Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study

Gender-Affirming Surgery Improves Mental Health Outcomes and Decreases Antidepressant Use in Patients with Gender Dysphoria

BACKGROUND

Patients with gender dysphoria face significant health disparities and barriers to care. Transition-related care includes hormonal therapy, mental health care, and gender-affirming surgery. Studies have described favorable surgical outcomes and patient satisfaction; however, the degree to which these procedures affect mental health conditions is not fully understood. The purpose of this study was to evaluate the effect of gender-affirming plastic surgery on mental health and substance misuse in the transgender population.

METHODS

A national insurance claims-based database was used for data collection. Patients with a diagnosis of gender dysphoria were propensity score-matched for the likelihood of undergoing gender-affirming surgery (no surgery being the control cohort), based on comorbidities, age, and sex. Primary outcomes included postoperative antidepressant use and the prevalence of mental health conditions.

RESULTS

A total of 3134 patients with gender dysphoria were included in each cohort. Patients in the surgery group had overall lower rates of mental health conditions, substance misuse, and selective serotonin reuptake inhibitor or serotonin and norepinephrine reuptake inhibitor use. There was an absolute decrease of 8.8% in selective serotonin reuptake inhibitor or serotonin and norepinephrine reuptake inhibitor prescription after gender-affirming plastic surgery ( P < 0.001), and significant decreases were found in postoperative depression (7.7%), anxiety (1.6%), suicidal ideation (5.2%) and attempts (2.3%), alcohol misuse (2.1%), and drug misuse (1.9%).

CONCLUSION

Gender-affirming surgery in appropriately selected patients with gender dysphoria is associated with decreased postoperative rates of SSRI or SNRI use and improved mental health.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Transgender lives at the population level: Evidence from Danish administrative data

This paper provides the first rigorous account of the diverse characteristics of transgender individuals at the population level, using data from Danish population registers. We observe three transgender subpopulations within the same national setting: all who changed thier legal sex (T-Legal, n = 1,995), all who have been assigned trans-related diagnostic codes (T-ICD, n = 1,594), and those who self-identified as transgender in a representative survey (T-Survey, n = 197, weighted n = 44,958). Results show significant differences in the subpopulations' backgrounds, family, education and labour market characteristics, and healthcare use. These differences extend beyond comparisons with the general population to great variations between each of the transgender subpopulations. Individuals with legal sex changes, and particularly those with trans-related diagnostic codes, face substantial disadvantages across various outcomes. Compared to the general population and the T-Survey subpopulation, the T-Legal subpopulation and the T-ICD subpopulation have significantly higher numbers of psychiatric hospital visits, lower educational attainment, lower annual earnings, and reduced employment rates, also when controlling for background characteristics. Earnings and employment rates remained significantly lower also when controlling for educational attainment. Our results show that the strategy chosen to identify trans individuals in population data has a great impact on the characteristics observed, and that trans individuals captured by surveys do not necessarily represent all transgender individuals, including those who seek to medically or legally transition. Furthermore, our results indicate that high numbers of trans individuals observed in surveys do not necessarily correspond to high demands for gender-affirming treatments or legal sex change. Finally, we show that transgender individuals who seek gender-affirming healthcare constitute a distinct and significantly disadvantaged group, also compared to other trans subpopulations.

Genital gender-affirming surgery trends in Germany: Total population data with 19,600 cases from 2006 to 2022

PURPOSE

To delineate the current trends regarding gender-affirming surgeries (GAS) in Germany.

METHODS

Analysis of German hospital quality reports from 2006 to 2022 was conducted using the reimbursement.info tool. The German procedure classification (OPS) codes 5-646.0 for masculinizing- and 5-646.1 for feminizing surgery were assessed to identify GAS. Linear regression models were utilized for the analysis and depiction of current trends.

RESULTS

A total of 19,632 gender-affirming procedures were performed during the study period with an exponential increase over the years. Masculinizing surgeries increased from 246 in 2006 to 1291 cases in 2022 (increase by 424%; p < 0.001). The highest annual increase of 37.2% in numbers was from 2018 to 2019 (from 1235 to 1694 cases). Feminizing surgeries increased from 180 cases in 2006 to 799 procedures in 2022 (increase by 343%; p < 0.001). The cases increased most between 2015 and 2016 from 277 to 502 cases (81.2%). The number of hospitals offering these surgeries expanded from 24 in 2006 to 29 in 2022 (21% increase; p < 0.001).

CONCLUSION

This study demonstrates an exponential growth in numbers feminizing and masculinizing of GAS performed each year in Germany. Furthermore, a discernible trend emerges with a propensity for concentration of procedures within selected high-caseload centers across Germany.

Mental Health of Transgender Youth Following Gender Identity Milestones by Level of Family Support

Importance

Transgender youth are at an elevated risk for adverse mental health outcomes compared with their cisgender peers. Identifying opportunities for intervention is a priority.

Objective

To estimate differences in the association between gender identity milestones and mental health outcomes among transgender youth, stratified by level of family support.

Design, Settings, and Participants

This retrospective cohort study compares changes in mental health outcomes among transgender youth who initiate gender identity milestones compared with those who initiate the same milestones 1 year later, stratified by level of family support, using the 2015 US Transgender Survey. The analytic samples included 18 303 transgender adults aged 18 and older who had initiated at least 1 gender identity milestone between ages 4 and 18 years.

Exposure

Four gender identity milestones: feeling one's gender was different, thinking of oneself as transgender, telling another that one is transgender, and living full-time in one's gender identity, stratified by 3 levels of family support: supportive, neutral, and adverse.

Main Outcomes

Age at first suicide attempt and at running away.

Results

Study participants included 18 303 transgender adults (10 288 [56.2%] assigned female at birth; 14 777 [80.7%] White). Initiating a gender identity milestone was associated with a higher risk of suicide attempt and running away from home among transgender youth. This finding was driven by children who live in unsupportive families. For example, thinking of oneself as transgender was associated with a meaningful increase in the overall probability of attempting suicide among those in either adverse families (estimate = 1.75 percentage points; 95% CI, 0.47-3.03) or neutral families (estimate = 1.39 percentage points; 95% CI, 0.72-2.05). Among youth living with supportive families, there were no statistically significant associations between gender identity milestones and adverse mental health outcomes and 95% CIs generally ruled out any meaningful associations.

Conclusion

These results demonstrate that without a supportive family environment, gender identity development increases the risk of transgender youth attempting suicide or running away from home. Social services and community resources to establish supportive relationships between transgender children and their parents are essential.

"I'm not getting paid to give you a TED talk on how my trans body works". Experiences of hysterectomy gender affirming surgery: A qualitative study

OBJECTIVE

To explore the experiences of care surrounding hysterectomy as part of gender affirming surgery.

METHODS

An in-depth reflexive thematic analysis from accounts by 10 out of 12 people was undertaken. Experiences were then mapped to the surgery journey as a template for developing system responsiveness.

RESULTS

No one person's experience of the procedure was affirmed across the entire surgery journey. Transgender health literacy was central to inclusive practice as it mediated bodily autonomy being upheld. The physical care environment influenced the experience, for example, the waiting room was marginalizing (intimidating), with a gendered clinic name and toilets. Some participants took a female support person/partner so that "people looking would assume that I was there supporting her, not the other way around." Communication misalignments were evident around information provided/understood about fertility and ovarian preservation. Participants were also placed in the position of both receiving care and providing education: "I also shouldn't have to be going in there for treatment, and then being expected to educate the medical professional that's meant to be helping me… I'm not getting paid to give you a TED talk on how my trans body works." The experiences mapped across the surgery journey highlighted multiple levels of service provision development needed to foster inclusive practice, for example, from workforce education to healthcare policy.

CONCLUSION

Healthcare for transgender people can be unsafe and inequitable. Increasing transgender health responsiveness across the surgery journey will facilitate better alignments in communication and uphold bodily autonomy, leading to safer and inclusive practice.

Gender-affirming care through the lens of abnormal illness behaviour and abnormal treatment behaviour

OBJECTIVE

To describe the increasing number and changing demographics of patients presenting with gender dysphoria and provide an account of patient- and clinician-related factors which may have contributed to these changes. The concept of abnormal illness behaviours introduced by Pilowsky, and its extension to the concept of abnormal treatment behaviours by Singh, provides a framework for understanding healthy and pathological interactions between gender dysphoria patients and their doctors.

CONCLUSIONS

Abnormal illness behaviours driven by the reinforcing contingencies of gender-affirming care may explain, in part, the increasing number and changing demographics of gender dysphoria, as well as the increasing incidence of desistance and detransition. The under-diagnosis and under-treatment of mental health disorders by clinicians treating these patients are examples of abnormal treatment behaviours. Uncritical affirmation of patient reported gender identity appears likely to conceal unconscious motivations of some patients and clinicians, increasing the risks of harm to both.

Waiting for transgender care and its effects on health and equality: a mixed-methods population study in the Netherlands

Background

Access to gender-affirming medical care has life-saving effects on transgender and gender diverse (TGD) individuals. An increasing number of TGD individuals seek care which led to waiting times of years. We assessed the duration and effects of excessive waiting for gender-affirming care.

Methods

In this mixed-methods cross-sectional population study, conducted in the Netherlands between June and August 2019, all TGD individuals with experiences with receiving/applying for gender-affirming medical care could participate. Data of participants waiting for care was primarily analyzed. Demographic characteristics and requested care (multiple-choice questions) and the effects of waiting on health were surveyed (open-ended questions). Descriptive statistics were calculated per treatment, and differences in participant characteristics between those waiting for and already in care were assessed through Chi squared tests and post-hoc testing of residuals. Open text answers were thematically analyzed.

Findings

Of all 975 participants, 431 (44.2%) waited for gender-affirming medical care. For 10 out of 20 treatment modalities, the median waiting period was more than a year. Participants already in care were on average higher educated and less-frequently non-binary. Subjective effects of waiting were (very) negative for most treatments. Qualitative findings showed that long waiting was associated with a range of psychosocial distress, poorer health, increasing healthcare consumption, and increased inequality between TGD individuals.

Interpretation

Findings confirm that TGD individuals encounter long waiting times in multiple stages of their gender-affirming medical care. Waiting affects both physical and psychosocial health. Individual resilience and resources can mitigate these experiences, which increase inequality within this already marginalized group.

Funding

Ministry of Health, Welfare and Sport of the Netherlands and Zorgverzekeraars Nederland (Healthcare Insurers Netherlands).

Referrals For Gender-Affirming Hormone Treatment in Croatia's National Network for Transgender Healthcare

A network of healthcare professionals specializing in transgender care was established in Croatia in 2011, and legal advancements were subsequently made in 2014. Both achievements made gender transition more transparent and thus more attainable in Croatia. This observational study was conducted to assess the number of transgender individuals initiating gender-affirming hormone treatment (GAHT) in Croatia and describes trends in age and sex assigned at birth. Between 2011 and 2022, a total of 111 transgender individuals initiated GAHT. Within the cohort, 52 were assigned male at birth (AMAB) and 59 were assigned female at birth (AFAB). The overall annual incidence rate of transgender individuals initiating GAHT was 0.52 per 100,000 age-adjusted individuals. There was a statistically significant increase (p < 0.01) in transgender individuals commencing GAHT before the COVID-19 pandemic. Furthermore, a rising trend toward masculinizing rather than feminizing treatment was identified (p < 0.05), particularly among younger transgender individuals. The COVID-19 pandemic disrupted these trends in 2020, except for the trend of initiating therapy at a younger age (p < 0.01). The annual incidence and age distribution trends of transgender individuals initiating GAHT in Croatia closely mirrored those in other European countries, with a higher prevalence of individuals assigned female at birth. The study underscores a significant rise in the number of individuals initiating gender-affirming hormone treatment, emphasizing the need for proper legal regulation and healthcare system response.

Detransition Narratives Trouble the Simple Attribution of Madness in Transantagonistic Contexts: A Qualitative Analysis of 16 Canadians' Experiences

Emerging evidence suggests that transgender individuals are more likely than cisgender peers to receive a diagnosis with a primary mental disorder. Attributions of madness, though, may serve the social function of dismissing and discrediting transgender individual's self-perceptions. The narratives of individuals who stop or reverse an initial gender transition who also identify as living with mental health conditions can sometimes amplify these socio-political discourses about transgender people. Through a critical mental health lens, this article presents a qualitative analysis of 16 individuals who stopped or reversed a gender transition and who also reported a primary mental health condition. Semi-structured, virtual interviews were conducted with people living in Canada. Applying constructivist grounded theory methodology, and following an iterative, inductive approach to analysis, we used the constant comparative method to analyse these 16 in-depth interviews. Results show rich complexity such that participants narrated madness in nuanced and complex ways while disrupting biased attitudes that madness discredited their thoughts and feelings, including prior gender dysphoria. Instead, participants incorporated madness into expanding self-awareness and narrated their thoughts and feelings as valid and worthy. Future research must consider provider's perspectives, though, in treating mad individuals who detransitioned, since alternate gender-affirming care models may better support the identification and wellness of care-seeking individuals who may be identified (in the past, present, or future) as mad.

Barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with psychosis: a scoping review protocol

BACKGROUND

The prevalence of psychosis has been shown to be disproportionately high amongst sexual and gender minority individuals. However, there is currently little consideration of the unique needs of this population in mental health treatment, with LGBTQA+ individuals facing barriers in accessing timely and non-stigmatising support for psychotic experiences. This issue deserves attention as delays to help-seeking and poor engagement with treatment predict worsened clinical and functional outcomes for people with psychosis. The present protocol describes the methodology for a scoping review which will aim to identify barriers and facilitators faced by LGBTQA+ individuals across the psychosis spectrum in help-seeking and accessing mental health support.

METHODS

A comprehensive search strategy will be used to search Medline, PsycINFO, Embase, Scopus, LGBTQ+ Source, and grey literature. Original studies of any design, setting, and publication date will be included if they discuss barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with experiences of psychosis. Two reviewers will independently screen titles/abstracts and full-text articles for inclusion in the review. Both reviewers will then extract the relevant data according to pre-determined criteria, and study quality will be assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Key data from included studies will be synthesised in narrative form according to the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews.

DISCUSSION

The results of this review will provide a comprehensive account of the current and historical barriers and facilitators to mental healthcare faced by LGBTQA+ people with psychotic symptoms and experiences. It is anticipated that the findings from this review will be relevant to clinical and community services and inform future research. Findings will be disseminated through publication in a peer-reviewed journal and presented at conferences.

SCOPING REVIEW REGISTRATION

This protocol is registered in Open Science Framework Registries ( https://doi.org/10.17605/OSF.IO/AT6FC ).

Epidemiology of Gender Diversity

In the United States, approximately 1.6 million individuals identify as transgender and gender diverse (TGD), encompassing a wide range of identities and experiences. Despite progress in visibility and acceptance, TGD people continue to face health care and societal disparities, especially affecting racial minorities. Although legal advancements have been achieved, the key to addressing these persistent health care disparities lies in implementing comprehensive and culturally sensitive health care practices and supportive policies. With a growing number of TGD people seeking gender-affirming care, it is imperative that health care practitioners understand the unique challenges faced by this community and provide tailored services with sensitivity and expertise.

Gender-Affirming Mastectomy: Psychosocial and Surgical Outcomes in Transgender Adults

BACKGROUND

Limited literature exists examining the effects of gender-affirming mastectomy on transmasculine and nonbinary patients that is prospective and uses validated survey instruments.

STUDY DESIGN

The psychosocial functioning of transmasculine and nonbinary patients was compared between patients who underwent gender-affirming mastectomy and those who had not yet undergone surgery. Participants were enrolled in a single-site, combined study of surgical and psychosocial outcomes, including a cross-sectional cohort of preoperative and postoperative patients, as well as separate prospective cohort. Participants completed the BREAST-Q psychosocial and sexual well-being modules, the BODY-Q satisfaction with chest and nipples modules, the Body Image Quality of Life Inventory, the Transgender Congruence Scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7 scale before and after surgery. We also examined how patient demographic factors correlated with postoperative surgical and psychosocial outcomes.

RESULTS

A total of 111 transmasculine and nonbinary patients 18 to 63 years of age (mean ± SD 26.5 ± 8) underwent mastectomy and were included in the study. All were included in the cross-sectional cohort, and 20 were enrolled in the prospective cohort. More than one-third (34.2%) of patients were nonbinary. After surgery, psychosocial and sexual well-being, satisfaction, body image-related quality of life, and gender congruence were increased (p < 0.001) in both cohorts, and depression (p < 0.009 cross-sectional), and anxiety (p < 0.001 cross-sectional) were decreased. The most common adverse event was hypertrophic scarring, which occurred in 41 (36.9%) participants.

CONCLUSIONS

In this study of transmasculine and nonbinary adults, gender-affirming mastectomy was followed by substantial improvements in psychosocial functioning.

Qualitative Assessment of the Experiences of Transgender Individuals Assigned Female at Birth Undergoing Gender-Affirming Mastectomy for the Treatment of Gender Dysphoria

Purpose

Evaluation and comparison of outcomes following gender-affirming mastectomy have been hindered by the lack of a validated population- and surgery-specific patient-reported outcome measure (PROM). The purpose of this study was to explore the lived experiences of transgender individuals assigned female at birth (AFAB) from before-to-after gender-affirming mastectomy to identify key qualitative themes that might inform the creation of a quantitative PROM in the future.

Methods

Identified candidates were transgender men AFAB, 18-65 years of age (mean±standard deviation: 30.3±12.2), who had undergone gender-affirming mastectomy from 2015 through 2017 (n=53). Twelve individuals participated in either focus groups (6) or phone interviews (6), carried out in a semistructured fashion. Verbatim transcriptions were anonymized. Conventional content analysis was used to code all transcripts.

Results

Content analysis identified six key themes experienced by transgender men undergoing gender-affirming mastectomy. In contrast to their experiences before surgery, participant reported that after surgery they experienced fewer symptoms of gender dysphoria, lower anxiety associated with gender dysphoria, less fear about physical safety, no need to hide a female chest shape, and that they passed as male. Also explored were themes about experiences with the health care team.

Conclusion

This study presents the first qualitative data based on the lived experiences of transgender individuals AFAB who underwent gender-affirming mastectomy. These qualitative themes should be heavily considered when creating a quantitative PROM that will fully capture the changes transgender individuals AFAB experience from before-to-after gender-affirming mastectomy.

Gender dysphoria and gender-affirming surgery: The New York state experience

BACKGROUND

Transgender and gender nonconforming (TGNC) individuals experience incongruence between their self-identified gender versus their birth-assigned sex. In some cases, TGNC patients undergo gender-affirming surgical (GAS) procedures. Although GAS is an evolving surgical field, there is currently limited literature documenting patient characteristics and procedures. Addressing this knowledge gap, this retrospective cohort analysis described the characteristics of New York State's TGNC residents with gender dysphoria (GD) diagnosis, including patients undergoing at least one gender-affirming surgical procedure.

METHODS

Using the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2002 to 2018, we identified patients' first-time TCNC records and their risk characteristics. Patients who received GAS procedures were sub-classified as top-only, bottom-only, or combined top/bottom procedures and were compared with TGNC patients who did not receive GAS.

RESULTS

Of 24,615 records extracted from TGNC SPARCS database, 11,427 (46.4%) were transmasculine (female-to-male) and 13,188 (53.6%) were transfeminine (male-to-female). Overall, 2.73% of transgender patients received at least one GAS procedure. Of these patients, 78.2% had masculinizing and 21.8% had feminizing surgeries. After a diagnosis of GD, the positive predictors for a GAS-based procedure included female birth sex, pediatric age (<18 years) or older age (60+ years), commercial insurance coverage, and Hispanic race. In contrast, negative GAS predictors included male birth sex and government insurance coverage (i.e., Medicare and Medicaid).

CONCLUSIONS

Compared with transgender women, transgender men were more likely to receive at least one GAS procedure. Because the race, ethnicity, and payor status of TGNC patients can impact GAS treatment rates, additional research is warranted to examine post-diagnosis GAS treatment disparities among TGNC patients.

Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery

Introduction With the growing acceptance of transgender individuals, the number of gender affirmation surgeries has increased. Transgender individuals face elevated depression rates, leading to an increase in suicide ideation and attempts. This study evaluates the risk of suicide or self-harm associated with gender affirmation procedures. Methods This retrospective study utilized de-identified patient data from the TriNetX (TriNetX, LLC, Cambridge, MA) database, involving 56 United States healthcare organizations and over 90 million patients. The study involved four cohorts: cohort A, adults aged 18-60 who had gender-affirming surgery and an emergency visit (N = 1,501); cohort B, control group of adults with emergency visits but no gender-affirming surgery (N = 15,608,363); and cohort C, control group of adults with emergency visits, tubal ligation or vasectomy, but no gender-affirming surgery (N = 142,093). Propensity matching was applied to cohorts A and C. Data from February 4, 2003, to February 4, 2023, were analyzed to examine suicide attempts, death, self-harm, and post-traumatic stress disorder (PTSD) within five years of the index event. A secondary analysis involving a control group with pharyngitis, referred to as cohort D, was conducted to validate the results from cohort C. Results Individuals who underwent gender-affirming surgery had a 12.12-fold higher suicide attempt risk than those who did not (3.47% vs. 0.29%, RR 95% CI 9.20-15.96, p < 0.0001). Compared to the tubal ligation/vasectomy controls, the risk was 5.03-fold higher before propensity matching and remained significant at 4.71-fold after matching (3.50% vs. 0.74%, RR 95% CI 2.46-9.024, p < 0.0001) for the gender affirmation patients with similar results with the pharyngitis controls. Conclusion Gender-affirming surgery is significantly associated with elevated suicide attempt risks, underlining the necessity for comprehensive post-procedure psychiatric support.

Psychiatric Diagnoses and Psychotropic Drug Usage in Gender-Affirming Voice Surgery Patients

OBJECTIVES

To describe the burden of psychiatric illness and psychotropic medication usage among the subset of transgender patients who undergo gender-affirming laryngeal surgery and describe some of the most commonly encountered conditions experienced by this population.

METHODS

An Institutional Review Board-approved chart review was conducted for the 18 patients who have undergone gender-affirming laryngeal procedures from August 2019 to June 2022 performed at a single institution. Patient demographic data, treatment details, and psychiatric diagnoses and prescriptions for psychotropic medications were recorded.

RESULTS

Of the 18 patients who underwent gender-affirming laryngeal surgery at this institution, 16 patients underwent these operations as part of a transition from male to female gender, while 2 patients were transitioning from female to male gender. In this cohort, 13 patients were diagnosed with a psychiatric comorbidity (72.2%). Of these patients, 11 were prescribed at least 1 psychotropic medication (61.1%). The most common psychiatric illnesses encountered in these patients were depression, anxiety, and post-traumatic stress disorder. Ten patients were diagnosed with more than 1 psychiatric comorbidity (55.6%). The most commonly prescribed psychotropic drugs were selective serotonin/norepinephrine reuptake inhibitors. Three patients in this cohort had a recorded history of at least one prior suicide attempt.

CONCLUSIONS

Multiple studies have demonstrated increased rates of mental illness in transgender individuals, however, this is the first study to describe the burden of these conditions specifically in the subset of patients who undergo gender-affirming laryngeal surgery.

Agents of scientific uncertainty: Conflicts over evidence and expertise in gender-affirming care bans for minors

Globally, as medical and mental health associations increasingly have expressed support for the gender-affirming care model for trans and gender expansive youth, this model has been paradoxically banned across the United States. Ban proponents have deemed the science behind gender-affirming care to be dangerously uncertain. Examining the first gender-affirming care ban for minors, Arkansas's Save Adolescents from Experimentation (SAFE) Act of 2021, we addressed the following two questions: 1) who are the scientists, clinicians, and political organizations that promote SAFE and similar bans?; and 2) what are the scientific arguments they make to defend SAFE in federal court? First, we developed a typology of the various "agents of scientific uncertainty" behind these bans, drawing on literature from the sociology and history of science and medicine as well as the political economy of scientific doubt. Second, we created and qualitatively analyzed a dataset featuring 375 unique citations referenced throughout federal litigation over SAFE to identify these agents of scientific uncertainty's arguments. We sorted these arguments into eight categories, which reveal how agents distorted scientific evidence and exaggerated real uncertainties and risks in gender-affirming care. This case study establishes a frame for understanding the growing prevalence and legal impact of scientific arguments against gender-affirming care.

Patterns of psychotropic medication prescribing and potential drug-hormone interactions among transgender and gender-diverse adults within 2 years of hormone therapy

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.

Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration

BACKGROUND

Transgender and gender diverse (TGD) veterans have a greater prevalence of suicide morbidity and mortality than cisgender veterans. Gender-affirming surgery (GAS) has been shown to improve mental health for TGD veterans. In 2021, the Veterans Health Administration (VHA) announced the initiation of a rulemaking process to cover GAS for TGD patients.

OBJECTIVE

This study explores patients' and providers' perspectives about access to GAS and other gender-affirming medical interventions not offered in the VHA including barriers, facilitators, and clinical and policy recommendations.

PARTICIPANTS

TGD patients (n = 30) and VHA providers (n = 22).

APPROACH

Semi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data.

KEY RESULTS

VHA policy exclusions were the most cited barrier to GAS. Additional barriers included finding information about GAS, traveling long distances to non-VHA surgeons, out-of-pocket expenses, post-surgery home care, and psychological challenges related to the procedure. Factors facilitating access included surgical care information from peers and VHA providers coordinating care with non-VHA GAS providers. Pre- and post-operative care through the VHA also facilitated receiving surgery; however, patients and providers indicated that knowledge of these services is not widespread. Respondents recommended disseminating information about GAS-related care and resources to patients and providers to help patients navigate care. Additional recommendations included expanding access to TGD mental health specialists and establishing referrals to non-VHA GAS providers through transgender care coordinators. Finally, transfeminine patients expressed the importance of facial GAS and hair removal.

CONCLUSIONS

A policy change to include GAS in the VHA medical benefits package will allow the largest integrated healthcare system in the United States to provide evidence-based GAS services to TGD patients. For robust and consistent policy implementation, the VHA must better disseminate information about VHA-provided GAS-related care to TGD patients and providers while building capacity for GAS delivery.

Assessing the Readability of Online Patient Education Resources Related to Neophallus Reconstruction

INTRODUCTION

Online patient education materials (PEMs) often exceed the recommended 6th grade reading level. This can negatively affect transmasculine patients' understanding of treatment plans, increasing barriers to care and worsening health outcomes and patient satisfaction. This study assessed the readability of online English and Spanish PEMs regarding phalloplasty and urethroplasty.

METHODS

The English and Spanish terms for phalloplasty and urethroplasty were queried on Google. The first fifty results were grouped into institutional (government, medical school, teaching hospital), noninstitutional (private practice, news channel, blog, etc.), and academic (journal articles, book chapters) categories. Readability scores were generated using the Simple Measure of Gobbledygook and Spanish Simple Measure of Gobbledygook scales.

RESULTS

All PEMs exceeded recommended reading levels. For both procedures, English PEMs had an average reading level approximately of a university sophomore and Spanish PEMs had an average reading level approximately of a high school junior. For both procedures, English PEMs were harder to read than Spanish PEMs overall (P < 0.001) and when compared across the three categories between the two languages (P < 0.001). For Spanish urethroplasty PEMs, noninstitutional PEMs were more difficult to read than institutional PEMs (P < 0.05).

CONCLUSIONS

Online information for phalloplasty and urethroplasty should be revised and/or standardized materials should be created by trans-affirming health-care providers and national organizations in order to more fully educate the public and prospective patients prior to intervention. A well-informed patient population will improve patient decision-making and surgeon-patient communication, ultimately leading to better health outcomes.

Images: Irregular sleep-wake rhythm disorder in transgender individuals

Growing evidence suggests that transgender individuals face a significant health disparity and are particularly vulnerable to sleep disorders. We present two patients who developed irregular sleep-wake rhythm disorder after gender reassignment and hormone replacement therapy. The growing interest in transgender health warrants further evaluation of the effects and frequency of all sleep disorders in this population. Efforts to address sleep disorders should consider assessing sleep disturbance in terms of sleep/wake patterns and schedules.

CITATION

Kokash A, Vendrame M. Images: irregular sleep-wake rhythm disorder in transgender individuals. J Clin Sleep Med. 2023;19(11):1981-1984.

An Exploratory Study to Describe Transgender People with HIV Who Accessed Medicaid and Their Viral Suppression Over Time in New York City, 2013-2017

Purpose

Although HIV surveillance contains information on HIV outcomes among transgender persons with HIV (TPWH), it does not include other important data, for example, gender-affirming health care, which may influence viral suppression (VS). We describe TPWH accessing Medicaid and the association of gender-affirming surgery with VS.

Methods

Through matching Medicaid claims with HIV registry data, a cohort of previously identified TPWH in Medicaid was compared to cisgender women and men in terms of VS in 2013-2017 in New York City. Medicaid claims were used to identify TPWH who obtained gender-affirming surgery (e.g., chest, genital surgeries). We described the VS of those who had surgery and examined temporal trends in VS pre- and postsurgery and by surgery type.

Results

1730 TPWH were enrolled in Medicaid and in HIV care in 2013-2017. Overall for VS at last laboratory, TPWH in Medicaid had lower VS (76.0%) than cisgender women (80.4%) and men (83.3%). The exception was the 185 TPWH who obtained gender-affirming surgery (86.5%). Among 160 TPWH in Medicaid who obtained gender-affirming surgery and achieved VS, VS increased presurgery (66.3% 2 years prior, 76.9% 1 year prior) and remained high 1 year after (86.3%) and 2 years after (87.7%) (the last percentage is only among those who had surgery before 2017, N=81).

Conclusion

Gender-affirming surgery may be an important motivator to becoming virally suppressed and was associated with sustained high VS, which can lead to improved survival and quality of life. Medicaid and other insurers should consider improving access to gender-affirming surgery among TPWH.

Gender-affirming treatment and mental health diagnoses in Danish transgender persons: a nationwide register-based cohort study

IMPORTANCE

Gender affirming treatment aims to improve mental health.

OBJECTIVE

To investigate longitudinal mental health outcomes in Danish transgender persons.

DESIGN

National register-based cohort study in Danish transgender persons with diagnosis code of "gender identity disorder" during the period 2000-2021.

PARTICIPANTS

Five age-matched controls of the same sex at birth and five age-matched controls of the other sex at birth were included for each transgender person.

MAIN OUTCOMES

Diagnosis codes of mental and behavioral disorders and/or prescription of psychopharmacological agents until June 2022.

RESULTS

The cohort included 3812 transgender persons with median age (interquartile range) 19 (15; 24) years for persons assigned female at birth (AFAB, N = 1993) and 23 (19; 33) years for persons assigned male at birth (AMAB, N = 1819) and 38 120 controls. Follow up duration was up to 10 years with mean (standard deviation) 4.5 (4.3) years. In transgender persons AFAB compared to control women, the odds ratio (OR) (95% confidence interval) for mental and behavioral disorders was 6.7 (5.5; 8.1) before the index date, 9.9 (8.4; 11.7) at 1 year, 5.8 (4.4; 7.7) at 5 years, and 3.4 (2.1; 7.5) at 8 years follow up. In transgender persons AMAB compared to control men, corresponding ORs were 5.0 (4.0; 6.4), 11.3 (9.3; 13.7), 4.8 (3.5; 6.5), and 6.6 (4.2; 10.3) at 8 years follow up (all P < .001).

CONCLUSION

The OR for mental health disorders was higher in transgender persons compared to controls and remained elevated throughout follow up, especially in transgender persons AMAB.

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

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

Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand

BACKGROUND

Past studies have demonstrated better mental health and well-being among transgender youth who had accessed gender-affirming care. However, few existing studies have assessed unmet need for gender-affirming care as a social determinant of mental health inequities.

METHODS

Data on unmet need for gender-affirming care, distress and suicidality were analysed from the 2018 Counting Ourselves nationwide community-based survey of transgender people in Aotearoa/New Zealand. Associations between unmet need for gender-affirming care and mental health indicators were tested for transgender youth within the sample (aged 14-26 years; n = 608; Mage = 20.5).

RESULTS

Transgender youth reported unmet needs ranging from 42% for gender-affirming hormone to 100% for feminizing surgeries and voice surgeries. Overall unmet need for gender-affirming care was associated with worse mental health. Trans men with an unmet need for chest reconstruction (84%) scored an average of 7.13 points higher on the K10 Psychological Distress Scale relative to those whose need had been met. Participants reporting unmet need for hormones (42%) had twice the odds (adjusted odds ratios = 2.01; CI = 1.02-3.98) of having attempted suicide in the last 12 months.

CONCLUSIONS

Dismantling barriers to accessing gender-affirming care could play a crucial role in reducing mental health inequities faced by transgender youth.

Sociodemographics of Patient Populations Undergoing Gender-Affirming Surgery: A Systematic Review of All Cohort Studies

Importance

Sociodemographic and health characteristics of patients undergoing gender-affirming surgery (GAS) are currently unknown. Understanding these patient characteristics is vital to optimizing patient-centered care for transgender patients.

Objective

To determine sociodemographic characteristics for the transgender population undergoing GAS. Collected sociodemographic information included the following: age, race/ethnicity, body metrics, hormone replacement therapy administration and duration, substance use, psychiatric comorbidities, and medical comorbidities.

Evidence Review

A search of seven electronic databases (PubMed, PsycINFO, Embase, CINAHL, Web of Science, Cochrane, and Gender Studies) was used to find all articles on GAS from inception through May 2019. The 15,190 articles were then subjected to two levels of screening, and articles unrelated to gender-affirming care, unavailable in English, n<5, and with no outcomes reporting were excluded. Textbook chapters and letters were also excluded.

Findings

A total of 406 studies were fully extracted, with 307 studies reporting age (n=22,727 patients), 19 reporting race/ethnicity (n=1184), 74 reporting body metrics (body mass index [BMI] n=6852, height n=416, and weight n=475), 58 reporting hormone therapies (n=5104), 56 reporting substance use (n=1146), 44 reporting psychiatric comorbidities (n=574), and 47 reporting medical comorbidities (n=573). From the 406 studies, 80 were done in the United States. Regarding U.S. studies, 59 studies reported age (n=5365), 10 reported race/ethnicity (n=709), 22 reported body metrics (BMI n=2519), 18 reported hormone therapies (n=3285), 15 reported substance use (n=478), 44 reported psychiatric comorbidities (n=394), and 47 reported medical comorbidities (n=293). Age was the most reported characteristic, reported in 75.62% of studies (73.75% of U.S. studies). Race/ethnicity was the least commonly reported data, reported in 4.68% of studies (12.50% of U.S. studies).

Conclusions and Relevance

The type of sociodemographic information reported by GAS studies is inconsistently reported. To improve patient-centered care for transgender patients, further work is needed to create a standardization of collected sociodemographic information.

Reports of Negative Interactions with Healthcare Providers among Transgender, Nonbinary, and Gender-Expansive People assigned Female at Birth in the United States: Results from an Online, Cross-Sectional Survey

Over one million people in the United States are transgender, nonbinary, or gender expansive (TGE). TGE individuals, particularly those who have pursued gender-affirming care, often need to disclose their identities in the process of seeking healthcare. Unfortunately, TGE individuals often report negative experiences with healthcare providers (HCPs). We conducted a cross-sectional online survey of 1684 TGE people assigned female or intersex at birth in the United States to evaluate the quality of their healthcare experiences. Most respondents (70.1%, n = 1180) reported at least one negative interaction with an HCP in the past year, ranging from an unsolicited harmful opinion about gender identity to physical attacks and abuse. In an adjusted logistic regression model, those who had pursued gender-affirming medical care (51.9% of the sample, n = 874) had 8.1 times the odds (95% CI: 4.1-17.1) of reporting any negative interaction with an HCP in the past year, compared to those who had not pursued gender-affirming care, and tended to report a higher number of such negative interactions. These findings suggest that HCPs are failing to create safe, high-quality care interactions for TGE populations. Improving care quality and reducing bias is crucial for improving the health and well-being of TGE people.

The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes

BACKGROUND

According to the minority stress theory, stigma affects the health of marginalized populations. Previous stigma research has focused on the health effects of individual and interpersonal stigma, paying less attention to structural factors. Laws on legal gender recognition affect the lives of transgender individuals in unique ways. The fact that these laws and population attitudes vary greatly between European countries, offer a unique opportunity to study the role of structural stigma in the lives of transgender individuals. Little is known about how transgender specific structural stigma relates to individual health determinants. Consequently, the aim of this study was to explore the association between structural stigma and access to gender affirming care, gender identity disclosure in health care, and experiences of discrimination in health care across 28 European countries.

METHODS

By using multilevel regression, we combined data on health seeking behavior, transgender identity disclosure to health care providers, and experiences of discrimination in health care from 6,771 transgender individuals participating in the 2012 European Union Lesbian, Gay, Bisexual and Transgender survey with a structural stigma measure, consisting of population attitudes towards transgender individuals as well as national legislation on gender recognition. Reasons to refrain from seeking care and discrimination in health care were assessed by categorizing countries as low or high in structural stigma and using Chi-square statistics.

RESULTS

Country-level structural stigma was negatively associated experiences of seeking gender affirming care and positively associated with concealment of being transgender to health care providers. Identity concealment was associated with a lower likelihood of exposure to discrimination in the health care setting across countries regardless of their level of structural stigma. The most prevalent reasons to forgo gender affirming care were shared between low and high structural stigma country groups and centered around fear.

CONCLUSION

The results highlight the importance of changing stigmatizing legislation and population attitudes to promote access to gender affirming care as well as openness of being transgender towards providers. Measures to decrease discrimination in the health care setting are warranted in high as well as in low structural stigma countries.

Transcranial Direct Current Stimulation for Depression in Transgender Patient

Transgender and gender-diverse (TGD) individuals experience higher rates of mood and anxiety disorders than the general public. Transcranial direct current stimulation (tDCS) is an effective and well-tolerated treatment for major depressive disorder, in cisgender patients. With the very recent exception of electroconvulsive therapy (ECT), neuromodulation in TGD patients is not addressed in the literature. We described here the efficacy and tolerability of tDCS in a 22-year-old Caucasian female-to-male transgender individual (hereafter referred to as a male) suffering from a severe non-treatment-resistant major depressive disorder. This case report suggests that combined tDCS and antidepressant therapy have the potential to treat depressive disorders in patients of all gender identities.

Exploring gender dysphoria and related outcomes in a prospective cohort study: protocol for the Swedish Gender Dysphoria Study (SKDS)

INTRODUCTION

There has been a drastic increase in the reported number of people seeking help for gender dysphoria in many countries over the last two decades. Yet, our knowledge of gender dysphoria and related outcomes is restricted due to the lack of high-quality studies employing comprehensive approaches. This longitudinal study aims to enhance our knowledge of gender dysphoria; different aspects will be scrutinised, focusing primarily on the psychosocial and mental health outcomes, prognostic markers and, secondarily, on the underlying mechanisms for its origin.

METHODS AND ANALYSIS

The Swedish Gender Dysphoria Study is an ongoing multicentre longitudinal cohort study with 501 registered participants with gender dysphoria who are 15 years old or older. Participants at different phases of their clinical evaluation process can enter the study, and the expected follow-up duration is three years. The study also includes a comparison group of 458 age- and county-matched individuals without gender dysphoria. Data on the core outcomes of the study, which are gender incongruence and experienced gender dysphoria, body satisfaction and satisfaction with gender-affirming treatments, as well as other relevant outcomes, including mental health, social functioning and life satisfaction, are collected via web surveys. Two different research visits, before and after starting on gender-affirming hormonal treatment (if applicable), are planned to collect respective biological and cognitive measures. Data analysis will be performed using appropriate biostatistical methods. A power analysis showed that the current sample size is big enough to analyse continuous and categorical outcomes, and participant recruitment will continue until December 2022.

ETHICS AND DISSEMINATION

The ethical permission for this study was obtained from the Local Ethical Review Board in Uppsala, Sweden. Results of the study will be presented at national and international conferences and published in peer-reviewed journals. Dissemination will also be implemented through the Swedish Gender Dysphoria Study network in Sweden.

Queers in quarantine: Young LGBTQ+ people's experiences during the COVID-19 pandemic in Sweden

The COVID-19 pandemic led to major restrictions of everyday life activities. This worsened the social situation of many people, and marginalized groups have been especially affected. This article explores how LGBTQ+ young adults in Sweden have been affected by the COVID-19 pandemic and the subsequent recommendations and restrictions. Fifteen participants between 20-29 years, who self-identified as lesbian, gay, bisexual, transgender, and queer (LGBTQ+), were interviewed about their experiences. A thematic analysis of the data showed that the participants perceived their psychological wellbeing to have been greatly affected by the pandemic. Several reported symptoms of clinical depression, as well as anxiety, worry, rumination, and a heightened sensitivity to stress. Stressors included fear of the disease itself, and fear of spreading the virus, as well as the negative consequences of adhering to the recommendations of social distancing, which constantly interplayed with the marginalized position of being a young LGBTQ+ person. Most participants experienced a decrease in minority stress in face-to-face interaction with social distancing measures in place, but an increase in minority stress online. Those who faced minority stress at home experienced the isolation as particularly stressful. Limited access to the LGBTQ+ community was a common stressor. For transgender participants, the effects on transgender healthcare, such as prolonged waiting times for gender dysphoria assessment and hormone treatment, were a major challenge. Our results have added valuable knowledge to research indicating how vulnerable young adults were highly affected by the COVID-19 pandemic restrictions.

Assessing and Addressing the Risk of Venous Thromboembolism Across the Spectrum of Gender Affirming Care: A Review

OBJECTIVE

Accumulating evidence demonstrates that gender affirming hormone therapy (GAHT) improves mental health outcomes in transgender persons. Data specific to the risks associated with GAHT for transgender persons continue to emerge, allowing for improvements in understanding, predicting, and mitigating adverse outcomes while informing discussion about desired effects. Of particular concern is the risk of venous thromboembolism (VTE) in the context of both longitudinal GAHT and the perioperative setting. Combining what is known about the risk of VTE in cisgender individuals on hormone therapy (HT) with the evidence for transgender persons receiving HT allows for an informed approach to assess underlying risk and improve care in the transgender community.

OBSERVATIONS

Hormone formulation, dosing, route, and duration of therapy can impact thromboembolic risk, with transdermal estrogen formulations having the lowest risk. There are no existing risk scores for VTE that consider HT as a possible risk factor. Risk assessment for recurrent VTE and bleeding tendencies using current scores may be helpful when assessing individual risk. Gender affirming surgeries present unique perioperative concerns, and certain procedures include a high likelihood that patients will be on exogenous estrogens at the time of surgery, potentially increasing thromboembolic risk.

CONCLUSIONS AND RELEVANCE

Withholding GAHT due to potential adverse events may cause negative impacts for individual patients. Providers should be knowledgeable about the management of HT in transgender individuals of all ages, as well as in the perioperative setting, to avoid periods in which transgender individuals are off GAHT. Treatment decisions for both anticoagulation and HT should be individualized and tailored to patients' overall goals and desired outcomes, given that the physical and mental health benefits of gender affirming care may outweigh the risk of VTE.

Association Between California's State Insurance Gender Nondiscrimination Act and Utilization of Gender-Affirming Surgery

Importance

Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies.

Objective

To investigate the association between California's 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient's sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents.

Design, Setting, and Participants

Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California-January 1, 2014. The date of last follow-up was December 31, 2019.

Exposures

California's Insurance Gender Nondiscrimination Act, implemented on July 9, 2013.

Main Outcomes and Measures

Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure.

Results

A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions-2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P < .001). Implementation of the policy was associated with an absolute 12.1% (95% CI, 10.3%-13.9%; P < .001) increase in the probability of undergoing gender-affirming surgery in California vs control states observed in the subset of insured patients (13.4% [95% CI, 11.5%-15.4%]; P < .001) but not self-pay patients (-22.6% [95% CI, -32.8% to -12.5%]; P < .001).

Conclusions and Relevance

Implementation in California of its Insurance Gender Nondiscrimination Act was associated with a significant increase in utilization of gender-affirming surgery in California compared with the control states Washington and Arizona. These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients.

The Often-Circuitous Path to Affirming Mental Health Care for Transgender and Gender-Diverse Adults

PURPOSE OF REVIEW

We describe recent research regarding access to affirming mental health services for transgender and gender-diverse (TGD) adults and explore new resources available for therapists to inform evidence-based practice with TGD clients.

RECENT FINDINGS

Barriers and facilitators at all socioecological levels impact TGD adults' mental health help-seeking. TGD adults often interface with mental health providers while accessing gender-affirming medical care, though new standards of care are likely to alter this typically common path to mental health services. Efforts to improve therapist education, such as therapy manuals, are increasingly available and a necessary step to increase the number of competent, affirming therapists. More work-both advocacy and research-is needed to fully expand accessible, affirming mental health services for TGD adults. Better understanding factors impacting different steps of the mental health help-seeking process and conducting randomized controlled trials of affirming mental health services are important next steps.

Suicide-Related Outcomes Following Gender-Affirming Treatment: A Review

Gender-affirming treatment remains a topic of controversy; of particular concern is whether gender-affirming treatment reduces suicidality. A narrative review was undertaken evaluating suicide-related outcomes following gender-affirming surgery, hormones, and/or puberty blockers. Of the 23 studies that met the inclusion criteria, the majority indicated a reduction in suicidality following gender-affirming treatment; however, the literature to date suffers from a lack of methodological rigor that increases the risk of type I error. There is a need for continued research in suicidality outcomes following gender-affirming treatment that adequately controls for the presence of psychiatric comorbidity and treatment, substance use, and other suicide risk-enhancing and reducing factors. There is also a need for future systematic reviews given the inherent limitations of a narrative review. There may be implications on the informed consent process of gender-affirming treatment given the current lack of methodological robustness of the literature reviewed.

Implementing Gender-Affirming Care in Correctional Settings: A Review of Key Barriers and Action Steps for Change

Transgender and gender-diverse (TGD) people are disproportionately impacted by incarceration, interpersonal violence, HIV and other sexually transmitted infections, substance use disorders, and suicidality. Little is known about successful approaches to improve health outcomes for TGD individuals impacted by incarceration. We review the barriers to providing gender-affirming clinical care in correctional systems in the United States, identify key knowledge gaps regarding the provision of gender-affirming care to incarcerated TGD populations, and highlight necessary steps to improve the health and safety of this highly vulnerable population. We also describe the components of a gender-affirming care model implemented in a state correctional facility, including support from correctional administrators, identifying a gender-affirming care provider, standardizing clinical care protocols, and adapting clinical services to TGD population needs. Similar models should be employed elsewhere to improve health outcomes for TGD populations during incarceration and on release.

Suicidal Ideation Disparities Among Transgender and Gender Diverse Compared to Cisgender Community Health Patients

BACKGROUND

Transgender and gender diverse (TGD) individuals experience more severe psychological distress and may be at higher risk for suicide compared to cisgender individuals. The existing literature largely consists of small-sample studies that do not assess subgroup differences.

OBJECTIVE

To examine rates of self-reported suicidal ideation among four TGD groups compared to cisgender individuals.

DESIGN

Data were extracted from the electronic health records of patients receiving primary care at a community health center specializing in sexual and gender minority health. A logistic regression was used to examine the relationship between sociodemographic variables and the presence of current suicidal ideation.

PARTICIPANTS

29,988 patients receiving care at a community health center in Northeastern US between 2015 and 2018.

MAIN MEASURES

Demographic questionnaire, 9-item Patient Health Questionnaire KEY RESULTS: Younger age, sexual and gender minority identity, and public/grants-based insurance were associated with significantly higher odds of suicidal ideation. Relative to cisgender men, transgender men (OR=2.08; 95% CI=1.29-3.36; p=.003), transgender women (OR=3.08; 95% CI=2.05-4.63; p<.001), nonbinary (NB) individuals assigned male at birth (AMAB; OR=3.55; 95% CI=1.86-6.77; p<001), and NB individuals assigned female at birth (AFAB; OR=2.49; 95% CI=1.52-4.07; p<001) all endorsed significantly higher odds of current suicidal ideation, controlling for age, race, ethnicity, sexual orientation, and insurance status. Larger proportions of transgender women (23.6%) and NB AMAB individuals (26.7%) reported suicidal ideation not only compared to cisgender men (6.1%) and women (6.6%), but also compared to transgender men (17.4%; χ²[5, n=25,959]=906.454, p<0.001).

CONCLUSIONS

TGD patients were at significantly increased risk of suicidal ideation, even after accounting for age, race, ethnicity, sexual orientation, and insurance status. Findings suggest distinct risk profiles by assigned sex at birth. Consistent assessment of and intervention for suicidal ideation should be prioritized in settings that serve TGD patients.

The Myth of "Reliable Research" in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies-and research that has followed

Two Dutch studies formed the foundation and the best available evidence for the practice of youth medical gender transition. We demonstrate that this work is methodologically flawed and should have never been used in medical settings as justification to scale this "innovative clinical practice." Three methodological biases undermine the research: (1) subject selection assured that only the most successful cases were included in the results; (2) the finding that "resolution of gender dysphoria" was due to the reversal of the questionnaire employed; (3) concomitant psychotherapy made it impossible to separate the effects of this intervention from those of hormones and surgery. We discuss the significant risk of harm that the Dutch research exposed, as well as the lack of applicability of the Dutch protocol to the currently escalating incidence of adolescent-onset, non-binary, psychiatrically challenged youth, who are preponderantly natal females. "Spin" problems-the tendency to present weak or negative results as certain and positive-continue to plague reports that originate from clinics that are actively administering hormonal and surgical interventions to youth. It is time for gender medicine to pay attention to the published objective systematic reviews and to the outcome uncertainties and definable potential harms to these vulnerable youth.

Comment l’évolution de l’opinion publique et des réformes législatives influence-t-elle la satisfaction de vie des minorités sexuelles ?

INTRODUCTION

Structural stigma in the form of legal discrimination and population acceptance of same-sex relationships vary greatly across European countries. Previous cross-sectional research has linked such county variation in stigma with life-satisfaction among sexual minorities, but the consequences of the past decade's improvement in legal recognition and social acceptance of same-sex relationships are unknown. In the current study, we, therefore, examined the change in life-satisfaction among sexual minorities between 2012 and 2019 in France, Sweden, and Poland - three countries for which the legal situation and social acceptance of sexual minorities have changed in different directions during the past decade.

METHOD

Between April and July 2012, and again between May and July 2019, the European Union Agency for Fundamental Rights conducted web-based surveys to monitor the fundamental rights situation affecting lesbian, gay, and bisexual (LGB) individuals, living in 28 European countries. For the current study, we analyzed data from all LGB respondents in France, Sweden, and Poland, with no history of migration in 2012 (n = 12,357) and 2019 (n = 21,858).

RESULTS

Regression models adjusted for age, gender, education, and relationship status, showed a strong and significant improvement in life-satisfaction among sexual minorities in France between 2012 and 2019 (β = 0.397, 95 % CI: 0.337, 0.457, p &lt; .001), a country that had experienced improvements in legal recognition (e.g., same-sex marriage legislation in 2013) and improved social acceptance during the same period. In Sweden, which had a high degree of legal recognition and social acceptance in place already in 2012, we found a small increase life-satisfaction among sexual minorities between 2012 and 2019 (β = 0.188, 95 % CI: 0.042, 0.333, p = .012). In Poland, who had experienced deteriorating social acceptance between 2012 and 2019, we found a declined in life-satisfaction among sexual minorities (β = - 0.289, 95 % CI: - 0.385, - 0.193, p &lt; .001).

CONCLUSIONS

Although life satisfaction has increased during the past decade among sexual minorities living in Europe, there are significant variations across countries largely due to the structural stigma and degree of legal recognition of same-sex relationships of those countries. The findings highlight the importance of further efforts to reduce structural stigma by improving legal recognition and social acceptance of same-sex relationships to promote equitable life satisfaction.

Identifying Coping Strategies Used by Transgender Individuals in Response to Stressors during and after Gender-Affirming Treatments-An Explorative Study

BACKGROUND

Gender-affirming treatments are reported to improve mental health significantly. However, a substantial number of transgender individuals report a relapse in, or persistence of, mental health problems following gender-affirming treatments. This is due to multiple stressors occurring during this period, and in general as a consequence of widespread stigma and minority stress.

AIM

The aim of this pilot study was to identify different coping strategies that transgender individuals use in response to stressors prior to and following gender-affirming treatments, as mediator of mental health.

METHODS

Qualitative interviews were conducted to better understand the treatment outcomes and healthcare experiences of Dutch transgender individuals who had received gender-affirming treatments. Nineteen participants were included, of which 12 identified as (transgender) male, six as (transgender) female and one as transgender.

OUTCOMES

Inductive coding and theory-informed thematic analysis were used to assess stressors (n_codes = 335) and coping strategies (n_codes = 869).

RESULTS

Four stressor domains were identified, including lack of support system, stressors related to transition, and physical and psychosocial stressors post-transition. We identified six adaptive coping strategies of which acceptance, help seeking and adaptive cognitions concerning gender and transition were reported most frequently. Of the seven maladaptive strategies that we identified, social isolation and maladaptive cognitions concerning gender and transition were the most-reported maladaptive coping strategies Clinical implications: The results indicated that transgender individuals may experience significant stress, both transgender-specific and non-specific, prior to and following gender-affirming treatments and, as a result, use many coping strategies to adapt. Increased awareness of stressors and (mal)adaptive coping strategies may help to improve mental healthcare and overall support for transgender individuals. Strengths and Limitations: This is the first (pilot) study to provide insight into the range of stressors that transgender individuals experience during and after gender-affirming treatments, as well as the variety of coping strategies that are used to adapt. However, since this was a pilot study assumptions and generalizations of the evidence should be made cautiously.

CONCLUSION

Results of this pilot study showed that transgender individuals may undergo significant stress during and after gender-affirming medical treatment related to the treatments and the social experiences that occur during this period, and as a result, use a range of coping strategies to adapt to the stress.

Some Limitations of "Challenges in the Care of Transgender and Gender-Diverse Youth: An Endocrinologist's View"

There is significant disagreement about how to support trans-identified or gender-dysphoric young people. Different experts and expert bodies make strikingly different recommendations based upon the same (limited) evidence. The US-originating "gender-affirmative" model emphasizes social transition and medical intervention, while some other countries, in response to evidence reviews of medical intervention outcomes, have adopted psychological interventions as the first line of treatment. A proposed model of gender-affirming care, comprising only medical intervention for "eligible" youth, is described in Rosenthal (2021). Determining eligibility for these medical interventions is challenging and engenders considerable disagreement among experts, neither of which is mentioned. The review also claims without support that medical interventions have been shown to clearly benefit mental health, and leaves out significant risks and less invasive alternatives. The unreliability of outcome studies and the corresponding uncertainties as to how gender dysphoria develops and responds to treatment are also unreported.

Prevalence of gender dysphoria and suicidality and self-harm in a national database of paediatric inpatients in the USA: a population-based, serial cross-sectional study

BACKGROUND

Transgender and non-binary young people experience discrimination that has been linked to suicidal ideation and self-harm, but few studies have examined this association systematically. We aimed to study the association between gender dysphoria-related diagnostic coding and hospital admission for suicidality or self-harm in a large representative pediatric inpatient database from the USA.

METHODS

Using the 2016 and 2019 Kids' Inpatient Database (KID), we identified transgender and non-binary young people (aged 6-20 years) with International Classification of Diseases (ICD)-10 codes related to gender dysphoria. We identified suicidal ideation using explicit suicidality ICD-10 codes, and self-harm using 355 self-harm ICD-10 codes. Prevalence of suicidality (primary outcome), self-harm, and the combination of suicidality and self-harm (secondary outcomes) was compared between young people with and without gender dysphoria-related codes. Univariable and multivariable regression was used to test for an association between gender dysphoria and suicidality, self-harm, or suicidality and self-harm combined.

FINDINGS

1 090 544 individuals were included from KID 2016 and 1 026 752 from KID 2019. Gender dysphoria-related diagnoses were prevalent in 161 per 100 000 hospital admissions in KID 2016 and 475 per 100 000 hospital admissions in KID 2019. In KID 2016 and KID 2019, among individuals who were White, privately insured, or from higher median income ZIP code areas, proportionately more had gender dysphoria-related codes. Prevalence of suicidality was greater in individuals with gender dysphoria-related codes than in individuals without gender dysphoria-related codes in KID 2016 (635 [36%] of 1755 individuals with gender dysphoria-related codes vs 55 351 [5%] of 1 088 789 individuals without gender dysphoria-related codes; unadjusted prevalence ratio [PR] 7·19 [95% CI 6·75-7·66]) and KID 2019 (2680 [55%] of 4872 individuals with gender dysphoria-related codes vs 38 831 [4%] of 1 021 880 individuals without gender dysphoria-related codes; unadjusted PR 5·45 [5·30-5·60]). This association persisted in multivariable modelling adjusting for confounders in KID 2016 (adjusted PR 5·02 [95% CI 4·67-5·41]) and KID 2019 (4·14 [4·02-4·28]). Increased unadjusted and adjusted PRs for individuals with gender dysphoria-related codes, relative to those without, were also evident for self-harm and when combining suicidality and self-harm in both the 2016 and 2019 datasets.

INTERPRETATION

In a large representative national sample, transgender and non-binary young people with gender dysphoria-related diagnoses were frequently admitted to hospital for suicidality or self-harm. The lower rates of gender-dysphoria-related codes among young people who were non-White, publicly insured, and from low-income households suggest that underlying inequities might shape the identification and management of gender dysphoria. Structural and health-care provider-level interventions are needed to reduce discrimination and expand gender-affirming competencies to prevent adverse outcomes for hospitalised transgender and non-binary young people with gender dysphoria.

FUNDING

National Institutes of Health.

Gender identity and transition: relationships with sleep disorders in US youth

STUDY OBJECTIVES

Transgender or gender-nonconforming (TGNC) identity is associated with higher burden of sleep disorders relative to cisgender identity. However, the role of gender-affirming therapy (GAT) in sleep disorders is poorly understood. This study examined relationships between TGNC identity, transition, and sleep disorders among TGNC and cisgender youth.

METHODS

This retrospective cross-sectional study utilized a large US-based administrative claims database (deidentified Optum Clinformatics Data Mart Database) to identify youth aged 12-25 years who obtained a diagnosis of TGNC identity and those who pursued GAT. Descriptive statistics estimated distributions of demographic and health characteristics by gender identity. Unadjusted and age-adjusted logistic regression models were used to examine associations between TGNC identity, GAT, and sleep disorders.

RESULTS

This study included 1,216,044 youth, of which 2,603 (0.2%) were identified as TGNC. Among the 1,387 TGNC who pursued GAT, 868 and 519 were identified as transmasculine and transfeminine, respectively. Adjusted analysis showed increased odds of insomnia (odds ratio = 5.4, 95% confidence interval 4.7, 6.2), sleep apnea (odds ratio = 3.0, 95% confidence interval 2.3, 4.0), and other sleep disorders (odds ratio = 3.1, 95% confidence interval 2.5, 3.9) in TGNC relative to cisgender youth. Decreased odds of any sleep disorder were observed in the TGNC youth on GAT (odds ratio = 0.5, 95% confidence interval 0.4, 0.7) relative to those not on GAT.

CONCLUSIONS

This study demonstrated a high burden of sleep disorders in TGNC youth in comparison to cisgender. However, GAT may confer a protective effect on sleep disorders among TGNC youth. Longitudinal assessments of sleep disorders prior to and post-GAT are needed to uncover their temporal relationships.

CITATION

Gavidia R, Whitney DG, Hershner S, Selkie EM, Tauman R, Dunietz GL. Gender identity and transition: relationships with sleep disorders in US youth. J Clin Sleep Med. 2022;18(11):2553-2559.