Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations

An Endocrine Society Scientific Statement

Alicia M. Diaz-Thomas; Sherita Hill Golden; Dana M. Dabelea; Adda Grimberg; Sheela N. Magge; Joshua D. Safer; Daniel E. Shumer; Fatima Cody Stanford

Disclosures

J Clin Endocrinol Metab. 2023;108(7):1533-1584.

Abstract and Introduction

Abstract

Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions—growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.

Introduction

Recognizing that health disparities exist among population subgroups with respect to disease burden, comorbidities, and outcomes, the Endocrine Society released its inaugural scientific statement on health disparities in 2012. These disparities continue to be pervasive throughout the world, making inequities in health and health care among the most pressing issues facing science and medicine today. Our expanded understanding of factors that contribute to these disparities recognizes that biological differences associated with poor disease outcomes in marginalized communities result from unequal access to high-quality health care and social conditions and policies that perpetuate health inequities. In 2008, the World Health Organization (WHO) Committee on Social Determinants of Health (SDoH) published a report proposing the ambitious goal of achieving health equity within a generation stating "Social injustice is killing people on a grand scale".^[1]

Given endocrinology's expansive scope, the inaugural statement focused on health disparities in highly prevalent endocrine conditions in adults. These included type 2 diabetes mellitus (T2D) and related conditions (prediabetes and diabetes complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. A high-level summary of findings from the 2012 scientific statement is included in Table 1. The statement reported that that for certain endocrine disorders (1) there were discrepancies between incidence and mortality by race/ethnicity and sex; (2) obesity and body fat distribution were important contributors to race/ethnic and sex differences in disease incidence and outcomes; (3) heterogeneity in subgroups of Hispanic American and Asian American people resulted in disparities within these groups, and (4) genetic differences were not significant contributors to disparities. Several themes emerged in the statement, including a need for basic science and translational studies to explore underlying molecular mechanisms that may contribute to endocrine health disparities, in addition to the need to explore the etiology in clinical, population-based, and health services research studies.

Since publication of the 2012 scientific statement, health and health care disparities have continued to plague our societies globally, as highlighted by the COVID-19 pandemic. Endocrine conditions, particularly diabetes and obesity, have been highlighted as enhancing mortality risk among people with COVID-19. Because these endocrine disorders are highly prevalent in Black, Hispanic, Native American, and Pacific Islander communities, people in these groups have experienced higher mortality rates in the setting of COVID-19. The disproportionate impact of health disparities on these populations again highlights the importance of addressing the underpinnings of these disparities and working to eradicate them. Most recently, medical societies have acknowledged that race is a social and not biological construct, and gender "inhabits a complex social system that structures the life experience of human beings".^[2,3] Several medical societies, including the Endocrine Society, have called for the re-examination, if not elimination, of race-based medicine.^[4]

Several endocrine conditions and vulnerable populations were not addressed in the inaugural statement due to insufficient data. However, over the last 10 years, new information has drawn attention to additional populations where disparities in endocrinology also exist. This updated scientific statement will examine disparities in and barriers to care in pediatric endocrine health disorders and endocrine care of adult and pediatric sexual and gender minority populations (SGM; eg, lesbian, gay, bisexual, transgender, queer/questioning [LGBTQ] persons). We will also conceptualize contributors to health and health care disparities with an eye toward multilevel interventions that have been shown to reduce disparities and improve clinical outcomes. While the bulk of the information presented here reflects United States (US) populations, international data will be addressed in conditions where sufficient information exists.

Research suggests that many health disparities experienced in adulthood are rooted in early childhood. For instance, exposure to stressors (in pediatrics often described as adverse childhood experiences) can negatively affect health over a person's lifetime, disrupting metabolic, neurological and immunological systems, and contributing to poor developmental outcomes.^[5] There are race/ethnic/sex differences in adverse childhood experiences. Health disparities in pediatrics may negatively contribute to and complicate care for children with chronic endocrine conditions and further negatively exacerbate downstream adult morbidity and mortality. Examination of health disparities in pediatric endocrine disorders must also consider the unique characteristics of child developmental stages and the impacts of health disparities at each of these junctures, many of which are believed to be critical "windows," biologically and psychosocially. Moreover, infants, children, and teenagers do not function as independent agents of their own health care; they are subject to the ability of parents or guardians to function effectively in the health care system and society at large, and are thus characterized as vulnerable populations.

In SGM populations, health disparities exist in cardiovascular disease, malignancies, fertility, and in the ability to access necessary, timely, and appropriate high-quality medical care. We will examine how these disparities may be exacerbated by the intersection of racism, transphobia, and sexism.^[6] Restrictive environments, where care is expressly prohibited, are especially deleterious for both physical and mental health outcomes for SGM populations.

In addition to examining the biological consequences of race, ethnicity, and sex in pediatric endocrine and SGM populations, we include an overview of structural factors that contribute to health disparities in these populations. With the COVID-19 pandemic, modalities of care expanded and new avenues opened for routine care of endocrine patients, such as telehealth. As noted in the 2022 Appropriate Use of Telehealth Visits in Endocrinology: Policy Perspective of the Endocrine Society, careful consideration will need to be given about how to use these tools to improve health equity, not exacerbate existing injustices.^[7] The 2003 Institute of Medicine report, "Unequal Treatment,"^[8] did not include SGM and pediatric populations as data then were scarce; however, issues perpetuating health disparities related to the health care system, the provider, and the patient continue to hold true for multiple marginalized populations almost 20 years after its publication.

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Table 1. Major race/ethnic and sex disparities in adults
Discrepancies in endocrine disease incidence and mortality	Compared with non-Hispanic White (NHW) populations, non-Hispanic black (NHB) populations have worse outcomes and higher mortality from certain disorders despite having a lower (eg, macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (eg, thyroid cancer) incidence of these disorders • Inadequate access to high-quality health care among minoritized populations
	NHBs with diabetic nephropathy have lower mortality on dialysis than NHW despite higher incidence of end-stage renal disease
Contributions of obesity to endocrine disease disparities	Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that interventions targeting weight loss may favorably impact multiple endocrine disorders.
	There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian Americans and overestimation in NHB women • Ethnic-specific thresholds for central obesity should be determined so that clinicians can adequately assess metabolic risk
Sex differences in endocrine disorders	Sex disparities exist in certain endocrine disorders, with autoimmune thyroid disease and cardiovascular complications of diabetes being more common in women than men
Identifying heterogeneity in race/ethnic groups	A major gap in our current understanding of race/ethnic disparities in endocrine disorders is a failure of most studies to specify Hispanic American and Asian American subgroups • Where these data are available, clear ethnic-specific differences exist within Hispanic and Asian subgroups, particularly related to diabetes and obesity risk In general, there are few data on endocrine disorders in AIAN
Genetic contributors to endocrine disorder disparities	There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined, but significant heterogeneity and admixture^a among populations may mask genetic differences in GWAS studies

Reprinted from Reprinted from Golden SH, et al. J Clin Endocrinol Metab. 2012; 97(1): e1579-e1639. © Endocrine Society. (9)
^aRefers to being biracial or multiracial.
Abbreviations: AIAN; GWAS.

Table 2. Definitions of race and ethnic groups
	Race/ethnic groups
Non-Hispanic Black (NHB)	Individuals with descent from any of the Black racial groups of Africa (eg, African American, African, Afro-Caribbean)
Non-Hispanic White (NHW)	Nonminoritized individuals of White European descent but not of Hispanic ethnicity
Hispanic	Individuals with descent from Cuba, Mexico, Puerto Rico, South or Central America, or other Spanish culture or origin, regardless of race
Asian	Individuals with descent from the following regions: • Central Asia (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan) • East Asia (China [including Macau and Hong Kong], Japan, Mongolia, North Korea, South Korea, Taiwan) • South Asia (Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka) • Southeast Asia (Burma, Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, Timor-Leste, and Vietnam) • Western Asia (Armenia, Azerbaijan, and Georgia)
Middle Eastern and North African (MENA)	Individuals with descent from the following regions: • Middle East (Bahrain, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Palestine Qatar, Saudi Arabia, Syria, United Arab Emirates, Yemen • North Africa (Algeria, Egypt, Libya, Morocco, Sudan, Tunisia)
Indigenous Peoples	• American Indians and Alaska Natives—individuals with descent in any of the original peoples of North and South America (including Central America) born and/or residing in the United States and who maintains tribal affiliation or community attachment • Non-American indigenous individuals
Native Hawaiian/Other Pacific Islander	Individuals with descent from the original peoples of Polynesia, Micronesia, and Melanesia • Polynesia includes American Samoa, Hawaii, Samoa, , Tahiti, Tokelau, and Tonga • Micronesia includes Chuuk, Guam, Kiribati, Kosrae, Mariana Islands, Marshall Islands, Palau, Pohnpei, Saipan, and Yap • Melanesia includes Fiji, Papua New Guinea, Solomon Islands, and Vanuatu

United States Census Bureau. Office of Management and Budget (OMB) Standards. 2020. United States Census Bureau. Washington, DC.; Defining Diaspora: Asian, Pacific Islander, and Desi Identities. 2021. Cross-Cultural Center, California State University, San Marcos (11, 12).

Table 3. Gender identity definitions
Descriptor	Definition
Cisgender	Person whose gender identity aligns with the sex recorded at birth
Transgender/Trans	• Used umbrella terms describing gender identity that is not cisgender Transgender Female/Transfeminine/Trans woman • Person recorded male at birth but who has a gender identity on the feminine spectrum
	Transgender Male/Transmasculine/Trans man • Person who was recorded female at birth but who has a gender identity on masculine spectrum
Genderqueer	Person whose gender identity and/or gender expression falls outside of the masculine/feminine gender binary
Nonbinary	Person who does not exclusively have a gender identity that is either male or female
Agender	Person who does not identify with any gender
Intersex	General term for conditions in which a person is born with reproductive or sexual anatomy that does not fit the typical definition of male or female (also known as differences in sexual differentiation). Intersex individuals may incorporate their being intersex as an important element of identity similar to sexual orientation and gender identity (17)

Safer JD & Tangpricha V. N Engl J Med. 2019; 381(25):2451–2460; Shumer DE et al. Adv Pediatr. 2016; 63(1):79–102. (15, 16)

Table 4. Sexual orientation definitions
Descriptor	Definition
Straight	Person who identifies as a heterosexual and is attracted to members of the opposite gender in a binary view of gender such as men attracted to women and vice versa (not lesbian or gay)
Lesbian	A woman who is emotionally, romantically, sexually, affectionately, or relationally attracted to other women or who identifies as lesbian
Gay	A person who is emotionally, romantically, sexually, affectionately, or relationally attracted to others of the same sex or who identifies as being gay. The term is often used to describe when men are attracted to men. However, the term is also used by some as an umbrella term to encompass all sexual minority groups, including those who are lesbians and bisexual
Asexual	Person who does not experience sexual attraction towards other people and who identifies as asexual. May still have romantic, emotional, affectional, and relational attractions to other people
Bisexual	A person who is emotionally, romantically, sexually, affectionately, or relationally attracted to both men and women or who identifies as bisexual
Pansexual	A person who is emotionally, romantically, sexually, affectionately, or relationally attracted to other people regardless of their gender identity

Reprinted from GLAAD Media Reference Guide, 11th Edition. 2022. Glossary of Terms: LGBTQ. (18)

Table 5. FDA-approved indications for pediatric growth hormone treatment
Year of FDA approval	Indication	Definition	Epidemiology	References/Guidelines
1985	Growth hormone deficiency (GHD)	Inadequate GH secretory capacity that can be congenital or acquired	1:3500 children	Grimberg et al 2016 (26)
1993	Chronic renal insufficiency	Reduced creatinine clearance (glomerular filtration rate) for at least 3 months	Prevalence ranges from 15 to 74.7 cases per 1 million children Male/female ratio ranging from 1.3 to 2.0 (higher incidence in males of congenital anomalies of the kidney and urinary tract)	Drube et al 2019 (27) Harambat et al 2012 (28)
1996	Turner syndrome	Partial or complete absence of the second X chromosome in girls (45,X genotype); may be mosaic	Females only 1:2000 live newborn females	• (Gravholt et al 2016 (29)
2000	Prader–Willi syndrome	Loss of paternally inherited imprinted genes on chromosome 15q11–13	~1:15 000–25 000 children Females = males.	Heksch et al 2017 (30) McCandless 2011 (31)
2001	Small-for-gestational age (SGA) without catch-up growth	SGA = birth length below –2 SD for gestational age, or birth weight below 10th centile for population. Must allow at least 2 years for endogenous catch-up growth before consider GH	Variable prevalence globally (4.6–15.3% across Europe to 27% in low- to middle-income countries) ~85% of infants born SGA experience catch-up growth in the first 2 years of life and would be ineligible for GH	Clayton et al 2007 (32)
2003	Idiopathic short stature	Height below –2.25 SD, growth velocity not expected to reach a normal adult height, and causes of growth failure that should be observed or treated by other means have been excluded	–2.25 SD = 1.2nd centile Females = males	Grimberg et al 2016 (26)
2007	SHOX gene haploinsufficiency	Deletion or mutation in a copy of the SHOX gene on the short arm pseudoautosomal region 1 (PAR 1) of both the X and Y chromosomes	2–15% of individuals with formerly idiopathic short stature Females and males	• (Binder 2011 (33)
2008	Noonan syndrome	Germ-line mutation in a gene of the RAS/mitogen-activated protein kinase (MAPK) pathway (PTPN11, SOS1, RAF1, and KRAS)	1:1100–2500 live births; may be closer to 1:100 for milder phenotypes Short stature present in up to 70% of people with Noonan syndrome	Romano et al 2010 (34)

Table 6. Characteristics of normal and abnormal pubertal development
	Physical features	Physiological underpinnings	Timing characteristics	Other
Typical female puberty	Tanner (SMR) 2 breast development or thelarche is appreciated as a palpable subareolar breast bud before it can be observed visually Age 8–12 year	Timely activation of the hypothalamic–pituitary–gonadal axis	Progression through pubertal stages to completion of growth and hypothalamic–pituitary–growth axis maturation	Thelarche = initiation of breast development Menarche = initiation of menses Thelarche (early marker) and/or age at menarche (late marker) are typically used for female pubertal development
Typical male puberty	Tanner (SMR) 2 genital stage is characterized by increase of testicular volume to ≥ 4 mL, enlargement of the phallus, thinning of the scrotum Age 9–14 years	Timely activation of the hypothalamic–pituitary–gonadal axis	Progression through pubertal stages to completion of growth and HPG maturation	Gonadarche = increase in testicular volume to >4 mL Appearance of pubic hair or change in genital appearance (early marker) and age at voice breaking (late marker), commonly used for male pubertal development. Testicular enlargement is less often used.
Isosexual central precocious puberty	Female: breast development Tanner (SMR 2) age <8 years Male: testicular volume ≥4 mL age <9	Premature activation of the hypothalamic–pituitary–gonadal axis leading	Progression through pubertal stages to completion of growth and HPG maturation	Global incidence rate 5.66 cases per million person years at risk (114) Annual incidence 0.02–1.07 cases/100 000
Delayed puberty	Female: lack of breast development tanner (SMR 2) by age 13 years; male: lack of testicular volume ≥4 mL by age >14; failure to progress through puberty in 4 years	Heterogeneous causes including lack of activation of the hypothalamic–pituitary–gonadal axis, primary gonadal failure, or functional hypogonadism	Nonprogressive or slowly progressive
Premature thelarche	Breast development <8 years in female	Exposure to endogenous estrogen or estrogen analogs	Non progressive or slowly progressive
Premature adrenarche	Pubic hair development prior to thelarche or gonadarche Age <9 years for boys and <8 years for girls	Activation of the hypothalamic–pituitary–adrenal axis (1 proposed mechanism)	Slowly progressive

Table 7. Race/ethnic differences in metabolic syndrome components in NHB and NHW compared with White youth
	Hypertension	Obesity	Dyslipidemia	Insulin resistance
NHB youth	↑	↑	↓ (compared with NHW and Hispanic)	↑
Hispanic youth		↑	↑ (compared with NHW and NHB)	No difference compared with NHW

Abbreviations: NHB, non-Hispanic Black; NHW, non-Hispanic White.

Table 8. Summary recommendations for future research and policy needs to address pediatric endocrine health and health care disparities
Race/ethnic disparities	Sex disparities
Overall: Ensure adequate enrollment of non-White and gender diverse participants into clinical trials and clinical research studies so that they are adequately powered for meaningful subgroup analyses
Pediatric growth disorders • Educate pediatric care providers to recognize growth failure in minoritized children and girls as a potential sign of an underlying health issue requiring further evaluation • Evaluate whether interventions, such as electronic health system-based alerts, may identify children with worrisome growth patterns in a demographic-blind manner	• Develop assessment and intervention strategies to prevent overtreatment of idiopathic short stature in NHW boys
Puberty • Launch longitudinal studies, starting at very early ages, to collect robust, standardized data on pubertal development and its variations in race/ethnic groups other than White in the United States and globally • Identify biological and nonbiological variables associated with disparities in pubertal development • Expand genetic methods, such as GWAS, to focus on non-European racial and ethnic groups, particularly those focused on African and African-American cohorts • Establish data on morbidity and mortality for adults with a history of early pubertal development in race/ethnic groups other than US Whites (with attention to the role of nonbiological factors in these disparities)	• Expand research studies focused on puberty in male youth • Launch studies to evaluate the importance of intersectionality in understanding how pubertal development and stereotypes/discrimination among youth of color and sexual and gender minority youth impact pubertal outcomes
Metabolic bone disease • Launch prospective studies to determine peak bone mass accrual in diverse populations based on race, ethnicity sex, and age to support calculation of fracture risk during childhood and puberty and into adulthood and to identify best opportunity/window for achieving peak bone mass by population • Conduct environmental studies to examine the impact of endocrine disruptors on bone health in children • Design randomized controlled trials to establish the optimal dose, duration and effect of vitamin D supplementation on multiple health outcomes (eg, bone mass, fracture risk) globally • Develop a worldwide initiative to eradicate rickets through food fortification efforts
Diabetes mellitus • Elucidate etiology for race/ethnic differences in prevalence and incidence of T1D in youth • Elucidate the mechanisms of the differential contribution of obesity to youth-onset T2D in different world regions, with particular attention to normal weight T2D and the role of body fat distribution	• Determine the contributors to lower physical activity levels and sex difference in dietary choices contributing to higher T2D prevalence in female youth • Understand why males and race/ethnic minority youth less likely to undergo bariatric surgery • Etiology of higher diabetes-related mortality rate among women compared with men and Blacks
Diabetes complications (acute) • Elucidate the etiology for higher rates of DKA in racial and ethnic minority youth (difference in glucose metabolism) • Development of interventions to ensure earlier and more consistent health care access for minority youth for earlier T1D detection (so they do not present with DKA so often and need to utilize ED and hospital so often)
Diabetes complications (chronic) • Basic and clinical research studies are needed to elucidate the etiology for the increased metformin monotherapy failure among Black youth (which contributes to glycemic control deterioration) • Design intervention studies to address hypertension and dyslipidemia in minority youth with an eye toward preventing microvascular and macrovascular complications in adulthood • Remove financial and policy barriers contributing to race/ethnic disparities in initiation and ongoing use of pumps and CGM, which improve glycemic control (advocate for insurance plans to decrease out-of-pocket costs)
Metabolic syndrome • Develop race/ethnic specific cut-offs and percentiles for metabolic syndrome in youth	• Develop sex specific cut-offs and percentiles for metabolic syndrome in youth
Obesity • Develop early multilevel interventions and novel strategies to address the disproportionate rise in obesity in racial and ethnic minority children and adolescents, including policies to increase availability of and access to healthy food options	• Develop strategies to reduce the gender disparities in obesity prevalence
Sexual and gender minority health • Design studies to quantify and elucidate endocrine health and health care disparities in non-White LGBTQIA youth	• Design health care demographic data collection systems to allow patients to report self-identified sexual orientation and gender identity data. • Determine the optimal timing and duration of gonadotropin hormone agonist therapy in transgender youth related to bone health • Design longitudinal studies to determine the prevalence of osteoporosis, osteopenia, and fractures among transgender youth and adults • Generate the evidence base to determine the best practices in fertility preservation options and reproductive care of sexual and gender minority patients • Design studies to examine how sexual and gender identity may be impacted by chronic disease and how chronic disease management may be impacted by sexual and/or gender identity minority status • Develop policy changes to ensure broadening of insurance coverage for sexual and gender minorities and to depathologize sexual orientation and gender identity to remove further barriers to care

Abbreviations: CGM, continuous glucose monitoring; DKA, diabetic ketoacidosis; ED, Emergency Department; GWAS, genome-wide association study; LGBTQIA, lesbian, gay, bisexual, transgender, queer, intersex, and asexual; NHW, non-White Hispanic; T1D, type 1 diabetes; T2D, type 2 diabetes.

Authors and Disclosures

Alicia M. Diaz-Thomas,^1,* Sherita Hill Golden,^2,3,* Dana M. Dabelea,⁴ Adda Grimberg,⁵ Sheela N. Magge,⁶ Joshua D. Safer,⁷ Daniel E. Shumer,⁸ and Fatima Cody Stanford⁹

¹Department of Pediatrics, Division of Endocrinology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
²Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
³Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
⁴Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
⁵Department of Pediatrics, Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
⁶Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
⁷Department of Medicine, Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10001, USA
⁸Department of Pediatric Endocrinology, C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
⁹Massachusetts General Hospital, Department of Medicine-Division of Endocrinology-Neuroendocrine, Department of Pediatrics-Division of Endocrinology, Nutrition Obesity Research Center at Harvard (NORCH), Boston, MA 02114, USA

Correspondence
Alicia M. Diaz-Thomas MD, MPH, Department of Pediatrics, University of Tennessee Health Science Center, 910 Madison Ave, Suite 1010, Memphis, TN 38163. Email: adiaztho@uthsc.edu.

*Denotes joint first authorship.

Disclosures
S.H.G. served on the Health Disparities Advisory Committee for Abbott and the Health Equity Advisory Committee for Medtronic, Inc. A.G. received the 2020 Growth Hormone Research Competitive Grant Program Award from Pfizer, Inc. and served as consultant for a seminar on growth hormone deficiency for Pfizer medical staff. J.S. is a board member of the World Professional Association for Transgender Health, has consulted for the American Civil Liberties Union, and has received honoraria for talks in academic settings. F.C.S. served as an advisor/consultant for Novo Nordisk, Eli Lilly, Boehringer Ingelheim, Currax, Gelesis, Rhythm Pharmaceuticals, Calibrate, and Pfizer. The other authors declare no conflicts.

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Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations

An Endocrine Society Scientific Statement

Abstract and Introduction

Abstract

Introduction

Tables

Tables

Tables

Tables

Tables

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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