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Objective: Gender minority youth (i.e., children/adolescents whose gender identity and/or expression is inconsistent with their birth-assigned sex) experience elevated rates of emotional and behavioral problems relative to cisgender youth (who identify with their birth-assigned sex), which are not intrinsic to gender identity but attributable to unique minority stressors. Although empirically-supported treatments have proven effective in treating these mental health concerns generally, randomized controlled trials have not examined effects for gender minority youth.Method: To address this gap, we pooled data from clinically-referred youth (N = 432; M(SD)age = 10.6(2.2); 55.1% White) assigned to empirically-supported treatment conditions across four previous randomized controlled trials of modular psychotherapy. A proxy indicator of gender identity (i.e., youth's wish to be the opposite sex) was used to classify gender minority (n = 64) and cisgender (n = 368) youth. Youth-and caregiver-reported pretreatment internalizing and externalizing problems, treatment effectiveness on these domains, and treatment acceptability were compared across groups.Results: Gender minority youth reported more severe pretreatment internalizing and externalizing problems compared to cisgender youth; in contrast, their caregivers reported less severe problems. Though treatment was equally effective for both groups on most outcomes, gender minority youth's caregiver-reported externalizing problems improved more slowly and less reliably, and their self-reported internalizing problems were more likely to remain clinically elevated. Further, gender minority youth reported lower treatment satisfaction.Conclusions: While findings suggest that empirically-supported treatments may effectively address many mental health problems for gender minority youth, they also underscore the need for treatment enhancements that improve acceptability and outcomes.Public Significance Statement: This study examined the effectiveness and acceptability of empirically-supported mental health treatments for gender minority youth (who endorsed a wish to be the opposite sex) and cisgender youth. Gender minority youth reported more severe problems before treatment, demonstrated slower improvement in caregiver-reported behavior problems, and endorsed lower treatment satisfaction. Findings support the potential need for provider-focused trainings relevant to gender minority youth.

Objective: The study examined whether cultural racism moderates the efficacy of psychotherapy interventions among youth.Method: We analyzed a subset of studies from a previous meta-analysis of five decades of youth psychotherapy randomized controlled trials. Studies were published in English between 1963 and 2017 and identified through a systematic search. The 194 studies (N=14,081; ages 2-19) across 34 states comprised 2,678 effect sizes (ESs) measuring mental health problems (e.g., depression) targeted by interventions. Cultural racism was operationalized using a composite index of 31 items measuring explicit racial attitudes (obtained from publicly available sources; e.g., General Social Survey), aggregated to the state level and linked to the meta-analytic database. Analyses were conducted with samples of majority (i.e., ≥50%) Black (n=36 studies) and majority-White (n=158 studies) youth.Results: Two-level random effects meta-regression analyses indicated that higher cultural racism was associated with lower ESs for studies with majority-Black youth (β=-0.21, CI: -0.37, -0.05, p=0.01) but was unrelated to ESs for studies with majority-White youth (β=0.003, CI: -0.03, 0.03, p=0.80), controlling for state-level poverty and White population density. In studies with majority-Black youth, mean ESs were significantly lower in states with the highest cultural racism (>1 SD above the mean; g=0.19) compared to states with the lowest racism (<1 SD below the mean; g=0.60). Conclusions: Psychotherapy randomized controlled trials with samples comprised of majority-Black youth were significantly less effective in states with higher (vs. lower) levels of cultural racism, suggesting that cultural racism may be one contextual moderator of treatment effect heterogeneity.

Objective: Transgender adolescents experience adversity accessing mental healthcare, which is exacerbated by transgender-specific mental health provider shortages in the United States.Factors associated with variability in transgender-specific mental health provider availability across states-especially at the macro-social level-have yet to be identified, hindering efforts to address these shortages. To remedy this gap, we queried whether transgender-specific adolescent mental health provider availability varied by states' transgender-specific policy climate. Method:We quantified states' policy climate by factor-analyzing tallies of the presence/absence of 33 transgender-specific state laws/policies in six domains: parental/relationship recognition, nondiscrimination, education, healthcare, criminal justice, and identity documentation. We then tested whether states' transgender-specific policy climate was associated with rates of transgender-specific adolescent mental health providers-identified via Psychology Today-per transgender adolescent in all 50 states and the District of Columbia.Results: Transgender-specific adolescent mental health provider availability was substantially lower in states with more restrictive laws/policies for transgender people (rate ratio=0.65, 95% CI [0.52, 0.81], p=0.00017), controlling for state-level conservatism, religiosity, and urbanicity.States' transgender-specific policy climate was unrelated to rates of adolescent Attention-Deficit/Hyperactivity Disorder-specialty providers, Oppositional Defiant Disorder-specialty providers, and youth mental health provider shortages broadly, providing evidence for result specificity. Conclusions:Transgender adolescents appear to have access to considerably fewer transgenderspecific mental health providers in states with more restrictive laws/policies for transgender people, which may compound their already high mental health burden in these contexts.State Policy Climate and Trans-specific Adolescent Mental Health Provider Availability 3 Intervention and policy efforts are needed to address these shortages, particularly in states with increasingly prohibitive laws/policies targeting transgender adolescents.

Acknowledgements. The authors thank Mr. Shuai ("Eddy") Jiang for his help adding references and formatting this manuscript and Dr. Jonathan S. Jay for his thoughtful review and recommendations.