Abstract Disclosure: C.M. Roberts: None. M.M. Knoll: None. G. Robertson: None. A. Egan: None. C. Moser: None. Introduction: The demographics of patients seeking care for gender dysphoria have changed significantly since care was started in 1987. The criteria for prescribing sex hormones have also evolved to allow a greater range of patients to receive gender-affirming hormones. We examined factors associated with prescription of gender-affirming hormones to patients presenting for gender-affirming care our clinic. Methods: Secondary analysis of sex hormone initiation as a minor among 14-17-year-old adolescents diagnosed with gender dysphoria, seen in the pediatric gender clinic between 2/19/2018 and 7/20/2022. We extracted demographic variables, appointment dates, and sex hormone prescription data from our electronic medical record. We collected patient reports of gender identity and suicidal behavior, and parent and adolescent reports of general adolescent well-being, months of gender dysphoria and social transition, and parental support for the adolescent’s gender identity from electronic clinic surveys. Results: We identified 273 adolescent-parent dyads with complete data. Most of our sample were assigned female at birth (74.4%), transgender male (59.3%), and white (83.5%) adolescents who lived in urban (86.4%) and lower-middle-income (64.5%) areas. The average age was 15.9+/-1.1 years. A minority of adolescents reported recent suicidal ideation 60/273 (22%), and prior suicide attempts 20/273 (7%). Parents reported a shorter duration of gender dysphoria (-16.7 months (95%CI: -22.0, -11.5)) and social transition (-4.7: -6.5, -3.0), and higher levels of parental support than adolescents. Approximately half, 146/273 (53.5%), of adolescents started sex hormones. The average age at initiation was 16.5 years +/- 0.9. Age at presentation, length of gender dysphoria or social transition, and the presence of suicidal ideation or attempts were not associated with initiation of sex hormones. Assigned males (OR:1.82:95%CI 1.04, 3.19), adolescents with higher parent-reported parental support for the adolescent’s identity (1.03:1.01, 1.04), and adolescents with private insurance rather than Medicaid (Blue Cross- 5.39:2.73, 10.64) were more likely to start sex hormones as a minor. Conclusion: Published criteria for the initiation of sex hormones among adolescents with gender dysphoria, including age, persistence of dysphoria, and the presence of suicidality, did not predict the prescription of sex hormones to minors in our clinic. Parent-reported support for the adolescent’s gender identity played a small role in predicting the prescription of hormones, but male sex assigned at birth and having private health insurance played larger roles. Further exploration of these findings is needed to ensure equity in the treatment of gender dysphoria. Presentation: 6/3/2024

Introduction: Research indicates that transgender/gender diverse (TGD) youth are more likely to engage in sexual behavior, have more sexual partners, and initiate sexual behavior earlier than their cisgender peers. However, no gender-inclusive self-report survey questionnaires (ie, those that do not assume the gender of sexual partners or body parts used for sex) exist to assess the sexual behavior of TGD youth. The current study illustrates a questionnaire with nuanced wording to more accurately portray the sexual behavior of TGD youth presenting for gender-affirming medical care compared with national adolescent norms. Methods: A retrospective chart review was conducted of 323 youth, ages 13-18, presenting to a pediatric gender clinic between 2015 and 2021. The youth self-reported their gender identity (ie, masculine, feminine, gender queer, questioning/unsure), sexual behaviors, and partners via a REDCAP survey. Results: Rates of dating among TGD youth were significantly lower than national norms (33.7% vs 68.3%; chi (2) = 172.644, P < .0 0 01), as was sexual behavior (14.9% vs. 39.5% chi (2) = 80.419, P < .0 0 01). Rates of self-reported involuntary sexual activity among TGD youth did not differ significantly from national norms (7.1% vs. 6.9%, ns). The body parts used for sex, the number of sexual partners, and the gender identity of sexual partners are reported. Discussion: The results suggest that rates of dating and sexual behavior among TGD youth are significantly lower than national norms, supporting a need for screening of sexual health among TGD youth utilizing gender-inclusive measures. A standardized gender-inclusive questionnaire of sexual behavior is needed to improve data accuracy and help develop inclusive programs to address the sexual health needs of TGD youth.

Background: Transgender/gender diverse (TGD) youth are at risk for weight-related problems. We describe factors associated with their body mass index (BMI) category. Methods: Chart review of 228 TGD patients, 12-20 years (u = 15.7, standard deviation 1.3), 72% female assigned at birth. BMI percentile was calculated using CDC growth charts. We examined bivariate relationships of 18 clinically derived factors, utilizing analysis of variance (ANOVA) for continuous variables and chi-squared/Fisher's exact test for categorical variables. Nonparametric Classification and Regression Tree (CART) analyses were used to predict BMI category. Results: Almost half (49.6%) of TGD youth presenting for their initial visit for pediatric gender-affirming care fell in the healthy weight range, 4.4% in the underweight range, 16.7% in the overweight range, and 29.4% in the obese range. Self-described weight, weight management intentions, unhealthy weight management, prescription of psychiatric medications, and medications associated with weight gain were associated with BMI category. Use of psychiatric medications (54.8%) and medications associated with weight gain (39.5%) was associated with BMI in the overweight/obese categories. Youth with obesity most often reported unhealthy weight management. In CART models, self-described weight was the strongest predictor of BMI category. Conclusion: TGD youth have high rates of underweight and overweight/obesity. Unhealthy BMI should be treated as part of gender-affirming care. Self-described body weight is associated with weight category. More than half of TGD youth were prescribed psychiatric medications; those with overweight and obesity were more likely prescribed psychiatric and medications with associated weight gain. Youth with obesity were most likely to use unhealthy weight management.

OBJECTIVE:The aim of this study was to examine the emotional well-being of pediatric brain tumor survivors (PBTS) from the perspective of children's self-reports and parents' reports relative to matched comparison peers (COMP) and their parents. It was hypothesized that PBTS would self-report more depression symptoms, loneliness, and lower self-concept than COMP. We also hypothesized that mothers and fathers of PBTS would report more internalizing symptoms and lower total competence for their children. Age and sex effects were examined in exploratory analyses.METHODS:Families of 187 PBTS and 186 COMP participated across 5 sites. Eligible children in the PBTS group were 8-15 years of age and 1-5 years post-treatment for a primary intracranial tumor without progressive disease. COMP were classmates matched for sex, race, and age.RESULTS:PBTS self-reported lower scholastic, athletic, and social competence, but not more depression, loneliness, or lower global self-worth than COMP. Parents of PBTS reported more internalizing symptoms and lower total competence than parents of COMP. With few exceptions, group differences did not vary as a function of child age and sex.CONCLUSION:PBTS reported diminished self-concept in scholastic, athletic, and social domains, while their parents reported broader challenges with internalizing symptoms and total competence. Discrepancies between self-report and parent report require further study to inform targeted interventions for PBTS. Screening survivors for emotional challenges in follow-up clinic or in school setting may help with the allocation of psychosocial support and services for PBTS and their families.

Background: Studies of transgender/gender diverse (TGD) youth indicate a high prevalence of overweight/obesity and concern for unhealthy weight management behavior. This study describes the association of weight status with medication use and recreational activities among treatment-naïve, pediatric TGD patients. Methods: This study is a chart review of 277 patients [aged 9-18 years, 79.1% female sex assigned at birth (SAB), and 86.3% white] seen at a medical center from 2017 to 2020. BMI was calculated by age and SAB using CDC growth charts. BMI percentile (BMI%) and BMI z-score (BMIz) were used to define weight status. Results: By BMI% category, 3.6% patients were in the underweight range (BMI <5%); 50.5% had BMI >85%; and 30.3% had BMI >95%. Overweight and obesity rates were higher than national norms (χ2 = 15.152, p < 0.01). Female SAB participants had higher BMIz values than male SAB participants. Youth who reported watching/listening to media (t = 3.50, p < 0.01) and parent-reported creative arts involvement (t = 1.97, p = 0.05) were associated with higher BMIz values. Conversely, spending time with friends and family was associated with a lower BMIz. Over half of the patients were prescribed medications, and those patients taking medications had higher BMIz values than those not taking medications (t = -1.96, p < 0.05). Female SAB, involvement in sedentary recreational activities, and taking medications to treat gastrointestinal conditions were associated with elevated BMIz. Conclusions: Overweight/obesity is a common problem among TGD youth. TGD youth should be considered a high-risk group and targeted in obesity prevention and treatment efforts. Interventions to decrease sedentary activities and improve connections with friends and family are promising strategies to address overweight and obesity among TGD youth.

Weitzman, Carol C. MD, Editor; Egan, Anna PhD, ABPP; Ledesma, Michele MD; Sia, Jan Harold MD; Winningham, Grace MD Author Information

Assessment of caregiver needs is a recommended standard of care in pediatric oncology. Caregivers of pediatric brain tumor survivors (PBTS) are a subgroup that may be at highest psychosocial risk. This study examined psychosocial functioning of caregivers of PBTS in comparison to caregivers of youth without cancer history. We hypothesized that caregivers of PBTS would exhibit more psychological symptoms, higher caregiver burden, and lower perceptions of social support than caregivers of comparison youth.

Differences of sex development (DSDs) are a constellation of conditions that result in genital ambiguity or complete sex reversal. Although determining the underlying genetic variants can affect clinical management, fewer than half of undermasculinized males ever receive molecular diagnoses. Next-generation sequencing (NGS) technology has improved diagnostic capabilities in several other diseases, and a few small studies suggest that it may improve molecular diagnostic capabilities in DSDs. However, the overall diagnostic rate that can be achieved with NGS for larger groups of patients with DSDs remains unknown. In this study, we aimed to implement a tiered approach to genetic testing in undermasculinized males seen in an interdisciplinary DSD clinic to increase the molecular diagnosis rate in this group. We determined the diagnosis rate in patients undergoing all clinically available testing. Patients underwent a stepwise approach to testing beginning with a karyotype and progressing through individual gene testing, microarray, panel testing, and then to whole-exome sequencing (WES) if no molecular cause was found. Deletion/duplication studies were also done if deletions were suspected. Sixty undermasculinized male participants were seen in an interdisciplinary DSD clinic from 2008 to 2016. Overall, 37/60 (62%) of patients with Y chromosomes and 46% of those who were 46XY received molecular diagnoses. Of the 46,XY patients who underwent all available genetic testing, 18/28 (64%) achieved molecular diagnoses. This study suggests that the addition of WES testing can result in a higher rate of molecular diagnoses compared to genetic panel testing.

Abstract Introduction: Differences of Sex Development (DSDs) encompass variations in formation of internal or external sex characteristics. Historically, sex assignment in children with DSDs depended on phenotype, and gender was thought to be malleable. Attention in DSD has recently shifted toward reducing gender dysphoria and preserving fertility potential. Our multidisciplinary DSD clinic was formed in 2008 with these goals and includes specialists from Endocrinology, Gynecology, Urology, Psychology, Social Work, Genetics, and Chaplaincy. Subjects: A chart review was done on all patients seen in our DSD clinic between April 2008 and June 2019 to determine rates of sex reassignment and gender dysphoria. Two hundred patients were seen: 23 were found to not have DSDs; 61 were 46,XX; 66 were 46,XY; 31 had a sex chromosome DSD; 5 had gonadal dysgenesis without known chromosome mosaicism; and 14 had syndromic genital atypia. Mean age of follow-up is 8.77 years. Results: Only 2 patients underwent sex reassignment at our institution. One was assigned male at birth, but was found to be 46,XX with 21-hydroxylase deficiency and was reassigned female at 1 month of age. The second was assigned male at birth and was found to be 46,XY with an NR5A1 variant. Sex was reassigned female at two months of age. Two additional patients had a sex reassignment outside our institution. One was born abroad and assigned male at birth. The patient was found to be 46,XY with an NR5A1 variant, and was reassigned female. The second patient was assigned male at birth, but was found to be 46,XX with P450 oxidoreductase deficiency. The parents changed the sex of rearing to female at 19 months of age. To date, none has signs of gender dysphoria. A total of three patients experienced gender dysphoria and underwent transition. The first had genital ambiguity with sex chromosome mosaicism in the gonads and was assigned female at birth. We held care conferences with the family and discussed the possibility of gender dysphoria. At age 3, the patient declared that he was male, and parents socially transitioned him at that time. Two were assigned female after receiving the diagnosis of 46,XX 21-hydroxylase deficiency. Both declared male gender identity later, one at 12.5 years of age, and one at 20.5 years of age. Conclusion: Whereas our patient population is still relatively young, it is reassuring that the overall rate of gender dysphoria is low. The rate in patients with CAH is similar to previous reports in the literature. Careful attention to sex assignment in early childhood may reduce the rates of gender dysphoria in children with DSDs.

Objective: This study is a longitudinal evaluation of the effectiveness of gender-affirming hormones for improving psychological well-being and decreasing suicidality among transgender youth referred to a transgender health specialty clinic at a large Midwest children's hospital. Method: Forty-seven youth (13.73-19.04 years; M = 16.59. SD = 1.19) who received gender-affirming hormones were assessed at least 2 times: before the start of treatment and at least 3 months after treatment. Results: After gender-affirming hormones, a significant increase in levels of general well-being and a significant decrease in levels of suicidality were observed. Conclusion: These findings suggest that gender-affirming hormones are a valuable medical intervention with promising psychosocial outcomes for transgender youth.

ADA guidelines recommend regularly screening teens for depression. We examined sensitivity and specificity of the long and short-form of the Patient Health Questionnaire (PHQ) to identify depressive disorders in teens with T1D against a gold-standard diagnostic interview. Teens (N=100; Mean age = 15.0 ± 1.7; 60% Male; 87% white; Mean HbA1c = 8.88 ± 1.8%) completed the PHQ-9 electronically. We used the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS DSM-5) depression module to determine whether the teen met criteria for any depressive disorder (DD; e.g., major depression, dysthymia, adjustment disorder-depressed mood, bipolar). We compared teens’ pre-existing PHQ cut-off scores (PHQ-9 ≥ 10; PHQ-2 ≥ 3) to KSADS results. Per KSADS, 15% of teens met criteria for current DD, 11% endorsed past DD, and 25% endorsed past/present suicidal ideation (SI). Only 6% and 8% of teens exceeded PHQ-9 and PHQ-2 cut-off scores, respectively, and 10% endorsed current SI on PHQ item 9. Sensitivity and specificity outcomes are in Table 1. The PHQ-9 and PHQ-2 showed low sensitivity and high false negative rates. Lower cut-offs or alternative screening measures may be indicated to reliably identify DD in teens with T1D. High rates of reported SI, even by teens who did not meet full criteria for DD, highlight the importance of screening for suicidality and/or treating subthreshold depressive symptoms. Disclosure A.M. Marker: None. R. McDonough: None. A. Egan: None. M.A. Clements: Advisory Panel; Self; Glooko, Inc. Consultant; Self; Eli Lilly and Company. Speaker's Bureau; Self; Medtronic. S.R. Patton: None.

OBJECTIVES:To test the longitudinal associations between hope and optimism and health outcomes (i.e., HbA1c and self-monitored blood glucose [SMBG]) among youths with Type 1 diabetes mellitus (T1DM) over a 6-month period.METHODS:A total of 110 participants (aged 10-16 years) completed study measures at Time 1, and 81 completed measures at Time 2. Analyses examined hope and optimism as predictors of change in health outcomes, and examined SMBG as a mediator of the relationship between hope and optimism, and HbA1c.RESULTS:Change in hope, but not optimism, was associated with change in SMBG and HbA1c. Change in SMBG mediated the relationship between change in hope and HbA1c, but not between optimism and HbA1c.CONCLUSIONS:It may be beneficial to assess hope in pediatric T1DM patients to identify youths who may be at risk for poor diabetes management, and to test the benefit of hope-based intervention efforts in clinical studies.

BackgroundDue to the ongoing medical challenges we hypothesized that older adolescents with sickle cell disease (SCD) would report greater rates of internalizing symptoms and diagnoses. This study is a follow-up to a previous study [1] that found few differences between the emotional well-being of children ages 8-15 with SCD and comparison peers. Our aim is to re-assess internalizing symptoms of youth with SCD and comparison peers at age 18.ProcedureAt follow-up, trained staff members administered semi-structured psychiatric interviews and widely use behavioral health questionnaires to adolescents with SCD (n=48), their comparison peers (COMP; n=51) and a caregiver. Mood, internalizing symptoms and diagnoses, were evaluated cross-sectionally at the follow-up (age 18).ResultsPsychiatric interview data showed that COMP reported more phobias relative to adolescents with SCD; no significant differences were reported for any other current symptoms (depression, anxiety, or mania). Questionnaire data showed all scores in the normal range with two significant differences: older adolescents with SCD reported more symptoms of tension-anxiety and fatigue-inertia. Both groups reported significant rates of internalizing disorders with 31% of youth with SCD and 35% of COMP having a DSM-IV diagnosis.ConclusionsPsychiatric interview data for both groups of older adolescents suggested considerable psychopathology; questionnaire data for both groups were in the normal range. We report few significant differencesmore phobias in comparisons peers; more tension-anxiety and fatigue-inertia reported by youth with SCD. The overall findings suggest considerable resilience for youth with SCD, but both groups of adolescents report significant rates of psychopathology similar to national rates. Pediatr Blood Cancer 2015;62:637-642. (c) 2014 Wiley Periodicals, Inc.

Introduction: The purpose of this study was to examine the incidence and severity of depression and health-related quality of life (HRQoL) in youth with insulin resistance (IR) who are overweight/obese and to examine the impact on making lifestyle changes.Method: New patients presenting for treatment in an IR clinic were screened for depression and HRQoL and reassessed twice during a 1-year treatment period. Metabolic and growth parameters were obtained for each participant.Results: Elevated symptoms of depression were reported in 51% of the sample, and these symptoms were stable over time. Approximately 10% of these youth reported moderate or severe symptoms of depression. HRQoL scores indicated a good quality of life overall with slight improvement in some areas over time. Depression scores were not associated with demographic variables or metabolic parameters.Discussion: More than 50% of adolescents with IR and obesity reported elevated symptoms of depression. These results provide sufficient evidence for the need to conduct routine screening of depression for all youth with IR so that appropriate mental health referrals can be made. J Pediatr Health Care. (2013) 27, 120-126.