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. Author manuscript; available in PMC: 2016 Mar 1.
Published in final edited form as: J Adolesc Health. 2015 Jan 7;56(3):274–279. doi: 10.1016/j.jadohealth.2014.10.264

Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study

Sari L Reisner 1,2, Ralph Vetters 3, M Leclerc 4, Shayne Zaslow 2, Sarah Wolfrum 2, Daniel Shumer 5, Matthew J Mimiaga 1,2,6
PMCID: PMC4339405  NIHMSID: NIHMS641059  PMID: 25577670

Abstract

Purpose

Transgender youth represent a vulnerable population at risk for negative mental health outcomes including depression, anxiety, self-harm, and suicidality. Limited data exists to compare the mental health of transgender adolescents and emerging adults to cisgender youth accessing community-based clinical services; the current study aimed to fill this gap.

Methods

A retrospective cohort study of electronic health record (EHR) data from 180 transgender patients age 12–29 years seen between 2002–2011 at a Boston-based community health center was performed. The 106 female-to-male (FTM) and 74 male-to-female (MTF) patients were matched on gender identity, age, visit date, and race/ethnicity to cisgender controls. Mental health outcomes were extracted and analyzed using conditional logistic regression models. Logistic regression models compared FTM to MTF youth on mental health outcomes.

Results

The sample (n=360) had a mean age of 19.6 (SD=3.0); 43% white, 33% racial/ethnic minority, and 24% race/ethnicity unknown. Compared to cisgender matched controls, transgender youth had a two- to three-fold increased risk of depression, anxiety disorder, suicidal ideation, suicide attempt, self-harm without lethal intent, and both inpatient and outpatient mental health treatment (all p<0.05). No statistically significant differences in mental health outcomes were observed comparing FTM and MTF patients, adjusting for age, race/ethnicity, and hormone use.

Conclusions

Transgender youth were found to have a disparity in negative mental health outcomes compared to cisgender youth, with equally high burden in FTM and MTF patients. Identifying gender identity differences in clinical settings and providing appropriate services and supports are important steps in addressing this disparity.

Keywords: mental health, transgender, gender minority, adolescent, health disparity

Introduction

Transgender youth have an assigned sex at birth that is different from their current gender identity1. Gender identity refers to a person’s internal felt sense of self 2. Transgender adolescents and emerging adults represent an underserved and under-researched population with specific medical and mental health needs3,4. U.S. population-level surveys do not routinely include survey items to identify transgender youth respondents; therefore, there is a lack of national epidemiologic data to document and monitor health disparities by gender identity1, including among youth5. Despite the dearth of quality comparative national-level data on the mental health of transgender versus cisgender (non-transgender) youth, local and regional studies suggest transgender adolescents and emerging adults are a subpopulation of youth burdened by adverse health indicators, particularly in the mental health domain including depression, anxiety, suicidality, and self-harm behaviors6–11.

Clinical settings and electronic health records (EHR) have been identified as important and under-utilized sources of information about sexual minority (lesbian/gay/bisexual) and gender minority (transgender) health12,13. Clinical settings and EHR are particularly valuable for transgender health in light of the dearth of comparative data that exist to understand the health and wellbeing of transgender relative to cisgender patients. Only a small handful of studies using transgender youth patient data have been conducted in clinical settings in the U.S., and most of these have occurred in multidisciplinary gender clinics7,14,15. Spack and colleagues conducted a chart review study to explore characteristics of 97 children and adolescents age < 21 years (mean age=14.8; SD=3.4) with Gender Identity Disorder (GID) seen consecutively between 1998 and 2009 at a multidisciplinary gender clinic at Boston Children’s Hospital in Massachusetts. Overall, 44% (n=43) of patients presented for medical care with significant psychiatric histories, including diagnoses of depression (58%), general anxiety disorder (16%), a history of self-mutilation (21%), and/or one or more suicide attempts (9%)15. Another study conducted at Children’s Hospital, Los Angeles in California examined associations between quality of life measures and psychosocial factors among 66 youth age 12 to 24 with GID who received care between 2011 and 2012. Perceived burden–the extent to which transgender identity interferes with life activities or causes distress–was positively correlated with greater depression and negatively associated with self-reported life satisfaction7.

These clinical studies offer valuable information about transgender youth accessing services at multidisciplinary gender clinics at U.S. pediatric medical centers. However, there are limitations. Youth in these studies all received a psychiatric GID diagnosis per the Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR)16. Given the 2013changes to the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) which changed diagnoses from to Gender Dysphoria, research is needed that a) does not use GID as a sole inclusion criteria, and b) refrains from conceptualizing gender identity variation as psychopathology17. Patients presenting to specialized multidisciplinary gender clinics may not represent the larger population of transgender patients, including those who do not meet diagnostic criteria for Gender Dysphoria. The youth in these studies tend to be from higher socioeconomic status families that have health insurance, present for medical care with their parents/families—meaning their guardians are engaged in some way—and are largely white (non-latino/hispanic)/caucasian14,15. In addition, U.S. studies of transgender youth in clinical settings have not included a cisgender comparison group which is essential to examine mental health disparities18.

There are no published studies that utilize EHR data to examine the mental health of diverse transgender youth with varied socioeconomic and racial/ethnic backgrounds presenting to U.S. community-based primary care youth clinic settings. Community-based health clinics are a unique point of entry to care for youth, especially for people of low socioeconomic and racial/ethnic minority backgrounds19. In 2008, children and youth made up 33% of all patients seen in over 1100 Federally-Qualified Community Health Centers (FQCHC), and they were more likely to be uninsured, poor, or from a racial/ethnic minority background than those seen in private practice settings19,20. Examining gender differences among transgender youth who access community-based primary care youth clinic settings is also important to understand whether and how healthcare utilization and service needs differ for FTM and MTF youth patients.

This study is designed to compare the mental health of transgender and cisgender youth in a community-based setting. To achieve this goal, this study: (1) examines mental health indicators among diverse transgender youth engaged in care at an urban pediatric and young adult community-based health center; (2) tests whether transgender youth patients bear increased mental health burden compared to matched cisgender patients; (3) explores differences in psychiatric diagnoses between FTM spectrum and MTF spectrum youth patient populations.

Patients and Methods

Study Design, Participants, and Procedures

A retrospective observational cohort study of electronic health record (EHR) data was conducted at the Sidney Borum, Jr. Health Center, an urban community-based health center serving youth in Boston, Massachusetts that is part of Fenway Health. Transgender patients age 12–29 years seen for one or more medical and/or behavioral health care visits between 2002–2011 were included in this study. Transgender patients (n=180) were identified by an EHR code “transgender” based on self-reported transgender identity on patient registration forms, behavioral health assessment forms, or direct communication with medical or behavioral health professionals during clinical visits. Direct patient communication of transgender identity to a physician or behavioral health professional was documented in narrative notes on the clinical visit and/or listed as a diagnosis of Gender Identity Disorder16 in the patient’s diagnostic history. All study activities were reviewed and approved by the organization’s Institutional Review Board.

Description of Clinical Context

During the period covered by data collection from the Sidney Borum, Jr. Health Center clinical site, annual visits by unduplicated patients varied between 2,000 to 3,000 patients per year at the clinic. Clinicians providing care for transgender youth at the site included MDs, nurse practitioners, LICSWs and MSWs all working collaboratively as a team. This team met regularly once to twice a month to review cases and assess medical and behavioral health protocol applicability before supporting hormones for gender transition and writing prescriptions for hormones and other adjunct medications. Transgender care for youth under age 18 years required family participation, broadly defined, and the consent of the youth’s guardians, including state-appointed guardians in some situations. Youth age 18 years and older could consent to care supporting gender transition for themselves. Health insurance or the ability to pay for services was required for transition-focused transgender care at the clinic. However, with the implementation of Massachusetts state health insurance reform starting in 2006, many barriers to access to care for transgender youth were removed.

Matched Sampling

Matched sampling was utilized to reduce bias, increase precision, and control for confounding in this observational study21. Transgender youth were categorized as being on the female-to-male (FTM) spectrum (assigned a female sex at birth and identify as man, male, transgender, FTM, trans man, trans masculine) or on the male-to-female (MTF) spectrum (assigned a male sex at birth and identify as woman, female, transgender, MTF, trans woman, trans feminine). The 106 FTM and 74 MTF patients were matched to cisgender patient controls on: (1) visit date: an office visit +/− 3 months of the office visit where the transgender patient received a transgender “flag” in their patient chart or the office visit where this was first reported; (3) gender identity; (3) age; and (4) race/ethnicity. If a patient’s ethnicity was latino/hispanic and their race was listed as something other than latino/hispanic, the patient was categorized as multiracial and matched to other multiracial individuals. Six transgender patients (3.3% of the transgender patient sample) were partially matched on age and gender identity only, not on race/ethnicity, due to the few number and homogeneity of younger age patients.

A Structured Query Language (SQL) query pulled the matching criteria for each transgender patient, and a second query was done to find a match for each patient. When multiple patients matched, a randomly generated number was assigned to each possible control, and the matching cisgender patient with the highest randomly generated number was assigned as the control. Once a control was selected they were removed from the pool of available matches.

For transgender patients that did not have an exact match on all matching criteria, the matching criteria were ranked (as numbered previously) and adjusted in a systematic way in order to obtain a match for the patient. When no match was found, the criterion that patients must match on race/ethnicity was removed. If still no matches were found then the age of matches was expanded to be +/− one year of the case patient. These revisions to the matching criteria were sufficient to find matches for all of the transgender patients in the cohort.

A Microsoft Access database was created with separate forms and tables corresponding to each category of the data extraction measures. SQL queries extracted demographic and some medical information from the EHR, which was then exported into the Access database. Data about patients’ mental health history were obtained by individual manualized chart review.

Measures

Demographic data were extracted from patient registration and behavioral intake forms, as well as clinical visit physician narratives. Demographics extracted included age (continuous in years calculated by subtracting date of first appointment from date of birth), race/ethnicity (white, black, latino/hispanic, other race/ethnicity, multiracial, missing/unknown), gender identity (non-gender minority female, non-gender minority male, FTM, MTF), and cross-sex hormone use (yes/no).

Depression and anxiety disorders were recorded only for patients with physician-endorsed diagnoses listed in the EHR per DSM-IV-TR criteria16. Patient self-report of lifetime suicidality (suicidal ideation and suicide attempt captured separately), self-harm without lethal intent (non-suicidal self-injury; NSSI; e.g., cutting, burning, other self-harm behaviors), outpatient mental health care (e.g., psychotherapy), and inpatient mental health care (e.g., inpatient psychiatric hospitalization, substance abuse treatment) were recorded in data abstraction from physician clinical visit narratives.

Data Analysis

SAS version 9.3 statistical software was used for data analysis. Statistical significance was pre-determined at the alpha 0.05-level. Univariable, descriptive statistics (frequencies, means, standard deviations (SD)) were estimated. Bivariate statistics compared transgender and cisgender youth. T-test statistics were estimated for continuous variables (with appropriate tests for normality) and χ2 test statistics were used for binary and categorical variables. Conditional logistic regression models for matched pairs data22 compared transgender and matched cisgender youth to examine between-group differences in mental health. To examine within-group differences, logistic regression models restricted to transgender youth were fit to compare FTM and MTF patients, regressing each mental health outcome on gender identity (FTM vs MTF) (unadjusted), then adjusting for age and race/ethnicity, and finally adjusting for age, race/ethnicity, and cross-sex hormone use. Risk Ratios (RR) and 95% Confidence Intervals (95% CI) were estimated rather than Odds Ratios (OR) because the prevalence of outcomes was > 10%23.

Results

Demographics

The overall sample had a mean age of 19.6 (SD=3.0), 42.5% were white, 33.3% were racial/ethnic minority, and 24.2% were race/ethnicity unknown. As expected due to matching by age and race/ethnicity, no significant differences were found by age and race/ethnicity comparing transgender and cisgender youth (Table 1). The majority (61.7%; n=111) of transgender youth were being treated with cross-sex hormones.

Table 1.

Sociodemographics: Comparing Transgender Youth and Cisgender (Non-Transgender) Controls (n=360).

Transgender Cisgender Bivariate Statistics
n=180 50.0% n=180 50.0%
Mean (SD) Mean (SD) t-test (df) p-value
Age −0.78 (358) 0.435
 Continuous in Years 19.7 3.1 19.5 3.0
n % n % χ2 (df) p-value
Race/Ethnicity 7.18 (5) 0.208
 1 White 87 48.3 66 36.7
 2 Black/African American 17 9.4 23 12.8
 3 Latino/Hispanic 19 10.6 23 12.8
 4 Other Race/Ethnicity 12 6.7 10 5.6
 5 Multiracial 9 5.0 7 3.9
 6 Unknown Race/Ethnicity 36 20.0 51 28.3
Race/Ethnicity 5.77 (2) 0.056
 Racial/Ethnic Minority 57 31.7 63 35.0
 White (Non-Hispanic) 87 48.3 66 36.7
 Unknown Race/Ethnicity 36 20.0 51 28.3
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Between-Group Differences: Comparing Transgender and Cisgender Youth

Compared to cisgender matched controls, transgender youth had an elevated probability of having DSM-IV-TR diagnosed depression (50.6% vs 20.6%; RR=3.95; 95% CI=2.60, 5.99) and anxiety (26.7% vs 10.0%; RR=3.27; 95% CI=1.80, 5.95) (Table 2). Transgender youth also disproportionately endorsed suicide ideation (31.1% vs 11.1%; RR=3.61; 95% CI=2.17, 6.03), suicide attempt (17.2% vs 6.1%; RR=3.20; 95% CI=1.53, 6.70), and self-harm without lethal intent (16.7% vs 4.4%; RR=4.30; 95% CI=1.95, 9.51) relative to matched controls. A significantly greater proportion of transgender youth compared to matched cisgender controls accessed inpatient mental health care (22.8% vs 11.1%; RR=2.36; 95% CI=1.33, 4.20) and outpatient mental health care (45.6% vs 16.1%; RR=4.36; 95% CI=2.69, 7.05) services.

Table 2.

Between-Group Differences Documenting Mental Health Disparities: Transgender Compared to Matched Cisgender (Non-Transgender) Youth Patients (n=360).+

Transgender n=180 Cisgender n=180 Transgender Versus Cisgender Total Sample n=360
n % n % RR (95% CI) p-value n %
Depression (DSM-IV-TR Diagnosis) 91 50.6 37 20.6 3.95 (2.60, 5.99) <0.0001 128 35.6
Anxiety (DSM-IV-TR Diagnosis) 48 26.7 18 10.0 3.27 (1.80, 5.95) 0.0001 66 18.3
Suicide Ideation 56 31.1 20 11.1 3.61 (2.17, 6.03) <0.0001 76 21.1
Suicide Attempt 31 17.2 11 6.1 3.20 (1.53, 6.70) 0.002 42 11.7
Self-Harm Without Lethal Intent 30 16.7 8 4.4 4.30 (1.95, 9.51) 0.0003 38 10.6
Inpatient Mental Health Services 41 22.8 20 11.1 2.36 (1.33, 4.20) 0.004 61 16.9
Outpatient Mental Health Services 82 45.6 29 16.1 4.36 (2.69, 7.05) <0.0001 111 30.8
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+

Participants were matched on age, race/ethnicity, and visit date.

Within-Group Differences: Comparing FTM and MTF Transgender Youth

FTM and MTF transgender youth were compared on mental health indicators. No statistically significant differences in mental health indicators were found comparing FTM and MTF adolescent and emerging adult patients, including after adjustment for age, race/ethnicity, and hormone use (Table 3).

Table 3.

Within-Group Differences: Comparing FTM and MTF Transgender Youth Patients (n=180).

FTM (n=106) MTF (n=74) FTM Versus MTF Transgender+
Bivariate Age- and Race- Adjusted Age-, Race-, and Hormone- Adjusted
n % n % RR (95% CI) p-value RR (95% CI) p-value RR (95% CI) p-value
Depression (DSM-IV-TR Diagnosis) 58 54.7 33 44.6 1.50 (0.83, 2.73) 0.182 1.17 (0.54, 2.51) 0.697 1.64 (0.86, 3.09) 0.131
Anxiety (DSM-IV-TR Diagnosis) 28 26.4 20 27.0 0.97 (0.50, 1.90) 0.927 0.47 (0.19, 1.17) 0.105 0.77 (0.37, 1.61) 0.490
Suicide Ideation 32 30.2 24 32.4 0.90 (0.48, 1.71) 0.750 1.09 (0.47, 2.53) 0.834 0.99 (0.50, 1.96) 0.979
Suicide Attempt 16 15.1 15 20.3 0.70 (0.32, 1.52) 0.367 0.50 (0.18, 1.41) 0.188 0.86 (0.38, 1.95) 0.713
Self-Harm Without Lethal Intent 21 19.8 9 12.2 1.78 (0.77, 4.15) 0.179 1.68 (0.69, 4.10) 0.256 1.75 (0.71, 4.30) 0.222
Inpatient Mental Health Services 23 21.7 18 24.3 0.86 (0.43, 1.74) 0.680 0.99 (0.39, 2.49) 0.982 0.96 (0.46, 2.03) 0.922
Outpatient Mental Health Services 50 47.2 32 43.2 1.17 (0.65, 2.13) 0.603 1.18 (0.54, 2.61) 0.676 1.43 (0.75, 2.71) 0.277
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+

Age, race/ethnicity, and cross-sex hormone use were not statistically significant in any of the fitted models.

FTM = Female-to-male. MTF = Male-to-female. RR = Risk Ratio. 95% CI = 95% Confidence Interval.

Discussion

The current study fills a key gap in the existing mental health research literature on transgender adolescents and emerging adults. First, in a transgender patient population not defined solely by GID and presenting at a community-based youth clinic, this study found high prevalence of depression, anxiety, suicide ideation, suicide attempt, self-harm without lethal intent, and lifetime inpatient mental health care utilization, corroborating research in other clinical settings7,14,15,24 and in convenience sample studies6,9,10,25,26. Second, this study’s ability to compare mental health in transgender and cisgender patients in a community-based setting provides a unique addition to the literature. Findings demonstrate that a significantly higher proportion of transgender adolescent and emerging adult patients were burdened by mental health concerns than cisgender youth. Third, no statistically significant differences in mental health were found between FTM and MTF transgender youth patients. This suggests equally high burden of mental health disorders in FTM and MTF adolescent and emerging adult patients. Findings point to the need for gender-affirming mental health services and interventions to support transgender youth. Community-based clinics should be prepared to provide mental health services or referrals for transgender patients.

Study findings should be interpreted alongside several limitations. First, nearly half of transgender patients were accessing outpatient mental health services, and transgender patients were more likely to access mental health services than cisgender youth. Therefore, transgender youth may be more likely to have had a DSM-IV-TR-based depression and/or anxiety diagnosis in their EHR which could inflate prevalence estimates (i.e., issues of measurement equivalence). Second, as a retrospective chart review this study is subject to common limitations of this research design (e.g., incomplete documentation, information that is unrecorded, variance in the quality of information recorded by medical professionals)27. Third, several transgender patients were partially matched to cisgender patients on age and gender identity only which may have introduced some bias in study findings. Fourth, youth in this study were seeking care at an urban community-based health center; thus, findings may not generalize to other clinic settings and geographic locations. Lastly, the elevated mental health burden among transgender youth is hypothesized to result from experiences of social stress such as family rejection, bullying, violence, victimization, and discrimination which occur due to disadvantaged social status 28,29. These potential confounding variables were not captured in our chart review. Future research is needed to contextualize the mental health concerns of transgender adolescent and emerging adult patients in community-based clinic settings, including prospective assessment of social stressors and mental health symptoms and diagnoses over time. Such longitudinal investigations will also allow for specific consideration of developmental processes that may accompany mental health outcomes in different developmental periods, which the current study was not able to examine due to the age-matched design.

A strength of this study is that the sample was not restricted to youth with a GID diagnosis. As reflected in recent changes to the 2013 Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)30 which removed GID as a diagnosis and replaced it with Gender Dysphoria, being transgender is no longer conceptualized as a disorder. Over the past 10 years there has been a move away from pathologizing transgender people in mental health and clinical settings31. It generally accepted that wide spectrum of non-pathological diverse gender identities and gender expressions exist31–33. Thus, this study offers unique comparative data that directly compare the health and wellbeing of transgender and cisgender youth using a non-pathological perspective of gender variation.

Reducing health disparities34—through addressing inequities—is a core aim of Healthy People 202035. Collecting gender-inclusive measures in patient settings is recommended for health services research and surveillance efforts to monitor health disparities and improve clinical practice12,13. A two-step approach is recommended where assigned sex at birth and current gender identity are both assessed, either routinely at patient registration and/or during clinical care. Clinical assessment of patient reported outcomes (PROs)36,37 can be implemented as part of routine clinical care visits for transgender youth to collect data that will inform clinical practice and future intervention development to reduce mental health disparities.

Conclusion

The current study is one of the first studies in the U.S. to document mental health disparities by transgender status in youth using patient data and a controlled design to compare transgender and cisgender adolescents and emerging adults. Based on these findings, and consistent with prior clinical recommendations38–40, it is recommended that primary care providers include gender identity as part of a basic patient history. Training programs and continuing education programs for primary care providers and mental health providers should include gender identity education. Providers should familiarize themselves with community resources for transgender youth. Patients with a transgender identity or history should be recognized as having higher risk for mental health concerns and should be carefully screened and evaluated. Patients identified with co-occurring transgender identity and mental health concerns should be seen by a mental health provider who is qualified to provide evidence-based care with sensitivity to the diversity of gender identity and expression.

The Sidney Borum, Jr. Health Center, the clinic site where this study took place, while devoting a good part of its resources to the care of transgender youth, is still a primary care clinic for adolescents and emerging adults. Therefore, this study shows that expanded care for transgender youth can be provided in the context of overall pediatric care: integration of behavioral health, psychiatry, and pediatric primary care – a medical home approach – can more than adequately support the medical and behavioral health needs of transgender youth and provide a locus of care for reduction of psychiatric outcomes described by the study. Including questions about gender as well as sexuality in standardized annual health reviews in pediatric practices in combination with recognized adolescent depression screenings can identify transgender youth at high-risk for self-harm and other mental health outcomes. The practice of care at this clinic creates a framework within which risk behaviors can potentially be addressed and may serve as a model for other youth-oriented clinics so that transgender youth feel safe, accepted, and receive the gender affirming care they need and deserve.

Highlights.

  • Transgender youth represent a vulnerable population at-risk for negative mental health outcomes including depression, anxiety, self-harm, and suicidality.

  • Limited mental health data are available in this patient population from community-based clinic settings, including comparative data that examine disparities in mental health outcomes.

  • Transgender patients have disparately negative mental health outcomes compared to their non-transgender counterparts, with equally high burden for FTM and MTF youth.

  • Clinicians serving transgender youth should screen for mental health concerns.

  • Collecting gender-inclusive measures in electronic health records is recommended, including assigned sex at birth and current gender identity at patient registration.

Implications and Contributions.

Transgender youth were found to have a disparity in negative mental health outcomes compared to cisgender youth, with equally high burden in FTM and MTF youth. Identifying gender identity differences in clinical settings and providing appropriate services and supports are important steps in addressing this disparity.

Acknowledgments

Dr. Reisner and Dr. Mimiaga are partly supported by NIMH R01 MH094323-01A1. Dr. Shumer is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, 1T32HD075727-01.

Abbreviations

GM

gender minority

MTF

male-to-female

FTM

female-to-male

Footnotes

Financial Disclosure: The authors have no financial relationships relevant to this article to disclose.

Conflict of Interest: The authors have no conflicts of interest to disclose.

Contributors’ Statement

Sari L. Reisner: Dr. Reisner conceptualized and designed the study, conducted all statistical analyses, drafted the initial manuscript, and approved the final manuscript as submitted.

Ralph Vetters: Dr. Vetters conceptualized and designed the study, critically reviewed the manuscript, and approved the final manuscript as submitted.

M Leclerc: Co-Author Leclerc conducted manual chart review and data extraction from patient charts, conducted quality assurance activities to ensure integrity of the data, assisted with literature review for the manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted.

Shayne Zaslow: Co-Author Zaslow wrote the initial query to extract data from patient charts, designed the data collection instruments and database, assisted with data collection and quality assurance, reviewed and revised the manuscript, and approved the final manuscript as submitted.

Sarah Wolfrum: Co-Author Wolfrum assembled the matched cohort of patients for chart review, supervised data collection, conducted data quality reviews, reviewed and revised the manuscript, and approved the final manuscript as submitted.

Daniel Shumer: Dr. Shumer critically reviewed the manuscript, and approved the final manuscript as submitted.

Matthew J. Mimiaga: Dr. Mimiaga critically reviewed the manuscript, and approved the final manuscript as submitted.

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References

  • 1.Institute of Medicine (IOM) The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. Washington, DC: Institute of Medicine; 2011. [PubMed] [Google Scholar]
  • 2.Egan SK, Perry DG. Gender identity: a multidimensional analysis with implications for psychosocial adjustment. Developmental psychology. 2001 Jul;37(4):451–463. doi: 10.1037//0012-1649.37.4.451. [DOI] [PubMed] [Google Scholar]
  • 3.Grossman AH, D’Augelli AR. Transgender youth: invisible and vulnerable. Journal of homosexuality. 2006;51(1):111–128. doi: 10.1300/J082v51n01_06. [DOI] [PubMed] [Google Scholar]
  • 4.Olson J, Forbes C, Belzer M. Management of the transgender adolescent. Archives of pediatrics & adolescent medicine. 2011 Feb;165(2):171–176. doi: 10.1001/archpediatrics.2010.275. [DOI] [PubMed] [Google Scholar]
  • 5.Conron KJ, Landers SJ, Reisner SL, Sell RL. Sex and gender in the US health surveillance system: a call to action. Am J Public Health. 2014 Jun;104(6):970–976. doi: 10.2105/AJPH.2013.301831. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Grossman AH, D’Augelli AR. Transgender youth and life-threatening behaviors. Suicide & life-threatening behavior. 2007 Oct;37(5):527–537. doi: 10.1521/suli.2007.37.5.527. [DOI] [PubMed] [Google Scholar]
  • 7.Simons L, Schrager SM, Clark LF, Belzer M, Olson J. Parental support and mental health among transgender adolescents. The Journal of adolescent health: official publication of the Society for Adolescent Medicine. 2013 Dec;53(6):791–793. doi: 10.1016/j.jadohealth.2013.07.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Kosciw JG, Greytak EA, Bartkiewicz MJ, Boesen MJ, Palmer NA. The 2011 National School Climate Survey: The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools. New York, NY: GLSEN; 2012. [Google Scholar]
  • 9.Garofalo R, Deleon J, Osmer E, Doll M, Harper GW. Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. The Journal of adolescent health: official publication of the Society for Adolescent Medicine. 2006 Mar;38(3):230–236. doi: 10.1016/j.jadohealth.2005.03.023. [DOI] [PubMed] [Google Scholar]
  • 10.Mustanski BS, Garofalo R, Emerson EM. Mental health disorders, psychological distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths. Am J Public Health. 2010 Dec;100(12):2426–2432. doi: 10.2105/AJPH.2009.178319. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Burgess C. Internal and external stress factors associated with the identity development of transgender youth. In: Mallon G, editor. Social Services with Transgender Youth. New York, NY: Harrington Park Press; 1999. pp. 35–47. [Google Scholar]
  • 12.Cahill S, HM Sexual orientation and gender identity data collection in clinical settings and in electronic health records: A key to ending LGBT health disparities. LGBT Health. 2014;1(1):34–41. doi: 10.1089/lgbt.2013.0001. [DOI] [PubMed] [Google Scholar]
  • 13.Deutsch MB, Green J, Keatley J, Mayer G, Hastings J, Hall AM. Electronic medical records and the transgender patient: Recommendations from the World Professional Association for Transgender Health EMR Working Group. J Am Inform Assoc. doi: 10.1136/amiajnl-2012-001472. in press. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Edwards-Leeper L, Spack NP. Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “Gender Management Service” (GeMS) in a major pediatric center. Journal of homosexuality. 2012;59(3):321–336. doi: 10.1080/00918369.2012.653302. [DOI] [PubMed] [Google Scholar]
  • 15.Spack NP, Edwards-Leeper L, Feldman HA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics. 2012 Mar;129(3):418–425. doi: 10.1542/peds.2011-0907. [DOI] [PubMed] [Google Scholar]
  • 16.American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) (DSM-IV-TR) Washington, DC: American Psychiatric Association; 2000. [Google Scholar]
  • 17.Hidalgo MA, Ehrensaft D, Tishelman AC, et al. The gender affirmative model: What we know and what we aim to learn. Human Development. 2013;56(6):285–290. [Google Scholar]
  • 18.Schwartz S, Meyer IH. Mental health disparities research: the impact of within and between group analyses on tests of social stress hypotheses. Social science & medicine. 2010 Apr;70(8):1111–1118. doi: 10.1016/j.socscimed.2009.11.032. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Hedberg VA, Byrd RS, Klein JD, Auinger P, Weitzman M. The role of community health centers in providing preventive care to adolescents. Archives of pediatrics & adolescent medicine. 1996 Jun;150(6):603–608. doi: 10.1001/archpedi.1996.02170310037007. [DOI] [PubMed] [Google Scholar]
  • 20.Shin P, Sharac J, Alvarez C, Rosenbaum S. Community Health Centers in an Era of Health Reform: An Overview of Key Challenges to Health Center Growth. Washington, DC: Kaiser Family Foundtion; 2013. [Google Scholar]
  • 21.Rubin DB. Matched sampling for causal inference. New York, NY: Cambridge University Press; 2006. [Google Scholar]
  • 22.Hosmer DW, Lemeshow S. Applied Logistic Regression, 2nd edition. Danversa, MA: John Wiley & Sons; 2004. Chapter 7: Logistic Regression for Matched Case-Control Studies; pp. 223–259. [Google Scholar]
  • 23.Spiegelman D, Hertzmark E. Easy SAS calculations for risk or prevalence ratios and differences. American journal of epidemiology. 2005 Aug 1;162(3):199–200. doi: 10.1093/aje/kwi188. [DOI] [PubMed] [Google Scholar]
  • 24.Wallien MS, van Goozen SH, Cohen-Kettenis PT. Physiological correlates of anxiety in children with gender identity disorder. European child & adolescent psychiatry. 2007 Aug;16(5):309–315. doi: 10.1007/s00787-007-0602-7. [DOI] [PubMed] [Google Scholar]
  • 25.Toomey RB, Ryan C, Diaz RM, Card NA, Russell ST. Gender-nonconforming lesbian, gay, bisexual, and transgender youth: school victimization and young adult psychosocial adjustment. Developmental psychology. 2010 Nov;46(6):1580–1589. doi: 10.1037/a0020705. [DOI] [PubMed] [Google Scholar]
  • 26.Liu RT, Mustanski B. Suicidal ideation and self-harm in lesbian, gay, bisexual, and transgender youth. American journal of preventive medicine. 2012 Mar;42(3):221–228. doi: 10.1016/j.amepre.2011.10.023. [DOI] [PubMed] [Google Scholar]
  • 27.Hess DR. Retrospective studies and chart reviews. Respiratory care. 2004 Oct;49(10):1171–1174. [PubMed] [Google Scholar]
  • 28.Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Professional Psychology: Research and Practice. 2012;43(5):460–467. [Google Scholar]
  • 29.Reisner SL, Greytak EA, Parsons JP, Ybarra M. Gender minority social stress in adolescence: Disparities in adolescent bullying and substance use by gender identity. The Journal of Sex Research. doi: 10.1080/00224499.2014.886321. in press. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders. 5. Arlington, VA: American Psychiatric Association; 2013. (DSM-5) [Google Scholar]
  • 31.Bockting WO. Psychotherapy and the real life experience: From gender dichotomy to gender diversity. Sexologies. 2008;17:211–224. [Google Scholar]
  • 32.Kuper LE, Nussbaum R, Mustanski B. Exploring the diversity of gender and sexual orientation identities in an online sample of transgender individuals. Journal of sex research. 2012;49(2–3):244–254. doi: 10.1080/00224499.2011.596954. [DOI] [PubMed] [Google Scholar]
  • 33.Fausto-Sterling A. Sex/Gender: Biology in a Social World. New York, NY: Routledge; 2012. [Google Scholar]
  • 34.Braveman P. Health disparities and health equity: concepts and measurement. Annual review of public health. 2006;27:167–194. doi: 10.1146/annurev.publhealth.27.021405.102103. [DOI] [PubMed] [Google Scholar]
  • 35.U.S. Department of Health and Human Services (U.S. DHHS) [Accessed March 5, 2014];Health disparities. 2010 http://www.healthypeople.gov/2020/about/disparitiesAbout.aspx.
  • 36.Wolpert M, Ford T, Trustam E, et al. Patient-reported outcomes in child and adolescent mental health services (CAMHS): use of idiographic and standardized measures. Journal of mental health. 2012 Apr;21(2):165–173. doi: 10.3109/09638237.2012.664304. [DOI] [PubMed] [Google Scholar]
  • 37.Basch E, Torda P, Adams K. Standards for patient-reported outcome-based performance measures. JAMA: the journal of the American Medical Association. 2013 Jul 10;310(2):139–140. doi: 10.1001/jama.2013.6855. [DOI] [PubMed] [Google Scholar]
  • 38.Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007 Nov;120(5):e1313–1326. doi: 10.1542/peds.2006-1395. [DOI] [PubMed] [Google Scholar]
  • 39.Zuckerbrot RA, Cheung AH, Jensen PS, Stein RE, Laraque D, Group G-PS. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics. 2007 Nov;120(5):e1299–1312. doi: 10.1542/peds.2007-1144. [DOI] [PubMed] [Google Scholar]
  • 40.Adelson SL American Academy of C. Adolescent Psychiatry Committee on Quality I. Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 2012 Sep;51(9):957–974. doi: 10.1016/j.jaac.2012.07.004. [DOI] [PubMed] [Google Scholar]

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