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BACKGROUND AND OBJECTIVES: The progression of gender-expansive behavior to gender dysphoria and to gender-affirming hormonal treatment (GAHT) in children and adolescents is poorly understood. METHODS: A cohort of 958 gender-diverse (GD) children and adolescents who did not have a gender dysphoria-related diagnosis (GDRD) or GAHT at index were identified. Rates of first GDRD and first GAHT prescription were compared across demographic groups. RESULTS: Overall, 29% of participants received a GDRD and 25% were prescribed GAHT during the average follow-up of 3.5 years (maximum 9 years). Compared with youth assigned male sex at birth, those assigned female sex at birth were more likely to receive a diagnosis and initiate GAHT with hazard ratio (95% confidence interval) estimates of 1.3 (1.0-1.7), and 2.5 (1.8-3.3), respectively. A progression to diagnosis was more common among those aged ≥15 years at initial presentation compared with those aged 10 to 14 years and those aged 3 to 9 years (37% vs 28% vs 16%, respectively). By using the youngest group as a reference, the adjusted hazard ratios (95% confidence interval) for a GDRD were 2.0 (1.3-3.0) for age 10 to 14 years and 2.7 (1.8-3.9) for age ≥15 years. Racial and ethnic minorities were less likely to receive a diagnosis or be prescribed GAHT. CONCLUSIONS: This study characterized the progression of GD behavior in children and adolescents. Less than one-third of GD youth receive an eventual GDRD, and approximately one-quarter receive GAHT. Female sex at birth, older age of initial GD presentation to medical care, and non-Hispanic white race and ethnicity increased the likelihood of receiving diagnosis and treatment.

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OBJECTIVE: To examine temporal changes in the number and demographic composition of transgender/gender non-binary (TGNB) population using data from integrated health care systems. METHODS: Electronic health records from Kaiser Permanente health plans in Georgia and Northern and Southern California were used to identify TGNB individuals, who sought care from January 2006 to December 2014, and the data were analyzed by year, site, age, and sex assigned at birth. RESULTS: In 2006, the number of TGNB people (and corresponding 95% CI) per 100 000 population were 3.5 (1.9, 6.3) in Georgia, 5.5 (4.8, 6.4) in Southern California, and 17 (16, 19) in Northern California. In 2014, these frequencies increased to 38 (32, 45), 44 (42, 46), and 75 (72, 78) per 100 000 population, respectively. When analyzed by age, the most rapid increase was observed among persons 18 to 25 years old, and this increase accelerated after 2010. The ratio of transmasculine to transfeminine persons also changed from 1:1.7 in 2006 to 1:1 in 2014 overall and from 1:1 in 2006 to 1.8:1 in 2014 among persons <18 years of age. CONCLUSION: This analysis confirms previous observations that the proportion of TGNB people is growing, especially among young adults. The composition of the TGNB population is also changing from predominantly transfeminine to roughly 1:1 overall and to predominantly transmasculine in children and adolescents.

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BACKGROUND: Several studies have demonstrated that cultural competence improves patient-provider communication, which promotes adherence to established care plans and improves patient satisfaction and health outcomes. However, there is very little data available regarding the costs associated with the development and implementation of cultural competence training, or the cost-effectiveness of these programs. To that end, this evaluation aims to describe costs, program effectiveness, and cost-effectiveness of a culturally tailored communication training program to improve cultural competence among multi-disciplinary care management teams. METHODS: As part of a region-wide quality improvement initiative to reduce healthcare disparities among African American patients with uncontrolled hypertension, three multi-disciplinary care management teams were invited to participate in a two-part communication training program. A paired samples t-test was used to assess program effectiveness based on participant responses to a validated cultural competence self-assessment survey 2 weeks before and after the training program. A micro-costing approach was used to estimate programmatic costs for content development and delivery. Cost-effectiveness was then determined using the average cost-effectiveness ratio, and sensitivity analyses were conducted to assess the impact of participant mix on this result. RESULTS: All scores (n = 17) improved after training; however, only the culturally competent behaviors (CCB) subscale change was statistically significant (p = 0.02). Overall program costs were $5754.19. The average program cost per participant was $138.51, with an ACER of $337.83 per 1-unit increase in CCB score. Sensitivity analyses yielded a range of ACERs between $122.59 and $457.07, where all participants are support staff or nurses, respectively. CONCLUSIONS: Culturally tailored communication training increases how frequently participants demonstrate culturally competent behaviors and may be a cost-effective intervention for care management teams to address individual cultural competence. Detailed costs associated with cultural competence training are largely unavailable in the literature; as such, these data may serve as a financial framework for organizations considering the implementation of similar programs.

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INTRODUCTION: Transgender and gender diverse people often face discrimination and may experience disproportionate emotional distress that leads to suicide attempts. Therefore, it is essential to estimate the frequency and potential determinants of suicide attempts among transgender and gender diverse individuals. METHODS: Longitudinal data on 6,327 transgender and gender diverse individuals enrolled in 3 integrated healthcare systems were analyzed to assess suicide attempt rates. Incidence was compared between transmasculine and transfeminine people by age and race/ethnicity and according to mental health status at baseline. Cox proportional hazards models examined rates and predictors of suicide attempts during follow-up. Data were collected in 2016, and analyses were conducted in 2019. RESULTS: During follow-up, 4.8% of transmasculine and 3.0% of transfeminine patients had at least 1 suicide attempt. Suicide attempt rates were more than 7 times higher among patients aged <18 years than among those aged >45 years, more than 3 times higher among patients with previous history of suicide ideation or suicide attempts than among those with no such history, and 2-5 times higher among those with 1-2 mental health diagnoses and more than 2 mental health diagnoses at baseline than among those with none. CONCLUSIONS: Among transgender and gender diverse individuals, younger people, people with previous suicidal ideation or attempts, and people with multiple mental health diagnoses are at a higher risk for suicide attempts. Future research should examine the impact of gender-affirming healthcare use on the risk of suicide attempts and identify targets for suicide prevention interventions among transgender and gender diverse people in clinical settings.

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BACKGROUND: Visual conformity with affirmed gender (VCAG) or "passing" is thought to be an important, but poorly understood, determinant of well-being in transgender people. VCAG is a subjective measure that is different from having an inner sense of being congruent with one's gender identity. AIM: We examined the frequency and determinants of VCAG and explored its association with mental health outcomes in a cohort of transgender adults. METHODS: The "Study of Transition, Outcomes & Gender (STRONG)" is a cohort of transgender individuals recruited from 3 Kaiser Permanente health plans located in Georgia, Northern California and Southern California. A subset of cohort members completed a survey between 2015 and 2017. VCAG was assessed as the difference between 2 scales: scale 1 reflecting the person's sense of how they are perceived by others, and scale 2 reflecting the person's desire to be perceived. Participants were considered to have achieved VCAG when their scale 1 scores were equal to or exceeded their scale 2 scores. The frequency of VCAG and their independent associations with anxiety and depression symptoms were explored using data from 620 survey respondents including 309 transwomen and 311 transmen. Based on self-described gender identity, none of the participants identified as nonbinary or gender fluid. OUTCOMES: VCAG, depression, and anxiety. RESULTS: VCAG was achieved in 28% of transwomen and 62% of transmen and was more common in persons who reported greater sense of acceptance and pride in their gender identity as measured on the Transgender Congruence Scale. Another factor associated with greater likelihood of VCAG was receipt of gender-affirming surgery, but the association was only evident among transmen. Participants who achieved VCAG had a lower likelihood of depression and anxiety with prevalence ratios (95% confidence intervals) of 0.79 (0.65, 0.96) and 0.67 (0.46, 0.98), respectively. CLINICAL IMPLICATIONS: VCAG may serve as an important outcome measure after gender-affirming therapy. STRENGTHS AND LIMITATIONS: Strengths of this study include a well-defined sampling frame and use of a novel patient-centered outcome of interest. Cross-sectional design and uncertain generalizability of results are the limitations. CONCLUSION: These results, once confirmed by prospective studies, may help better characterize the determinants of well-being in the transgender community, facilitating the design of interventions to improve the well-being and quality of life of this vulnerable population. To M, Zhang Q, Bradlyn A, et al. Visual Conformity With Affirmed Gender or "Passing": Its Distribution and Association With Depression and Anxiety in a Cohort of Transgender People. J Sex Med 2020;17:2084-2092.

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CONTEXT: The effect of gender-affirming hormone therapy (HT) on erythropoiesis is an area of priority in transgender health research. OBJECTIVE: To compare changes in hematologic parameters and rates of erythrocytosis and anemia among transgender people to those of cisgender controls. DESIGN: Longitudinal observational study. PARTICIPANTS AND SETTING: We compared 559 transfeminine (TF) and 424 transmasculine (TM) people enrolled in 3 integrated health care systems to matched cisgender referents. INTERVENTIONS AND OUTCOME: Hormone therapy receipt was ascertained from filled prescriptions. Hemoglobin (Hb) and hematocrit (Hct) levels were examined from the first blood test to HT initiation, and from the start of HT to the most recent blood test. Rates of erythrocytosis and anemia in transgender participants and referents were compared by calculating adjusted hazard ratios and 95% confidence intervals (CI). RESULTS: In the TF group, there was a downward trend for both Hb and Hct. The corresponding changes in the TM cohort were in the opposite direction. TM study participants experienced a 7-fold higher rate (95% CI: 4.1-13.4) of erythrocytosis relative to matched cisgender males, and an 83-fold higher rate (95% CI: 36.1-191.2) compared to cisgender females. The corresponding rates for anemia were elevated in TF subjects but primarily relative to cisgender males (hazard ratio 5.9; 95% CI: 4.6-7.5). CONCLUSIONS: Our results support previous recommendations that hematological parameters of transgender people receiving HT should be interpreted based on their affirmed gender, rather than their sex documented at birth. The clinical significance of erythrocytosis following testosterone therapy, as well as anemia following feminizing HT, requires further investigation.

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A key priority of transgender health research is the evaluation of long-term effects of gender affirmation treatment. Thus, accurate assessment of treatment receipt is critical. The data for this analysis came from an electronic medical records (EMR) based cohort of transgender individuals. A subset of cohort members were also asked to complete a self-administered survey. Information from the EMR was compared with survey responses to assess the extent of agreement regarding transmasculine (TM)/transfeminine (TF) status, hormone therapy receipt, and type of surgery performed. Logistic regression models were used to assess whether participant characteristics were associated with disagreement between data sources. Agreement between EMR and survey-derived information was high regarding TM/TF status (99%) and hormone therapy receipt (97%). Lower agreement was observed for chest reconstruction surgery (72%) and genital reconstruction surgery (84%). Using survey responses as the "gold standard", both chest and genital reconstruction surgeries had high specificity (95 and 93%, respectively), but the corresponding sensitivities were low (49 and 68%, respectively). A lower proportion of TM had concordant results for chest reconstruction surgery (64% versus 79% for TF) while genital reconstruction surgery concordance was lower among TF (79% versus 89% for TM). For both surgery types, agreement was highest among the youngest participants. Our findings offer assurance that EMR-based data appropriately classify cohort participants with respect to their TM/TF status or hormone therapy receipt. However, current EMR data may not capture the complete history of gender affirmation surgeries. This information is useful in future studies of outcomes related to gender affirming therapy.

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Most adolescents do not achieve the recommended levels of moderate-to-vigorous physical activity (MVPA), placing them at increased risk for a diverse array of chronic diseases in adulthood. There is a great need for scalable and effective interventions that can increase MVPA in adolescents. Here we report the results of a measurement validation study and a preliminary proof-of-concept experiment testing the impact of Zamzee, an accelerometer-linked online intervention system that combines proximal performance feedback and incentive motivation features to promote MVPA. In a calibration study that parametrically varied levels of physical activity in 31 12-14 year-old children, the Zamzee activity meter was shown to provide a valid measure of MVPA (sensitivity in detecting MVPA = 85.9%, specificity = 97.5%, and r = .94 correspondence with the benchmark RT3 accelerometer system; all p < .0001). In a subsequent randomized controlled multi-site experiment involving 182 middle school-aged children assessed for MVPA over 6 wks, intent-to-treat analyses found that those who received access to the Zamzee intervention had average MVPA levels 54% greater than those of a passive control group (p < 0.0001) and 68% greater than those of an active control group that received access to a commercially available active videogame (p < .0001). Zamzee's effects on MVPA did not diminish significantly over the course of the 6-wk study period, and were statistically significant in both females and males, and in normal- vs. high-BMI subgroups. These results provide promising initial indications that combining the Zamzee activity meter with online proximal performance feedback and incentive motivation features can positively impact MVPA levels in adolescents.

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We described the prevalence of overweight and obesity among low-income women in rural West Virginia (WV) and urban Los Angeles County (LA County). Both communities participated in the national Communities Putting Prevention to Work program during 2010-2012. In each community, we completed health assessments on adult women recruited from public-sector clinics serving low-income populations. All participants answered survey questions regarding socio-demographics and diets. In both jurisdictions, we assessed obesity using objectively measured height and weight (calculated BMI). As part of each community case study, we performed multivariable regression analyses to describe the relationships between overweight and obesity and selected covariates (e.g., dietary behaviors). Overweight and obesity were prevalent among low-income women from WV (73%, combined) and LA County (67%, combined). In both communities, race and ethnicity appeared to predict the two conditions; however, the associations were not robust. In LA County, for example, African American and Hispanic women were 1.4 times (95% CI=1.12, 1.81) more likely than white women to be overweight and obese. Collectively, these subpopulation health data served as an important guide for further planning of obesity prevention efforts in both communities. These efforts became a part of the subsequent Community Transformation Grants portfolio.

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BACKGROUND: Physical education (PE) provides a natural opportunity for students to be physically active during the school day; however, the amount and intensity of this activity varies. The Centers for Disease Control and Prevention recommends that students engage in MVPA for at least 50% of their PE class period. The purpose of the present study was to quantify the amount of MVPA that occurs during elementary school PE. METHODS: Accelerometer data were collected from 203 students (100 2nd grade; 103 5th grade) in 10 West Virginia elementary schools. At each school, PE teachers identified three 2nd grade classes and three 5th grade classes in which to collect the physical activity data. For each selected class, the teachers identified the first 4 students on their alphabetic roll to wear the accelerometers. PE teachers recorded the date and time of the class and the gender of the students wearing the accelerometers. RESULTS: Using 5-second epochs and Puyau's cut-offs, results indicated that, on average, students engaged in MVPA for 27% of their PE class. No significant differences were observed in MVPA between 2nd and 5th grade students or between males and females. Male and female students spent equal amounts of PE class in MVPA. CONCLUSION: Findings support policy to increase the required minimum amount of MVPA during each PE class.

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Childhood obesity and health behavior programs are increasingly a focus within literature and individual provider practices. This study was designed to inform "best practices" for establishing effective programs in the medical setting by identifying persons and factors that influence children's willingness to be active, eat healthy, and lose weight when medically appropriate. A total of 342 child and parent dyads living in a rural setting participated in this study. Child and parent report of theory of planned behavior constructs and child intentions to lose weight, eat healthier, and increase own exercise was established as the study outcomes. Parent and child perceptions and child characteristics (e.g., weight status) were associated with children's intentions to lose weight and obtain more exercise whereas only child perceptions were associated with children's intentions to eat healthier. Incorporating children as young as 10 years of age in conversations and planning for diet and physical activity lifestyle changes is essential for the success of the treatment option.

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Parental concern about child weight has been identified as a factor in parental monitoring and regulation of child diet. However, little is known about factors that influence parental concern or about how concern may influence parent management of child physical activity. The objectives of the current study were to identify the factors associated with parental concern about child weight and determine if parental concern is associated with specific actions to improve diet and increase physical activity. A stratified random sample of 1,500 parents of children in kindergarten, 2nd, 4th, 5th, 7th, and 9th grade were interviewed. Interviews addressed: (a) child and parent physical activity, (b) child and family nutrition, (c) child and parent BMI weight category, (d) interactions with health care providers, (e) parent obesity knowledge, (f) school assessment of BMI, and (g) parent perception of and concern about child weight. Child gender, weight status, and parent perception of child weight were significant predictors of parental concern. Parents were significantly more likely to report concern if their child was female, they believed their child to be overweight/obese, or their child was overweight/obese as indicated by BMI percentile. Concerned parents were significantly more likely to limit child screen time, take steps to improve child diet, and increase child physical activity than were parents who reported no concern. Treatment and prevention efforts should emphasize parental concern and awareness about child weight by providing accurate feedback on child weight status and education regarding the health risks associated with childhood overweight and obesity. Schools can play an important role in this process through the incorporation of BMI screenings.

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BACKGROUND: The West Virginia Healthy Lifestyles Act contained 5 school-based mandates intended to reduce childhood obesity. These addressed the sale of healthy beverages, physical education time, fitness assessment, health education and assessment, and Body Mass Index measurement. This article describes the processes and methods used to evaluate efforts to implement the legislation. METHODS: University researchers and state public health and education staff formed the collaborative evaluation team. To assess perceptions and practices, surveys were completed with school personnel (53 superintendents, 586 principals, 398 physical education teachers, 214 nurses) and telephone interviews were conducted with a multistage, stratified sample of 1500 parents and 420 students statewide. Healthcare providers (N = 122) were surveyed regarding current child weight practices and interactions with families. Statewide data reflecting fitness, physical education plans, local wellness policies, and health knowledge were included in the evaluation. RESULTS: The evaluation was facilitated by state officials and agencies, resulting in good access to survey groups and high survey response rates for school personnel (57% to 95% response rates); a substantially lower response rate was obtained for healthcare providers (22%). CONCLUSIONS: Collaborative design and implementation was a key factor in the successful conduct of this obesity policy evaluation.

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The Coronary Artery Risk Detection in Appalachian Communities Project was developed to reduce children's future cardiovascular risk by implementing a school-based screening program statewide. Despite the elimination of environmental barriers related to screening cost and accessibility, only half of eligible children participate in the program each year. The authors used the theory of planned behavior to identify health beliefs associated with screening participation. This article describes the process used to identify community health beliefs and the development of theoretically based materials to increase participation. Focus groups and individual interviews were conducted to identify core health beliefs held by parents, community leaders, and children (Phase I). Data obtained were used to expand and revise a Health Beliefs Questionnaire, which was distributed to larger samples (Phase II). This information was used to design recruitment materials that emphasized the benefits of screening while directly addressing potential belief-based barriers to screening participation (Phase III).

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OBJECTIVE: Suboptimal adherence to self-administered medications is a common problem. The purpose of this study was to determine the effectiveness of a video-game intervention for improving adherence and other behavioral outcomes for adolescents and young adults with malignancies including acute leukemia, lymphoma, and soft-tissue sarcoma. METHODS: A randomized trial with baseline and 1- and 3-month assessments was conducted from 2004 to 2005 at 34 medical centers in the United States, Canada, and Australia. A total of 375 male and female patients who were 13 to 29 years old, had an initial or relapse diagnosis of a malignancy, and currently undergoing treatment and expected to continue treatment for at least 4 months from baseline assessment were randomly assigned to the intervention or control group. The intervention was a video game that addressed issues of cancer treatment and care for teenagers and young adults. Outcome measures included adherence, self-efficacy, knowledge, control, stress, and quality of life. For patients who were prescribed prophylactic antibiotics, adherence to trimethoprim-sulfamethoxazole was tracked by electronic pill-monitoring devices (n = 200). Adherence to 6-mercaptopurine was assessed through serum metabolite assays (n = 54). RESULTS: Adherence to trimethoprim-sulfamethoxazole and 6-mercaptopurine was greater in the intervention group. Self-efficacy and knowledge also increased in the intervention group compared with the control group. The intervention did not affect self-report measures of adherence, stress, control, or quality of life. CONCLUSIONS: The video-game intervention significantly improved treatment adherence and indicators of cancer-related self-efficacy and knowledge in adolescents and young adults who were undergoing cancer therapy. The findings support current efforts to develop effective video-game interventions for education and training in health care.

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CONTEXT: West Virginians are at increased risk for heart disease. Given that the process of atherosclerosis begins in childhood, the Coronary Artery Risk Detection in Appalachian Communities Project was developed to reduce this risk by implementing a cholesterol screening program in the schools. However, participation rates have been less than desired. PURPOSE: This study examined the barriers to participation in preventive health screenings, specifically cholesterol screenings, in adults and children of West Virginia using the theory of planned behavior to guide conceptualization. METHODS: A total of 14 community leaders, 36 parents, and 92 fifth-grade children from 6 West Virginia counties with predominately rural populations participated in individual and focus group interviews. Qualitative analysis was used to examine interview transcripts. FINDINGS: Adult and child attitudes about preventive care were the largest barrier to cholesterol screenings. Adult attitudinal barriers included concerns with outcomes of testing, lack of knowledge about cholesterol and heart disease, concerns about needles, and traditional Appalachian cultural beliefs (resistance to change, denial, and fatalism). Children cited concerns about needles, outcomes of testing, privacy, and lack of concern about health and cholesterol. Adults also acknowledged environmental barriers to screenings. Finally, children reported a lack of social pressure to participate in prevention activities. CONCLUSIONS: Attitudinal, social normative, and environmental barriers to health screenings may be characteristic of impoverished rural Appalachians. Interventions are being designed to target these belief barriers to improve participation in cholesterol screenings for fifth graders.

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In contrast to the extensive research on the information needs of older patients with cancer, the question of what information is most relevant for adolescents seems to have been addressed in only one published study. The aim of the present study was to update and extend the sole previous survey of oncology professionals' views about the information needs of adolescent patients. This was achieved by including professionals other than physicians, by structuring the questionnaire to show whether perceived information needs were different for the time of diagnosis versus during treatment, and by differentiating between the 6 cancer diagnoses most commonly affecting adolescents. Fifteen hundred surveys were distributed to pediatric cancer professionals, and 556 valid returns were analyzed. The main finding was that information was considered more important to provide during treatment than at the time of diagnosis. Also, medical information topics were generally considered more essential than psychological topics. The magnitude of this difference was influenced to a small extent by professional discipline, gender, age and experience of respondent, and whether the information was being given at diagnosis or during treatment. It is notable that whereas respondents generally were confident in their ability to communicate information, physicians rated themselves as better communicators at the time of diagnosis than during treatment.

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This article presents information regarding the current status of health-related quality of life (HRQL) assessment in pediatric oncology, including the substantial advances in our knowledge that have occurred during the past 10 years. Additionally, issues that continue to challenge researchers who are attempting to measure health-related quality of life in children from point of diagnosis to cure or to death are identified. It is posited that researchers must conduct investigations of the impact of health-related quality-of-life data on clinical care and outcomes for the field to continue to advance, and for these data to be valued by patients, families, and health care providers.

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