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Kiely E, Millet N, Baron A, Kreukels BPC, Doyle DM. Unequal geographies of gender-affirming care: A comparative typology of trans-specific healthcare systems across Europe. Soc Sci Med 2024; 356:117145. [PMID: 39067377 DOI: 10.1016/j.socscimed.2024.117145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 06/09/2024] [Accepted: 06/15/2024] [Indexed: 07/30/2024]
Abstract
RATIONALE Gender-affirming healthcare can carry significant benefits for trans people. However, there are substantial geographical inequalities in the provision of and access to trans-specific healthcare across Europe. Comparative healthcare systems research has typically focused on universal services, neglecting provision which serves specific groups within populations (e.g., trans people). OBJECTIVE This study aimed to develop a comparative typology of trans-specific healthcare systems across 28 European countries (the EU 27 plus the UK), and to examine country-level correlates which may influence or be influenced by these systems. METHODS Using hierarchical and k-means cluster analysis, countries were classified into four types based on measures of trans-specific healthcare provision, regulation and access. Possible country-level correlates (including socio-political climate, medical outcomes, and the general healthcare system) were investigated. RESULTS AND DISCUSSION The cluster analysis identified four clusters of trans-specific healthcare systems in Europe, characterized as: 1) Centralized conservative (highly centralized, extensive range of treatments, few trans-specific government policies); 2) Centralized reformist (highly centralized, extensive range of treatments, multiple trans-specific government policies); 3) Decentralized marketized (highly decentralized, moderate range of treatments, few trans-specific government policies); 4) Underdeveloped (highly decentralized, limited range of treatments, few or no trans-specific government policies). We found statistically significant differences between the clusters in rates of: public support for trans people; gender identity concealment; treatment access; overall health expenditure; gender inequality. CONCLUSIONS The study develops a novel typology of trans-specific healthcare systems in Europe. It also identifies a range of potential drivers and outcomes of geographical divergences and inequalities in trans-specific healthcare provision. Building on this typology, future comparative research should aim to link the structure of healthcare systems to outcomes for trans people. Comparative healthcare systems research must account for the distinctive forms taken by services and systems that provide healthcare to specific groups within populations.
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Affiliation(s)
- Ed Kiely
- Department of Medical Psychology, Amsterdam UMC, the Netherlands; Department of Geography, University of Cambridge, United Kingdom
| | - Nessa Millet
- Department of Medical Psychology, Amsterdam UMC, the Netherlands
| | - Asher Baron
- Department of Sociology, Columbia University, New York, NY, 10027, USA
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2
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Strand N, Gomez DA, Kacel EL, Morrison EJ, St Amand CM, Vencill JA, Pagan-Rosado R, Lorenzo A, Gonzalez C, Mariano ER, Reece-Nguyen T, Narouze S, Mahdi L, Chadwick AL, Kraus M, Bechtle A, Kling JM. Concepts and Approaches in the Management of Transgender and Gender-Diverse Patients. Mayo Clin Proc 2024; 99:1114-1126. [PMID: 38960496 DOI: 10.1016/j.mayocp.2023.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/10/2023] [Accepted: 12/28/2023] [Indexed: 07/05/2024]
Abstract
The terms transgender and gender diverse (TGD) describe persons whose gender is different from the sex assigned to them at birth. While TGD persons have experienced a rise in cultural and social visibility in recent decades, they continue to experience significant health inequities, including adverse health outcomes and multiple barriers to accessing medical care. Transgender and gender-diverse persons are at a higher risk for pain conditions than their cisgender counterparts, but research on chronic pain management for TGD persons is lacking. Clinicians from all disciplines must be informed of best practices for managing chronic pain in the TGD population. This includes all aspects of care including history, physical examination, diagnosis, treatment, and perioperative management. Many TGD persons report delaying or avoiding care because of negative interactions with medical practitioners who do not have sufficient training in navigating the specific health care needs of TGD patients. Furthermore, TGD persons who do seek care are often forced to educate their practitioners on their specific health care needs. This paper provides an overview of existing knowledge and recommendations for physicians to provide culturally and medically appropriate care for TGD persons.
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Affiliation(s)
- Natalie Strand
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA
| | - Diego Alan Gomez
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Elizabeth L Kacel
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Eleshia J Morrison
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Colt M St Amand
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA; Department of Psychology, University of Houston, TX, USA, and the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer A Vencill
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA; Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert Pagan-Rosado
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Andrea Lorenzo
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Cesar Gonzalez
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA, and Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Travis Reece-Nguyen
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Stanford Children's Hospital, Palo Alto, CA, USA
| | - Samer Narouze
- Center for Pain Relief, Summa Western Reserve Hospital, Cuyahoga Falls, OH, USA
| | - Layth Mahdi
- Department of Emergency Medicine, NYP Brooklyn Methodist, Brooklyn, New York
| | - Andrea L Chadwick
- Department of Anesthesiology, Pain, and Perioperative Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Molly Kraus
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA
| | - Alexandra Bechtle
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Juliana M Kling
- Division of Women's Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
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Eustaquio PC, Olansky E, Lee K, Marcus R, Cha S. The Association Between Sexual Violence and Suicidal Ideation Among Transgender Women and the Role of Gender-Affirming Healthcare Providers in Seven Urban Areas in the United States, 2019 to 2020. JOURNAL OF INTERPERSONAL VIOLENCE 2024:8862605241257592. [PMID: 38842225 DOI: 10.1177/08862605241257592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Transgender women are disproportionately affected by sexual violence and corresponding mental health sequelae; however, many do not access healthcare due to experiences with transphobia. This analysis evaluated the association between sexual violence and suicidal ideation and the moderating effect of having a healthcare provider (HCP) with whom transgender women were comfortable discussing gender-related issues ("gender-affirming HCP"). We analyzed cross-sectional data from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance among Transgender Women (NHBS-Trans). Transgender women were recruited using respondent-driven sampling from seven urban areas from 2019 to 2020 and participated in an HIV biobehavioral survey. This analysis was restricted to transgender women who visited a HCP in the past 12 months ("healthcare-seeking transgender women" [HSTW]) (N = 1,489). Log-linked Poisson regression models provided adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to estimate the association between sexual violence and suicidal ideation in the past 12 months. The interaction between sexual violence and having a gender-affirming HCP was statistically significant (p-value = .034). Among 1,489 HSTW, 225 (15.1%) experienced sexual violence and 261 (17.5%) reported suicidal ideation; 1,203 (80.8%) reported having a gender-affirming HCP. Sexual violence was associated with suicidal ideation (aPR = 2.65, 95% CI [2.08, 3.38]); the association was notably higher among those who did not have a gender-affirming HCP (aPR = 3.61, [2.17, 6.02]) than among those who did (aPR = 1.87, [1.48, 2.37]). Eliminating transphobia and promoting trauma- and violence-informed approaches in healthcare are necessary for sexual violence and suicide prevention among HSTW.
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Affiliation(s)
- Patrick C Eustaquio
- Centers for Disease Control and Prevention, Atlanta, GA, USA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Evelyn Olansky
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kathryn Lee
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ruthanne Marcus
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Susan Cha
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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Kelly PJ, Myers-Matthews P, Collins AB, Wolfe HL, Miller-Jacobs C, Davis M, Adrian H, Briody V, Fernández Y, Operario D, Hughto JM. A qualitative study of reasons to use substances and substance use treatment experiences among transgender and gender diverse adults in Rhode Island. SSM. QUALITATIVE RESEARCH IN HEALTH 2024; 5:100399. [PMID: 38854803 PMCID: PMC11157666 DOI: 10.1016/j.ssmqr.2024.100399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Affiliation(s)
- Patrick J.A. Kelly
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
- Center for Promotion and Health Equity, Brown University School of Public Health, Box G-121-8, Providence, RI, 02912, USA
| | | | - Alexandra B. Collins
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
| | - Hill L. Wolfe
- Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
| | - Cameron Miller-Jacobs
- Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
| | - Madison Davis
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
| | - Haley Adrian
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
| | - Victoria Briody
- Warren Alpert School of Medicine, Brown University, 222 Richmond Street, Providence, RI, 02903, USA
| | - Yohansa Fernández
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
- Warren Alpert School of Medicine, Brown University, 222 Richmond Street, Providence, RI, 02903, USA
| | - Don Operario
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30329, USA
| | - Jaclyn M.W. Hughto
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
- Center for Promotion and Health Equity, Brown University School of Public Health, Box G-121-8, Providence, RI, 02912, USA
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
- The Fenway Institute, Fenway Health, 1340 Boylston Street, Boston, MA, 02215, USA
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Beccia AL, Agénor M, Baek J, Ding EY, Lapane KL, Austin SB. Methods for structural sexism and population health research: Introducing a novel analytic framework to capture life-course and intersectional effects. Soc Sci Med 2024; 351 Suppl 1:116804. [PMID: 38825380 DOI: 10.1016/j.socscimed.2024.116804] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 01/19/2024] [Accepted: 03/19/2024] [Indexed: 06/04/2024]
Abstract
Accumulating evidence links structural sexism to gendered health inequities, yet methodological challenges have precluded comprehensive examinations into life-course and/or intersectional effects. To help address this gap, we introduce an analytic framework that uses sequential conditional mean models (SCMMs) to jointly account for longitudinal exposure trajectories and moderation by multiple dimensions of social identity/position, which we then apply to study how early life-course exposure to U.S. state-level structural sexism shapes mental health outcomes within and between gender groups. Data came from the Growing Up Today Study, a cohort of 16,875 children aged 9-14 years in 1996 who we followed through 2016. Using a composite index of relevant public policies and societal conditions (e.g., abortion bans, wage gaps), we assigned each U.S. state a year-specific structural sexism score and calculated participants' cumulative exposure by averaging the scores associated with states they had lived in during the study period, weighted according to duration of time spent in each. We then fit a series of SCMMs to estimate overall and group-specific associations between cumulative exposure from baseline through a given study wave and subsequent depressive symptomology; we also fit models using simplified (i.e., non-cumulative) exposure variables for comparison purposes. Analyses revealed that cumulative exposure to structural sexism: (1) was associated with significantly increased odds of experiencing depressive symptoms by the subsequent wave; (2) disproportionately impacted multiply marginalized groups (e.g., sexual minority girls/women); and (3) was more strongly associated with depressive symptomology compared to static or point-in-time exposure operationalizations (e.g., exposure in a single year). Substantively, these findings suggest that long-term exposure to structural sexism may contribute to the inequitable social patterning of mental distress among young people living in the U.S. More broadly, the proposed analytic framework represents a promising approach to examining the complex links between structural sexism and health across the life course and for diverse social groups.
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Affiliation(s)
- Ariel L Beccia
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, 333 Longwood Avenue, Boston, MA, 02115, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, 02115, USA.
| | - Madina Agénor
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, 02903, USA.
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 55 Lake Ave North, Worcester, MA, 01655, USA.
| | - Eric Y Ding
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, 02903, USA.
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 55 Lake Ave North, Worcester, MA, 01655, USA.
| | - S Bryn Austin
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, 333 Longwood Avenue, Boston, MA, 02115, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, 02115, USA; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA.
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6
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McBrinn S, Antoni C, Al Yaghchi C. Current approaches to gender-affirming vocal care. Curr Opin Otolaryngol Head Neck Surg 2024; 32:143-150. [PMID: 38393690 DOI: 10.1097/moo.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
PURPOSE OF REVIEW This review addresses the challenges faced by transgender women in achieving congruence between gender identity and voice characteristics and emphasizes the importance of a multidisciplinary approach involving therapeutic and surgical interventions. RECENT FINDINGS Recent literature on gender-affirming vocal care emphasizes key themes such as assessment, voice feminization therapy, and various surgical techniques, including glottoplasty and its modifications. Recent publications focused on outcomes, duration, and impact on vocal quality and scrutinized complications associated with surgical interventions. SUMMARY Most publications in the last 18 months advocate for the integration of voice therapy and surgery for optimal outcomes. Utilising a combined approach is significantly more effective in terms of fundamental frequency gain compared to therapy alone. Modified Wendler's glottoplasty remains the preferred and most reliable surgical intervention. However, surgery is not without its complications and vocal trade-offs, in particular, its impact on vocal projection and the risk of long-term dysphonia. Postsurgery rehabilitation improves long-term outcomes. Recent publications on alternative surgical approaches, namely laser reduction glottoplasty and feminization laryngoplasty, show promise but the results are more difficult to generalise. FUTURE DIRECTION Prospective multicentre studies with standardized protocols are needed to establish best evidence-based practices.
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Affiliation(s)
- Sarah McBrinn
- National Centre for Airway Reconstruction, Imperial College Healthcare NHS Trust
| | | | - Chadwan Al Yaghchi
- National Centre for Airway Reconstruction, Imperial College Healthcare NHS Trust
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7
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Chen WJ, Radix AE. Primary Care and Health Care of Transgender and Gender-Diverse Older Adults. Clin Geriatr Med 2024; 40:273-283. [PMID: 38521598 DOI: 10.1016/j.cger.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
Clinicians working with older transgender and gender-diverse (TGD) individuals need to acquire the necessary knowledge and skills to provide care that is high quality and culturally appropriate. This includes supporting patients in their exploration of gender and attainment of gender-affirming medical interventions. Clinicians should strive to create environments that are inclusive and safe, and that will facilitate health care access and build constructive provider-patient relationships. Clinicians should be aware of best practices, including that age-appropriate health screenings should be anatomy based, and ensure that TGD older adults on gender-affirming hormone therapy (GAHT) receive ongoing laboratory monitoring and physical assessments, including serum hormone levels and biomarkers. Older TGD adults underutilize advance care planning, and need individualized assessments that consider their unique family structures, social support, and financial situation. End-of-life care services should ensure that TGD individuals are treated with dignity and respect.
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Affiliation(s)
- Wendy J Chen
- Department of Medicine, Loyola University Medicine Center, Chicago, IL, USA; Internal Medicine, ACP AGS WPATH USPATH.
| | - Asa E Radix
- Department of Medicine, Callen-Lorde Community Health Center, 356 West 18th Street, New York, NY 10011, USA; Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY 10032, USA
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8
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Trinh MH, Quint M, Coon D, Bhasin S, Tocci B, Reisner SL. Transgender Patients Report Lower Satisfaction with Care Received than Cisgender Patients Receiving Care in an Academic Medical Care System. LGBT Health 2024; 11:202-209. [PMID: 38100315 DOI: 10.1089/lgbt.2023.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023] Open
Abstract
Purpose: Transgender and gender diverse (TGD) patients experience challenges in health care settings, including stigma, lack of culturally competent providers, and suboptimal gender-affirming care. However, differences in patient satisfaction between TGD patients compared with cisgender patients have been inadequately studied. This study aimed to assess such differences in patient satisfaction with care received in a large academic medical care system in Boston, Massachusetts. Methods: Routine patient satisfaction surveys were fielded from January to December 2021 and were summarized. Logistic regression models compared low net promoter scores (NPS; ≤6) between gender identity groups (cisgender women, transmasculine and nonbinary/genderqueer people assigned female at birth [AFAB], transfeminine and nonbinary/genderqueer people assigned male at birth) relative to cisgender men, adjusting for age, race, ethnicity, education, inpatient/outpatient service delivery, and distance from medical center. Results: Of 94,810 patients, 246 (0.3%) were TGD and 94,549 (99.7%) were cisgender. The mean age was 58.3 years (standard deviation = 16.6). Of the total sample, 17.0% of patients were people of color, 6.6% were Hispanic/Latinx, 48.6% were college graduates, and 2.6% had received inpatient care. In general, patient satisfaction with health care received was lower for TGD patients than for cisgender patients (7.3% vs. 4.5% reporting low NPS; adjusted odds ratio [aOR] = 1.14; 95% confidence interval [CI] = 0.70-1.85). Transmasculine and nonbinary/genderqueer patients AFAB had elevated odds of low NPS compared with cisgender men (8.8% vs. 3.6%; aOR = 1.71; 95% CI = 1.02-2.89). Conclusion: Future research is warranted to better understand factors driving lower ratings among TGD patients. Health care quality improvement efforts are needed to address gender identity inequities in care.
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Affiliation(s)
- Mai-Han Trinh
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Meg Quint
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Devin Coon
- Center for Transgender Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Shalender Bhasin
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Transgender Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Benjamin Tocci
- Office of Patient Experience, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sari L Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Transgender Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, and Brigham and Women's Hospital, Boston, Massachusetts, USA
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9
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August-Rae BC, Baker JT, Buzzanell PM. "Not just rebellious, it's revolutionary": Do-it-yourself hormone replacement therapy as Liberatory Harm Reduction. Soc Sci Med 2024; 345:116681. [PMID: 38418336 DOI: 10.1016/j.socscimed.2024.116681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/19/2024] [Accepted: 02/08/2024] [Indexed: 03/01/2024]
Abstract
For some transgender people, hormone replacement therapy (HRT) is "an ontological necessity for a livable life" (Fondén, 2020, p. 29). Some trans people engage in do-it-yourself (DIY) HRT (aka "DIYers") because of care barriers, including medication costs, difficulty accessing healthcare providers, and mistrust in professionalized medical systems. Although DIY HRT is often framed as highly risky, we analyzed in-depth interviews with 36 U.S. DIYers to understand how they themselves perceived their goals, challenges, and risk mitigation using the Liberatory Harm Reduction and lay expertise frameworks. Participants emphasized experiences of transphobia within medical spaces. In contrast, participants characterized DIY HRT as a community-driven, accessible, and empowering practice. Through self-organized online forums and mutual aid, DIYers constructed adaptive health-promoting practices that challenge biomedical conceptualizations of risk and affirm trans agency.
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Affiliation(s)
- Brianna C August-Rae
- Department of Communication, University of South Florida, 4202 E Fowler Ave CIS 3068, Tampa, FL, 33620, United States; Department of Communication Studies & Storytelling, East Tennessee State University, 1276 Gilbreath Dr., Johnson City, TN, 37614, United States.
| | - Jonathan T Baker
- Department of Communication, University of South Florida, 4202 E Fowler Ave CIS 3068, Tampa, FL, 33620, United States; School of Communication Studies, Ohio University, Schoonover Center 1 Ohio University, Athens, OH, 45701, United States.
| | - Patrice M Buzzanell
- Department of Communication, University of South Florida, 4202 E Fowler Ave CIS 3068, Tampa, FL, 33620, United States.
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DuBois LZ, Puckett JA, Jolly D, Powers S, Walker T, Hope DA, Mocarski R, Huit TZ, Lash BR, Holt N, Ralston A, Miles M, Capannola A, Tipton C, Eick G, Juster RP. Gender minority stress and diurnal cortisol profiles among transgender and gender diverse people in the United States. Horm Behav 2024; 159:105473. [PMID: 38190769 DOI: 10.1016/j.yhbeh.2023.105473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024]
Abstract
The field of behavioral neuroendocrinology has only begun to explore the lived experiences of transgender and gender diverse (TGD) people exposed to stigma. In light of escalating attacks and legislation targeting TGD people in the United States, it is crucial to examine the physiological pathways through which gender minority stressors become embodied, impact health, and contribute to health inequities. The Trans Resilience and Health Study included baseline data collection from fall 2019 to spring 2020 from a sample of 124 TGD people, reflecting a diversity of gender identities (e.g., trans masculine, trans feminine, and nonbinary) and ages (range = 19-70 years old; M = 34.10), living in Michigan, Nebraska, Oregon, and Tennessee. These analyses examine experiences of gender-related enacted stigma in association with hypothalamic-pituitary-adrenal (HPA)-axis functioning. Among those experiencing the highest levels of enacted stigma, findings show a blunted cortisol awakening response and sluggish daily decline that resulted in elevated concentrations at bedtime compared to those experiencing less enacted stigma. These results of flattened diurnal activity are consistent with an emergent literature on discrimination as a social determinant of potential stress pathophysiology. In contrast, community connectedness was associated with a larger, more dynamic cortisol awakening response. These findings emphasize the importance of incorporating gender-minority stress and resilience measures when studying HPA-axis functioning among TGD people.
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Affiliation(s)
- L Zachary DuBois
- Department of Anthropology, 1218 University of Oregon, Eugene, OR 97403, United States.
| | - Jae A Puckett
- Department of Psychology, Michigan State University, 316 Physics Road, East Lansing, MI 48824, United States.
| | - Dee Jolly
- Department of Anthropology, 1218 University of Oregon, Eugene, OR 97403, United States.
| | - Sally Powers
- Department of Psychological and Brain Sciences, University of Massachusetts at Amherst, 135 Hicks Way, Amherst, MA 01003, United States.
| | - Tian Walker
- Department of Anthropology, 1218 University of Oregon, Eugene, OR 97403, United States.
| | - Debra A Hope
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnette Hall, Lincoln, NE 68588, United States; Office of Graduate Studies, University of Nebraska-Lincoln, Lincoln, NE 68588, United States.
| | - Richard Mocarski
- Office of Research, San José State University, One Washington Square, San José, CA, United States.
| | - T Zachary Huit
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnette Hall, Lincoln, NE 68588, United States
| | - Brenna R Lash
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnette Hall, Lincoln, NE 68588, United States
| | - Natalie Holt
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnette Hall, Lincoln, NE 68588, United States
| | - Allura Ralston
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnette Hall, Lincoln, NE 68588, United States
| | - Makinna Miles
- College of Public Health and Human Sciences, Oregon State University, 160 SW 26th St, Corvallis, OR 97331, United States
| | - A Capannola
- Department of Child & Family Studies, The University of Tennessee at Knoxville, 1215 W. Cumberland Ave., Knoxville, TN 37996, United States.
| | - Clove Tipton
- Department of Sociology, The University of Tennessee at Knoxville, 901 McClung Tower, Knoxville, TN 37996, United States.
| | - Geeta Eick
- Department of Anthropology, 1218 University of Oregon, Eugene, OR 97403, United States
| | - Robert-Paul Juster
- Department of Psychiatry and Addiction, University of Montreal, Research Center of the Montreal Mental Health University Institute, 7331 Hochelaga, FS-145-12, Montreal, Quebec H1N 3V2, Canada.
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11
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Watson DL, Listerud L, Drab RA, Lin WY, Momplaisir FM, Bauermeister JA. HIV pre-exposure prophylaxis programme preferences among sexually active HIV-negative transgender and gender diverse adults in the United States: a conjoint analysis. J Int AIDS Soc 2024; 27:e26211. [PMID: 38332521 PMCID: PMC10853582 DOI: 10.1002/jia2.26211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/16/2024] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION Current implementation efforts have failed to achieve equitable HIV pre-exposure prophylaxis (PrEP) provision for transgender and gender-diverse (trans) populations. We conducted a choice-based conjoint analysis to measure preferences for key attributes of hypothetical PrEP delivery programmes among a diverse online sample predominantly comprised of transmasculine and nonbinary individuals in the United States. METHODS Between April 2022 and June 2022, a national online survey with an embedded conjoint analysis experiment was conducted among 304 trans individuals aged ≥18 years in the United States to assess five PrEP programme attributes: out-of-pocket cost; dispensing venue; frequency of visits for PrEP-related care; travel time to PrEP provider; and ability to bundle PrEP-related care with gender-affirming hormone therapy services. Participants responded to five questions, each of which presented two PrEP programme scenarios and one opt-out option per question and selected their preferred programme in each question. We used hierarchical Bayes estimation and multinomial logistic regression to measure part-worth utility scores for the total sample and by respondents' PrEP status. RESULTS The median age was 24 years (range 18-56); 75% were assigned female sex at birth; 54% identified as transmasculine; 32% as nonbinary; 14% as transfeminine. Out-of-pocket cost had the highest attribute importance score (44.3%), followed by the ability to bundle with gender-affirming hormone therapy services (18.7%). Minimal cost-sharing ($0 out-of-pocket cost) most positively influenced the attribute importance of cost (average conjoint part-worth utility coefficient of 2.5 [95% CI 2.4-2.6]). PrEP-experienced respondents preferred PrEP delivery in primary care settings (relative utility score 4.7); however, PrEP-naïve respondents preferred pharmacies (relative utility score 5.1). CONCLUSIONS Participants preferred programmes that offered PrEP services without cost-sharing and bundled with gender-affirming hormone therapy services. Bolstering federal regulations to cover PrEP services and prioritizing programmes to expand low-barrier PrEP provision are critical to achieving equitable PrEP provision. Community-engaged implementation research conducted by and in close collaboration with trans community stakeholders and researchers are needed to streamline the design of patient-centred PrEP programmes and develop implementation strategies that are salient to the diverse sexual health needs of trans patients.
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Affiliation(s)
- Dovie L. Watson
- Department of Medicine (Infectious Diseases)University of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Louis Listerud
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ryan A. Drab
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Willey Y. Lin
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Florence Marie Momplaisir
- Department of Medicine (Infectious Diseases)University of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - José A. Bauermeister
- Department of Family and Community HealthUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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12
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Restar AJ, Layland EK, Davis B, Thompson H, Streed C. The Public Health Crisis State of Transgender Health Care and Policy. Am J Public Health 2024; 114:161-163. [PMID: 38335490 PMCID: PMC10862226 DOI: 10.2105/ajph.2023.307523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 02/12/2024]
Affiliation(s)
- Arjee Javellana Restar
- Arjee Javellana Restar is with the departments of Epidemiology and Health Systems and Population Health, School of Public Health, University of Washington, Seattle, as well as the Department of Social and Behavioral Sciences, Yale University, New Haven, CT. Eric K. Layland is with the Department of Human Development and Family Sciences, University of Delaware, Newark. Bee Davis is with the Digital Forensics, Brown University, Providence, RI. Hale Thompson is with Howard Brown Health, Chicago, IL. Carl Streed Jr is with the Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, and the GenderCare Center, Boston Medical Center, Boston, MA
| | - Eric K Layland
- Arjee Javellana Restar is with the departments of Epidemiology and Health Systems and Population Health, School of Public Health, University of Washington, Seattle, as well as the Department of Social and Behavioral Sciences, Yale University, New Haven, CT. Eric K. Layland is with the Department of Human Development and Family Sciences, University of Delaware, Newark. Bee Davis is with the Digital Forensics, Brown University, Providence, RI. Hale Thompson is with Howard Brown Health, Chicago, IL. Carl Streed Jr is with the Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, and the GenderCare Center, Boston Medical Center, Boston, MA
| | - Bee Davis
- Arjee Javellana Restar is with the departments of Epidemiology and Health Systems and Population Health, School of Public Health, University of Washington, Seattle, as well as the Department of Social and Behavioral Sciences, Yale University, New Haven, CT. Eric K. Layland is with the Department of Human Development and Family Sciences, University of Delaware, Newark. Bee Davis is with the Digital Forensics, Brown University, Providence, RI. Hale Thompson is with Howard Brown Health, Chicago, IL. Carl Streed Jr is with the Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, and the GenderCare Center, Boston Medical Center, Boston, MA
| | - Hale Thompson
- Arjee Javellana Restar is with the departments of Epidemiology and Health Systems and Population Health, School of Public Health, University of Washington, Seattle, as well as the Department of Social and Behavioral Sciences, Yale University, New Haven, CT. Eric K. Layland is with the Department of Human Development and Family Sciences, University of Delaware, Newark. Bee Davis is with the Digital Forensics, Brown University, Providence, RI. Hale Thompson is with Howard Brown Health, Chicago, IL. Carl Streed Jr is with the Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, and the GenderCare Center, Boston Medical Center, Boston, MA
| | - Carl Streed
- Arjee Javellana Restar is with the departments of Epidemiology and Health Systems and Population Health, School of Public Health, University of Washington, Seattle, as well as the Department of Social and Behavioral Sciences, Yale University, New Haven, CT. Eric K. Layland is with the Department of Human Development and Family Sciences, University of Delaware, Newark. Bee Davis is with the Digital Forensics, Brown University, Providence, RI. Hale Thompson is with Howard Brown Health, Chicago, IL. Carl Streed Jr is with the Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, and the GenderCare Center, Boston Medical Center, Boston, MA
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13
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Casas-Ramírez M, Martínez-Linares JM, Cortés-Martín JJ, López-Entrambasaguas OM. Trans people perceptions of care received from healthcare professionals - A phenomenological study. Heliyon 2024; 10:e23328. [PMID: 38163130 PMCID: PMC10755318 DOI: 10.1016/j.heliyon.2023.e23328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/20/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Trans people have unique health needs and turn to the public health system to meet them. Offering them a more inclusive assistance requires health professionals to know these needs and work on cultural competence. Understanding trans people perceptions of service received will improve therapeutic relationships and the assistance provided to them. Objective To understand trans patients experiences with health care and their perception of care rendered by the Andalusian Public Health System. Design A qualitative phenomenological study according to Ricoeur's hermeneutic approach. Methodology 18 in-depth interviews were conducted between January and April 2022 with trans adult users of the Andalusian Public Health System. These interviews were audio recorded, transcribed and analyzed following the steps proposed by Tan. The Consolidated Criteria for Reporting Qualitative Research was used for writing the study report. Results Three themes were generated from trans patients experiences in the Andalusian Public Health System related to the assistance provided to them: 1) Positive and negative feelings during their pass through the public health system, 2) The importance of being able to receive the care they need, and 3) Having the chosen identity in official documents in order to utterly complete their transition. Conclusion Care rendered by healthcare professionals to trans people was received as positive in mostly cases. However, trans people think these professionals need more training in order to avoid some behaviors they perceive as discriminatory and which they believe tends to pathologize gender identity. They also require more information about the treatments in particular they are about to receive and they demand to end drug shortages. Administrative procedures to change identity are also problematic. So the healthcare system must undergo some modifications in order to become more inclusive.
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14
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Zubizarreta D, Trinh MH, Reisner SL. Quantitative approaches to measuring structural cisgenderism. Soc Sci Med 2024; 340:116437. [PMID: 38000173 DOI: 10.1016/j.socscimed.2023.116437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023]
Abstract
There is rapidly growing interest in understanding the impacts of structural cisgenderism on health and health inequities for transgender and nonbinary populations. This growing interest has led to an influx of novel measures of structural cisgenderism. In this commentary, we discuss and identify gaps in existing measures and offer considerations for the development of future measures. Developing and utilizing valid measures of structural cisgenderism is crucial to quantify its impacts on health and health inequities, and to inform public health interventions, laws, and policies to eliminate gender identity and modality-based health inequities.
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Affiliation(s)
- Dougie Zubizarreta
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Mai-Han Trinh
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sari L Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA, USA; The Fenway Institute, Fenway Health, Boston, MA, USA
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15
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Kalayjian A, Laszlo K, Fassler M, Schonrock Z, Delarose KE, Ly AM, English CD, Cirrincione LR. Patterns of psychotropic medication prescribing and potential drug-hormone interactions among transgender and gender-diverse adults within 2 years of hormone therapy. J Am Pharm Assoc (2003) 2024; 64:283-289.e2. [PMID: 37839699 PMCID: PMC10873097 DOI: 10.1016/j.japh.2023.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Transgender and gender-diverse (TGD) people have a high prevalence of psychotropic medication use, yet knowledge about the patient-level psychotropic medication burden is limited. TGD patients may take hormone therapy to meet their gender expression goals. Potential drug-hormone interactions exist between psychotropic medications and hormone therapy, requiring increased knowledge about psychotropic medication use for TGD adults undergoing hormone therapy. OBJECTIVES The objective of this study was to examine the extent of psychotropic medication polypharmacy in a cohort of TGD adults within 2 years of starting hormone therapy. We also characterized potential drug-hormone interactions and the association with psychotropic polypharmacy. METHODS Retrospective cross-sectional analysis of patients with ≥1 transgender health-related visit (2007-2017) in the University of Washington Medical System (Seattle, WA). Eligible patients had ≥1 psychotropic medication including antidepressants, antipsychotics, mood stabilizers, and sedative-hypnotics ordered within 2 years of starting hormone therapy (testosterone or estradiol with or without spironolactone, progesterone, finasteride, or dutasteride). We defined psychotropic polypharmacy as ≥2 psychotropic medication orders with overlapping treatment durations for at least 90 days and characterized potential drug-hormone interactions (Lexicomp, Hudson, OH). We descriptively summarized patients with and without polypharmacy (frequencies and percentages) and compared drug-hormone interactions using chi-square or Fishers exact tests (P < 0.05 considered significant). RESULTS A total of 184 patients had ≥1 psychotropic medication order within 2 years of hormone therapy; 68 patients (37.0%) had psychotropic polypharmacy. The most frequent type of psychotropic polypharmacy was antidepressant+sedative-hypnotic (18 of 68, 26.5%). More patients had a potential drug-hormone interaction among those with psychotropic polypharmacy (23 of 68, 33.8%) versus those without (8 of 116, 6.9%, P < 0.001). CONCLUSION Among TGD patients on psychotropic medications within 2 years of hormone therapy, one-third had psychotropic polypharmacy. Most polypharmacy types appeared to align with mental health treatment guidelines. The number of patients with a potential drug-hormone interaction was significantly higher among those with polypharmacy. Prospective studies are needed to characterize drug-hormone interactions.
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Affiliation(s)
- Alin Kalayjian
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Kaeleb Laszlo
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Molly Fassler
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | | | | | - Andrew M. Ly
- School of Pharmacy, University of Washington, Seattle, WA, USA
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16
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Kia H, Kenney KA, Abramovich A, Ferlatte O, MacKinnon KR, Knight R. "Nowhere else to be found": Drawing on peer support experiences among transgender and gender-diverse people to substantiate community-driven gender-affirming care. Soc Sci Med 2023; 339:116406. [PMID: 37979491 DOI: 10.1016/j.socscimed.2023.116406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/19/2023] [Accepted: 11/06/2023] [Indexed: 11/20/2023]
Abstract
Increasingly, applied social scientists and clinicians recognize the value of engaging transgender and gender-diverse (TGD) people, particularly TGD individuals with lived experience as care recipients (peers), to inform the provision of gender-affirming care. Despite this trend, few researchers have systematically examined how this group can contribute to and enhance the development and delivery of interventions intended to affirm gender diversity. In this article, we address limitations in the literature by drawing on a secondary analysis of qualitative data - originally collected to examine the peer support experiences of TGD individuals - to explore the potential that TGD peers hold for elevating gender-affirming care. The study was informed methodologically by an abductive approach to grounded theory, and conceptually by critical resilience and intersectional scholarship. Data collection involved virtual, semi-structured interviews with 35 TGD individuals in two Canadian cities who indicated having experiences of seeking, receiving, and/or providing peer support. Data analysis comprised an iterative, abductive process of cross-referencing participant accounts with relevant scholarship to arrive at an account of how TGD peers may contribute to the growth of gender-affirming care. Our findings suggest, broadly, that TGD peers may enhance gender-affirming care by: (1) validating a growing diversity of embodiments and experiences in healthcare decision-making, (2) nurturing and diversifying relevant networks of safety, community support, and advocacy outside formal systems of care, and (3) strengthening possibilities for resisting and transforming existing healthcare systems. After outlining these findings, we briefly consider the implications of our analysis and leverage our inferences to substantiate the notion of community-driven gender-affirming care, meaning care that is intentional in its incorporation of relevant community stakeholders to shape governance and service provision. We conclude with reflections on the promise of community-driven care at a time of heightened volatility across systems serving TGD populations.
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Affiliation(s)
- Hannah Kia
- School of Social Work, The University of British Columbia, Canada.
| | - K A Kenney
- School of Social Work, The University of British Columbia, Canada
| | - Alex Abramovich
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Canada; Dalla Lana School of Public Health, University of Toronto, Canada
| | | | | | - Rod Knight
- École de Santé Publique, Université de Montréal, Canada
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17
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Linsenmeyer W, Heiden-Rootes K, Drallmeier T, Rahman R, Buxbaum E, Walcott K, Rosen W, Gombos BE. The power to help or harm: student perceptions of transgender health education using a qualitative approach. BMC MEDICAL EDUCATION 2023; 23:836. [PMID: 37936098 PMCID: PMC10629163 DOI: 10.1186/s12909-023-04761-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Lack of transgender health education among health professional education programs is a limitation to providing gender-affirming care. Educational interventions have advanced in the past decade using a variety of pedagogical approaches. Although evidence supports that educational interventions can significantly improve student knowledge, comfort levels, preparedness, and clinical skills, few studies have addressed student perceptions of or receptiveness towards transgender health education. The study purpose was to explore student perceptions of transgender health education using a qualitative approach. METHODS We utilized a basic qualitative design to explore student perceptions of transgender health education at a Catholic, Jesuit institution. Participants were medical students (n = 182), medical family therapy students (n = 8), speech, language and hearing sciences students (n = 44), and dietetic interns (n = 30) who participated in an Interprofessional Transgender Health Education Day (ITHED) in partnership with transgender educators and activists. Participants completed an online discussion assignment using eight discussion prompts specific to the ITHED sessions. Data were analyzed using the constant comparative method and triangulated across four medical and allied health programs. RESULTS A total of 263 participants provided 362 responses across eight discussion prompts. Three major themes resulted: (1) The Power to Help or Harm, (2) The Responsibility to Provide Health Care, and (3) A Posture of Humility: Listen and Learn. Each theme was supported by three to four subthemes. CONCLUSIONS Health professional students were highly receptive towards transgender health education delivered by transgender community members. First-person accounts from session facilitators of both positive and negative experiences in healthcare were particularly effective at illustrating the power of providers to help or harm transgender patients. Reflection and constructive dialogue offers students an opportunity to better understand the lived experiences of transgender patients and explore their identities as healthcare providers at the intersection of their religious and cultural beliefs.
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Affiliation(s)
- Whitney Linsenmeyer
- Department of Nutrition and Dietetics, Saint Louis University, 3437 Caroline Street, Room 3076, St. Louis, MO, 63105, USA.
| | - Katie Heiden-Rootes
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1008 S. Spring Avenue, 3rd Floor, St. Louis, MO, 63110, USA
| | - Theresa Drallmeier
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1008 S. Spring Avenue, 3rd Floor, St. Louis, MO, 63110, USA
| | - Rabia Rahman
- Department of Nutrition and Dietetics, Saint Louis University, 3437 Caroline Street, Room 3076, St. Louis, MO, 63105, USA
| | - Emily Buxbaum
- Department of Speech, Language & Hearing Sciences, Saint Louis University, 3750 Lindell Blvd., Suite 23, St. Louis, MO, 63108, USA
| | - Katherine Walcott
- Department of Nutrition and Dietetics, Saint Louis University, 3437 Caroline Street, Room 3076, St. Louis, MO, 63105, USA
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18
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Marzinke MA, Hanscom B, Wang Z, Safren SA, Psaros C, Donnell D, Richardson PA, Sullivan P, Eshleman SH, Jennings A, Feliciano KG, Jalil E, Coutinho C, Cardozo N, Maia B, Khan T, Singh Y, Middelkoop K, Franks J, Valencia J, Sanchez N, Lucas J, Rooney JF, Rinehart AR, Ford S, Adeyeye A, Cohen MS, McCauley M, Landovitz RJ, Grinsztejn B. Efficacy, safety, tolerability, and pharmacokinetics of long-acting injectable cabotegravir for HIV pre-exposure prophylaxis in transgender women: a secondary analysis of the HPTN 083 trial. Lancet HIV 2023; 10:e703-e712. [PMID: 37783219 PMCID: PMC10842527 DOI: 10.1016/s2352-3018(23)00200-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND The HIV Prevention Trials Network (HPTN) 083 trial showed that long-acting injectable cabotegravir was more effective than tenofovir disoproxil fumarate plus emtricitabine in preventing HIV in cisgender men and transgender women who have sex with men. We aimed to characterise the cohort of transgender women included in HPTN 083. METHODS HPTN 083 is an ongoing, phase 2b/3, randomised, multicentre, double-blind, double-dummy clinical trial done at 43 sites in seven countries (Argentina, Brazil, Peru, the USA, South Africa, Thailand, and Viet Nam). HIV-negative participants were randomly assigned (1:1) to receive injectable cabotegravir or tenofovir disoproxil fumarate plus emtricitabine. The study design and primary outcomes of the blinded phase of HPTN 083 have already been reported. An enrolment minimum of 10% transgender women was set for the trial. Here we characterise the cohort of transgender women enrolled from Dec 6, 2016, to May 14, 2020, when the study was unblinded. We report sociodemographic characteristics, use of gender affirming hormone therapy, and behavioural assessments of the transgender women participants. Laboratory testing and safety evaluations are also reported. The trial is registered at ClinicalTrials.gov, NCT02720094. FINDINGS HPTN 083 enrolled 570 transgender women (304 tenofovir disoproxil fumarate plus emtricitabine; 266 injectable cabotegravir). Transgender women were primarily from Asia (225 [39%]) and Latin America (205 [36%]); 330 (58%) reported using gender affirming hormone therapy. Intimate partner violence was common (270 [47%] reported emotional abuse and 172 [30%] reported physical abuse) and 323 (57%) reported a history of childhood sexual abuse. 159 (28%) transgender women disagreed that they were at risk for HIV, and 142 (25%) screened positive for depressive symptoms. During study follow-up, incidence of syphilis was 16·25% (95% CI 13·28-19·69), rectal gonorrhoea was 11·66% (9·14-14·66), and chlamydia was 20·61% (17·20-24·49). Frequency of adverse events was similar between the treatment groups. Nine seroconversions occurred among transgender women during the blinded phase of the study (seven in the tenofovir disoproxil fumarate plus emtricitabine group and two in the injectable cabotegravir group); overall incidence was 1·19 per 100 person-years (95% CI 0·54-2·25): 1·80 per 100 person-years (0·73-3·72) in the tenofovir disoproxil fumarate plus emtricitabine group and 0·54 per 100 person-years (0·07-1·95) in the injectable cabotegravir group (hazard ratio 0·34 [95% CI 0·08-1·56]). Cabotegravir concentrations did not differ by gender affirming hormone therapy use. INTERPRETATION HIV prevention strategies for transgender women cannot be addressed separately from social and structural vulnerabilities. Transgender women were well represented in HPTN 083 and should continue to be prioritised in HIV prevention studies. Our results suggest that injectable cabotegravir is a safe and effective pre-exposure prophylaxis option for transgender women. FUNDING National Institute of Allergy and Infectious Diseases and ViiV Healthcare.
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Affiliation(s)
| | | | - Zhe Wang
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | | | | | | | | | | | | | | | - Emilia Jalil
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Manguinhos, Rio de Janeiro, Brazil
| | - Carolina Coutinho
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Manguinhos, Rio de Janeiro, Brazil
| | | | | | | | - Yashna Singh
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Keren Middelkoop
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | | | | | | | | | - Myron S Cohen
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Raphael J Landovitz
- Center for Clinical AIDS Research and Education, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Manguinhos, Rio de Janeiro, Brazil.
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Salway T, Kinitz DJ, Kia H, Ashley F, Giustini D, Tiwana A, Archibald R, Mallakzadeh A, Dromer E, Ferlatte O, Goodyear T, Abramovich A. A systematic review of the prevalence of lifetime experience with 'conversion' practices among sexual and gender minority populations. PLoS One 2023; 18:e0291768. [PMID: 37792717 PMCID: PMC10550144 DOI: 10.1371/journal.pone.0291768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/25/2023] [Indexed: 10/06/2023] Open
Abstract
RATIONALE Conversion practices (CPs) refer to organized attempts to deter people from adopting or expressing non-heterosexual identities or gender identities that differ from their gender/sex assigned at birth. Numerous jurisdictions have contemplated or enacted legislative CP bans in recent years. Syntheses of CP prevalence are needed to inform further public health policy and action. OBJECTIVES To conduct a systematic review describing CP prevalence estimates internationally and exploring heterogeneity across country and socially relevant subgroups. METHODS We performed literature searches in eight databases (Medline, Embase, PsycInfo, Social Work Abstracts, CINAHL, Web of Science, LGBTQ+ Source, and Proquest Dissertations) and included studies from all jurisdictions, globally, conducted after 2000 with a sampling frame of sexual and gender minority (SGM) people, as well as studies of practitioners seeing SGM patients. We used the Hoy et al. risk of bias tool for prevalence studies and summarized distribution of estimates using median and range. RESULTS We identified fourteen articles that reported prevalence estimates among SGM populations, and two articles that reported prevalence estimates from studies of mental health practitioners. Prevalence estimates among SGM samples ranged 2%-34% (median: 8.5). Prevalence estimates were greater in studies conducted in the US (median: 13%), compared to Canada (median: 7%), and greater among transgender (median: 12%), compared to cisgender (median: 4%) subsamples. Prevalence estimates were greatest among people assigned male at birth, whether transgender (median: 10%) or cisgender (median: 8%), as compared to people assigned female at birth (medians: 5% among transgender participants, 3% among cisgender participants). Further differences were observed by race (medians: 8% among Indigenous and other racial minorities, 5% among white groups) but not by sexual orientation. CONCLUSIONS CPs remain prevalent, despite denouncements from professional bodies. Social inequities in CP prevalence signal the need for targeted efforts to protect transgender, Indigenous and racial minority, and assigned-male-at-birth subgroups.
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Affiliation(s)
- Travis Salway
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Centre for Gender and Sexual Health Equity, Vancouver, British Columbia, Canada
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - David J. Kinitz
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Hannah Kia
- School of Social Work, University of British Columbia, Vancouver, British Columbia, Canada
| | - Florence Ashley
- Faculty of Law & Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada
| | - Dean Giustini
- Biomedical Branch Library, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amrit Tiwana
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Reilla Archibald
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Amirali Mallakzadeh
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Elisabeth Dromer
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Olivier Ferlatte
- École de santé publique, Université de Montréal, Montréal, Quebec, Canada
- Centre de Recherche en Santé Publique, Université de Montréal et CIUSSS du Centre-Sud-de-l’Île-de-Montréal, Montréal, Quebec, Canada
| | - Trevor Goodyear
- Centre for Gender and Sexual Health Equity, Vancouver, British Columbia, Canada
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex Abramovich
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Babu TM, Wald A, Restar AJ. Health equity necessitates the inclusion of gender identity data in COVID-19 clinical trials. Ann Epidemiol 2023; 85:3-5. [PMID: 37391114 PMCID: PMC10303319 DOI: 10.1016/j.annepidem.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/14/2023] [Accepted: 06/26/2023] [Indexed: 07/02/2023]
Abstract
COVID-19 has highlighted the importance of studying differences by sex and gender. The under-reporting of gender identity in COVID-19 studies limits the generalizability of study results to nonbinary persons. Some of the data on sex-assigned associated complications of both COVID-19 infection and COVID-19 immunizations is presented in this manuscript.
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Affiliation(s)
- Tara M Babu
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle; Department of Behavioral and Social Sciences, Yale University School of Public Health, New Haven, CT.
| | - Anna Wald
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle; Department of Laboratory Medicine and Pathology, University of Washington, Seattle; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Department of Epidemiology, School of Public Health, University of Washington, Seattle; Department of Behavioral and Social Sciences, Yale University School of Public Health, New Haven, CT
| | - Arjee J Restar
- Department of Epidemiology, School of Public Health, University of Washington, Seattle; Department of Behavioral and Social Sciences, Yale University School of Public Health, New Haven, CT
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21
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Restar AJ. Gender-affirming care is preventative care. LANCET REGIONAL HEALTH. AMERICAS 2023; 24:100544. [PMID: 37383047 PMCID: PMC10290445 DOI: 10.1016/j.lana.2023.100544] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 06/01/2023] [Accepted: 06/13/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Arjee Javellana Restar
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
- Department of Social and Behavioral Sciences, Yale University School of Public Health, New Haven, CT, USA
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22
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Round R, Gokool N, Manica G, Paschall L, Foulcer S. Improving access for and experience of transgender and non-binary patients in clinical research: Insights from a transgender patient focus group and targeted literature reviews. Contemp Clin Trials 2023; 131:107243. [PMID: 37245727 DOI: 10.1016/j.cct.2023.107243] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 05/30/2023]
Abstract
INTRODUCTION The transgender and non-binary communities make up a significant, growing proportion of the population, but, to date, few clinical trials report including transgender and non-binary individuals. METHODS As part of a mixed-method approach, multiple literature searches for articles published from January 2018 to July 2022 and a Patient Advisory Council (a semi-structured patient focus group) meeting were conducted to identify challenges faced by the transgender and non-binary communities when accessing healthcare and participating in clinical research. A set of guidelines to promote inclusivity in clinical research was developed using these findings. RESULTS During this time period, only 107 (0.08%) of 141,661 published articles of clinical trials reported participation of transgender or non-binary patients. A targeted search identified only 48 articles reporting specific barriers to inclusion in clinical research, while an expanded search identified 290 articles reporting barriers to healthcare access for transgender and non-binary patients. Several key considerations to promote study inclusivity emerged from the literature searches and Patient Advisory Council: adjust clinical protocols, informed consent documents, and data collection forms to distinguish sex assigned at birth from gender identity; involve members of the transgender and non-binary communities in research whenever possible; provide communication training to personnel involved in clinical research; and maximize accessibility for potential participants. CONCLUSION Future research on investigational drug dosing and drug interactions in transgender and non-binary patients, along with regulatory guidance, are recommended to ensure clinical trials' processes, designs, systems, and technologies are transgender and non-binary patient-friendly, inclusive, and welcoming.
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23
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Restar A, Minalga BJ, Quilantang MI, Adamson T, Dusic E, van der Merwe LA, Millet G, Rosadiño D, Laguing T, Lett E, Everhart A, Phillips G, Janamnuaysook R, Seekaew P, Baker K, Ashley F, Wickersham J, Wallace SE, Operario D, Gamarel KE. Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations. Curr HIV/AIDS Rep 2023; 20:160-169. [PMID: 37012537 PMCID: PMC10071255 DOI: 10.1007/s11904-023-00656-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2023] [Indexed: 04/05/2023]
Abstract
PURPOSE OF REVIEW Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic. RECENT FINDINGS While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.
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Affiliation(s)
- Arjee Restar
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.
- Department of Social and Behavioral Sciences, Yale University School of Public Health, New Haven, CT, USA.
| | | | - Ma Irene Quilantang
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Tyler Adamson
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emerson Dusic
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA, USA
| | - Leigh-Ann van der Merwe
- Social, Health and Empowerment Feminist Collective of Transgender Women of Africa, East London, South Africa
| | - Greg Millet
- The Foundation for AIDS Research, amfAR, amfAR, Washington, D.C, USA
| | | | - Tanya Laguing
- LoveYourself Inc, Manila, Philippines
- DIOSSA Inc, Taguig, Philippines
| | - Elle Lett
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA, USA
| | - Avery Everhart
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Gregory Phillips
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rena Janamnuaysook
- Institute of HIV Research and Innovation, Bangkok, Thailand
- Tangerine Community Health Clinic, Bangkok, Thailand
| | - Pich Seekaew
- Institute of HIV Research and Innovation, Bangkok, Thailand
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Kellan Baker
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Whitman-Walker Institute, Washington, D.C, USA
| | - Florence Ashley
- Faculty of Law and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Jeffrey Wickersham
- Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephaun E Wallace
- Fred Hutchinson Cancer Center, Seattle, WA, USA
- Global Health, University of Washington, Seattle, WA, USA
| | - Don Operario
- Department of Behavioral, Social, and Health Education Sciences, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Kristi E Gamarel
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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24
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Steinberg H, Garfield T, Becker A, Shea L. What Category Best Fits: Understanding Transgender Identity in a Survey of Autistic Individuals. AUTISM IN ADULTHOOD 2023; 5:204-209. [PMID: 37346989 PMCID: PMC10280170 DOI: 10.1089/aut.2021.0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Introduction Calls for improved measures of gender identity to understand the experience of transgender individuals have grown rapidly in the past 5 years. The need for methodological innovation in this topic area has particular importance for the autistic population since a higher co-occurrence of transgender identities among autistic people has been documented but is not well understood. We use a survey with questions that reflect standards in 2018 to demonstrate how binary conceptualizations of gender did not adequately capture gender identities of transgender autistic individuals. Methods Using descriptive statistics from a statewide survey of 1527 autistic adults (mean age 27.5 years), this study compared self-reported survey responses to close-ended standard questions at the time about gender identity to understand shortcomings in capturing this population authentically. Results We found a mismatch between respondents answering that they were transgender, the sex assigned at birth, and gender identity on separate questions. We postulate that transgender men and women were likely selecting binary responses when asked about gender identity. Furthermore, we found that many qualitative responses reported in the self-selected "other" category reflected nonbinary identities and utilized specific terminology that revealed nuance in how they understood gender identities. Conclusions We urge researchers to provide multiple flexible options when measuring gender identity in autistic populations as they are likely to encompass many identities. We endorse best practices for measuring gender identity for autistic research.
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Affiliation(s)
- Hillary Steinberg
- Policy Analytics Center, AJ Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania, USA
| | - Tamara Garfield
- Policy Analytics Center, AJ Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania, USA
| | - Alec Becker
- Policy Analytics Center, AJ Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania, USA
| | - Lindsay Shea
- Policy Analytics Center, AJ Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania, USA
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25
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Ackley SF, Zimmerman SC, Flatt JD, Riley AR, Sevelius J, Duchowny KA. Discordance in chromosomal and self-reported sex in the UK Biobank: Implications for transgender- and intersex-inclusive data collection. Proc Natl Acad Sci U S A 2023; 120:e2218700120. [PMID: 37094118 PMCID: PMC10161036 DOI: 10.1073/pnas.2218700120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/10/2023] [Indexed: 04/26/2023] Open
Abstract
There is growing need to distinguish between sex and gender. While sex is assigned at birth, gender is socially constructed and may not correspond to one's assigned sex. However, in most research studies, sex or gender is assessed in isolation or the terms are used interchangeably, which has implications for research accuracy and inclusivity. We used data from the UK Biobank to quantify the prevalence of disagreement between chromosomal and self-reported sex and identify potential reasons for discordance. Among approximately 200 individuals with sex discordance, 71% of discordances were potentially explained by the presence of intersex traits or transgender identity. The findings indicate that when describing sex- and/or gender-specific differences in health, researchers may be limited in their ability to draw conclusions regarding specific sex and/or gender health information.
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Affiliation(s)
- Sarah F. Ackley
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA94158
| | - Scott C. Zimmerman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA94158
| | - Jason D. Flatt
- Department of Social and Behavioral Science, School of Public Health, University of Nevada, Las Vegas, NV89119
| | - Alicia R. Riley
- Department of Sociology, University of California, Santa Cruz, CA95064
| | - Jae Sevelius
- Center for AIDS Prevention Studies, University of California, San Francisco, CA94158
- Center of Excellence for Transgender Health, University of California, San Francisco, CA94158
| | - Kate A. Duchowny
- Institute for Social Research, University of Michigan, Ann Arbor, MI48104
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26
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Restar A, Streed CG. Improving the cardiovascular health care of transgender and non-binary persons. Nat Rev Cardiol 2023; 20:367-368. [PMID: 37041344 DOI: 10.1038/s41569-023-00871-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Affiliation(s)
- Arjee Restar
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
- Center for Studies in Demography and Ecology, University of Washington School of Public Health, Seattle, WA, USA
| | - Carl G Streed
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
- GenderCare Center, Boston Medical Center, Boston, MA, USA.
- The Fenway Institute, Fenway Health, Boston, MA, USA.
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Kline NS, Webb NJ, Johnson KC, Yording HD, Griner SB, Brunell DJ. Mapping transgender policies in the US 2017-2021: The role of geography and implications for health equity. Health Place 2023; 80:102985. [PMID: 36804680 DOI: 10.1016/j.healthplace.2023.102985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/18/2023]
Abstract
Transgender individuals globally face varying policy contexts that can influence their health. In the United States (US), a patchwork of exclusionary and inclusive policies exists, creating potentially different social and political contexts that shape transgender health depending on the state. In this article, we consider how recent legislation introduced in US states focused on transgender people may be a political determinant of health and affect health equity goals. To advance this aim, we employed the perspective of legal epidemiology to systematically search a US legal database (Westlaw) for policies focused on transgender individuals proposed between January of 2017 and September of 2021.698 policies were analyzed as affirming or exclusionary of transgender identities and categorized by content. We calculated a ratio of affirming versus exclusionary bills to create "exclusionary density" and "affirming density" measures. Those measures were used to calculate an inclusivity score and corresponding maps of inclusivity and exclusionary contexts by US state. Exclusionary and affirming density measures showed deeply polarized policy responses to transgender individuals depending on US state. Further, we observed differences in magnitude regarding the laws being proposed. Exclusionary laws largely focused on criminalization while inclusionary laws focused on representation in government agencies. These findings highlight that transgender individuals in the US can experience vastly different political contexts depending on where they live.
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Affiliation(s)
- Nolan S Kline
- University of North Texas Health Science Center, School of Public Health, Department of Health Behavior and Health Systems, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA.
| | - Nathaniel J Webb
- University of North Texas Health Science Center, School of Public Health, Department of Health Behavior and Health Systems, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
| | - Kaeli C Johnson
- University of North Texas Health Science Center, School of Public Health, Department of Health Behavior and Health Systems, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
| | - Hayley D Yording
- University of North Texas Health Science Center, Gibson D. Lewis Library, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
| | - Stacey B Griner
- University of North Texas Health Science Center, School of Public Health, Department of Health Behavior and Health Systems, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
| | - David J Brunell
- University of North Texas Health Science Center, School of Public Health, Department of Health Behavior and Health Systems, 3500 Camp Bowie Boulevard, Fort Worth, TX, 76107, USA
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Cirrincione LR, Grieve VLB, Holloway J, Marzinke MA. Inclusion of Transgender and Gender Diverse People in Phase III Trials: Examples from HIV Pharmacologic Prevention Studies. Clin Pharmacol Ther 2023; 113:557-564. [PMID: 36416569 PMCID: PMC9957832 DOI: 10.1002/cpt.2801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022]
Abstract
Although at least 25 million adults are transgender worldwide, few phase III clinical trials have enrolled transgender and gender diverse (TGD) people. HIV is the only therapeutic area to include TGD people intentionally in phase III randomized clinical trials during the development of certain newer HIV pharmacologic prevention interventions. Pharmacologic assessments for HIV prevention efficacy in TGD populations are important, as there may be specific considerations for product use and potential interactions with hormone therapies. Herein, we summarize ongoing and completed phase III HIV trials that included TGD people as part of the study population, we examine investigators' strategies for recruiting and engaging TGD priority populations in these phase III trials, and we comment on the implications of these studies for prioritizing TGD populations in clinical pharmacology research within the phase III clinical trial landscape.
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Affiliation(s)
| | | | - Jay Holloway
- Independent Researcher, Los Angeles, California, USA
| | - Mark A Marzinke
- Department of Medicine, Division of Clinical Pharmacology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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29
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Sirufo MM, Magnanimi LM, Ginaldi L, De Martinis M. Overcoming LGBTQI+ Disparities in Cardio-Oncology. JACC: CARDIOONCOLOGY 2023; 5:267-270. [PMID: 37144105 PMCID: PMC10152199 DOI: 10.1016/j.jaccao.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Affiliation(s)
- Maria Maddalena Sirufo
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
- Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, Teramo, Italy
- Technical Group for the Coordination of Gender Medicine, AUSL 04 Teramo, Teramo, Italy
| | - Lina Maria Magnanimi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
| | - Lia Ginaldi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
- Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, Teramo, Italy
- Technical Group for the Coordination of Gender Medicine, Regione Abruzzo, Italy
| | - Massimo De Martinis
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
- Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, Teramo, Italy
- Technical Group for the Coordination of Gender Medicine, Regione Abruzzo, Italy
- UniCamillus-Saint Camillus International University of Health Sciences, Rome, Italy
- Address for correspondence: Dr Massimo De Martinis, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi n. 1, 67100 L’Aquila, Italy.
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30
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Mental health and substance use risks and resiliencies in a U.S. sample of transgender and gender diverse adults. Soc Psychiatry Psychiatr Epidemiol 2022; 57:2305-2318. [PMID: 36112161 DOI: 10.1007/s00127-022-02359-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 09/02/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Victimization contributes to mental and behavioral health inequities among transgender and gender diverse (TGD) people, but few studies have simultaneously examined health-promoting resiliencies. We sought to identify classes of risk and resilience among TGD adults, assess characteristics associated with these classes, and examine their relationship with mental health and substance use outcomes. METHODS Cross-sectional data were from the 2015 US Transgender Survey, a non-probability study including 26,957 TGD adults. Using latent class analysis, we classified patterns of vulnerability and resilience based on risk (past-year denial of equal treatment, verbal harassment, physical attack, bathroom-related discrimination; lifetime sexual assault, intimate partner violence) and protective (activism; family, work, classmate support) factors. Regression models were fit to (1) determine the association between sociodemographic and gender affirmation characteristics and latent classes; (2) model associations between latent classes and mental health (current serious psychological distress, past-year and lifetime suicidal thoughts and attempts, and lifetime gender identity/transition-related counseling) and substance use (current binge alcohol use, smoking, illicit drug use; past-year drug/alcohol treatment) outcomes. RESULTS Three latent classes were identified: high risks, with activism involvement ("risk-activism," 35%); low risks, with not being out about one's TGD identity ("not-out," 25%); and low risks, with high family support ("family-support," 40%). Gender affirmation and sociodemographic characteristics, such as race/ethnicity and sexual orientation, were associated with latent classes. Risk-activism class membership was associated with higher odds of negative mental health and substance use outcomes, while the family-support class had lower odds of these outcomes. CONCLUSIONS Interventions leveraging family support, and policy protections from discrimination and victimization, may promote TGD mental and behavioral health.
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31
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Tran NK, Baker KE, Lett E, Scheim AI. State-level heterogeneity in associations between structural stigma and individual healthcare access: A multilevel analysis of transgender adults in the United States. J Health Serv Res Policy 2022; 28:109-118. [PMID: 36040166 DOI: 10.1177/13558196221123413] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE State-level variation in how restrictive policies affect health care access for transgender populations has not been widely studied. Therefore, we assessed the association between structural stigma and four measures of individual health care access among transgender people in the United States, and the extent to which structural stigma explains state-level variability. METHODS Data were drawn from the 2015-2019 Behavioral Risk Factor Surveillance System and the Human Rights Campaign's State Equality Index. We calculated weighted proportions and conducted multilevel logistic regression of individual heterogeneity and discriminatory accuracy. RESULTS An increase in the structural stigma score by one standard deviation was associated with lower odds of health care coverage (OR = 0.80; 95% CI: 0.66, 0.96) after adjusting for individual-level confounders. Approximately 11% of the total variance for insurance coverage was attributable to the state level; however, only 18% of state-level variability was explained by structural stigma. Adding Medicaid expansion attenuated the structural stigma-insurance association and explained 22% of state-level variation in health insurance. For the remaining outcomes (usual source of care, routine medical check-up, and cost-related barriers), we found neither meaningful associations nor considerable between-state variability. CONCLUSIONS Our findings support the importance of Medicaid expansion and transgender-inclusive antidiscrimination protections to enhance health care insurance coverage. From a measurement perspective, however, additional research is needed to develop and validate measures of transgender-specific structural stigma to guide future policy interventions.
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Affiliation(s)
- Nguyen K Tran
- Doctoral Fellow, Department of Epidemiology and Biostatistics, 582373Drexel University, USA
| | - Kellan E Baker
- Executive Director, Whitman-Walker Institute, USA.,Associate Faculty Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, USA
| | - Elle Lett
- Senior Fellow, Center for Applied Transgender Studies, USA.,Postdoctoral Fellow, Computational Health Informatics Program, Boston Children's Hospital, USA.,Doctor of Medicine Candidate, Perelman School of Medicine, 6572University of Pennsylvania, USA
| | - Ayden I Scheim
- Assistant Professor, Department of Epidemiology and Biostatistics, 582373Drexel University, USA.,Adjunct Assistant Professor, Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Canada
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32
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Thomeer MB, Patterson B. Using Administrative Data to Assess Transgender Health and Mortality Disparities. Am J Public Health 2022; 112:1365-1367. [PMID: 35981272 DOI: 10.2105/ajph.2022.307046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Mieke Beth Thomeer
- Mieke Beth Thomeer is an Associate Professor of Sociology at the University of Alabama at Birmingham. Brianna Patterson is a Medical Sociology PhD student and the Program Director of the Gender Health Clinic at the University of Alabama at Birmingham
| | - Brianna Patterson
- Mieke Beth Thomeer is an Associate Professor of Sociology at the University of Alabama at Birmingham. Brianna Patterson is a Medical Sociology PhD student and the Program Director of the Gender Health Clinic at the University of Alabama at Birmingham
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