One survey fits all? Evaluating the relevance of sexual function measures designed for cis women in trans women postvaginoplasty

BACKGROUND

Providers are currently using surveys designed for cisgender women and/or creating their own questionnaires to evaluate the sexual function and satisfaction (SFS) of transgender women postvaginoplasty (TWPV), despite the marked difference in anatomy and lived experience between these groups.

AIM

To evaluate the appropriateness of the current assays that have been validated in cisgender women and to assess their applicability in studying SFS in TWPV.

METHODS

Surveys assessing female SFS that were validated in English speakers in North America were compiled and reviewed. Percentages reflect the proportion of surveys that asked questions deemed relevant or irrelevant for TWPV. Assessed variables included questions about endogenous lubrication, pain/discomfort with penetration, and other sexual activity.

OUTCOMES

Outcomes of interest were questions that fell into 1 of 2 categories: questions irrelevant to TWPV (present/irrelevant) and those relevant for TWPV (present/relevant).

RESULTS

All surveys contained present/irrelevant questions. Endogenous lubrication-a property of the natal vagina that may not be present in the neovagina-was the primary present/irrelevant question and was asked in 69.2% of the surveys. Vaginal pain, a present/relevant question, was assessed in 46.2% of surveys. Furthermore, questions requiring a partnered relationship to answer were asked in 61.5% of surveys, which may detract from the assessment of SFS in individuals who do not have sexual partners. Notably, there was also a lack of questions important for evaluating SFS in TWPV, such as assessing satisfaction of the caliber and depth of the neovagina, erogenous stimulation of the prostate during insertive intercourse, and cosmetic appearance of the vulva.

CLINICAL IMPLICATIONS

This analysis raises concerns about the clinician's ability to meaningfully assess SFS in TWPV using the tools available.

STRENGTHS AND LIMITATIONS

This article is the first of its kind to qualitatively assess the applicability of currently validated SFS questionnaires in TWPV. Limitations include the inability to draw definitive conclusions due to the qualitative nature of the study and the possibility of missing complex biopsychosocial factors, as trans individuals were not directly involved in the assessments of applicability.

CONCLUSION

Given that the existing surveys are not designed to assess the SFS of TWPV, we call for the development of a validated survey for this population, which is in line with the precedent set by several other questionnaires validated for similarly specific populations.

Corrigendum: The impact of the COVID-19 pandemic on the lives of people with Gender Dysphoria

[This corrects the article DOI: 10.3389/fpubh.2022.878348.].

Effects of Tobacco Versus Electronic Cigarette Usage on Nonsuicidal Self-Injury and Suicidality Among Chinese Youth: Cross-Sectional Self-Report Survey Study

BACKGROUND

The increase in tobacco/conventional cigarette (CC) and electronic cigarette (EC) usage among Chinese youth has become a growing public health concern. This is the first large-scale study to compare the impact of CC and EC usage on risk for nonsuicidal self-injury (NSSI) and suicidality in cis-heterosexual and sexual and gender minority (SGM) youth populations in China.

OBJECTIVE

This study examines the CC and EC risks for NSSI and suicidality among Chinese youth and compares the extent to which SGM and cis-heterosexual youth's risks for NSSI and suicidality are influenced by their CC and EC usage and dependence.

METHODS

A total of 89,342 Chinese participants completed a cross-sectional self-report survey in 2021. Sociodemographic information, sexual orientations, gender identities, CC and EC usage, CC and EC dependence, and risks for suicidality and NSSI were assessed. The Mann-Whitney U test and chi-square test were performed for nonnormally distributed continuous variables and categorical variables, respectively. The multivariable linear regression model was used to examine both the influence of CC and EC usage and CC and EC dependence on NSSI and suicidality as well as the interaction effects of CC and EC usage and CC and EC dependence on NSSI and suicidality by group.

RESULTS

The prevalence of CC usage (P<.001) and dependence (P<.001) among SGM participants was lower than that among their cis-heterosexual counterparts. However, the prevalence of EC usage (P=.03) and EC dependence (P<.001) among SGM participants was higher than that among their cis-heterosexual counterparts. The multivariable linear regression model showed that CC dependence and EC dependence had a unique effect on NSSI and suicidality (CCs: B=0.02, P<.001; B=0.09, P<.001; ECs: B=0.05, P<.001; B=0.14, P<.001, respectively). The interaction effects of (1) CC usage and group type on NSSI and suicidality (B=0.34, P<.001; B=0.24, P=.03, respectively) and dual usage and group type on NSSI and suicidality (B=0.54, P<.001; B=0.84, P<.001, respectively) were significant, (2) CC dependence and group type on NSSI were significant (B=0.07, P<.001), and (3) EC dependence and group type on NSSI and suicidality were significant (B=0.04, P<.001; B=0.09, P<.001, respectively). No significant interaction effect was observed between EC usage and group type on NSSI and suicidality (B=0.15, P=.12; B=0.33, P=.32, respectively) and between CC dependence and group type on suicidality (B=-0.01, P=.72).

CONCLUSIONS

Our study shows evidence of intergroup differences in NSSI and suicidality risks between SGM and cis-heterosexual youth related to CC and EC usage. These findings contribute to the growing literature on CC and EC in cis-heterosexual and SGM populations. Concerted efforts are necessary at a societal level to curb the aggressive marketing strategies of the EC industry and media coverage and to maximize the impact of educational campaigns on EC prevention and intervention among the youth population.

Higher Prevalence of Adverse Childhood Experiences in Transgender Than in Cisgender Individuals: Results from a Single-Center Observational Study

Adverse childhood experiences (ACE) have been shown to have a tremendous negative impact on health outcomes later in life. This study presents data on the prevalence of ACEs, psychological distress, and trauma-related symptoms in transgender and gender-diverse (TGD) people compared to cisgender people. TGD adults (n = 35) and a matched sample of nonpsychiatric hospital patients (n = 35) were surveyed between September 2018 and March 2019. Participants completed the Maltreatment and Abuse Chronology of Exposure Scale to assess ACEs, as well as the Brief Symptom Inventory and the Essener Trauma Inventory to assess psychological distress and trauma-related symptoms. TGD patients reported a higher number of ACEs than cisgender patients (0.7 vs. 2.4; p < 0.001; d = 0.94). A total of 28.6% of TGD vs. 5.7% cisgender patients reported four or more ACEs (p < 0.001). The most common forms of ACEs were parental abuse (54.3%) and peer abuse (54.3%). No significantly increased prevalence of sexual abuse was found (p > 0.05). TGD patients also reported a higher prevalence of depression (48.4% vs. 5.7%, p < 0.001), posttraumatic stress disorder symptoms (59.4% vs. 13.8%, p < 0.001), and anxiety (58.1% vs. 28.6%, p = 0.016). Health care providers should be aware of and assess ACEs, especially in vulnerable groups such as TGD people, and create a safe place through open-minded, affirming care.

Review of adult gender transition medications: mechanisms, efficacy measures, and pharmacogenomic considerations

Gender dysphoria is the imparity between a person's experienced gender and their birth-assigned gender. Gender transition is the process of adapting a person's sexual characteristics to match their experienced gender. The number of adults receiving sex hormone therapy for gender dysphoria is increasingly and these pharmacotherapies are increasing being prescribed in a general practice setting. The role of hormone therapy is to reverse or reduce physical sexual characteristics of the birth-assigned gender and enhance and build characteristics aligning to the expressed gender and these therapies apply to both transgender and gender nonconforming patients. Recognizing the options and interpreting the effects of gender transition therapies are fundamental to the discussion and treatment of gender dysphoria. This review summarizes pharmacodynamics, comparative dosing, adverse effects, monitoring, and potential pharmacogenetic influence of current pharmacotherapy. These include the use of 17-beta-estradiol, spironolactone, testosterone, GnRH agonists as well as adjunctive phosphodiesterase-5 inhibitors. The article also addresses gaps within the published literature including optimal routes of administration for individual patients, risks of malignancy and dosing reductions as transgender patients age.

'It's Just Safer When I Don't Go There': Trans People's Locker Room Membership and Participation in Physical Activity

Building on findings demonstrating that transgender and gender non-binary (trans) people's participation in physical activity is impacted by their experiences in locker rooms, this study examines how trans people navigate transphobia and cissexism in locker rooms. I consider the concepts of membership and belonging to illuminate how locker room access impacts trans people's participation in the public sphere. Drawing on interviews with trans people, this study suggests that-because of iterative encounters of surveillance, scrutiny, harassment, and violence-trans people regularly adopt strategies for navigating locker rooms as nonmembers. To access locker rooms despite a denial of membership, trans people employ various strategies to minimize the visibility of their transness and/or gender non-conformity through managing the perceived threat their gender expression poses to a "cisgendered reality." Strategies such as hurrying, avoiding nudity and eye contact, and recruiting ally support function to facilitate locker room access by minimizing attention to trans nonmembership. The findings of this study suggest that whiteness broadens the availability of strategies for navigating locker rooms. This study offers insight into how people respond to stigma, evade surveillance and exclusion, and access public space despite a denial of membership.

[Affirming one's gender: supporting and accompanying trans young people and their families]

Support for trans teenagers and young adults is based on a comprehensive approach to care, taking into account the needs and desires of the individual and his or her environment. It involves welcoming their requests and listening to their questions, in order to help them assert themselves. The aim is to be particularly attentive to these young people, sometimes in vulnerable psychological, social and educational situations, as well as to their families, by welcoming them, listening to them and taking charge of them through multidisciplinary networks.

Sex Differences in Athletic Performance: Perspectives on Transgender Athletes

Sex hormone concentrations, particularly testosterone, are primary determinants of sex-based differences in athletic and sports performance, and this relationship may inform fair competition and participation for athletes. This article describes the sex-based dichotomy in testosterone and the implications for sex-based differences in individual sports performance, including factors that relate to athletic performance for transgender individuals, and areas of future investigation.

Tradeoffs, Constraints, and Strategies in Transgender and Nonbinary Young Adults' Romantic Relationships: The Identity Needs in Relationships Framework

Prior research suggests that prejudice and structural disadvantage (e.g., cissexism, racism, sexism) put transgender and nonbinary (TNB) young adults at risk for adverse romantic relationship experiences, yet supportive romantic relationships may help TNB young adults cope with these stressors and promote their psychological wellbeing. Accordingly, there is a need to better understand how TNB young adults navigate romantic relationships in the context of prejudice and structural disadvantage. To address this topic, we analyzed in-depth interviews with TNB young adults (18-30 years; N=30) using template-style thematic analysis, guided by intersectionality as an analytical framework. Our analysis resulted in three themes. Theme 1 describes how prejudice and structural disadvantage constrained the strategies that TNB young adults used to pursue fulfilling romantic relationships (e.g., leaving adverse relationships). Theme 2 addresses the tradeoffs that some participants faced in their romantic relationships, including tradeoffs between psychological needs related to their social identities (e.g., gender identity affirmation) and general psychological needs (e.g., intimacy). Theme 3 highlights individual and contextual factors (e.g., lessons from prior romantic relationships) that helped participants build fulfilling romantic relationship. These themes form the basis for the Identity Needs in Relationships Framework, a new conceptual framework addressing how TNB young adults navigate romantic relationships in the context of prejudice and structural disadvantage. The framework offers an explanation for why some TNB young adults maintain romantic relationships that seem to undermine their wellbeing, and it draws attention to strategies and resources that may help TNB young adults form fulfilling romantic relationships despite the prejudice and structural disadvantage they face.

Study of FGF21 Levels in Transgender People and its Association with Metabolic Parameters

Background

Fibroblast growth factor (FGF21) is a metabolic regulator whose role in humans is unidentified. FGF21 has generated a lot of potential of becoming a therapeutic agent for the management of type 2 diabetes mellitus and dyslipidaemia. The role of FGF21 in gender dysphoria individuals has not been studied.

Objective

Primary objective was to assess FGF21 levels in transgender individuals and compare with controls and secondary objective was to compare FGF21 levels with lipid and glucose parameters in transgender people.

Results

Twenty-three transfemales and 21 transmales were included in the study and compared with 44 controls. Height and fasting blood glucose of transfemales was statistically greater than transmales, with no other differences in baseline characteristics. Although FGF21 levels were numerically greater in transfemales (183.50 ± 97.39), it was not statistically significant. FGF21 levels did not vary statistically when compared to controls although it was numerically higher. Univariate analysis was done in transgender patients and FGF21 levels were positively correlated with serum total cholesterol and serum LDL cholesterol in transfemales but not in transmales. Multivariate analysis was also done taking 50th centile and 75th centile of FGF21 levels of controls and was found that only serum total cholesterol and serum LDL positively correlated with FGF21 levels in transfemales with 75th centile as cutoff.

Conclusion

FGF21 levels correlated positively with serum triglycerides and serum LDL cholesterol in transfemales but not in transmales. Hence, FGF21 levels can be used as a marker for the development of metabolic syndrome in transfemales.

The Treatment of Young Transgender People and the Law

The law has slowly recognised the concept of a transgender person. After initially fixating on someone's physical birth gender, it has now accepted the concept of gender identity. It has been challenged by young people experiencing gender dysphoria seeking medical treatment. Though in recent years it has increasingly accepted the right of such a person to access appropriate treatment, this article suggests further improvements in this area of the law are desirable, including no longer making the distinction between therapeutic and non-therapeutic treatment, reforming the extent of judicial power in this context, and according greater autonomy to mature young people.

Barriers in Dental Care Utilization-An Explorative Study among Transgender Community of Bhubaneswar, Odisha

Introduction

Transgenders (TGs) are one of the vulnerable groups in our society. Trans people experience substantial health disparities and barriers to appropriate health care services that keep them from achieving the highest possible health status.

Methodology

The study was conducted over the course of 12 months at the Transgender Shelter Home. Focus group discussion (FGD) took place with 6-12 participants and the researcher acted as moderator. The questions were asked under four domains; sociodemographic variables, behavioral variables, medical and health status variables, and access and utilization of dental services barrier variables. Transcripts were coded and data analysis was concurrent with data collection to allow to know new insights. The data analysis was done by MAXQDA software 2022.0.0. It is being developed and distributed by VERBI Software based in Berlin, Germany.

Results

The barriers and facilitators explored were categorized at three levels: (1) the personal level, relating to those barriers and facilitators that the individual faced for their oral health care, and the perspectives regarding the delivery of care; (2) the inter-personal level; and (3) the system level, for identifying the wider elements and their influence.

Discussion

Social stigma and marginalization have been linked to adverse health effects, including personal attributes, structural and environmental factors, and personal perceptions of stigmatization.

Conclusion

It is evident that lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities have specific but varied health care needs, and the greatest way to treat these necessities is via exposure to professional, health care coverage.

Fertility preservation and realignment in transgender women

Medical care for transgender people is multi-faceted and attention to individual reproductive aspirations and planning are an essential, yet often overlooked aspect of care. Given the impact of hormonal therapy and other gender affirmation procedures on reproductive function, extensive counselling and consideration of fertility preservation is recommended prior to their commencement. This review article explores the reproductive aspirations of transgender women and considers the current disparity between stated desires regarding utilisation of fertility preservation services. Current fertility preservation options and prospective treatments currently showing promise in the research arena are explored.

[Care pathways for young transgender people]

Gender incongruence corresponds to the mismatch between gender identity and gender/sex assigned at birth gender/sex assigned at birth. It can be accompanied by psychological distress. In line with the literature, an increase in consultations for gender incongruence has been observed, especially among young people. Multidisciplinary care should be offered to this population; here we provide an example of healthcare proposed at the university hospital of Nancy.

Patterns of gender identity data within electronic health record databases can be used as a tool for identifying and estimating the prevalence of gender-expansive people

Objective

Electronic health records (EHRs) within the United States increasingly include sexual orientation and gender identity (SOGI) fields. We assess how well SOGI fields, along with International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) codes and medication records, identify gender-expansive patients.

Materials and Methods

The study used a data set of all patients that had in-person inpatient or outpatient encounters at an academic medical center in a rural state between December 1, 2018 and February 17, 2022. Chart review was performed for all patients meeting at least one of the following criteria: differences between legal sex, sex assigned at birth, and gender identity (excluding blank fields) in the EHR SOGI fields; ICD-10 codes related to gender dysphoria or unspecified endocrine disorder; prescription for estradiol or testosterone suggesting use of gender-affirming hormones.

Results

Out of 123 441 total unique patients with in-person encounters, we identified a total of 2236 patients identifying as gender-expansive, with 1506 taking gender-affirming hormones. SOGI field differences or ICD-10 codes related to gender dysphoria or both were found in 2219 of 2236 (99.2%) patients who identify as gender-expansive, and 1500 of 1506 (99.6%) taking gender-affirming hormones. For the gender-expansive population, assigned female at birth was more common in the 12-29 year age range, while assigned male at birth was more common for those 40 years and older.

Conclusions

SOGI fields and ICD-10 codes identify a high percentage of gender-expansive patients at an academic medical center.

Psychopharmacological Considerations for Gender-Affirming Hormone Therapy

ABSTRACT

The field of transgender health has grown exponentially since the early 2010s. While this increased visibility has not been without controversy, there is growing acknowledgement of the needs of transgender, nonbinary, and gender expansive (TNG) patients and the health disparities they experience compared to the cisgender population. There is also increased interest among clinicians and trainees in providing gender-affirming care in all medical specialties. This is particularly relevant in psychiatry as mental health disparities in TNG patients have been well-documented. TNG patients experience significant minority stress and higher rates of psychiatric illness, self-harm, suicidality, and psychiatric hospitalization compared to their cisgender peers. In this review, we will cover potential interactions and side effects relevant to psychiatric medication management for the three most common medication classes prescribed as part of gender-affirming hormone therapy (GAHT): gonadotropin-releasing hormone receptor agonists, estradiol, and testosterone. Although no studies directly examining the efficacy of psychiatric medications or their interactions with GAHT for TNG patients have been published yet, we have synthesized the existing literature from both cisgender and TNG patients to shed light on health care disparities seen in TNG patients. Since clinicians' lack of comfort and familiarity with gender-affirming care contributes significantly to these disparities, we hope this narrative review will help psychiatric prescribers provide TNG patients with the same quality of care that cisgender patients receive.

Brief Report: Interruptions in HIV Prevention and Treatment During the COVID-19 Pandemic: A Cross-Sectional Study of Transgender and Gender Nonbinary Adults in the United States

BACKGROUND

Transgender and gender nonbinary (TNB) people have been disproportionately affected by HIV and the COVID-19 pandemic. This study explored the prevalence of HIV prevention and treatment (HPT) interruptions during the pandemic and identified factors associated with these interruptions.

SETTING

Data were drawn from LITE Connect, a US-based, nationwide, online, self-administered survey designed to examine the experiences of TNB adults during the COVID-19 pandemic. A convenience sample of 2134 participants were recruited between June 14, 2021, and May 1, 2022.

METHODS

The analytic sample was restricted to participants taking antiretroviral medications to prevent or treat HIV before the onset of the pandemic (n = 153). We calculated descriptive statistics as well as Pearson χ 2 bivariate tests and multivariable models to identify factors associated with HPT interruptions during the pandemic.

RESULTS

Thirty-nine percent of participants experienced an HPT interruption. We found a lower odds of HPT interruptions among participants living with HIV [adjusted odds ratios (aOR) 0.45; 95% Confidence Intervals (CI): 0.22, 0.92; P = 0.02] and essential workers [aOR 0.49; 95% CI: 0.23, 1.0; P = 0.06] and higher odds among people with chronic mental health conditions [aOR 2.6; 95% CI: 1.1, 6.2; P = 0.03]. When sex and education were included, we found a lower odds of interruptions among people with higher education. CI widened, but the magnitude and direction of effects did not change for the other variables.

CONCLUSIONS

Focused strategies to address longstanding psychosocial and structural inequities are needed to mitigate HPT treatment interruptions in TNB people and prevent similar challenges during future pandemics.

Outcomes of oocyte vitrification in trans masculine individuals

RESEARCH QUESTION

What are the outcomes and experiences of oocyte vitrification treatment in trans masculine individuals (TMI) before and after testosterone use?

DESIGN

This retrospective cohort study was conducted at the Amsterdam UMC in the Netherlands between January 2017 and June 2021. The TMI who had completed an oocyte vitrification treatment were consecutively approached for participation. Informed consent was provided by 24 individuals. Participants (n = 7) who initiated testosterone therapy were advised to stop 3 months before stimulation. Demographic characteristics and oocyte vitrification treatment data were retrieved from medical records. Evaluation of the treatment was collected via an online questionnaire.

RESULTS

The median age of participants was 22.3 years (interquartile range 21.1-26.0) and mean body mass index was 23.0 kg/m2 (SD 3.2). After ovarian hyperstimulation, a mean of 20 oocytes (SD 7) were retrieved and a mean of 17 oocytes (SD 6) could be vitrified. Aside from a lower cumulative FSH dose, there were no significant differences between the prior testosterone users and testosterone naïve TMI. The overall satisfaction of oocyte vitrification treatment in participants was high. Hormone injections were considered the most strenuous part of treatment by 29% of participants, closely followed by oocyte retrieval (25%).

CONCLUSIONS

No difference in response to ovarian stimulation was found for oocyte vitrification treatment between the prior testosterone users and testosterone naïve TMI. The questionnaire identified hormone injections as the most burdensome aspect of oocyte vitrification treatment. This information can be used to improve gender sensitive fertility counselling and fertility treatment strategies.

Body Mass Index Categories of Transgender and Gender Diverse Youth: Clinical Associations and Predictors

Background: Transgender/gender diverse (TGD) youth are at risk for weight-related problems. We describe factors associated with their body mass index (BMI) category. Methods: Chart review of 228 TGD patients, 12-20 years (u = 15.7, standard deviation 1.3), 72% female assigned at birth. BMI percentile was calculated using CDC growth charts. We examined bivariate relationships of 18 clinically derived factors, utilizing analysis of variance (ANOVA) for continuous variables and chi-squared/Fisher's exact test for categorical variables. Nonparametric Classification and Regression Tree (CART) analyses were used to predict BMI category. Results: Almost half (49.6%) of TGD youth presenting for their initial visit for pediatric gender-affirming care fell in the healthy weight range, 4.4% in the underweight range, 16.7% in the overweight range, and 29.4% in the obese range. Self-described weight, weight management intentions, unhealthy weight management, prescription of psychiatric medications, and medications associated with weight gain were associated with BMI category. Use of psychiatric medications (54.8%) and medications associated with weight gain (39.5%) was associated with BMI in the overweight/obese categories. Youth with obesity most often reported unhealthy weight management. In CART models, self-described weight was the strongest predictor of BMI category. Conclusion: TGD youth have high rates of underweight and overweight/obesity. Unhealthy BMI should be treated as part of gender-affirming care. Self-described body weight is associated with weight category. More than half of TGD youth were prescribed psychiatric medications; those with overweight and obesity were more likely prescribed psychiatric and medications with associated weight gain. Youth with obesity were most likely to use unhealthy weight management.

Decision making in metoidioplasty and phalloplasty gender-affirming surgery: a mixed methods study

BACKGROUND

Gender-affirming surgical procedures, such as metoidioplasty and phalloplasty for those assigned female at birth, are complex and multistaged and involve risks. Individuals considering these procedures experience greater uncertainty or decisional conflict, compounded by difficulty finding trustworthy information.

AIM

(1) To explore the factors contributing to decisional uncertainty and the needs of individuals considering metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) and (2) to inform development of a patient-centered decision aid.

METHODS

This cross-sectional study was based on mixed methods. Adult transgender men and nonbinary individuals assigned female at birth at various stages of MaPGAS decision making were recruited from 2 study sites in the United States to participate in semistructured interviews and an online gender health survey, which included measures of gender congruence, decisional conflict, urinary health, and quality of life. Trained qualitative researchers conducted all interviews with questions to explore constructs from the Ottawa decision support framework.

OUTCOMES

Outcomes included goals and priorities for MaPGAS, expectations, knowledge, and decisional needs, as well as variations in decisional conflict by surgical preference, surgical status, and sociodemographic variables.

RESULTS

We interviewed 26 participants and collected survey data from 39 (24 interviewees, 92%) at various stages of MaPGAS decision making. In surveys and interviews, affirmation of gender identity, standing to urinate, sensation, and the ability to "pass" as male emerged as highly important factors for deciding to undergo MaPGAS. A third of survey respondents reported decisional conflict. Triangulation of data from all sources revealed that conflict emerged most when trying to balance the strong desire to resolve gender dysphoria through surgical transition against the risks and unknowns in urinary and sexual function, appearance, and preservation of sensation post-MaPGAS. Insurance coverage, age, access to surgeons, and health concerns further influenced surgery preferences and timing.

CLINICAL IMPLICATIONS

The findings add to the understanding of decisional needs and priorities of those considering MaPGAS while revealing new complexities among knowledge, personal factors, and decisional uncertainty.

STRENGTHS AND LIMITATIONS

This mixed methods study was codeveloped by members of the transgender and nonbinary community and yielded important guidance for providers and individuals considering MaPGAS. The results provide rich qualitative insights for MaPGAS decision making in US contexts. Limitations include low diversity and sample size; both are being addressed in work underway.

CONCLUSIONS

This study increases understanding of the factors important to MaPGAS decision making, and results are being used to guide development of a patient-centered surgical decision aid and informed survey revision for national distribution.

A Transgender Chatbot (Amanda Selfie) to Create Pre-exposure Prophylaxis Demand Among Adolescents in Brazil: Assessment of Acceptability, Functionality, Usability, and Results

BACKGROUND

HIV incidence rates have increased in adolescent men who have sex with men (AMSM) and adolescent transgender women (ATGW). Thus, it is essential to promote access to HIV prevention, including pre-exposure prophylaxis (PrEP), among these groups. Moreover, using artificial intelligence and online social platforms to create demand and access to health care services are essential tools for adolescents and youth.

OBJECTIVE

This study aims to describe the participative process of developing a chatbot using artificial intelligence to create demand for PrEP use among AMSM and ATGW in Brazil. Furthermore, it analyzes the chatbot's acceptability, functionality, and usability and its results on the demand creation for PrEP.

METHODS

The chatbot Amanda Selfie integrates the demand creation strategies based on social networks (DCSSNs) of the PrEP1519 study. She was conceived as a Black transgender woman and to function as a virtual peer educator. The development process occurred in 3 phases (conception, trial, and final version) and lasted 21 months. A mixed methodology was used for the evaluations. Qualitative approaches, such as in-depth adolescent interviews, were used to analyze acceptability and usability, while quantitative methods were used to analyze the functionality and result of the demand creation for PrEP based on interactions with Amanda and information from health care services about using PrEP. To evaluate Amanda's result on the demand creation for PrEP, we analyzed sociodemographic profiles of adolescents who interacted at least once with her and developed a cascade model containing the number of people at various stages between the first interaction and initiation of PrEP (PrEP uptake). These indicators were compared with other DCSs developed in the PrEP1519 study using chi-square tests and residual analysis (P=.05).

RESULTS

Amanda Selfie was well accepted as a peer educator, clearly and objectively communicating on topics such as gender identity, sexual experiences, HIV, and PrEP. The chatbot proved appropriate for answering questions in an agile and confidential manner, using the language used by AMSM and ATGW and with a greater sense of security and less judgment. The interactions with Amanda Selfie combined with a health professional were well evaluated and improved the appointment scheduling. The chatbot interacted with most people (757/1239, 61.1%) reached by the DCSSNs. However, when compared with the other DCSSNs, Amanda was not efficient in identifying AMSM/ATGW (359/482, 74.5% vs 130/757, 17.2% of total interactions, respectively) and in PrEP uptake (90/359, 25.1% vs 19/130, 14.6%). The following profiles were associated (P<.001) with Amanda Selfie's demand creation, when compared with other DCS: ATGW and adolescents with higher levels of schooling and White skin color.

CONCLUSIONS

Using a chatbot to create PrEP demand among AMSM and ATGW was well accepted, especially for ATGW with higher levels of schooling. A complimentary dialog with a health professional increased PrEP uptake, although it remained lower than the results of the other DCSSNs.

A Curricular Audit Method: Addressing the Erasure of Intersex, Trans and Two-Spirit People and the Imprecise Use of Gender and Sex Concepts in Undergraduate Medical Education

Phenomenon: Intersex, trans, and Two-Spirit people report overwhelmingly negative experiences with health care providers, including having to educate their providers, delaying, foregoing, and discontinuing care due to discrimination and being denied care. Medical education is a critical site of intervention for improving the health and health care experiences of these patients. Medical research studies, clinical guidelines, textbooks, and medical education generally, assumes that patients will be white, endosex, and cisgender; gender and sex concepts are also frequently misused. Approach: We developed and piloted an audit framework and associated tools to assess the quantity and quality of medical education related to gender and sex concepts, as well as physician training and preparedness to meet the needs of intersex, trans, and Two-Spirit patients. We piloted our framework and tools at a single Canadian medical school, the University of British Columbia, focused on their undergraduate MD program. We were interested in assessing the extent to which endosexnormativity, cisnormativity, transnormativity, and the coloniality of gender were informing the curriculum. In this paper, we detail our audit development process, including the role of advisory committees, student focus groups, and expert consultation interviews. We also detail the 3-pronged audit method, and include full-length versions of the student survey, faculty survey, and purpose-built audit question list. Findings: We reflect on the strengths, limits, and challenges of our audit, to inform the uptake and adaptation of this approach by other institutions. We detail our strategy for managing the volume of curricular content, discuss the role of expertise, identify a section of the student survey that needs to be reworked, and look ahead to the vital task of curricular reform and recommendations implementation. Insights: Our findings suggest that curricular audits focused on these populations are lacking but imperative for improving the health of all patients. We detail how enhancing curriculum in these areas, including by adding content about intersex, trans, and Two-Spirit people, and by using gender and sex concepts more accurately, precisely and inclusively, is in line with the CanMEDS competencies, the Medical Council of Canada's Objectives for the Qualifying Examinations, many institutions' stated values of equity, inclusion and diversity, and physicians' ethical, legal and professional obligations.

Are Age-Friendly Communities "Friendly" for All? Perspectives from LGBTQ2S+ Communities

Age-friendly initiatives have grown in popularity in their efforts to promote active aging among older adults in Canada and other countries worldwide. However, these initiatives often overlook underrepresented populations, such as lesbian, gay, bisexual, trans, queer, and two-spirit (LGBTQ2S+) older adults, who have unique social and historical contexts which impact their aging experiences. The study involved a survey and key-informant interviews with local leaders, volunteers, staff, and/or LGBTQ2S+ older adults involved in initiatives that were both age and LGBTQ2S+ friendly to explore what it means for a community to be age and LGBTQ2S+ friendly and learn what can further be done to promote these communities. Through a qualitative template analysis, our findings suggest that safety within the social environment should be at the forefront of age-friendly policy initiatives. Considerations and avenues to create this safety and an overall culture of acceptance for all older adults include recognizing generational differences among aging cohorts, increasing LGBTQ2S+ visibility and involvement and highlighting the importance of policy and cultural humility. These considerations and the voices of LGBTQ2S+ older adults need to be integrated into age-friendly community planning and policies to ensure they are inclusive and that all older adults feel safe and can thrive within their communities.

A Transgender Health Information Resource: Participatory Design Study

BACKGROUND

Despite the abundance of health information on the internet for people who identify as transgender and gender diverse (TGD), much of the content used is found on social media channels, requiring individuals to vet the information for relevance and quality.

OBJECTIVE

We developed a prototype transgender health information resource (TGHIR) delivered via a mobile app to provide credible health and wellness information for people who are TGD.

METHODS

We partnered with the TGD community and used a participatory design approach that included focus groups and co-design sessions to identify users' needs and priorities. We used the Agile software development methodology to build the prototype. A medical librarian and physicians with expertise in transgender health curated a set of 97 information resources that constituted the foundational content of the prototype. To evaluate the prototype TGHIR app, we assessed the app with test users, using a single item from the System Usability Scale to assess feature usability, cognitive walk-throughs, and the user version of the Mobile Application Rating Scale to evaluate the app's objective and subjective quality.

RESULTS

A total of 13 people who identified as TGD or TGD allies rated their satisfaction with 9 of 10 (90%) app features as good to excellent, and 1 (10%) of the features-the ability to filter to narrow TGHIR resources-was rated as okay. The overall quality score on the user version of the Mobile Application Rating Scale was 4.25 out of 5 after 4 weeks of use, indicating a good-quality mobile app. The information subscore received the highest rating, at 4.75 out of 5.

CONCLUSIONS

Community partnership and participatory design were effective in the development of the TGHIR app, resulting in an information resource app with satisfactory features and overall high-quality ratings. Test users felt that the TGHIR app would be helpful for people who are TGD and their care partners.

Young transgender individuals' lived experiences of facing life's challenges: a qualitative study in Iran

Introduction

In recent years, several studies have addressed the challenges and psychological issues that transgender individuals face. However, only a few studies have explored the experiences of this population in Iran. Life experiences are heavily influenced by the dominant religious and cultural conditions and common beliefs in a society. The present study aimed to investigate transgender individuals' lived experiences of facing life's challenges in Iran.

Methods

This is a qualitative study with a descriptive and phenomenological design conducted from February to April 2022. Data were collected using semi-structured, in-depth interviews with 23 transgender individuals (13 AFAB and 10 AMAB). The collected data were analyzed using Colaizzi's method.

Results

Analysis of the qualitative data resulted in the emergence of three themes and 11 subthemes. The three main themes included mental health disparities (fear of having one's secret revealed, depression and despair, suicidal thoughts, and secrecy in the family), gender dysphoria (contradictory gender identity and contradictory behaviors), and stigma and insecurity (sexual abuse, social discrimination, disrupted occupational performance, a lack of support, disrepute, and disgrace).

Conclusions

The findings of the study indicated that transgender people in Iran are exposed to considerable mental health disparities. In addition to disrepute, infamy, and stigma, transgender people face sexual abuse, social discrimination, and a lack of family social support. The results of the present study can help mental health experts and the healthcare system as a whole to adjust their mental and physical health programs according to the needs and experiences of transgender people and their families. It is recommended that future research address the problems and psychological challenges that transgender people's families have to confront.

Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand

BACKGROUND

Past studies have demonstrated better mental health and well-being among transgender youth who had accessed gender-affirming care. However, few existing studies have assessed unmet need for gender-affirming care as a social determinant of mental health inequities.

METHODS

Data on unmet need for gender-affirming care, distress and suicidality were analysed from the 2018 Counting Ourselves nationwide community-based survey of transgender people in Aotearoa/New Zealand. Associations between unmet need for gender-affirming care and mental health indicators were tested for transgender youth within the sample (aged 14-26 years; n = 608; Mage = 20.5).

RESULTS

Transgender youth reported unmet needs ranging from 42% for gender-affirming hormone to 100% for feminizing surgeries and voice surgeries. Overall unmet need for gender-affirming care was associated with worse mental health. Trans men with an unmet need for chest reconstruction (84%) scored an average of 7.13 points higher on the K10 Psychological Distress Scale relative to those whose need had been met. Participants reporting unmet need for hormones (42%) had twice the odds (adjusted odds ratios = 2.01; CI = 1.02-3.98) of having attempted suicide in the last 12 months.

CONCLUSIONS

Dismantling barriers to accessing gender-affirming care could play a crucial role in reducing mental health inequities faced by transgender youth.

Implications of gender-affirming endocrine care for sports participation

Many transgender (trans) individuals utilize gender-affirming hormone therapy (GAHT) to promote changes in secondary sex characteristics to affirm their gender. Participation rates of trans people in sport are exceedingly low, yet given high rates of depression and increased cardiovascular risk, the potential benefits of sports participation are great. In this review, we provide an overview of the evidence surrounding the effects of GAHT on multiple performance-related phenotypes, as well as current limitations. Whilst data is clear that there are differences between males and females, there is a lack of quality evidence assessing the impact of GAHT on athletic performance. Twelve months of GAHT leads to testosterone concentrations that align with reference ranges of the affirmed gender. Feminizing GAHT in trans women increases fat mass and decreases lean mass, with opposite effects observed in trans men with masculinizing GAHT. In trans men, an increase in muscle strength and athletic performance is observed. In trans women, muscle strength is shown to decrease or not change following 12 months of GAHT. Haemoglobin, a measure of oxygen transport, changes to that of the affirmed gender within 6 months of GAHT, with very limited data to suggest possible reductions in maximal oxygen uptake as a result of feminizing GAHT. Current limitations of this field include a lack of long-term studies, adequate group comparisons and adjustment for confounding factors (e.g. height and lean body mass), and small sample sizes. There also remains limited data on endurance, cardiac or respiratory function, with further longitudinal studies on GAHT needed to address current limitations and provide more robust data to inform inclusive and fair sporting programmes, policies and guidelines.

Fertility preservation options for transgender and nonbinary individuals

Transgender and nonbinary individuals are historically underserved by healthcare systems. A crucial area for improvement is fertility preservation counseling and service delivery, as gender-affirming hormone therapy and gender-affirming surgery may negatively affect future fertility. The methods available for fertility preservation depend on the patient's pubertal status and utilization of gender-affirming therapies, and counseling and delivery of these services are complex and require a multidisciplinary approach. Further research is needed to identify pertinent stakeholders in managing the care of these patients, as well as to better understand the optimal frameworks for delivering integrated and comprehensive care to this patient population. Fertility preservation is an active and exciting area of scientific discovery and offers a wealth of opportunities to improve the care of transgender and nonbinary individuals.

Cancer care in transgender and gender-diverse persons: results from two national surveys among providers and health service users by the Italian Association of Medical Oncology

BACKGROUND

Transgender and gender-diverse (TGD) population represents an underserved group across the cancer care continuum. To assess the perspective of both oncology health care providers (OHPs) and TGD individuals in Italy, we conducted two national surveys: one among 2407 OHPs about their attitudes, knowledge and behavior toward TGD patients, and one among TGD persons about their health needs, experiences and barriers encountered in the use of health services across the cancer continuum.

MATERIALS AND METHODS

The surveys were self-compiled web-based computer-aided web interview, conducted in Italy within the 'OncoGender-Promoting Inclusion in Oncology' project, led by the Italian national cancer society [Associazione Italiana di Oncologia Medica (AIOM)]-associated researchers. All members of AIOM were invited by e-mail to participate in the OHP survey. TGD persons were reached through advocacy groups and consumers' panel. The recruitment was completed on a voluntary basis. Survey data were collected and managed using an online platform managed by ELMA Research, an independent pharmaceutical marketing agency.

RESULTS

A total of 305 OHPs (13% of AIOM members) and 190 TGD individuals participated in the surveys. Only 19% of OHPs felt competent in providing care to TGD patients and 21% declared not to feel comfortable in treating TGD patients. Seventy-one percent of TGD persons reported that they had never joined any cancer screening program; 32% reported one or more acts of discrimination by health care providers. Seventy-two percent of OHPs recognized the lack of specific education on cancer care for TGD patients and deemed it necessary to receive adequate training.

CONCLUSIONS

A general lack of knowledge among OHPs about TGD health issues seems to be the main driver of difficulties in providing assistance and of discriminatory attitudes against TGD individuals. Ultimately, this whole issue generates access barriers and contributes to lack of trust in health care services. Educational interventions and an implementation of person-centric cancer policies are urgently needed.

'Stuck in the System': An Interpretative Phenomenological Analysis of Transmasculine Experiences of Gender Transition in the UK

A gender dysphoria diagnosis is currently required in the UK to access NHS transition-related treatment. However, this approach has been criticised by academics and activists as pathologising, 'gatekeeping' transgender identities, and can be viewed by the transgender community as a barrier to necessary medical care. The present research examines transmasculine experiences of gender transition in the UK, focusing on exploring the barriers encountered during identity development and medical transition. Semi-structured interviews were conducted with three individuals, and nine individuals took part in a single focus group. The data were analysed using Interpretative Phenomenological Analysis producing three main themes: 'Conceptualising Stages of Transition'; 'NHS Communication and Support'; and 'Medicalisation, Power and Non-disclosure'. Participants conceptualised access to transition-related treatment as an intrusive and complicated process that negatively impacts identity development. They spoke of barriers such as lack of trans-specific healthcare knowledge, insufficient communication and support from healthcare professionals, and restricted autonomy arising from the pathologisation of trans identities. Results suggest transmasculine individuals may face numerous barriers when trying to access healthcare, and therefore, a move towards the Informed Consent Model could ameliorate many of these barriers and would empower service-users to make informed choices.

The Intersection of Autism and Transgender and Nonbinary Identities: Community and Academic Dialogue on Research and Advocacy

Many transgender people are autistic. Community expressions of the autism transgender intersection abound. Some commentators have questioned the proportional overrepresentation of autism among gender-diverse people, suggesting these individuals may not be truly autistic or truly transgender. However, increasing evidence challenges assertions that deny the authenticity of co-occurring autistic and transgender identities. Specifically, research by authors of this article indicates autistic transgender people show neurophenotypes generally consistent with cisgender autistic people and implicit gender phenotypes consistent with nonautistic transgender people. This article features a dialogue between eight leading experts in the field of intersectional autism and gender diversity, including clinicians, researchers, community advocates, and experts who are themselves autistic transgender. Key topics of discussion included: how research findings on autism and gender diversity inform respectful and supportive responses to autistic transgender people; the benefits and harms of increased societal attention toward the autism transgender intersection; and research and advocacy priorities. The expert panel concluded the following: (1) it is important to respect transgender autistic people's wellness and resilience, while also acknowledging the pathologization and stigmatization they face; (2) autistic gender-diverse people are experts of their own identity and should be involved in all aspects of research and clinical care; (3) research is needed to understand the disparities autistic transgender people face; (4) attempts to restrict autistic transgender people's access to gender care are unsupported by existing research; (5) adult gender care may benefit from incorporating universal design principles and neurodiversity-affirming strategies to reduce barriers to care and improve clinician-client communication in treatment delivery and the informed consent process; (6) cross-cultural and cross-societal research will improve best care practices in diverse contexts; (7) research and advocacy must be inclusive across ethnoracial identities, including in leadership and perspectives represented; and (8) a life span developmental framework is needed for adult research in this field.

Feminizing hormone therapy in a Canadian cohort of transgender women with and without HIV

BACKGROUND

Potential bidirectional drug-drug interactions between feminizing hormone therapy (FHT) and antiretroviral therapy (ART) are of concern for trans women with HIV and their healthcare providers. This study aimed to characterize patterns of FHT and ART among trans women with HIV and to compare serum hormone levels to trans women without HIV.

METHODS

Charts of trans women were reviewed at seven HIV primary care or endocrinology clinics in Toronto and Montreal from 2018 to 2019. ART regimens, FHT use, serum estradiol, and serum testosterone levels were compared on the basis of HIV status (positive, negative, missing/unknown).

RESULTS

Of 1495 trans women, there were 86 trans women with HIV, of whom 79 (91.8%) were on ART. ART regimens were most commonly integrase inhibitor-based (67.4%), many boosted with ritonavir or cobicistat (45.3%). Fewer (71.8%) trans women with HIV were prescribed FHT, compared to those without HIV (88.4%) and those with missing/unknown status (90.2%, p < 0.001). Among trans women on FHT with recorded serum estradiol (n = 1153), there was no statistical difference in serum estradiol between those with HIV (median: 203 pmol/L, IQR: 95.5, 417.5) and those with negative (200 mol/L [113, 407]) or missing/unknown HIV status (227 pmol/L [127.5, 384.5) (p = 0.633). Serum testosterone concentrations were also similar between groups.

CONCLUSIONS

In this cohort, trans women with HIV were prescribed FHT less often than trans women with negative or unknown HIV status. There was no difference in serum estradiol or testosterone levels of trans women on FHT regardless of HIV status, providing reassurance regarding potential drug-drug interactions between FHT and ART.

Customer Abuse and Aggression as Labour Control Among LGBT Workers in Low-Wage Services

This study examines the relation between customer abuse and aggression, the gender and sexual expression of workers, and labour control in low-wage services. In-depth interviews with 30 lesbian, gay, bisexual, and transgender (LGBT)1 low-wage service sector workers reveal how customer abuse and aggression works in consort with management strategies to reproduce cis- and heteronormativity. Customer abuse and aggression disciplined worker expressions of non-normative gender and sexual identities, leading to concealment and self-policing. Management was complicit in this dynamic, placing profitability and customer satisfaction over the safety of LGBT workers, only intervening in instances of customer abuse and aggression when it had a limited economic impact. It is posited that customer abuse and aggression is not only a response to unmet expectations emanating from the labour process but is also a mechanism of labour control that disciplines worker behaviour and aesthetics, directly and indirectly, by influencing management prerogatives.

Predictors of PrEP awareness, PrEP discussion and interest in long-acting injectable PrEP among Filipina transfeminine adults

INTRODUCTION

Transfeminine adults are impacted by the HIV epidemic in the Philippines, and newly approved modalities of pre-exposure prophylaxis (PrEP), including long-acting injectable (LAI-PrEP), could be beneficial for this group. To inform implementation, we analysed PrEP awareness, discussion and interest in taking LAI-PrEP among Filipina transfeminine adults.

METHODS

We utilized secondary data from the #ParaSaAtin survey that sampled Filipina transfeminine adults (n = 139) and conducted a series of multivariable logistic regressions with lasso selection to explore factors independently associated with PrEP outcomes, including awareness, discussion with trans friends and interest in LAI-PrEP.

RESULTS

Overall, 53% of Filipina transfeminine respondents were aware of PrEP, 39% had discussed PrEP with their trans friends and 73% were interested in LAI-PrEP. PrEP awareness was associated with being non-Catholic (p = 0.017), having previously been HIV tested (p = 0.023), discussing HIV services with a provider (p<0.001) and having high HIV knowledge (p = 0.021). Discussing PrEP with friends was associated with older age (p = 0.040), having experienced healthcare discrimination due to transgender identity (p = 0.044), having HIV tested (p = 0.001) and having discussed HIV services with a provider (p < 0.001). Very interested in LAI-PrEP was associated with living in Central Visayas (p = 0.045), having discussed HIV services with a provider (p = 0.001) and having discussed HIV services with a sexual partner (p = 0.008).

CONCLUSIONS

Implementing LAI-PrEP in the Philippines requires addressing systemic improvements across personal, interpersonal, social and structural levels in healthcare access, including efforts to create healthcare settings and environments with providers who are trained and competent in transgender health and can address the social and structural drivers of trans health inequities, including HIV and barriers to LAI-PrEP.

Brief Report: An Exploration of Alexithymia in Autistic and Nonautistic Transgender Adults

Background

Research has shown that many autistic people have alexithymia, a psychological trait characterized by difficulties in identifying and describing emotions. It is also now clear that there is a high rate of autism among transgender people, but we know little about the intersection of autism and gender diversity or about the clinical features of autistic transgender individuals.

Methods

Seventy-eight nonautistic transgender, 56 autistic transgender, 106 nonautistic cisgender, and 107 autistic cisgender adults completed the Toronto Alexithymia Scale-20 and the Autism-spectrum Quotient as part of an online study. We also used the General Alexithymia Factor Score-8 as an additional alexithymia score.

Results

We found that nonautistic transgender participants reported significantly higher mean levels of alexithymia than nonautistic cisgender participants, and that there was a significant overrepresentation of individuals in this group who met the clinical cutoff for alexithymia. The difference in alexithymia between autistic cisgender and autistic transgender participants was nonsignificant, with >50% of each group scoring above the clinical cutoff point. Of note, when we used the General Alexithymia Factor Score-8, the difference between autistic transgender participants and autistic cisgender participants was significant, with autistic transgender participants reporting higher mean levels of alexithymia.

Conclusion

Results suggest that nonautistic transgender individuals might be more prone to experience alexithymia (including at clinically significant levels) than nonautistic cisgender people. When autism occurs in transgender people, the average level and clinical rate of alexithymia is higher than among nonautistic transgender people and potentially higher than among autistic cisgender people. Our findings are in keeping with evidence of a subgroup of transgender people with "subclinical autism" and inconsistent with the notion that autism among transgender and gender diverse people is a "phenomimic" of autism. Lastly, our study highlights the potential importance of screening autistic and nonautistic transgender people for alexithymia.

Exploring the Experiences of Autistic Transgender and Non-Binary Adults in Seeking Gender Identity Health Care

Background

This study sought to obtain an in-depth understanding of autistic transgender and/or non-binary adults' experiences in accessing, or trying to access, gender identity health care (GIH). To our knowledge, no prior study researched this topic.

Methods

Through semi-structured interviews, we obtained the first-hand experiences of 17 participants. H.B. (cisgender, non-autistic) conducted a reflexive thematic analysis using an inductive approach, in collaboration with K.M., an autistic transgender disability community researcher, and under the supervision of S.K.K., a cisgender autistic autism researcher.

Results

Thematic analysis determined that poor knowledge of professionals, accessibility issues, and bureaucratic and economic barriers impacted participants' experiences when accessing GIH. Participants experienced a perceived lack of professional knowledge around autism and gender diverse health care needs, limited communication methods and accommodations, and misdiagnosis of mental health difficulties. Accessibility issues included unmet sensory needs, disruption to routine, and a lack of local provision. Further, participants shared that they struggled with unclear processes, standardization of care, long waiting lists, and confusing or inaccessible insurance coverage. Recommendations for improvements highlighted the need to listen to service users to positively impact their experiences in accessing GIH.

Conclusion

This study suggests that more training needs to be given to health care providers and professionals around autistic experience to help improve providers' competence in communication and providing person-centered accommodations. More training around gender diverse identities is needed, as well as increased knowledge on the co-occurrence of autism and transgender/non-binary identities, to positively impact patient experiences and help improve access to care.

Perioperative Oncology Health Care Providers and Transgender Health: A Single-Institution Survey to Gauge Attitudes, Knowledge, Behaviors, and Education

Purpose

Patients identifying as transgender report that a lack of access to providers with trans-specific medical knowledge represents one of the largest barriers to equitable health care access. Through an institutional survey, we assessed and analyzed the attitudes, knowledge, behaviors, and education of perioperative clinical staff when caring for transgender patients with cancer.

Methods

A web-based survey was distributed to 1100 perioperative clinical staff at the National Cancer Institute (NCI)-Designated Comprehensive Cancer Center in New York City between January 14, 2020, and February 28, 2020, and received 276 responses. The survey instrument consisted of 42 nondemographic questions about attitudes, knowledge, behaviors, and education regarding transgender health care and 14 demographic questions. Questions were presented as a mix of Yes/No, free text response, and a 5-point Likert scale.

Results

Certain demographic groups (younger, lesbian, gay, or bisexual [LGB], fewer years employment at the institution) held more favorable attitudes toward the transgender population and were more knowledgeable regarding their health needs. Respondents underreported the rates of mental illness and risk factors for cancer like HIV and substance use among the transgender population. A greater proportion of respondents identifying as LGB endorsed witnessing an interaction wherein a colleague exhibited attitudes/beliefs about the transgender population that were barriers to care. Only 23.2% of respondents were ever trained on the health needs of transgender patients.

Conclusion

There is a need for institutions to assess the cultural competency of perioperative clinical staff toward transgender health, especially within certain demographics. This survey may inform quality education initiatives to eliminate biases and knowledge gaps.

The Gender-Diversity and Autism Questionnaire: A Community-Developed Clinical, Research, and Self-Advocacy Tool for Autistic Transgender and Gender-Diverse Young Adults

Background

Autistic transgender people face unique risks in society, including inequities in accessing needed care and related mental health disparities. Given the need for specific and culturally responsive accommodations/supports, the characterization of key experiences, challenges, needs, and resilience factors within this population is imperative. This study developed a structured self-report tool for autistic transgender young adults to communicate their experiences and needs in a report format attuned to common autistic thinking and communication styles.

Methods

This cross-nation project developed and refined the Gender-Diversity and Autism Questionnaire through an iterative community-based approach using Delphi panel methodology. This proof-of-principle project defined "expertise" broadly, employing a multi-input expert search approach to balance academic-, community-, and lived experience-based expertise.

Results

The expert collaborators (N = 24 respondents) completed a two-round Delphi study, which developed 85 mostly closed-ended items based on 90% consensus. Final item content falls within six topic areas: the experience of identities; the impact of experienced or anticipated discrimination, bias, and violence toward autistic people and transgender people; tasks and experiences of everyday life; gender diversity- or autism-related care needs and history; the experience of others doubting an individual's gender identity and/or autism; and the experience of community and connectedness. The majority of retained items relate to tasks and experiences of everyday life or the impact of experienced or anticipated discrimination, bias, and violence.

Conclusions

This study employed a multipronged multimodal search approach to maximize equity in representation of the expert measure development team. The resulting instrument, designed for clinical, research, and self-advocacy applications, has parallel Dutch and English versions and is available for immediate use. Future cross-cultural research with this instrument could help identify contextual risk and resilience factors to better understand and address inequities faced by this large intersectional population.

Sexual healthcare and at-home STI test collection: attitudes and preferences of transgender women in the Southeastern United States

Background

HIV and sexually transmitted infections (STIs) disproportionally affect transgender women in the United States, particularly in the Southeast where rates of HIV and bacterial STIs are especially high. Despite the high HIV/STI burden among transgender women, their engagement in sexual healthcare services, including HIV/STI testing, is low. Understanding reasons for this disconnect is essential in developing HIV/STI prevention efforts for this population, especially in the Southeastern US, where access to affirming sexual healthcare providers and resources is limited. We aimed to perform an exploratory qualitative study to describe the attitudes and preferences of transgender women living in Alabama with regards to sexual healthcare and at-home STI test collection.

Methods

Transgender women ≥18 years old residing in Alabama were invited to participate in virtual individual in-depth interviews via Zoom. The interview guide explored participant experiences engaging with sexual healthcare services as well as preferences related to extragenital (i.e., rectal, pharyngeal) and at-home STI testing for gonorrhea and chlamydia. A trained qualitative researcher coded transcripts after each interview and iteratively amended the interview guide as themes emerged. Data were coded and thematically analyzed using NVivo qualitative software.

Results

Between June 2021-April 2022, 22 transgender women were screened and 14 eligible women enrolled. Eight participants were white (57%), and six were black (43%). Five participants (36%) were living with HIV and engaged with HIV care services. Interview themes included preference for sexual healthcare environments specializing in LGBTQ+ care, enthusiasm toward at-home STI testing, an emphasis on affirming patient-provider interactions in sexual healthcare settings, a preference for sexual healthcare providers involved in STI testing who were not cisgender men, and gender dysphoria around sexual health discussions and testing.

Conclusion

Transgender women in the Southeastern US prioritize affirming provider-patient interactions, however resources in the region are limited. Participants were enthusiastic about at-home STI testing options, which have the potential to mitigate gender dysphoria. Further investigation into development of remote sexual healthcare services for transgender women should be performed.

Reports of Negative Interactions with Healthcare Providers among Transgender, Nonbinary, and Gender-Expansive People assigned Female at Birth in the United States: Results from an Online, Cross-Sectional Survey

Over one million people in the United States are transgender, nonbinary, or gender expansive (TGE). TGE individuals, particularly those who have pursued gender-affirming care, often need to disclose their identities in the process of seeking healthcare. Unfortunately, TGE individuals often report negative experiences with healthcare providers (HCPs). We conducted a cross-sectional online survey of 1684 TGE people assigned female or intersex at birth in the United States to evaluate the quality of their healthcare experiences. Most respondents (70.1%, n = 1180) reported at least one negative interaction with an HCP in the past year, ranging from an unsolicited harmful opinion about gender identity to physical attacks and abuse. In an adjusted logistic regression model, those who had pursued gender-affirming medical care (51.9% of the sample, n = 874) had 8.1 times the odds (95% CI: 4.1-17.1) of reporting any negative interaction with an HCP in the past year, compared to those who had not pursued gender-affirming care, and tended to report a higher number of such negative interactions. These findings suggest that HCPs are failing to create safe, high-quality care interactions for TGE populations. Improving care quality and reducing bias is crucial for improving the health and well-being of TGE people.

Comparing Smokeless Tobacco Use between Male-to-Female and Female-to-Male Transgender Adults in the United States

Background: The shifted gender social norms and tobacco cessation advice associated with estrogen therapy as a result of thrombosis risk could be responsible for the tobacco use differences between Male-to-Female (MTF) and Female-to-Male (FTM) transgender adults. Research has established this disparity in cigarette smoking, but none has looked at smokeless tobacco. Aim: This study aimed to compare smokeless tobacco use MTF and FTM transgender adults in the United States. Furthermore, it assessed the other potential determinants of smokeless tobacco use among the transgender population. Methods: The study analyzed data from the 2021 Behavioral Risk Factor Surveillance System (BRFSS), which included 1,070 transgender individuals aged 18 and above (382 MTF and 688 FTM). Gender identity (MTF vs. FTM) was used to predict smokeless tobacco use using logistic regression, adjusting for other socio-demographic and behavioral determinants. Results: The prevalence of smokeless tobacco use among the transgender population was 5.7%, 3.8% among MTF, 6.3% among FTM, and 6.7% among gender non-conforming transgender individuals. FTM transgender individuals were 2.23 times more likely to use smokeless tobacco than MTF transgender individuals. Smokeless tobacco use among MTF and FTM transgender individuals was also significantly associated with being older than 54 years (OR = 1.94), having a high school education or lower (OR = 1.98), living with at least a child (OR = 2.17), a current smoker (OR = 1.78) and a current e-cigarette user (OR = 2.97). Discussion: This study found a significant difference in smokeless tobacco use among transgender subgroups and addressed a critical tobacco knowledge gap among this population.

Desired decision-making role and treatment satisfaction among trans people during medical transition: results from the ENIGI follow-up study

BACKGROUND

Shared decision making (SDM) is particularly important in transition-related medical interventions (TRMIs) given the nature of treatment and history of gatekeeping in transgender health care. Yet few studies have investigated trans people's desired decision-making role within TRMI and factors that influence these desires.

AIMS

The study investigated trans people's desired level of decision making during medical transition as well as possible sociodemographic predictors and correlations between decision-making desires and satisfaction with treatment.

METHODS

Data were collected from a clinical sample from 3 trans health care centers, as part of the larger ENIGI study. The data consisted of 568 trans individuals (60.2% assigned male at birth) 20 to 82 years of age (mean age = 38.58 years) who took part in the study 4 to 6 years after initial clinical contact. Binary logistic regressions were conducted to determine whether independent variables predicted group membership in decision-making role subgroups while a Spearman rank-order correlation was conducted to determine the relationship between desired decision-making involvement and satisfaction with care.

OUTCOMES

Main measures were desired decision-making role, satisfaction with treatment, age, education level, country of residence, treatment status, individual treatment progress score (ITPS), gender identity, and sex assigned at birth.

RESULTS

The vast majority of participants wanted to make medical decisions themselves. Age, education level, country of residence, treatment status, gender identity, and sex assigned at birth showed no significant effects in desired level of decision making, while the ITPS neared significance. Satisfaction with treatment was overall very high. For participants assigned male at birth, desire for a more active role in decision making was negatively correlated with satisfaction of labia surgery.

CLINICAL IMPLICATIONS

A desired decision-making role cannot be predicted based on the trans person's sociodemographic characteristics. More involvement from health professionals addressing medical information and education obligations may be needed when offering surgical construction of labia to individuals assigned male at birth.

STRENGTHS AND LIMITATIONS

This study builds on the few existing analyses of desired levels of decision-making role among trans people during transition. It is the first to investigate the role of education level and treatment status/ITPS on the desire of decision-making role. Gender identity and influence of nonbinary identity were not investigated for treatment satisfaction as these items were presented based on sex assigned at birth.

CONCLUSION

This study highlights that trans people in 3 European trans health care centers during medical transition desire a more active role in decision making. Satisfaction with treatment received was overall very high.

Exploring Care Needs of Partners of Transgender and Gender Diverse Individuals in Co-Transition: A Qualitative Interview Study

Scientific knowledge on the impact of a gender-affirming transition on intimate partners of transgender and gender diverse (TGD) individuals is limited. It is unclear which care needs partners have and which role health care professionals can play during this transition process. The aim of this study was to explore the unique experiences and care needs of people partnering with TGD people in the context of a gender-affirming transition. A qualitative research method was chosen, and a semi-structured interview was conducted with a sample of nine participants. After transcription, thematic analysis was used to analyse the data. Three main themes, with three subthemes each, were identified: (1) intrapersonal processes, with (1a) the process of acceptance, (1b) concerns surrounding the medical transition and (1c) impact on sexual orientation as subthemes; (2) dyadic processes, with (2a) the importance of mutual commitment, (2b) experiences regarding intimacy and (2c) relational growth as subthemes; and (3) perception of support, with (3a) need for support, (3b) the importance of support and (3c) evaluation of support as subthemes. The results suggest that health care providers can help partners to navigate the process of a gender-affirming transition; however, the care needs of partners are currently not satisfied with the available professional support.

Loneliness and Social Isolation among Transgender and Gender Diverse People

Here, we report the prevalence of loneliness and social isolation and investigate the levels of loneliness and social isolation among transgender and gender diverse people using cross-sectional data from the HH-TPCHIGV study. Using the De Jong Gierveld tool, we assess loneliness, using the Bude and Lantermann tool, we assess perceived social isolation and using the Lubben Social Network Scale, we assess objective social isolation. The prevalence rate of loneliness was 83.3% (perceived social isolation: 77.7%; objective social isolation: 34.4%). Regressions revealed that favorable outcomes (i.e., lower loneliness levels, lower perceived social isolation, and lower objective social isolation) were consistently associated with higher school education. Beyond that, we identify an association between particularly poor health-related factors and higher loneliness and objective social isolation levels. We also report that unemployment was significantly associated with higher levels of perceived social isolation. In conclusion, we show high prevalence rates of loneliness and social isolation among transgender and gender diverse people. Additionally, important correlates (e.g., education, health-related factors, or unemployment) were identified. Such knowledge may provide help to address transgender and gender diverse people at risk for loneliness and social isolation.

Corrigendum: The impact of the parental support on risk factors in the process of gender affirmation of transgender and gender diverse people

[This corrects the article DOI: 10.3389/fpsyg.2018.00399.].

Validation of an administrative algorithm for transgender and gender diverse persons against self-report data in electronic health records

OBJECTIVE

To adapt and validate an algorithm to ascertain transgender and gender diverse (TGD) patients within electronic health record (EHR) data.

METHODS

Using a previously unvalidated algorithm of identifying TGD persons within administrative claims data in a multistep, hierarchical process, we validated this algorithm in an EHR data set with self-reported gender identity.

RESULTS

Within an EHR data set of 52 746 adults with self-reported gender identity (gold standard) a previously unvalidated algorithm to identify TGD persons via TGD-related diagnosis and procedure codes, and gender-affirming hormone therapy prescription data had a sensitivity of 87.3% (95% confidence interval [CI] 86.4-88.2), specificity of 98.7% (95% CI 98.6-98.8), positive predictive value (PPV) of 88.7% (95% CI 87.9-89.4), and negative predictive value (NPV) of 98.5% (95% CI 98.4-98.6). The area under the curve (AUC) was 0.930 (95% CI 0.925-0.935). Steps to further categorize patients as presumably TGD men versus women based on prescription data performed well: sensitivity of 97.6%, specificity of 92.7%, PPV of 93.2%, and NPV of 97.4%. The AUC was 0.95 (95% CI 0.94-0.96).

CONCLUSIONS

In the absence of self-reported gender identity data, an algorithm to identify TGD patients in administrative data using TGD-related diagnosis and procedure codes, and gender-affirming hormone prescriptions performs well.

Facilitators and barriers in HIV testing and continuum of care among migrant transgender women who are sex workers residing in Florence, Italy

Background

An increased risk of contracting HIV infection, suboptimal adherence, and a loss to follow-up have been observed in migrants, particularly if those individuals are transgender or sex workers. A clear picture of the HIV epidemic among migrants is complex due to the lack of specific national data.

Aims

We developed a qualitative study that describes the barriers and facilitators (cultural, social, and personal) in HIV testing and the continuum of care for a group of migrant transgender women who are sex workers.

Methods

A semi-structured interview was conducted with a group of migrant transgender women who are sex workers living with HIV or with unknown HIV serostatus residing in the Florentine metropolitan area.

Results

We included 12 participants: 3 had unknown HIV serostatus and 9 were living with HIV in follow-up at the Clinic of Infectious and Tropical Diseases, Careggi University hospiral, Florence, Italy. Among barriers, the perceived stigma due to their identity as migrants and transgender people, the language lack of ability and the legal position in the host country played a significant role. Moreover, the interviewees claimed having no alternative to sex work: for those individuals, changing their lifestyle condition is perceived as difficult or impossible due to social prejudices. Conversely, the interviewees considered support services, such as cultural mediators/interpreters and street units, as facilitators to HIV testing, access to care, and continuum of care. Having regular and accessible ART and the availability of a more consistent health care system, represent reasons for HIV-positive migrants living with HIV to move to Italy.

Conclusions

Knowledge of this population's personal experience regarding the barriers and factors that facilitate access to the HIV care system is essential for planning public health interventions capable of responding to the real needs of patients.

Mistrust Among Rescue Workers After the Terrorist Attack in Berlin in 2016 - Gender-Specific Health Inequality

OBJECTIVES

In this single-case-by-group comparison, we examine whether previously found cisgender differences in paranoid ideation after a terror attack are also seen in a transgender male emergency worker.

METHODS

Sixty emergency personnel who were exposed to the 2016 terror attack in Berlin were evaluated 3 to 4 and 21-25 mo after the attack.

RESULTS

On paranoid ideation, the transgender male showed higher scores than cisgender males (+2 standard deviations [SD]) and the overall group (+1 SD).

CONCLUSIONS

This underpins the previously identified gender effects. It would be useful to consider specified pre- and postdeployment modules that take cis- and transgender differences into account.