The experiences of transgender and nonbinary adults in primary care: A systematic review

BACKGROUND

Transgender and nonbinary (TNB) people face barriers to primary care, which remains the main entry point for accessing gender-affirming healthcare in the UK.

OBJECTIVES

This systematic review aims to summarise the evidence regarding TNB people's experiences of primary care to inform improvements in service and patient outcomes.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. A systematic literature search was conducted across articles from 2005 to April 2023 across Ovid Medline, Ovid Embase and PsychInfo using established keywords relating to gender identity, primary care and experiences. Qualitative data were thematically analysed and quantitative data were compiled using a descriptive narrative.

RESULTS

Following eligibility criteria, 16 articles were included in this review. This review identified both facilitators and limitations and barriers experienced by TNB people related to primary care provider knowledge; the patient-provider relationship, and healthcare settings. Quantitative findings reported up to 54.4% of participants were uncomfortable discussing TNB issues with their physician. Overall findings suggest TNB people face discrimination on a systemic level utilising primary care services, though positive healthcare encounters at a local level were reported. Participants expressed a desire for primary care-led gender-affirming healthcare services, with involvement from local TNB communities.

CONCLUSION

This review demonstrates TNB people's mixed experiences of primary care alongside their recommendations for service improvement. This is the first systematically reviewed evidence on the topic, emphasising the need for clinicians and policymakers to centre the voices of the TNB community in service design and improvement.

Effects of the COVID-19 Pandemic on the Wellbeing of LGBTQ+ Individuals in Moldova: A Mixed Methods Analysis

Research on the effects of the COVID-19 pandemic for LGBTQ+ people is limited, particularly in eastern Europe. This mixed methods study explored the direct and indirect effects of the pandemic on the mental and physical wellbeing of LGBTQ+ individuals in Moldova. From June to the end of July 2022, 86 surveys and 12 interviews were completed by self-identified LGBTQ+ adults in Moldova. Survey data were analyzed with descriptive statistics and interviews were coded and analyzed using the grounded theory methodology. The two data sets were interpreted concurrently to identify emergent themes. Overall, data suggest LGBTQ+ people experienced both negative and positive effects on their mental wellbeing due to the pandemic. Participants expressed feelings of anxiety, loneliness, and depression, and an inability to be their authentic selves. Conversely, participants had more capacity to explore their identities and they demonstrated social support within the LGBTQ+ community. Regarding physical impacts, there were interruptions to transgender medical care and concerns about housing affordability. Findings highlight the unique impacts of the pandemic on LGBTQ+ people and stress the importance of further research in this area and policies and plans to address the needs of LGBTQ+ people in response to the pandemic and future health crises.

"I Should've Been Able to Decide for Myself, but I Didn't Want to Be Left Alone." A Qualitative Interview Study of Clients' Ethical Challenges and Norms Regarding Decision-Making in Gender-Affirming Medical Care

This qualitative study aimed to map and provide insight into the ethical challenges and norms of adult transgender and gender diverse (TGD) clients in gender-affirming medical care (GAMC). By doing so, we seek to make an empirical and constructive contribution to the dialogue on and moral inquiry into what good decision-making in GAMC should entail. We conducted 10 semi-structured interviews with adult Dutch TGD people who received GAMC. In our thematic analysis, we (1) included both ethical challenges and norms, (2) differentiated between explicit and implicit ethical challenges and norms, and (3) ascertained the specific context in which the latter emerged. We identified the following themes: (1) clients should be in the lead, (2) harm should be prevented, and (3) the decision-making process should be attuned to the individual client. These themes arose in the context of (1) a precarious client-clinician relationship and (2) distinct characteristics of GAMC. Our findings highlight divergent and dynamic decisional challenges and normative views-both within individual clients and among them. We conclude that there is no single ideal model of good decision-making in GAMC and argue that elucidating and jointly deliberating on decisional norms and challenges should be an inherent part of co-constructing good decision-making.

Highs, Lows, and Hormones: A Qualitative Metasynthesis of Transgender Individuals' Experiences Undergoing Gender-Affirming Hormone Therapy

Gender Affirming Hormone Therapy (GAHT) is a key therapeutic approach which aims to help trans and gender diverse (or simply "trans") individuals' transition from their sex-presumed-at-birth to their experienced gender identity. Previous reviews have focused on synthesizing quantitative experiences; however, a qualitative lens is important to understand the personal journey of GAHT. This review provides a qualitative meta-synthesis of the experiences of trans people around the world who have undergone GAHT to elicit contextualized understanding of the changes experienced. Systematic searches of eight databases identified an initial 2670 papers, refined to a final 28 papers. Overall, findings suggested that the GAHT journey is unique and elicited a myriad of changes which, whilst challenging at times, were life-changing and brought about positive psychological, physical, and social changes. Other themes explored GAHT not being treated as a fix-all for associated mental health issues, the rules that govern appraisal of physical changes, how privilege and social identity evolve, and the power of affirmation. This work offers important recommendations to improve the care offered to trans people undergoing GAHT. Namely, person-centered support is essential, and peer-navigation may be a useful future direction to explore.

Exploring the knowledge and attitudes of college-educated Hispanics toward the transgender community in Puerto Rico

OBJECTIVE

This study aimed to assess the knowledge and attitudes of a sample of Hispanics in Puerto Rico (PR) toward the transgender community.

METHODS

A cross-sectional study addressing Hispanics, aged 21 years or older who lived in PR, was performed from March to September 2021. Participants were invited through online advertisement shared on social media pages. Data were collected via SurveyMonkey and analyzed with Stata 17. Descriptive statistics were employed to summarize findings.

RESULTS

A total of 404 participants were sampled. Most were female, 278 (68.8%), had completed at least a bachelor's degree, 292 (72.2%), and referred exposure to trans-related topics during education, 237 (58.7%). Most correctly defined the terms sex, 257 (63.6%), sexual orientation, 334 (82.7%) and transgenderism, 297 (73.5%). The majority also agreed that transgender individuals should be able to change their name, 353 (93.6%) and undergo gender-affirming procedures, 335 (88.9%). Most also believed trans individuals were a valuable part of society, 339 (89.9%) and should be allowed free gender expression, 358 (95.0%).

CONCLUSIONS

PR is characterized by a patriarchal, religious, and conservative culture which could promote a negative attitude toward transgender people. Our findings challenged such assumption. The level of knowledge and positive attitude toward trans individuals identified in this study could counteract the existing violence and stigma affecting this community in PR.

A Comparative Content Analysis of the News Media Framing of Trans Homicide Between Trans Men and Trans Women in the U.S. from 2016 to 2022

Recently, the media's coverage of trans homicides has increased in the U.S. Studies show that the news media's framing has been largely negative but has improved in recent times. Yet, research has mostly analyzed the news media's framing of victims who were trans women, thus limiting our understanding of this issue across different trans groups. The present study employs a mixed method approach to comparatively analyze articles (N = 124) published in online news media outlets of 15 trans men and 15 trans women murdered between 2016 and 2022. The findings indicate news media outlets used more positive and neutral frames than negative for both groups. However, when compared to trans women, trans men were delegitimized at higher rates. These findings highlight the ways that the police, news media, family, friends, and community members simultaneously contribute to the humanization and delegitimization of trans victims of homicide, demonstrating the importance of ensuring all information released about the victims correctly reflects who they were, or the cycle of delegitimization will continue. By studying how the news media frames trans homicide victims, we can look at how the media shapes cultural beliefs and ideologies about trans people, the role of language in reinforcing stereotypes, and the implications of these framings for trans people.

States, 2021

PURPOSE

Transgender youths (those whose gender identity differs from their sex assigned at birth) experience stigma and discrimination that can place them at increased risk for poor health outcomes compared with cisgender youths (those whose gender identity aligns with their sex assigned at birth). Limited population-based data exist on disparities among transgender and cisgender youths.

METHODS

We examined differences in experiences of violence, substance use, mental health, suicide, sexual behavior, unstable housing, parental monitoring, and school connectedness among 98,174 transgender and cisgender high school students using data from 18 states that included an item to assess transgender identity on their 2021 Youth Risk Behavior Survey.

RESULTS

Overall, 2.9% of students identified as transgender and 2.6% questioned whether they were transgender. Among transgender students, 71.5% reported that their mental health was not good, 32.3% had attempted suicide, and 29.0% experienced sexual violence. Transgender students were more likely than cisgender students to report experiences of violence, substance use, poor mental health, suicide risk, some sexual risk behaviors, and unstable housing, and were less likely to report feeling connected to others at school.

CONCLUSIONS

Interventions that can address the causes of these adverse outcomes and promote the health and wellbeing of transgender youths are warranted.

What do measures of gender identity tell us about gender identity over time?

Gender identity is a multifaceted concept and is represented by a wide range of measures and constructs including both self-report and researcher observations of preferences and behaviours. However, despite their similar theoretical underpinning, gender identity measures are rarely found to correlate with one another, and contrasting patterns and trajectories are often found for each construct (Egan & Perry, Developmental Psychology, 37, 2001, 451). Therefore, this systematic review aimed to present a review of the longitudinal research evidence surrounding gender identity development in the absence of formal intervention. Using a systematic search strategy, 21 studies were identified. Narrative synthesis was used to synthesize the data collected in these studies and trajectories were explored for (1) self-identification measures of gender identity, (2) clothing preferences, (3) peer preferences, and (4) object/activity preferences. Overall, the results of this systematic review are consistent with wider research suggesting that distinct developmental patterns can be observed when using different constructs and measures of gender identity.

Developmental uterovaginal anomalies and histologic findings in transgender patients receiving gender-affirming hysterectomies: A large case series

OBJECTIVE

To describe the incidence of uterovaginal anomalies and histologic findings in transgender and nonbinary (TGNB) patients seeking hysterectomies.

METHODS

All patients receiving gender-affirming hysterectomies between 2013 and 2023 were retrospectively reviewed. Primary outcomes included uterovaginal anomalies and histological findings. Multivariable logistic regressions were performed to evaluate relationships between variables of interest and whether they predict findings of uterovaginal anomalies, inactive endometrium, adenomyosis, leiomyoma, endometriosis, and cervical atrophy.

RESULTS

278 patients received hysterectomies at an average age of 29.2 ± 8.3 years. Seven patients (2.5%) were found to have a developmental anomaly, including two bicornuate uterus (0.7%), two unicornuate uterus (0.7%), one septate uterus (0.4%), and two vaginal septum (0.7%). 60 patients (21.6%) were found to have inactive endometrium and 26 patients (9.4%) had cervical atrophy. Although 262 patients (94.2%) were on testosterone therapy, hormone duration was not a significant predictor of any uterine findings.

CONCLUSION

This study describes uterovaginal anomalies in a large cohort of patients receiving gender-affirming hysterectomies. Although long-term testosterone use is commonly believed to be associated with endometrial and cervical atrophy, this study shows no such association.

'They're not as MSM, they're a bufta': using the categories 'men who have sex with men' and 'transgender' as technologies in Vanuatu

In Vanuatu, the use of the terms such as 'men who have sex with men' (MSM) and 'transgender' has increased over the past decade. This paper draws on twenty months ethnographic research in Port Vila, the country's capital, to analyse what happens on the ground when MSM and transgender categories are taken up to identify people or to narrate the self. The focus is on who uses these terms, in what ways they are experienced, and what is rendered visible (or not) by their use. This research departs from approaches framing 'non-heteronormative' categories as related solely to gender and sexuality. It argues that MSM and transgender categories are used in various ways to refer not only to sexual practices and/or gender identity, but also to health risk behaviours, transactional sex and LGBT rights advocacy. The analysis offered suggests we view MSM and transgender categories as technologies that, depending on the interactional context, contribute to bureaucratic tasks or to maintaining or, on the contrary, changing established socio-political relations.

Personal pronouns and person perception - Do paired and nonbinary pronouns evoke a normative gender bias?

Research on gender-fair language aims to identify language inclusive to a multitude of individuals, for example, increasing the visibility of women by using paired pronouns (he/she) instead of generic masculine forms (he). However, binary presentations like he/she might come with unwanted side effects and evoke what we label as normative gender bias. A normative gender bias is defined as when words lead to stronger associations with individuals with normative gender expressions than with individuals with non-normative gender expressions, thus contributing to making non-normative individuals invisible. In three experiments, we compared the extent to which the paired pronoun he/she (Swedish and English), the neo-pronouns hen (Swedish), ze (English), and the generic pronoun singular they (English) evoked a normative gender bias. Swedish- (N = 219 and 268) and English- (N = 837, from the UK) speaking participants read about individuals referred to with the paired pronoun he/she or with hen, ze, or they. In Experiment 1 (Swedish), there was no main effect of condition on a normative bias, but in Experiment 2 (Swedish), the paired pronouns he/she evoked normative gender bias while hen did not. In Experiment 3 (English), both ze and singular they evoked normative gender bias, although normative associations were lower in these conditions compared to he/she. Furthermore, the normative bias was lower among participants who had knowledge about the use of ze as a nonbinary pronoun. Finally, neither ze nor they evoked a normative gender bias when their use was explicitly stated to be nonbinary. A potential explanation for why singular they did not generally result in less normative associations, despite almost all participants knowing about it, may include its more common use as a generic pronoun. Taken together, our results suggest that neo-pronouns, but not paired pronouns, have the potential to evoke less normative associations, but that they must be both (1) actively created new words and (2) well-known to language users as nonbinary pronouns.

Utilizing Virtual Reality for Gender-Affirming Voice Training: Surveying the Attitudes and Perspectives of Potential Consumers

BACKGROUND

Undertaking voice and communication training is an important part of the gender-affirming journey for many trans, gender-diverse and non-binary individuals. Training supports the alignment of voice with gender identity helping to reduce gender dysphoria as individuals are better able to connect with their voices. However, for training to be effective, regular practice is needed and the demands of training can often be difficult to meet.

AIMS

To investigate the interest, attitudes and perspectives on the use of immersive virtual reality (VR) to support gender-affirming voice and communication training by transgender, gender non-binary and gender-diverse people, and speech-language pathologists providing gender-affirming voice and communication training.

METHODS & PROCEDURES

A mixed-methods survey (i.e., collecting quantitative data through multiple-choice question and qualitative data through free text questions) was hosted online from 23 August to 21 September 2021. A total of 17 questions asked about technology use, and attitudes and perspectives towards VR. The survey included video examples of three different voice-activated VR applications to prompt participant responses about the technology.

OUTCOMES & RESULTS

A total of 70 survey responses were included in the analysis. All participants had previous experience using smart phones, but only 27.2% had previously used VR. Four key themes were identified relating to potential uptake of VR in gender-affirming voice and communication training: (1) general audience appeal, (2) perceived therapeutic value, (3) exposure to or protection from harm and (4) relatability to real life.

CONCLUSIONS & IMPLICATIONS

VR games may represent a viable option to support practice of voice exercises. Gamification through VR is likely to motivate some to increase frequency of practice. VR applications that are used in voice training need to be fit-for-purpose, and detailed co-design is necessary to build appropriate applications for future use. This study provides a foundation to inform the design, development and implementation of VR applications to be used in gender-affirming voice training.

WHAT THIS PAPER ADDS

What is already known on the subject? Speech-language pathologists work closely with transgender and gender-diverse individuals to help them achieve gender congruent voice and communication. Clients need to undertake regular and ongoing practice outside of training sessions to achieve and maintain their ideal voice. Motivation and adherence to regular practice sessions remain an ongoing challenge. What this study adds to the existing knowledge This study explores the use of immersive VR technologies to create safe, motivating and enjoyable environments to encourage regular practice of gender-affirming voice and communication exercises. It engages stakeholders in an early-stage participant-involved design to gauge interest in, and perspectives on, VR and technology-based training support tools. The results suggest that voice-activated VR applications would highly motivate some individuals if they were appropriately designed but would not be ideal for all. What are the actual and clinical implications of this work? Immersion in VR can be a highly motivating tool to enhance adherence to practice schedules for some individuals. However, tools need to be specifically designed with outcomes in mind to be fit-for-purpose, to support individual goals and to minimize the risk of harm. The few existing VR voice-activated applications that are available require further assessment, and redesign through co-design with users to functionally and safely support gender-affirming voice and communication training.

Unmet Needs, Minority Stress and Mental Health Outcomes Among Transgender Individuals: The Mediating Role of Schema Domains

Exposure to gender-related minority stressors, the negative experiences and beliefs that stem from anti-trans stigma increases transgender and gender diverse (TGD) people's vulnerability to experiencing poor mental health outcomes. This study examined if the relationships between experiences of minority stress and mental health outcomes were mediated by early maladaptive schemas: mental representations shaping the way people view themselves, others and the world. Drawing from a schema therapy perspective, the study additionally examined if caregivers' failure to meet TGD people's core emotional needs was associated with mental health outcomes and if schemas similarly mediated these relationships. A total of 619 TGD adults completed an online survey about early maladaptive schemas, core emotional needs, gender-related minority stress and psychological distress and wellbeing. Causal mediation analyses indicated that caregivers who did not meet TGD people's core emotional needs and greater experiences of minority stress were associated with increased distress and lower wellbeing. These relationships were mediated by schema severity, particularly the disconnection and rejection and impaired autonomy domains. These findings provide empirical support for the schema therapy model's assumption that unmet core emotional needs are associated with schema formation. For TGD people, maladaptive beliefs about the self, others and world can form in response to manifestations of anti-trans stigma within the individual, their interpersonal relationships, community and broader society. Caregivers' failure to meet needs, plus experiences of minority stress throughout the individual's system, leads to greater distress and lower wellbeing; however, clinical interventions targeting schemas may improve outcomes for this at-risk group.

Transgender migration and displacement: the experience of khwaja sira sex workers in Lahore

This study uses an aspirations-capabilities framework to provide insight into transgender mobility based on in-depth interviews with 30 khwaja sira sex workers in Lahore. Respondents narrated mobility as a defining and persistent feature of their lives linked to their gender variance and experience of everyday violence and discrimination. Mobilities were experienced as oppressive or liberating depending on how much control they provided sex workers within managing risk in their lives. Respondents differentiated between two main forms of mobility: migration and displacement. Descriptions of migration included movement from their family of birth to a khwaja sira community as well as between khwaja sira communities, and entailed both rural-urban and inter-city travel. Unforced migration was associated with resilience as it increased sex workers control over the social environment. Experiences of forced and intra-city movement resulting from everyday interactions with clients and law enforcement agents were seen as displacement. These experiences resulted in enhanced social, physical, and occupational vulnerability and decreased khwaja sira sex workers' control over their social environment.

Prevalence and correlates of workplace violence: descriptive results from the National Transgender Discrimination Survey

OBJECTIVE

To describe the lifetime prevalence of workplace harassment, physical violence and sexual assault against transgender and non-binary workers targeted due to their gender identity and to identify correlates of this workplace violence.

METHODS

This descriptive cross-sectional study used data from 4597 transgender or non-binary respondents from the 2008-2009 National Transgender Discrimination Survey. Respondents reported if they had ever experienced harassment, physical violence or sexual assault at work specifically because of their gender identity. We estimated the prevalence of each type of violence stratified by gender identity, race/ethnicity, age, educational attainment, history of working in the street economy (eg, sex industry, drug sales) and if people at work knew their gender identity.

RESULTS

Workplace violence was prevalent, with 50% of transgender and non-binary workers having ever experienced harassment, 7% physical violence and 6% sexual assault at work because of their gender identity. Harassment was common among all of these workers, but physical violence and sexual assault were more than twice as common among transfeminine and non-binary workers assigned male at birth, workers of colour, workers with low educational attainment and those who had ever worked in the street economy.

CONCLUSIONS

Transgender and non-binary workers commonly face violence at work because of their gender identity. Workplace violence prevention programmes should incorporate ways to prevent gender identity-based violence and facilitate channels for workers to report the occurrence of discrimination and violence.

Gender-Affirming Hormone Therapy and Cervical Cancer Screening Rates in Transgender Men and Nonbinary People: A Cross-Sectional Study from a Boston Community Health Center

Purpose: Clinical monitoring for patients receiving gender-affirming hormone therapy (GAHT) has the potential to facilitate their receipt of preventive health services. We aimed to determine whether GAHT is associated with increased utilization of cervical cancer screening among transgender men (TM) and nonbinary persons assigned female at birth (NB-AFAB). Methods: We conducted a cross-sectional observational study of a single community health center in Boston. Persons of all gender identities eligible for cervical cancer screening during 2008-2019 were assessed. The outcome of interest was receipt of cervical cancer screening based on U.S. Preventive Services Task Force recommendations. We compared the proportion of persons who received cervical cancer screening by prescription of GAHT. Results: We identified 13,267 eligible persons. This cohort included 10,547 (79.5%) cisgender women, 1547 (11.7%) TM, and 1173 (8.8%) NB-AFAB persons. Among all persons eligible for cervical cancer screening, TM and NB-AFAB persons were less likely to receive screening than cisgender women (56.2% and 56.1% vs. 60.5% respectively; odds ratio [OR] = 0.84; 95% confidence interval [CI] = 0.75-0.93; OR = 0.84; 95% CI = 0.74-0.94, respectively). Among TM, those prescribed testosterone were more likely to receive cervical cancer screening than those not prescribed testosterone (57.9% vs. 48.2%, OR = 1.47; 95% CI = 1.14-1.92). Among NB-AFAB adults, those prescribed testosterone were more likely to receive cervical cancer screening than those not prescribed testosterone (61.9% vs. 51.5%, OR = 1.53; 95% CI = 1.21-1.93). Conclusions: The benefits of engagement in care to access GAHT may extend beyond the hormonal intervention to preventive health services.

Research methods at the intersection of gender diversity and autism: A scoping review

LAY ABSTRACT

Research has increasingly focused on the intersection between gender diversity and autism. To better understand this literature, this scoping review systematically searched five databases for peer-reviewed literature on gender diversity and autism published between 2018 and 2023. Included studies (N = 84) were of English language, featured original qualitative or quantitative findings, and examined a psychosocial connection between autism and gender spectra variables. Most studies focused on measuring prevalence of autism among gender-diverse individuals. While the overall study rigor was acceptable, weaknesses in measurement, sample selection, and definition of key terms were noted. Promisingly, studies in this area appear to be shifting away from a pathologizing lens and towards research methods that engage in meaningful collaboration with the autistic, gender-diverse community to investigate how to best enhance the quality of life and wellbeing of this population.

Are cisnormative surveys adequate to assess sexual well-being in trans men post-genital gender-affirming surgery?

INTRODUCTION

For transmasculine spectrum individuals, there is a lack of validated surveys to assess sexual well-being (SWB) post-genital gender-affirming surgery. Currently, either providers are designing their own SWB surveys or surveys designed for cisgender men are being used.

OBJECTIVE

This study investigated the applicability of SWB surveys validated for cisgender men to transmasculine spectrum individuals post-genital gender-affirming surgery (TMSX). Recognizing the paucity of validated tools for assessing SWB in transmasculine individuals post-genital gender-affirming surgery (TMSX), we evaluated current surveys for their inclusiveness and relevance to this population.

METHODS

Our methodology involved analyzing surveys validated in English-speaking North American cisgender men. We conducted a systematic review, yielding 31 surveys, out of which 12 met our inclusion criteria. These were then assessed against the 10 domains of holistic SWB as identified by Özer et al. Each survey was scored based on its reflection of these domains, thus generating an SWB score. Additionally, we performed a thematic analysis to identify areas needing modification for better applicability to TMSX.

RESULTS

Our findings indicate an average SWB score of 5.17 out of 10 across the surveys. The surveys predominantly addressed sexual function, with a marked underrepresentation of domains like quality of life, sexuality, and sexual pleasure. This underscores the tendency of these surveys to focus more on the biological mechanisms of sex, rather than on a nuanced biopsychosocial understanding. Thematic analysis revealed significant gaps, such as the irrelevance of questions about erections and ejaculations for TMSX, and the need for greater emphasis on psychosocial factors.

CONCLUSION

Given these gaps and the inadequacy of most cisnormative surveys, we recommend the creation of a novel, validated SWB survey specifically for TMSX. This should be developed in collaboration with a multidisciplinary panel and TMSX community advisory board, ensuring a tool that truly reflects the unique SWB needs of this population.

An Historical Case Study of Trans Exclusion and Empowerment: Implications for Transgender Older Adults and Aging

Transgender older adults have a long history of exclusion that shapes current experiences with social services. However, scant gerontological research uses archival data, which can provide critical context for service providers. Moreover, sparse research examines how exclusion can be a catalyst for change that social workers could leverage. Empowerment theory provides a theoretical tool to explain how this is possible. This multidisciplinary case study blends community member interviews and archival data to answer this question: How did exclusion shape empowerment and social change for transgender Americans? This study focuses on the events before and after the Compton's Cafeteria Riot, one of the first acts of LGBTQIA+ collective resistance that led to new services for and by transgender Americans. Data reveal how exclusion facilitated the emergence of collective empowerment among transgender women and queer youth in San Francisco. Archival data shows how exclusion preceded self-efficacy, critical consciousness, involvement with similar others, acquisition of new skills, and ultimately action to eliminate social, economic, and political barriers and power imbalances. This study provides both empirical and theoretical tools to contribute new data and perspectives on trans exclusion and empowerment and its implications for social workers serving transgender older adults.

No observed bidirectional effect between tenofovir diphosphate concentrations and gender-affirming hormone concentrations among transgender persons switching from tenofovir disoproxil fumarate/emtricitabine to tenofovir alafenamide/emtricitabine for HIV pre-exposure prophylaxis

AIMS

Many transgender and gender diverse (TGD) individuals have expressed concerns about the potential for oral pre-exposure prophylaxis to affect hormonal concentrations achieved from taking gender-affirming hormone therapy (GAHT). The purpose of this study was to understand the bidirectional effects between hormone and intraerythrocytic tenofovir diphosphate concentrations when switching from tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) to tenofovir alafenamide/emtricitabine (TAF/FTC) in TGD users/nonusers of GAHT.

METHODS

The study evaluated stored blood samples and dried blood spot cards from TGD adults without HIV who took ≥12 weeks of TDF/FTC and then switched to ≥12 weeks of TAF/FTC for pre-exposure prophylaxis.

RESULTS

Thirty-nine individuals met the study inclusion criteria. Regardless of sex assigned at birth and the use of GAHT, there were no significant differences in hormone concentrations when individuals taking GAHT were taking TDF/FTC and then switched to TAF/FTC. Further, there was no significant difference in intraerythrocytic tenofovir diphosphate concentrations between users and nonusers of GAHT.

CONCLUSION

There are no bidirectional effects between hormone and intraerythocytic tenofovir diphosphate concentrations when switching from TDF/FTC to TAF/FTC in TGD users/nonusers of GAHT.

Characteristics of Clinicians Caring for Transgender Men and Nonbinary Individuals and Guideline Concordance of Clinicians' Cervical Cancer Screening Counseling for Cisgender Individuals Versus Transgender Men and Nonbinary Individuals with a Cervix

Purpose: We examined characteristics of clinicians caring for transgender men and nonbinary (TMNB) individuals and guideline concordance of clinicians' cervical cancer screening recommendations. Methods: Using a survey of clinicians who performed ≥10 cervical cancer screenings in 2019, we studied characteristics of clinicians who do versus do not report caring for TMNB individuals and guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women. Results: In our sample (N = 492), 49.2% reported caring for TMNB individuals, and 25.4% reported performing cervical cancer screening for TMNB individuals with a cervix. Differences in guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women (45.8% vs. 50% concordant) were not statistically significant. Conclusion: Sizable proportions of clinicians cared for and performed cervical cancer screening for TMNB individuals. Research is needed to better understand clinicians' identified knowledge deficits to develop interventions (e.g., clinician trainings) to improve gender-affirming cervical cancer prevention.

Demographic and mental health profile of youth in a gender service: An African case series

Background

Despite a massive global increase in research on gender-diverse youth, there have been no studies in Africa on gender-diverse children and adolescents presenting to health services.

Aim

This study aimed to present the first African findings of the demographic and mental health profile of youth who have presented at a gender service in South Africa.

Setting

A specialist mental health outpatient service, consisting of psychiatry, psychology and nursing input, for gender-diverse child and adolescent patients in the Western Cape.

Methods

All consenting youth seen at a gender service, consisting of psychiatry, psychology and nursing input, in state and by the same clinician in private practice between January 2012 and May 2019 were participants of a retrospective, sequential case series study. Data of interest, including gender identity and sexuality, mental health history and social information, were extracted from the psychiatry files of participants.

Results

Thirty-nine participants were part of the registry and qualified for the study: 72% self-identified as white, 15% as coloured and 13% as black African. The rate of co-occurring psychopathology was high (64%) and included high rates of autism, particularly in trans males (26%), suicidal ideation in 31% and a history of suicide attempt(s) in 10%.

Conclusions

This first study describing gender-diverse youth seeking support relating to their gender identity in Africa showed they had remarkable similarities to those studied internationally.

Contribution

Establishing that transgender youth of all major racial groups in the province with similar demographic profiles to other parts of the world are presenting to services in South Africa and in need of mental health support and interventions.

Improving gay, bisexual and transgender inclusion in blood and plasma donation policies and programmes in Canada: A qualitative study

BACKGROUND AND OBJECTIVES

An increasing number of blood operators around the world, including those in Canada, have removed time-based deferral periods for gay, bisexual and other men who have sex with men and replaced them with sexual behaviour-based questions for all donors. While this marks a significant shift in screening approach, what remains unclear is how members of two-spirit, lesbian, gay, bisexual, transgender and queer (2S/LGBTQ+) communities view blood operators' initiatives to be more inclusive. As such, this study was conducted to assess the awareness of donor screening changes and other initiatives among members of 2S/LGBTQ+ communities and to explore their recommendations for blood operators' work with these communities.

MATERIALS AND METHODS

Semi-structured qualitative interviews (n = 15) were conducted with 2S/LGBTQ+ people across Canada. Data were analysed using open inductive coding methods.

RESULTS

Reported here are the key results on recommendations for blood operators. Three themes were identified from the data: (1) the need for increased communications with 2S/LGBTQ+ communities surrounding changes to donor policies and guidelines; (2) the need for trans-inclusive policy and procedures; and (3) the need for culturally responsive and equity-informed staff training at donor centres.

CONCLUSION

Results suggest that blood operators should consider 2S/LGTBQ+ communities when developing blood and plasma donation policies, screening procedures and staff training. Increased consultation with these communities is desired, and further research specific to the experiences of transgender blood donors is needed.

Research priorities in trans health: a Delphi-study

Purpose

Progress has been made in understanding trans health needs, but research priorities are often set by policy or healthcare professionals without trans input, which may not reflect public needs. Our study sought to identify trans health research priorities in France from both researchers and the trans community.

Methods

Expert stakeholders (health and social sciences professionals, trans individuals, and their families) answered a three-round Delphi survey on trans health research priorities. The first round involved an open-ended questionnaire, analyzed qualitatively. In the second round, participants ranked research propositions from round one using a Likert scale. The study's second phase involved a two-hour workshop with experts and trans individuals.

Results

53 participants (32% trans individuals/relatives, 60% health professionals) contributed 217 responses to open-ended questions, leading to 44 research priorities. After the two voting rounds, a total of five proposals reached a strong consensus cut-off and were considered as the main research priorities: evaluation of the effect of puberty blocker use in trans children and adolescents (95%), evaluation of the effect of supporting trans children and adolescents (92%), study of the support systems available for trans youth and their parents (86%), persistence of trans identity around puberty (prevalence, persistent persons characteristics) (86%), and needs assessment survey of the support for adolescents and their families (83%). Thirteen other proposals were considered moderate priorities.

Conclusion

The main consensus in our French study concerned research on trans-youth care and support needs. Our results may guide further trans-health research that meets the public's needs and desires.

Comprehending Health of the Transgender Population in India Through Bibliometric Analysis

Objective: In India research on health issues of transgender populations are very recent and limited though transgenders are an important sub-group of the population. Hence, this study attempts to understand the state of transgender health research in India through a systematic review of literature. Methods: A systematic literature review was conducted using bibliometric analysis. Initially, 132 studies were identified, and only 37 articles meeting selection criteria were subsequently selected for review using PRISMA 2020 guidelines. The research landscape was examined with tools such as Biblioshiny, Arc-GIS (10.1), and Vos-Viewer. Results: The review highlights that existing literature on transgender health in India mainly focuses on sexual health while neglecting their overall health status. It also emphasises the skewed geographical coverage of these studies. Based on the analysis, the interdisciplinary nature of the subject is illustrated in a three-field plot and through term co-occurrence. These indicate the need for culture-specific gender-affirmative services promoting a holistic approach to comprehend the health of transgender populations in India. Conclusion: In India research on transgender health is lopsided and at an initial stage. There is a need to develop diverse research focus on various health issues of transgenders that should also be geographically representative. Future in-depth research on this subject will enable optimizing resource allocation, developing effective gender-inclusive policies, and support holistic planning for better health status of transgender people in India, and other countries with similar socio-cultural background.

Gender identity importance in cisgender and gender diverse adolescents in the US and Canada

Transgender adolescents often categorize themselves in the same way that cisgender adolescents do-that is, as girls/women and boys/men. Potential differences in the extent to which these self-categorizations matter to transgender and cisgender adolescents, however, have yet to be explored, as has the relative importance transgender adolescents place on their gender compared to their transgender self-categorization. In the current study, we explored self-reported identity importance in a sample of 392 primarily White (70%) and multiracial/ethnic (20%) 12-18-year-old (M = 15.02) binary transgender (n = 130), binary cisgender (n = 236), and nonbinary (n = 26) adolescents in the United States and Canada. Results revealed that binary transgender adolescents considered their gender self-categorization to be more important to them than both binary cisgender and nonbinary adolescents did. Most binary transgender adolescents rated their gender self-categorization as maximally important to them. Additionally, transgender adolescents considered their gender self-categorization to be more important to them than their transgender self-categorization (that is, their identification with the label "transgender"). These findings demonstrate that the identities that are often denied to binary transgender adolescents may be the very identities that are most important to them. Results also suggest that gender diverse adolescents with different gender identities may differ in the importance they place on these identities.

Combined Motivational Interviewing and Ecological Momentary Intervention to Reduce Hazardous Alcohol Use Among Sexual Minority Cisgender Men and Transgender Individuals: Protocol for a Randomized Controlled Trial

BACKGROUND

Sexual minority cisgender men and transgender (SMMT) individuals, particularly emerging adults (aged 18-34 years), often report hazardous drinking. Given that alcohol use increases the likelihood of HIV risk behaviors, and HIV disproportionately affects SMMT individuals, there is a need to test interventions that reduce hazardous alcohol use and subsequent HIV risk behaviors among this population. Ecological momentary interventions (EMIs), which use mobile phones to deliver risk reduction messages based on current location and behaviors, can help to address triggers that lead to drinking in real time.

OBJECTIVE

This study will test an EMI that uses motivational interviewing (MI), smartphone surveys, mobile breathalyzers, and location tracking to provide real-time messaging that addresses triggers for drinking when SMMT individuals visit locations associated with hazardous alcohol use. In addition, the intervention will deliver harm reduction messaging if individuals report engaging in alcohol use.

METHODS

We will conduct a 3-arm randomized controlled trial (N=405 HIV-negative SMMT individuals; n=135, 33% per arm) comparing the following conditions: (1) Tracking and Reducing Alcohol Consumption (a smartphone-delivered 4-session MI intervention), (2) Tracking and Reducing Alcohol Consumption and Environmental Risk (an EMI combining MI with real-time messaging based on geographic locations that are triggers to drinking), and (3) a smartphone-based alcohol monitoring-only control group. Breathalyzer results and daily self-reports will be used to assess the primary and secondary outcomes of drinking days, drinks per drinking day, binge drinking episodes, and HIV risk behaviors. Additional assessments at baseline, 3 months, 6 months, and 9 months will evaluate exploratory long-term outcomes.

RESULTS

The study is part of a 5-year research project funded in August 2022 by the National Institute on Alcohol Abuse and Alcoholism. The first 1.5 years of the study will be dedicated to planning and development activities, including formative research, app design and testing, and message design and testing. The subsequent 3.5 years will see the study complete participant recruitment, data collection, analyses, report writing, and dissemination. We expect to complete all study data collection in or before January 2027.

CONCLUSIONS

This study will provide novel evidence about the relative efficacy of using a smartphone-delivered MI intervention and real-time messaging to address triggers for hazardous alcohol use and sexual risk behaviors. The EMI approach, which incorporates location-based preventive messaging and behavior surveys, may help to better understand the complexity of daily stressors among SMMT individuals and their impact on hazardous alcohol use and HIV risk behaviors. The tailoring of this intervention toward SMMT individuals helps to address their underrepresentation in existing alcohol use research and will be promising for informing where structural alcohol use prevention and treatment interventions are needed to support SMMT individuals.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05576350; https://www.clinicaltrials.gov/study/NCT05576350.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/55166.

Towards a Robust Definition of Sport Sex

Elite individual sports in which success depends on power, speed or endurance are conventionally divided into male and female events using traditional binary definitions of sex. Male puberty creates durable physical advantages due to the 20-30-fold increase in circulating testosterone producing a sustained uplift in men's muscle, bone, hemoglobin, and cardiorespiratory function resulting from male puberty and sustained during men's lives. These male physical advantages provide strong justification for separate protected category of female events allowing women to achieve the fame and fortune from success they would be denied if competing against men. Recent wider social acceptance of transgender individuals, together with the less recognized involvement of intersex (46 XY DSD) individuals, challenge and threaten to defeat the sex classifications for elite individual female events. This can create unfair advantages if seeking inclusion into elite female events of unmodified male-bodied athletes with female gender identity who have gained the physical advantages of male puberty. Based on reproductive physiology, this paper proposes a working definition of sport sex based primarily on an individual's experience of male puberty and can be applied to transgender and various XY intersex conditions. Consistent with the multidimensionality of biological sex (chromosomal, genetic, hormonal, anatomical sex), this definition may be viewed as a multistrand cable whose overall strength survives when any single strand weakens or fails, rather than as a unidimensional chain whose strength is only as good as its weakest link.

The impact of gender-affirming hormone therapy on nutrition-relevant biochemical measures

Gender-affirming hormone therapy carries the potential risk for shifts in biochemical markers that may impact cardiometabolic, hematologic, hepatic, and renal health. The critical evaluation of biochemical data is an integral part of a comprehensive nutrition assessment; therefore, nutrition professionals should be aware of shifts that are expected during the course of masculinizing and feminizing hormone therapy. Changes in important biochemical values along with binary sex-specific standards for interpreting laboratory data can pose significant challenges for nutrition professionals working with transgender and gender-diverse patients who receive gender-affirming hormone therapy. Overall, research on the biochemical impact of masculinizing and feminizing hormone therapy is nascent and limited. Methodologies and outcomes measured are heterogenous across studies, introducing complexities that impede researchers from drawing definitive conclusions. In light of these limitations, this narrative review aims to describe the potential implications of masculinizing and feminizing hormone therapy regimens on biochemical measures that may influence nutrition strategies and interventions to promote optimal health.

Trans men can achieve adequate muscular development through low-dose testosterone therapy: A long-term study on body composition changes

BACKGROUND

Transgender individuals undergo the gender-affirming hormone therapy (GAHT) to achieve physical changes consistent with their gender identity. Few studies are available on the long-term safety and efficacy of GAHT.

OBJECTIVES

To investigate the long-term physical effects and the safety of the testosterone therapy for trans men and to assess the impact of differential hormone dose.

MATERIALS AND METHODS

Trans men who initiated GAHT between May 2000 and December 2021 were included in this retrospective analysis. Physical findings (body mass index, body fat percentage (BFP), lean body mass (LBM), and grip strength), blood testing results (hemoglobin, hematocrit, uric acid, creatinine, total cholesterol, triglycerides, and total testosterone), and menstrual cessation were recorded. We assessed the effects of testosterone on body composition changes and laboratory parameters, comparing a low-dose group (≤ 62.5 mg/wk) to a high-dose group (> 62.5 mg/wk).

RESULTS

Of 291 participants, 188 patients (64.6%) were in the low-dose group and 103 (35.4%) in the high-dose group. Cumulative menstrual cessation rates up to 12 months were not significantly different between groups. Both groups showed a decrease in BFP and an increase in LBM during the first year of therapy, followed by a slight increase in both over the long term. The high-dose group exhibited greater LBM gains during the first year. Higher hormone doses and lower initial LBM values were associated with LBM increases at 3 and 6 months (3 mo, P = 0.006, P < 0.001; 6 mo, P = 0.015, P < 0.001). There were no long-term, dose-dependent side effects such as polycythemia or dyslipidemia.

CONCLUSION

Long-term GAHT for trans men is safe and effective. Low-dose testosterone administration is sufficient to increase LBM in trans men. Higher testosterone doses can lead to an earlier increase in muscle mass.

Pubertal Status at the Time of Fertility Preservation in Transgender Girls

BACKGROUND

Puberty blockade and gender-affirming hormone therapy can impair fertility. Counseling on fertility preservation is important before initiation of therapy. Our study aimed to assess Tanner staging and the presence of virilizing secondary sex characteristics at the time of sperm collection and correlate the viability of sperm with the Tanner staging and degree of virilization.

METHODS

A retrospective chart review of 23 transgender girls referred to pediatric urology at our academic pediatric transgender clinic for fertility preservation counseling was performed. At the initial visit before treatment, pubertal staging along with the assessment of virilizing secondary characteristics was performed. The semen analyses were evaluated for volume, sperm concentration, total sperm count, motility, and total motile count.

RESULTS

Of the first 23 transgender girls evaluated and counseled, 8 transgender females successfully produced a sperm sample for cryopreservation. The average testicular volume was 18.5 ml and ranged from 12 ml to 20 ml. The median semen parameters were at or above the 2021 World Health Organization threshold. The 8 transgender females who successfully underwent fertility preservation presented with at least 1 secondary sex characteristic. In 1 subject with Tanner stage 3 pubic hair development and a testicular volume of 12 ml, only voice change was reported. Facial hair and laryngeal prominence were not present on examination.

CONCLUSION

More than a third of our patients who accepted a referral to pediatric urology agreed to produce a sperm sample for cryopreservation. All of these patients successfully preserved sperm. With counseling and early referral to pediatric urology, a high percentage of fertility preservation in transgender girls was achieved.

HIV/Pre-Exposure Prophylaxis Knowledge and Acceptability of Rapid HIV Testing Among Transgender Adolescents in a Multidisciplinary Gender Clinic

Purpose

The objectives of this study were to assess the knowledge of HIV and pre-exposure prophylaxis (PrEP) in transgender adolescents and young adults (AYAs) and to test the acceptability of rapid HIV testing among transgender adolescents in a multidisciplinary gender clinic.

Methods

Participants enrolled on the same day as their mental health or medical appointment in a multidisciplinary gender clinic. They completed survey questions regarding HIV and PrEP knowledge and were also offered an optional same-day, rapid, fourth-generation HIV test. Participants who had an HIV test answered additional questions about their testing experience.

Results

We enrolled 61 participants; just over half (n=31) were assigned female at birth. Less than a third (n=20, 32.8%) scored 80% or above regarding HIV knowledge. Nearly half of the participants (n=29, 47.5%) were not interested in PrEP. Forty-one percent of participants chose to have a rapid HIV test; all were "satisfied" with the testing experience. There were no positive HIV results.

Conclusions

Transgender AYAs have gaps in their understanding of HIV acquisition and transmission. Rapid HIV testing in the setting of gender care is well received by those who desire testing and may be a way to increase knowledge of transgender AYA HIV status.

Qualitative Assessment of the Experiences of Transgender Individuals Assigned Female at Birth Undergoing Gender-Affirming Mastectomy for the Treatment of Gender Dysphoria

Purpose

Evaluation and comparison of outcomes following gender-affirming mastectomy have been hindered by the lack of a validated population- and surgery-specific patient-reported outcome measure (PROM). The purpose of this study was to explore the lived experiences of transgender individuals assigned female at birth (AFAB) from before-to-after gender-affirming mastectomy to identify key qualitative themes that might inform the creation of a quantitative PROM in the future.

Methods

Identified candidates were transgender men AFAB, 18-65 years of age (mean±standard deviation: 30.3±12.2), who had undergone gender-affirming mastectomy from 2015 through 2017 (n=53). Twelve individuals participated in either focus groups (6) or phone interviews (6), carried out in a semistructured fashion. Verbatim transcriptions were anonymized. Conventional content analysis was used to code all transcripts.

Results

Content analysis identified six key themes experienced by transgender men undergoing gender-affirming mastectomy. In contrast to their experiences before surgery, participant reported that after surgery they experienced fewer symptoms of gender dysphoria, lower anxiety associated with gender dysphoria, less fear about physical safety, no need to hide a female chest shape, and that they passed as male. Also explored were themes about experiences with the health care team.

Conclusion

This study presents the first qualitative data based on the lived experiences of transgender individuals AFAB who underwent gender-affirming mastectomy. These qualitative themes should be heavily considered when creating a quantitative PROM that will fully capture the changes transgender individuals AFAB experience from before-to-after gender-affirming mastectomy.

Support Saves Lives: Exploring the Relationship Between Age of Transition, Family Support, and Retrospective K-12 Educational Experiences in Transgender Suicidality

Purpose

The purpose of this study is to test the association between protective and risk factors, including age of transition, K-12 experiences, and family support, on suicidality among transgender and gender nonbinary/gender queer (TNB) adults.

Methods

Our analysis relies on data from the 2015 United States Transgender Survey. We used separate logistic regression models to predict lifetime suicidal ideation and suicide attempt among 19,121 survey respondents.

Results

Negative K-12 experiences significantly predict higher likelihood of both suicidal ideation and suicide attempt for transgender people, regardless of age of transition, and after controlling for a host of covariates. The age a transgender person begins to live full time in a gender different from the one assigned at birth has little association with suicidality. However, supportive families act as a buffer against suicidal ideation, and unsupportive families significantly predict higher likelihood of suicide attempt for transgender people when controlling for numerous covariates.

Conclusion

Our findings underscore the importance of supportive environments for TNB adolescents. Interventions that strengthen interpersonal relationships and local environments will reduce suicidality among TNB youth. Importantly, recent anti-trans legislation may interfere with the ability of teachers and families to provide needed supports and will likely have deleterious effects on the mental health of TNB individuals.

What Underlies the Opposition to Trans-Inclusive Policies? The Role of Concerns About Male Violence Versus Attitudes Toward Trans People

Transgender women's access to women-only spaces is controversial. Arguments against trans-inclusive policies often focus on cisgender women's safety from male violence, despite little evidence to suggest that such policies put cisgender women at risk. Across seven studies using U.S. and U.K. participants (N = 3,864), we investigate whether concerns about male violence versus attitudes toward trans people are a better predictor of support for trans-inclusive policies and whether these factors align with the reasons given by opponents and supporters regarding their policy views. We find that opponents of these policies do not accurately report their reasons for opposition: Specifically, while opponents claim that concerns about male violence are the primary reason driving their opposition, attitudes toward transgender people more strongly predicted policy views. These results highlight the limitations of focusing on overt discourse and emphasize the importance of investigating psychological mechanisms underlying policy support.

Using focus groups to inform a peer health navigator service for people who are transgender and gender diverse in Saskatchewan, Canada

BACKGROUND

This study investigated healthcare access and quality for people who are transgender and gender-diverse (PTGD) in Saskatchewan (SK), Canada, to inform a larger project that was piloting two peer health navigators for PTGD.

METHODS

Two online focus groups were held. Nineteen participants were recruited to represent a broad range in age, gender and location in SK. Transcripts of the focus groups were analyzed using a thematic approach.

RESULTS

The core theme that was identified was participants' desire for culturally safe healthcare. This core theme had two component themes: (1) systemic healthcare factors and (2) individual healthcare provider (HCP) factors. The healthcare system primarily acted as a barrier to culturally safe healthcare. HCPs could be either barriers or facilitators of culturally safe care; however, negative experiences outweighed positive ones.

CONCLUSIONS

PTGD in SK face discrimination, with delays and barriers to care at all levels of the healthcare system. Peer health navigators can address some of these discrepancies; however, greater support is required for PTGD to be able to access culturally safe healthcare.

PATIENT OR PUBLIC CONTRIBUTION

People with lived experience/PTGD were involved in all stages of this project. They were included on the team as community researchers and co-developed the research project, conducted the focus groups, participated in the analyses and are co-authors. As well, both navigators and all the participants in the focus groups were also PTGD.

Bridging Gaps in Collaboration Between Community Organizations and Hospital-Based Violence Treatment Centers Serving Transgender Sexual Assault Survivors

Community and healthcare organizations have not historically collaborated effectively, leaving gaps in the continuum of care for survivors of sexual assault. These gaps are particularly acutely felt by transgender (trans) survivors, who experience additional barriers to care and face higher rates of sexual assault. To bridge these gaps and enhance the provision of comprehensive support for trans people, we developed an intersectoral network of trans-positive community and hospital-based organizations in Ontario, Canada. As part of a baseline evaluation of the network, we conducted a social network analysis to determine the extent and nature of collaboration between members within and across these two sectors. Using a validated social network analysis tool (PARTNER survey), data were collected from June 22 to July 22, 2021. The extent of collaboration was examined by relationship type: intrasectoral (same sector) and intersectoral (different sectors). The nature of collaboration was examined using relational scores (value: power, level of involvement, potential resource contribution; trust: reliability, mission congruence, openness to discussion). Fifty-four community organizations (65.9% of 82 invited) and 24 hospital-based violence treatment centers (64.9% of 37 invited) responded. The majority of collaborations were within, rather than across, the two sectors: of all 378 collaborations described, 70.9% (n = 268) were intrasectoral collaborations and 29.1% (n = 110) were intersectoral collaborations. Intersectoral relationships were characterized by lower scores for level of involvement, trust, reliability, and mission congruence than intrasectoral relationships, but higher scores for power. These findings were shared in a virtual consultation session of key stakeholders, in which some participants expressed "surprise" and concern for the lack of collaboration and character of relationships across sectors. Recommendations to increase intersectoral collaboration, which included intersectoral program planning and service design and supporting increased opportunities for intersectoral training and knowledge exchange, are presented.

"Extremely toxic and evil" reflections on gender identity change efforts by Christian religious leaders: Implications for therapy with transgender and nonbinary clients

Given the religious groundings that support the practice of gender identity change efforts (GICE), we sought to explore the beliefs of Christian religious leaders about this practice and their understanding of marginalized gender identities. Nineteen religious leaders mainly from diverse Mainline Christian Protestant traditions were interviewed. Queer theory-informed thematic analysis revealed two themes related to participants' beliefs about transgender and nonbinary identities: (1) Transgender and nonbinary identities are normative and authentic and (2) God created gender diversity. The analyses also highlighted two themes reflecting the pastors' beliefs about GICE: (1) GICE is harmful and (2) Therapy should affirm transgender and nonbinary identities. Finally, the thematic analysis exploring participants' messages for couple and family therapists could be organized into two themes: (1) Christian religious beliefs do not justify the use of GICE and (2) Therapists should be helpful and not harmful. Implications for couple and family therapists are also discussed.

Patient Characteristics Associated with Receiving Gender-Affirming Hormone Therapy in the Veterans Health Administration

Purpose

This study aimed to examine patient characteristics associated with receipt of gender-affirming hormone therapy in the Veterans Health Administration (VHA).

Methods

This cross-sectional study included a national cohort of 9555 transgender and gender diverse (TGD) patients with TGD-related diagnosis codes who received care in the VHA from 2006 to 2018. Logistic regression models were used to determine the association of health conditions and documented social stressors with receipt of gender affirming hormone therapy.

Results

Of the 9555 TGD patients, 57.4% received gender-affirming hormone therapy in the VHA. In fully adjusted models, patients who had following characteristics were less likely to obtain gender-affirming hormones in the VHA: Black, non-Hispanic versus white (adjusted odds ratio [aOR]: 0.61; 95% confidence interval [CI]: 0.52-0.72), living in the Northeast versus the West (aOR: 0.72; 95% CI: 0.62-0.84), a documented drug use disorder (aOR: 0.56; 95% CI: 0.47-0.68), ≥3 versus no comorbidities (aOR: 0.44; 95% CI: 0.34-0.57), and ≥3 versus no social stressors (aOR: 0.42; 95% CI: 0.30-0.58; all p<0.001). Younger patients aged 21-29 years were almost 3 times more likely to receive gender affirming hormone therapy in the VHA than those aged ≥60 (aOR: 2.98; 95% CI: 2.55-3.47; p<0.001).

Conclusion

TGD individuals who were older, Black, non-Hispanic, and had more comorbidities and documented social stressors were less likely to receive gender-affirming hormone therapy in the VHA. Further understanding of patient preferences in addition to clinician- and site-level determinants that may impact access to gender-affirming hormone therapy for TGD individuals in the VHA is needed.

Transgender Patients Report Lower Satisfaction with Care Received than Cisgender Patients Receiving Care in an Academic Medical Care System

Purpose: Transgender and gender diverse (TGD) patients experience challenges in health care settings, including stigma, lack of culturally competent providers, and suboptimal gender-affirming care. However, differences in patient satisfaction between TGD patients compared with cisgender patients have been inadequately studied. This study aimed to assess such differences in patient satisfaction with care received in a large academic medical care system in Boston, Massachusetts. Methods: Routine patient satisfaction surveys were fielded from January to December 2021 and were summarized. Logistic regression models compared low net promoter scores (NPS; ≤6) between gender identity groups (cisgender women, transmasculine and nonbinary/genderqueer people assigned female at birth [AFAB], transfeminine and nonbinary/genderqueer people assigned male at birth) relative to cisgender men, adjusting for age, race, ethnicity, education, inpatient/outpatient service delivery, and distance from medical center. Results: Of 94,810 patients, 246 (0.3%) were TGD and 94,549 (99.7%) were cisgender. The mean age was 58.3 years (standard deviation = 16.6). Of the total sample, 17.0% of patients were people of color, 6.6% were Hispanic/Latinx, 48.6% were college graduates, and 2.6% had received inpatient care. In general, patient satisfaction with health care received was lower for TGD patients than for cisgender patients (7.3% vs. 4.5% reporting low NPS; adjusted odds ratio [aOR] = 1.14; 95% confidence interval [CI] = 0.70-1.85). Transmasculine and nonbinary/genderqueer patients AFAB had elevated odds of low NPS compared with cisgender men (8.8% vs. 3.6%; aOR = 1.71; 95% CI = 1.02-2.89). Conclusion: Future research is warranted to better understand factors driving lower ratings among TGD patients. Health care quality improvement efforts are needed to address gender identity inequities in care.

Pediatric Gender Diversity Beyond the Binary: An Exploration of Gender-Affirming Care for Nonbinary and Genderqueer Youth Seen Over Time at a Single Institution Gender Center

Purpose

The nonbinary and genderqueer (NBGQ) youth population is growing, yet scant research focuses on this distinct group. We aim to gain a deeper understanding of desired gender-affirming care and interventions pursued by NBGQ youth.

Methods

A retrospective chart review of NBGQ patients seen at the University of California, San Francisco Child and Adolescent Gender Center from January 1, 2009, to December 31, 2020, was performed. Demographic information, desired gender-affirming care, and gender-affirming interventions pursued at initial and most recent visits were collected.

Results

Initial visit charts of 116 NBGQ youth who attended more than one clinic visit were reviewed. In total, 48 unique genders were documented; gender evolved over time for some youth, as did desired gender-affirming care. At the most recent visit, 15 youth (12.9%) had a binary gender, and 101 youth (87.1%) had an NBGQ gender. At the initial visit, 56 youth (48.3%) were interested in gender-affirming hormone therapy, compared with 75 youth (65.6%) at the most recent visit. In addition, 21 (18.1%) and 49 (42.2%) youth were interested in surgery at the initial and most recent visits, respectively. In general, interest in interventions was higher than pursuit of interventions.

Conclusion

There is vast diversity of gender and differences in desired gender-affirming care within the NBGQ youth population. Desires for gender-affirming care within the cohort changed over time, and not all those who expressed a desire for an intervention received it. The reasons are likely multifactorial, highlighting the need for expectation-free and patient-specific affirming care and research on the NBGQ youth population, while also considering barriers to care.

Novel Lactation Induction Protocol for a Transgender Woman Wishing to Breastfeed: A Case Report

Background: Lactation induction in transgender women is a clinical and research priority in the field of breastfeeding medicine. To date, there are four case reports detailing successful induced lactation in transgender patients who wished to breastfeed. The Academy of Breast Feeding Medicine does not formally recommend a specific medication regimen for transgender patients due to lack of high-quality research. Case Presentation: A 50-year-old transgender woman with a hypercoagulable disorder who was able to lactate and breastfeed with novel hormone regimen management at a gender care clinic. Her baseline hormone treatment was an estradiol 0.3 mg transdermal patch every 72 hours and micronized progesterone 200 mg daily. Results: Within four weeks of initiating a modified hormone regimen (estradiol 0.4 mg patch every 72 hours, progesterone 300 mg daily, metoclopramide 10 mg three times daily), the patient was lactating spontaneously. On multiple occasions, she breastfed and expressed up to 30 mL of milk through pumping. Conclusion: This report offers a new effective hormone regimen for transgender patients who wish to lactate and cannot access domperidone-the galactagogue used in previous case reports. It also provides a review of previously published case reports on this subject. Future research in this field should prioritize cohort studies of transgender patients who desire lactation to further assess patient attitudes, experiences, and outcomes.

Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery

Introduction With the growing acceptance of transgender individuals, the number of gender affirmation surgeries has increased. Transgender individuals face elevated depression rates, leading to an increase in suicide ideation and attempts. This study evaluates the risk of suicide or self-harm associated with gender affirmation procedures. Methods This retrospective study utilized de-identified patient data from the TriNetX (TriNetX, LLC, Cambridge, MA) database, involving 56 United States healthcare organizations and over 90 million patients. The study involved four cohorts: cohort A, adults aged 18-60 who had gender-affirming surgery and an emergency visit (N = 1,501); cohort B, control group of adults with emergency visits but no gender-affirming surgery (N = 15,608,363); and cohort C, control group of adults with emergency visits, tubal ligation or vasectomy, but no gender-affirming surgery (N = 142,093). Propensity matching was applied to cohorts A and C. Data from February 4, 2003, to February 4, 2023, were analyzed to examine suicide attempts, death, self-harm, and post-traumatic stress disorder (PTSD) within five years of the index event. A secondary analysis involving a control group with pharyngitis, referred to as cohort D, was conducted to validate the results from cohort C. Results Individuals who underwent gender-affirming surgery had a 12.12-fold higher suicide attempt risk than those who did not (3.47% vs. 0.29%, RR 95% CI 9.20-15.96, p < 0.0001). Compared to the tubal ligation/vasectomy controls, the risk was 5.03-fold higher before propensity matching and remained significant at 4.71-fold after matching (3.50% vs. 0.74%, RR 95% CI 2.46-9.024, p < 0.0001) for the gender affirmation patients with similar results with the pharyngitis controls. Conclusion Gender-affirming surgery is significantly associated with elevated suicide attempt risks, underlining the necessity for comprehensive post-procedure psychiatric support.

The association between gender-affirming care and disordered eating in transgender and gender diverse individuals: Exploring appearance congruence and gender-related motivating factors for weight loss

OBJECTIVE

The objective of this study is to explore between-group differences across different stages of gender-affirming care, and associations between appearance congruence, gender-related motivations for weight loss, and disordered eating in transgender and gender expansive (TGE) individuals.

METHOD

A total of 160 TGE adults (aged 18-30) were recruited across the United States. Participants completed a comprehensive online survey. Data were analyzed using generalized linear models and bivariate correlations.

RESULTS

Significant differences in appearance congruence among participants at different transition stages were revealed, with the group that achieved their desired transition reporting the highest appearance congruence compared to all other groups. Furthermore, gender-related motivations for weight loss were significantly lower in individuals who achieved their desired transition compared to those with no plans to transition.

DISCUSSION

Findings suggest significantly higher appearance congruence in those who achieved their desired transition compared to other groups, and individuals who attained their desired transition exhibited significantly reduced gender-related motivations for weight loss compared to those with no plans to transition. These findings underscore the potential psychological benefits associated with successful gender-affirming care, highlighting its role not only in fostering appearance congruence but also in mitigating gender-related motivations for weight loss among TGE individuals. Future research should include larger and more diverse samples, longitudinal designs, and considerations of other factors influencing body image outcomes in this population.

PUBLIC SIGNIFICANCE

This study sheds light on the crucial relationship between gender-affirming care and body image outcomes in TGE individuals. Understanding how appearance congruence and gender-related motivations for weight loss are associated with disordered eating can inform tailored support and interventions. By recognizing the association of gender affirming care and well-being, healthcare providers can enhance care for TGE individuals.

Double longitudinal myotomy in gender-affirming colovaginoplasty: an innovative surgical technique to prevent and treat neovaginal spasms

BACKGROUND

Gender-affirming colovaginoplasty (GACv) presents excellent postoperative results. However, neovaginal spasms, reported as painful cramps, can affect the sexual life of patients.

AIM

The study sought to describe an innovative surgical technique and evaluate its impact on the prevention and treatment of neovaginal spasms.

METHODS

This was a single-center prospective observational study with 2 series of patients: (1) patients who underwent GACv with double myotomy (DM) for spasm prevention (series A), in which longitudinal myotomies were performed across the defunctionalized colon, transecting the taenias, and resecting 2 strips of the intestinal muscle layer of approximately 1- to 2-mm wide and tall, leaving intact colonic tissue between strips; and (2) patients who reported neovaginal spasms in whom intravaginal-DM was performed as treatment surgery (series B), in which the posterior wall of the neovagina was dissected from the rectum and transected by longitudinal myotomies, resecting 2 strips of endoluminal mucosa and submucosal muscle of approximately 1- to 2-mm wide and tall, and the colonic mucosa was subsequently closed.

OUTCOMES

Patient-reported outcomes and neovaginal examination were performed following standardized protocols.

RESULTS

In series A, 177 patients underwent GACv with the DM technique and were prospectively followed for a median time of 18 months (interquartile range, 13-60 months). No patients reported neovaginal spasms. In series B, 18 patients who reported neovaginal spasms after GACv were treated with intravaginal DM. After a median time of 35 months (interquartile range, 26-45 months), 83% (n = 15 of 18) reported remission of symptoms.

CLINICAL IMPLICATIONS

Double longitudinal myotomy performed on the derived portion of the colon in colovaginoplasty is an easy-to-perform and safe technique that may prevent and treat postoperative neovaginal spasms.

STRENGTHS AND LIMITATIONS

Our results presented certain limitations, mainly associated with a low prevalence of neovaginal spasms, which, being of personal perception, can be underdiagnosed. To the same extent, the fact that it is a monocentric experience limits the possibility of extrapolating it to other centers. Moreover, a more trained surgical team may be the cause of fewer postoperative complications. On the other hand, the fact of being a reference center for gender-affirming surgery, having our procedures protocolized, and the prospective nature of the study allowed us to obtain a certain homogeneity and granularity of the results.

CONCLUSION

DM is a safe procedure and appears to be highly effective for the prevention and treatment of neovaginal spasms after GACv. Routine use of this technique does not increase the operating time or postoperative complications. Multicenter, prospective studies are required to validate our results.

A European Network for the Investigation of Gender Incongruence in adolescents

BACKGROUND

Knowledge regarding the effects and side effects of gender-affirming hormone therapy (GAHT) in adults is rapidly growing, partly through international research networks such as the European Network for the Investigation of Gender Incongruence (ENIGI). However, data on the effects of puberty suppression (PS) and GAHT in transgender and gender diverse (TGD) youth are limited, although these data are of crucial importance, given the controversies surrounding this treatment.

AIM

We sought to present a detailed overview of the design of the ENIGI Adolescents study protocol, including the first baseline data.

METHODS

The ENIGI Adolescents study is an ongoing multicenter prospective cohort study. This study protocol was developed by 3 European centers that provide endocrine care for TGD adolescents and were already part of the ENIGI collaboration: Amsterdam, Ghent, and Florence.

OUTCOMES

Study outcomes include physical effects and side effects, laboratory parameters, bone mineral density, anthropometric characteristics, attitudes toward fertility and fertility preservation, and psychological well-being, which are measured in the study participants during PS and GAHT, up to 3 years after the start of GAHT.

RESULTS

Between November 2021 and May 2023, 172 TGD adolescents were included in the ENIGI Adolescents protocol, of whom 51 were assigned male at birth (AMAB) and 121 were assigned female at birth (AFAB); 3 AFAB participants reported a nonbinary gender identification. A total of 76 participants were included at the start of PS, at a median (IQR) age of 13.7 (12.9-16.5) years in AMAB and 13.5 (12.4-16.1) years in AFAB individuals. The remaining 96 participants were included at start of GAHT, at a median (IQR) age of 15.9 (15.1-17.4) years in AFAB and 16.0 (15.1-16.8) years in AMAB individuals. At the time of this report the study was open for inclusion and follow-up measurements were ongoing.

CLINICAL IMPLICATIONS

In response to the rising demand for gender-affirming treatment among TGD youth, this ongoing study is fulfilling the need for prospective data on the effects and safety of PS and GAHT, thus providing a foundation for evidence-based healthcare decisions.

STRENGTHS AND LIMITATIONS

This study has a strong multicenter, prospective design that allows for systematic data collection. The use of clinical and self-reported data offers a broad range of outcomes to evaluate. Nevertheless, the burden of additional measurements and questionnaires may lead to withdrawal or lower response rates. Few participants with a non-binary gender identity have been included.

CONCLUSION

With the ENIGI Adolescents study we aim to create a comprehensive dataset that we can use for a wide range of studies to address current controversies and uncertainties and to improve healthcare for TGD adolescents.

Adapting mHealth Interventions (PrEPmate and DOT Diary) to Support PrEP Retention in Care and Adherence Among English and Spanish-Speaking Men Who Have Sex With Men and Transgender Women in the United States: Formative Work and Pilot Randomized Trial

BACKGROUND

A growing number of mobile health (mHealth) technologies are being developed to support HIV preexposure prophylaxis (PrEP) adherence and persistence; however, most tools have focused on men who have sex with men (MSM), and few are available in Spanish. To maximize the potential impact of these tools in reducing gender and racial/ethnic disparities and promoting health equity, mHealth tools tailored to Spanish-speaking people and transgender women are critically needed.

OBJECTIVE

The aim of this study is to adapt and tailor 2 mHealth technologies, PrEPmate and DOT Diary, to support daily PrEP adherence and persistence among Spanish-speaking MSM and English- and Spanish-speaking transgender women and to evaluate the feasibility and acceptability of these tools.

METHODS

PrEPmate, an interactive, bidirectional, text messaging intervention that promotes personalized communication between PrEP users and providers, and DOT Diary, a mobile app that promotes self-management of PrEP use and sexual health through an integrated electronic pill-taking and sexual activity diary, were previously developed for English-speaking MSM. We conducted 3 focus groups with 15 English- and Spanish-speaking transgender women and MSM in San Francisco and Miami to culturally tailor these tools for these priority populations. We then conducted a 1-month technical pilot among 21 participants to assess the usability and acceptability of the adapted interventions and optimize the functionality of these tools.

RESULTS

Participants in focus groups liked the "human touch" of text messages in PrEPmate and thought it would be helpful for scheduling appointments and asking questions. They liked the daily reminder messages, especially the fun facts, gender affirmations, and transgender history topics. Participants recommended changes to tailor the language and messages for Spanish-speaking and transgender populations. For DOT Diary, participants liked the adherence tracking and protection level feedback and thought the calendar functions were easy to use. Based on participant recommendations, we tailored language within the app for Spanish-speaking MSM and transgender women, simplified the sexual diary, and added motivational badges. In the technical pilot of the refined tools, mean System Usability Scale scores were 81.2/100 for PrEPmate and 76.4/100 for DOT Diary (P=.48), falling in the "good" to "excellent" range, and mean Client Satisfaction Questionnaire scores were 28.6 and 28.3 for PrEPmate and DOT Diary, respectively (maximum possible score=32). Use of both tools was high over the 1-month pilot (average of 10.5 messages received from each participant for PrEPmate; average of 17.6 times accessing the DOT Diary app), indicating good feasibility for both tools.

CONCLUSIONS

Using a user-centered design approach, we culturally tailored PrEPmate and DOT Diary to support daily PrEP use among Spanish-speaking MSM and English- and Spanish-speaking transgender women. Our positive findings in a technical pilot support further testing of these mHealth interventions in an upcoming comparative effectiveness trial.

Diagnostic assessment of autism spectrum disorder in transgender and gender diverse youth

Objective: Higher prevalence of autism spectrum disorder (ASD) diagnosis and associated traits has been observed among transgender and gender diverse (TGD) youth, and the number of TGD youth requesting evaluation for autism is growing. This study explored the demographic and clinical profiles of TGD youth evaluated in a specialty autism clinic. Method: Retrospective autism evaluation results for 41 TGD youth aged 5-18 years and 67 cisgender-matched controls were included in the study. Results: Approximately, half of TGD youth were diagnosed with autism (TGDASD+; n = 19 vs. TGDASD-; n = 22). There were no group differences in sex assigned at birth, gender identity, FSIQ, race, or ethnicity. Compared to TGDASD- (allistic) youth, TGD autistics had significantly lower adaptive functioning and were more likely to have an IEP eligibility of ASD. Anxiety and mood disorders were more common in TGD youth, whereas language disorders were more prevalent in cisgender controls. Attention-Deficit/Hyperactivity Disorder (ADHD) was more common among TGDASD- youth (72%) than TGDASD+ youth (47%), though not significantly. Conclusions: TGD youth with school-based IEP eligibilities of ASD and lower adaptive functioning are more likely to be diagnosed with ASD upon medical evaluation. The combination of identifying as TGD and having ADHD may heighten suspicion for ASD. Asking about gender identity during autism evaluations for children middle school-aged and older is recommended.