play an important role in emotional eating. This study examined emotion dysregulation as a potential moderator of the association between perceived stress and emotional eating in adolescent military dependents. METHOD: Participants were military-dependent youth (N = 163, 57.7% female, Mage = 14.5 ± 1.6, MBMI-z = 1.9 ± 0.4) at risk for adult binge-eating disorder and high weight enrolled in a randomized controlled prevention trial. Prior to intervention, participants completed questionnaires assessing perceived stress and emotional eating. Parents completed a questionnaire assessing their adolescent's emotion dysregulation. Moderation analyses were conducted using the PROCESS macro in SPSS and adjusted for theoretically relevant sociodemographic covariates. RESULTS: The interaction between adolescent perceived stress and emotion dysregulation (parent-reported about the adolescent) in relation to adolescent emotional eating was found to be significant, such that higher emotion dysregulation magnified the association between perceived stress and emotional eating (p = .010). Examination of simple slopes indicated that associations between perceived stress and emotional eating were strongest for youth with above-average emotion dysregulation, and non-significant for youth with average or below-average emotion dysregulation. DISCUSSION: Findings suggest that greater emotion dysregulation may increase risk for emotional eating in response to stress among military-dependent youth at risk for binge-eating disorder or high weight. Improving emotion regulation skills may be a useful target for eating disorder prevention among youth who are at risk for emotional eating. PUBLIC SIGNIFICANCE: Prior research has shown that adolescent military dependents are at increased risk for eating disorders and high weight. The current study found that emotion dysregulation moderated the relationship between perceived stress and emotional eating among military-dependent youth. There may be clinical utility in intervening on emotion regulation for adolescent dependents at particular risk for emotional eating and subsequent eating disorders.

Associated features of pediatric loss-of-control eating severity during a laboratory-based feeding paradigm.

Laboratory-based loss-of-control eating (LOC-eating; i.e., feeling like one cannot stop eating) paradigms have provided inconsistent evidence that the features of pediatric LOC-eating are consistent with those of DSM-5-TR binge-eating episodes. Thus, this study investigated whether recent LOC-eating (in the prior month) and/or greater LOC-eating severity during a meal are positively associated with faster eating rate, energy intake when adjusting for hunger, post-meal stomachache and sickness (a proxy for eating until uncomfortably full), depression, and guilt. Recent LOC-eating was assessed via interview. Participants were presented with a buffet-type meal and instructed to "Let yourself go and eat as much as you want." Immediately following, youth reported on their experience of LOC-eating during the meal (LOC-eating severity). Eating rate (kcal/min) was computed by dividing total energy intake by the duration of the meal. Prior to and following the meal, youth reported hunger, sickness, and stomachache via sliding Visual Analog Scales, depression via the Brunel Mood Scale and guilt via the PANAS-X. Three-hundred-ten youth participated (61.2 % Female; 46.3 % non-Hispanic White, 12.96 ± 2.72 y). Recent LOC-eating was not significantly associated with any DSM-5-TR binge-eating feature during the laboratory meal (ps = 0.07-0.85). However, LOC-eating severity during the meal was positively associated with eating rate, eating adjusted for hunger, post-meal sickness and stomachache, and guilt (ps < 0.045). LOC-eating severity during a laboratory-based feeding paradigm meal, but not recent LOC-eating, was associated with several features of DSM-5-TR binge-eating episodes. Future studies should assess multiple components of LOC-eating to further characterize the phenomenology of pediatric LOC-eating.

Incidence and prevalence of eating disorders among active duty US military-dependent youth from 2016 to 2021.

OBJECTIVE: The offspring of US military service members may be at increased risk for eating disorders. However, no epidemiological studies to date have evaluated eating disorder incidence rates and prevalence estimates among military-dependent youth. METHOD: This retrospective cohort study examined eating disorder diagnoses in the military healthcare system (MHS) from 2016 through 2021. Active duty and national guard military-dependent youth, aged 10-17 years, who received care in the MHS via TRICARE Prime insurance, were identified by one or more ICD-10 codes indicative of an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, binge-eating disorder, and other-specified eating disorders). RESULTS: During the 6-year surveillance period, 2534 dependents received incident diagnoses of eating disorders, with a crude overall incidence rate of 1.75 cases per 10,000 person-years. The most common diagnosis was other-specified eating disorder, followed by anorexia nervosa, bulimia nervosa, and binge-eating disorder. The crude annual incidence rate of all eating disorder diagnoses increased by nearly 65% from 2016 to 2021. Rates for all diagnoses were highest in 2020 and 2021. Period prevalence estimates were .08% for any eating disorder diagnosis, .01% for anorexia nervosa, .004% for bulimia nervosa, .004% for binge-eating disorder, and .06% for other-specified eating disorders. DISCUSSION: The observed increase in eating disorder diagnoses during the surveillance period appeared to be driven by female dependents. More military dependents experienced a new-onset diagnosis during the COVID-19 pandemic compared to previous years. These findings highlight the need for eating disorder screening, identification, and treatment for dependents within the MHS. PUBLIC SIGNIFICANCE STATEMENT: Children of US military service members may be at increased risk for eating disorders. Results indicate new-onset eating disorder cases increased 65% from 2016 to 2021, primarily among girls compared to boys. The most diagnosed and fastest growing diagnosis was other-specified eating disorder. Rates of anorexia nervosa increased following the COVID-19 pandemic. Findings highlight the need for eating disorder screening, identification, and treatment within the military healthcare system.

Longitudinal Associations Between Perceived Discrimination and Suicidality in Youth.

Research among adults reveals robust associations between discrimination and suicidality. However, the relationship between discrimination and suicidality is understudied in youth. Participants in the Adolescent Brain Cognitive Development study (n = 10  312) completed a measure of discrimination based on multiple attributes. The Kiddie Schedule for Affective Disorders and Schizophrenia was administered 1 year later to assess depressive disorders and suicidality (ideation and behavior). Logistic regressions, adjusting for age, sex, race/ethnicity, family income, lifetime depressive disorders, and body composition were conducted. Adjusting for covariates, discrimination based on weight (OR: 2.19), race/ethnicity/color (OR: 3.21), and sexual orientation (OR: 3.83) were associated with greater odds of reporting suicidality 1 year later (ps < 0.025). Nationality-based discrimination was not significantly associated with suicidality. Compared with those reporting no discrimination, youths reporting discrimination based on 2 or more attributes had nearly 5 times greater odds of recent suicidality (OR: 4.72; P < .001). The current study highlights the deleterious impacts of discrimination on mental health among youths reporting multiple forms of discrimination.

The prospective relationship between weight-based discrimination and eating pathology among youth.

Among adults and adolescents, weight-based discrimination is associated with disordered eating. However, these relationships remain understudied in children. Given that weight-based discrimination is commonly reported among youth, and that childhood is a crucial developmental period for the onset of disordered eating, the current study assessed prospective associations between weight-based discrimination and eating pathology among participants in the Adolescent Brain Cognitive Development Study. At the one-year visit, children indicated whether they had experienced discrimination due to their weight within the past year. Parents completed a computerized clinical interview to determine the presence of sub-or-full threshold eating disorders (AN, BN, and BED) among their children. At the two-year visit, children completed the same assessment. Height and fasting weight were obtained. Logistic regressions, adjusting for age, sex, race/ethnicity, family income, BMI%ile, and parent-reported presence of the respective eating disorder at one-year, were conducted to assess the associations between weight-based discrimination and eating pathology. Participants were 10,299 children who completed measures at both the one- and two-year visits (Mage at one-year: 10.92 ± 0.64, 47.6 % female, 45.9 % racial/ethnic minority). The presence of weight-based discrimination, reported by 5.6 % (n = 574) of children, was significantly associated with a greater likelihood of reporting AN, BN, and BED one-year later (ORs: 1.94-4.91). Findings suggest that weight-based discrimination may confer additional risk for the onset of disordered eating, above and beyond the contribution of body weight. Intersectional research is needed to examine the role of multiple forms of discrimination in relation to the development of eating pathology.

Parents of children with high weight and disordered eating: Commentary on Wilksch (2023).

In Wilksch (International Journal of Eating Disorders, 2023), survey results from parents of youth with eating disorders (EDs) indicate that parents are often the first to detect their children's ED symptoms, and that they face barriers in accessing appropriate, timely treatment, and experience emotional and financial strain. Wilksch highlights gaps in research and practice, and identifies recommendations to mitigate them. We propose prioritizing similar recommendations for parents of children with higher weight (HW). As EDs and body size are often inextricably entwined, our recommendations involve consideration of both eating- and weight-related impacts. The fields of EDs and HW tend to work independently; as a result, disordered eating, HW, and the convergence of the two, are often overlooked or unaddressed in children. We recommend the prioritization of research, practice, training, and advocacy for youth with HW and their parents. We propose evidence-based ED screening in youth across the weight spectrum, developing and testing therapies to address both EDs and HW concurrently, training more providers to deliver established interventions, reducing weight-based stigmatization and parental blame, and advocating for policies that protect children with HW and their families. Finally, we urge policymakers to ensure financial coverage of early intervention to prevent adverse eating and weight-related outcomes in youth.

Practical Considerations for Using the Eating Disorder Examination Interview with Adolescents.

Approximately 35 years after its initial publication, the Eating Disorder Examination (EDE) remains one of the most widely used semi-structured interviews for assessing eating disorder diagnoses and symptomatology. Although the interview provides certain advantages over other common measurement approaches (ie, questionnaires), there are particular considerations regarding the EDE that warrant attention, including in its use with adolescents. The aims of this paper are therefore to: 1) provide a brief overview of the interview itself, as well as a description of its origin and underlying conceptual framework; 2) describe relevant factors for administering the interview with adolescents; 3) review potential limitations regarding use of the EDE with adolescents; 4) address considerations for using the EDE with pertinent subpopulations of adolescents who may experience distinct eating disorder symptoms and/or risk factors; and 5) discuss the integration of self-report questionnaires with the EDE. Advantages of using the EDE include the ability for interviewers to clarify complex concepts and mitigate inattentive responding, enhanced orientation to the interview timeframe to improve recall, increased diagnostic accuracy compared to questionnaires, and accounting for potentially salient external factors (eg, food/eating rules imposed by a parent/guardian). Limitations include more extensive training requirements, greater assessment burden, variable psychometric performance across subgroups, lack of items evaluating muscularity-oriented symptoms and avoidant/restrictive food intake disorder diagnostic criteria, and lack of explicit consideration for salient risk factors other than weight and shape concerns (eg, food insecurity).

The Relationship Between Anxiety, Coping, and Disordered-Eating Attitudes in Adolescent Military-Dependents at High-Risk for Excess Weight Gain.

Adolescent military-dependents are an understudied population who face unique stressors due to their parents' careers. Research suggests that adolescent military-dependents report more anxiety and disordered-eating than their civilian counterparts. While anxiety symptoms predict the onset and worsening of disordered-eating attitudes, the mechanisms underlying this relationship remain unclear. One factor that may underlie this relationship, and be particularly relevant for military-dependent youth, is coping. Therefore, we examined adolescent military-dependents (N=136; 14.5±1.5 years; 59.6% female; BMI-z: 1.9±0.4) who were at-risk for adult obesity and binge-eating disorder due to an age- and sex-adjusted BMI ≥ 85th percentile and loss-of-control eating and/or elevated anxiety. Participants completed an interview assessing disordered-eating attitudes and questionnaires on anxiety symptoms and coping strategies at a single time point. Bootstrapping models were conducted to examine the indirect paths between anxiety symptoms and disordered-eating attitudes through five coping subscales (aggression, distraction, endurance, self-distraction, and stress-recognition). Adjusting for relevant covariates, no significant indirect paths through the coping subscales (ps > .05) were found in any models. General coping, non-specific to eating, may not be a pathway between anxiety symptoms and disordered-eating attitudes among adolescents. Future research should examine other potential mediators of this relationship.

Negative affect and loss-of-control eating in relation to adiposity among non-Hispanic youth identifying as black or white.

Negative affect and loss-of-control (LOC)-eating are consistently linked and prevalent among youth identifying as non-Hispanic Black (NHB) and non-Hispanic White (NHW), particularly those with high weight. Given health disparities in high weight and associated cardiometabolic health concerns among NHB youth, elucidating how the association of negative affect with adiposity may vary by racial/ethnic group, and whether that relationship is impacted by LOC-eating, is warranted. Social inequities and related stressors are associated with negative affect among NHB youth, which may place this group at increased risk for excess weight gain. Across multiple aggregated protocols, 651 youth (13.0 ± 2.7 y; 65.9 % girls, 40.7 % NHB; 1.0 ± 1.1 BMIz; 37.6 % LOC-eating) self-reported trait anxiety and depressive symptoms as facets of negative affect. LOC-eating was assessed by interview and adiposity was measured objectively. Cross-sectional moderated mediation models predicted adiposity from ethno-racial identification (NHB, NHW) through the pathway of anxiety or depressive symptoms and examined whether LOC-eating influenced the strength of the pathway, adjusting for SES, age, height, and sex. The association between ethno-racial identity and adiposity was partially mediated by both anxiety (95 % CI = [0.01, 0.05]) and depressive symptoms (95 % CI = [0.02, 0.08]), but the mediation was not moderated by LOC-eating for either anxiety (95 % CI = [-0.04, 0.003]) or depressive symptoms (95 % CI = [-0.07, 0.03]). Mechanisms underlying the link between negative affect and adiposity among NHB youth, such as stress from discrimination and stress-related inflammation, should be explored. These data highlight the need to study impacts of social inequities on psychosocial and health outcomes.

Stigma and Barriers in Health Care Among a Sample of Transgender and Gender-Diverse Active Duty Service Members.

BACKGROUND: Transgender and/or gender-diverse (TGD) persons are vulnerable to stigma and health care inequities; however, data are particularly limited among TGD active duty military service members despite ongoing changes to service policies. TGD-related stressors may impede access to and utilization of health care due to fear of potential discrimination and distress, thereby adversely impacting military readiness. METHODS: We examined stigma and barriers in health care and associations with physical and mental health in an online sample of 177 active duty service members who self-identified as TGD. To assess associations between stigma and barriers in health care with mental and physical health, linear regressions were conducted adjusting for age, gender identity, race, and rank. RESULTS: Over half (65%) of the participants reported at least 1 instance of stigma and/or barrier in health care. Stigma and barriers to health care were significantly associated with greater self-reported depressive symptoms (ß=0.20, P =0.03), anxiety (ß=0.21, P =0.03), stress (ß=0.30, P =0.001), and poorer overall mental health (ß=-0.23, P =0.007), after adjusting for covariates. Nearly one-quarter of participants had not disclosed their gender identity to their primary care clinician. CONCLUSIONS: Findings suggested that stigma and barriers to affirming health care were prevalent among active duty service members identifying as TGD, specifically, difficulty accessing gender-affirming care and negative assumptions from clinicians. These experiences may adversely affect mental health and impede the quality of health care received by a population already vulnerable to health inequities. Given recent changes to military policy, efforts may be warranted to improve access to timely, affirming care and clinician training.

Prescriptions of Psychotropic Medications by Providers Treating Children of Military Service Members.

INTRODUCTION: There are approximately 1.5 million U.S. military-dependent children. However, little is known about mental health referrals for these youths. This study sought to examine the type of mental health treatment referrals made by primary care providers for child military-dependent beneficiaries receiving care in the direct (within Military Treatment Facilities) and private care (civilian-fee-for service facilities) sectors of the Military Health System. MATERIALS AND METHODS: A between-subjects, cross-sectional study was performed on children aged 5-18 years old in fiscal years 2011-2015 and enrolled in TRICARE Prime. Study analyses examined specialty ("talk therapy") mental health care and psychotropic medication referrals from TRICARE Prime (the Defense Health Agency-managed health care program) providers for beneficiary children diagnosed with attention-, mood-, anxiety-, or behavior-related disorders in direct versus private sector care. RESULTS: Of 1,533,630 children enrolled in TRICARE Prime (50.03% female), 8.6% (n = 131,393) were diagnosed with a psychological disorder during FY 2011-2015. Most were attention-related (5.2%, n = 79,770), followed by mood (1.7%, n = 25,314), anxiety (1.1%, n = 16,155), and conduct-related diagnoses (0.7%, n = 10,154). Adjusting for age, sex, and sponsor rank, children within direct care diagnosed with attention-related disorders were 1.7 times more likely to receive a prescription for psychotropic medication than those in private sector care, odds ratio (OR) = 1.72, 95% confidence interval (CI): [1.66, 1.77]. Children diagnosed with mood-related disorders in direct care were 2.1 times more likely to receive a prescription for psychotropic medication than those in private sector care, OR = 2.08, 95% CI: [1.96, 2.21]. Across disorders, children who received private sector care were more likely to have a referral specialty mental health ("talk therapy") follow-up (ps < 0.0001). CONCLUSIONS: For attention- and mood-related disorders, but not anxiety- or conduct-related disorders, direct care providers were more likely than private sector care providers to prescribe psychotropic medications. Inconsistencies of provider referrals within and outside of the Military Health System should be elucidated to determine the impact on outcomes.

Help-seeking among psychiatrically hospitalized military personnel at risk for suicide.

INTRODUCTION: Promoting help-seeking is a key suicide prevention strategy. Yet, research on help-seeking patterns by high-risk individuals is limited. This study examined help-seeking among United States military Service members admitted for psychiatric inpatient care. METHODS: Participants were active duty Service members (N = 111) psychiatrically hospitalized for a suicide-related event. Data were collected as part of a larger randomized controlled trial. Reported types and perceived helpfulness of resources sought 30 days before hospitalization were examined. Hierarchical binary logistic regressions were used to examine associations among types of helping resources, mental health treatment stigma, and perceived social support. RESULTS: Approximately 90% of participants sought help prior to hospitalization, most frequently from behavioral health providers and friends. Accessed resources were generally considered helpful. Adjusting for covariates, mental health treatment stigma was not associated with seeking help from any resource type. Higher perceived social support was associated with greater likelihood of help-seeking from a friend (OR = 1.08, p = 0.013 [95% CI = 1.02, 1.14]). Marital status, education level, and organizational barriers were associated with specific types of resources, and/or not seeking help. CONCLUSION: Help-seeking is a complex human behavior. Promoting help-seeking among vulnerable subgroups requires further understanding of multiple interconnected factors.

The Mediating Role of Family Acceptance and Conflict on Suicidality among Sexual and Gender Minority Youth.

INTRODUCTION: Prior research suggests sexual and gender minority (SGM) youth are profoundly impacted by levels of parental support. This study assessed mediating effects of generalized family acceptance and conflict on lifetime suicidal behaviors among a large diverse sample comprising both SGM and non-SGM youth in early adolescence, when intervention to optimize family dynamics may be critical. MATERIALS: Using data from the first-year follow-up of the Adolescent Brain Cognitive Development Study based in the United States, mediation was tested using a binary logistic regression model fitted with a generalized structural equation. Models included SGM status as the independent variable, family acceptance or family conflict sum score as the mediator, and the presence of lifetime suicidal behaviors as the dependent variable. Models adjusted for age, birth-assigned sex (as reported by the parent/guardian), and race/ethnicity. RESULTS: Of 11,235 youths, lifetime suicidal behaviors were reported by 1.5% (n = 164). Youths with SGM identities reported 40% less parental acceptance and 47% greater family conflict, compared to non-SGM peers. Both parental acceptance and family conflict partially mediated associations between SGM identification and odds of lifetime suicidal behavior (ps = .001). CONCLUSIONS: Identification of modifiable risk factors for suicidality in this vulnerable population, including parental acceptance and family conflict, is critical to improving health outcomes. Clinicians should work with SGM youth and their families starting in childhood to optimize family dynamics and bolster acceptance to potentially reduce adverse health outcomes. HIGHLIGHTSYouths with SGM identity reported 40% less parental acceptance than non-SGM peers.Parental acceptance was associated with lower odds of lifetime suicidal behaviors.Family factors partially mediated associations between SGM status and suicidal behaviors.

Association of Gonadotropin-Releasing Hormone Analogue Use With Subsequent Use of Gender-Affirming Hormones Among Transgender Adolescents.

Importance: Gonadotropin-releasing hormone analogue (GnRHa) use during puberty improves mental health among transgender and gender-diverse (TGD) adolescents. In previous studies, most (96.5%-98.1%) TGD adolescents who started GnRHa subsequently started gender-affirming hormones (GAH), raising concerns that GnRHa use promotes later use of GAH. Objective: To determine whether GnRHa use among TGD adolescents is associated with increased subsequent GAH use. Design, Setting, and Participants: This is a retrospective cohort study of administrative records collected between 2009 and 2018. The current analysis was completed in August 2022. Participants were enrolled in the US Military Healthcare System (MHS) with an initial TGD-related encounter occurring between ages 10 and 17 years. Exposures: GnRHa use. Main Outcomes and Measures: Initiation of GAH. Results: The 434 patients were a mean (SD) of 15.4 (1.6) years old at the time of their first TGD-related encounter; 312 (71.9%) were assigned female at birth, and 300 (69.1%) had an enlisted insurance sponsor. GnRHa use was more common among patients who were assigned male at birth (28 patients [23.0%]) than those assigned female (42 patients [13.5%]), but GAH use was not. Socioeconomic status was not associated with GnRHa or GAH use. Compared with older patients (aged 14-17 years), those who were younger (aged 10-13 years) at the time of the initial TGD-related encounter had a higher rate of GnRHa use (32 patients [57.1%] vs 38 patients [10.1%]) and a longer median time to starting GAH. The median interval from the date of the initial encounter to starting GAH decreased over time, from 2.3 years (95% CI, 1.7-2.8 years) between October 2009 and December 2014 to 0.6 years (95% CI, 0.5-0.6 years) between September 2016 and April 2018. Patients who were prescribed GnRHa had a longer median time to starting GAH (1.8 years; 95% CI, 1.1-2.4 years) than patients who were not (1.0 years; 95% CI, 0.8-1.2 years) and were less likely to start GAH during the 6 years after their first TGD-related encounter (hazard ratio, 0.52; 95% CI, 0.37-0.71). Among 54 younger (aged 10-13 years) patients who were not eligible to start GAH at their first encounter, GnRHa use was associated with a longer median time to starting GAH, but age at the first TGD-related visit was not. Conclusions and Relevance: In this cohort study of TGD adolescents, GnRHa use was not associated with increased subsequent GAH use. These findings suggest that clinicians can offer the benefits of GnRHa treatment without concern for increasing rates of future GAH use.

Heart Rate Variability and Laboratory-Based Loss-of-Control Eating in Children and Adolescents.

Among youth, greater heart rate (HR) and lesser HR variability (HRV) are precursors to loss-of-control (LOC) eating episodes in the natural environment. However, there are limited data examining whether pre-meal HR and HRV are associated with greater LOC-eating in the laboratory setting. We therefore examined temporal relationships between pre-meal HR, frequency- and time-based metrics of pre-meal HRV, perceived LOC-eating, and energy intake during a meal designed to simulate a LOC-eating episode. Among 209 participants (54.5% female, 12.58 ± 2.72 years, 0.52 ± 1.02 BMIz), 19 reported LOC-eating in the prior month. Perceived LOC-eating during the laboratory meal was not significantly linked to pre-meal HR (p = 0.37), but was positively related to pre-meal HRV (ps = 0.02-0.04). This finding was driven by youth with recent LOC-eating, as these associations were not significant when analyses were run only among participants without recent reported LOC-eating (p = 0.15-0.99). Pre-meal HR and HRV were not significantly related to total energy intake (ps = 0.27-0.81). Additional research is required to determine whether early-stage pediatric LOC-eating is preceded by a healthy pre-meal stress response. Longitudinal studies could help clarify whether this pattern becomes less functional over time among youth who develop recurrent LOC-eating episodes.

Associations among alexithymia, disordered eating, and depressive symptoms in treatment-seeking adolescent military dependents at risk for adult binge-eating disorder and obesity.

PURPOSE: Evidence suggests that difficulties identifying and describing one's feelings, core components of alexithymia, are associated with attitudinal and behavioral symptoms of disordered eating; depressive symptoms also may underlie these associations. Specifically, research indicates that alexithymia is positively related to depressive symptoms, which in turn may promote both disordered-eating attitudes and certain disinhibited-eating behaviors (e.g., emotional eating). Findings also suggest that military-dependent youth with high weight may exhibit elevated depressive symptoms and disordered eating. As such, understanding associations among alexithymia, depressive symptoms, and disordered eating is particularly relevant for this vulnerable population. METHODS: We examined 149 adolescent military dependents (14.4 ± 1.6y; 55.0% female; 20.0% non-Hispanic Black; BMIz: 1.9 ± 0.4) at high risk for binge-eating disorder and obesity in adulthood. Participants completed questionnaires assessing two components of alexithymia (difficulty identifying feelings [DIF] and difficulty describing feelings [DDF]), depressive symptoms, emotional eating, and trait anxiety; disordered-eating attitudes were assessed via semi-structured interview. RESULTS: A series of regression-based models examined indirect relationships of DIF and DDF with disordered-eating attitudes and emotional eating through depressive symptoms. Bootstrapped 95% confidence intervals revealed a significant indirect path from each of the alexithymia components to disordered-eating attitudes via depressive symptoms; indirect paths to emotional eating were non-significant. CONCLUSION: Results support the salience of depressive symptoms in the relationship between alexithymia and disordered-eating attitudes. Future research should utilize prospective designs and explore direct and indirect associations of alexithymia with other disordered-eating behaviors. LEVEL OF EVIDENCE: Level III, evidence obtained from a well-designed cohort study.