This is the first study aimed at understanding perceived barriers to care among transgender youth and their caregivers. Themed barriers to care led to the following recommendations: (1) mandatory training on gender-affirming health care and cultural humility for providers/staff; (2) development of protocols for the care of young transgender patients, as well as roadmaps for families; (3) asking and recording of chosen name/pronoun; (4) increased number of multidisciplinary gender clinics; (5) providing cross-sex hormones at an age that permits peer-congruent development; and (6) designating a navigator for transgender patients in clinics.
A total of 310 youth met the inclusion criteria; 160 youth were mentored, and 150 youth were nonmentored. Demographic characteristics were similar for mentored and nonmentored youth. Mentored youth were more likely to report favorable overall health and were less likely to report suicidal ideation, having received a diagnosis of a sexually transmitted infection, and having hurt someone in a fight in the past year. There was also a borderline significant trend toward more participation in higher education among mentored youth. On the summary measure, mentored youth had, on average, a significantly greater number of positive outcomes than nonmentored youth. CONCLUSIONS; Mentoring relationships are associated with positive adjustment during the transition to adulthood for youth in foster care. Strategies to support natural mentoring relationships for this population should be developed and evaluated.
IMPORTANCETransgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes owing to decreased social support and increased stigma and discrimination.Although gender-affirming care is associated with decreased long-term adverse mental health outcomes among these youths, less is known about its association with mental health immediately after initiation of care. OBJECTIVE To investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality. DESIGN, SETTING, AND PARTICIPANTSThis prospective observational cohort study was conducted at an urban multidisciplinary gender clinic among TNB adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 through November 2021. EXPOSURES Time since enrollment and receipt of PBs or GAHs. MAIN OUTCOMES AND MEASURES Mental health outcomes of interest were assessed via thePatient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales, which were dichotomized into measures of moderate or severe depression and anxiety (ie, scores Ն10), respectively. Any self-report of self-harm or suicidal thoughts over the previous 2 weeks was assessed using PHQ-9 question 9. Generalized estimating equations were used to assess change from baseline in each outcome at 3, 6, and 12 months of follow-up. Bivariate and multivariable logistic models were estimated to examine temporal trends and investigate associations between receipt of PBs or GAHs and each outcome. RESULTS Among 104 youths aged 13 to 20 years (mean [SD] age, 15.8 [1.6] years) who participated in the study, there were 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26.0%), 10 nonbinary or gender fluid individuals (9.6%), and 4 youths who responded "I don't know" or did not respond to the gender identity question (3.8%). At baseline, 59 individuals (56.7%) had moderate to severe depression, 52 individuals (50.0%) had moderate to severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. By the end of the study, 69 youths (66.3%) had received PBs, GAHs, or both interventions, while 35 youths had not received either intervention (33.7%). After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. There was no association between PBs or GAHs and anxiety (aOR, 1.01; 95% CI, 0.41, 2.51).
Foster youth are at risk of poor adult outcomes. Research on the role of mentoring relationships for this population suggests the value of strategies that increase their access to adult sources of support, both while in foster care and as they reach adulthood. We conducted semi-structured, individual qualitative interviews with 23 former foster youth ages 18-25 regarding their relationships with supportive non-parental adults. We sought to identify factors that influence the formation, quality, and duration of these relationships and to develop testable hypotheses for intervention strategies. Findings suggest several themes related to relationship formation with non-parental adults, including barriers (e.g., youth's fears of being hurt) and facilitators (e.g., patience from the adult). Distinct themes were also identified relating to the ongoing development and longevity of these relationships. Youth also described multiple types of support and positive contributions to their development. Proposed intervention strategies include systematic incorporation of important non-parental adults into transition planning, enhanced training and matching procedures within formal mentoring programs, assistance for youth to strengthen their interpersonal awareness and skills, and the targeting of specific periods of need when linking youth to sources of adult support. Recommended research includes the development, pilot-testing, and evaluation of proposed strategies.
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