Estimating biotic integrity to capture existence value of freshwater ecosystems.

The US Environmental Protection Agency (EPA) uses a water quality index (WQI) to estimate benefits of proposed Clean Water Act regulations. The WQI is relevant to human use value, such as recreation, but may not fully capture aspects of nonuse value, such as existence value. Here, we identify an index of biological integrity to supplement the WQI in a forthcoming national stated preference survey that seeks to capture existence value of streams and lakes more accurately within the conterminous United States (CONUS). We used literature and focus group research to evaluate aquatic indices regularly reported by the EPA's National Aquatic Resource Surveys. We chose an index that quantifies loss in biodiversity as the observed-to-expected (O/E) ratio of taxonomic composition because focus group participants easily understood its meaning and the environmental changes that would result in incremental improvements. However, available datasets of this index do not provide the spatial coverage to account for how conditions near survey respondents affect their willingness to pay for its improvement. Therefore, we modeled and interpolated the values of this index from sampled sites to 1.1 million stream segments and 297,071 lakes across the CONUS to provide the required coverage. The models explained 13 to 36% of the variation in O/E scores and demonstrate how modeling can provide data at the required density for benefits estimation. We close by discussing future work to improve performance of the models and to link biological condition with water quality and habitat models that will allow us to forecast changes resulting from regulatory options.

Random Forest models to estimate bankfull and low flow channel widths and depths across the conterminous United States.

Channel dimensions (width and depth) at varying flows influence a host of instream ecological processes, as well as habitat and biotic features; they are a major consideration in stream habitat restoration and instream flow assessments. Models of widths and depths are often used to assess climate change vulnerability, develop endangered species recovery plans, and model water quality. However, development and application of such models require specific skillsets and resources. To facilitate acquisition of such estimates, we created a dataset of modeled channel dimensions for perennial stream segments across the conterminous U.S. We used random forest models to predict wetted width, thalweg depth, bankfull width, and bankfull depth from several thousand field measurements of the National Rivers and Streams Assessment. Observed channel widths varied from <5 m to >2000 m and depths varied from <2 m to >125 m. Metrics of watershed area, runoff, slope, land use, and more were used as model predictors. The models had high pseudo R-squared values (0.70 to 0.91) and median absolute errors within ±6% to ±21% of the interquartile range of measured values across ten stream orders. Predicted channel dimensions can be joined to 1.1 million stream segments of the 1:100K resolution National Hydrography Dataset Plus (version 2.1). These predictions, combined with a rapidly growing body of nationally available data, will further enhance our ability to study and protect aquatic resources.

Wetland Flowpaths Mediate Nitrogen and Phosphorus Concentrations across the Upper Mississippi River Basin.

Eutrophication, harmful algal blooms, and human health impacts are critical environmental challenges resulting from excess nitrogen and phosphorus in surface waters. Yet we have limited information regarding how wetland characteristics mediate water quality across watershed scales. We developed a large, novel set of spatial variables characterizing hydrological flowpaths from wetlands to streams, that is, "wetland hydrological transport variables," to explore how wetlands statistically explain the variability in total nitrogen (TN) and total phosphorus (TP) concentrations across the Upper Mississippi River Basin (UMRB) in the United States. We found that wetland flowpath variables improved landscape-to-aquatic nutrient multilinear regression models (from R2 = 0.89 to 0.91 for TN; R2 = 0.53 to 0.84 for TP) and provided insights into potential processes governing how wetlands influence watershed-scale TN and TP concentrations. Specifically, flowpath variables describing flow-attenuating environments, for example, subsurface transport compared to overland flowpaths, were related to lower TN and TP concentrations. Frequent hydrological connections from wetlands to streams were also linked to low TP concentrations, which likely suggests a nutrient source limitation in some areas of the UMRB. Consideration of wetland flowpaths could inform management and conservation activities designed to reduce nutrient export to downstream waters.

Geospatial Patterns of Antimicrobial Resistance Genes in the US EPA National Rivers and Streams Assessment Survey.

Antimicrobial resistance (AR) is a serious global problem due to the overuse of antimicrobials in human, animal, and agriculture sectors. There is intense research to control the dissemination of AR, but little is known regarding the environmental drivers influencing its spread. Although AR genes (ARGs) are detected in many different environments, the risk associated with the spread of these genes to microbial pathogens is unknown. Recreational microbial exposure risks are likely to be greater in water bodies receiving discharge from human and animal waste in comparison to less disturbed aquatic environments. Given this scenario, research practitioners are encouraged to consider an ecological context to assess the effect of environmental ARGs on public health. Here, we use a stratified, probabilistic survey of nearly 2000 sites to determine national patterns of the anthropogenic indicator class I integron Integrase gene (intI1) and several ARGs in 1.2 million kilometers of United States (US) rivers and streams. Gene concentrations were greater in eastern than in western regions and in rivers and streams in poor condition. These first of their kind findings on the national distribution of intI1 and ARGs provide new information to aid risk assessment and implement mitigation strategies to protect public health.

Transgender Youth Executive Functioning: Relationships with Anxiety Symptoms, Autism Spectrum Disorder, and Gender-Affirming Medical Treatment Status.

Executive function (EF) underlies broad health and adaptive outcomes. For transgender youth, navigating gender discernment and gender affirmation demand EF. Yet, factors associated with transgender youth EF are unknown. We investigate hypothesized predictors of EF: over-represented conditions among transgender youth (anxiety and depression symptoms, autism spectrum disorder [ASD]) and gender-affirming care. One-hundred twenty-four transgender 11-21-year-olds participated. Parents/caregivers completed EF and mental health report measures. ASD diagnostics and gender-affirming medication histories were collected. 21 % of non-autistic and 69 % of autistic transgender youth had clinically elevated EF problems. Membership in the gender-affirming hormone treatment group was associated with better EF. ASD, anxiety symptoms, and membership in the long-duration pubertal suppression group were associated with poorer EF. Given the importance of EF skills for multiple outcomes, and the unique and additional EF demands specific to transgender youths' experiences, EF skill monitoring-and when appropriate, supports-should be considered for transgender youth.

Parsing Weather Variability and Wildfire Effects on the Post-Fire Changes in Daily Stream Flows : A Quantile-Based Statistical Approach and its Application.

Determining wildland fire impacts on streamflow can be problematic as the hydrology in burned watersheds is influenced by post-fire weather conditions. This study presents a quantile-based analytical framework for assessing fire impacts on low and peak daily flow magnitudes, while accounting for post-fire weather influences. This framework entails (a) the bootstrap method to compute the relative change in the post-fire annual flow and weather statistics, (b) Double Mass analysis to detect if post-fire baseflow and quick flow yield ratios are significantly altered, and (c) a quantile regression method to parse fire effects on flow at a specific quantile. We illustrate the applicability of this analytical framework using 44 western US streams with at least 5% of their watershed area burned. Results indicate that large, high-severity burns in upland watersheds can raise the streamflow magnitude at the 0.05 th and 0.95 th quantiles for at least the five post-fire years. Quantile regression results show that the median fire-related increase in flow for the five post-fire years can be up to 5000% (Standard Error; SE < 2%) at the 0.05 th quantile and 161% (SE < 10%) at the 0.95 th quantile. The fire-related increase in flow was often pronounced at the 0.05 th quantile for streams in the Pacific Northwest and California regions. The difference in fire effects on flow (at both quantiles) across streams was related to post-fire weather, pyrology, physiography, and land cover. The proposed analytical framework can be useful for detecting and quantifying fire effects on the low and peak stream flows in burned watersheds without overlapping disturbances.

Applying the index of watershed integrity to the Matanuska-Susitna basin.

The Matanuska-Susitna Borough is the fastest growing region in the State of Alaska and is impacted by a number of human activities. We conducted a multiscale assessment of the stressors facing the borough by developing and mapping the Index of Watershed Integrity (IWI) and Index of Catchment Integrity (the latter considers stressors in areas surrounding individual stream segments exclusive of upstream areas). The assessment coincided with the borough's stormwater management planning. We adapted the list of anthropogenic stressors used in the original conterminous United States IWI application to reflect the borough's geography, human activity, and data availability. This analysis also represents an early application of the NHDPlus High Resolution geospatial framework and the first use of the framework in an IWI study. We also explored how remediation of one important stressor, culverts, could impact watershed integrity at the catchment and watershed scales. Overall, we found that the integrity scores for the Matanuska-Susitna basin were high compared to the conterminous United States. Low integrity scores did occur in the rapidly developing Wasilla-Palmer core area. We also found that culvert remediation had a larger proportional impact in catchments with fewer stressors.

Adapting the Index of Watershed Integrity for Watershed Managers in the Western Balkans Region.

Sustainable development supports watershed processes and functions. To aid the sustainable development of the western Balkans' transboundary river and lake basins, the Regional Environmental Center for Central and Eastern Europe and the US Environmental Protection Agency (EPA) adapted the EPA's Index of Watershed Integrity (IWI) following the devasting 2014 floods in Albania, Bosnia and Herzegovina, Kosovo, North Macedonia, Montenegro, and Serbia. The IWI evaluates six watershed functions based on a suite of anthropogenic stressors (e.g., impervious surfaces, reservoirs). A key feature of the IWI is its ability to accumulate the impact of upstream activities of any specific location in a river network. A novel feature of the IWI, compared with other watershed assessment tools, is its capacity to provide actionable information at the local scale. IWI scores-ranging from 0 (low integrity) to 1 (high integrity)-calculated for the 1084 catchments of the study area indicated highest integrity in the Alpine geographic region (mean = 0.55, standard deviation (SD) = 0.11) and intermediate to lowest integrity within the Mediterranean (mean = 0.49, SD = 0.12) and Continental (mean = 0.40, SD = 0.10) geographic regions. The IWI results are presented hierarchically for data analysts (stressor, functional component, Index of Catchment Integrity and IWI), ecologists (stream/catchment, watershed, basin), and managers (local, national, international). We provide real-world examples for managers, and suggestions for improving the assessment.

Arsenic Drinking Water Violations Decreased across the United States Following Revision of the Maximum Contaminant Level.

Arsenic poses a threat to public health due to widespread environmental prevalence and known carcinogenic effects. In 2001, the US EPA published the Final Arsenic Rule (FAR) for public drinking water, reducing the maximum contaminant level (MCL) from 50 to 10 µg/L. We investigated impacts of the FAR on drinking water violations temporally and geographically using the Safe Drinking Water Information System. Violations exceeding the MCL and the population served by violating systems were analyzed across the conterminous US from 2006 (onset of FAR enforcement) to 2017. The percentage of public water system violations declined from 1.3% in 2008 to 0.55% in 2017 (p < 0.001, slope = -0.070), and the population served decreased by over 1 million (p < 0.001, slope = -106 886). Geographical analysis demonstrated higher mean violations and populations served in certain counties rather than evenly distributed across states. The decline in violations is likely due to the adoption of documented and undocumented treatment methods and possibly from reduced environmental releases. Considering other studies that have shown decreased urinary arsenic levels in the population served by public water systems since the new standard, it may be inferred that the FAR is facilitating the reduction of arsenic exposure in the US.

Watershed integrity and associations with gastrointestinal illness in the United States.

Gastrointestinal (GI) illnesses are associated with various environmental factors, such as water quality, stormwater runoff, agricultural runoff, sewer overflows, and wastewater treatment plant effluents. However, rather than assessing an individual factor alone, two indices incorporating a combination of ecological and environmental stressors were created to represent (1) overall watershed integrity, Index of Watershed Integrity (IWI) and (2) catchment integrity, Index of Catchment Integrity (ICI). These indices could provide a more comprehensive understanding of how watershed/catchment integrity potentially impact the rates of GI illness, compared to assessing an individual stressor alone. We utilized the IWI and ICI, as well as agricultural and urban land uses, to assess associations at the county level with the rates of GI illness in a population of adults over 65 years of age. Our findings demonstrated that both watershed and catchment integrity are associated with reduced hospitalizations for any GI outcomes, though association varied by urbanicity. We believe that improved versions of the IWI and ICI may potentially be useful indicators for public health analyses in other circumstances, particularly when considering rural areas or to capture the complex stressors impacting the ecological health of a watershed.

Do geographically isolated wetlands influence landscape functions?

Geographically isolated wetlands (GIWs), those surrounded by uplands, exchange materials, energy, and organisms with other elements in hydrological and habitat networks, contributing to landscape functions, such as flow generation, nutrient and sediment retention, and biodiversity support. GIWs constitute most of the wetlands in many North American landscapes, provide a disproportionately large fraction of wetland edges where many functions are enhanced, and form complexes with other water bodies to create spatial and temporal heterogeneity in the timing, flow paths, and magnitude of network connectivity. These attributes signal a critical role for GIWs in sustaining a portfolio of landscape functions, but legal protections remain weak despite preferential loss from many landscapes. GIWs lack persistent surface water connections, but this condition does not imply the absence of hydrological, biogeochemical, and biological exchanges with nearby and downstream waters. Although hydrological and biogeochemical connectivity is often episodic or slow (e.g., via groundwater), hydrologic continuity and limited evaporative solute enrichment suggest both flow generation and solute and sediment retention. Similarly, whereas biological connectivity usually requires overland dispersal, numerous organisms, including many rare or threatened species, use both GIWs and downstream waters at different times or life stages, suggesting that GIWs are critical elements of landscape habitat mosaics. Indeed, weaker hydrologic connectivity with downstream waters and constrained biological connectivity with other landscape elements are precisely what enhances some GIW functions and enables others. Based on analysis of wetland geography and synthesis of wetland functions, we argue that sustaining landscape functions requires conserving the entire continuum of wetland connectivity, including GIWs.

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.

Mapping watershed integrity for the conterminous United States.

Watershed integrity is the capacity of a watershed to support and maintain the full range of ecological processes and functions essential to sustainability. Using information from EPA's StreamCat dataset, we calculated and mapped an Index of Watershed Integrity (IWI) for 2.6 million watersheds in the conterminous US with first-order approximations of relationships between stressors and six watershed functions: hydrologic regulation, regulation of water chemistry, sediment regulation, hydrologic connectivity, temperature regulation, and habitat provision. Results show high integrity in the western US, intermediate integrity in the southern and eastern US, and the lowest integrity in the temperate plains and lower Mississippi Valley. Correlation between the six functional components was high (r = 0.85-0.98). A related Index of Catchment Integrity (ICI) was developed using local drainages of individual stream segments (i.e., excluding upstream information). We evaluated the ability of the IWI and ICI to predict six continuous site-level indicators with regression analyses - three biological indicators and principal components derived from water quality, habitat, and combined water quality and habitat variables - using data from EPA's National Rivers and Streams Assessment. Relationships were highly significant, but the IWI only accounted for 1-12% of the variation in the four biological and habitat variables. The IWI accounted for over 25% of the variation in the water quality and combined principal components nationally, and 32-39% in the Northern and Southern Appalachians. We also used multinomial logistic regression to compare the IWI with the categorical forms of the three biological indicators. Results were consistent: we found positive associations but modest results. We compared how the IWI and ICI predicted the water quality PC relative to agricultural and urban land use. The IWI or ICI are the best predictors of the water quality PC for the CONUS and six of the nine ecoregions, but they only perform marginally better than agriculture in most instances. However, results suggest that agriculture would not be appropriate in all parts of the country, and the index is meant to be responsive to all stressors. The IWI in its present form (available through the StreamCat website; https://www.epa.gov/national-aquatic-resource-surveys/streamcat) could be useful for management efforts at multiple scales, especially when combined with information on site condition. The IWI could be improved by incorporating empirical or literature-derived relationships between functional components and stressors. However, limitations concerning the absence of data for certain stressors should be considered.

CONNECTIVITY OF STREAMS AND WETLANDS TO DOWNSTREAM WATERS: AN INTEGRATED SYSTEMS FRAMEWORK.

Interest in connectivity has increased in the aquatic sciences, partly because of its relevance to the Clean Water Act. This paper has two objectives: (1) provide a framework to understand hydrological, chemical, and biological connectivity, focusing on how headwater streams and wetlands connect to and contribute to rivers; and (2) review methods to quantify hydrological and chemical connectivity. Streams and wetlands affect river structure and function by altering material and biological fluxes to the river; this depends on two factors: (1) functions within streams and wetlands that affect material fluxes; and (2) connectivity (or isolation) from streams and wetlands to rivers that allows (or prevents) material transport between systems. Connectivity can be described in terms of frequency, magnitude, duration, timing, and rate of change. It results from physical characteristics of a system, e.g., climate, soils, geology, topography, and the spatial distribution of aquatic components. Biological connectivity is also affected by traits and behavior of the biota. Connectivity can be altered by human impacts, often in complex ways. Because of variability in these factors, connectivity is not constant but varies over time and space. Connectivity can be quantified with field-based methods, modeling, and remote sensing. Further studies using these methods are needed to classify and quantify connectivity of aquatic ecosystems and to understand how impacts affect connectivity.

HYDROLOGICAL, PHYSICAL, AND CHEMICAL FUNCTIONS AND CONNECTIVITY OF NON-FLOODPLAIN WETLANDS TO DOWNSTREAM WATERS: A REVIEW.

We reviewed the scientific literature on non-floodplain wetlands (NFWs), freshwater wetlands typically located distal to riparian and floodplain systems, to determine hydrological, physical, and chemical functioning and stream and river network connectivity. We assayed the literature for source, sink, lag, and transformation functions, as well as factors affecting connectivity. We determined NFWs are important landscape components, hydrologically, physically, and chemically affecting downstream aquatic systems. NFWs are hydrologic and chemical sources for other waters, hydrologically connecting across long distances and contributing compounds such as methylated mercury and dissolved organic matter. NFWs reduced flood peaks and maintained baseflows in stream and river networks through hydrologic lag and sink functions, and sequestered or assimilated substantial nutrient inputs through chemical sink and transformative functions. Landscape-scale connectivity of NFWs affects water and material fluxes to downstream river networks, substantially modifying the characteristics and function of downstream waters. Many factors determine the effects of NFW hydrological, physical, and chemical functions on downstream systems, and additional research quantifying these factors and impacts is warranted. We conclude NFWs are hydrologically, chemically, and physically interconnected with stream and river networks though this connectivity varies in frequency, duration, magnitude, and timing.

BIOTA CONNECT AQUATIC HABITATS THROUGHOUT FRESHWATER ECOSYSTEM MOSAICS.

Freshwater ecosystems are linked at various spatial and temporal scales by movements of biota adapted to life in water. We review the literature on movements of aquatic organisms that connect different types of freshwater habitats, focusing on linkages from streams and wetlands to downstream waters. Here, streams, wetlands, rivers, lakes, ponds, and other freshwater habitats are viewed as dynamic freshwater ecosystem mosaics (FEMs) that collectively provide the resources needed to sustain aquatic life. Based on existing evidence, it is clear that biotic linkages throughout FEMs have important consequences for biological integrity and biodiversity. All aquatic organisms move within and among FEM components, but differ in the mode, frequency, distance, and timing of their movements. These movements allow biota to recolonize habitats, avoid inbreeding, escape stressors, locate mates, and acquire resources. Cumulatively, these individual movements connect populations within and among FEMs and contribute to local and regional diversity, resilience to disturbance, and persistence of aquatic species in the face of environmental change. Thus, the biological connections established by movement of biota among streams, wetlands, and downstream waters are critical to the ecological integrity of these systems. Future research will help advance our understanding of the movements that link FEMs and their cumulative effects on downstream waters.

Sexual Health Competencies for Undergraduate Medical Education in North America.

INTRODUCTION: The number of hours spent teaching sexual health content and skills in medical education continues to decrease despite the increase in sexual health issues faced by patients across the lifespan. In 2012 and 2014, experts across sexuality disciplines convened for the Summits on Medical School Education and Sexual Health to strategize and recommend approaches to improve sexual health education in medical education systems and practice settings. One of the summit recommendations was to develop sexual health competencies that could be implemented in undergraduate medical education curricula. AIM: To discuss the process of developing sexual health competencies for undergraduate medical education in North America and present the resulting competencies. METHODS: From 2014 to 2016, a summit multidisciplinary subcommittee met through face-to-face, phone conference, and email meetings to review prior competency-based guidelines and then draft and vet general sexual health competencies for integration into undergraduate medical school curricula. The process built off the Association of American Medical Colleges' competency development process for training medical students to care for lesbian, gay, bisexual, transgender, and gender non-conforming patients and individuals born with differences of sex development. MAIN OUTCOME MEASURES: This report presents the final 20 sexual health competencies and 34 qualifiers aligned with the 8 overall domains of competence. RESULTS: Development of a comprehensive set of sexual health competencies is a necessary first step in standardizing learning expectations for medical students upon completion of undergraduate training. CONCLUSIONS: It is hoped that these competencies will guide the development of sexual health curricula and assessment tools that can be shared across medical schools to ensure that all medical school graduates will be adequately trained and comfortable addressing the different sexual health concerns presented by patients across the lifespan. Bayer CR, Eckstrand KL, Knudson G, et al. Sexual Health Competencies for Undergraduate Medical Education in North America. J Sex Med 2017;14:535-540.

Predictive mapping of the biotic condition of conterminous U.S. rivers and streams.

Understanding and mapping the spatial variation in stream biological condition could provide an important tool for conservation, assessment, and restoration of stream ecosystems. The USEPA's 2008-2009 National Rivers and Streams Assessment (NRSA) summarizes the percentage of stream lengths within the conterminous United States that are in good, fair, or poor biological condition based on a multimetric index of benthic invertebrate assemblages. However, condition is usually summarized at regional or national scales, and these assessments do not provide substantial insight into the spatial distribution of conditions at unsampled locations. We used random forests to model and predict the probable condition of several million kilometers of streams across the conterminous United States based on nearby and upstream landscape features, including human-related alterations to watersheds. To do so, we linked NRSA sample sites to the USEPA's StreamCat Dataset; a database of several hundred landscape metrics for all 1:100,000-scale streams and their associated watersheds within the conterminous United States. The StreamCat data provided geospatial indicators of nearby and upstream land use, land cover, climate, and other landscape features for modeling. Nationally, the model correctly predicted the biological condition class of 75% of NRSA sites. Although model evaluations suggested good discrimination among condition classes, we present maps as predicted probabilities of good condition, given upstream and nearby landscape settings. Inversely, the maps can be interpreted as the probability of a stream being in poor condition, given human-related watershed alterations. These predictions are available for download from the USEPA's StreamCat website. Finally, we illustrate how these predictions could be used to prioritize streams for conservation or restoration.

Trends in Drinking Water Nitrate Violations Across the United States.

Drinking water maximum contaminant levels (MCL) are established by the U.S. EPA to protect human health. Since 1975, U.S. public water suppliers have reported MCL violations to the national Safe Drinking Water Information System (SDWIS). This study assessed temporal and geographic trends for violations of the 10 mg nitrate-N L-1 MCL in the conterminous U.S. We found that the proportion of systems in violation for nitrate significantly increased from 0.28% to 0.42% of all systems between 1994 and 2009 and then decreased to 0.32% by 2016. The number of people served by systems in violation decreased from 1.5 million in 1997 to 200 000 in 2014. Periodic spikes in people served were often driven by just one large system in violation. On average, Nebraska and Delaware had the greatest proportion of systems in violation (2.7% and 2.4%, respectively), while Ohio and California had the greatest average annual number of people served by systems in violation (278 374 and 139 149 people, respectively). Even though surface water systems that serve more people have been improving over time, groundwater systems in violation and average duration of violations are increasing, indicating persistent nitrate problems in drinking water.

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

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