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State of Transgender Health Education and Provision of Gender-Affirming Care to Transgender and Gender Diverse Adolescents

      The Authors respond:
      We agree with Sirufo and colleagues: there is a critical need to expand provider education and training to make gender-affirming care more accessible to transgender and gender diverse (TGD) adolescents, especially given access to this care has been associated with improved mental health [
      • Sirufo M.M.
      • Magnanimi J.P.
      • Price L.M.
      • Ginaldi L.
      • DeMartinis M.
      Breaking Down Barriers to Facilitate Access to Healthcare Among Transgender People.
      ,
      • Green A.E.
      • DeChants J.P.
      • Price M.N.
      • Davis C.K.
      Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth.
      ].
      To improve access to this care, which many adolescents today experience notable barriers to receiving, we suggest improved transgender health education for medical trainees and practicing providers and increased advocacy against legislation banning gender-affirming care. When it is offered, transgender health content in medical education is often delivered as a single, elective session for undergraduate medical students [
      • van Heesewijk J.
      • Kent A.
      • van de Grift T.C.
      • et al.
      Transgender health content in medical education: A theory-guided systematic review of current training practices and implementation barriers & facilitators.
      ] and rarely assesses provider-level knowledge retention or clinical skills [
      • Mains-Mason J.B.
      • Ufomata E.
      • Peebles J.K.
      • et al.
      Knowledge retention and clinical skills Acquisition in sexual and gender minority health curricula: A systematic review.
      ]. Instead, this content should be integrated into required curricula over multiple sessions for medical trainees of all levels, measure knowledge and skill retention and, ultimately, its impact on patient-level outcomes. We must also develop opportunities for providers currently in practice to receive education and consultation in this area, as few were taught about transgender health in their training programs. Finally, providers must advocate for ongoing access to evidence-based care for TGD youth, which is currently under attack in the United States (US) and worldwide.
      Since January 2022, 15 US states have passed bills to limit access to gender-affirming care. Alabama and Arkansas enacted laws prohibiting the provision of gender-affirming medications (e.g., puberty blockers, hormones) for adolescents. Arizona banned gender-affirming surgeries for minors. Directives in Texas considered the provision of gender-affirming care child abuse. Although the laws and directives in Alabama, Arkansas, and Texas are temporarily blocked, future access to care for adolescents in these states remains uncertain.
      Anti-transgender legislation is discriminatory and threatens TGD adolescents' health and well-being by increasing societal stigma. This legislation prevents TGD adolescents from receiving care that improves mental health [
      • Sirufo M.M.
      • Magnanimi J.P.
      • Price L.M.
      • Ginaldi L.
      • DeMartinis M.
      Breaking Down Barriers to Facilitate Access to Healthcare Among Transgender People.
      ] and is supported by every major medical organization including the Society of Adolescent Health and Medicine [
      • Mains-Mason J.B.
      • Ufomata E.
      • Peebles J.K.
      • et al.
      Knowledge retention and clinical skills Acquisition in sexual and gender minority health curricula: A systematic review.
      ]. Many bills threaten to criminalize providers for delivering medically recommended care, leaving them with the decision to either (1) provide evidence-based care to their patients and risk criminalization or (2) do harm by withholding care to avoid risking their medical license and/or receiving criminal charges [
      • Hembree W.C.
      • Cohen-Kettenis P.T.
      • Gooren L.
      • et al.
      Endocrine treatment of gender-dysphoric/gender-incongruent persons: An endocrine society clinical practice guideline.
      ]. Because anti-transgender bills are expected to increase in upcoming legislative sessions, all providers must engage with TGD youth, their families, and their communities to advocate for making gender-affirming care more accessible for adolescents, not less [
      • Montano G.T.
      • Arrington-Sanders R.
      • Bonifacio J.
      • et al.
      Promoting health equality and nondiscrimination for transgender and gender-diverse youth.
      ].

      Acknowledgments

      This letter was, in part, supported by the National Institutes of Health , National Institute on Alcoholism and Alcohol Abuse (K01AA027564 to Coulter), and the Agency for Healthcare Research and Quality (K12HS026393-03 to Sequeira). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the funders, institutions, the Department of Veterans Affairs, or the United States Government. All authors contributed to the idea conceptualization and manuscript writing that warrant authorship.

      References

        • Sirufo M.M.
        • Magnanimi J.P.
        • Price L.M.
        • Ginaldi L.
        • DeMartinis M.
        Breaking Down Barriers to Facilitate Access to Healthcare Among Transgender People.
        J Adolesc Health. 2022; 71: 768-769
        • Green A.E.
        • DeChants J.P.
        • Price M.N.
        • Davis C.K.
        Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth.
        J Adolesc Health. 2022; 70: 643-649
        • van Heesewijk J.
        • Kent A.
        • van de Grift T.C.
        • et al.
        Transgender health content in medical education: A theory-guided systematic review of current training practices and implementation barriers & facilitators.
        Adv Health Sci Educ Theory Pract. 2022; 27: 817-846
        • Mains-Mason J.B.
        • Ufomata E.
        • Peebles J.K.
        • et al.
        Knowledge retention and clinical skills Acquisition in sexual and gender minority health curricula: A systematic review.
        Acad Med. 2022; 10: 1097
        • Montano G.T.
        • Arrington-Sanders R.
        • Bonifacio J.
        • et al.
        Promoting health equality and nondiscrimination for transgender and gender-diverse youth.
        J Adolesc Health. 2020; 66: 761-765
        • Hembree W.C.
        • Cohen-Kettenis P.T.
        • Gooren L.
        • et al.
        Endocrine treatment of gender-dysphoric/gender-incongruent persons: An endocrine society clinical practice guideline.
        J Clin Endocrinol Metab. 2017; 102: 3869-3903

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