Lived experience and allostatic load among transmasculine people living in the United States

Theory of health promotion for sexual and gender minority populations with cancer

BACKGROUND

Structural factors (e.g., cisheteronormativity) promote minority stressors, which generate healthcare disparities among sexual and gender minority (SGM) populations (also known as lesbian, gay, bisexual, transgender, queer, intersexual, asexual, and other sexual and gender-expansive persons--LGBTQIA+) with cancer. The individual's biological, behavioral, social, and psychological response to minority stressors will vary throughout their life course. However, there is a lack of empirical and theoretical guidance for conceptualizing health outcomes among SGM subgroups.

PURPOSE

To propose a nursing theory for the health promotion of SGM populations with cancer.

METHODS

Walker and Avant's strategies for theoretical derivation were followed.

RESULTS

I present the definition, theoretical assumptions, concepts, propositions, and implications for practice, education, research, and policy of the derived theory.

DISCUSSION AND CONCLUSION

The theory provides a nursing framework to understand and address the multilevel impact of minority stress on the health of SGM individuals throughout their cancer care continuum.

The mediating role of child delay of gratification in the link between early and prolonged poverty exposure and adolescent allostatic load

Early and prolonged exposure to poverty disrupts biological processes associated with the body's stress response system, leading to long-term negative health outcomes, including obesity, autoimmune disorders, and cardiovascular disease. Allostatic load (AL), a composite measure of chronic stress on the body, is a robust predictor of subsequent health outcomes. However, developmental research examining the associations of early poverty exposure with AL in adolescence, as well as the underlying mechanisms of influence is limited. Early poverty exposure also impedes healthy development of child self-regulation, which may increase risk for high AL in adolescence, but this mechanistic pathway has not yet been tested. We used data from the national Study of Early Child Care and Youth Development (SECCYD) to examine the longitudinal associations between prolonged poverty exposure in early childhood (0-3 years) and AL in adolescence (age 15). We also tested the mediating role of child delay of gratification, a behavioral measure of self-regulation (at age 54 months), in the potential association between early poverty exposure and adolescent AL. Accounting for model covariates (i.e., child biological sex and race-ethnicity) and individual differences in child delay of gratification, early and prolonged poverty exposure was significantly associated with higher AL at age 15. The indirect effect through child delay of gratification was not significant, but the individual pathways of the indirect effect were significant, and the overall direct association of early poverty exposure with adolescent AL was significant. Our findings show that prolonged exposure to poverty in early childhood (0-3 years) can have significant negative associations with both child delay of gratification (at 54 months) and AL (at age 15). Given that the detrimental impacts of poverty exposure can be detected at an early age, targeted prevention efforts (e.g., anti-poverty programs such as cash assistance programs) may be able to offset some of the risks of early poverty exposure on self-regulation and AL.

Mental Health for LGBTQIA+ Older Adults

LGBTQIA+ older adults share a unique set of risk factors that impact mental health. This article provides an overview of the minority stress and allostatic load models and how they can lead to worse physical and mental health outcomes. The article also describes unique epidemiologic and psychosocial context for various aspects of mental health among LGBTQIA+ older adults. Within each section are suggestions for health care providers when addressing these mental health issues and caring for LGBTQIA+ older adults in all settings.

Associations Between Structural Stigma and Allostatic Load Among Sexual Minorities: Results From a Population-Based Study

OBJECTIVE

Structural forms of stigma and discrimination are associated with adverse health outcomes across numerous stigmatized groups, including lesbian, gay, and bisexual (LGB) individuals. However, the biological consequences of structural stigma among LGB populations are understudied. To begin to address this gap, we assessed associations between indicators of structural stigma (i.e., state-level policies) targeting LGB individuals and allostatic load (AL) indices representing physiological dysregulations.

METHODS

Pooled data from the continuous 2001-2014 National Health and Nutritional Examination Survey were analyzed (LGB: n = 864; heterosexual: n = 20,310). Ten state-level LGB-related policies (e.g., employment nondiscrimination protections, same-sex marriage) were used to operationalize structural stigma. A sex-specific AL index representing 11 immune, metabolic, and cardiovascular biomarkers was estimated. Multilevel models were used to examine associations between structural stigma and AL, net of nine individual-level characteristics (e.g., education, race/ethnicity, age, and health behaviors).

RESULTS

Sexual minority men living in states with low levels of structural stigma experienced significantly lower AL ( β = -0.45, p = .02) compared with sexual minority men living in states with high structural stigma (i.e., fewer protective policies). There was no significant association between structural stigma and AL among sexual minority women.

CONCLUSIONS

By demonstrating direct associations between structural stigma and indices of physiological dysregulation, our findings provide a mechanistic understanding of how the social environment can "get under the skin and skull" for sexual minority men in the United States. Future research should explore whether these mechanisms generalize to other marginalized groups exposed to structural stigma.

Gender minority stress and diurnal cortisol profiles among transgender and gender diverse people in the United States

The field of behavioral neuroendocrinology has only begun to explore the lived experiences of transgender and gender diverse (TGD) people exposed to stigma. In light of escalating attacks and legislation targeting TGD people in the United States, it is crucial to examine the physiological pathways through which gender minority stressors become embodied, impact health, and contribute to health inequities. The Trans Resilience and Health Study included baseline data collection from fall 2019 to spring 2020 from a sample of 124 TGD people, reflecting a diversity of gender identities (e.g., trans masculine, trans feminine, and nonbinary) and ages (range = 19-70 years old; M = 34.10), living in Michigan, Nebraska, Oregon, and Tennessee. These analyses examine experiences of gender-related enacted stigma in association with hypothalamic-pituitary-adrenal (HPA)-axis functioning. Among those experiencing the highest levels of enacted stigma, findings show a blunted cortisol awakening response and sluggish daily decline that resulted in elevated concentrations at bedtime compared to those experiencing less enacted stigma. These results of flattened diurnal activity are consistent with an emergent literature on discrimination as a social determinant of potential stress pathophysiology. In contrast, community connectedness was associated with a larger, more dynamic cortisol awakening response. These findings emphasize the importance of incorporating gender-minority stress and resilience measures when studying HPA-axis functioning among TGD people.

Queering food security research: A critical analysis of 2SLGBTQ+ People's experiences of food insecurity in Toronto during the COVID-19 pandemic

INTRODUCTION

Household food insecurity (HFI), stress, isolation, and discrimination are major determinants of health that disproportionately affect 2SLGBTQ + people. The COVID-19 pandemic potentially exacerbated these inequities. This study investigates HFI rates among 2SLGBTQ + adults living in diverse household conditions during the pandemic and explores the idea that heteronormative conceptions of the "household" may affect measurement of HFI.

METHODS

Cross-sectional survey responses were collected from 437 self-identified 2SLGBTQ + people from Toronto, Canada between March and July 2021. The survey measured HFI, sexual/gender identities, socio-demographic factors, household composition, and psycho-social stress/distress. Multinomial logistic regression was used to assess variation in odds of marginal, moderate, and severe HFI in relation to sexual/gender identities, household composition, psycho-social distress, and socio-demographic covariates.

RESULTS

Forty-two percent of respondents reported some level of HFI, with severe HFI higher among respondents who were bisexual, transgender/gender diverse, and/or assigned-female-at-birth. Living alone was associated with decreased odds of reporting marginal HFI but increased odds of moderate or severe HFI compared to living with a partner, family, or roommates; living with children was associated with decreased odds of both marginal and severe HFI. One indicator of psycho-social distress (perceived discrimination) was associated with higher odds of all levels of HFI, while the other (isolation) was associated with decreased odds of marginal HFI.

CONCLUSION

These findings highlight the high prevalence of HFI linked with discrimination among 2SLGBTQ + individuals during the pandemic. The complicated results regarding household composition and social isolation may suggest a need to revise definitions of the household when measuring, monitoring, and seeking to mitigate HFI in 2SLGBTQ + communities.

Toward a Better Understanding of Cardiovascular Risk in the Transgender and Gender-Diverse Community: A Global Call to Action

On World Heart Day 2022, the Mexican Society of Cardiology, the Inter-American Society of Cardiology, and the World Heart Federation collaborated on a public call to action regarding the increased risk of adverse cardiovascular health outcomes in transgender and gender diverse (TGD) individuals. The aim of this article is to unpack the numerous factors that contribute to this, such as the social stigma faced by members of the TGD community, their reduced access to clinical care, and the scarcity of research regarding the unique needs of their community, which makes it difficult for clinicians to provide individualized medical care. Decreasing the incidence of adverse cardiovascular events among TGD individuals requires interventions such as educational reform in the medical community, an increase in inclusive research studies, and broader social initiatives intended to reduce the stigma faced by TGD individuals.

Future Directions in the Mental Health of Transgender Youth: Towards a Social-Affective Developmental Model of Health Disparity

Mental health disparities in transgender and gender diverse (TGD) youth are well-documented. These disparities are often studied in the context of minority stress theory, and most of this research focuses on experiences of trauma and discrimination TGD youth experience after coming out. However, TGD youth may be targets of violence and victimization due to perceived gender nonconformity before coming out. In this Future Directions, we integrate research on attachment, developmental trauma, and effects of racism and homophobia on mental health to propose a social-affective developmental framework for TGD youth. We provide a clinical vignette to highlight limitations in current approaches to mental health assessment in TGD youth and to illustrate how using a social-affective developmental framework can improve clinical assessment and treatment approaches and deepen our understanding of mental health disparities in TGD people.

Cardiovascular Disease Risk Estimation for Transgender and Gender-Diverse Patients: Cross-Sectional Analysis of Baseline Data From the LITE Plus Cohort Study

Introduction

Approximately 2% of the U.S. population identifies as transgender, and transgender people experience disproportionate rates of cardiovascular disease mortality. However, widely used cardiovascular disease risk estimators have not been validated in this population. This study sought to determine the impact on statin therapy recommendations using 3 different approaches to operationalizing sex in the American Health Association/American College of Cardiology Pooled Cohort Equation Risk Estimator.

Methods

This is a cross-sectional analysis of baseline clinical data from LITE Plus, a prospective cohort study of Black and/or Latina transgender women with HIV. Data were collected from October 2020 to June 2022 and used to calculate Pooled Cohort Equation scores.

Results

The 102 participants had a mean age of 43 years. A total of 88% were Black, and 18% were Latina. A total of 79% were taking gender-affirming hormones. The average Pooled Cohort Equation risk score was 6% when sex assigned at birth was used and statins would be recommended for the 31% with Pooled Cohort Equation >7.5%. The average risk score was 4%, and 18% met the criteria for statin initiation when current gender was used; the mean risk score was 5%, and 22% met the criteria for statin initiation when current hormone therapy was used.

Conclusions

Average Pooled Cohort Equation risk scores vary substantially depending on the approach to operationalizing the sex variable, suggesting that widely used cardiovascular risk estimators may be unreliable predictors of cardiovascular disease risk in transgender populations. Collection of sex, gender, and hormone use in longitudinal studies of cardiovascular health is needed to address this important limitation of current risk estimators.

Differential associations between enacted and expected stigma with psychological distress, alcohol use, and substance use in transgender and gender diverse people

BACKGROUND

Transgender and gender diverse (TGD) people experience high rates of stigma and marginalization that are theorized to exacerbate substance use and psychological distress. However, little research has examined the role of various minority stressors in relation to substance use in TGD populations.

METHODS

In this sample of 181 TGD individuals in the U.S. who reported substance use or binge drinking over the past month (M age = 25.6; SD = 5.6), we evaluated whether enacted stigma predicted alcohol use, substance use, and psychological distress.

RESULTS

Participants endorsed a high rate of exposure to enacted stigma over the past 6 months (e.g., 52% had been verbally insulted). Furthermore, 27.8% of the sample was classified as having moderate or higher severity drug use, and 35.4% were classified as having hazardous drinking levels. We found that enacted stigma was significantly related to moderate-high drug use and psychological distress. There were no significant associations between stigma variables and hazardous levels of drinking. Enacted stigma had an indirect effect on psychological distress via increased expectations of stigma.

CONCLUSIONS

This study adds to the growing literature exploring minority stressors in relation to substance use and mental health. Subsequent research is needed to examine TGD-specific factors that may more fully explain how TGD people cope with enacted stigma or that may influence substance use, particularly alcohol use.

Identity affirmation is associated with adaptive cardiovascular flexibility in response to stress among sexual and gender minority people of color

BACKGROUND

Research with sexual and gender minority (e.g., lesbian, gay, bisexual, queer, asexual, trans, non-binary) people of Color (SGM-PoC) has largely focused on risk and negative health outcomes. The existing strengths-based mental health research suggests that identity affirmation may be associated with psychological resilience and good mental health among SGM-PoC, but little is known about predictors of physiological resilience and biomarkers of physical health in this population. Adaptive cardiovascular flexibility is an indicator of physiological resilience and physical health in that it enables the body to mobilize resources to adapt to challenges. This study explored the association between identity affirmation and physiological resilience, observed through cardiovascular flexibility in response to stress among SGM-PoC.

METHODS

Participants were 95 SGM-PoC of varying ethnoracial backgrounds, sexual orientations, and gender identities, residing in Canada. Participants completed questionnaires on sociodemographic and psychosocial variables, including a measure of identity affirmation, the Queer People of Color Identity Affirmation Scale (QPIAS). In a laboratory setting, we induced stress using the Trier Social Stress Test and measured heart rate variability (HRV) over time using wearable electrocardiogram devices.

RESULTS

Results from multilevel modeling analyses revealed that high QPIAS scores were associated with adaptive cardiovascular flexibility, as evidenced by reduced HRV during stress exposure, followed by HRV increase during recovery. As QPIAS scores increased, the shape of HRV trajectory increasingly reflected our predicted pattern of adaptive cardiovascular flexibility. Meanwhile, low QPIAS scores were not associated with this pattern and appeared to predict a more flatlined HRV activity during the experiment.

CONCLUSIONS

Findings indicate that Queer People of Color identity affirmation may be related to physiological resilience, observed through a more adaptive cardiovascular profile when responding to stress. Identity affirmation may thus be a protective factor for SGM-PoC, pointing to the critical importance of affirming resources and strengths-based health research.

Advances in stress and depression research

PURPOSE OF REVIEW

Stress plays a central role in the onset and course of depression. However, only a subset of people who encounter stressful life events go on to experience a depressive episode. The current review highlights recent advances in understanding when, why, and for whom the stress-depression link occurs, and we identify avenues for future research.

RECENT FINDINGS

In the last 18 months, researchers have taken a more nuanced perspective on the biopsychosocial mechanisms critical to the stress-depression link. For example, examination of specific facets of emotion regulation, including emotion regulation flexibility and interpersonal emotion regulation, has been critical to understanding its role in depression. Similarly, refined investigations of social support allowed researchers to identify distinct - and occasionally opposite - outcomes depending on the context or manner in which the support was provided. Researchers also documented that the stress-depression link was enhanced by dysregulation of several stress-sensitive biological systems, such as the immune system, microbiome, endocrine system, and neuroanatomical substrates.

SUMMARY

Recent studies highlight the importance of adopting a nuanced understanding of mechanisms and moderators that explain the stress-depression link. We also encourage continued engagement in collaborative, open science that uses multiple methods to study the full breadth of human diversity.

Disparities in health condition diagnoses among aging transgender and cisgender medicare beneficiaries, 2008-2017

INTRODUCTION

The objective of this research is to provide national estimates of the prevalence of health condition diagnoses among age-entitled transgender and cisgender Medicare beneficiaries. Quantification of the health burden across sex assigned at birth and gender can inform prevention, research, and allocation of funding for modifiable risk factors.

METHODS

Using 2009-2017 Medicare fee-for-service data, we implemented an algorithm that leverages diagnosis, procedure, and pharmacy claims to identify age-entitled transgender Medicare beneficiaries and stratify the sample by inferred gender: trans feminine and nonbinary (TFN), trans masculine and nonbinary (TMN), and unclassified. We selected a 5% random sample of cisgender individuals for comparison. We descriptively analyzed (means and frequencies) demographic characteristics (age, race/ethnicity, US census region, months of enrollment) and used chi-square and t-tests to determine between- (transgender vs. cisgender) and within-group gender differences (e.g., TMN, TFN, unclassified) difference in demographics (p<0.05). We then used logistic regression to estimate and examine within- and between-group gender differences in the predicted probability of 25 health conditions, controlling for age, race/ethnicity, enrollment length, and census region.

RESULTS

The analytic sample included 9,975 transgender (TFN n=4,198; TMN n=2,762; unclassified n=3,015) and 2,961,636 cisgender (male n=1,294,690, female n=1,666,946) beneficiaries. The majority of the transgender and cisgender samples were between the ages of 65 and 69 and White, non-Hispanic. The largest proportion of transgender and cisgender beneficiaries were from the South. On average, transgender individuals had more months of enrollment than cisgender individuals. In adjusted models, aging TFN or TMN Medicare beneficiaries had the highest probability of each of the 25 health diagnoses studied relative to cisgender males or females. TFN beneficiaries had the highest burden of health diagnoses relative to all other groups.

DISCUSSION

These findings document disparities in key health condition diagnoses among transgender Medicare beneficiaries relative to cisgender individuals. Future application of these methods will enable the study of rare and anatomy-specific conditions among hard-to-reach aging transgender populations and inform interventions and policies to address documented disparities.

Refining Research and Representation of Sexual and Gender Diversity in Neuroscience

There are opportunities to improve neuroscience that include lesbian, gay, bisexual, and transgender (LGBT) people. In this review, we briefly describe how the history of LGBT people in psychiatry has influenced neuroimaging approaches; how these attitudes have shifted over time; and what we can do to ensure that our future work is rigorous, ethical, and in service of the LGBT community. We suggest ways to refine neuroimaging methodologies to improve our understanding of marginalization and stigma while shifting away from research that focuses solely on the "etiology" or origins of LGBT identities. We also offer suggestions for conducting representative research that is LGBT-inclusive, regardless of the population of interest.

Sex and Gender and Allostatic Mechanisms of Cardiovascular Risk and Disease

Cardiovascular diseases are leading causes of mortality and morbidity in adults worldwide. Multiple studies suggest that there are clinically relevant sex differences in cardiovascular disease. Women and men differ substantially in terms of prevalence, presentation, management, and outcomes of cardiovascular disease. To date, however, little is known about why cardiovascular disease affects women and men differently. Because many studies do not differentiate the concept of sex and gender, it is sometimes difficult to discriminate sociocultural vs biological contributors that drive observed clinical differences. Female sex has some biological advantages in relation to cardiovascular disease, but many of these advantages seem to disappear as soon as women develop cardiovascular risk factors (eg, type 2 diabetes, hypertension, dyslipidemia). Furthermore, stress and allostatic load could play an important role in the relationship between sex/gender and cardiovascular diseases. In this narrative review, we argue that chronic stress and psychosocial factors might better encompass the patterns of allostatic load increases seen in women, while biological risk factors and unhealthy behaviours might be more important mechanisms that drive increased allostatic load in men. Indeed, men show allostatic load patterns that are more associated with impaired anthropometric, metabolic, and cardiovascular functioning and women have greater dysregulation in neuroendocrine and immune functioning. Thus gender-related factors might contribute to the pathogenesis of cardiovascular disease especially through stress mechanisms. It is important to continue to study the mechanisms by which gender influences chronic stress, because chronic stress could influence modifiable gendered factors to promote cardiovascular disease prevention.

Minimally invasive biomarkers in human population biology research, part 2: An introduction to the special issue

Over the past several decades, biomarkers have become indispensable tools in human biology, allowing researchers to investigate biocultural and evolutionary questions and to generate basic data on health and well-being. Human biologists are central players in biomarker methods development, pioneering the creation of "field friendly," minimally invasively collected biomarker approaches, as well as leading the innovative use of biomarkers, most notably to map the complex pathways from social and environmental conditions to altered physiology to health effects. This special issue, Part 2 of a collection focused on minimally invasively collected biomarkers, is comprised of nine papers that jointly contribute to driving the science of biomarker methods development and application. This compilation of papers engages with topics such as biological normalcy, ecoimmunology, and the ethics of working with vulnerable and underserved populations. It also focuses attention on research areas at present not emphasized in human biology such as bone turnover markers as a window onto osteoporosis and osteoarthritis and the use of cancer-related biomarkers in population screening and epidemiology. Taken together, these papers help draw the roadmap for future biomarker work, emphasizing: (1) the need for systematic and transparent approaches to assay validation, with open access publication; (2) simultaneous measurement of multiple biomarkers and expanded use of instrument platforms that increase the range of physiological, genomics, and omics markers available to researchers; and, (3) increased attention to ethics and researcher responsibilities, encouraging a mindset that recognizes our obligation to provide benefits to individuals and communities and to help redress past abuses.