Transgender Youth Referred to Clinics for Gender-Affirming Medical Care in Canada.

BACKGROUND AND OBJECTIVES: Referrals of transgender and gender-diverse (trans) youth to medical clinics for gender-affirming care have increased. We described characteristics of trans youth in Canada at first referral visit. METHODS: Baseline clinical and survey data (2017-2019) were collected for Trans Youth CAN!, a 10-clinic prospective cohort of n = 174 pubertal and postpubertal youth <16 years with gender dysphoria, referred for hormonal suppression or hormone therapy, and 160 linked parent-participants. Measures assessed health, demographics, and visit outcome. RESULTS: Of youth, 137 were transmasculine (assigned female) and 37 transfeminine (assigned male); 69.0% were aged 14 to 15, 18.8% Indigenous, 6.6% visible minorities, 25.7% from immigrant families, and 27.1% low income. Most (66.0%) were gender-aware before age 12. Only 58.1% of transfeminine youth lived in their gender full-time versus 90.1% of transmasculine (P < .001). Although transmasculine youth were more likely than transfeminine youth to report depressive symptoms (21.2% vs 10.8%; P = .03) and anxiety (66.1% vs 33.3%; P < .001), suicidality was similarly high overall (past-year ideation: 34.5%, attempts: 16.8%). All were in school; 62.0% reported strong parental gender support, with parents the most common support persons (91.9%). Two-thirds of families reported external gender-related stressors. Youth had met with a range of providers (68.5% with a family physician). At clinic visit, 62.4% were prescribed hormonal suppression or hormone therapy, most commonly depot leuprolide acetate. CONCLUSIONS: Trans youth in Canada attending clinics for hormonal suppression or gender-affirming hormones were generally healthy but with depression, anxiety, and support needs.

Treatment Needs and Rates of Mental Health Comorbidity in Adolescent Patients With ARFID.

The purpose of this paper is to provide a descriptive overview of a single-center ARFID-specific pilot clinic that sought to better understand the specific needs of patients with ARFID including rates of comorbidities, and to gain insight into treatment requirements. A retrospective cohort study was completed on patients meeting criteria for ARFID admitted to a specialized pilot clinic within a tertiary care hospital. Over an 18 month period, a total of 26 patients were assessed and had follow-up data for a 12 month period. Patients presented with heterogeneous manifestations of ARFID and high rates of comorbid mood and anxiety disorders were noted. Treatment plans were tailored to meet individual needs at assessment and over the treatment period. A multidisciplinary approach was most often administered, including a combination of individual therapy, family therapy, medical monitoring, and prescribed medications. Only 30% of patients were treated exclusively by therapists on the eating disorder team. The experiences gained from this pilot study highlight the need for specialized resources for assessment and treatment of patients with ARFID, the importance of a multidisciplinary approach to treatment, and the necessity of utilization of ARFID-specific measures for program evaluation purposes.

The impact of COVID-19 on adolescents with eating disorders: a cohort study.

BACKGROUND: There is a noticeable lack of evidence regarding the impact of COVID-19 and the associated lockdown on young people with eating disorders. The goals of this study were 1) to examine characteristics of adolescents presenting for eating disorder (ED) assessment since the onset of the COVID-19 pandemic; 2) to compare adolescents presenting for ED assessment since the onset of the COVID-19 pandemic to those that presented for assessment 1 year previously; 3) to examine implications of the pandemic on the system of care. METHODS: A retrospective chart review was completed on all patients assessed at a pediatric tertiary care ED program during the pandemic between April 1 and October 31, 2020, and on youth assessed during the same time frame 1 year previously. Data including body measurements and results of psychological measures was extracted from patients' charts. Clinician reports were utilized for accounts of ED symptoms. Referrals to our program were also compared for the two time periods. RESULTS: Of the 48 youth assessed between April and October 2020, average age was 14.6 years and average percentage of treatment goal weight was 77.7%. 40% cited the pandemic as a trigger for their ED; of these youth, 78.9% were medically unstable compared to 55.2% of those whose ED was not triggered by the pandemic. When comparing the 2020 cohort to those assessed in 2019, youth who presented for assessment during the pandemic trended towards having lower percentage of goal weights and higher rates of self-reported impairment, and were significantly more likely to be medically unstable (p = 0.005) and to require hospitalization (p = 0.005). Higher rates of inpatient admissions, emergency room consultation requests and outpatient referrals deemed "urgent" were likewise associated with the pandemic period. CONCLUSIONS: During the COVID-19 pandemic, youth assessed for an ED presented with high rates of medical instability and need for hospitalization. Caring for these youth may be more challenging during the pandemic, when access to services may be limited. Further research is required to better understand the impact of the pandemic on the clinical course and outcomes of EDs in adolescents.

The objective of this study was to examine characteristics of adolescents presenting for eating disorder (ED) assessment during the COVID-19 pandemic, and also to compare them to a similar group assessed 1 year previously. A review of medical charts was completed on patients assessed at a pediatric ED program between April 1 and October 31, 2020 and on patients assessed between April 1 and October 31, 2019. Forty-eight adolescents were assessed during the pandemic-specific timeframe and 43 were assessed during the same timeframe the year previously. Forty percent of those in the 2020 cohort cited pandemic effects as a trigger for their ED; these youth had a shorter course of illness and were somewhat more likely to be medically compromised compared to those whose ED was not triggered by the pandemic. Compared to those seen in 2019, adolescents assessed for an ED in 2020 exhibited higher rates of nutritional restriction and functional impairment, were significantly more likely to be medically unstable, and required more hospitalizations or urgent consultations. Further research is required to better understand the impact of COVID-19 on the clinical course and outcomes of EDs in youth.

Gender diversity training in Canadian paediatric postgraduate medical education: A needs assessment survey.

OBJECTIVES: Evaluate the current state of postgraduate medical education on gender diversity in Canadian paediatric residency programs, exploring both resident and program director perceptions. BACKGROUND: Primary care providers are seeing more gender diverse children and youth in their offices, along with an exponential growth in referrals to Canadian specialty clinics and potential for significant mental health comorbidities. Gender-affirming support and management have been shown to improve overall outcomes. There is no mandatory curriculum on gender diversity for Canadian paediatric residency programs. METHODS: Cross-sectional online surveys in English and French distributed to program directors (PDs) and paediatric residents in the 17 Canadian paediatric residency programs. Data were analyzed by descriptive statistics with 95% confidence intervals. RESULTS: Response rate was 88.2% from PDs and 24.5% from paediatric residents. Among PDs, 14.3% (95% confidence interval [CI]: 6.3, 22.3) reported a formal curriculum for gender diversity teaching. Sixty-four per cent (53.3, 75.2) of PDs estimated their residents received ≤ 2 hours teaching on gender diversity. Residents reported comfort levels ≤ 50% on specific topics. Among residents, 73.8% (67.9, 79.6) reported that mandatory time in a gender diversity clinic would be the most effective teaching tool while PDs favoured an online module (66.7% [58.2, 75.1]). Barriers to more teaching included lack of time in a busy curriculum. Over 90% of resident indicated that more teaching on gender diversity is required. CONCLUSIONS: Significant variability in education on gender diversity is seen amongst Canadian paediatric residency programs. Discussion regarding a formal paediatric curriculum on gender diversity is needed.

The experiences of gender diverse and trans children and youth considering and initiating medical interventions in Canadian gender-affirming speciality clinics.

Background: Canadian specialty clinics offering gender-affirming care to trans and gender diverse children and youth have observed a significant increase in referrals in recent years, but there is a lack of information about the experiences of young people receiving care. Furthermore, treatment protocols governing access to gender-affirming medical interventions remain a topic of debate. Aims: This qualitative research aims to develop a deeper understanding of experiences of trans youth seeking and receiving gender-affirming care at Canadian specialty clinics, including their goals in accessing care, feelings about care and medical interventions they have undergone, and whether they have any regrets about these interventions. Methods: The study uses an adapted Grounded Theory methodology from social determinants of health perspective. Thirty-five trans and gender diverse young people aged 9 to 17 years were recruited to participate in semi-structured interviews through the specialty clinics where they had received or were waiting for gender-affirming medical interventions such as puberty blockers, hormone therapy, and surgery. Results: Young people felt positively overall about the care they had received and the medical interventions they had undergone, with many recounting an improvement in their well-being since starting care. Most commonly shared frustrations concerned delays in accessing interventions due to clinic waiting lists or treatment protocols. Some youth described unwanted medication side-effects and others said they had questioned their transition trajectory at certain moments in the past, but none regretted their choice to undergo the interventions. Discussion : The results suggest that trans youth and gender diverse children are benefiting from medical gender-affirming care they receive at specialty clinics, providing valuable insight into their decision-making processes in seeking care and specific interventions. Providers might consider adjusting aspects of treatment protocols (such as age restrictions, puberty stage, or mental health assessments) or applying them on a more flexible, case-by-case basis to reduce barriers to access.

Evaluation of the Effectiveness and Safety of Olanzapine as an Adjunctive Treatment for Anorexia Nervosa in Adolescents: An Open-Label Trial.

OBJECTIVES: To evaluate the effectiveness and safety of adjunctive olanzapine treatment for low weight adolescents with anorexia nervosa (AN). METHODS: A non-randomized open-label trial was conducted between 2010 and 2014. Participants received standard treatment and were invited to take olanzapine at study enrollment. Participants could accept, continue, or discontinue olanzapine as treatment progressed. Weight and psychological outcomes were monitored. RESULTS: Of 239 adolescents assessed, 65 met inclusion criteria, 38 enrolled in the study, and 32 were retained for analysis. Twenty-two participants took olanzapine (medication group) and ten participants did not (comparison group). Participants in the medication group demonstrated a higher rate of weight gain compared to those who did not receive olanzapine (p = .012). No serious adverse events were noted, although seven participants (31.8%) discontinued olanzapine due to a side effect. CONCLUSION: Preliminary results suggest that olanzapine may help facilitate weight gain in adolescents with AN. The importance of medical monitoring over the course of treatment is discussed. Evaluation of the Efficacy and Safety of Olanzapine for Anorexia Nervosa in Children and Adolescents; http://clinicaltrials.gov; NCT01184443.

OBJECTIFS: Évaluer l'efficacité et l'innocuité d'un traitement d'appoint par olanzapine pour les adolescents de faible poids souffrant d'anorexie mentale (AM). MÉTHODES: Un essai ouvert non randomisé a été mené entre 2010 et 2014. Les participants ont reçu un traitement standard et ont été invités à prendre de l'olanzapine lors de l'inscription à l'étude. Les participants pouvaient accepter, continuer ou cesser l'olanzapine à mesure que le traitement progressait. Le poids et les résultats psychologiques ont été surveillés. RÉSULTATS: Sur les 239 adolescents évalués, 65 satisfaisaient aux critères d'inclusion, 38 se sont inscrits à l'étude, et 32 ont été retenus pour analyse. Vingt-deux participants ont pris de l'olanzapine (groupe du médicament) et 10 participants n'en ont pas pris (groupe de comparaison). Les participants du groupe du médicament ont démontré un taux plus élevé de prise de poids comparativement à ceux qui n'ont pas reçu d'olanzapine (p = 0,012). Aucun effet indésirable sérieux n'a été noté, bien que 7 participants (31,8 %) aient cessé l'olanzapine en raison d'un effet secondaire. CONCLUSION: Les résultats préliminaires suggèrent que l'olanzapine peut aider à faciliter la prise de poids chez les adolescents souffrant d'AM. L'importance de la surveillance médicale en cours de traitement est discutée. Evaluation of the Efficacy and Safety of Olanzapine for Anorexia Nervosa in Children and Adolescents; http://clinicaltrials.gov; NCT01184443.

Exploring the association between eating disorders and gender dysphoria in youth.

This study reviews the overlap between eating disorders (EDs) and gender dysphoria (GD) in an adolescent population. A retrospective chart review was conducted on a clinical population presenting for concerns of GD. It was noted that five of the 97 patients had been found to be suffering from an ED at presentation. An additional 10 patients were noted to have ED-related symptoms. Although ED risk was elevated in trans males and females, absolute risk was higher in trans males when compared to population based prevalence rates. Our results suggest that rates of EDs and ED-related symptoms are high in patients presenting with GD, and that standard screening for these symptoms should be considered in both populations at assessment and over the course of treatment.

Gastrointestinal complications associated with anorexia nervosa: A systematic review.

OBJECTIVE: A systematic review identifying gastrointestinal (GI) complications attributable to anorexia nervosa (AN) was completed. METHOD: Studies of any design exploring the pathogenesis of complications and treatment strategies were included. The review was completed in accordance with PRISMA standards. RESULTS: A total of 123 articles were retained, including one randomized control trial. The majority of included studies were case reports and case series. Controlled studies demonstrated that patients with AN were more likely to have delays in gastric motility, gastric emptying and intestinal transit than comparator groups although results were not uniform across all studies. Published reports suggest that complications can occur at any segment of the GI tract. These issues may derive as a consequence of severe malnourishment, from eating disorder related symptoms such as self-induced purging or from the refeeding process itself. Multiple studies noted that patients with AN report high rates of GI symptoms although in the few cases where medical testing was undertaken, correlations between self-reported symptoms and measurable pathology were not demonstrated. DISCUSSION: GI complications may occur throughout the entire GI tract in patients with AN. It is recommended that clinicians use careful judgment when pursuing targeted investigation or introducing symptom specific treatments in response to GI complaints. Evidence suggests that most GI complications resolve with refeeding and cessation of ED symptoms.

A family-based eating disorder day treatment program for youth: examining the clinical and statistical significance of short-term treatment outcomes.

This article describes an innovative family-based day treatment program (DTP) for youth with moderate to severe eating disorders. A sample of 65 youth completed a battery of psychological measures pre- and post-treatment and 6 months after program completion. Treatment outcomes were assessed in three main domains: (a) medical stabilization, (b) normalization of eating behavior, and (c) improved psychological functioning. Overall, patients demonstrated statistically significant and clinically meaningful improvements on all outcome measures. Findings indicate that a comprehensive DTP can successfully facilitate positive outcomes in youth with eating disorders and that these improvements can be maintained 6 months post-treatment.

Eating disorder symptom severity scale: a new clinician rated measure.

This study describes the development and validation of the clinician-rated Eating Disorder Symptom Severity Scale (EDS(3)), created to address a gap in measurement options for youth with eating disorders. The EDS(3) is modeled on the Childhood Severity and Acuity of Psychiatric Illness Scales (Lyons, J. S, 1998). Factor analysis revealed a 5-factor solution and accounted for 78% of the variance, and internal consistency within the subscales was good (Cronbach alphas: 0.69 to 0.93). The EDS(3) is a valid and reliable measure designed for clinicians to help assess the severity of a youth's eating disorder and to facilitate outcomes research.

BodySense: an evaluation of a positive body image intervention on sport climate for female athletes.

The goal of the present study was to evaluate the effectiveness of a selective prevention program designed to reduce pressures to be thin in sport, and to promote positive body image and eating behaviors in young female athletes. Participants were competitive female gymnasts (aged 11 to 18 years), parents, and coaches from 7 gymnastic clubs across Ontario, Canada. Four of the seven clubs were randomized to receive the 3-month intervention program (IG) aimed at increasing awareness and positive climate change of body image pressures for athletes in their clubs. Three clubs were randomized to the control group (CG). A total of 62 female gymnasts (IG n = 31; CG n = 31) completed self-report questionnaires examining perceptions of pressure to be thin within their sports clubs, self-efficacy over dieting pressures, awareness and internalization of societal pressure to be thin, body esteem, and eating attitudes and behaviours before and following the intervention. A total of 32 mothers (IG n = 24; CG n = 8) completed measures examining their perceptions of their daughter's pressure to be thin, awareness and internalization of societal pressures to be thin, daughter's self-efficacy over dieting pressures, in addition to mothers' beliefs regarding thinness and success for women in society, before and following the intervention. The findings revealed that participation in the BodySense program resulted in athletes perceiving a reduction in pressure from their sports clubs to be thin, though no changes were found in body esteem, the EAT, or the SATAQ. No significant change was observed over time on mothers' measures. The role of climate change for prevention of eating disorders in athletes is discussed.

Evaluation of the efficacy and safety of olanzapine as an adjunctive treatment for anorexia nervosa in adolescent females: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Anorexia Nervosa (AN) is a serious, debilitating condition that causes significant physical, emotional, and functional impairment. The condition is characterized by destructive weight loss behaviours and a refusal to maintain body weight at or above a minimally normal weight for age and height. AN often develops in adolescence and is a predominantly female disorder. Treatment for AN typically involves medical, nutritional and psychological interventions. Pharmacotherapy is also often used; however, the literature on the effectiveness of these drugs in a pediatric population is very limited. Olanzapine, which is an 'atypical' antipsychotic, is becoming more widespread in the treatment of AN. Olanzapine is hypothesized to facilitate weight gain, while decreasing levels of agitation and decreasing resistance to treatment in young women with AN. This randomized, double-blind placebo-controlled trial seeks to examine the effectiveness and safety of olanzapine in female youth with AN. METHODS/DESIGN: Adolescent females between the ages of 12 and 17 diagnosed with AN (either restricting or binge/purge type) or Eating Disorder Not Otherwise Specified with a Body Mass Index of less than or equal to 17.5, will be offered inclusion in the study. Patients will be randomly assigned to receive either olanzapine or placebo. Patients assigned to receive olanzapine will start at a low dose of 1.25 mg/day for three days, followed by 2.5 mg/day for four days, 5 mg/day for one week, then 7.5 mg/day (the target dose chosen) for 10 weeks. After 10 weeks at 7.5 mg the medication will be tapered and discontinued over a period of two weeks. The effectiveness of olanzapine versus placebo will be determined by investigating the change from baseline on measures of eating attitudes and behaviors, depression and anxiety, and change in Body Mass Index at week 12, and after a follow-up period at week 40. It is anticipated that 67 participants will be recruited over two years to complete enrollment. DISCUSSION: Randomized controlled trials designed to measure the safety and effectiveness of olanzapine in comparison to placebo are desperately needed, particularly in the adolescent population. TRIAL REGISTRATION: Current Controlled Trials ISRCTN23032339.