318 - Timelines from Dysphoria Onset to First Appointment with Pediatric Endocrinology: Age, Pubertal Stage, and Delays in Care Among Transgender and Gender Diverse Youth in New York City

Publication Number: 318.6936

Rachel G.. Kasdin, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Farimata Mbaye, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Daniela K. Shill, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Neha R. Malhotra, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Ralph Fader, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Christopher J. Romero, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Mabel Yau, The Mount Sinai Kravis Children's Hospital, New York, NY, United States

Background: Care of transgender and gender-diverse (TGD) pediatric patients includes gonadotropin-releasing hormone analogue (GnRHa) therapy to suppress puberty and gender affirming hormonal therapy (GAHT) to align physical traits with gender identity. As puberty progresses, secondary sexual characteristics are more pronounced and GnRHa therapy is less clinically impactful. Younger age of presentation is associated with lower rates of depression, anxiety and suicidality. However, trends in timing and pubertal stage at care initiation are not well understood.

Objective: To identify the timeline from onset of dysphoria to access to gender-affirming care including age and Tanner stage in TGD youth in order to provide guidelines in the optimization of timing and personalization of treatment.

Design/Methods: A retrospective chart review was conducted at an outpatient pediatric endocrinology clinic in NYC. Inclusion criteria were TGD identity confirmed by mental health evaluation, age 22 years, and care initiation between 2020-23. Charts were reviewed for demographics, history of dysphoria, timelines of initial care, and Tanner Staging at first visit. Primary outcomes included timing from onset to disclosure of dysphoria and to first endocrinology visit, as well as Tanner Stage at presentation.

Results: 89 patients (Table 1) met inclusion criteria. 42% were transgender girls, 45% transgender boys, and 14% nonbinary. 47% were assigned male at birth (AMAB), 52% assigned female at birth (AFAB), and 1% assigned intersex. The mean age of first dysphoria was 11.75 years, disclosure to guardians 12.96 years, and first visit to pediatric endocrinology 15.03 years. Transgender girls presented for care younger than transgender boys (14.47 vs. 15.57 years). At initial presentation, 75% of AFAB patients were Tanner Stage 5, while most AMAB patients were Tanner Stage 3 (32%) or 4 (38%); 6% of patients were pre-pubertal.

Conclusion(s): Pubertal stage at initial presentation guides counseling and management options. Delays in care typically occur after disclosure of dysphoria and prior to involvement of healthcare providers, likely due to personal, familial, and societal factors. Transgender girls tend to present for GAHT earlier in puberty when development of unwanted secondary sexual characteristics can be halted. Transgender boys mostly present in late puberty, perhaps owing in part to younger onset of AFAB puberty, when GnRHa therapy has limited effect. Facilitating timely access to endocrinology care for TGD youth increases management options, better supporting alignment of care with personal and familial preferences.

Table 1: Initial Presentation to Pediatric Endocrinology 
PedsEndo_Table1.pdf*Tanner Stage unknown due to factors such as deferral of examination for patient comfort or nature of limitations to physical exams in telehealth intake appointments.