Biological origins of sexual orientation and gender identity: Impact on health

Carving the Biodevelopment of Same-Sex Sexual Orientation at Its Joints

Sexual orientation is a core aspect of human experience and understanding its development is fundamental to psychology as a scientific discipline. Biological perspectives have played an important role in uncovering the processes that contribute to sexual orientation development. Research in this field has relied on a variety of populations, including community, clinical, and cross-cultural samples, and has commonly focused on female gynephilia (i.e., female sexual attraction to adult females) and male androphilia (i.e., male sexual attraction to adult males). Genetic, hormonal, and immunological processes all appear to influence sexual orientation. Consistent with biological perspectives, there are sexual orientation differences in brain development and evidence indicates that similar biological influences apply across cultures. An outstanding question in the field is whether the hypothesized biological influences are all part of the same process or represent different developmental pathways leading to same-sex sexual orientation. Some studies indicate that same-sex sexually oriented people can be divided into subgroups who likely experienced different biological influences. Consideration of gender expression in addition to sexual orientation might help delineate such subgroups. Thus, future research on the possible existence of such subgroups could prove to be valuable for uncovering the biological development of sexual orientation. Recommendations for such future research are discussed.

Etiology of gender incongruence and its levels of evidence: A scoping review protocol

INTRODUCTION

Gender Incongruence refers to the discordance between biological sex and gender identity. Although it is possible to find literature reviews about the etiology of Gender Incongruence, almost all of these correspond to non-systematic narrative reviews, so they do not make explicit the methodology used in the collection and analysis of sources, even less its levels of evidence. In order to remedy this, we will conduct a scoping review to answer the question: what are the factors associated with gender incongruence and what level of evidence is there for each factor in the scientific literature?

METHODS AND ANALYSIS

We will conduct a scoping review according to the methodology specified in the JBI Manual for Evidence Synthesis (Chapter 11) and the PRISMA extension for scoping reviews (PRISMA-ScR). Four databases will be reviewed to identify papers that match our search criteria, followed by a screening of titles and abstracts, the complete reading of those articles that have not been excluded, and the coding of these using the data extraction instrument developed for this research (see S1 Appendix). Data extracted will be analyzed in terms of frequency counts of factors, types of factors and levels of evidence for each factor. Results will be presented in tabular or diagrammatic forms supported by a narrative summary.

FINDINGS

The present review will help to map the factors associated with incongruence between biological sex and gender identity, specifying their levels of evidence. This evidence-based knowledge will be useful for clinicians evaluating gender incongruence, especially given that international guidelines recommend careful assessment of factors that may interfere with the clarity of gender identity development and decision making.

A holistic health determinants model for public health nursing education and practice

Baccalaureate nursing graduates (BSNs) in the 21st century need to be prepared to manage the population health needs of diverse populations across the lifespan and take actions to improve health equity. A need for a Holistic Health Determinants Model that included the Social Determinants of Health was identified. A model incorporating the Healthy People 2020 Health Determinants Model and the Healthy People 2030 Social Determinants of Health Model was developed. Two theoretical approaches provided a foundation for the model. Social ecological theory stresses the lived experience in an ever-changing environment from the micro to the macro biological, behavioral, social and physical environmental levels. Public health intersectionality added the construct of constant interactions among the health determinants that resulted in different levels of health status among individuals and groups. This Holistic Health Determinants Model is a tool to use in teaching nursing students how to address the needs of individuals/families, diverse populations, and communities. It also facilitates integration of the new AACN Population Health Competencies across the curriculum. The model facilitates the preparation of BSN graduates to address the factors that shape health status and to take actions to improve health equity.

Perceptions of and barriers to cancer screening by the sexual and gender minority community: a glimpse into the health care disparity

PURPOSE

A disparity exists in cancer screening rates for the Sexual and Gender Minority (SGM) community. We sought to understand the perceptions and baseline knowledge of cancer screening among SGM community members.

METHODS

Survey administered via social media from June 2018 to October 2018. We asked 31 questions focused on cancer screening, human papillomavirus, emotional distress, and experience with the health care system. Those included were 18 years or older. Cancer screening attitudes and knowledge, as well as perceptions of the health care system were investigated.

RESULTS

There were 422 respondents analyzed: 24.6% identified as female, 25.5% as male, 40.1% transgender, and 9.6% as other. 65.4% of the SGM community is not certain what cancer screening to do for themselves. Only 27.3% and 55.7% knew that HPV was a risk factor associated with head and neck cancer and anal cancer, respectively. Half stated their emotional distress prevents them from getting cancer screening. It was identified that process changes in making appointments, comforts during the visit, and formal training for physicians and nurses could increase cancer screening compliance for this community. The transgender population had a trend in more gaps in knowledge of appropriate cancer screening and significant excess emotional distress.

CONCLUSION

Gaps in cancer screening knowledge and emotional and financial distress may be responsible for the disparity of lower cancer screening rates for the SGM population and the transgender population may be most at risk. Appreciating the cancer screening concerns of the SGM population can help shape future clinical and institutional approaches to improve health care delivery.

The Effect of Early Traumatic Experiences on Attachment Styles in Sexual Gender Minority Individuals

PURPOSE

This study was carried out to specify the attachment characteristics of sexual gender minority individuals and to determine the effects of childhood traumatic experiences on attachment styles.

DESIGN AND METHODS

A descriptive cross-sectional study was conducted on 141 sexual gender minority individuals from 2016 to 2017.

FINDINGS

The number of childhood physical and sexual trauma episodes was found to be high in sexual minorities; in particular, the traumatized narratives were found to be associated with an avoidant attachment style (p > 0.05).

PRACTICE IMPLICATIONS

The study results may contribute to healthcare professionals' understanding of childhood trauma as it relates to sexual identity development and attachment disorders sexual identity development and attachment disorders.

A Dynamic Systems Framework for Gender/Sex Development: From Sensory Input in Infancy to Subjective Certainty in Toddlerhood

From birth to 15 months infants and caregivers form a fundamentally intersubjective, dyadic unit within which the infant's ability to recognize gender/sex in the world develops. Between about 18 and 36 months the infant accumulates an increasingly clear and subjective sense of self as female or male. We know little about how the precursors to gender/sex identity form during the intersubjective period, nor how they transform into an independent sense of self by 3 years of age. In this Theory and Hypothesis article I offer a general framework for thinking about this problem. I propose that through repetition and patterning, the dyadic interactions in which infants and caregivers engage imbue the infant with an embodied, i.e., sensori-motor understanding of gender/sex. During this developmental period (which I label Phase 1) gender/sex is primarily an intersubjective project. From 15 to 18 months (which I label Phase 2) there are few reports of newly appearing gender/sex behavioral differences, and I hypothesize that this absence reflects a period of developmental instability during which there is a transition from gender/sex as primarily inter-subjective to gender/sex as primarily subjective. Beginning at 18 months (i.e., the start of Phase 3), a toddler's subjective sense of self as having a gender/sex emerges, and it solidifies by 3 years of age. I propose a dynamic systems perspective to track how infants first assimilate gender/sex information during the intersubjective period (birth to 15 months); then explore what changes might occur during a hypothesized phase transition (15 to 18 months), and finally, review the emergence and initial stabilization of individual subjectivity-the period from 18 to 36 months. The critical questions explored focus on how to model and translate data from very different experimental disciplines, especially neuroscience, physiology, developmental psychology and cognitive development. I close by proposing the formation of a research consortium on gender/sex development during the first 3 years after birth.

Screening for HPV and dysplasia in transgender patients: Do we need it?

INTRODUCTION

Aim of this study was the evaluation of prevalence of HPV infection and resulting genital dysplasia to assess the necessity and reasonability of pap smears and HPV testing in transgender patients. HPV is the most common sexually transmitted infection and responsible for the majority of genital dysplasias and malignancies. However, few data exist about the prevalence of HPV and dysplasia in transgender people.

METHODS

This retrospective data analysis of prospectively collected data includes all patients seen in our specialized outpatient clinic for transgender people. Gynecologic exam, colposcopy, cellular swabs and HPV typing were carried out. Primary endpoint was the prevalence of HPV and genital dysplasias in transgender patients. Secondary endpoints were the subtypes of HPV, demographic data, sexual orientation and co-morbidities in these patients.

RESULTS

We investigated overall 98 patients whereof 53 were transwomen and 45 transmen. Of those, 10.2 % had positive HPV tests and 10.2 % dysplastic changes in the PAP and one case of invasive anal carcinoma (1.02 %). Comorbidities included recurrent urinary tract infections, psychologic comorbidies and other, possibly hormone replacement related conditions.

CONCLUSION

The results underline the necessity of a routine gynecological examination including PAP and/or HPV screening and vaccinating, respectively, no matter of sexual orientation or comorbidities. Monitoring the existent anatomy may prevent invasive carcinoma requiring more invasive therapies. Moreover, concomitant pathologies are present and require long-term care of these patients almost all using hormone therapy and carrying several specific risk factors. Transgender-focused guidelines to take into account these peculiarities are needed.

Sex Hormone Levels in Lesbian, Bisexual, and Heterosexual Women: Systematic Review and Exploratory Meta-Analysis

Lesbian and bisexual women may have different levels of sex hormones compared to heterosexual women. We systematically reviewed comparative studies measuring any sex hormones. A protocol was prospectively registered (PROSPERO-CRD42017072436) and searches conducted in six databases. Any relevant empirical studies published within the last 50 years reporting any circulating sex hormones in sexual minority women compared to heterosexual women were included, with no language or setting restrictions. Inclusions, data extraction, and quality assessment were conducted in duplicate. Random-effects meta-analyses of hormone levels, using standardized-mean-differences (SMD) were conducted where five or more studies reported results. From 1236 citations, 24 full papers were examined and 14 studies of mixed designs included, 12 in women without known ovarian problems. Hormones were measured in plasma (n = 9), saliva (n = 4), and urine (n = 2) and included androstenedione, luteinizing hormone, estradiol, pregnanediol, progesterone, testosterone, and several other hormones. Most studies were small, biased, and had considerable heterogeneity. Few found statistically significant differences between groups. All-sample meta-analysis showed increased testosterone in sexual minority women compared to heterosexual women (n = 9; SMD = 0.90; 95% Confidence interval (CI) 0.22, 1.57, I² = 84%). This was the only difference found. We conclude that the small amount of heterogeneous research, from 50 years to date, suggests little discernable difference in sex hormone levels between lesbian, bisexual, and heterosexual women excepting possibly higher testosterone. A large-scale primary study would be required before placing any certainty in the findings or their implications.

Valuing the Vulnerable - The Important Role of Transgender Communities in Biomedical Research

Every cell has a genetic sex that is determined at the time of fertilization. However, the natal sex of cells may not match the hormonal environment in which they reside in transgender individuals. This discordance provides a unique opportunity to study the short- and long-term effects across a range of cellular functions, health conditions, physiologic processes and psychosocial outcomes to the benefit of transgender and cisgender communities. While there is a growing body of knowledge as the literature on sex differences in virtually every organ system accumulates, there remains a paucity of data on the effect of cross hormonal therapy on cellular function in transgender individuals. Beyond cellular function, the effect of cross hormonal therapy on neuroanatomy, the interpretation of neuropsychological assessments or even the effect of daily stressors of stigma and discrimination on long-term neurocognitive function remain unclear. In 2011 the Institute of Medicine indicated that transgender adults were an understudied population and in critical need of more biomedical and population health research, yet the experience of stigma, discrimination, microaggressions, limited access to culturally competent care continue to make this an unfulfilled mandate. In addition to using a life course perspective, it is essential to identify research gaps and formulate a responsive research agenda while maintaining scientific rigor and respectful involvement of the population under study. None of this, however, will enhance the participation of transgender communities in biomedical research until the transgender and biomedical research communities can engage in open, respectful and bidirectional dialogue. From respectful, sensitive and appropriate health care to culturally competent research engagement from study inception to data dissemination, transgender communities can make an important and valuable contribution to biomedical research. Inclusion of their voices at all levels, including investigators from transgender communities, are essential to advance this much overdue scientific agenda. Transgender, cisgender and the biomedical research communities will all benefit from a more inclusive and expansive research agenda.

Overview of care for transgender children and youth

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.

Stress: Influence of sex, reproductive status and gender

Emerging evidence from the preclinical and human research suggests sex differences in response to different types of stress exposure, and that developmental timing, reproductive status, and biological sex are important factors influencing the degree of HPA activation/function. Here we review data regarding: i) sex differences in behavioral and neural responses to uncontrollable and controllable stressors; ii) distinct trajectories of behavioral development and HPA-axis function in male and female rats following adolescent stress exposure; iii) normative changes in behavior and dopamine function in early postpartum rats; iv) aberrant HPA-axis function and its link to abnormal behaviors in two independent, preclinical mouse models of postpartum depression; and, v) data indicating that gender, in addition to sex, is an important determinant of stress reactivity in humans. Based on these findings, we conclude it will be important for future studies to investigate the short and long-term effects of a wide variety of stressors, how these effects may differ according to developmental timing and in relation to gonadal function, the relationship between aberrant HPA-axis activity during the postpartum and mood disorders, and influences of both sex and gender on stress reactivity in humans.

Born This Way: Using Intrinsic Disorder to Map the Connections between SLITRKs, TSHR, and Male Sexual Orientation

Recently, genome-wide association study reveals a significant association between specific single nucleotide polymorphisms (SNPs) in men and their sexual orientation. These SNPs (rs9547443 and rs1035144) reside in the intergenic region between the SLITRK5 and SLITRK6 genes and in the intronic region of the TSHR gene and might affect functionality of SLITRK5, SLITRK6, and TSHR proteins that are engaged in tight control of key developmental processes, such as neurite outgrowth and modulation, cellular differentiation, and hormonal regulation. SLITRK5 and SLITRK6 are single-pass transmembrane proteins, whereas TSHR is a heptahelical G protein-coupled receptor (GPCR). Mutations in these proteins are associated with various diseases and are linked to phenotypes found at a higher rate in homosexual men. A bioinformatics analysis of SLITRK5, SLITRK6, and TSHR proteins is conducted to look at their structure, protein interaction networks, and propensity for intrinsic disorder. It is assumed that this information might improve understanding of the roles that SLITRK5, SLITRK6, and TSHR play within neuronal and thyroidal tissues and give insight into the phenotypes associated with male homosexuality.