Opportunities and Gaps in Primary Care Preventative Health Services for Transgender Patients: A Systemic Review

Strategies to Optimize Cervical Cancer Screening Rates Among Transgender and Gender-Diverse People Assigned Female at Birth

Self-sampling for primary HPV detection for cervical cancer screening is now FDA-approved. Many persons interested in cervical cancer screening are eager to opt out of the invasive speculum exam and opt into the self-sampling. There is no limitation on which persons can choose self-sampling. Transgender, nonbinary, and gender-diverse assigned female at birth (TGD AFAB) people experience barriers such as gender dysphoria and discomfort with sensitive exams. They may find more comfort with this equivalent method of screening. However, no clinical guidelines describe the best practices to increase screening among this underserved population. Much community work needs to occur to make the language of screening gender-affirming for all participants. Solutions to currently invasive follow-up exams after abnormal screens need to be communicated in language directed by the TGD AFAB community.

Primary care provider beliefs and knowledge of prescribing gender-affirming hormone therapy to transgender and gender diverse patients

BACKGROUND

Transgender patients often cannot access a provider who is knowledgeable about providing gender-affirming hormone therapy (GAHT). This study evaluated primary care provider (PCP) comfort and experience with, opinions about, and knowledge of prescribing GAHT to adults.

METHODS

An anonymous Qualtrics survey was distributed to PCPs in San Diego County. Fisher's exact test assessed any association between age, years in practice, or practice setting and 1) comfort in prescribing GAHT and 2) favorable statements about learning about, providing, and benefitting from training in GAHT. T-tests determined relationship between age, years in practice, or practice type setting with number of correctly answered multiple choice knowledge-based questions out of 4.

RESULTS

Out of 220 responses, median age was 41, 60% had practiced for ≤ 10 years, and 19% had practiced in an academic setting. Forty-two percent did not receive any education about transgender healthcare during medical training. The most commonly reported barrier to providing GAHT was lack of training (74%). PCPs age ≤ 41 (67% vs 49%, p = 0.009), PCPs practicing for ≤ 10 years (65% vs 51%, p = 0.037), and PCPs in non-academic settings (64% vs. 41%, p = 0.013) were more likely to report being comfortable with prescribing GAHT. PCPs age ≤ 41 (89% vs 62%, p < 0.001) and PCPs practicing for ≤ 10 years (86% vs 66%, p < 0.001) were more likely to show interest in learning about GAHT. PCPs age ≤ 41 (74% vs 46%, p < 0.001) and PCPs practicing for ≤ 10 years (70% vs 50%, p = 0.003) were more likely to show interest in prescribing GAHT. Knowledge scores were higher for PCPs age  ≥42 (mean 1.7 vs 1.4, p = 0.033) and PCPs working in academic centers (mean 2.0 vs 1.4, p = 0.002).

CONCLUSION

Younger (age ≤ 41) and early career (practicing for ≤ 10 years) PCPs reported being more comfortable with prescribing GAHT and had more favorable opinions in learning about, providing, and benefitting from training in GAHT. They are interested in providing GAHT; however, few prescribe GAHT with most reporting lack of training as a major barrier. This was evident with overall low knowledge scores regardless of age, experience, or clinical setting and underscores the need for increased educational efforts in transgender care throughout medical training.

Effect of an Education Intervention on Nursing Students' Knowledge of and Attitudes Toward Caring for Transgender and Nonbinary People

BACKGROUND

Transgender and nonbinary (TGNB) people experience inequities in health care access, quality, and outcomes. Health care professionals' lack of knowledge and biased attitudes toward gender minorities contribute to inequitable care.

PURPOSE

This study examined the effect of TGNB health education on nursing students' knowledge and attitudes about caring for TGNB clients.

METHODS

A quasi-experimental study using a one-group pretest/posttest design was conducted with 46 nursing students at 2 private baccalaureate nursing programs.

RESULTS

A paired-samples t test found a significant increase in knowledge about caring for TGNB clients at posttest ( P = .02). Attitudes toward caring for TGNB clients showed a significant improvement in the Sex and Gender Beliefs subscale at posttest ( P = .014).

CONCLUSIONS

The findings suggest that TGNB health education is effective for inclusion in nursing curricula to better prepare nurses to care for gender-diverse clients.

Caring for the Older Transgender Adults: Social, Nursing, and Medical Challenges

Aging is a challenging process for people with gender nonconformity. Indeed, the older transgender population faces several disparities in accessing and using health care and social support services. Furthermore, the clinical management of gender transition in later life is empirical since clear research evidence is lacking. This paper aimed to present the problems encountered by older transgender adults in their access to social support and health care and to propose insightful solutions to address them both from a social and medical/nursing perspective. Trans elders face profound disparities in health and social care due to factors associated with limited accessibility to health services, social restrictions, administrative failures, and physical vulnerabilities. The medical treatment of older transgender adults also needs a careful approach to achieve satisfying gender affirmation without clinically significant risks. The potential induction of hormone-sensitive malignancies and the provocation of major adverse vascular events are the main concerns. Gender transition in older adults without a prior history of following gender-affirming therapy is challenging due to biological factors related to advanced age. Caring for elderly trans people unfolds at multiple levels. International organizations and governmental bodies should address the underprivileged status of elderly transgender people by creating and implementing inclusive policies. Safe and respectful clinical and residential environments and the formation of clearer medical guidelines could meet the unique needs of older trans adults. Care providers must advocate for their patients and be equipped to provide safe and effective services.

A Community Survey of Referral Sources to Identify Primary Care and Gender-Affirming Care Providers

Introduction

Barriers exist in access to primary care as well as specialty healthcare such as gender-affirming care. Understanding the referral sources used to identify new providers for these types of care can help healthcare systems facilitate access.

Methods

Using data from a community-based survey, demographics and information relevant to finding new healthcare providers were assessed.

Results

Data from 165 participants suggest that seeking a new primary care provider was perceived as challenging. The most common referral sources for primary care providers were family/friends, a doctor, or a medical center website. The most common referral sources for gender-affirming care providers were a doctor, family/friends, or social media. There were significant differences in the types of referral sources most likely to be utilized for primary versus gender-affirming care.

Conclusions

Personal connections, including trusted doctors, can be important sources of provider referrals. Additional resources may be needed to facilitate their ability to make quality connections. Community resources and social media can be important sources when existing social networks may not have knowledge about the needs of particular communities, especially those who may be at risk of discrimination. More inclusive and secure referral sources may be needed to ensure gender-affirming care referrals are made.

Mediational pathways exploring the link between adverse childhood experiences and physical health in a transgender population

BACKGROUND

Adverse childhood experiences (ACEs) consist of instances of abuse, neglect, or household dysfunction occurring before adulthood. Prevalence rates of ACEs are higher among specific populations, including gender minorities. In addition to ACEs, transgender individuals (TG) face many personal, social, and structural factors that have the potential to negatively impact their physical health.

OBJECTIVE

This study examines exploratory mediational pathways between ACEs and two health outcomes (i.e., general health and days physically ill) in TG. Mediators include everyday discrimination, social support, gender non-affirmation, and mental distress.

METHODS

Cross-sectional data from the U.S. Transgender Population Health Survey (TransPop) was used to conduct a serial/parallel mediation analysis. The TransPop survey included a total of 274 TG.

RESULTS

For both outcome variables, the same three indirect pathways were significant. First, ACEs were associated with increased mental distress, which was associated with a decrease in general health and an increase in days physically ill. Second, ACEs were associated with increased discrimination, which was associated with increased mental distress, and this was associated with a decrease in general health and an increase in days physically ill. Finally, ACEs were associated with discrimination, which was associated with increased gender non-affirmation which was associated with increased mental distress, and this was associated with a decrease in general health and an increase in days physically ill.

CONCLUSION

Interventions focused on reducing discrimination, gender non-affirmation, and poor mental health may be vital to improving the health of TG and to mitigating the indirect role of ACEs on TG health.

Shared care and gender identity support in Primary Care: The perspectives and experiences of parents/carers of young trans people

This article addresses the complex issues surrounding trans youths' shared care perceived by parents in primary care settings in the UK. The analyses in this article draws on qualitative data derived from an online survey of 153 parents with trans children. Through the conceptual framework of healthcare assemblages, findings suggest that quality shared care for trans youth is based upon transient service relationships inherent in their healthcare-primary care, gender identity services, endocrinologists, and Adolescent Mental Health Services (CAHMS)-and, as such, this complexity must be understood better by GPs in order for quality shared care to be administered. We explored various blockages to quality shared care within primary care surgeries that produced limit situations, such as lack of knowledge, training, or experience with trans healthcare. One other key factor was that there were strong external forces that were limiting trans youths' quality shared care in the form of abject depictions from beyond the consultation, which all produced negative effects. Despite these blockages, we also demonstrate how and where quality shared care is received. For instance, we show that continuity of care or treatment after an initial diagnosis or assessment contributes to quality shared care as too does personalized care to those youths receiving it. Overall, this research provides insights into the complex perceptions of parents about what quality shared care is and ought to be for trans youth.

Cardiovascular disease in transgender individuals

The population of people identifying as transgender has grown rapidly in recent years, resulting in a substantive increase in individuals obtaining gender-affirming medical care to align their secondary sex characteristics with their gender identity. This has established benefits for patients including improvements in gender dysphoria and psychosocial functioning, while reducing adverse mental health outcomes. Despite these potential advantages, recent evidence has suggested that gender-affirming hormone therapy (GAHT) may increase the risk of cardiovascular disease. However, owing to a paucity of research, the mechanisms underpinning these increased risks are poorly understood. Moreover, previous research has been limited by heterogenous methodologies, being underpowered, and lacking appropriate control populations. Consequently, the need for evidence regarding cardiovascular health in LGBTQ + individuals has been recognised as a critical area for future research to facilitate better healthcare and guidance. Recent research investigating the effect of transmasculine (testosterone) GAHT on cardiovascular disease risk points to testosterone effecting the nitric oxide pathway, triggering inflammation, and promoting endothelial dysfunction. Equivalent studies focussing on transfeminine (oestrogen) GAHT are required, representing a crucial area of future research. Furthermore, when examining the effects of GAHT on the vasculature, it cannot be ignored that there are multiple factors that may increase the burden of cardiovascular disease in the transgender population. Such stressors include major psychological stress; increased adverse health behaviours, such as smoking; discrimination; and lowered socioeconomic status; all of which undoubtedly impact upon cardiovascular disease risk and offers the opportunity for intervention.

Voices from a Multidisciplinary Healthcare Center: Understanding Barriers in Gender-Affirming Care-A Qualitative Exploration

When seeking gender-affirming care, trans* and gender-diverse individuals often describe experiencing barriers. However, a deeper understanding of what constitutes such barriers is generally lacking. The present research sought to better understand the barriers trans* and gender-diverse individuals experienced, and their effects, when seeking gender-affirming care in the Netherlands. Qualitative interviews were conducted with trans* and gender-diverse individuals who sought care at a Dutch multidisciplinary medical center. Twenty-one participants were included, of which 12 identified as (trans) male, six identified as (trans) female, one as trans*, and one as gender-nonconforming (GNC)/non-binary. The interviews were mostly conducted at the homes of the participants and lasted between 55 min and 156 min (mean = 85 min). Following data collection and transcription, the interviews were analyzed using axial coding and thematic analysis. A total of 1361 codes were extracted, which could be classified into four themes describing barriers: lack of continuity: organizational and institutional factors (n_codes = 546), patient-staff dynamics (n_codes = 480), inadequate information and support (n_codes = 210), and lack of autonomy in decision making (n_codes = 125). Within our study, trans* and gender-diverse individuals described encountering multiple and diverse barriers when seeking gender-affirming care in the Netherlands. Future studies are needed to evaluate whether individualized care, the decentralization of care, and the use of decision aids can improve the experienced barriers of trans* and gender-diverse individuals seeking gender-affirming care within the Dutch healthcare system.

White paper: Gender affirming care in college health

College health services are uniquely situated to reduce barriers that have historically made it difficult for Transgender and Gender Diverse (TGD) people to access care. The Big 10 Gender Care Coalition recognizes the importance of providing gender-affirming care and presents recommendations for integrative, inclusive college health services.

Measuring Geographic Access to Transgender Hormone Therapy in Texas: A Three-step Floating Catchment Area Analysis

While the extant literature has established that transgender people face significant barriers to accessing healthcare, no studies to date have offered an explicitly spatial analysis of their access to trans-specific care. This study aims to fill that gap by providing a spatial analysis of access to gender-affirming hormone therapy (GAHT) using Texas as a case study. We used the three-step floating catchment area method, which relies on census tract-level population data and location data for healthcare facilities to quantify spatial access to healthcare within a specific drive-time window, in our case 120 min. For our tract-level population estimates we adapt estimates of the rates of transgender identification from a recent data source, the Household Pulse Survey, and use these in tandem with a spatial database of GAHT providers of the lead author's creation. We then compare results of the 3SFCA with data on urbanicity and rurality, as well as which areas are deemed medically underserved. Finally, we conduct a hot-spot analysis that identifies specific areas where health services could be planned in ways that could improve both access to GAHT for trans people and access to primary care for the general population. Ultimately, we conclude that our results illustrate that patterns of access to trans-specific medical care, like GAHT, do not neatly follow patterns of access to primary care for the general population and that therefore trans communities' access to healthcare warrants specific, further investigation.

Disparities in Prostate Cancer Screening for Transgender Women: An Analysis of the MarketScan Database

OBJECTIVE

To describe the prevalence of PSA screening amongst transgender women. A transgender individual is someone whose gender identity differs from their birth sex or the societal norms of that assigned sex. There are no formal guidelines regarding PSA screening in transgender women, even though they retain prostatic tissue throughout the gender-affirming process, and there is a lack of existing data to adequately inform clinical practice.

METHODS

We identified a cohort of transgender women in the IBM MarketScan dataset using ICD codes. The patient...s eligibility for inclusion was determined on an annual basis for the years 2013-2019. For each year, we required continuous enrollment, 3 months of post-transgender diagnosis follow-up, and aged 40-80 without a prior diagnosis of prostate malignancy. This cohort was compared to cisgender men with similar eligibility criteria. The proportions of individuals undergoing PSA screening were compared using log-binomial regression.

RESULTS

A group of 2957 transgender women met the inclusion criteria. We saw significantly lower PSA screening rates among transgender individuals for ages 40-54 and 55-69, but higher rates within the age group 70-80 (P.ß<.ß.001 for all).

CONCLUSION

This is the first study evaluating PSA screening rates for insured transgender women. While the rates for screening in transgender women over the age of 70 are higher, the overall rate of screening for all other age groups lags below the general population in this dataset. Further investigation is necessary to provide equitable care for the transgender community.

Improving the inclusion of transgender and nonbinary individuals in the planning, completion, and mobilization of cardiovascular research

Cardiovascular disease is the leading cause of morbidity and mortality globally. Transgender and nonbinary (TNB) individuals face unclear but potentially significant cardiovascular health inequities, yet no TNB-specific evidence-based interventions for cardiovascular risk reduction currently exist. To address this gap, we propose a road map to improve the inclusion of TNB individuals in the planning, completion, and mobilization of cardiovascular research. In doing so, the adoption of inclusive practices would optimize cardiovascular health surveillance and care for TNB communities.

Barriers to uptake of PrEP across the continuum among transgender women: A global scoping review

BACKGROUND

Although preexposure prophylaxis (PrEP) has demonstrated high efficacy for HIV prevention, rates of PrEP uptake remain low among the transgender population, especially in transgender women (TGW). We conducted this scoping review to assess and characterize barriers to PrEP use along the PrEP care continuum among TGW.

METHODS

We conducted this scoping review by searching studies in Embase, PubMed, Scopus, and Web of Science. Eligibility criteria included: reporting a PrEP related quantitative result among TGW; peer-reviewed and published in English between 2010-2021.

RESULTS

Globally, high willingness (80%) to use PrEP was found, yet uptake and adherence (35.4%) were low. TGW experiencing hardship, including poverty, incarceration, and substance use, were associated with higher odds of PrEP awareness but lower odds of PrEP use. Structural and social barriers such as stigma, medical mistrust, and perceived racism can be important barriers for PrEP continuation. High social cohesion and hormone replacement therapy were associated with greater odds of awareness. In addition, our study confirmed prior research showing that PrEP does not lower feminizing hormone levels in TGW.

CONCLUSIONS

Significant demographic factors among TGW that are associated with PrEP engagement. It is imperative to focus on TGW as a population with independent needs, requiring specific PrEP care guidelines and tailored resource allocation, that fully considers individual-, provider-, and community/structural-level barriers and facilitators. The present review also indicates that combining PrEP care with GAHT or broader gender-affirmation care may facilitate PrEP use.

Culturally safe, appropriate, and high-quality breast cancer screening for transgender people: A scoping review

Background

There is a recognized need for evidence to inform breast cancer screening guidelines and services for transgender people, who face barriers to accessing appropriate and inclusive health care.

Aims

This review summarized evidence for breast cancer risk and screening guidelines in transgender individuals, including the potential impact of gender-affirming hormone therapy (GAHT); factors that may influence screening decision-making and behaviors; and considerations for providing culturally safe, high-quality screening services.

Methods

A protocol was developed based on the Joanna Briggs Institute scoping review methodology. Searches were performed in Medline, Emcare, Embase, Scopus, and the Cochrane Library for articles reporting information on the provision of culturally safe, high-quality breast cancer screening services for transgender people.

Results

We identified 57 sources for inclusion: 13 cross-sectional studies, 6 case reports, 2 case series, 28 review or opinion articles, 6 systematic reviews, 1 qualitative study, and 1 book chapter. Evidence on rates of breast cancer screening among transgender people and the association between GAHT and breast cancer risk was inconclusive. Factors negatively associated with cancer screening behaviors included socioeconomic barriers, stigma, and lack of health provider awareness of transgender health issues. Breast cancer screening recommendations varied and were generally based on expert opinion due to the lack of clear evidence. Considerations for providing culturally safe care to transgender people were identified and mapped to the areas of workplace policies and procedures, patient information, clinic environment, professional conduct, communication, and knowledge and competency.

Discussion

Screening recommendations for transgender individuals are complicated by the lack of robust epidemiological data and clear understanding of the role GAHT may play in breast cancer pathogenesis. Guidelines have been developed based on expert opinion and are subsequently not uniform or evidence based. Further work is required to clarify and consolidate recommendations.

Recommendations from Latinx Trans and Non-Binary Individuals to Promote Cancer Prevention in Puerto Rico and Florida

Latinx trans and non-binary individuals (LTNB) face increased cancer-related health disparities. Studies evidence how barriers at the individual, provider and organizational levels drive cancer disparities among LTNB individuals. These barriers increase the emotional discomfort associated with testing and disengagement from cancer prevention efforts. Moreover, there are no guidelines or interventions that address cancer prevention specifically among LTNB individuals. There is a need to develop interventions informed by the LTNB communities to promote cancer prevention and screening. The study aims to describe the recommendations provided by LTNB individuals to foster cancer screening and prevention in the communities residing in Puerto Rico and Florida. We conducted two online focus groups with a total of 15 LTNB participants. Participants were recruited using non-probabilistic purposive sampling. We used rapid-qualitative analysis for data interpretation. Findings are gathered in three main themes: (1) recommendations for promoting cancer prevention screening among providers; (2) specific recommendations to promote cancer screening among LTBN individuals; and (3) recommendations on delivery formats to foster cancer prevention. These results evidence the need and feasibility of developing community informed tailored interventions targeting cancer screening and preventative care to reduce cancer-related health disparities among the LTNB population.

Gender-Affirming Primary Care Access Among Rural Transgender and Gender Diverse Adults in Five Northeastern U.S. States

Purpose: Little is known about the prevalence and predictors of gender-affirming primary care (GAPC) access among rural transgender and gender diverse (TGD) adults. This study therefore sought to characterize the prevalence and predictors of GAPC within a sample of rural TGD adults. Methods: A nonprobability convenience sample (n = 244) of rural TGD adults was recruited across five Northeastern U.S. states (Connecticut, Massachusetts, New Hampshire, New York, Vermont) and completed a health needs assessment from March 2019 to October of 2019. Results: Transgender women and men had higher odds of accessing GAPC than nonbinary and gender diverse respondents. Respondents aged 25-39 had higher odds of accessing GAPC than those 18-24 years old. Conclusion: This study found high prevalence of barriers to GAPC among rural TGD people, highlighting system-level improvement opportunities.

Positive patient-provider relationships among transgender and nonbinary individuals in New York City

Background: Transgender and nonbinary (TGNB) individuals have diverse health needs and may face disproportionate barriers to healthcare, including developing positive patient-provider relationships. While there is mounting evidence of gender-based stigma and discrimination in healthcare, little is known about how TGNB individuals develop positive patient-provider relationships. Aims: To examine TGNB individuals' interactions with healthcare providers and identify main characteristics of positive patient-providers relationships. Methods: We conducted semi-structured interviews with a purposive sample of 13 TGNB individuals in New York, NY. Interviews were transcribed verbatim and analyzed inductively for themes related to characteristics of positive and trusting relationships with healthcare providers. Results: Participants' mean age was 30 years (IQR = 13 years) and most participants were nonwhite (n = 12, 92%). Receiving peer referrals to specific clinics or providers helped many participants find providers perceived to be competent and created initial grounds for positive patient-provider relationships. Providers with whom participants had positive relationships commonly managed primary care and gender-affirming care and relied on a network of interdisciplinary providers for other specialized care. Providers who were positively evaluated were perceived to possess in-depth clinical knowledge on the issues they were responsible for managing, including gender-affirming interventions, particularly for TGNB patients who perceived themselves to be knowledgeable about TGNB-specific care. Provider and staff cultural competence and a TGNB-affirming clinic environment were also important, particularly early in the patient-provider relationship, and if combined with TGNB clinical competence. Discussion: Provider-focused training and education programs should combine components of TGNB clinical and cultural competence to facilitate development of positive relationships between TGNB patients and providers, thereby improving the health and wellbeing of TGNB people.

Utilization of Recommended Preventive Health Screenings Between Transgender and Cisgender Older Adults in Sexual and Gender Minority Communities

ObjectivesTransgender older adults are among the most health disparate populations in the United States; they also face some of the most significant barriers in accessing high quality, affordable, preventive healthcare services. We compare utilization rates of eight recommended preventive health screenings for adults aged 50 and older, by gender identity. Methods: We analyzed data from 2514 lesbian, gay, bisexual, and transgender adults aged 50 and older, testing associations between gender identities and screening service utilizations by applying a series of multivariate logistic regression analyses, controlling for sociodemographics. Results: Compared to cisgender LGB participants, transgender participants had significantly lower odds to have met four of the recommended screenings. Transgender men had significantly lower odds than transgender women to have met two of the recommended screenings. Discussion: Increasing transgender older adults' access to preventative health screening tests is critical to reduce the health burden in this aging population.

Health Insurance Prevalence Among Gender Minority People: A Systematic Review and Meta-Analysis

Purpose

Gender minority (GM) (people whose gender does not align with the sex assigned at birth) people have historically been insured at lower rates than the general population. The purpose of this review is to (1) assess the prevalence of health insurance among GM adults in the United States, (2) examine prevalence by gender, and (3) examine trends in prevalence before and after implementation of the Affordable Care Act.

Methods

Published articles from PubMed, EMBASE, and Web of Science databases before April 26th, 2019, were included. This review is registered on PROSPERO (CRD42019133627). Analysis was guided by a random-effects model to obtain a meta-prevalence estimate for all GM people and stratified by gender subgroup. Heterogeneity was assessed using a Q-test and I 2 measure.

Results

Of 55 included articles, a random pooled estimate showed that 75% GM people were insured (95% confidence interval [CI]: 0.71-0.79; p<0.001). Subgroup analysis by gender determined 70% of transgender women (95% CI: 0.64-0.76; p<0.001; I 2=97.16%) and 80% of transgender men (95% CI: 0.77-0.83; p=0.01; I 2=54.51%) were insured. Too few studies provided health insurance prevalence data for gender-expansive participants (GM people who do not identify as solely man or woman) to conduct analysis.

Conclusion

The pooled prevalence of health insurance among GM people found in this review is considerably lower than the general population. Standardized collection of gender across research and health care will improve identification of vulnerable individuals who experience this barrier to preventative and acute care services.

Transgender Cardiovascular Health: Practical Management for the Clinician

PURPOSE OF REVIEW

Transgender individuals represent a growing part of our population with current trends indicating that clinicians will be treating more transgender patients in both the inpatient and outpatient setting. Current cardiovascular guidelines lack recommendations for transgender care secondary to limited data in this population. As we await future guideline recommendations, we provide a comprehensive review of the literature and practical management strategies related to transgender cardiovascular health.

RECENT FINDINGS

Transgender individuals are at higher risk for some cardiovascular diseases compared to their cisgender counterparts. Gender-affirming hormone therapy, concomitant health conditions, lifestyle habits, access to services, and quality of care all contribute to this finding. While it is likely both safe and appropriate to apply current CVD guidelines to the care of transgender men and women, clinicians should consider additional factors in risk assessment and address unique aspects of care at every visit.

Gender-affirming Care for Transgender Patients

Lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, plus (LGBTQIA+ or LGBTQ+) individuals face a wide array of health disparities both within and separate from the healthcare system. Transgender patients are subject to microaggressions, misgendering, and harassment from providers, medical staff, and fellow patients. These patients experience drastic disparities in suicidality, depression, anxiety, substance use, malignancy, sexually transmitted disease (STD), and victimization of violence. Providers have the opportunity to intervene and positively impact patient experiences through gender-affirming care, but they first require an adequate knowledge base and understanding of the importance of sensitive and inclusive care. Seemingly small interventions, such as listing one's own pronouns, using gender-neutral language, validating and affirming patients, and utilizing appropriate mental and physical health screenings, can lead to significant impacts on the patient experience, health outcomes, and quality of life. This article will discuss some of the most common disparities and obstacles faced by transgender patients and will argue the paramount role of the provider in establishing gender-affirming care and some high-impact avenues which the provider, regardless of specialty, may pursue when caring for these patients.

PrEP Use and Adherence Among Transgender Patients

This cross-sectional study used 2012 to 2019 Oregon Medicaid claims to estimate the prevalence of PrEP use and identify determinants of high adherence across transgender and cisgender men and women. Gender identity (cisgender woman/man; transgender, assigned female sex at birth [AFAB]; transgender, assigned male sex at birth [AMAB]) was based on medical history and enrollment records. Proportion of days covered ≥ 0.80 was considered high adherence to PrEP. The association between gender identity and PrEP uptake or high adherence was estimated using multivariable logistic regression. 1555 PrEP users, including 171 (11.0%) cis women, 1171 (75.3%) cis men, 67 (4.3%) AFAB, and 146 (9.4%) AMAB individuals, were included. The probability of PrEP use per 10,000 people was highest in transgender groups (AMAB 546.8, 95% CI 462.4-631.3; AFAB 226.5, 95% CI 173.4-279.6), followed by cisgender men (20.6, 95% CI 19.4, 21.8) and women (2.6, 95% CI 2.2, 3.0). High adherence was significantly lower in AMAB recipients (72.6%) than cisgender women (86.0%) and cisgender men (82.2%). Among the 279 PrEP users with female on their enrollment record, 76 (27.2%) were AMAB, while among the 1276 PrEP users with male on their enrollment record, 35 (2.7%) were AFAB. This demonstrates the importance of surveillance methods that take gender identity into account in addition to sex assigned at birth. There were significant differences in PrEP use and adherence by gender identity. PrEP surveillance, outreach, and prescribing practices must consider gender identity-unique risk factors.

Chronic Kidney Disease in the Transgender, Nonbinary, or Gender Diverse Person

Nephrologists are increasingly providing care to transgender, nonbinary, and gender diverse (TNBGD) individuals with chronic kidney disease. This narrative review discusses the care of TNBGD individuals from a nephrology perspective. TNBGD individuals are under-represented in the nephrology literature. TNBGD individuals are at an increased risk of adverse outcomes compared with the cisgender population including mental health, cardiovascular disease, malignancy, sexually transmitted infections, and mortality. Gender-affirming hormone therapy (GAHT) with estradiol in transfeminine individuals potentially increases the risk of venous thromboembolism and cardiovascular disease. GAHT with testosterone in transmasculine individuals potentially increases the risk of erythrocytosis and requires careful monitoring. GAHT modifies body composition and lean muscle mass, which in turn influence creatinine generation and excretion, which may impact the performance of estimated glomerular filtration rate (GFR) equations and the estimation of 24-hour urine values from spot urine albumin/protein to creatinine ratios. There are limited studies regarding TNBGD individuals with chronic kidney disease. Additional research is needed to evaluate the effects of GAHT on GFR and biomarkers of kidney function and the performance of the estimated GFR equation in TNBGD populations.

Transgender and gender-diverse (TGD) individuals' perspectives on research seeking genetic variants associated with TGD identities: a qualitative study

Recent genetic research has explored how genetic variants may contribute to gender dysphoria and transgender and gender-diverse (TGD) identities. When investigating communities that have been marginalized, it is important for researchers to incorporate perspectives of the communities the research is targeting. Therefore, investigators should incorporate the TGD community's opinions into this research to mitigate potential ethical issues, given the history of pathologization of TGD identities and utilization of genetics for eugenics. The aim of this study was to understand the perspectives of TGD individuals about trans-associated genetic research (TAGR). Eighteen semi-structured interviews were conducted with members of the TGD community to explore how TGD individuals view TAGR. Through inductive content analysis, five major themes were emergent: (1) TAGR could affect self-perception of identity; (2) TAGR could affect external views of TGD people; (3) TAGR could affect access to gender-affirming services; (4) TAGR could contribute to the pathologization and elimination of TGD identities; and (5) researchers should consult TGD community members and consider ethical concerns before conducting research. Participants highlighted concerns about TAGR being used as a tool for discrimination. Those who identified potential advantages of TAGR gave warning that TAGR would be unlikely to solely have positive effects. It is important for genetic researchers to prioritize the perspectives and concerns of TGD people highlighted in this study. Research about the TGD community needs to include TGD individuals as core members of the research team. Moreover, due to the serious ethical issues outlined in this study, TAGR should be reconsidered altogether.

LGBTQ2S+ childbearing individuals and perinatal mental health: A systematic review

BACKGROUND

The perinatal period may uniquely impact the mental health and wellbeing of lesbian, gay, bisexual, transgender, queer, and Two-Spirit (LGBTQ2S+) childbearing individuals.

OBJECTIVES

To characterise and synthesise the experiences of LGBTQ2S+ childbearing individuals regarding perinatal mental health, including symptomatology, access to care and care-seeking.

SEARCH STRATEGY

We conducted and reported a systematic review following PRISMA guidelines of eight databases (EMBASE, MEDLINE-OVID, CINAHL, Scopus, Web of Science: Core Collection, Sociological Abstracts, Social Work Abstract, and PsycINFO) from inception to 1 March 2021.

SELECTION CRITERIA

Original, peer-reviewed research related to LGBTQ2S+ mental health was eligible for inclusion if the study was specific to the perinatal period (defined as pregnancy planning, conception, pregnancy, childbirth, and first year postpartum; includes miscarriages, fertility treatments and surrogacy).

DATA COLLECTION AND ANALYSIS

Findings were synthesised qualitatively via meta-aggregation using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI), and the ConQual approach.

MAIN RESULTS

Our systematic search included 26 eligible studies encompassing 1199 LGBTQ2S+ childbearing participants. Using the JBI SUMARI approach, we reported 65 results, which we synthesised as six key findings. The studies described unique considerations for LGBTQ2S+ individuals' perinatal mental health, including heteronormativity, cisnormativity, isolation, exclusion from traditional pregnancy care, stigma, and distressing situations from the gendered nature of pregnancy. Many participants described a lack of knowledge from healthcare providers related to care for LGBTQ2S+ individuals. In addition, LGBTQ2S+ individuals described barriers to accessing mental healthcare and gaps in health systems. Strategies to improve care include provider education, avoidance of gendered language, documentation of correct pronouns, trauma-informed practices, cultural humility training and tailored care for LGBTQ2S+ people.

CONCLUSIONS

Pregnancy, postpartum, and the perinatal period uniquely impacts the mental health and wellbeing of LGBTQ2S+individuals, largely due to systems-level inequities and exclusion from perinatal care. Healthcare providers should implement the identified strategies to improve perinatal care and address inequities.

Transmasculine Persons' Experiences of Encounters with Health Care Professionals Within Reproductive, Perinatal, and Sexual Health in Sweden: A Qualitative Interview Study

Purpose: Transmasculine persons may experience stigma, which increases the risk of psychological distress. They may need reproductive, perinatal, and sexual health care; however, qualitative studies addressing transgender individuals' experiences are scarce. This study aimed at interpreting and describing the experiences of transmasculine persons in encounters with health care professionals (HCPs) within reproductive, perinatal, and sexual health care.

Methods: Nine qualitative semi-structured online interviews were conducted via email with transmasculine persons, and data were analyzed by using Braun and Clarke's thematic analysis.

Results: Two themes were identified. The first theme is normalization and confirmation of the gender identity. This theme comprises the knowledge and experience that these transmasculine persons are facing. The verbal approach from the HCPs was important as well as could be addressed with a non-binary approach. The second theme is Respect in an especially exposed situation. This theme shows the great importance of being involved in the care and at the same time being met with openness and empathy. There must be good prospects of being able to preserve dignity.

Conclusion: Transmasculine persons are in an exposed position in reproductive, perinatal, and sexual health care. The encounters in health care could be negatively affected if HCPs show inadequate knowledge or express gender stereotypical attitudes. A good encounter is characterized by respect, preserved integrity, involvement in the care, and an open attitude toward gender variations.

Initial Clinical Needs Among Transgender and Non-binary Individuals in a Large, Urban Gender Health Program

BACKGROUND

Transgender and gender-diverse individuals are particularly vulnerable to healthcare discrimination and related health sequelae.

OBJECTIVE

To demonstrate diversity in demographics and explore variance in needs at the time of intake among patients seeking care at a large, urban gender health program.

DESIGN

We present summary statistics of patient demographics, medical histories, and gender-affirming care needs stratified by gender identity and sexual orientation.

PARTICIPANTS

We reviewed all intake interviews with individuals seeking care in our gender health program from 2017 to 2020.

MAIN MEASURES

Clients reported all the types of care in which they were interested at the time of intake as their "reason for call" (i.e., establish primary care, hormone management, surgical services, fertility services, behavioral health, or other health concerns).

KEY RESULTS

Of 836 patients analyzed, 350 identified as trans women, 263 as trans men, and 223 as non-binary. The most prevalent sexual identity was straight among trans women (34%) and trans men (38%), whereas most (69%) non-binary individuals identified as pansexual or queer; only 3% of non-binary individuals identified as straight. Over half of patients reported primary care, hormone management, or surgical services as the primary reason for contacting our program. Straight, transgender women were more likely to report surgical services as their primary reason for contacting our program, whereas gay transgender men were more likely to report primary care as their reason.

CONCLUSIONS

Individuals contacting our gender health program to establish care were diverse in sexual orientation and gender-affirming care needs. Care needs varied with both gender identity and sexual orientation, but primary care, hormone management, and surgical services were high priorities across groups. Providers of gender-affirming care should inquire about sexual orientation and detailed treatment priorities, as trans and gender-diverse populations are not uniform in their treatment needs or goals.

Trans*Forming Access and Care in Rural Areas: A Community-Engaged Approach

Research indicates that rural transgender and gender diverse (TGD) populations have a greater need for health services when compared with their urban counterparts, face unique barriers to accessing services, and have health disparities that are less researched than urban TGD populations. Therefore, the primary aim of this mixed-methods study (n = 24) was to increase research on the health care needs of TGD people in a rural Appalachian American context. This study was guided by a community-engaged model utilizing a community advisory board of TGD people and supportive parents of TGD children. Quantitative results indicate that travel burden is high, affirming provider availability is low, and the impacts on the health and mental health of TGD people in this sample are notable. Qualitative results provide recommendations for providers and health care systems to better serve this population. Integrated mixed-methods results further illustrate ways that rural TGD people and families adapt to the services available to them, sometimes at significant economic and emotional costs. This study contributes to the small but growing body of literature on the unique needs of rural TGD populations, including both adults and minors with supportive parents, by offering insights into strategies to address known disparities.

Evolving Primary Care Utilization of Transgender and Gender-Nonconforming People at a Community Sexual Health Clinic

Purpose

Prior research has found that transgender people are less likely to have access to health care and health insurance than their cisgender peers and are more likely to delay seeking care due to systemic discrimination and stigma. To this end, this study seeks to measure transgender and gender-nonconforming (TGNC) clients' primary care utilization and compare them to their cisgender peers.

Methods

Demographic data and self-reported primary care utilization from 14,372 clients attending a community health center in Los Angeles, CA, from 2018 to 2020 were examined. Descriptive statistics and multivariable regression analyses were used to examine correlates of gender identity on primary care utilization metrics-Hepatitis A, Hepatitis B, and Human Papillomavirus (HPV) vaccinations and recent primary care visits.

Results

Of TGNC clients, 38.0% reported being vaccinated for Hepatitis A compared to 49.2% of cisgender clients (p<0.01) and 42.6% reported being vaccinated for Hepatitis B compared to 51.6% of cisgender clients (p<0.01). TGNC clients had higher odds of engaging with the HPV vaccination series than their cisgender peers (adjusted odds ratio [aOR]=1.28, 95% confidence interval [CI] 1.03-1.59). TGNC clients had higher odds of seeing their primary care provider within the preceding 2 years (aOR=1.72, 95% CI 1.01-2.93) compared to non-TGNC clients.

Conclusions

This study's results found that TGNC clients were more likely to access certain primary care services more often than their cisgender counterparts. Our results support the efficacy of such interventions, such as a health care setting designed to support the health of gender minority people, and see similar, if not greater, primary care engagement in transgender persons compared to their cisgender peers.

USPSTF Approach to Addressing Sex and Gender When Making Recommendations for Clinical Preventive Services

Clinical preventive service recommendations from the US Preventive Services Task Force (USPSTF) are based on transparent, systematic, and rigorous methods that consider the certainty of the evidence and magnitude of net benefit. These guidelines aim to address the needs of diverse populations. Biological sex and gender identity are sources of diversity that are not often considered in studies of clinical preventive services that inform the recommendations, resulting in challenges when evaluating the evidence and communicating recommendations for persons in specific gender identification categories (man/woman/gender nonbinary/gender nonconforming/transgender). To advance its methods, the USPSTF reviewed its past recommendations that included the use of sex and gender terms, reviewed the approaches of other guideline-making bodies, and pilot tested strategies to address sex and gender diversity. Based on the findings, the USPSTF intends to use an inclusive approach to identify issues related to sex and gender at the start of the guideline development process; assess the applicability, variability, and quality of evidence as a function of sex and gender; ensure clarity in the use of language regarding sex and gender; and identify evidence gaps related to sex and gender. Evidence reviews will identify the limitations of applying findings to diverse groups from underlying studies that used unclear terminology regarding sex and gender. The USPSTF will use gender-neutral language when appropriate to communicate that recommendations are inclusive of people of any gender and will clearly state when recommendations apply to individuals with specific anatomy associated with biological sex (male/female) or to specific categories of gender identity. The USPSTF recognizes limited evidence to inform the preventive care of populations based on gender identity.

Trans intracommunity support & knowledge sharing in the United States & Canada: A scoping literature review

Intracommunity support and knowledge sharing is used in transgender ("trans") communities as they navigate systems of oppression. Even for individuals with access to accepting families and service providers, connecting with other trans individuals can provide useful insight and resources. Conducted between December 2018 and April 2019, this scoping literature review examines the extent, range and nature of research activity regarding intracommunity knowledge and support sharing within trans communities. Drawing from Weeks' framework regarding sexual communities and the concepts of positive in-group identity and group-level coping, this review specifically addresses the guiding questions of what, how and why knowledge and support are shared within trans communities. Empirical studies conducted between 2004 and 2019 in the United States and Canada that were published in English and had a discernible trans sample or subsample were included. Thirty-one studies met the criteria. Key themes from this literature are (a) sharing information related to advocacy & education, identity/expression and personal stories/experience while (b) utilising an array of both online and/or in-person methods in order to (c) build community/support and navigate identity development and transition. Implications from the review, including impacts on both clients and students in social work and care programs, are discussed.

Acceptability and satisfaction towards self-collection for chlamydia and gonorrhoea testing among transgender women in Tangerine Clinic, Thailand: shifting towards the new normal

Introduction

Provider‐collected swabs are an unappealing procedure for many transgender women and may have led to suboptimal rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) testing. Self‐collection for CT/NG testing is recommended for men who have sex with men. However, the information on acceptability and clinical performance to support a recommendation for transgender women is lacking. We aimed to determine the acceptability and satisfaction towards self‐collection for CT/NG testing among Thai transgender women.

Methods

Thai transgender women who attended Tangerine Clinic (a transgender‐led, integrated, gender‐affirming care and sexual health services clinic in Bangkok, Thailand) between May and July 2020 and had condomless sexual intercourse within the past six months were offered to collect urine and perform self‐swabs of pharyngeal, rectal, and if applicable, neovaginal compartments for pooled nucleic acid amplification testing for CT/NG infections. Participants received a diagram, video and oral instructions about how to perform self‐collection procedure. Those who accepted self‐collection were also offered to receive provider collection to evaluate the performance between the two methods. Self‐administered questionnaires were used to assess satisfaction.

Results

Among 216 transgender women enrolled, 142 (65.7%) accepted self‐collection. All who accepted had pharyngeal, rectal and urine samples collected. Of 31 transgender women who had undergone genital surgery, 28 (90.3%) accepted neovaginal self‐swab. The acceptance rate increased from 46.2% in May to 84.5% in July 2020. One participant had an invalid result. All transgender women who accepted self‐collection could perform it without assistance, and 82.8% were highly satisfied with the method. None reported dissatisfaction. Due to the COVID‐19 pandemic, provider collection services were discontinued early, and only eight transgender women were able to perform both methods for performance evaluation. The performance agreement was 100%.

Conclusions

Thai transgender women had high acceptability and satisfaction towards self‐collection for CT/NG testing. The performance was promising compared to provider collection. Our results support the implementation of self‐collection to the sexually transmitted infection services, particularly during the COVID‐19 pandemic where physical distancing is the new normal. A larger study is warranted to determine the performance of self‐collection for CT/NG testing in each anatomical compartment and confirm the performance between self‐collection and provider collection.

Experienced barriers of care within European treatment seeking transgender individuals: A multicenter ENIGI follow-up study

Objectives: To evaluate the experienced barriers of care for treatment-seeking trans individuals (TSTG) in three large European clinics. Methods: An online follow-up questionnaire was filled out by 307 TSTG individuals as part of the research protocol of the European Network for the Investigation of Gender Incongruence (ENIGI). Data was collected during follow-up in 2017/2018, around 5 years after participants had their initial clinical appointments in Ghent (Belgium), Amsterdam (the Netherlands), or Hamburg (Germany). Background characteristics, country, treatment characteristics and mental health were analyzed in relation to experienced barriers of care (EBOC, measured though agreement with statements). Results: The majority of participants reported various EBOC, oftentimes more than one. The most-frequently reported EBOCs pertained to the lack of family and friends' support (28.7%, n = 88) and travel time and costs (27.7%, n = 85), whereas around one-fifth felt hindered by treatment protocols. Also, a significant share expressed the feeling that they had to convince their provider they needed care and/or express their wish in such way to increase their likelihood of receiving care. A higher number of EBOCs reported was associated with more mental health problems, lower income and female gender. Conclusions: A substantial number of TSTG individuals within three European health care systems experiences EBOCs. EBOCs relate to both personal and systemic characteristics. These findings can help health care providers and centers to improve care. More research must be done to better understand the diversity among TSTG individuals and the corresponding barriers experienced. Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1964409.

Transition Coverage and Clarity in Self-Insured Corporate Health Insurance Benefit Plans

Purpose: While many health insurance plans now cover at least some gender-affirming care for transgender persons, no study to date has examined contract language about gender-affirming care in self-insured corporate plans. We sought to evaluate private company offerings from the perspective of an employee, analyzing clarity as well as what gender-affirming care is covered or excluded. Methods: We coded 435 health insurance contracts from 40 U.S. self-insured corporations from 2019 for inclusion of 52 coverage aspects from the World Professional Association for Transgender Health (WPATH) recommendations. We categorize contracts by clarity of the document and its inclusions and exclusions, and compare each company's contract ratings to their 2019 Human Rights Campaign (HRC) Workplace Equality Index rating. Results: Findings reveal higher levels of total exclusions in contracts (9% here vs. 3% found in prior studies of more highly regulated plans), as well as extensive variation in clarity, coverage specifications, and types of exclusions. Facial confirmation surgery procedures are commonly excluded even in plans that affirm the WPATH guidelines. Twenty-five percent of the companies in the study offered at least one contract with a categorical exclusion. HRC ratings did not match up to our ratings of gender-affirming coverage. Conclusion: Legal complexity has resulted in a patchwork of continued health insurance exclusions of gender-affirming care even as coverage has expanded. Lack of transparency and clarity also contributes to challenges in understanding one's own coverage as well as mapping the national picture of transgender inclusion in health care plans.

A Latent Class Analysis of Chronic Health Conditions Among HIV-Positive Transgender Women of Color

Research on the health of transgender people has focused on the risk for and health consequences of HIV and other sexually transmitted infections with little known about the prevalence of a broader range of medical conditions experienced by transgender people. This study used latent class (LC) analysis to examine a range of chronic medical conditions among 223 HIV-positive transgender women of color receiving primary care and psychosocial services in Chicago. The best-fitting model had 2 classes: low and moderate/high multimorbidity with 26% of participants classified in the moderate/high multimorbidity LC. Age group (i.e., under 35 vs 35 and older; AOR 13.8, p < 0.001), ever having AIDS (AOR 4.0, p < 0.05) and psychological distress (AOR 5.1, p < 0.05) were associated with increased probability of moderate/high multimorbidity class membership. The results suggest focusing on HIV-related care or hormonal treatment and potential cardiovascular issues could result in sub-optimal treatment for a population dis-engaged from primary care but which has a broad spectrum of largely untreated medical conditions.

Human Papillomavirus Vaccination Among Transgender and Gender Diverse People in the United States: An Integrative Review

Objective

This integrative review explores the barriers to and facilitators for human papillomavirus (HPV) vaccination among adult transgender and gender diverse (TGD) people in the United States.

Data Source

A systematic search of electronic databases included PubMed/MEDLINE, CINAHL, and EMBASE from 1985 to 2020.

Inclusion and Exclusion Criteria

Inclusion criteria included studies from the United States that described HPV vaccination barriers or facilitators and included adult TGD participants, both quantitative and qualitative studies. Exclusion criteria were studies that reported only HPV vaccine prevalence, non-English/non-U.S. studies, and studies limited to pediatric populations.

Data Extraction

Two investigators used Covidence software to screen studies and manage data extraction. Quality of the quantitative studies was appraised using a checklist proposed by the Joanna Briggs Institute (JBI); qualitative studies were appraised using quality criteria informed by the literature.

Data Synthesis

The Social Ecological Model guided the review to organize barriers to and facilitators for HPV vaccination at the patient-, provider-, and system-levels.

Results

Database searches and hand-searching yielded 843 citations. After screening, eight articles were retained in the review. Seven were cross-sectional studies and one was a qualitative focus-group. All retained quantitative studies met six of the eight JBI quality checklist items.

Conclusion

The low proportion of TGD participants in the retained studies highlights a gap in knowledge about HPV vaccination among this population. Future studies of HPV vaccination should recruit TGD people to better represent their perspectives.

Developing a Culturally and Linguistically Targeted Breast Cancer Educational Program for a Multicultural Population

Breast cancer is the most commonly diagnosed cancer among women in the USA. Despite the availability of screening mammograms, significant disparities still exist in breast cancer outcomes of racial/ethnic and sexual/gender minorities. To address these disparities, the Mount Sinai Mobile Breast Health Program in New York City collaborated with local organizations to develop culturally and linguistically appropriate breast cancer education programs aimed at increasing screening mammogram utilization. Literature review of the barriers to mammography screening formed the basis to allow us to draft a narrative presentation for each targeted cultural group: African American, African-born, Chinese, Latina, and Muslim women, as well as LGBTQ individuals. The presentations were then tested with focus groups comprised of gatekeepers and members from local community and faith-based organizations which served the targeted populations. Feedback from focus groups and gatekeepers was incorporated into the presentations, and if necessary, the presentations were translated. Subsequently, the presentations were re-tested for appropriateness and reviewed for consistency in message, design, educational information, and slide sequencing. Our experience demonstrated the importance of collaborating with community organizations to provide educational content that is culturally and linguistically appropriate for minority groups facing barriers to uptake of screening mammography.

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.

Providing Care for Transgender Persons With Kidney Disease: A Narrative Review

Purpose of review

Nephrologists are increasingly providing care to transgender individuals with chronic kidney disease (CKD). However, they may lack familiarity with this patient population that faces unique challenges. The purpose of this review is to discuss the care of transgender persons and what nephrologists should be aware of when providing care to their transgender patients.

Sources of information

Original research articles were identified from MEDLINE and Google Scholar using the search terms "transgender," "gender," "sex," "chronic kidney disease," "end stage kidney disease," "dialysis," "transplant," and "nephrology."

Methods

A focused review and critical appraisal of existing literature regarding the provision of care to transgender men and women with CKD including dialysis and transplant to identify specific issues related to gender-affirming therapy and chronic disease management in transgender persons.

Key findings

Transgender persons are at an increased risk of adverse outcomes compared with the cisgender population including mental health, cardiovascular disease, malignancy, sexually transmitted infections, and mortality. Individuals with CKD have a degree of hypogonadotropic hypogonadism and decreased levels of endogenous sex hormones; therefore, transgender persons with CKD may require reduced exogenous sex hormone dosing. Exogenous estradiol therapy increases the risk of venous thromboembolism and cardiovascular disease which may be further increased in CKD. Exogenous testosterone therapy increases the risk of polycythemia which should be closely monitored. The impact of gender-affirming hormone therapy on glomerular filtration rate (GFR) trajectory in CKD is unclear. Gender-affirming hormone therapy with testosterone, estradiol, and anti-androgen therapies changes body composition and lean body mass which influences creatinine generation and the performance for estimated glomerular filtration rate (eGFR) equations in transgender persons. Confirmation of eGFR with measured GFR is reasonable if an accurate knowledge of GFR is needed for clinical decision-making.

Limitations

There are limited studies regarding the intersection of transgender persons and kidney disease and those that exist are mostly case reports. Randomized controlled trials and observational studies in nephrology do not routinely differentiate between cisgender and transgender participants.

Implications

This review highlights important considerations for providing care to transgender persons with kidney disease. Additional research is needed to evaluate the performance of eGFR equations in transgender persons, the effects of gender-affirming hormone therapy, and the impact of being transgender on outcomes in persons with kidney disease.

A Qualitative Scoping Review of Transgender and Gender Non-conforming People's Physical Healthcare Experiences and Needs

Trans and gender non-conforming (TGNC) people experience poor health care and health outcomes. We conducted a qualitative scoping review of studies addressing TGNC people's experiences receiving physical health care to inform research and practice solutions. A systematic search resulted in 35 qualitative studies for analysis. Studies included 1,607 TGNC participants, ages 16–64 years. Analytic methods included mostly interviews and focus groups; the most common analysis strategy was theme analysis. Key themes in findings were patient challenges, needs, and strengths. Challenges dominated findings and could be summarized by lack of provider knowledge and sensitivity and financial and insurance barriers, which hurt TGNC people's health. Future qualitative research should explore the experiences of diverse and specific groups of TGNC people (youth, non-binary, racial/ethnic minority), include community-based methods, and theory development. Practice-wise, training for providers and skills and support for TGNC people to advocate to improve their health, are required.

Providing Care for Transgender Persons With Kidney Disease: A Narrative Review

Purpose of review:

Nephrologists are increasingly providing care to transgender individuals with chronic kidney disease (CKD). However, they may lack familiarity with this patient population that faces unique challenges. The purpose of this review is to discuss the care of transgender persons and what nephrologists should be aware of when providing care to their transgender patients.

Sources of information:

Original research articles were identified from MEDLINE and Google Scholar using the search terms “transgender,” “gender,” “sex,” “chronic kidney disease,” “end stage kidney disease,” “dialysis,” “transplant,” and “nephrology.”

Methods:

A focused review and critical appraisal of existing literature regarding the provision of care to transgender men and women with CKD including dialysis and transplant to identify specific issues related to gender-affirming therapy and chronic disease management in transgender persons.

Key findings:

Transgender persons are at an increased risk of adverse outcomes compared with the cisgender population including mental health, cardiovascular disease, malignancy, sexually transmitted infections, and mortality. Individuals with CKD have a degree of hypogonadotropic hypogonadism and decreased levels of endogenous sex hormones; therefore, transgender persons with CKD may require reduced exogenous sex hormone dosing. Exogenous estradiol therapy increases the risk of venous thromboembolism and cardiovascular disease which may be further increased in CKD. Exogenous testosterone therapy increases the risk of polycythemia which should be closely monitored. The impact of gender-affirming hormone therapy on glomerular filtration rate (GFR) trajectory in CKD is unclear. Gender-affirming hormone therapy with testosterone, estradiol, and anti-androgen therapies changes body composition and lean body mass which influences creatinine generation and the performance for estimated glomerular filtration rate (eGFR) equations in transgender persons. Confirmation of eGFR with measured GFR is reasonable if an accurate knowledge of GFR is needed for clinical decision-making.

Limitations:

There are limited studies regarding the intersection of transgender persons and kidney disease and those that exist are mostly case reports. Randomized controlled trials and observational studies in nephrology do not routinely differentiate between cisgender and transgender participants.

Implications:

This review highlights important considerations for providing care to transgender persons with kidney disease. Additional research is needed to evaluate the performance of eGFR equations in transgender persons, the effects of gender-affirming hormone therapy, and the impact of being transgender on outcomes in persons with kidney disease.

Barriers to Accessing Health Care in Rural Regions by Transgender, Non-Binary, and Gender Diverse People: A Case-Based Scoping Review

Research shows an overrepresentation of trans people in vulnerable socioeconomic situations, primarily due to experiences of discrimination. At the same time, rural or suburban living areas often lack specialized trans-related health care, which a majority of trans people rely on to some extent. Taken together, the lack of both socioeconomic resources and access to trans-related health care can exacerbate health-related distress and impairment for trans people. We illustrate this problem using case vignettes of trans people from rural and suburban areas in (Northern) Germany. They are currently participating in an e-health intervention and randomized controlled trial (RCT) called i²TransHealth, whose case vignettes provided the impetus for the scoping review. The scoping review analyzes the impact of place of residence and its intersection with barriers to accessing trans-related health care. PubMed and Web of Science Data bases were searched for relevant studies using a search strategy related to trans people and remote, rural, or suburban residences. 33 studies were selected after full-text screening and supplemented via reference list checks and study team expertise by 12 articles addressing the living conditions of remotely living trans people and describing requirements for trans-related health care. The literature on trans people living remotely reveals intersections of trans mental health with age, race, gender expression, geographic location, community size, socioeconomic status, discrimination experiences, and attitudes towards health care providers. Several structural health care barriers are identified. The role of health care professionals (HCPs) for remotely living trans people is discussed. There is no need assuming that rural life for trans people is inevitably worse for health and well-being than urban life. Nevertheless, some clear barriers and health disparities exist for trans people in remote settings. Empowering trans groups and diversity-sensitive education of remote communities in private and institutional settings are needed for respectful inclusion of trans people. Facilitating access to trans-related health care, such as through video-based e-health programs with HCPs, can improve both the health and socioeconomic situation of trans people.

Transgender women of color in the U.S. South: A qualitative study of social determinants of health and healthcare perspectives

Background: Research has shown that transgender and nonbinary people experience health disparities. However, few studies have explored, in-depth, the health-related experiences, perceptions, needs, and priorities of transgender women of color living in the U.S. South, a region that poses unique challenges to achieving health for transgender people. Aims: This study explored the social determinants of health, healthcare experiences, and health-related priorities of transgender women of color living in the U.S. South. Methods: Using a community-based participatory research approach, we conducted iterative in-depth interviews with 15 African American/Black and Latinx transgender women in North Carolina in May-July 2019 for a total of 30 interviews. We analyzed interview data using constant comparison, an approach to grounded theory. Results: Participants' mean age was 34 (range 19-56) years. Twenty themes emerged that were categorized into three domains: (1) social determinants of health (family rejection; bullying, discrimination, and violence; isolation; policy barriers; mistrust in systems; employment obstacles; sex work; high cost of care; transportation barriers; church antagonism; and substance misuse), (2) healthcare experiences (emotional burden of healthcare interactions; name and gender misidentification; staff discomfort and insensitivity; sexual risk assumptions; and use of nonmedical or predatory providers), and (3) health-related priorities (understanding healthcare; respect at all levels of healthcare; inclusive gender-affirming care; and comprehensive resources). Discussion: Transgender women of color living in the U.S. South face profound health barriers compounded throughout the life course and have unmet healthcare needs. Participants faced multilayered minority stressors: racial discrimination from society at large and within the LGTBQ community; gender identity discrimination within their regional context and racial/ethnic communities; and exclusion from existing health equity movements for transgender women of color, which often are found in and focus on larger urban communities. Health interventions mindful of this intersection are needed, including antidiscrimination policies and increasing gender-affirming healthcare access.

The expectations of transgender people in the face of their health-care access difficulties and how they can be overcome. A qualitative study in France

AIM

Our objective was to explore the difficulties experienced by transgender people in accessing primary health-care services and their expectations towards primary care providers to improve their health-care access.

BACKGROUND

Because transgender people are exposed to many discriminations, their health-care access is particularly poor. Guidelines recommend greater involvement of primary care providers in the processes because of the accessibility feature of primary care services.

METHODS

A qualitative study using semi-directed interviews was conducted among 27 transgender people (February 2018 - August 2018). These voluntary participants were recruited through different means: local trans or LGBTI (lesbian, gay, bisexual, trans, and/or intersex) associations, primary care providers, and social networks. The data analysis was based on reflexive thematic analysis in an inductive approach.

FINDINGS

Difficulties in accessing health-care occurred at all the levels of the primary health-care system: primary care providers - transgender people interaction, access to the primary care team facility (starting with the secretariat), access to secondary care specialists, and continuity of care. Transgender people report ill-adapted health-care services as a result of gender-based identification in health-care settings. Their main expectation was depsychiatrization and self-determination. They supported mixed health network comprising primary care providers and transgender people with a coordinating role for the general practitioner. These expectations should be priorities to consider in our primary health-care system to improve access to health-care for transgender people.

Transgender and Gender Nonconforming Patient Experience in the Inland Empire, California

Analyzing secondary data from a 2015 survey of 90 transgender and gender nonconforming individuals in California's Inland Empire, this study reports frequencies of physical and mental health and health care access and discrimination outcomes and differences by age, race/ethnicity, and sex assigned at birth. Nearly three-quarters of respondents reported positive physical health, yet only about half reported positive mental health-an outcome poorer for respondents <50 years. Lesser than 50% found it very easy to find providers for routine care and only 16% found it very easy to find a transgender-competent provider, underscoring the need for more health professional training.

Homeless experiences and support needs of transgender people: A systematic review of the international evidence

AIM

To examine the experiences and support needs of homeless transgender people by synthesizing the existing evidence.

BACKGROUND

Transgender people face many challenges in society in terms of people's knowledge, understanding and acceptance of a person's gender identity. Evidence regarding the homelessness experiences and available supports to transgender people remains sparse.

METHODS

A systematic review was undertaken and included qualitative and quantitative studies. A total of twelve papers were included in the review, utilizing the PRISMA method. Methodological quality was evaluated using the Mixed Methods Assessment Tool (MMAT).

RESULTS

Following analysis, the themes that emerged were (a) pathways into homelessness, (b) experiences whilst homeless and (c) routes out of homelessness.

CONCLUSION

It has become increasingly clear that the distinct needs of this group are complex and multifaceted. In order to adequately address the issues and concerns comprehensively, coordinated and effective collaborations need to be in place.

IMPLICATIONS FOR NURSING MANAGEMENT

Clinical nurses need to recognize and respond to the distinct needs of trans homeless people. Nurse managers need to provide leadership to promote the needs of homeless trans people and ensure that policies and procedures are in place that are responsive to issues and concerns.

Transgender women's satisfaction with healthcare services: A mixed-methods pilot study

BACKGROUND

Many transgender women are dissatisfied with healthcare services PURPOSE: (a) To describe satisfaction/dissatisfaction with healthcare services; and (b) to describe barriers/facilitators of satisfaction with healthcare services among a sample of transgender women.

DESIGN AND METHODS

A mixed methods design collected quantitative data (n = 50) and qualitative data (n = 25) from transgender women.

FINDINGS

Quantitatively, satisfaction with healthcare services was high among the participants, with lower areas related to healthcare systems issues. Qualitatively, participants identified barriers and facilitators of healthcare satisfaction.

IMPLICATIONS

This study provides clinical, research, educational, and policy implications for improving healthcare satisfaction among transgender women.