ABSTRACT
BACKGROUND: Gender-incongruent youth may present to gender-affirming medical care (GAMC) later in adolescence and puberty when hormone blockers provide less benefit. Factors influencing age of presentation to GAMC have not been described. METHODS: A sequential mixed methods study. Participants were categorized on the basis of age at presentation to GAMC. Youth presenting at ≥15 years comprised the older-presenting youth, whereas those presenting at <15 years comprised the younger-presenting youth. Caregivers were categorized on the basis of the youth's age of presentation. Twenty-four individuals were interviewed, 6 youth and 6 caregivers from each age category. Thematic analysis identified themes related to timing of presentation to GAMC. Themes differentially endorsed between older and younger youth or between caregivers of older and younger youth were used to design a questionnaire distributed to 193 youths and 187 caregivers. Responses were compared between age groups for youths and caregivers. RESULTS: Five themes differed between age groups: validity of gender identity, gender journey barriers, influential networks, perceptions of medical therapy, and health care system interactions. Questionnaires were completed by 121 youths and 121 caregivers. Compared with younger-presenting youth, older-presenting youth recognized gender incongruence at older ages, were less likely to have caregivers who helped them access care or LGBTQ+ (lesbian, gay, bisexual, transgender, queer) family members, more often endorsed familial religious affiliations, and experienced greater youth-caregiver disagreement around importance of GAMC. CONCLUSIONS: Family environment appears to be a key determinant of when youth present to GAMC. Whether this association occurs through affecting transgender identity formation and recognition requires further study.
