Pathways to Care for Adolescents Attending a First Hormone Appointment at Canadian Gender Affirming Medical Clinics: A Cross-Sectional Analysis From the Trans Youth CAN! Study.

PURPOSE: Limited research has examined adolescents' pathways to gender-affirming medical care. METHODS: Enrollment in Trans Youth CAN! was at an initial appointment for hormone suppression or gender-affirming hormones, if pubertal or postpubertal, and < 16 years old. Adolescent/parent surveys and clinical records were obtained for 174 adolescents and 160 matched parents at 10 medical clinics across Canada. RESULTS: Participants' mean age was 14.3 years, 95% confidence interval (CI) [14.1-14.6]; 126 (75.8%) identified as boys, 32 (15.9%) girls, and 14 (8.3%) nonbinary. Average wait time after referral was 269 days (95% CI [244, 294]). Adolescents reported 13.5 months seeking gender-affirming medical care, longer than reported by their parents (p = .0001). Family physicians or pediatricians provided 68% of referrals. Prior to clinic, adolescents saw an average of 2.7 (maximum eight) different types of providers (95% CI [2.4, 2.9]). Indigenous background and greater number of types of providers seen were associated with longer time seeking care. The majority of adolescents had ever engaged in self-harm (67.6%), with 58.1% ever seriously considering suicide and 36.0% attempting. Previous self-harm and suicidal thoughts were associated with longer wait times and older age. Seventeen point seven percent of parents/caregivers reported their adolescents had participated in conversion therapy or that parents had considered it. DISCUSSION: The majority of participants were referred by family physicians or pediatricians, seeing multiple types of providers regarding their gender prior to referral. Adolescents experienced significant wait times. Indigenous adolescents reported longer times seeking care. Adolescents with longer wait times were more likely to have ever engaged in self-harm or had suicidal ideation.

Experiences and Stressors of Parents of Trans and Gender-Diverse Youth in Clinical Care from Trans Youth CAN!

Parents of trans and gender-diverse youth can experience challenges navigating gender-affirming (GA) care such as stigma, transphobia, and lack of support. There is little information available about stressors, worries, and positive feelings of parents as they try to support their youth accessing GA care. This article presents baseline survey data on experiences and stressors of 160 parents/caregivers in the Trans Youth CAN! cohort study, which examined medical, social, and family outcomes in youth age 16 years or younger considering puberty blockers or GA hormones. Data were collected at 10 Canadian gender clinics. Authors report on participating parents' characteristics, levels of support toward youth, stressors, worries, concerns, and positive feelings related to youth's gender. Most parent participants were White (85.1 percent), female (85.1 percent), birth or adoptive parents (96.1 percent), and reported strong support for youth's gender. Participants' concerns included their youth facing rejection (81.9 percent), generalized transphobia (74.6 percent), or encountering violence (76.4 percent). Parents also reported positive feelings about seeing their youth grow more confident. Most parental worries and stressors were situated outside the family, reflecting the systemic discrimination faced by youth and their families. Social workers could address these by developing systems-focused interventions and by further taking into account intersectional health disparities.

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.

Words with weight: The construction of obesity in eating disorders research.

In current public health discourse, obesity is conceptualized as a disease epidemic, with treatment being weight loss. The pursuit of weight loss as a treatment for the "disease" of obesity is in direct contradiction to the history of research in eating disorders, which has demonstrated the risks for the development of eating disorders. In this study, we critically examined the eating disorder literature to explore this contradiction. We analyzed 30 of the top-cited articles in the eating disorder literature between 1994 and 2011, asking: how is the concept of obesity examined in eating disorder research? We identified tensions related to body mass index and the perceived associated risks of lower or higher body mass index, assumptions of the "causes" of fatness (i.e. overeating and inactivity), and the anti-diet voice challenging the prescription of dieting for those in fat bodies. In our analysis, we highlight the problematics of, for instance, prescribing a body mass index range of 20-24 in eating disorder recovery, how many studies in eating disorders do not problematize the presumption that a higher body mass index is necessarily associated with ill health, and a lack of cultural sensitivity and acknowledgment of intersectional spaces of belonging. We discuss these themes in the context of biomedical discourses of obesity contributing to the cultural thin ideal. We argue that biomedical discourses on obesity contribute to the thin ideal nuanced against discourses of healthism that permeate our society. Rather than an ideal of emaciation, it is an ideal of a healthy, productive person, often constructed as morally superior. The moral panic around obesity is evident throughout the eating disorder literature, which is a concern given that we would hope that the aim of eating disorder treatment would be to promote wellness for all-not only those who are thin.

Primary Care Practitioner Training in Child and Adolescent Psychiatry (PTCAP): A Cluster-Randomized Trial.

OBJECTIVES: Rural primary care practitioners (PCPs) have a pivotal role to play in frontline pediatric mental health care, given limited options for referral and consultation. Yet they report a lack of adequate training and confidence to provide this care. The aim of this study was to test the effectiveness of the Practitioner Training in Child and Adolescent Psychiatry (PTCAP) program, which was designed to enhance PCPs' pediatric mental health care confidence. The program includes brief therapeutic skills and practice guidelines PCPs can use to address both subthreshold concerns and diagnosable conditions, themselves. METHODS: The study design was a pilot, cluster-randomized, multicenter trial. Practices were randomly assigned to intervention (n practices = 7; n PCPs = 42) or to wait-list control (n practices = 6; n PCPs = 34). The intervention involved 8 hr of training in practice guidelines and brief therapeutic skills for depression, anxiety, attention deficit hyperactivity disorder, and behavioral disorders with case discussion and video examples, while the control practiced as usual. A linear random-effects model controlling for clustering and baseline was carried out on the individual-level data to examine between-group differences in the primary (i.e., confidence) and secondary (i.e., attitude and knowledge) outcomes at 1-week follow-up. RESULTS: Findings were a statistically significant difference in the primary outcomes. Compared to the control group, the intervention group indicated significantly greater confidence in managing diagnosable conditions (d = 1.81) and general concerns (d = 1.73), as well as in making necessary referrals (d = 1.27) and obtaining consults (d = 0.74). While the intervention did not significantly impact secondary outcomes (attitudes and knowledge), regression analysis indicated that the intervention may have increased confidence, in part, by ameliorating the adverse impact of negative mental health care attitudes. CONCLUSION: PTCAP enhances PCPs' child/youth mental health care confidence in managing both general and diagnosable concerns. However, an 8-hr session focused on applying brief therapeutic skills was insufficient to significantly change attitudes and knowledge. Formal testing of PTCAP may be warranted, perhaps using more intensive training and including outcome assessments capable of determining whether increased PCP confidence translates to more effective management and better patient outcomes.

A Study Protocol for the "Practitioner Training in Child and Adolescent Psychiatry" Cluster-randomized Pilot Study.

BACKGROUND: Primary care providers (PCPs) are increasingly called upon to assist in meeting the growing demand for paediatric mental health care in Canada, yet they report inadequate training and confidence to do so. The Practitioner Training in Child and Adolescent Psychiatry (PTCAP) program was designed to fill this gap by teaching PCPs the skills needed to provide frontline care themselves, particularly in rural/remote regions where specialist resources are limited. This innovative educational intervention may improve paediatric mental health care capacity, but a pilot study is needed. METHODS: We designed a cluster randomized, controlled pilot of PTCAP. Random assignment to intervention or control (treatment-as-usual) will occur at the practice level. Participating PCPs (N=61) at sites randomized to intervention will receive eight hours of training in the use of practice guidelines and brief counseling techniques (i.e., common skills/elements) for addressing diagnosable conditions and more general, transdiagnostic concerns. Mental health care capacity at one-week post-intervention will be the primary outcome, assessed through self-report questionnaires of mental health care confidence, and through a more objective, observational assessment of trained skills. We will also examine retention of these skills at one-month follow-up. We expect use of trained common skills/elements to be associated with better child mental health outcomes on the Strengths and Difficulties Questionnaire (N = 250). DISCUSSION: As one of the first RCTs of its kind in Canada, this study will provide unique, preliminary evidence in regards to the feasibility and efficacy of the PTCAP intervention for enhancing rural, paediatric mental health care capacity.

CONTEXTE: Les prestataires de soins de première ligne (PSPL) sont de plus en plus sollicités pour aider à répondre à la demande croissante de soins de santé mentale pédiatriques au Canada, et pourtant, ils déplorent une formation et une confiance inadéquates pour ce faire. Le programme de Formation du médecin en psychiatrie de l'enfant et de l'adolescent (FMPEA) a été conçu pour combler cette lacune en enseignant aux PSPL les aptitudes nécessaires pour prodiguer eux-mêmes les soins de première ligne, particulièrement en région rurale/éloignée où les ressources de spécialistes sont limitées. Cette intervention éducative innovatrice peut améliorer la capacité des soins de santé mentale pédiatriques, mais une étude pilote est requise. MÉTHODES: Nous avons conçu un pilote contrôlé en grappes randomisées de la FMPEA. Cette assignation aléatoire de l'intervention ou du contrôle (traitement habituel) aura lieu au niveau de la pratique. Les PSPL participants (N = 61) aux endroits aléatoires de l'intervention recevront huit heures de formation en matière d'utilisation des lignes directrices de la pratique et de brèves techniques de consultation (c.-à-d., aptitudes/éléments communs) pour aborder les affections qui peuvent être diagnostiquées et des problèmes trans-diagnostiques plus généraux. À une semaine après l'intervention, la capacité des soins de santé mentale sera le principal résultat, évalué par des questionnaires auto-déclarés sur la confiance dans les soins de santé mentale, et par une évaluation observationnelle plus objective des aptitudes apprises. Nous examinerons également la rétention de ces aptitudes au suivi d'un mois. Nous prévoyons que l'utilisation des aptitudes/éléments communs appris soit associée à de meilleurs résultats de santé mentale des enfants au questionnaire des forces et des difficultés (N = 250). DISCUSSION: À titre d'un des premiers essais randomisés contrôlés (ERC) du genre au Canada, cette étude offrira des données probantes préliminaires uniques à l'égard de la faisabilité et de l'efficacité de l'intervention de FMPEA pour améliorer la capacité des soins de santé mentale pédiatriques en milieu rural.

Evaluating Training Programs for Primary Care Providers in Child/Adolescent Mental Health in Canada: A Systematic Review.

INTRODUCTION: The need for child/adolescent mental health care in Canada is growing. Primary care can play a key role in filling this gap, yet most providers feel they do not have adequate training. This paper reviews the Canadian literature on capacity building programs in child and adolescent psychiatry for primary care providers, to examine how these programs are being implemented and evaluated to contribute to evidence-based initiatives. METHODS: A systematic literature review of peer-reviewed published articles of capacity building initiatives in child/adolescent mental health care for primary care practitioners that have been implemented in Canada. RESULTS: Sixteen articles were identified that met inclusion criteria. Analysis revealed that capacity building initiatives in Canada are varied but rigorous evaluation methodology is lacking. Primary care providers welcome efforts to increase mental health care capacity and were satisfied with the implementation of most programs. DISCUSSION: Objective conclusions regarding the effectiveness of these programs to increase mental health care capacity is challenging given the evaluation methodology of these studies. CONCLUSION: Rigorous evaluation methods are needed to make evidence-based decisions on ways forward to be able to build child/adolescent mental health care capacity in primary care. Outcome measures need to move beyond self-report to more objective measures, and should expand the measurement of patient outcomes to ensure that these initiative are indeed leading to improved care for families.

INTRODUCTION: Le besoin de soins de santé mentale pour les enfants/adolescents s'accroît au Canada. Les soins de première ligne peuvent jouer un rôle clé pour combler ces besoins croissants, et pourtant, la plupart des prestataires de soins ne croient pas avoir de formation adéquate. Cet article examine la littérature canadienne sur les programmes de renforcement des capacités en pédopsychiatrie pour les prestataires de soins de première ligne, afin d'examiner comment ces programmes sont mis en oeuvre et évalués pour contribuer aux initiatives fondées sur les données probantes. MÉTHODES: Une revue systématique de la littérature et des articles révisés par les pairs publiés sur les initiatives de renforcement des capacités en soins de santé mentale aux enfants/adolescents pour les prestataires de soins de première ligne qui ont été mises en oeuvre au Canada. RÉSULTATS: Seize articles ont été repérés qui satisfaisaient aux critères d'inclusion, L'analyse a révélé que les initiatives de renforcement des capacités au Canada sont variées mais qu'il leur manque une méthodologie d'évaluation rigoureuse. Les prestataires de soins de première ligne acceptent volontiers les initiatives en vue d'accroître leur capacité en matière de soins de santé mentale et étaient satisfaits de la mise en oeuvre de la plupart des programmes. DISCUSSION: Des conclusions objectives sur l'efficacité de ces programmes de renforcement des capacités en soins de santé mentale sont difficiles étant donné la méthodologie d'évaluation de ces études. CONCLUSION: Des méthodes d'évaluation rigoureuses sont nécessaires pour prendre des décisions fondées sur les données probantes à l'égard des moyens de renforcer les capacités des soins de santé mentale pour enfants/adolescents dans les soins de première ligne. Les mesures des résultats doivent aller plus loin que l'auto-déclaration et adopter des mesures plus objectives, et devraient étendre la mesure des résultats des patients pour faire en sorte que ces initiatives mènent vraiment à de meilleurs soins pour les familles.

Perceptions of sexual assault victims/survivors: the influence of sexual history and body weight.

The intersection between a woman's body weight and sexual history and the victim blaming attitudes of future health care providers was investigated. University undergraduate students (N = 91) enrolled in programs associated with the provision of health care read 1 of 4 patient files of a woman reporting a rape as well as 2 distracter files. Results showed that, for overweight rape victims/survivors, study participants' antifat attitudes were correlated with victim blaming attitudes. Male participants held the attacker significantly less responsible than did female participants if the victim/survivor had several previous sexual partners. Findings suggest that body weight should be considered as a contributing factor in attitudes toward rape victims/survivors, and the gender of the health care provider can be a factor in the post-assault treatment of overweight rape victims/survivors.