Health and Care Utilization of and NonconformingG. Nicole Rider, PhD,​a Barbara J. McMorris, PhD,​b AmyYouth: L. Gower, PhD,​c Eli Coleman, PhD,​a Marla E. Eisenberg, ScD, MPHc

BACKGROUND: A Population-Based Study abstract

Transgender and gender nonconforming (TGNC) adolescents have difficulty accessing and receiving health care compared with youth, yet research is limited by a reliance on small and nonrepresentative samples. This study's purpose was to examine mental and physical health characteristics and care utilization between youth who are METHODS: TGNC and cisgender and across perceived gender expressions within the TGNC sample. n Data came from the 2016 Minnesota Student Survey, which consisted of 80929 students in ninth and 11th grade ( = 2168 TGNC, 2.7%). Students self-reported , perceived , 4 health status measures, and 3 care utilization measures. Chi-squares and multiple analysis of covariance tests (controlling for RESULTS: demographic covariates) were used to compare groups. We found that students who are TGNC reported significantly poorer health, lower rates of preventive health checkups, and more nurse office visits than cisgender youth. For χ example,P 62.1% of youth who are TGNC reported their general health as poor,2 fair, or good versus very good or excellent, compared with 33.1% of cisgender youth ( = 763.7, < .001). Among the TGNC sample, those whose gender presentation was perceived as very congruent with their birth-assigned were less likely to report poorer health and long- CONCLUSIONS: term mental health problems compared with those with other gender presentations. Health care utilization differs between TGNC versus cisgender youth and across gender presentations within TGNC youth. With our results, we suggest that health care providers should screen for health risks and identify barriers to care for TGNC youth while NIH promoting and bolstering wellness within this community. aProgram in Human Sexuality, Department of Family Medicine and Community Health, cDivision of General What’sw Kno n on This Subject: Transgender and Pediatrics and Adolescent Health, Department of Pediatrics, School of Medicine, and bSchool of Nursing, gender nonconforming (TGNC) adolescents are significantly University of Minnesota, Minneapolis, Minnesota affected by mental health disparities and have difficulty accessing and receiving health care compared with Dr Rider assisted with conceptualizing and designing this study, conducted data analyses and cisgender youth. Previous research in this field is limited by interpretation, drafted the initial manuscript, and revised the manuscript; Drs McMorris, Gower, reliance on small, nonrepresentative, and adult samples. Coleman, and Eisenberg assisted with conceptualizing and designing the study and interpreting the data and reviewed and revised the manuscript; and all authors approved the final manuscript What This Study Adds: TGNC adolescents reported as submitted and agree to be accountable for all aspects of the work. poorer health, fewer health checkups, and more nurse visits than their cisgender peers. TGNC adolescents whose Preliminary findings from this study were summarized in a symposium presentation at the gender expression strongly matched their birth-assigned Rainbow Health Initiative’s Opportunity Conference; February 27, 2017; Saint Paul, MN. sex had better health and fewer long-term mental health DOI: https://​doi.​org/​10.​1542/​peds.​2017-​1683 problems compared with other gender presentations. Accepted for publication Nov 30, 2017 To cite: Rider GN, McMorris BJ, Gower AL, et al. Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study. Pediatrics. 2018;141(3): e20171683

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 141, number 3, March 2018:e20171683 Article Youth who are transgender have a risk for bullying victimization and and expressions contribute to a gender identity and/or expression depressive symptoms. lack of knowledge and training for differing from societal expectations health care providers and thereby This vulnerability for poorer health based on their birth-assigned sex, place youth who are TGNC at risk outcomes reveals the importance whereas youth who are cisgender for poorer health outcomes. In of access to affordable, competent have a gender identity aligning with the current study, we address health care services for youth who their birth-assigned sex. Gender these concerns and illuminate are TGNC. However, historical nonconforming describes individuals health-related disparities in this marginalization in health care whose gender expression does not underserved youth population. settings and a lack of competent follow stereotypical conventions providers create barriers to of masculinity and femininity and Limitations in the extant research treatment and contribute– to delayed who may or may not identify as include reliance on samples of 1 access to care and longer-term health 2 transgender. Although research 11 18 adults,​ convenience samples, and consequences. ‍ ‍ For example, on youth who are transgender and 19 small sample sizes. Population- Gordon et al found that gender gender nonconforming (TGNC) is based studies with large samples of nonconformity was associated with in its nascence, studies indicate adolescents are needed to generalize an increased risk for problems with that adolescents who identify as findings and make accurate mobility, usual activities, pain or TGNC versus cisgender experience comparisons between gender identity 2 discomfort, anxiety, and depression. significant mental health disparities. groups (TGNC versus cisgender). Our Health scores were lower for Additional studies are needed to purpose in this study was to examine participants with moderate gender better understand other health risks, the prevalence of mental and physical conformity and lowest for those disparities, and access to health care health concerns and health care with low gender conformity when among youth who are TGNC. utilization among youth who identify compared with participants reporting as TGNC versus cisgender and across ’ high gender conformity. Given the A paucity of health research examines perceived gender expressions within limited research on perceived gender TGNC adolescents perceived our TGNC sample, using a large-scale, ’ nonconformity and health outcomes, gender expression (ie, the way 20 population-based sample. Wylie et al emphasized the others interpret a person s gender importance of assessing perceived presentation along a spectrum Methods gender expression as a determinant from feminine to masculine). The of health disparities, particularly in authors of the gender minority 3 ’ population-based studies. Data Source and Study Design stress and resilience model theorize that misperceptions of a person s Previously, researchers have most gender expression may result in a often dichotomized gender into young individual feeling as if their binary categories (exclusively Data are from the Minnesota gendered experience is negated or masculine [man 13or boy] or feminine Student Survey (MSS), a statewide not affirmed. The young individual [woman or girl],​ which minimizes21 surveillance system coordinated may also be placed at an elevated risk the complexity of TGNC identities. by the Departments of Education, for harassment and victimization, In a recent study, researchers found Health, Human Services, and Public which in turn may contribute to a that 41% of a Canadian TGNC sample Safety that is used to assess health heightened risk for negative health identified as gender nonbinary and well-being among select grades ’ outcomes, such as depressive (ie, identifying as both, neither, or of public school students. In 2016, symptoms, self-harm, posttraumatic– somewhere between masculine 85% of the state s school districts stress, disordered eating, and 4 9 and feminine), which illustrates participated. Passive parental suicidal ideation and attempts10 . ‍‍ the importance of investigating the consent procedures were used in For example, Roberts et al found heterogeneity of gender identities accordance with federal laws. The 22 that youth who reported childhood and expressions among this group. analytic sample was composed of gender nonconformity were at Health researchers who do not 80929 students in ninth and 11th heightened risk for depressive incorporate options to indicate grade who were asked about their ’ symptoms during adolescence and nonbinary gender identities and gender identity. The University early adulthood compared with expressions are at risk for having of Minnesota s Institutional those reporting childhood gender categories that misclassify or exclude21 Review Board determined that conformity. Birth-assigned males certain gender diverse participants. this secondary analysis of existing who reported childhood gender This categorical invisibility and anonymous data was exempt from nonconformity were at the greatest erasure of diverse gender identities review. Downloaded from www.aappublications.org/news by guest on September 27, 2021 2 Rider et al Survey Measures TABLE 1 MSS Health Status and Health Care Utilization Measures Measure Survey Item Dichotomized Responses Health status Gender identity was assessed by using General health How would you describe your health in 1 = poor, fair, or gooda a modified version of the validated– general? 0 = very good or excellent 2-item approach recommended by Long-term physical Do you have any physical disabilities, or 1 = yes 23 26 disabilities or health long-term health problems (such as 0 = no transgender health experts. ‍‍ “ problems asthma, cancer, diabetes, epilepsy, or Birth-assigned sex was assessed ” something else)? Long-term means by the question, What is your “ lasting 6 months or more biological sex? (male or female), Long-term mental health Do you have any long-term mental 1 = yes followed by gender identity: Do problems health, behavioral, or emotional 0 = no problems? Long-term means lasting 6 you consider yourself transgender, ” months or more genderqueer, genderfluid, or unsure Stayed home sick (last During the last 30 days, how many times 1 = 1+ times about your gender identity? (yes or 30 days) have you. . .stayed home because you 0 = none no). Adolescents who provided an were sick? affirmative response to the gender Health care utilization Nurse office visits (last During the last 30 days, how many times 1 = 1+ times identity measure comprised the TGNC 30 days) have you. . .gone to the nurse’s office? 0 = none group. Perceived gender expression Preventive medical When was the last time you saw a doctor 1 = during the last yearb was measured by combining 2 items “ 20 ’ checkup or nurse for a checkup or physical 0 = not in the last year validated with young adults to examination when you were not sick create the following item: A person s or injured? Preventive dental When was the last time you saw a 1 = during the last yearc appearance, style, dress, or the way checkup dentist or dental hygienist for a 0 = not in the last year they walk or talk may affect how regular checkup, examination, teeth people describe them. How do you ” cleaning, or other dental work? think other people at school would a Response options for general health were dichotomized because of a skewed distribution. describe you? (response options: b Following recommendations by the American Academy of Pediatrics for wellness checkups.27 c 28 very or mostly feminine, somewhat Following recommendations by the American Academy of Pediatric Dentistry for regular checkups. feminine, equally feminine and masculine, somewhat masculine, or very or mostly masculine). Native Hawaiian or other Pacific simultaneously for TGNC students by Dependent variables included health Islander [non-Hispanic]; White [non- their perceived gender expression status (general health, long-term Hispanic]; and multiple race [non- while controlling for grade, free physical health problems, long- Hispanic]). An indicator of poverty or reduced-price lunch, race and/ ’ term mental health problems, and included whether students received or ethnicity, and school location. staying home sick from school) and free or reduced-price lunch at school. Pillai s trace value statistic was used care utilization (nurse office visits School location was coded as within to assess the significant effects of and preventive medical and dental or outside the 7-county Minneapolis perceived gender expression and checkups). A description of these Dataand St. Analysis Paul metropolitan area. control variables on the dependent measures is presented in Table 1. “ variables. For dichotomous Notably, response options for general ” “ dependent variables, adjusted least health were dichotomized into very ” Analyses were conducted by squares means can be interpreted good or excellent versus poor, using IBM SPSS version 23 (IBM as predicted probabilities. Analyses χ fair, or good because of a skewed were conducted separately for birth- Corporation,2 Armonk, NY). First, distribution. assigned male and birth-assigned tests were used to compare α female adolescents who are TGNC Demographics and personal demographic characteristics, health α characteristics included 4 variables. status, and care utilization measures by using an level of .05. Bonferroni Students were asked their grade between students who are TGNC tests were used to correct for and to endorse 1 or more of 5 racial and cisgender. A 2-sided significance all post hoc comparisons between groups and whether they self- level of .001 was selected to reduce perceived gender expression groups. identified with a Hispanic ethnicity. type I error rate because of the Results Responses were combined to create large sample. Second, multiple a race and/or ethnicity variable analysis of covariance (MANCOVA) Sample Characteristics (Hispanic or Latino; American Indian models were used to estimate least or Alaskan Native [non-Hispanic]; squares means of the 4 health status Asian [non-Hispanic]; Black, African, variables simultaneously and then Participants included 2168 (2.7%) or African American [non-Hispanic]; the 3 care utilization variables students who identified as TGNC Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 141, number 3, March 2018 3 TABLE 2 Demographic Characteristics of MSS Participants by Gender Identity (N = 80 929) TGNC, n (%) Cisgender, n (%) Pa and 78761 (97.3%) students who identified as cisgender. As shown in Birth-assigned sex <.001 Male 684 (31.9) 40 014 (50.9) ‍Table 2, the TGNC sample included a Female 1457 (68.1) 38 639 (49.1) higher proportion of those assigned Grade .001 female at birth, youth of color, and Ninth 1271 (58.6) 43 368 (55.1) those receiving free or reduced-price 11th 897 (41.4) 35 393 (44.9) lunch than the cisgender sample. Race and/or ethnicity .001 American Indian or Alaskan Native, NH 44 (2.1) 805 (1.0) No significant differences emerged Asian, NH 181 (8.5) 4677 (6.0) between students in metropolitan Black, African, or African American, NH 140 (6.5) 4545 (5.8) versus nonmetropolitan locations. Native Hawaiian or other Pacific Islander, NH 11 (0.5) 117 (0.1) Health Statuses and Care Utilization White, NH 1257 (58.7) 55962 (71.5) Between Adolescents Who Are TGNC Multiple race, NH 252 (11.8) 5319 (6.8) Versus Cisgender Hispanic or Latino 255 (11.9) 6816 (8.7) Free or reduced-price lunch .001 Yes 834 (38.8) 20 936 (26.8) No 1315 (61.2) 57 226 (73.2) Almost two-thirds (62.1%) of youth Location .148 who are TGNC reported their general Twin Cities metropolitan area 1188 (54.8) 41 921 (53.2) health as poor, fair, or good as Nonmetropolitan 980 (45.2) 36840 (46.8) opposed to very good or excellent, NH, non-Hispanic. a 2 which is Pnearly twice the rate among χ tests of associations were used to examine differences in demographic factors. youth who identify as cisgender (33.1%, < .001; Table 3). Over half TABLE 3 Health Status and Care Utilization of MSS Participants by Gender Identity (N = 80 929) (59.3%) of youth who are TGNC also TGNC Cisgender Pa endorsed having long-termP mental (n = 2168), n (%) (n = 78 761), n (%) health problems compared with Health status 17.4% of cisgender youth ( < .001). General health <.001 Over half (51.5%) of youth who are Poor, fair, or good 1299 (62.1) 25 496 (33.1) TGNC reported staying home from Very good or excellent 793 (37.9) 51 504 (66.9) school because of illness at least once Long-term physical disabilities or <.001 P health problems in the past month (versus 42.6% Yes 522 (25.2) 11 633 (15.2) of youth who are cisgender; < ’ No 1551 (74.8) 65 050 (84.8) .001). Youth who are TGNC visited Long-term mental health problems <.001 the nurse s office more often and Yes 1220 (59.3) 13 304 (17.4) reported lower rates of preventive No 838 (40.7) 63 096 (82.6) Stayed home sick (last 30 days) <.001 medical and dental checkups during 1+ times 1096 (51.5) 33 367 (42.6) the last year than their cisgender None 1031 (48.5) 44 871 (57.4) peers. Care utilization Health Status and Care Utilization Nurse office visits (last 30 days) <.001 by Birth-Assigned Sex and Perceived 1+ times 877 (41.2) 20 298 (25.9) Gender Expression None 1252 (58.8) 57 954 (74.1) Preventive medical check-up <.001 During the last year 1248 (60.0) 49 570 (64.7) Not in the last year 832 (40.0) 27 052 (35.3) Perceived gender expression among Preventive dental check-up <.001 youth who are TGNC is shown in During the last year 1477 (71.1) 62 854 (82.0) ‍Table 4. We found that youth who Not in the last year 601 (28.9) 13 803 (18.0) are TGNC varied across perceived a χ2 tests of associations were used to examine differences in health status and care utilization. gender expressions. Notably, the prevalence of TGNC adolescents with an equally feminine and P masculine perceived gender and pairwise comparisons for youth male at birth on health status expression was highest for both who are TGNC by perceived gender measures ( < .001) after controlling ’ those assigned male (29.3%) and expression, stratified by birth- for covariates. Statistically assigned female (41.2%) at birth assigned sex. As indicated by Pillai s significant differences between at compared with other perceived trace, there was a significant effect least 2 groups on general health and gender presentations. In Table 5, of perceived gender expression for long-term mental health problems we present predicted probabilities students who are TGNC and assigned were indicated in our results. Downloaded from www.aappublications.org/news by guest on September 27, 2021 4 Rider et al TABLE 4 Perceived Gender Expression of TGNC Students by Birth-Assigned Sex (n = 2095) TGNC Students Pairwise comparisons revealed that Assigned Male at Birth Assigned Female at Birth participants perceived as equally (n = 661), n (%) (n = 1434), n (%) feminine or masculine (49.2%) or somewhat masculine (57.5%) were Perceived gender expression Very feminine 104 (15.7) 177 (12.3) significantly more likely to report Somewhat feminine 100 (15.1) 327 (22.8) poorer general health than those Equally feminine and masculine 194 (29.3) 591 (41.2) with a very masculine (32.1%) Somewhat masculine 132 (20.0) 243 (16.9) perceived gender expression. When Very masculine 131 (19.8) 96 (6.7) compared with those with a very Data for birth-assigned sex or perceived gender expression were missing for 73 cases. masculine perceived presentation (15.8%), all other perceived gender expression groups were more likely Discussion – to report long-term mental health problems (range: 40.7% 45.7%). while promoting29,30​ wellness within this community. ‍ Although a significantP effect for Population-based research in long-term physical disability which both binary and nonbinary Among the TGNC sample, important or health problems ( = .048) gender categories are examined is differences emerged across perceived was indicated in our results, no essential for a more comprehensive statistically significant between- gender expressions by birth-assigned ’ understanding of health disparities sex. Youth who are TGNC with group comparisons were found. and health care needs of adolescents 13 perceived gender expressions that By using Pillai s trace, a statistically who are TGNC. In this study, we are incongruent or that somewhat significant effect of perceivedP address research gaps related to deviate from societal expectations gender expression on care health status and care utilization of for their birth-assigned sex were utilization measures ( = .52) was youth who are TGNC by describing a at higher risk for poorer health not indicated after controlling for variety of physical and mental health outcomes. This is not surprising covariates. indicators in a large, population- given the social pressures to conform based sample of adolescents and ’ to gender roles and stereotypes For adolescents who are TGNC and identifying perceived gender associated with one s birth-assigned were assigned female at birth, a expression as an important factor in sex and is consistent with previous significantP effect of perceived gender understanding health disparities for 10 expression on health status measures studies. Comparisons between ’ this understudied group. ( = .001) was indicated by using perceived gender expression groups Pillai s trace after controlling for We found that students who were not significantly different for covariates. Pairwise comparisons are TGNC reported significantly any care utilization measure. poorer health status, lower rates revealed that participants with a ’ somewhat feminine (69.5%), equally of preventive health checkups, and School nurses are uniquely feminine and masculine (70.4%), more visits to the nurse s office than positioned to promote, educate, or somewhat masculine (71.7%) their cisgender peers. Although youth and advocate for optimal health perceived gender expression were who are TGNC reported an overall for students who are TGNC. For significantly more likely to report worse health status compared with example, school nurses can promote poorer general health than those with their cisgender peers, nearly three- antibullying policies and clubs such a very feminine (54.0%) perceived quarters of youth who are TGNC did as -Straight31, Alliances32​ to improve gender expression. Compared with not experience long-term physical school climate. ‍ School nurses participants assigned female with disabilities or health problems, which can assist adolescents by providing a very feminine perceived gender is consistent with previous findings resources and information about expression (55.4%), participants that this group typically does not gender identity and expression. with all other perceived gender struggle with2 chronic physical health When appropriate, school nurses expressions were more likely to concerns. Over half of adolescents can also discuss with parents of – report long-term mental health who are TGNC have received self-disclosing adolescents who problems (range: 68.1% 76.7%). No preventive medical and dental care; are seeking support that family other pairwise comparisons were these rates are slightly lower than support is protective and rejection statistically significant. The effect of those reported previously, but with is potentially detrimental to health. perceived gender expression on care this information, we can continue to In addition, nurses can assist with utilization measures was also not highlight the importance of health health promotion by referring32 to statistically significant. care providers addressing health risk appropriate resources. Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 141, number 3, March 2018 5 TABLE 5 Predicted Probabilities of TGNC Students’ Health Status and Health Care Utilization, Stratified by Perceived Gender Expression and Birth-Assigned Sex (n = 2095) TGNC Assigned Male at Birth TGNC Assigned Female at Birth Consistent with gender minority (n = 661) (n = 1434) and resilience theory, individuals Responses Predicted Responses Predicted perceived as gender nonconforming (n) Probability (n) Probability may be vulnerable to discrimination (%) (%) and have difficulty accessing and

Health status receiving health care compared14,29,​ 30,​ 33​ General health is poor, fair, or good P = .003a P = .001b with their cisgender peers. ‍ ‍ ‍ Very feminine 82 49.2 163 54.0 Perceived gender nonconformity may Somewhat feminine 90 50.8 314 69.5 be a risk factor for minority stressors Equally feminine and masculine 177 49.2 564 70.4 (eg, nonaffirmation, victimization, Somewhat masculine 123 57.5 231 71.7 Very masculine 113 32.1 85 68.6 discrimination, or rejection), which Long-term physical disability or P = .048 P = .418 may in turn elevate adverse3,13​ health health problems outcomes for these youth. ‍ Youth Very feminine 82 19.5 163 22.7 who are perceived or identify as Somewhat feminine 90 35.8 314 24.9 gender nonconforming or nonbinary Equally feminine and masculine 177 27.1 564 25.0 Somewhat masculine 123 29.0 231 25.5 must also overcome unique barriers Very masculine 113 18.8 85 33.9 to accessing affirming health Long-term mental health problems P < .001c P < .001d care compared with other TGNC Very feminine 82 40.7 163 55.4 adolescents, such as mistrust of Somewhat feminine 90 44.6 314 68.1 ’ health care providers because of fear Equally feminine and masculine 177 45.7 564 69.8 Somewhat masculine 123 42.8 231 76.7 of the youth s own gender identity34, or35​ Very masculine 113 15.8 85 73.2 expression being misunderstood. ‍ Stayed home sick (last 30 days) P = .210 P = .265 These barriers contribute to delays Very feminine 82 50.9 163 48.3 in seeking services, which may Somewhat feminine 90 57.5 314 55.1 result in poorer health outcomes. Equally feminine and masculine 177 48.6 564 55.4 Somewhat masculine 123 48.2 231 48.6 More research with a focus on Very masculine 113 40.7 85 55.0 differences across gender identities Care utilization and expressions is needed to better Nurse office visits (last 30 days) P = .947 P = .688 understand associations contributing Very feminine 81 34.0 163 47.4 to health risk disparities among Somewhat feminine 90 34.2 321 42.1 Equally feminine and masculine 178 34.5 571 42.5 youth who are TGNC. Somewhat masculine 123 31.6 235 46.2 Very masculine 113 30.4 86 45.4 To our knowledge, this is the Preventive medical checkup P = .558 P = .175 first large, population-based Very feminine 81 51.5 163 69.4 study of TGNC adolescents in Somewhat feminine 90 54.0 321 61.8 the United States conducted to Equally feminine and masculine 178 57.6 571 61.3 describe prevalence rates of Somewhat masculine 123 62.4 235 57.2 Very masculine 113 59.6 86 64.3 health status and care utilization Preventive dental checkup P = .059 P = .225 compared with cisgender youth Very feminine 81 63.8 163 74.7 and to explore perceived gender Somewhat feminine 90 63.9 321 75.2 expression. Because of the census- Equally feminine and masculine 178 64.9 571 71.9 like recruitment strategy in which Somewhat masculine 123 74.3 235 67.2 Very masculine 113 77.0 86 76.1 all schools in the state were In these analyses, we controlled for free and/or reduced-price lunch, race and/or ethnicity, grade, and school location. α invited to participate, findings are level set at .05. Post hoc tests used Bonferroni's correction to adjust α for all pairwise comparisons. Numbers do not sum more generalizable than results to the sample size because of missing data on at least 1 variable. from previous studies in which a Post hoc analysis indicated significant differences between equally feminine and masculine and very masculine perceived gender expressions as well as somewhat masculine and very masculine perceived gender expressions. convenience samples were used. The b Post hoc analysis indicated significant differences between somewhat feminine and very feminine perceived gender numerous measures of health status expressions, equally feminine and masculine and very feminine perceived gender expressions, as well as somewhat (including both mental and physical masculine and very feminine perceived gender expressions. c Post hoc analysis indicated significant differences between very masculine and all other perceived gender expression health) and care utilization are groups. considerable strengths of the survey, d Post hoc analysis indicated significant differences between very feminine and all other perceived gender expression with which we address a gap in the groups. literature for youth who are TGNC. Although valuable information about health status and care utilization Downloaded from www.aappublications.org/news by guest on September 27, 2021 6 Rider et al for youth who are TGNC is provided about how they think others at appear healthy and many are using in our results, it is important to school perceive them, which might health care services, continued note limitations. First, asking about be interpreted as a question more research and advocacy are needed biological sex may be confusing for reflective of gender affirmation to decrease barriers to care and “ ” some students more accustomed to than personal gender expression improve health outcomes for these the phrase sex assigned at birth,​ and/or presentation. Missing data young people, particularly those which is commonly used in this (whether due to nonresponse or whose perceived gender expressions population. Likewise, the measure missed opportunities because of transgress societal expectations. As of gender identity does not allow school absence) may result in an such, it is important that providers for differentiation of students who underestimation of TGNC identity develop competency to work with identify as transgender, genderqueer, and health status. Lastly, youth who adolescents with diverse gender ’ or unsure. We were also unable are TGNC often use36 the bathroom in identities and expressions because to assess whether youth were the nurse s office ; thus, students health needs may differ across and interested in being perceived as may have overreported the frequency within gender groups. a different gender, had received of nurse office visits. Acknowledgments any gender-affirming medical Conclusions interventions (ie, puberty blockers, gender-affirming hormones), or MSS data were provided by public had socially transitioned to their Health status and care utilization school students in Minnesota via affirmed gender, which may impact differ between youth who are local public school districts and are how their gender expression is TGNC versus cisgender and across managed by the MSS Interagency perceived and how they feel about perceived gender presentations. With Team. particular perceptions of their our results, we suggest that health Abbreviations gender. Furthermore, we lack a care providers should screen for measure of actual gender expression health risks and identify barriers to (ie, how youth perceive and present care for youth who are TGNC while MSS: Minnesota Student Survey themselves in society through promoting and bolstering wellness TGNC: transgender and gender dress, mannerisms, and personal within this community. Although nonconforming style). Instead, students were asked youth who are TGNC generally

Address correspondence to G. Nicole Rider, PhD, Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, 1300 S 2nd St, Suite 180, Minneapolis, MN 55454. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2018 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (award R21HD088757). The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. 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. COMPANION PAPER: A companion to this article can be found online at www.pediatrics.​ ​org/​cgi/​doi/​10.​1542/​peds.​2017-​4079.

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Downloaded from www.aappublications.org/news by guest on September 27, 2021 Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study G. Nicole Rider, Barbara J. McMorris, Amy L. Gower, Eli Coleman and Marla E. Eisenberg Pediatrics 2018;141; DOI: 10.1542/peds.2017-1683 originally published online February 5, 2018;

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