{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T19:47:57Z","timestamp":1783108077579,"version":"3.54.6"},"reference-count":55,"publisher":"American Medical Association (AMA)","issue":"10","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Pediatr"],"published-print":{"date-parts":[[2024,10,1]]},"abstract":"Importance<\/jats:title>Use of exogenous sex steroid hormones, when indicated, may improve outcomes in adolescents and young adults with gender incongruence. Little is known about factors associated with the time from diagnosis of gender dysphoria to initiation of gender-affirming hormone therapy. Identification of inequities in time to treatment may have clinical, policy, and research implications.<\/jats:p><\/jats:sec>Objective<\/jats:title>To evaluate factors associated with time to initiation of gender-affirming hormone therapy after a diagnosis of gender dysphoria in adolescents and young adults receiving care within the US Military Health System.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>This retrospective cohort study used TRICARE Prime billing and pharmacy data contained in the Military Health System Data Repository. Patients aged 14 to 22 years, excluding service members and their spouses, who received a diagnosis of gender dysphoria between September 1, 2016, and December 31, 2021, were included. The data were analyzed between August 30 and October 12, 2023.<\/jats:p><\/jats:sec>Exposures<\/jats:title>Included patient characteristics were race and ethnicity, age group, first sex assigned in the medical record, and TRICARE Prime sponsor military rank and service at the time of diagnosis. Health care and contextual characteristics included the year of diagnosis and the primary system in which the patient received health care.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>The primary outcome was the time between initial diagnosis of gender dysphoria to the first prescription for gender-affirming hormone medication within a 2-year period. A Poisson generalized additive model was used to evaluate this primary outcome. Adjusted probability estimates were calculated per specified reference categories.<\/jats:p><\/jats:sec>Results<\/jats:title>Of the 3066 patients included (median [IQR] age, 17 [15-19] years; 2259 with first assigned gender marker of female [74%]), an unadjusted survival model accounting for censoring indicated that 37% (95% CI, 35%-39%) initiated therapy by 2 years. Age-adjusted curves indicated that the proportion initiating therapy by 2 years increased by age category (aged 14-16 years, 25%; aged 17-18 years, 39%; aged 19-22 years, 55%). Incidence rate ratios (IRRs) and 2-year adjusted probabilities indicated that longer times to hormone initiation were experienced by adolescents aged 14 to 16 years (IRR, 0.36; 95% CI, 0.30-0.44) and 17 to 18 years (IRR, 0.66; 95% CI, 0.54-0.79) compared with young adults aged 19 to 22 years and Black compared with White adolescents (IRR, 0.73; 95% CI, 0.54-0.99). Senior officer compared with junior enlisted insurance sponsor rank (IRR, 1.93; 95% CI, 1.04-3.55) and civilian compared with military health care setting (IRR, 1.21; 95% CI, 1.02-1.43) was associated with shorter time to hormone initiation.<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>In this cohort study, most adolescents and young adults with a diagnosis of gender dysphoria receiving health care through the US military did not initiate exogenous sex steroid hormone therapy within 2 years of diagnosis. Inequities in time to treatment indicate the need to identify and reduce barriers to care.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamapediatrics.2024.2835","type":"journal-article","created":{"date-parts":[[2024,8,19]],"date-time":"2024-08-19T15:02:02Z","timestamp":1724079722000},"page":"1049","source":"Crossref","is-referenced-by-count":4,"title":["Time to Gender-Affirming Hormone Therapy Among US Military\u2013Affiliated Adolescents and Young Adults"],"prefix":"10.1001","volume":"178","author":[{"given":"Evan R.","family":"Locke","sequence":"first","affiliation":[{"name":"Department of Family Medicine, David Grant Medical Center, Travis Air Force Base, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Krista B.","family":"Highland","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer A.","family":"Thornton","sequence":"additional","affiliation":[{"name":"Clinical Investigation Facility, David Grant Medical Center, Travis Air Force Base, California"},{"name":"Ripple Effect, Rockville, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin W.","family":"Sunderland","sequence":"additional","affiliation":[{"name":"Clinical Investigation Facility, David Grant Medical Center, Travis Air Force Base, California"},{"name":"Ripple Effect, Rockville, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wendy","family":"Funk","sequence":"additional","affiliation":[{"name":"Kennell and Associates, Falls Church, Virginia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Veronika","family":"Pav","sequence":"additional","affiliation":[{"name":"Kennell and Associates, Falls Church, Virginia"},{"name":"Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rick","family":"Brydum","sequence":"additional","affiliation":[{"name":"Kennell and Associates, Falls Church, Virginia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Noelle S.","family":"Larson","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Uniformed Services University, Bethesda, Maryland"},{"name":"Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Natasha A.","family":"Schvey","sequence":"additional","affiliation":[{"name":"Department of Medical and Clinical Psychology, Uniformed Services University, Bethesda, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christina M.","family":"Roberts","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Children\u2019s Mercy Hospital, Kansas City, Missouri"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David A.","family":"Klein","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, David Grant Medical Center, Travis Air Force Base, California"},{"name":"Department of Pediatrics, Uniformed Services University, Bethesda, Maryland"},{"name":"Department of Family Medicine, Uniformed Services University, Bethesda, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"2","key":"poi240049r2","doi-asserted-by":"publisher","first-page":"e1","DOI":"10.2105\/AJPH.2016.303578","article-title":"Transgender population size in the United States: a meta-regression of population-based probability samples.","volume":"107","author":"Meerwijk","year":"2017","journal-title":"Am J Public Health"},{"issue":"3","key":"poi240049r4","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2015-3223","article-title":"Mental health of transgender children who are supported in their identities.","volume":"137","author":"Olson","year":"2016","journal-title":"Pediatrics"},{"issue":"5","key":"poi240049r5","doi-asserted-by":"publisher","first-page":"489","DOI":"10.1016\/j.jadohealth.2016.06.012","article-title":"The mental health of transgender youth: advances in understanding.","volume":"59","author":"Connolly","year":"2016","journal-title":"J Adolesc Health"},{"issue":"8","key":"poi240049r6","doi-asserted-by":"publisher","first-page":"1444","DOI":"10.1016\/j.jsxm.2021.05.014","article-title":"Mental healthcare utilization of transgender youth before and after affirming treatment.","volume":"18","author":"Hisle-Gorman","year":"2021","journal-title":"J Sex Med"},{"issue":"4","key":"poi240049r7","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2019-3600","article-title":"Mental health and timing of gender-affirming care.","volume":"146","author":"Sorbara","year":"2020","journal-title":"Pediatrics"},{"issue":"1","key":"poi240049r8","doi-asserted-by":"publisher","first-page":"44","DOI":"10.3109\/09540261.2015.1115753","article-title":"Mental health and gender dysphoria: a review of the literature.","volume":"28","author":"Dhejne","year":"2016","journal-title":"Int Rev Psychiatry"},{"issue":"4","key":"poi240049r9","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2018-2162","article-title":"Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents.","volume":"142","author":"Rafferty","year":"2018","journal-title":"Pediatrics"},{"issue":"11","key":"poi240049r10","doi-asserted-by":"publisher","first-page":"3869","DOI":"10.1210\/jc.2017-01658","article-title":"Endocrine treatment of gender-dysphoric\/gender-incongruent persons: an endocrine society clinical practice guideline.","volume":"102","author":"Hembree","year":"2017","journal-title":"J Clin Endocrinol Metab"},{"key":"poi240049r12","doi-asserted-by":"publisher","first-page":"S1","DOI":"10.1080\/26895269.2022.2100644","article-title":"Standards of care for the health of transgender and gender diverse people, version 8.","volume":"23","author":"Coleman","year":"2022","journal-title":"Int J Transgend Health"},{"key":"poi240049r13","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1186\/s13633-020-00078-2","article-title":"Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results.","volume":"2020","author":"Achille","year":"2020","journal-title":"Int J Pediatr Endocrinol"},{"issue":"6","key":"poi240049r14","doi-asserted-by":"publisher","first-page":"699","DOI":"10.1016\/j.jadohealth.2019.12.018","article-title":"Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers.","volume":"66","author":"van der Miesen","year":"2020","journal-title":"J Adolesc Health"},{"issue":"2","key":"poi240049r15","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2019-1725","article-title":"Pubertal suppression for transgender youth and risk of suicidal ideation.","volume":"145","author":"Turban","year":"2020","journal-title":"Pediatrics"},{"issue":"4","key":"poi240049r16","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2019-3006","article-title":"Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy.","volume":"145","author":"Kuper","year":"2020","journal-title":"Pediatrics"},{"issue":"4","key":"poi240049r17","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2017-3742","article-title":"Hormonal treatment in young people with gender dysphoria: a systematic review.","volume":"141","author":"Chew","year":"2018","journal-title":"Pediatrics"},{"issue":"2","key":"poi240049r18","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2022.0978","article-title":"Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care.","volume":"5","author":"Tordoff","year":"2022","journal-title":"JAMA Netw Open"},{"issue":"12","key":"poi240049r19","doi-asserted-by":"publisher","first-page":"110","DOI":"10.1007\/s11920-018-0973-0","article-title":"Gender-affirming hormone use in transgender individuals: impact on behavioral health and cognition.","volume":"20","author":"Nguyen","year":"2018","journal-title":"Curr Psychiatry Rep"},{"issue":"1","key":"poi240049r20","doi-asserted-by":"publisher","first-page":"21","DOI":"10.1089\/trgh.2015.0008","article-title":"A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals.","volume":"1","author":"White Hughto","year":"2016","journal-title":"Transgend Health"},{"issue":"6","key":"poi240049r21","doi-asserted-by":"publisher","first-page":"486","DOI":"10.1111\/acps.13164","article-title":"Trends in suicide death risk in transgender people: results from the Amsterdam Cohort of Gender Dysphoria Study (1972-2017).","volume":"141","author":"Wiepjes","year":"2020","journal-title":"Acta Psychiatr Scand"},{"issue":"8","key":"poi240049r22","doi-asserted-by":"publisher","first-page":"2276","DOI":"10.1111\/j.1743-6109.2010.01943.x","article-title":"Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study.","volume":"8","author":"de Vries","year":"2011","journal-title":"J Sex Med"},{"issue":"3","key":"poi240049r23","doi-asserted-by":"publisher","first-page":"240","DOI":"10.1056\/NEJMoa2206297","article-title":"Psychosocial functioning in transgender youth after 2 years of hormones.","volume":"388","author":"Chen","year":"2023","journal-title":"N Engl J Med"},{"issue":"5","key":"poi240049r24","doi-asserted-by":"publisher","first-page":"1395","DOI":"10.1007\/s10508-020-01754-3","article-title":"\u201cYou have to wait a little longer\u201d: transgender (mental) health at risk as a consequence of deferring gender-affirming treatments during COVID-19.","volume":"49","author":"van der Miesen","year":"2020","journal-title":"Arch Sex Behav"},{"issue":"6","key":"poi240049r25","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2018-1537","article-title":"Ethical issues in gender-affirming care for youth.","volume":"142","author":"Kimberly","year":"2018","journal-title":"Pediatrics"},{"issue":"3","key":"poi240049r26","doi-asserted-by":"publisher","first-page":"266","DOI":"10.1037\/sgd0000130","article-title":"\u201cWithout this, I would for sure already be dead\u201d: a qualitative inquiry regarding suicide protective factors among trans adults.","volume":"2","author":"Moody","year":"2015","journal-title":"Psychol Sex Orientat Gend Divers"},{"issue":"2","key":"poi240049r27","doi-asserted-by":"publisher","first-page":"199","DOI":"10.1080\/15532739.2016.1252300","article-title":"A comparison of health disparities among transgender adults in Colorado (USA) by race and income.","volume":"18","author":"Seelman","year":"2017","journal-title":"Int J Transgend"},{"issue":"5","key":"poi240049r28","doi-asserted-by":"publisher","first-page":"813","DOI":"10.2105\/AJPH.2012.301069","article-title":"Stigma as a fundamental cause of population health inequalities.","volume":"103","author":"Hatzenbuehler","year":"2013","journal-title":"Am J Public Health"},{"issue":"23-24","key":"poi240049r29","doi-asserted-by":"publisher","first-page":"NP13054","DOI":"10.1177\/0886260520905091","article-title":"Transgender and nonbinary experiences of victimization in health care.","volume":"36","author":"Kattari","year":"2021","journal-title":"J Interpers Violence"},{"issue":"7","key":"poi240049r30","doi-asserted-by":"publisher","first-page":"905","DOI":"10.1093\/jamia\/ocy022","article-title":"Using clinician text notes in electronic medical record data to validate transgender-related diagnosis codes.","volume":"25","author":"Blosnich","year":"2018","journal-title":"J Am Med Inform Assoc"},{"issue":"4","key":"poi240049r31","doi-asserted-by":"publisher","first-page":"166","DOI":"10.1089\/lgbt.2018.0175","article-title":"Identifying Medicare beneficiaries accessing transgender-related care in the era of ICD-10.","volume":"6","author":"Ewald","year":"2019","journal-title":"LGBT Health"},{"issue":"12","key":"poi240049r32","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v057.i12","article-title":"Building bivariate tables: the compareGroups package for R.","volume":"57","author":"Subirana","year":"2014","journal-title":"J Stat Soft"},{"issue":"2","key":"poi240049r35","doi-asserted-by":"publisher","first-page":"1","DOI":"10.18637\/jss.v084.i02","article-title":"Weighted Cox regression using the R package coxphw.","volume":"84","author":"Dunkler","year":"2018","journal-title":"J Stat Softw"},{"issue":"3-4","key":"poi240049r36","doi-asserted-by":"publisher","first-page":"299","DOI":"10.1177\/1471082X17748083","article-title":"A generalized additive model approach to time-to-event analysis.","volume":"18","author":"Bender","year":"2018","journal-title":"Stat Model"},{"issue":"5","key":"poi240049r40","doi-asserted-by":"publisher","first-page":"420","DOI":"10.1089\/trgh.2021.0116","article-title":"Factors associated with time to receiving gender-affirming hormones and puberty blockers at a pediatric clinic serving transgender and nonbinary youth.","volume":"8","author":"Tordoff","year":"2023","journal-title":"Transgend Health"},{"issue":"1","key":"poi240049r41","doi-asserted-by":"publisher","first-page":"82","DOI":"10.1089\/trgh.2018.0002","article-title":"Associations between the length of time from transgender identity recognition to hormone initiation and smoking among transgender youth and young adults.","volume":"3","author":"Menino","year":"2018","journal-title":"Transgend Health"},{"issue":"4","key":"poi240049r42","doi-asserted-by":"publisher","first-page":"582","DOI":"10.1016\/j.jsxm.2018.01.016","article-title":"The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): trends in prevalence, treatment, and regrets.","volume":"15","author":"Wiepjes","year":"2018","journal-title":"J Sex Med"},{"issue":"2","key":"poi240049r43","doi-asserted-by":"publisher","first-page":"68","DOI":"10.1080\/15532739.2015.1064336","article-title":"Racial and ethnic differences in experiences of discrimination in accessing health services among transgender people in the United States.","volume":"16","author":"Kattari","year":"2015","journal-title":"Int J Transgenderism"},{"issue":"2","key":"poi240049r44","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1001\/jamapediatrics.2021.4483","article-title":"Anti-transgender legislation\u2014a public health concern for transgender youth.","volume":"176","author":"Barbee","year":"2022","journal-title":"JAMA Pediatr"},{"issue":"11","key":"poi240049r45","doi-asserted-by":"publisher","first-page":"1159","DOI":"10.1001\/jamapediatrics.2021.2061","article-title":"Experiences and perspectives of transgender youths in accessing health care: a systematic review.","volume":"175","author":"Chong","year":"2021","journal-title":"JAMA Pediatr"},{"issue":"3","key":"poi240049r46","doi-asserted-by":"publisher","first-page":"149","DOI":"10.1093\/hsw\/hlz016","article-title":"Barriers to mental health care for transgender and gender-nonconforming adults: a systematic literature review.","volume":"44","author":"Snow","year":"2019","journal-title":"Health Soc Work"},{"issue":"11","key":"poi240049r50","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2022.39758","article-title":"Association of gonadotropin-releasing hormone analogue use with subsequent use of gender-affirming hormones among transgender adolescents.","volume":"5","author":"Nos","year":"2022","journal-title":"JAMA Netw Open"},{"key":"poi240049r37","doi-asserted-by":"crossref","DOI":"10.1201\/9781315370279","volume-title":"Generalized Additive Models: An Introduction With R","author":"Wood","year":"2017","edition":"2nd ed"},{"key":"poi240049r38","doi-asserted-by":"crossref","DOI":"10.1201\/9781351201315","volume-title":"Advanced R","author":"Wickham","year":"2019","edition":"2nd ed"},{"key":"poi240049r55","volume-title":"Reducing Inequalities Between Lesbian, Gay, Bisexual, Transgender, and Queer Adolescents and Cisgender, Heterosexual Adolescents: Proceedings of a Workshop","author":"National Academies of Science, Engineering, and Medicine","year":"2022"},{"key":"poi240049r1","unstructured":"Flores? HJ, O\u2019Neill? K. How many adults identify as transgender in the United States? The Williams Institute, University of California, Los Angeles School of Law; 2022. Accessed January 10, 2023. https:\/\/williamsinstitute.law.ucla.edu\/publications\/trans-adults-united-states\/"},{"key":"poi240049r3","unstructured":"2022 National survey on LGBTQ youth mental health. The Trevor Project; 2022. Accessed October 24, 2023. https:\/\/www.thetrevorproject.org\/survey-2022\/"},{"key":"poi240049r11","unstructured":"Deutsch? MB, ed. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. 2nd ed. University of California, San Francisco; 2016. Accessed January 10, 2023. https:\/\/transcare.ucsf.edu\/guidelines"},{"key":"poi240049r33","doi-asserted-by":"crossref","unstructured":"Sjoberg? D, Baillie? M, Haesendonckx? S, Treis? T. ggsurvfit: Flexible time-to-event figures. The Comprehensive R Archive Network. Accessed November 13, 2023. https:\/\/cran.r-project.org\/web\/packages\/ggsurvfit\/index.html","DOI":"10.32614\/CRAN.package.ggsurvfit"},{"key":"poi240049r34","unstructured":"Kassambara? A, Kosinski? M, Miecek? P, Fabian? S. survminer: Drawing survival curves using \u2018gplot2\u2019. The Comprehensive R Archive Network. Accessed November 13, 2013. https:\/\/cran.r-project.org\/web\/packages\/survminer\/index.html"},{"key":"poi240049r39","doi-asserted-by":"crossref","unstructured":"Wickham? H. Ggplot2: Elegant Graphics for Data Analysis. Springer-Verlag New York; 2016. https:\/\/ggplot2.tidyverse.org","DOI":"10.1007\/978-3-319-24277-4_9"},{"key":"poi240049r47","unstructured":"Military pay tables & information. Defense Finance and Accounting Services; 2023. Accessed July 10, 2024. https:\/\/www.dfas.mil\/militarymembers\/payentitlements\/Pay-Tables\/"},{"key":"poi240049r48","unstructured":"Prestigiacomo J. Review and analysis of the state of transitioning soldiers. Soldier for Life. 2021. Accessed July 10, 2024. https:\/\/soldierforlife.army.mil\/Documents\/static\/FY21%20Review%20and%20Analysis.pdf"},{"key":"poi240049r49","unstructured":"Active component demographics: data as of 31 October 2022. US Army Public API. Accessed July 10, 2024. https:\/\/api.army.mil\/e2\/c\/downloads\/2022\/11\/15\/62a2d64b\/active-component-demographic-report-october-2022.pdf"},{"key":"poi240049r51","unstructured":"National Academies of Sciences, Engineering, and Medicine. Strengthening the Military Family Readiness System for a Changing American Society. National Academies Press; 2019. Accessed July 10, 2024. https:\/\/nap.nationalacademies.org\/catalog\/25380\/strengthening-the-military-family-readiness-system-for-a-changing-american-society"},{"key":"poi240049r52","unstructured":"Mental health among LGBTQ youth with a parent in the military. The Trevor Project; 2022. Accessed July 10, 2024. https:\/\/www.thetrevorproject.org\/research-briefs\/mental-health-among-lgbtq-youth-with-a-parent-in-the-military-aug-2022\/"},{"key":"poi240049r53","unstructured":"Asch? BJ, Rennane? S, Trail? TE, . Food insecurity among members of the armed forces and their dependents. RAND Corporation; 2023. Accessed January 10, 2023. https:\/\/www.rand.org\/pubs\/research_reports\/RRA1230-1.html"},{"key":"poi240049r54","unstructured":"2020 Demographics profile of the military community. Military One Source. 2021. Accessed July 10, 2024. https:\/\/download.militaryonesource.mil\/12038\/MOS\/Reports\/2020-demographics-report.pdf"}],"container-title":["JAMA Pediatrics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamapediatrics\/articlepdf\/2822490\/jamapediatrics_locke_2024_oi_240049_1728048791.65375.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,10,7]],"date-time":"2024-10-07T15:01:39Z","timestamp":1728313299000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamapediatrics\/fullarticle\/2822490"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,10,1]]},"references-count":55,"journal-issue":{"issue":"10","published-print":{"date-parts":[[2024,10,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamapediatrics.2024.2835","relation":{},"ISSN":["2168-6203"],"issn-type":[{"value":"2168-6203","type":"print"}],"subject":[],"published":{"date-parts":[[2024,10,1]]}}}