Trends in Referrals to a Pediatric Clinic Ted Handler, MD, MBA,a J. Carlo Hojilla, RN, PhD,b,c Reshma Varghese, BA,d Whitney Wellenstein, MD, MPH,d Derek D. Satre, PhD,b,c Eve Zaritsky, MDd

OBJECTIVES: We characterized referral trends over time at a transgender clinic within an abstract integrated health system in Northern . We identified the transition-related requests of pediatric transgender and -nonconforming patients and evaluated differences in referrals by age group. METHODS: Medical records were analyzed for all patients ,18 years of age in the Kaiser Permanente Northern California health system who were referred to a specialty transgender clinic between February 2015 and June 2018. Trends in treatment demand, demographic data, service requests, and surgical history were abstracted from medical charts and analyzed by using descriptive statistics. RESULTS: We identified 417 unique transgender and gender-nonconforming pediatric patients. The median age at time of referral was 15 years (range 3–17). Most (62%) identified on the masculine spectrum. Of the 203 patients with available ethnicity data, 68% were non- Hispanic. During the study period, the clinic received a total of 506 referrals with a significant increase over time (P , .001). Most referrals were for requests to start cross- hormones and/or blockers (34%), gender-affirming surgery (32%), and mental health (27%). Transition-related requests varied by age group: younger patients sought more mental health services, and older patients sought hormonal and surgical services. Eighty-nine patients underwent gender-affirming surgeries, mostly before age 18 and most frequently mastectomies (77%). CONCLUSIONS: The increase in referrals supports the need for expanded and accessible health care services for this population. The transition-related care of patients in this large sample varied by age group, underscoring the need for an individualized approach to gender-affirming care.

’ bDepartment of , Weill Institute for Neurosciences, University of California, , San WHAT S KNOWN ON THIS SUBJECT: Pediatric patients are Francisco, California; and cDivision of Research and aDepartments of Pediatrics and dObstetrics and Gynecology, presenting to health care settings in increasing numbers Kaiser Permanente Northern California, Oakland, California for assistance with transition-related needs and mental health issues related to gender incongruence. These Dr Hojilla conceptualized and designed the study, designed the data collection instruments, patients are at significantly increased risk for developing collected data, conducted the initial analyses, and reviewed and revised the manuscript; Dr Handler psychiatric diseases and risk-taking behaviors. collected data, conducted analyses, and reviewed and revised the manuscript; Dr Wellenstein collected data and reviewed and revised the manuscript; Ms Varghese collected data, conducted the WHAT THIS STUDY ADDS: Our findings highlight the analysis, and drafted the initial manuscript; Dr Satre provided feedback and revised the growing demand for pediatric transgender and gender- manuscript; Dr Zaritsky conceptualized and designed the study, collected data, supervised data nonconforming care. Patients most often sought medical fi collection, and reviewed and revised the manuscript; and all authors approved the nal manuscript and surgical interventions and mental health support. as submitted and agree to be accountable for all aspects of the work. Findings underscore the need for expanded access and DOI: https://doi.org/10.1542/peds.2019-1368 individualized services for pediatric transgender and Accepted for publication Aug 16, 2019 gender-nonconforming patients. Address correspondence to Ted Handler, MD, MBA, Department of Pediatrics, Kaiser Permanente To cite: Handler T, Hojilla J Carlo, Varghese R, et al. Northern California, 3600 Broadway, Oakland, CA 94611. E-mail: [email protected] Trends in Referrals to a Pediatric Transgender Clinic. Pediatrics. 2019;144(5):e20191368

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 144, number 5, November 2019:e20191368 ARTICLE Transgender and gender- development and can significantly home that had the appropriate nonconforming (TGNC) individuals reduce dysphoria and improve services. To ensure culturally – are persons who experience an psychological functioning.13,16 19 competent care, patients were triaged incongruence between their gender only to health care providers who The first study describing the identity and their sex assigned at were known to the clinic as demographics of pediatric TGNC birth. TGNC persons often experience transgender knowledgeable. patients in the was , or distress that Decisions around gender-affirming published in 2012 by Spack et al.12 arises from the discordance between medical and surgical interventions Since this study, there has been their sex assigned at birth and the were guided by a patient-directed evidence highlighting various changes gender with which they identify. care model informed by the World in TGNC pediatric patient Persons can identify on the masculine Professional Association for demographics and health care spectrum (eg, transmasculine), on the Transgender Health Standards of needs.10,11,14,20 Despite the rapidly feminine spectrum (eg, Care.2,21 evolving landscape of TGNC patient transfeminine), or as gender care, there is a scarcity of recent nonbinary. Although the exact Data Collection and Analysis research examining the demand for number of transgender individuals is In February 2015, a pediatric referral and use of gender-affirming services unclear, a recent meta-analysis database was established to track among pediatric TGNC patients. To suggests a global prevalence of 4.6 TGNC patients who were ,18 years help expand health care capacity and per 100 000 individuals.1 of age at the time of referral. All inform service delivery, it is critical to patients in this age group who were Although the visibility of transgender understand the unique health care referred to the TGNC specialty clinic persons and awareness of needs of this population. In this study, between February 2015 and June transgender health issues are we characterized referral patterns 2018 were included in this analysis. increasing, this marginalized over time at a specialty transgender Age at referral, date of referral, sex population faces health inequities. clinic in Northern California, assigned at birth, , and Transgender persons have higher identified the types of transition- reasons for referral were abstracted rates of psychopathology such as related services that TGNC children from the pediatric referral database. depression, anxiety, suicidality, and and their families most commonly Patients could have multiple referrals self-harm compared with the general sought, and evaluated differences in – over the study period. We categorized population.2 6 In addition, referrals by age group. Because referrals on the basis of the most transgender persons often have insurance coverage and awareness of common services that patients and poorer health outcomes that stem gender-affirming procedures have their families requested: puberty from social and structural factors increased in recent years, we also suppression and/or cross-sex such as homelessness, poverty, characterized the number of patients hormones; gender-affirming surgery; discrimination, and negative health who completed gender-affirming – mental health assessment and/or care experiences.7 9 surgery either before or over the treatment; or other, which included course of the study period. A weakness of transgender research requests for facial hair removal, voice is that studies have predominantly therapy, assistance with legal name focused on the adult population. METHODS change, and general resources. Mental Clinical reports suggest that the health services included assessment number of pediatric TGNC patients Setting and Patients for medical (eg, cross-sex hormones) presenting to health care settings has Kaiser Permanente Northern and surgical interventions as well as increased in the last decade,10,11 yet California (KPNC) is a large, ongoing therapy. Gender-affirming most studies have focused on integrated health care system that surgeries included mastectomy, psychiatric and medical serves .4.2 million members. In hysterectomy, , facial comorbidities.12–14 One study 2013, KPNC opened a specialty clinic feminization surgery, evaluating psychological outcomes in Oakland, California, as a referral and/or , and documented how children who were hub for transition-related services for mammoplasty. Referral categories supported in their gender identity TGNC members throughout Northern were not mutually exclusive because had comparable levels of depression California. Patients could be referred each referral could include requests as their (nontransgender) by any health care provider or by self- for multiple services (eg, patients peers.15 Gender-affirming health referral. A nurse coordinator could request to start cross-sex services, such as cross-sex hormones completed intake for each referral via hormones, meet with a mental health and gender-affirming surgery, can telephone and triaged patients to the provider, and start the process for have a protective effect on healthy KPNC facility closest to the patient’s gender-affirming surgery).

Downloaded from www.aappublications.org/news by guest on September 27, 2021 2 HANDLER et al Demographic information and median age at time of first referral 10% (17 of 164) were for surgical history were derived from was 15 years (range 3–17), and 73% vaginoplasty. the KPNC electronic health record. were assigned female sex at birth. Information on ethnicity was only Among all patients (N = 417), 62% Transition-related services that available with respect to whether the identified on the masculine patients and their families requested P , patient was non-Hispanic, and this spectrum, 24% identified on the varied by age group ( .001; Fig 2). information was available for 48.7% feminine spectrum, and 13% Patients aged 8 years or younger (n = 203) of the patient cohort. A identified as gender nonbinary. The were referred primarily for mental smaller set of patients had additional majority (44 of 56) of patients who health services (66%; 33 of 50) and ethnic information in their health identified as nonbinary were other requests, such assistance with record. However, this information assigned female sex at birth. Gender legal name change and general was not included in our analysis identity was not available for 2 resources (30%; 15 of 50). Most because it was not standardized patients. Information on ethnicity referrals for early adolescent patients and was deemed to have uncertain was available for 203 patients, of between 9 and 13 years of age were significance in representing whom 68% (n = 139) identified as for mental health services (46%; 38 ethnic variation of the patient non-Hispanic. of 82) and puberty suppression or population. cross-sex hormones (39%; 32 of 82). We observed a significant increase in Adolescents aged 14 to 17 years were Data were analyzed by using the volume of pediatric referrals referred primarily for gender- descriptive statistics. Testing of the between 2015 and 2018 (test of affirming surgery (42%; 157 of 374). linear trend in the number of linear trend P ,.001). During this A total of 104 gender-affirming referrals by year was done by period, the clinic received a total of surgeries were documented in the orthogonal contrasts. Differences in 506 referrals: 56 in 2015, 102 in electronic health record involving 89 services requested by age groups 2016, 194 in 2017, and 154 in the unique patients (Table 3), of whom were evaluated by using x2 tests. first 6 months of 2018 (Fig 1). 64% (n = 57) had at least 1 surgery Analyses were completed by using Average monthly referrals before the age of 18. Stata 14 (Stata Corp, College Station, increased from 5.1 in 2015 to TX). Study procedures were approved 25.7 in 2018, an increase of 504%. by the KPNC Institutional Review Of the 506 referrals, ∼34% were DISCUSSION Board. for puberty suppression or This study is among the first to cross-sex hormones, 32% were for evaluate specific transition-related RESULTS gender-affirming surgery, 27% health care needs and surgical use in Patient characteristics are described were for mental health, and 16% a large sample of pediatric TGNC in Table 1. Between February 2015 were for other services (Table 2). patients within an integrated health and June 2018, 417 unique patients Of the surgery referrals, 85% (139 care system. Between 2015 and 2018, were referred to the clinic. The of 164) were for mastectomy and we noted a significant increase in

TABLE 1 Characteristics of Pediatric Patients Referred to a Specialty Pediatric Transgender Clinic in Northern California Between February 2015 and June 2018 (N = 417) n (%) Age at first referral, y, median 15 (3–17) (range) Sex assigned at birth Male 114 (27) Female 303 (73) Gender identitya Transmasculine 257 (62) Transfeminine 102 (24) Gender nonbinary 56 (13) Ethnicitya Non-Hispanic 139 (33) FIGURE 1 Hispanic 64 (15) Number of pediatric patients referred to a specialty transgender clinic in Northern California Surgery before age 18 57 (14) between February 2015 and June 2018. The volume of referrals increased significantly, from 56 in a Totals may not add to 100% because of missing data. 2015 to 154 in year-to-date 2018 (linear test of trend P ,.001).

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 144, number 5, November 2019 3 TABLE 2 Pediatric Referrals to a Specialty Transgender Clinic in Northern California Between TABLE 3 Gender-Affirming Surgeries February 2015 and June 2018 (N = 506) Completed in Patients Referred to Referral Category n (%) a Specialty Pediatric Transgender Clinic in Northern California (N = 104) Puberty suppression and/or cross-sex hormones 173 (34) Gender-affirming surgery 164 (32) n (%) Mental health 137 (27) Mastectomy 80 (77) a Other 79 (16) Hysterectomy 9 (9) Gender-affirming surgeries requested Vaginoplasty 7 (7) Mastectomy 139 (27) Facial feminization surgery and/or 4 (4) Vaginoplasty 17 (3) chondrolaryngoplasty Hysterectomy 5 (1) Phalloplasty and/or metoidioplasty 2 (2) Facial feminization surgery 5 (1) Mammoplasty 2 (2) Phalloplasty and/or metoidioplasty 2 (,1) Includes those completed at age 18 or older. Mammoplasty 2 (,1) Totals may not add to 100% because of rounding. Categories are not mutually exclusive because patients could request multiple services in a single referral. fi 12 a Other requests included facial hair removal, voice therapy, assistance with legal name change, and general resources. speci c services. Spack et al documented a fourfold increase in the number of patients after the creation referrals for pediatric patients others over the last decade. In a study of a dedicated TGNC clinic in Boston, seeking transition-related care. A involving pediatric TGNC patients at Massachusetts. The Gender Identity large proportion of patients identified a pediatric endocrinology clinic over Development Service in the United on the masculine spectrum, and 13 years, 74% were referred within Kingdom also had a similar growth in although a majority of referrals were the last 3 years.14 Another study of referrals for children and adolescents for medical and surgical transition, 860 patients referred to a clinic in between 2011 and 2017.10 It is likely patients’ needs varied by age group. Amsterdam revealed an average that as acceptance continues to We also found that nearly two-thirds increase in the number of patients progress and barriers to care are of patients referred to undergo referred each year between 1988 and mitigated, the number of pediatric phenotypic transition through 2016.20 In our cohort, nearly 10% of TGNC patients seeking transition- surgery did so before the age of 18. referrals were for patients 8 years or related care will grow. younger. These trends may reflect We found a higher prevalence of The increasing number of pediatric changing societal norms and broader patients who identified on the TGNC referrals we observed are acceptance of gender diversity as well transmasculine spectrum, which is reflective of trends described by as improved availability of TGNC- consistent with previous findings of a predominance of natal females among pediatric TGNC patients.2,10–12,14,20 Our study also reflects the increased rates of patients who identify as gender nonbinary.22 This is a reversal of the adult transgender population, which has been described as a 3:1 ratio of natal- male–to–natal-female individuals.1 The reasons for this shift in the sex ratio are presently unclear. It has been hypothesized that there may be decreased stigma for natal females who behave more typically “male” than for natal males who behave typically “female,” which may lower the barrier to seeking treatment for FIGURE 2 gender dysphoria.10 Services requested varied by age group. Patients aged 8 years or younger were primarily referred for mental health services. Those in early (9–13 years old) mostly requested mental Although most referrals were for health services and puberty suppression or cross-sex hormones. The majority of patients in middle adolescence (14–17 years old) were referred for gender-affirming surgery and puberty suppression puberty suppression, cross-sex or cross-sex hormones. Referral categories are not mutually exclusive because patients could hormones, and surgery, we noted request multiple services. P ,.001. significant differences in transition-

Downloaded from www.aappublications.org/news by guest on September 27, 2021 4 HANDLER et al related needs across age groups. substance use compared with their on an individualized, patient-directed Patients 8 years or younger were cisgender counterparts.2,6,24–26 In basis over specific age requirements. most often referred for mental health a clinic-based sample of transgender However, surgical interventions are support and other resources, whereas youth in Los Angeles, 35% of patients irreversible and warrant careful older patients were more likely to be had clinically significant depressive consideration. The appropriateness of referred for gender-affirming surgery. symptoms, 30% attempted at a patient’s psychological readiness for Patients in early puberty and/or early least once, and 43% reported ever surgery should be assessed by adolescence were more often referred using illicit substances.26 The care of a gender specialist in conjunction for mental health and puberty TGNC patients is often grounded in with the patient’s family and other suppression or cross-sex hormones. mental health providers trained as health care providers. Appropriate This finding is supported by literature gender specialists. Beyond staff and services are needed to that describes the development of psychotherapy to alleviate distress, support patients and their families in increased comorbid psychiatric gender specialists play a critical role the decision-making process. conditions in transgender children in educating patients and their and adolescents. Puberty causes the families and in developing This study has several limitations. We development of secondary sex appropriate treatment goals, were limited in our ability to capture fi characteristics specific to a patient’s including assessing the suf cient information on natal sex, which may cause worsening appropriateness of medical and sociodemographics. This prevented distress and dysphoria about gender. surgical transition. Affirmative us from evaluating any relevant The burden of this dysphoria may be approaches to care that support racial, ethnic, and other demographic decreased by delaying puberty.5,15,16 a child’s gender identity are essential variations in our cohort. We were also Providers in our clinic initiate because many mental health unable to differentiate between hormone blockers and cross-sex outcomes are likely tied to patients referred for puberty hormones when patients have started experiences of rejection and suppression and cross-sex hormones. puberty, which is determined by abuse.27,28 When children and Furthermore, because our data set either a score of 2 on the Tanner adolescents are supported in their only included information on the Scale during physical examination or identity, mental health outcomes services that patients requested, we – laboratory confirmation. Decisions significantly improve.3,5,6,16,27 31 were unable to determine if patients surrounding when to initiate blockers ultimately received all the services and/or cross-sex hormone therapy Some patients seek phenotypic related to the referral reason. Our use are made by the health care team on transition through gender-affirming of referral data also limited our an individualized, patient-directed surgery. The majority of the of the analysis to a select subset of basis. The pediatric endocrinologist procedures were for mastectomy, individuals who were referred for fl works in collaboration with the many of which were completed care. Findings may not re ect the pediatric gender therapist in before patients turned 18. Guidelines health care needs of TGNC patients assessing the patient’s readiness to acknowledge that this procedure may who do not present for medical start medical transition. Age cutoffs be appropriate in some patients attention. Mental health accounted are not used, but blocker before the age of 18 and do not for a large proportion of the referrals monotherapy is generally avoided require a specific time period during we observed, but we were unable to after age 14 because of concerns which patients should be on cross-sex distinguish whether patients were about effects on bone density.23 hormones.21,32 In a study of TGNC referred solely for assessment of patients in the Netherlands, Cohen- readiness for medical and/or surgical Notably, more than one-quarter of all Kettenis and van Goozen33 found that interventions, for therapy and referrals were for mental health patients who underwent gender- treatment, or for both. Lastly, all services. Our findings support those affirming surgery before adulthood patients at KPNC have medical fi of previous studies that highlight the had highly favorable outcomes. After coverage including bene ts for fi fi importance of providing mental a median follow-up of .2 years, gender-af rming services, so ndings health services to TGNC youth.2,5,15,16 patients had comparable dysphoria may not be generalizable to the We were unable to collect data on scores as cisgender controls, with broader population of pediatric TGNC comorbid psychiatric conditions, but many experiencing improved patients. others have documented a high psychological functioning. Similar to prevalence of psychopathology in this decisions around blockers and cross- population. Studies have found that sex hormone therapy, decisions CONCLUSIONS TGNC youth often have higher rates of around gender-affirming surgeries Our findings highlight the growing depression, anxiety, self-harm, and were made by providers in our clinic demand for TGNC care and support

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 144, number 5, November 2019 5 the need for expanded and accessible individualized approach using Goldstein, Lauren B. health care services for this medically a multidisciplinary model that Hartman, Stephanie Hernandez, underserved population. Within provides colocated medical, surgical, Terri Hupfer, Josephine S. Lau, Lisa a short period of time, the volume of and mental health care services. The K. Taylor, Amy Vallerie, and Susanne referrals we observed increased by findings of this study provide insight E. Watson. Thank you also to Miranda threefold. As demand for TGNC into the transition-related needs of Weintraub at Kaiser Permanente services continues to grow, it will be pediatric TGNC patients, but more Northern California graduate important that health care providers research is needed to identify the best medical education and the Division are trained in the unique needs of interventions to mitigate dysphoria of Research at Kaiser Permanente TGNC patients so they can provide and improve long-term outcomes. Northern California. culturally competent care and help alleviate barriers to gender-affirming treatments. We found that patients ACKNOWLEDGMENTS ABBREVIATIONS and their families sought services We thank the patients who KPNC: Kaiser Permanente North- around medical, surgical, and mental contributed to our analysis. We also ern California health interventions at rates that vary thank the members of the Proud TGNC: transgender and gender- by age of the patient. This Clinic at Kaiser Permanente Northern nonconforming underscores the value of an California: Yvette Fan, Jillian

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2019 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Partly supported by the National Institutes of Health through the National Institute on Drug Abuse (T32 DA007250) and the National Institute on Alcohol Abuse and Alcoholism (K24 AA025703). Funded by the National Institutes of Health (NIH). POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES 1. Arcelus J, Bouman WP, Van Den preferences. J Dev Behav Pediatr. 2019; cohort study. J Adolesc Health. 2015; Noortgate W, et al. Systematic 40(1):60–71 56(3):274–279 review and meta-analysis of 6. Connolly MD, Zervos MJ, Barone CJ 2nd, 10. de Graaf NM, Carmichael P, Steensma prevalence studies in transsexualism. Eur Psychiatry. 2015;30(6):807–815 Johnson CC, Joseph CLM. The mental TD, Zucker KJ. Evidence for a change in health of transgender youth: advances the sex ratio of children referred for 2. Becerra-Culqui TA, Liu Y, Nash R, et al. in understanding. J Adolesc Health. gender dysphoria: data from the Mental health of transgender and 2016;59(5):489–495 Gender Identity Development Service in gender nonconforming youth compared London (2000–2017). J Sex Med. 2018; 7. Jaffee KD, Shires DA, Stroumsa D. with their peers. Pediatrics. 2018; 15(10):1381–1383 141(5):e20173845 Discrimination and delayed health care among transgender women and men: 11. Aitken M, Steensma TD, Blanchard R, 3. Durwood L, McLaughlin KA, Olson implications for improving medical et al. Evidence for an altered sex ratio KR. Mental health and self-worth in education and health care delivery. Med in clinic-referred adolescents with socially transitioned transgender youth. Care. 2016;54(11):1010–1016 gender dysphoria. J Sex Med. 2015; J Am Acad Child Adolesc Psychiatry. 12(3):756–763 2017;56(2):116–123.e2 8. Bradford J, Reisner SL, Honnold JA, 4. Diemer EW, Grant JD, Munn-Chernoff Xavier J. Experiences of transgender- 12. Spack NP, Edwards-Leeper L, Feldman MA, Patterson DA, Duncan AE. Gender related discrimination and implications HA, et al. Children and adolescents with identity, , and eating- for health: results from the Virginia gender identity disorder referred to related pathology in a national sample Transgender Health Initiative Study. Am a pediatric medical center. Pediatrics. of college students. J Adolesc Health. J Public Health. 2013;103(10):1820–1829 2012;129(3):418–425 2015;57(2):144–149 9. Reisner SL, Vetters R, Leclerc M, et al. 13. Wood H, Sasaki S, Bradley SJ, et al. 5. Reilly M, Desousa V, Garza-Flores A, Mental health of transgender youth in Patterns of referral to a gender identity Perrin EC. Young children with gender care at an adolescent urban community service for children and adolescents nonconforming behaviors and health center: a matched retrospective (1976-2011): age, sex ratio, and sexual

Downloaded from www.aappublications.org/news by guest on September 27, 2021 6 HANDLER et al orientation. J Sex Marital Ther. 2013; Amsterdam (1988–2016). J Sex Marital nonconformity: a risk indicator for 39(1):1–6 Ther. 2018;44(7):713–715 childhood abuse and posttraumatic stress in youth. Pediatrics. 2012;129(3): 14. Chen M, Fuqua J, Eugster EA. 21. Coleman E, Bockting W, Botzer M, et al. 410–417 Characteristics of referrals for gender Standards of care for the health of dysphoria over a 13-year period. , transgender, and gender- 28. Ryan C, Russell ST, Huebner D, Diaz R, J Adolesc Health. 2016;58(3):369–371 nonconforming people, version 7. Int Sanchez J. Family acceptance in J Transgenderism. 2012;13(4):165–232 adolescence and the health of LGBT 15. de Vries ALC, McGuire JK, Steensma TD, young adults. J Child Adolesc Psychiatr et al. Young adult psychological 22. Kaltiala-Heino R, Lindberg N. Gender Nurs. 2010;23(4):205–213 outcome after puberty suppression and identities in adolescent population: gender reassignment. Pediatrics. 2014; methodological issues and prevalence 29. Costa R, Dunsford M, Skagerberg E, 134(4):696–704 across age groups. Eur Psychiatry. et al. Psychological support, puberty 2019;55:61–66 suppression, and psychosocial 16. de Vries ALC, Steensma TD, Doreleijers 23. Vlot MC, Klink DT, den Heijer M, functioning in adolescents with gender TA, Cohen-Kettenis PT. Puberty Blankenstein MA, Rotteveel J, Heijboer dysphoria. J Sex Med. 2015;12(11): suppression in adolescents with gender AC. Effect of pubertal suppression and 2206–2214 identity disorder: a prospective follow- cross-sex hormone therapy on bone up study. J Sex Med. 2011;8(8): 30. Shumer DE, Nokoff NJ, Spack NP. turnover markers and bone mineral 2276–2283 Advances in the care of transgender apparent density (BMAD) in children and adolescents. Adv Pediatr. 17. Dhejne C, Lichtenstein P, Boman M, et al. transgender adolescents. Bone. 2017; 2016;63(1):79–102 Long-term follow-up of transsexual (95):11–19 persons undergoing sex reassignment 31. Olson KR, Durwood L, DeMeules M, 24. Reisner SL, Biello KB, White Hughto JM, surgery: cohort study in Sweden. PLoS McLaughlin KA. Mental health of et al. Psychiatric diagnoses and One. 2011;6(2):e16885 transgender children who are comorbidities in a diverse, multicity supported in their identities [published 18. Gómez-Gil E, Zubiaurre-Elorza L, Esteva I, cohort of young transgender women: correction appears in Pediatrics. 2018; et al. Hormone-treated baseline findings from Project 142(2):e20181436]. Pediatrics. 2016; report less social distress, anxiety and LifeSkills. JAMA Pediatr. 2016;170(5): 137(3):e20153223 depression. Psychoneuroendocrinology. 481–486 32. Hembree WC, Cohen-Kettenis PT, Gooren 2012;37(5):662–670 25. Olson-Kennedy J, Okonta V, Clark LF, L, et al. Endocrine treatment of gender- 19. Rotondi NK, Bauer GR, Scanlon K, et al. Belzer M. Physiologic response to dysphoric/ gender-incongruent fi Prevalence of and risk and protective gender-af rming hormones among persons: an endocrine society clinical factors for depression in female-to- transgender youth. J Adolesc Health. practice guideline [published – male transgender Ontarians: Trans 2018;62(4):397 401 correction appears in J Clin Endocrinol PULSE Project. Canadian Journal of 26. Olson J, Schrager SM, Belzer M, Simons Metab. 2018;103(7):2758–2759]. J Clin Community Mental Health. 2012;30(2): LK, Clark LF. Baseline physiologic and Endocrinol Metab. 2017;102(11): 135–155 psychosocial characteristics of 3869–3903 20. Steensma TD, Cohen-Kettenis PT, Zucker transgender youth seeking care for 33. Cohen-Kettenis PT, van Goozen SH. Sex KJ. Evidence for a change in the sex gender dysphoria. J Adolesc Health. reassignment of adolescent – ratio of children referred for gender 2015;57(4):374 380 transsexuals: a follow-up study. JAm dysphoria: data from the Center of 27. Roberts AL, Rosario M, Corliss HL, Acad Child Adolesc Psychiatry. 1997; Expertise on Gender Dysphoria in Koenen KC, Austin SB. Childhood gender 36(2):263–271

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2019/10/14/peds.2 019-1368 References This article cites 32 articles, 5 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2019/10/14/peds.2 019-1368#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Endocrinology http://www.aappublications.org/cgi/collection/endocrinology_sub Adolescent Health/Medicine http://www.aappublications.org/cgi/collection/adolescent_health:me dicine_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

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