51
|
Doom JR. Mapping future directions to test biopsychosocial pathways to health and well-being. Soc Sci Med 2020; 258:113083. [PMID: 32531687 PMCID: PMC8107041 DOI: 10.1016/j.socscimed.2020.113083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/03/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
The original biopsychosocial (BPS) model by Engel, although important for challenging the biomedical model and adding psychological and social factors to the study of health, has long been criticized for being too vague and untestable. The BPS-Pathways model introduced by Karunamuni et al. (2020) builds on the original model by making the model more specific and testable. The authors cite research that provides support for individual pathways between biological, psychological, and social variables that influence subjective well-being and physical health. The current commentary discusses three considerations for scientists and practitioners using the model, including: 1) expanding the range of outcomes that should be considered within the model to include mental health and societal well-being, 2) considering how certain factors may fall into more than one category (biological, psychological, and/or social), and 3) considering ways that social factors may directly affect biology independent of psychological mediation. Future directions are discussed, which include considering biopsychosocial pathways across development, studying individual differences in susceptibility to specific biological, psychological, or social factors, and using rigorous methods such as randomized controlled trials and advanced statistical tools at the biological, psychological, and societal levels to test these pathways and create more effective interventions.
Collapse
Affiliation(s)
- Jenalee R Doom
- Department of Psychology, University of Denver, 2155 S. Race St., Denver, CO, 80210, USA.
| |
Collapse
|
52
|
Thomas TR, Hofammann D, McKenna BG, I. R. van der Miesen A, Stokes MA, Daniolos P, Michaelson JJ. Community attitudes on genetic research of gender identity, sexual orientation, and mental health. PLoS One 2020; 15:e0235608. [PMID: 32639994 PMCID: PMC7343141 DOI: 10.1371/journal.pone.0235608] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 06/19/2020] [Indexed: 11/25/2022] Open
Abstract
Sex is an important factor in mental health, and a non-binary view of how variation in sex and gender influence mental health represents a new research frontier that may yield new insights. The recent acceleration of research into sexual orientation, gender identity, and mental health has generally been conducted without sufficient understanding of the opinions of sexual and gender minorities (SGM) toward this research. We surveyed 768 individuals, with an enrichment of LGBTQ+ stakeholders, for their opinions regarding genetic research of SGM and mental health. We found that the key predictors of attitudes toward genetic research specifically on SGM are 1) general attitudes toward genetic and mental health research 2) tolerance of SGM and associated behaviors and 3) age of the participant. Non-heterosexual stakeholder status was significantly associated with increased willingness to participate in genetic research if a biological basis for gender identity were discovered. We also found that heterosexual, cisgender participants with a low tolerance for SGM indicated their SGM views would be positively updated if science showed a biological basis for their behaviors and identities. These findings represent an important first step in understanding and engaging the LGBTQ+ stakeholder community in the context of genetic research.
Collapse
Affiliation(s)
- Taylor R. Thomas
- Department of Psychiatry, University of Iowa, Iowa City, Iowa, United States of America
| | - Dabney Hofammann
- Department of Psychiatry, University of Iowa, Iowa City, Iowa, United States of America
| | - Brooke G. McKenna
- Department of Psychology, Emory University, Atlanta, Georgia, United States of America
| | | | - Mark A. Stokes
- Department of Psychology, Deakin University, Melbourne, Victoria, Australia
| | - Peter Daniolos
- Department of Psychiatry, University of Iowa, Iowa City, Iowa, United States of America
| | - Jacob J. Michaelson
- Department of Psychiatry, University of Iowa, Iowa City, Iowa, United States of America
| |
Collapse
|
53
|
Manning JT, Trivers R, Fink B. Digit Ratio (2D:4D), Transgendered Belief, and Transsexual Drug Therapy in the BBC Internet Study. EVOLUTIONARY PSYCHOLOGICAL SCIENCE 2020. [DOI: 10.1007/s40806-020-00247-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
54
|
Oertelt-Prigione S, Mariman E. The impact of sex differences on genomic research. Int J Biochem Cell Biol 2020; 124:105774. [PMID: 32470538 DOI: 10.1016/j.biocel.2020.105774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 05/15/2020] [Accepted: 05/22/2020] [Indexed: 01/23/2023]
Abstract
Sex and gender differences affect all dimensions of human health ranging from the biological basis of disease to therapeutic access, choice and response. Genomics research has long ignored the role of sex differences as potential modulators and the concept is gaining more attention only recently. In the present review we summarize the current knowledge of the impact of sex differences on genomic and epigenomic research, the potential interaction of genomics and gender and the role of these differences in disease etiopathogenesis. Sex differences can emerge from differences in the sex chromosomes themselves, from their interaction with the genome and from the influence of hormones on genomic processes. The impact of these processes on the incidence of autoimmune and oncologic disease is well documented. The growing field of systems biology, which aims at integrating information from different networks of the human body, could also greatly benefit from this approach. In the present review we summarize the current knowledge and provide recommendations for the future performance of sex-sensitive genomics research.
Collapse
Affiliation(s)
- Sabine Oertelt-Prigione
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands; Institute of Legal and Forensic Medicine, Charité - Universitätsmedizin, Berlin, Germany.
| | - Edwin Mariman
- Department of Human Biology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, Maastricht, The Netherlands
| |
Collapse
|
55
|
Analysis of Four Polymorphisms Located at the Promoter of the Estrogen Receptor Alpha ESR1 Gene in a Population With Gender Incongruence. Sex Med 2020; 8:490-500. [PMID: 32409288 PMCID: PMC7471065 DOI: 10.1016/j.esxm.2020.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/28/2020] [Accepted: 04/05/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Gender incongruence defines a state in which individuals feel discrepancy between the sex assigned at birth and their gender. Some of these people make a social transition from male to female (trans women) or from female to male (trans men). By contrast, the word cisgender describes a person whose gender identity is consistent with their sex assigned at birth. AIM To analyze the implication of the estrogen receptor α gene (ESR1) in the genetic basis of gender incongruence. MAIN OUTCOME MEASURES Polymorphisms rs9478245, rs3138774, rs2234693, rs9340799. METHOD We carried out the analysis of 4 polymorphisms located at the promoter of the ESR1 gene (C1 = rs9478245, C2 = rs3138774, C3 = rs2234693, and C4 = rs9340799) in a population of 273 trans women, 226 trans men, and 537 cis gender controls. For SNP polymorphisms, the allele and genotype frequencies were analyzed by χ2 test. The strength of the SNP associations with gender incongruence was measured by binary logistic regression. For the STR polymorphism, the mean number of repeats were analyzed by the Mann-Whitney U test. Measurement of linkage disequilibrium and haplotype frequencies were also performed. RESULTS The C2 median repeats were shorter in the trans men population. Genotypes S/S and S/L for the C2 polymorphism were overrepresented in the trans men group (P = .012 and P = .003 respectively). We also found overtransmission of the A/A genotype (C4) in the trans men population (P = .017), while the A/G genotype (C4) was subrepresented (P = .009]. The analyzed polymorphisms were in linkage disequilibrium. In the trans men population, the T(C1)-L(C2)-C(C3)-A(C4) haplotype was overrepresented (P = .019) while the T(C1)-L(C2)-C(C3)-G(C4) was subrepresented (P = .005). CONCLUSION The ESR1 is associated with gender incongruence in the trans men population. Fernández R, Delgado-Zayas E,RamírezK, et al. Analysis of Four Polymorphisms Located at the Promoter of the Estrogen Receptor Alpha ESR1 Gene in a Population With Gender Incongruence. Sex Med 2020;8:490-500.
Collapse
|
56
|
Uribe C, Junque C, Gómez-Gil E, Abos A, Mueller SC, Guillamon A. Brain network interactions in transgender individuals with gender incongruence. Neuroimage 2020; 211:116613. [DOI: 10.1016/j.neuroimage.2020.116613] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/04/2020] [Indexed: 12/31/2022] Open
|
57
|
de Vries E, Kathard H, Müller A. Debate: Why should gender-affirming health care be included in health science curricula? BMC MEDICAL EDUCATION 2020; 20:51. [PMID: 32059721 PMCID: PMC7023748 DOI: 10.1186/s12909-020-1963-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 02/07/2020] [Indexed: 05/04/2023]
Abstract
BACKGROUND Every person who seeks health care should be affirmed, respected, understood, and not judged. However, trans and gender diverse people have experienced significant marginalization and discrimination in health care settings. Health professionals are generally not adequately prepared by current curricula to provide appropriate healthcare to trans and gender diverse people. This strongly implies that health care students would benefit from curricula which facilitate learning about gender-affirming health care. MAIN BODY Trans and gender diverse people have been pathologized by the medical profession, through classifications of mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD). Although this is changing in the new ICD-11, tension remains between depathologization discourses and access to gender-affirming health care. Trans and gender diverse people experience significant health disparities and an increased burden of disease, specifically in the areas of mental health, Human Immunodeficiency Virus, violence and victimisation. Many of these health disparities originate from discrimination and systemic biases that decrease access to care, as well as from health professional ignorance. This paper will outline gaps in health science curricula that have been described in different contexts, and specific educational interventions that have attempted to improve awareness, knowledge and skills related to gender-affirming health care. The education of primary care providers is critical, as in much of the world, specialist services for gender-affirming health care are not widely available. The ethics of the gatekeeping model, where service providers decide who can access care, will be discussed and contrasted with the informed-consent model that upholds autonomy by empowering patients to make their own health care decisions. CONCLUSION There is an ethical imperative for health professionals to reduce health care disparities of trans and gender diverse people and practice within the health care values of social justice and cultural humility. As health science educators, we have an ethical duty to include gender-affirming health in health science curricula in order to prevent harm to the trans and gender diverse patients that our students will provide care for in the future.
Collapse
Affiliation(s)
- Elma de Vries
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Harsha Kathard
- Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa
| | - Alex Müller
- Gender, Health and Justice Research Unit, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
58
|
Sadr M, Khorashad BS, Talaei A, Fazeli N, Hönekopp J. 2D:4D Suggests a Role of Prenatal Testosterone in Gender Dysphoria. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:421-432. [PMID: 31975034 PMCID: PMC7031197 DOI: 10.1007/s10508-020-01630-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 06/10/2023]
Abstract
Gender dysphoria (GD) reflects distress caused by incongruence between one's experienced gender identity and one's natal (assigned) gender. Previous studies suggest that high levels of prenatal testosterone (T) in natal females and low levels in natal males might contribute to GD. Here, we investigated if the 2D:4D digit ratio, a biomarker of prenatal T effects, is related to GD. We first report results from a large Iranian sample, comparing 2D:4D in 104 transwomen and 89 transmen against controls of the same natal sex. We found significantly lower (less masculine) 2D:4D in transwomen compared to control men. We then conducted random-effects meta-analyses of relevant studies including our own (k = 6, N = 925 for transwomen and k = 6, N = 757 for transmen). In line with the hypothesized prenatal T effects, transwomen showed significantly feminized 2D:4D (d ≈ 0.24). Conversely, transmen showed masculinized 2D:4D (d ≈ - 0.28); however, large unaccounted heterogeneity across studies emerged, which makes this effect less meaningful. These findings support the idea that high levels of prenatal T in natal females and low levels in natal males play a part in the etiology of GD. As we discuss, this adds to the evidence demonstrating the convergent validity of 2D:4D as a marker of prenatal T effects.
Collapse
Affiliation(s)
- Mostafa Sadr
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Behzad S Khorashad
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Talaei
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nasrin Fazeli
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Johannes Hönekopp
- Department of Psychology, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK.
| |
Collapse
|
59
|
Abstract
Sex and gender are not equivalent concepts, even though these 2 variables are often used interchangeably by researchers. The precise use of variables is critical to ensure that research and theoretical work is of the highest quality. This article defines sex and gender and the importance of recognizing both of these variables as being unique and then demonstrates the benefit of measuring both of these variables using the cardiovascular disease literature as an exemplar. Additionally, recommendations for scholars regarding the use of sex and gender in the research and theoretical literature are provided.
Collapse
|
60
|
Theisen JG, Sundaram V, Filchak MS, Chorich LP, Sullivan ME, Knight J, Kim HG, Layman LC. The Use of Whole Exome Sequencing in a Cohort of Transgender Individuals to Identify Rare Genetic Variants. Sci Rep 2019; 9:20099. [PMID: 31882810 PMCID: PMC6934803 DOI: 10.1038/s41598-019-53500-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/28/2019] [Indexed: 12/12/2022] Open
Abstract
Approximately 0.5-1.4% of natal males and 0.2-0.3% of natal females meet DSM-5 criteria for gender dysphoria, with many of these individuals self-describing as transgender men or women. Despite recent improvements both in social acceptance of transgender individuals as well as access to gender affirming therapy, progress in both areas has been hampered by poor understanding of the etiology of gender dysphoria. Prior studies have suggested a genetic contribution to gender dysphoria, but previously proposed candidate genes have not yet been verified in follow-up investigation. In this study, we expand on the topic of gender identity genomics by identifying rare variants in genes associated with sexually dimorphic brain development and exploring how they could contribute to gender dysphoria. To accomplish this, we performed whole exome sequencing on the genomic DNA of 13 transgender males and 17 transgender females. Whole exome sequencing revealed 120,582 genetic variants. After filtering, 441 variants in 421 genes remained for further consideration, including 21 nonsense, 28 frameshift, 13 splice-region, and 225 missense variants. Of these, 21 variants in 19 genes were found to have associations with previously described estrogen receptor activated pathways of sexually dimorphic brain development. These variants were confirmed by Sanger Sequencing. Our findings suggest a new avenue for investigation of genes involved in estrogen signaling pathways related to sexually dimorphic brain development and their relationship to gender dysphoria.
Collapse
Affiliation(s)
- J Graham Theisen
- Section of Reproductive Endocrinology, Infertility, & Genetics, Department of Obstetrics & Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia, United States.
| | - Viji Sundaram
- Section of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynecology, University of California, San Francisco, San Francisco, California, United States
| | - Mary S Filchak
- Section of Reproductive Endocrinology, Infertility, & Genetics, Department of Obstetrics & Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia, United States
| | - Lynn P Chorich
- Section of Reproductive Endocrinology, Infertility, & Genetics, Department of Obstetrics & Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia, United States
| | - Megan E Sullivan
- Section of Reproductive Endocrinology, Infertility, & Genetics, Department of Obstetrics & Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia, United States
| | - James Knight
- Department of Genetics, Yale University School of Medicine, New Haven, Connecticut, United States
- Yale Center for Genome Analysis, Yale University, New Haven, Connecticut, United States
| | - Hyung-Goo Kim
- Section of Reproductive Endocrinology, Infertility, & Genetics, Department of Obstetrics & Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia, United States
- Neurological Disorders Research Center, Qatar Biomedical Research Institute, Hamad Bin Khalifa University, Doha, Qatar
| | - Lawrence C Layman
- Section of Reproductive Endocrinology, Infertility, & Genetics, Department of Obstetrics & Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia, United States.
| |
Collapse
|
61
|
Meyer-Bahlburg HFL. "Diagnosing" Gender? Categorizing Gender-Identity Variants in the Anthropocene. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:2027-2035. [PMID: 30607711 DOI: 10.1007/s10508-018-1349-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 05/26/2023]
Abstract
In recent decades, two interrelated major controversies have been unfolding in the area of sex/gender research. (1) Are gender-identity variants to be understood as psychopathology or natural variation? (2) Is gender (and perhaps even sex) better conceptualized as binary or non-binary? The answer depends on the conceptual context and related considerations of utility. In the context of evolutionary biology, marked variants of sex and gender decrease reproductive success and are, thereby, deemed pathologic. In the present era of the anthropocene, however, the material conditions underlying the traditional division of labor between the sexes and the role of reproductive success have dramatically changed. These changes decrease the psychosocial importance of the binary gender distinction, provide more freedom for non-binary gender expression and identity formation, and render the distinction of pathologic and non-pathologic less useful, unless gender dysphoria develops secondary to a psychiatric condition. Although most people state their gender identity in the form of a nominal category, most self-report or interview-based ratings and multi-item scales of gender expression and/or identity show continuous distributions, either unimodal-asymmetric or bimodal, depending on whether they are designed for one or both of the traditional genders. Similarly, the rating scales of androgen-influenced variants of the genitalia-usually designed for one of the traditional sexes-typically represent a unipolar-asymmetric continuum. However, the binary gender system remains the primary framework against which individuals evaluate themselves. For those who develop gender dysphoria, assistance by mental-health service providers continues to be important.
Collapse
Affiliation(s)
- Heino F L Meyer-Bahlburg
- Department of Psychiatry, NYS Psychiatric Institute, Vagelos College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.
| |
Collapse
|
62
|
Sevlever M, Meyer-Bahlburg HFL. Late-Onset Transgender Identity Development of Adolescents in Psychotherapy for Mood and Anxiety Problems: Approach to Assessment and Treatment. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:1993-2001. [PMID: 30604171 DOI: 10.1007/s10508-018-1362-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/25/2018] [Accepted: 11/26/2018] [Indexed: 05/12/2023]
Abstract
The rate of adolescents with gender-nonconforming behavior and/or gender dysphoria seeking mental health care has dramatically increased in the past decade. Many of these youths also present with co-occurring psychiatric problems, including depression, anxiety, suicidality, substance use, and others. This combination may generate a complex clinical picture that challenges the ability of clinicians to accurately diagnose gender distress and develop suitable treatment recommendations. This article illustrates those challenges with two adolescent patients who developed late-onset gender dysphoria in the course of long-term mental health care for diverse psychiatric problems preceding the emergence of gender dysphoria. One underwent full progression from gender dysphoria as a male through social and medical transition to female, the other a less definitive progression from gender dysphoria as female through social transition to male without deciding for any medical treatment. The report provides details on the assessment procedures and the resulting findings, the rationale for treatment recommendations, and short-term follow-up information.
Collapse
Affiliation(s)
- Melina Sevlever
- Department of Psychiatry, Neurological Institute, Columbia University Irving Medical Center, 710 West 168th Street, 12th Floor, New York, NY, 10032, USA.
| | - Heino F L Meyer-Bahlburg
- Department of Psychiatry/NYS Psychiatric Institute, Vagelos College of Physicians, Surgeons of Columbia University, New York, NY, USA
| |
Collapse
|
63
|
Davis LK, Stranger BE. The new science of sex differences in neuropsychiatric traits. Am J Med Genet B Neuropsychiatr Genet 2019; 180:333-334. [PMID: 31237066 DOI: 10.1002/ajmg.b.32747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Lea K Davis
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center.,Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center.,Vanderbilt Genetics Institute, Vanderbilt University Medical Center
| | - Barbara E Stranger
- Section of Genetic Medicine, Department of Medicine, The University of Chicago.,Institute for Genomics and Systems Biology, The University of Chicago
| |
Collapse
|
64
|
Weiselberg EC, Shadianloo S, Fisher M. Overview of care for transgender children and youth. Curr Probl Pediatr Adolesc Health Care 2019; 49:100682. [PMID: 31706835 DOI: 10.1016/j.cppeds.2019.100682] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Over the past decade, more and more children and adolescents are identifying as transgender and gender diverse (TGD). Often, they and their parents first turn to their primary care pediatrician for guidance and support. Therefore, in 2018, the American Academy of Pediatrics (AAP) released a policy statement focusing on the health care of TGD youth.4 The AAP acknowledges that many pediatricians have a lack of training in this area and therefore need to increase their knowledge base and expertise in order to provide culturally competent care. While most sexual and gender minority individuals are healthy and well adjusted, some TGD youth are at an increased risk of mental health concerns, including anxiety, depression, substance abuse, eating disorders and suicidality. This is theorized to be due to the experienced or internalized marginalization, stigmatization, victimization, harassment or rejection and not inherent in having gender dysphoria or being transgender. The pediatrician therefore needs to be knowledgeable of, and skilled to screen for, the health disparities that may exist, as well as to be able to support the individual who may disclose their gender identity status during treatment. Parents and guardians may also turn to the pediatrician for guidance when faced with their child who presents with gender non-conforming behaviors or gender dysphoria. Therefore the pediatrician needs to be able to guide the parents as well, as their acceptance and support of their child's journey to gender identity is probably the most important protective factor against health disparities encountered. To deliver optimum care for TGD children and youth, the pediatrician needs to establish an office setting that is inclusive, gender-neutral and TGD friendly. By becoming familiar with the diversity of gender expression and identities, use of gender-appropriate terminology, health disparities often encountered and the importance of providing a safe and welcoming environment, issues that are all covered in this article, the primary care pediatrician will be in position to provide comprehensive health care to this often marginalized population.
Collapse
Affiliation(s)
- Eric C Weiselberg
- Division of Adolescent Medicine, Department of Pediatrics, Cohen Children's Medical Center, Northwell Health System, 410 Lakeville Road, Suite 108, New Hyde Park, NY, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States.
| | - Shervin Shadianloo
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States; Division of Child and Adolescent Psychiatry, Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, New Hyde Park, NY, United States
| | - Martin Fisher
- Division of Adolescent Medicine, Department of Pediatrics, Cohen Children's Medical Center, Northwell Health System, 410 Lakeville Road, Suite 108, New Hyde Park, NY, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| |
Collapse
|
65
|
Khramtsova EA, Davis LK, Stranger BE. The role of sex in the genomics of human complex traits. Nat Rev Genet 2019; 20:173-190. [PMID: 30581192 DOI: 10.1038/s41576-018-0083-1] [Citation(s) in RCA: 166] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nearly all human complex traits and disease phenotypes exhibit some degree of sex differences, including differences in prevalence, age of onset, severity or disease progression. Until recently, the underlying genetic mechanisms of such sex differences have been largely unexplored. Advances in genomic technologies and analytical approaches are now enabling a deeper investigation into the effect of sex on human health traits. In this Review, we discuss recent insights into the genetic models and mechanisms that lead to sex differences in complex traits. This knowledge is critical for developing deeper insight into the fundamental biology of sex differences and disease processes, thus facilitating precision medicine.
Collapse
Affiliation(s)
- Ekaterina A Khramtsova
- Section of Genetic Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA.,Institute for Genomics and Systems Biology, University of Chicago, Chicago, IL, USA
| | - Lea K Davis
- Division of Medical Genetics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Barbara E Stranger
- Section of Genetic Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA. .,Institute for Genomics and Systems Biology, University of Chicago, Chicago, IL, USA. .,Center for Data Intensive Science, University of Chicago, Chicago, IL, USA.
| |
Collapse
|
66
|
Ehrenfeld JM, Gottlieb KG, Beach LB, Monahan SE, Fabbri D. Development of a Natural Language Processing Algorithm to Identify and Evaluate Transgender Patients in Electronic Health Record Systems. Ethn Dis 2019; 29:441-450. [PMID: 31308617 DOI: 10.18865/ed.29.s2.441] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective To create a natural language processing (NLP) algorithm to identify transgender patients in electronic health records. Design We developed an NLP algorithm to identify patients (keyword + billing codes). Patients were manually reviewed, and their health care services categorized by billing code. Setting Vanderbilt University Medical Center. Participants 234 adult and pediatric transgender patients. Main Outcome Measures Number of transgender patients correctly identified and categorization of health services utilized. Results We identified 234 transgender patients of whom 50% had a diagnosed mental health condition, 14% were living with HIV, and 7% had diabetes. Largely driven by hormone use, nearly half of patients attended the Endocrinology/Diabetes/Metabolism clinic. Many patients also attended the Psychiatry, HIV, and/or Obstetrics/Gynecology clinics. The false positive rate of our algorithm was 3%. Conclusions Our novel algorithm correctly identified transgender patients and provided important insights into health care utilization among this marginalized population.
Collapse
Affiliation(s)
- Jesse M Ehrenfeld
- Vanderbilt University, Departments of Anesthesiology, Surgery, Biomedical Informatics, Health Policy; Nashville, Tennessee
| | | | - Lauren Brittany Beach
- Northwestern University, Institute for Sexual and Gender Minority Health & Wellbeing, Chicago, Illinois
| | - Shelby E Monahan
- Western Kentucky University, Department of Psychology; Bowling Green, Kentucky
| | - Daniel Fabbri
- Vanderbilt University, Departments of Biomedical Informatics & Computer Science; Nashville, Tennessee
| |
Collapse
|
67
|
Levitt HM. Applications of a Functionalist Theory of Gender: A Response to Reflections and a Research Agenda. PSYCHOLOGY OF WOMEN QUARTERLY 2019. [DOI: 10.1177/0361684319851467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Heidi M. Levitt
- Department of Psychology, University of Massachusetts Boston, Boston, MA, USA
| |
Collapse
|
68
|
Wren B, Launer J, Reiss MJ, Swanepoel A, Music G. Can evolutionary thinking shed light on gender diversity? BJPSYCH ADVANCES 2019. [DOI: 10.1192/bja.2019.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
SUMMARYIssues of sexual reproduction lie at the core of evolutionary thinking, which often places an emphasis on how individuals attempt to maximise the number of successful offspring that they can produce. At first sight, it may therefore appear that individuals who opt for gender-affirming medical interventions are acting in ways that are evolutionarily disadvantageous. However, there are persuasive hypotheses that might make sense of such choices in evolutionary terms and we explore these here. It is premature to claim knowledge of the extent to which evolutionary arguments can usefully be applied to issues of gender identity, although worth reflecting on the extent to which nature tends towards diversity in matters of sex and gender. The importance of acknowledging and respecting different views in this domain, as well as recognising both the uncertainty and likely multiplicity of causal pathways, has implications for clinicians. We make some suggestions about how clinicians might best respond when faced with requests from patients in this area.LEARNING OBJECTIVESAfter reading this article you will be able to:•understand evolutionary arguments about diversity in human gender identity•identify strengths and weaknesses in evolutionary arguments applied to transgender issues•appreciate the range and diversity of gender experience and gender expression among people who present to specialist gender services, as well as the likely complexities of their reasons for requesting medical intervention.
Collapse
|
69
|
Mollayeva T, Amodio V, Mollayeva S, D’Souza A, Colquhoun H, Quilico E, Haag H(L, Colantonio A. A gender-transformative approach to improve outcomes and equity among persons with traumatic brain injury. BMJ Open 2019; 9:e024674. [PMID: 31110084 PMCID: PMC6530315 DOI: 10.1136/bmjopen-2018-024674] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 02/19/2019] [Accepted: 04/01/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The initiation and translation of sex-sensitive and gender-sensitive research programmes into clinically useful considerations for patients with traumatic brain injury (TBI) have been difficult. Clinical frameworks are currently not specific according to sex and gender, despite evidence that these constructs influence the incidence, course and outcome of patients with TBI. The present protocol outlines a strategy for a research programme, supported by the Canadian Institutes of Health Research (CIHR) Institute of Gender and Health, which explores sex and gender topics in the context of TBI, with the goal of building an infrastructure to facilitate the implementation of sex/gender-sensitive research findings into clinical considerations. METHODS AND ANALYSIS A comprehensive multistep research programme is proposed to support three research objectives: (1) documentation of important concepts and ideas for education on topics of sex and gender in the TBI context using a knowledge-user feedback framework, current scientific evidence and the research team's expertise; (2) development of educational materials for patients with TBI, significant others and clinicians providing care that account for sex/gender and (3) testing the application of these educational materials for feasibility and effectiveness. This programme supports the CIHR Institute's mission by facilitating partnership with knowledge users across clinical, research, academic and community sectors, through a range of platforms and activities. ETHICS AND DISSEMINATION The Research Ethics Board of the University Health Network has approved the programme. It is anticipated that this work will add significant value to the advancement of the field of sex, gender and health by serving as a model to foster the integration of these constructs across the spectrum of disorders. This will transform clinical practices and ensure that generated knowledge is translated into improved training programmes, policies and health services that are responsive to the diverse needs of men and women with TBI. PROSPERO REGISTRATION NUMBER CRD42018098697.
Collapse
Affiliation(s)
- Tatyana Mollayeva
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
- Research Department, Toronto Rehabilitation Institute–University Health Network, Toronto, Ontario, Canada
| | - Vanessa Amodio
- Research Department, Toronto Rehabilitation Institute–University Health Network, Toronto, Ontario, Canada
| | - Shirin Mollayeva
- Research Department, Toronto Rehabilitation Institute–University Health Network, Toronto, Ontario, Canada
| | - Andrea D’Souza
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Heather Colquhoun
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Enrico Quilico
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Halina (Lin) Haag
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Lyle S. Hallman Faculty of Social Work, Wilfrid Laurier University, Ontario, Canada
| | - Angela Colantonio
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
- Research Department, Toronto Rehabilitation Institute–University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
70
|
Levitt HM. A Psychosocial Genealogy of LGBTQ+ Gender: An Empirically Based Theory of Gender and Gender Identity Cultures. PSYCHOLOGY OF WOMEN QUARTERLY 2019. [DOI: 10.1177/0361684319834641] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this invited article, I present an inclusive theory of gender that clarifies its interconnections with gender identity, gender expression, and sexuality. To support this functionalist theory, I summarize findings from an extensive body of mixed methods research on lesbian, gay, bisexual, transgender, queer, and other (LGBTQ+) genders in the United States. I use a feminist-intersectional lens to empirically base and historically situate a theory of gender that is grounded in research of LGBTQ+ communities (butch, femme, bear, leathermen, transgender, drag queens, and family/house systems). I define genders as either sets of personal qualities within a culture associated with physiological sex or sets of qualities that evolve in reaction to limitations of existing genders. The evolution of genders functions to meet needs in four domains: (1) psychological: an experience of fit between a core aspect of self and a gender construct; (2) cultural: the creation of an LGBTQ+ culture that asserts sets of gender characteristics, which were denied and stigmatized within preexisting cultural norms; (3) interpersonal: the communicating of affiliation and status to enhance safety; and (4) sexual: an erotic embodiment of signifiers of these needs via an aesthetic that structures sexual attraction. I detail how each function affects identity, security, belonging, and personal and social values. Online slides for instructors who want to use this article for teaching are available on PWQ's website at http://journals.sagepub.com/page/pwq/suppl/index
Collapse
Affiliation(s)
- Heidi M. Levitt
- Department of Psychology, University of Massachusetts Boston, Boston, MA, USA
| |
Collapse
|
71
|
Martinerie L, Condat A, Bargiacchi A, Bremont-Weill C, de Vries MC, Hannema SE. MANAGEMENT OF ENDOCRINE DISEASE: Approach to the management of children and adolescents with Gender Dysphoria. Eur J Endocrinol 2018; 179:R219-R237. [PMID: 30049812 DOI: 10.1530/eje-18-0227] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 07/07/2018] [Accepted: 07/25/2018] [Indexed: 02/03/2023]
Abstract
Over the past 20 years, the care for transgender adolescents has developed throughout many countries following the "Dutch Approach" initiated in the 90's in pioneer countries as the Netherlands, United States and Canada, with increasing numbers of children and adolescents seeking care in transgender clinics. This medical approach has considerable positive impacts on the psychological outcomes of these adolescents and several studies have been recently published underlining the relative safety of such treatments. This paper reviews the current standards of care for transgender children and adolescents with particular emphasis on disparities among countries and short to medium-term outcomes. Finally it highlights ethical considerations regarding categorization of gender dysphoria, timing of treatment initiation, infertility, and how to deal with the long-term consequences.
Collapse
Affiliation(s)
- L Martinerie
- Department of Pediatric Endocrinology, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Paris Diderot University, Sorbonne Paris Cité, Paris, France
- INSERM Unit 1145, Le Kremlin-Bicêtre, France
| | - A Condat
- Department of Adolescent and Child Psychiatry, Pitié-Salpétrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- CESP INSERM 1018, ED3C, Université Paris Descartes, Paris, France
| | - A Bargiacchi
- Department of Adolescent and Child Psychiatry, Robert Debré Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - C Bremont-Weill
- Department of Endocrinology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M C de Vries
- Departments of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
- Departments of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - S E Hannema
- Departments of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|