Advancing methods for US transgender health research

Examining Mechanisms and Moderators of the Relationship Between Discriminatory Health Care Encounters and Attempted Suicide Among U.S. Transgender Help-Seekers

This study examined how experiences of service denial and discrimination in three health care settings-doctors' offices, emergency rooms, and mental health clinics-might contribute to attempted suicide among transgender adults. Mechanisms of this relationship were examined, including treatment receipt and the use of substances to cope with mistreatment. Perceived emotional social support was also tested as a potential protective factor against the deleterious effects of service denial and discrimination on treatment receipt, substance use, and attempted suicide. The analysis included 4190 respondents from the National Transgender Discrimination Survey. Structural equation modeling was employed to test hypothesized relationships. Being denied a greater number of services and discriminated against in more settings were associated with lower levels of treatment receipt. Service denial was also correlated with increased rates of coping-motivated substance use and elevated rates of attempted suicide. Treatment receipt mediated the relationships between service denial/discrimination and substance use. Substance use mediated the relationship between treatment receipt and attempted suicide. Higher levels of support were protective to treatment receipt when denied services in one setting, but no longer retained protective effects when denied in two or three settings. Results have critical implications for service access and delivery and policies that protect transgender help-seekers in the health care system.

Gender and Frequent Mental Distress: Comparing Transgender and Non-Transgender Individuals' Self-Rated Mental Health

BACKGROUND

Transgender individuals are more likely to experience social and economic barriers to health and health care, and have worse mental health outcomes than cisgender individuals. Our study explores variations in mental health among minority genders after controlling for sociodemographic factors.

MATERIALS AND METHODS

Multistate data were obtained from the 2014 to 2016 Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. Data were included from respondents who were asked whether they identified as transgender, and if so, as male-to-female (MTF), female-to-male (FTM), or gender nonconforming. Frequent mental distress (≥14 days in the last month of "not good" mental health) was the primary outcome of interest. Analysis was performed using design-adjusted Chi-square tests and multivariable logistic regression models of frequent mental distress with gender identity as the independent variable of interest.

RESULTS

Of 518,986 respondents, 0.51% identified as transgender. Higher rates of frequent mental distress were found between FTM (24.7% [18.5-32.3]) and gender nonconforming populations (25.4% [18.7-33.5]), compared with the MTF population (14.2% [10.9-18.3]). After controlling for sociodemographic factors, non-transgender female (adjusted odds ratio [aOR] 1.39 [confidence interval, CI 1.32-1.46]), FTM (aOR 1.93 [CI 1.26-2.95]), and gender nonconforming (aOR 2.05 [CI 1.20-3.50]) identities were associated with increased odds of frequent mental distress compared with non-transgender males.

CONCLUSIONS

Our findings suggest differences in the mental health of transgender and non-transgender individuals, and between gender minorities within transgender population. The differences persist after controlling for sociodemographic factors. Our results suggest that considering the spectrum of minority genders within the transgender population may be important in understanding health outcomes.

Building a Pediatric Patient Registry to Study Health Outcomes Among Transgender and Gender Expansive Youth at a Rural Gender Clinic

Purpose: Significant knowledge gaps regarding outcomes of gender-affirming therapy in transgender (TG) and gender expansive (GE) youth impede an evidence-based approach to these patients. The Gender Wellness Center (GWC) Pediatric Patient Registry was established in 2017 to enable systematic, longitudinal research to describe the physical, mental, and quality-of-life outcomes of these youth.

Methods: All TG/GE youth, ages 8–21 years, presenting to the GWC were recruited on site. Ten research questions guided the creation of data fields. The following 131 variables were abstracted from electronic medical records: demographics, weight, height, body mass index, gender identity, sexual orientation, coexisting diagnoses, substance use, Tanner stage, sexual activity, medications, fertility preservation, Gonadotropin Releasing Hormone (GnRH) analog use, hormone therapy, surgery, and related outcomes. Health-related quality of life is assessed using the Child Health Questionnaire-87 for ages <18 and the Short Form-36 for ages 18–21.

Results: To date, 139 TG and GE youth (90% white and 93% non-Hispanic), have enrolled in the registry. Average age at enrollment was 17.5 years (±3.1, range: 8–21). Two-thirds of youth identified on the trans masculine spectrum (n=90), 28.8% identified on the trans feminine spectrum (n=40), and 6.5% identified as nonbinary/gender nonconforming (n=9). Nearly, all youth had socially transitioned (n=121, 87.7%) and were medically transitioning (n=123, 89.1%).

Conclusion: As one of the first rural-based registries, the GWC Registry has helped to delineate health outcomes attributable to gender-affirming care in a unique patient population of TG/GE youth. Our results will be used to describe treatment outcomes that will contribute to evidence-based guidelines.

Inclusion of LGBTQ persons in research related to pregnancy risk: a cognitive interview study

INTRODUCTION

Recently, researchers have begun considering whether and how to include lesbian, gay, bisexual, transgender and queer (LGBTQ) people in research about abortion and contraception care. Including LGBTQ people in research about abortion and contraception care, as well as the risk for unintended pregnancy more broadly, requires accurate assessment of risk for unintended pregnancy, which involves different considerations for LGBTQ people.

METHODS

We created a survey with existing sexual orientation and gender identity measures, new reproductive anatomy questions to guide skip patterns, gender neutral terminology in sexual and behavioural risk questions, and existing contraception and pregnancy intentions questions that were modified to be gender neutral. We then assessed the appropriateness of these measures through cognitive interviews with 39 individuals aged 18-44 years who were assigned female at birth and identified as LGBTQ. Participants were recruited in the San Francisco Bay Area of California, Baltimore, Maryland and other cities.

RESULTS

Existing demographic questions on sexual orientation and gender identity were well received by participants and validating of participant reported identities. Participants responded positively to new reproductive anatomy questions and to gender neutral terminology in sexual behaviour and pregnancy risk questions. They felt skip patterns appropriately removed them out of inappropriate items (eg, use of contraception to avoid unintended pregnancy); there was some question about whether pregnancy intention measures were widely appropriate or should be further restricted.

CONCLUSIONS

This study provides guidance on ways to appropriately evaluate inclusion of LGBTQ people in abortion and contraception research.

Agreement between medical records and self-reports: Implications for transgender health research

A key priority of transgender health research is the evaluation of long-term effects of gender affirmation treatment. Thus, accurate assessment of treatment receipt is critical. The data for this analysis came from an electronic medical records (EMR) based cohort of transgender individuals. A subset of cohort members were also asked to complete a self-administered survey. Information from the EMR was compared with survey responses to assess the extent of agreement regarding transmasculine (TM)/transfeminine (TF) status, hormone therapy receipt, and type of surgery performed. Logistic regression models were used to assess whether participant characteristics were associated with disagreement between data sources. Agreement between EMR and survey-derived information was high regarding TM/TF status (99%) and hormone therapy receipt (97%). Lower agreement was observed for chest reconstruction surgery (72%) and genital reconstruction surgery (84%). Using survey responses as the "gold standard", both chest and genital reconstruction surgeries had high specificity (95 and 93%, respectively), but the corresponding sensitivities were low (49 and 68%, respectively). A lower proportion of TM had concordant results for chest reconstruction surgery (64% versus 79% for TF) while genital reconstruction surgery concordance was lower among TF (79% versus 89% for TM). For both surgery types, agreement was highest among the youngest participants. Our findings offer assurance that EMR-based data appropriately classify cohort participants with respect to their TM/TF status or hormone therapy receipt. However, current EMR data may not capture the complete history of gender affirmation surgeries. This information is useful in future studies of outcomes related to gender affirming therapy.

The global response and unmet actions for HIV and sex workers

Female, male, and transgender sex workers continue to have disproportionately high burdens of HIV infection in low-income, middle-income, and high-income countries in 2018. 4 years since our Lancet Series on HIV and sex work, our updated analysis of the global HIV burden among female sex workers shows that HIV prevalence is unacceptably high at 10·4% (95% CI 9·5-11·5) and is largely unchanged. Comprehensive epidemiological data on HIV and antiretroviral therapy (ART) coverage are scarce, particularly among transgender women. Sustained coverage of treatment is markedly uneven and challenged by lack of progress on stigma and criminalisation, and sustained human rights violations. Although important progress has been made in biomedical interventions with pre-exposure prophylaxis and early ART feasibility and demonstration projects, limited coverage and retention suggest that sustained investment in community and structural interventions is required for sex workers to benefit from the preventive interventions and treatments that other key populations have. Evidence-based progress on full decriminalisation grounded in health and human rights-a key recommendation in our Lancet Series-has stalled, with South Africa a notable exception. Additionally, several countries have rolled back rights to sex workers further. Removal of legal barriers through the decriminalisation of sex work, alongside political and funding investments to support community and structural interventions, is urgently needed to reverse the HIV trajectory and ensure health and human rights for all sex workers.

Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study

BACKGROUND

Venous thromboembolism (VTE), ischemic stroke, and myocardial infarction in transgender persons may be related to hormone use.

OBJECTIVE

To examine the incidence of these events in a cohort of transgender persons.

DESIGN

Electronic medical record-based cohort study of transgender members of integrated health care systems who had an index date (first evidence of transgender status) from 2006 through 2014. Ten male and 10 female cisgender enrollees were matched to each transgender participant by year of birth, race/ethnicity, study site, and index date enrollment.

SETTING

Kaiser Permanente in Georgia and northern and southern California.

PATIENTS

2842 transfeminine and 2118 transmasculine members with a mean follow-up of 4.0 and 3.6 years, respectively, matched to 48 686 cisgender men and 48 775 cisgender women.

MEASUREMENTS

VTE, ischemic stroke, and myocardial infarction events ascertained from diagnostic codes through the end of 2016 in transgender and reference cohorts.

RESULTS

Transfeminine participants had a higher incidence of VTE, with 2- and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women. The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for VTE and ischemic stroke were observed among transfeminine participants who initiated hormone therapy during follow-up. The evidence was insufficient to allow conclusions regarding risk among transmasculine participants.

LIMITATION

Inability to determine which transgender members received hormones elsewhere.

CONCLUSION

The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute and Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers

BACKGROUND

Understanding the magnitude of mental health problems, particularly life-threatening ones, experienced by transgender and/or gender nonconforming (TGNC) youth can lead to improved management of these conditions.

METHODS

Electronic medical records were used to identify a cohort of 588 transfeminine and 745 transmasculine children (3-9 years old) and adolescents (10-17 years old) enrolled in integrated health care systems in California and Georgia. Ten male and 10 female referent cisgender enrollees were matched to each TGNC individual on year of birth, race and/or ethnicity, study site, and membership year of the index date (first evidence of gender nonconforming status). Prevalence ratios were calculated by dividing the proportion of TGNC individuals with a specific mental health diagnosis or diagnostic category by the corresponding proportion in each reference group by transfeminine and/or transmasculine status, age group, and time period before the index date.

RESULTS

Common diagnoses for children and adolescents were attention deficit disorders (transfeminine 15%; transmasculine 16%) and depressive disorders (transfeminine 49%; transmasculine 62%), respectively. For all diagnostic categories, prevalence was severalfold higher among TGNC youth than in matched reference groups. Prevalence ratios (95% confidence intervals [CIs]) for history of self-inflicted injury in adolescents 6 months before the index date ranged from 18 (95% CI 4.4-82) to 144 (95% CI 36-1248). The corresponding range for suicidal ideation was 25 (95% CI 14-45) to 54 (95% CI 18-218).

CONCLUSIONS

TGNC youth may present with mental health conditions requiring immediate evaluation and implementation of clinical, social, and educational gender identity support measures.

The Importance of Human Immunodeficiency Virus Research for Transgender and Gender-Nonbinary Individuals

Transgender and gender-nonbinary (trans/GNB) individuals are disproportionally affected by human immunodeficiency virus (HIV), yet they are not adequately represented in HIV research and often underserved in clinical care. By building on community strengths and addressing structural, psychological and biological challenges, we can improve the engagement of trans/GNB people in research and ultimately improve prevention, testing, and care for this population. Here, we review the current state of the science related to HIV for trans/GNB people and discuss next steps to expand research that aims to improve the lives and well-being of trans/GNB persons.

Metabolic and functional changes in transgender individuals following cross-sex hormone treatment: Design and methods of the GEnder Dysphoria Treatment in Sweden (GETS) study

Background

Although the divergent male and female differentiation depends on key genes, many biological differences seen in men and women are driven by relative differences in estrogen and testosterone levels. Gender dysphoria denotes the distress that gender incongruence with the assigned sex at birth may cause. Gender-affirming treatment includes medical intervention such as inhibition of endogenous sex hormones and subsequent replacement with cross-sex hormones. The aim of this study is to investigate consequences of an altered sex hormone profile on different tissues and metabolic risk factors. By studying subjects undergoing gender-affirming medical intervention with sex hormones, we have the unique opportunity to distinguish between genetic and hormonal effects.

Methods

The study is a single center observational cohort study conducted in Stockholm, Sweden. The subjects are examined at four time points; before initiation of treatment, after endogenous sex hormone inhibition, and three and eleven months following sex hormone treatment. Examinations include blood samples, skeletal muscle-, adipose- and skin tissue biopsies, arteriography, echocardiography, carotid Doppler examination, whole body MRI, CT of muscle and measurements of muscle strength.

Results

The primary outcome measure is transcriptomic and epigenomic changes in skeletal muscle. Secondary outcome measures include transcriptomic and epigenomic changes associated with metabolism in adipose and skin, muscle strength, fat cell size and ability to release fatty acids from adipose tissue, cardiovascular function, and body composition.

Conclusions

This study will provide novel information on the role of sex hormone treatment in skeletal muscle, adipose and skin, and its relation to cardiovascular and metabolic disease.

Nurse Practitioner Knowledge, Attitudes, and Beliefs When Caring for Transgender People

Purpose: The aim of this study was to explore Nurse Practitioner (NP) knowledge, attitudes, and beliefs when working with transgender people and to inform about Practitioner education needs.

Methods: A qualitative descriptive design was used to explore (NP) experiences. Focused semistructured interviews were conducted in 2016 with 11 (N=11) NPs in the northeastern United States who represent various years of experience and encounters with transgender patients. The interviews explored NP knowledge attitudes and beliefs when caring for transgender patients and described their overall experiences in rendering care in the clinical setting. The interviews were professionally transcribed and analyzed independently and jointly by two investigators using conventional content analysis.

Results: Four main themes and six subthemes were identified: Main themes include personal and professional knowledge gaps, fear and uncertainty, caring with intention and pride, and creating an accepting environment.

Conclusions: NPs in this study perceive gaps in their knowledge that threaten their ability to deliver quality, patient-centered care to transgender patients, despite their best intentions. These findings have implications for changes in nursing practice, education, and research needed to address vital gaps in the healthcare of transgender people.

Frequency and distribution of primary site among gender minority cancer patients: An analysis of U.S. national surveillance data

BACKGROUND

Transgender people and persons with disorders of sex development (DSD) are two separate categories of gender minorities, each characterized by unique cancer risk factors. Although cancer registry data typically include only two categories of sex, registrars have the option of indicating that a patient is transgender or has a DSD.

METHODS

Data for primary cancer cases in 46 states and the District of Columbia were obtained from the North American Association of Central Cancer Registries (NAACCR) database for the period 1995-2013. The distributions of primary sites and categories of cancers with shared risk factors were examined separately for transgender and DSD patients and compared to the corresponding distributions in male and female cancer patients. Proportional incidence ratios were calculated by dividing the number of observed cases by the number of expected cases. Expected cases were calculated based on the age- and year of diagnosis-specific proportions of cases in each cancer category observed among male and female patients.

RESULTS

Transgender patients have significantly elevated proportional incidence ratios (95% confidence intervals) for viral infection induced cancers compared to either males (2.3; 2.0-2.7) or females (3.3; 2.8-3.7). Adult DSD cancer patients have a similar distribution of primary sites compared to male or female patients but DSD children with cancer have ten times more cases of testicular malignancies than expected (95% confidence interval: 4.7-20).

CONCLUSION

The proportions of certain primary sites and categories of malignancies among transgender and DSD cancer patients are different from the proportions observed for male or female patients.

Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study

BACKGROUND

Transgender and gender nonconforming (TGNC) adolescents have difficulty accessing and receiving health care compared with cisgender youth, yet research is limited by a reliance on small and nonrepresentative samples. This study's purpose was to examine mental and physical health characteristics and care utilization between youth who are TGNC and cisgender and across perceived gender expressions within the TGNC sample.

METHODS

Data came from the 2016 Minnesota Student Survey, which consisted of 80 929 students in ninth and 11th grade (n = 2168 TGNC, 2.7%). Students self-reported gender identity, perceived gender expression, 4 health status measures, and 3 care utilization measures. Chi-squares and multiple analysis of covariance tests (controlling for demographic covariates) were used to compare groups.

RESULTS

We found that students who are TGNC reported significantly poorer health, lower rates of preventive health checkups, and more nurse office visits than cisgender youth. For example, 62.1% of youth who are TGNC reported their general health as poor, fair, or good versus very good or excellent, compared with 33.1% of cisgender youth (χ² = 763.7, P < .001). Among the TGNC sample, those whose gender presentation was perceived as very congruent with their birth-assigned sex were less likely to report poorer health and long-term mental health problems compared with those with other gender presentations.

CONCLUSIONS

Health care utilization differs between TGNC versus cisgender youth and across gender presentations within TGNC youth. With our results, we suggest that health care providers should screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.

Treatment of Depression in Women

Women are more likely than men to experience depression throughout the life span. Sex differences in neurochemistry and brain structure, as well as societal factors may contribute to women's increased likelihood of depression. Pharmacological research targeting depression has historically excluded women, leading to a knowledge gap regarding effective antidepressant treatment in women. Antidepressant pharmacokinetics and pharmacodynamics are clearly different in men and women, necessitating a thoughtful approach to their prescription and management. Hormone changes associated with the menstrual cycle, pregnancy, and menopause also contribute to differences in depression and effective antidepressant use in women. Finally, it is important to consider potential interactions between antidepressant drugs and medications specifically used by women (oral contraceptives, tamoxifen, and estrogen).

Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people

PURPOSE

The Study of Transition, Outcomes and Gender (STRONG) was initiated to assess the health status of transgender people in general and following gender-affirming treatments at Kaiser Permanente health plans in Georgia, Northern California and Southern California. The objectives of this communication are to describe methods of cohort ascertainment and data collection and to characterise the study population.

PARTICIPANTS

A stepwise methodology involving computerised searches of electronic medical records and free-text validation of eligibility and gender identity was used to identify a cohort of 6456 members with first evidence of transgender status (index date) between 2006 and 2014. The cohort included 3475 (54%) transfeminine (TF), 2892 (45%) transmasculine (TM) and 89 (1%) members whose natal sex and gender identity remained undetermined from the records. The cohort was matched to 127 608 enrollees with no transgender evidence (63 825 women and 63 783 men) on year of birth, race/ethnicity, study site and membership year of the index date. Cohort follow-up extends through the end of 2016.

FINDINGS TO DATE

About 58% of TF and 52% of TM cohort members received hormonal therapy at Kaiser Permanente. Chest surgery was more common among TM participants (12% vs 0.3%). The proportions of transgender participants who underwent genital reconstruction surgeries were similar (4%-5%) in the two transgender groups. Results indicate that there are sufficient numbers of events in the TF and TM cohorts to further examine mental health status, cardiovascular events, diabetes, HIV and most common cancers.

FUTURE PLANS

STRONG is well positioned to fill existing knowledge gaps through comparisons of transgender and reference populations and through analyses of health status before and after gender affirmation treatment. Analyses will include incidence of cardiovascular disease, mental health, HIV and diabetes, as well as changes in laboratory-based endpoints (eg, polycythemia and bone density), overall and in relation to gender affirmation therapy.

Puberty suppression in transgender children and adolescents

The World Professional Association for Transgender Health's standards of care recommend suspending puberty, preferably with the use of gonadotropin-releasing hormone agonists, in certain gender non-conforming minors (aged under 18 years) who have undergone a psychiatric assessment and have reached at least Tanner stage II of puberty. This approach seeks to lessen the discordance between assigned natal sex and gender identity by temporarily halting the development of secondary sexual characteristics, essentially widening the temporal window for gender clarification. Despite promising preliminary evidence on the clinical utility of this approach, there is a dearth of research to inform evidence-based practice. In view of these challenges, we review the available empirical evidence on the cognitive, physical, and surgical implications of puberty suppression in gender-incongruent children and adolescents. We also explore the historical underpinnings and clinical impetus for suspending puberty in this population, and propose key research priorities.

Review of the Transgender Literature: Where Do We Go from Here?

Purpose: The “transgender tipping point” has brought transgender social and health issues to the forefront of American culture. However, medical professionals have been lagging in academic research with a transgender-specific focus resulting in significant knowledge gaps in dealing with the care of our transgender patients. The aim of this article is to analyze all published Medline-available transgender-specific articles, identify these knowledge gaps, and direct future research to where it is most needed.

Methods: We surveyed all Medline-available articles up to June 2016 using a combination of medical subject headings and keywords in titles and abstracts. Articles meeting inclusion criteria were reviewed, categorized, and analyzed for content and study design.

Results: In our review of the literature, we identified 2405 articles published from January 1950 to June 2016 that focused on transgender health, primarily in the fields of surgery, mental health, and endocrinology.

Conclusion: Significant knowledge gaps were found across the subspecialties, and there was a lack of prospective robust research and representation of transgender-specific data in the core medical journals. More data and research are needed to bridge the knowledge gaps that currently exist and improve the care of the transgender community.

Vocal Timbre and the Classification of Respondent Sex in US Phone-Based Surveys

OBJECTIVES

To characterize the conflict of sex and gender identity variables in the 2014 Behavioral Risk Factor Surveillance System (BRFSS) sample and examine how this may affect the administration of sex-related health behavior items to transgender participants.

METHODS

We conducted a secondary analysis of the 2014 BRFSS gender identity, sex, and sex-related health behavior variables. Twenty states administered the gender-identity variables (n = 154 062), and 691 respondents identified as transgender in the survey (0.4%). We examined conflict among sex, gender identity, and gender-related variables, and compared conflicting and nonconflicting groups across 4 sociodemographic characteristics.

RESULTS

Nearly one third of respondents (27.8%; n = 171) who identified as transgender received sex-specific items that conflicted with their natal sex, thereby reducing the already small subsample of valid responses. There were no significant differences between conflicting and nonconflicting groups on the basis of region, age, race/ethnicity, or type of interview.

CONCLUSIONS

Public health surveys should ask respondents to self-identify their sex and gender identity. Interviewer assumptions of respondents' sex may lead to erroneous collection of sex- and gender-based items, inhibit survey administration, and create problems in data quality.

Distinct Coping Profiles Are Associated With Mental Health Differences in Transgender and Gender Nonconforming Adults

OBJECTIVE

This study assessed the unique coping strategies of transgender and gender nonconforming (TGNC) individuals in the United States used to manage gender-related stress, and examined associations between specific coping profiles and mental health.

METHODS

Data were from 316 participants in the 2014-2015 Transgender Stress and Health Study, an online study of TGNC mental and sexual health. A factor analysis of the coping measure (Brief COPE) was followed by a k-means cluster analysis to evaluate distinct profiles of coping with gender-related stress. Proportional odds models and logistic regression models indicated how coping profiles related to levels of self-reported depressive symptoms and suicidality.

RESULTS

A 4-factor structure was identified with three distinct profiles of coping with gender-related stress, each representative of the frequency (high or low) in which participants used functional and dysfunctional coping strategies: (a) high-functional/low-dysfunctional, (b) high-functional/high-dysfunctional, and (c) low-functional/low-dysfunctional. There were significant differences in depressive symptoms and suicidality based on distinct gender-related coping profiles. The high-functional/high-dysfunctional group reported significantly poorer mental health compared with the high-functional/low-dysfunctional group.

CONCLUSION

To improve mental health outcomes in TGNC individuals, health providers and researchers should strive to not only promote functional coping strategies for managing gender-related stress but also decrease dysfunctional coping strategies.

Oestrogen and anti-androgen therapy for transgender women

Transgender women experience lifelong gender dysphoria due to a gender assignment at birth that is incongruent with their gender identity. They often seek hormone therapy, with or without surgery, to improve their gender dysphoria and to better align their physical and psychological features with a more feminine gender role. Some of the desired physical changes from oestrogen and anti-androgen therapy include decreased body and facial hair, decreased muscle mass, breast growth, and redistribution of fat. Overall the risks of treatment are low, but include thromboembolism, the risk of which depends on the dose and route of oestrogen administration. Other associated conditions commonly seen in transgender women include increased risks of depression and osteoporosis. The risk of hormone-sensitive cancer seems to be low in transgender women, with no increased risk of breast cancer compared with women and no increase in prostate cancer when compared with men. The evidence base for the care of transgender women is limited by the paucity of high-quality research, and long-term longitudinal studies are needed to inform future guidelines.

Supporting the Health and Well-Being of Transgender Students

Throughout the United States, there has been a rise in public discourse about transgender people and transgender issues. Much of this attention stems from passed and proposed anti-LGBTQ (lesbian, gay, bisexual, transgender, queer or questioning) legislation, including "bathroom bills" that would require transgender people to use public facilities corresponding with the sex designated on their birth certificates. With the recent discussion and legislation impacting school-aged children and adolescents, what does this mean for school nurses and how can they care and advocate for their transgender students? In this article, we aim to empower school nurses to join the discussion, advocate for inclusive and equitable school policies, and deliver gender-affirming care to transgender students. We will explain transgender identities; transgender-related stigma, prejudice, discrimination, and health concerns; gender-affirming approaches in caring for transgender youth; and implications for school nurses. School nurses play a key role in creating a space that is welcoming and affirming where transgender students can thrive.

Interviews with Patients and Providers on Transgender and Gender Nonconforming Health Data Collection in the Electronic Health Record

Purpose: Meaningful use (MU) and Uniform Data Systems (UDSs) are calling for the collection of gender identity (GI) in electronic health record (EHR) systems; however, many transgender and nonconforming (TGNC) patients may not feel safe disclosing their GI and the data collection is not designed to guide care provision. This study explores the complexities surrounding the inclusion of GI in EHR data collection and how it can best serve patients and providers. Methods: Using a semistructured interview format, TGNC patients (n=7) and providers (n=5) who care for TGNC patients were asked about data collection procedures and the use of these data within community health centers in Oregon. Using a constant comparative data analysis methodology, interview transcripts were coded for emergent concepts until overlapping themes were identified. Results: Both patients and providers expressed a need for the EHR to expand upon MU and UDS-recommended fields to include current pronouns and name and gender identifiers in a forward-facing display to prevent misgendering by clinic staff and providers. Furthermore, they both cited the need for a broader range of birth-assigned sex and gender options. TGNC patients and providers disagreed on the scope of health information to be collected as well as who should be tasked with the data collection. Conclusion: These interviews offer us a glimpse into the structural difficulties of creating an EHR system that serves the needs of clinicians while providing safe and culturally competent care to TGNC patients.

Cancer in Transgender People: Evidence and Methodological Considerations

Transgender people comprise a diverse group of individuals whose gender identity or expression differs from that originally assigned to them at birth. Some, but not all, transgender people elect to undergo medical gender affirmation, which may include therapy with cross-sex hormones and/or surgical change of the genitalia and other sex characteristics. As cross-sex hormones administered for the purposes of gender affirmation may be delivered at high doses and over a period of decades, the carcinogenicity of hormonal therapy in transgender people is an area of considerable concern. In addition, concerns about cancer risk in transgender patients have been linked to sexually transmitted infections, increased exposure to well-known risk factors such as smoking and alcohol use, and the lack of adequate access to screening. Several publications have identified cancer as an important priority in transgender health research and called for large-scale studies. The goals of this article are to summarize the evidence on factors that may differentially affect cancer risk in transgender people, assess the relevant cancer surveillance and epidemiologic data available to date, and offer an overview of possible methodological considerations for future studies investigating cancer incidence and mortality in this population.

What's in a Guideline? Developing Collaborative and Sound Research Designs that Substantiate Best Practice Recommendations for Transgender Health Care

Transgender medicine presents a particular challenge for the development of evidence-based guidelines, due to limitations in the available body of evidence as well as the exclusion of gender identity data from most public health surveillance activities. The guidelines that have been published are often based on expert opinion, small studies, and data gathered outside the US. The existence of guidelines, however, helps legitimate the need for gender-affirming medical and surgical interventions. Research conducted on transgender populations should be grounded in gender-affirming methodologies and focus on key areas such as health outcomes after gender-affirming interventions.

The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices

INTRODUCTION

Globally, transgender ("trans") women are one of the key populations most disproportionately impacted by HIV. Pre-exposure prophylaxis (PrEP) is the newest and most promising biomedical HIV prevention intervention to date. This paper reviews relevant literature to describe the current state of the science and describes the potential role of PrEP among trans women, including a discussion of unique considerations for maximizing the impact of PrEP for this vulnerable population.

METHODS

Available information, including but not limited to existing scientific literature, about trans women and PrEP was reviewed and critiqued based on author expertise, including PrEP clinical trials and rollout.

RESULTS

To date, PrEP demonstration projects and clinical trials have largely excluded trans women, or have not included them in a meaningful way. Data collection strategies that fail to identify trans women in clinical trials and research further limit the ability to draw conclusions about trans women's unique needs and devise strategies to meet them. Gender-affirming providers and clinic environments are essential components of any sexual health programme that aims to serve trans women, as they will largely avoid settings that may result in stigmatizing encounters and threats to their identities. While there is currently no evidence to suggest drug-drug interactions between PrEP and commonly used feminizing hormone regimens, community concerns about potential interactions may limit interest in and uptake of PrEP among trans women.

CONCLUSIONS

In scaling up PrEP for trans women, it is essential to engage trans communities, utilize trans-inclusive research and marketing strategies and identify and/or train healthcare providers to provide gender-affirming healthcare to trans women, including transition-related care such as hormone provision. PrEP implementation guidelines must consider and address trans women's unique barriers and facilitators to uptake and adherence.

Perceptions of Barriers to and Facilitators of Participation in Health Research Among Transgender People

Purpose: Although transgender people may be at increased risk for a range of health problems, they have been the subject of relatively little health research. An important step toward expanding the evidence base is to understand and address the reasons for nonparticipation and dropout. The aim of this study was to explore the perceptions of barriers to and facilitators of participation in health research among a sample of transgender people in San Francisco, CA, and Atlanta, GA. Methods: Twelve in-person focus groups (FGs) were conducted; six (three with transwomen, three with transmen) were conducted in San Francisco and six FGs were conducted in Atlanta (three with transwomen and three with transmen). FGs were audiorecorded, transcribed, and uploaded to MaxQDA software for analysis. A codebook was used to code transcripts; new codes were added iteratively as they arose. All transcripts were coded by at least 2 of the 4 researchers and, after each transcript was coded, the researchers met to discuss any discrepancies, which were resolved by consensus. Results: Among 67 FG participants, 37 (55%) identified as transmen and 30 (45%) identified as transwomen. The average age of participants was ∼41 years (range 18-67) and the majority (61%) were non-Hispanic Whites. Several barriers that can hinder participation in health research were identified, including logistical concerns, issues related to mistrust, a lack of awareness about participation opportunities, and psychosocial/emotional concerns related to being "outed." A broad range of facilitators were also identified, including the opportunity to gain knowledge, access medical services, and contribute to the transgender community. Conclusion: These findings provide insights about the perceived barriers to and facilitators of research participation and offer some guidance for researchers in our ongoing effort to engage the transgender community in health research.

"I would have preferred more options": accounting for non-binary youth in health research

As a research team focused on vulnerable youth, we increasingly need to find ways to acknowledge non-binary genders in health research. Youth have become more vocal about expanding notions of gender beyond traditional categories of boy/man and girl/woman. Integrating non-binary identities into established research processes is a complex undertaking in a culture that often assumes gender is a binary variable. In this article, we present the challenges at every stage of the research process and questions we have asked ourselves to consider non-binary genders in our work. As researchers, how do we interrogate the assumptions that have made non-binary lives invisible? What challenges arise when attempting to transform research practices to incorporate non-binary genders? Why is it crucial that researchers consider these questions at each step of the research process? We draw on our own research experiences to highlight points of tensions and possibilities for change. Improving access to inclusive health-care for non-binary people, and non-binary youth in particular, is part of creating a more equitable healthcare system. We argue that increased and improved access to inclusive health-care can be supported by research that acknowledges and includes people of all genders.

Social Epidemiology of Depression and Anxiety by Gender Identity

PURPOSE

This study investigates depression and anxiety in gender minority (i.e., transgender and/or gender nonconforming) compared with nongender minority (cisgender) young adults.

METHODS

Data were from the Growing Up Today Study, a national cohort of U.S. young adults. A two-step method (maternal-reported natal sex in 1996 cross-classified with participant-reported current gender identity in 2010) was used to identify gender minority and nongender minority respondents (n = 7,831; mean age = 26 years). Differences in past week depressive symptoms and anxious symptoms were examined cross-sectionally by gender identity. Gender minority and nongender minority respondents were compared using age-adjusted logistic regression models.

RESULTS

In gender minorities, the prevalence of depressive and anxious symptoms meeting clinical cutoffs was 52% and 38%, respectively, compared with nongender minorities (27% and 30% in females and 25% and 14% in males; p < .01).

CONCLUSIONS

Gender identity is an understudied social determinant of mental health. Surveillance efforts to monitor mental health disparities should include survey questions to assess gender identity in epidemiologic research. Research and interventions to understand and ameliorate mental health disparities by gender identity are needed.

Determinants of and Barriers to Hormonal and Surgical Treatment Receipt Among Transgender People

Purpose: Medical gender confirmation therapy (GCT) plays an important role in transgender health; however, its prevalence and determinants constitute an area of uncertainty. Methods: Data for this cross-sectional study were obtained from an online survey distributed from October 2012 through the end of 2013 among persons who visited the social media sites of a transgender education and social networking meeting. Eligible respondents (n=280) were persons whose gender identity was different from their sex assigned at birth and who responded to questions about previously received or planned hormonal therapy (HT), chest reconstruction, or genital surgery. Multivariable logistic regression models examined how receipt and plans to receive different GCT types were associated with participants' characteristics and gender identity. Results: The respective percentages of ever and current HT were 58% and 47% for transwomen and 63% and 57% for transmen. Genital surgery was reported by 11 participants; all transwomen. Relative to transmen, transwomen were thrice more likely to report plans to undergo genital surgery. By contrast, transmen were more than 10 times as likely as transwomen to have had or planned chest surgery. Older participants and those who were in a committed relationship were less likely to plan future GCT. Having health insurance was not associated with GCT receipt. Treatment cost was named as the main problem by 23% of transwomen and 29% of transmen. Accessing a qualified healthcare provider for transgender-related care was listed as the primary reason for not receiving surgery by 41% of transmen and 2% of transwomen. Conclusions: Prevalence of GCT differed across subgroups of participants and was lower than corresponding estimates reported elsewhere. The variability of results may reflect differences in recruitment procedures and response rates; however, it is also possible that it may be driven by geographic, socioeconomic, and health-related heterogeneity of the transgender population.