Gender-Diverse Patients' Awareness and Utilization of Gender-Affirming Laryngological Services

OBJECTIVE

Despite gender-affirming laryngological services (GALS; eg, voice therapy or surgery) being available nationwide, there is a discrepancy between the number of transgender and gender diverse (TGD) people with vocal incongruence and those who pursue services. Primary care is an important setting for accessing gender-affirming care, including learning about GALS. The purpose of this study was to understand the relationship between access to primary care and utilization of GALS.

METHODS

An anonymous cross-sectional online survey was developed in REDCap. Between June-November 2022, 187 TGD respondents answered all questions related to this analysis. We assessed the relationship between having a primary care provider (PCP) and use of GALS via logistic regression.

RESULTS

Of the 167 individuals who reported having a PCP, 54% reported familiarity with GALS, compared to 45% of individuals without a PCP. Compared to the group without a PCP, a greater proportion of individuals with a PCP had received professional voice therapy (21% vs 5%) and voice surgery (3% vs 0%). Logistic regression models did not demonstrate a significant effect of primary care access on either familiarity with, or use of, GALS.

CONCLUSION

Most respondents (89%) were linked to the medical community through a PCP. A greater proportion of respondents with a PCP had accessed professional voice therapy and voice surgery compared with respondents without a PCP, though this difference was not statistically significant. Increased communication between GALS providers and PCPs would raise awareness of available services and may strengthen the referral pipeline to increase access to vocal care.

LEVEL OF EVIDENCE

Level III.

Gut-Directed Hypnotherapy May Pose Specific Challenges in Gender-Diverse Patients: A Review of 3 Patients

Disorders of gut-brain interaction are common and often characterized by chronic symptom courses. While gut-directed hypnotherapy is effective for refractory disorders of gut-brain interaction, the required internal awareness and vulnerability may be challenging. Driven by our own clinical experiences, we conducted qualitative interviews with patients who identified as transgender or gender diverse and who had discontinued gut-directed hypnotherapy. Four main themes were generated from these interviews related to distress resulting from body awareness, difficulty with vulnerability, the importance of gender-affirming supports, and external barriers. Providers are encouraged to consider gender diversity, and more broadly body image, in discussion of hypnosis treatment.

Erythrocytosis Is Rare With Exogenous Testosterone in Gender-Affirming Hormone Therapy

CONTEXT

Studies have found a variable incidence of erythrocytosis among people using testosterone as part of gender-affirming hormone therapy (GAHT).

OBJECTIVE

To examine the effect of using exogenous testosterone as GAHT on hematocrit in a large North American cohort.

METHODS

We conducted a cross-sectional analysis of testosterone and hematocrit laboratory values in 6670 patients who were prescribed testosterone through Plume, a national provider of GAHT. The prevalence of erythrocytosis, the mean hematocrit at predetermined testosterone thresholds and with varying routes of testosterone administration were assessed.

RESULTS

Among 6670 individuals, 560 (8.4%) had a hematocrit ≥50%, 182 ≥ 52% (2.7%), and 60 ≥ 54% (0.9%). There was significant variation (P < .001) in hematocrit between different clinically relevant testosterone thresholds (T < 50 vs T 50-299 vs T 300-999 vs T ≥ 1000 ng/dL) and when comparing serum testosterone in increments of 50 ng/dL within the target range for males (300-1000 ng/dL) (P < .001). Mean hematocrit ranged from 41.84% (T < 50 ng/dL) to 45.68% (T 900-949 ng/dL). Patients on intramuscular testosterone had a higher mean hematocrit than those on transdermal testosterone (44.96% vs 43.41%, P < .001). Both route of administration (P < .001) and testosterone level (P < .001) had statistically significant associations with hematocrit when controlling for each other.

CONCLUSION

While the magnitude of change in hematocrit with serum level and route of administration of testosterone was statistically significant, the absolute levels were within the normal range, unlikely to be clinically meaningful. These findings, along with the low prevalence of erythrocytosis, should help allay concerns about the use of testosterone as GAHT.

Sameness across Difference: A Postcolonial Feminist Analysis of Gender-Affirming Health Care in Thailand and the United States

Joining a growing body of research calling for the integration of social analysis and postcolonial theory, recent work in medical sociology has analyzed health, illness, and medicine from a postcolonial lens. In this article, I argue for a postcolonial feminist approach to medical sociology that builds on this extant work while challenging methodological nationalism and cultural essentialism. Based on an analysis of gender-affirming health care for transgender and gender diverse (TGD) people in Thailand and the United States, I propose "sameness across difference" as a framework to analyze commonalities in the health care experiences of marginalized populations across nations as the products of imperial legacies. Drawing on 83 interviews with health care providers, TGD patients, and TGD activists, I demonstrate the role of imperialism in sustaining barriers to gender-affirming health care through the uneven geographic distribution of care across rural and urban areas and the reinforcement of racial and class hierarchies within cities.

Gender diversity among adolescents with obesity in a weight management programme

Gender dysphoria (GD) and obesity share commonalities, including associations with mental health comorbidities, disordered eating, body dissatisfaction and may intensify with physical and developmental changes during adolescence. While associations of obesity and gender diversity have been identified, rates of gender diversity among adolescents with obesity remain unclear. The aim was to examine gender diversity among adolescents with obesity in a weight management programme. A single-centre cross-sectional questionnaire study was conducted. Eligible adolescents received the Gender Identity/GD Questionnaire for Adolescents and Adults (GIDYQ-AA), a validated instrument measuring gender diversity and GD. Gender identities, sexual orientations, questionnaire scores, and frequency of GD (GIDYQ-AA score <3) were determined. The relationship of GIDYQ-AA scores and BMI Z-score (BMIz) was assessed. Of 72 consenting youth, 29 assigned females (AF) and 17 assigned males (AM) completed GIDYQ-AA and demographic questions. Seventeen (59%) AF reported non-heterosexual orientations, and 6 (21%) reported non-cisgender identities. One (6%) AM reported non-cisgender identity. Two (4%) AF individuals had GD based on GIDYQ-AA scores. GIDYQ-AA scores did not correlate with BMIz. In conclusion, adolescents with obesity, particularly AF with non-heterosexual orientation, reported high rates of non-cisgender identity and GD. Routine screening for gender-related concerns in weight management settings may be warranted.

Computational phenotyping within electronic healthcare data to identify transgender people in the United States: A narrative review

PURPOSE

With the expansion of research utilizing electronic healthcare data to identify transgender (TG) population health trends, the validity of computational phenotype (CP) algorithms to identify TG patients is not well understood. We aim to identify the current state of the literature that has utilized CPs to identify TG people within electronic healthcare data and their validity, potential gaps, and a synthesis of future recommendations based on past studies.

METHODS

Authors searched the National Library of Medicine's PubMed, Scopus, and the American Psychological Association PsycInfo's databases to identify studies published in the United States that applied CPs to identify TG people within electronic healthcare data.

RESULTS

Twelve studies were able to validate or enhance the positive predictive value (PPV) of their CP through manual chart reviews (n = 5), hierarchy of code mechanisms (n = 4), key text-strings (n = 2), or self-surveys (n = 1). CPs with the highest PPV to identify TG patients within their study population contained diagnosis codes and other components such as key text-strings. However, if key text-strings were not available, researchers have been able to find most TG patients within their electronic healthcare databases through diagnosis codes alone.

CONCLUSION

CPs with the highest accuracy to identify TG patients contained diagnosis codes along with components such as procedural codes or key text-strings. CPs with high validity are essential to identifying TG patients when self-reported gender identity is not available. Still, self-reported gender identity information should be collected within electronic healthcare data as it is the gold standard method to better understand TG population health patterns.

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

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

Two Gender Medicine: Provider-Side Barriers to Caring for Transgender and Gender Diverse Patients

Experienced and anticipated discrimination during health care visits result in lower health care utilization rates, which contribute to persistent health disparities between transgender and gender diverse (TGD) individuals and the general population. Most strategies for improving health care delivery to TGD patients place the responsibility on providers, overlooking the role of medical systems and institutions in creating the environments where negative health care experiences occur. Relying on the inhabited institutionalism framework, this study explores system- and institutional-level barriers to the provision of quality care to TGD patients identified by health care providers and administrators, including relevant contextual details of, and interactions between, these barriers. Based on interview data from health care providers and administrators from a variety of practices across Texas, we identified two overarching themes and six subthemes. We demonstrate how our interviewees' responses reveal an institutional logic of "two-gender medicine," which creates barriers to health care provision in both formal medical education and training and throughout the managed care model of practice. We also illustrate how health care workers find ways to resist this logic in the course of their practice. Addressing these barriers to delivering competent and compassionate care to TGD patients that providers encounter could make long overdue strides toward addressing health disparities.

Attitudes of Spanish mental health professionals towards trans people: A cross-sectional study

WHAT IS KNOWN ABOUT THE SUBJECT?: The trans community perceives barriers to the mental health services in the form of professionals' transphobia, lack of knowledge, and cultural sensitivity in healthcare. The attitudes of health professionals are mediated by their social context, which can determine their behaviour or attitude towards users. WHAT DOES THE ARTICLE ADD TO EXISTING KNOWLEDGE?: The attitudes of mental health professionals towards trans people are related to variables such as the professional's age, gender, political ideology and religious beliefs. Mental health nursing, psychology and social work are the professions that present more favourable attitudes towards trans people. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The inclusion of a professional perspective that understands sexual and gender diversity among mental health professionals is required. It is necessary to train professionals to promote socio-healthcare based on respect and free from prejudice, discrimination and stigma. ABSTRACT: Introduction The trans community perceives barriers to the mental health services in the form of professionals' transphobia, lack of knowledge and cultural sensitivity in healthcare. Aim Evaluation of the attitudes towards trans people of the professionals who work in the different Spanish mental health services. Method A cross-sectional design was used with a sample of professionals from different professional groups working in mental health units, hospitals and outpatient settings throughout Spain. Results Gender differences were found, with higher values in genderism and sexism among males. Negative attitudes and sexism have also been associated with age and religious beliefs. Mental health nursing, psychology and social work presented more favourable attitudes towards trans people than other mental health professionals. Discussion/Implications for Practice The inclusion of a professional perspective that understands sexual and gender diversity and the acquisition of professional attitudes based on evidence and patient-centred model are basic aspects to promote socio-healthcare based on respect and free from prejudices, discrimination and stigma.

Is size in the eye of the beholder? Visual estimation of penis size among transgender and cisgender people and implications for genital gender-affirming surgery and sexual medicine

BACKGROUND

Transgender men (TM) seeking gender-affirming phalloplasty and transgender women (TW) seeking vaginoplasty and desiring insertive intercourse must consider penis size. Evidence has shown that, at least among cisgender men (CM), penile dimensions tend to be poorly estimated. In transgender patients desiring gender-affirming surgery, inaccuracy in estimation of penis dimensions may lead to unnecessary morbidity: for TW, trauma to the neovagina; for TM with excess girth, an inability to insert. Studies on the accuracy with which transgender and cisgender patients estimate penis size are limited.

AIM

To assess the degree of accuracy with which CM and CW, as well as TM and TW, visually estimate the size of the human penis, including length, width, and girth.

METHODS

There were 142 participants included (25 TM, 47 TW, 30 CM, and 40 CW; net mean ± SD age, 36.6 ± 11.2 years). Participants were shown these models and asked to estimate length, width, and midshaft girth by visual inspection of 6 realistic models of a penis and scrotum of varying lengths and widths. We evaluated the accuracy of the visual measurements by comparing mean perceived dimensions with the actual dimensions of each model.

OUTCOMES

We used a multivariate model of all 3 bias dimensions to test for differences in average bias among gender groups (CM, CW, TM, and TW).

RESULTS

TM significantly overestimated length across the longest models. TW significantly overestimated length in the longer 3 models. All groups except for TM significantly underestimated girth in at least 1 model. No groups significantly underestimated width. CM, CW, and TM significantly overestimated width in all 6 models.

CLINICAL IMPLICATIONS

When transgender patients use numbers to express penis size (either in neophallus or vaginal depth based on perceived partner size), the result is likely to be larger than expected. Use of realistic penis models as a decision-making tool may help manage patient expectations and surgery decision making preoperatively and improve postoperative patient satisfaction and safety.

STRENGTHS AND LIMITATIONS

To our knowledge, this is the first study to assess visual estimation in penis size in TM and CM, as well as TW and CW. The penile models in our study were shown side by side and in the flaccid state despite having dimensions more consistent with an erect penis, which may have influenced estimations across all dimensions.

CONCLUSION

Men and women (cisgender and transgender) tend to significantly overestimate penis length and width.

LGBTQ+ Microaggressions in Health Care: Piloting an Observation Framework in a Standardized Patient Assessment

Microaggressions are subtle derogatory behaviors that unintentionally communicate hostility toward marginalized social groups. This article describes the preliminarily validation of a framework for observing LGBTQ+ microaggressions in health care, which can lead to distrust and disengagement from the healthcare system. Coders used the framework to observe microaggressions in video-recorded clinical-skills assessments with medical students who elicited health histories from standardized patients. Microaggression classifications were reviewed to determine construct reliability and the presence/absence among eight framework categories. Among 177 encounters with sexual and gender minority standardized patients, heteronormative/cisnormative language and assumptions occurred in the largest proportion of encounters (85.3%). Only identity-based referrals decreased significantly after a clinical skills intervention (20.0% to 4.9%, p = .01). These outcomes show that LGBTQ+ healthcare microaggressions are pervasive and will likely require nuanced training to address them. This groundwork can also be used to develop scales for patients and observers to identify microaggressions and assess perceived impact.

Primary care in Northern Ontario for transgender people in the context of the COVID-19 pandemic: A qualitative secondary analysis

PURPOSE

To examine changes to primary care practice for transgender clients resulting from government mandated public health measures in response to COVID-19 in Northern Ontario.

DESIGN

Secondary analysis of qualitative data using interview transcripts from a dataset that included 15 interviews conducted between October 2020 and April 2021.

METHODS

The dataset came from a convergent mixed method study exploring the delivery of primary care services to transgender individuals in Northern Ontario. Qualitative interviews with primary care practitioners including nurse practitioners, nurses, physicians, social workers, psychotherapists, and pharmacists providing care for transgender people in Northern Ontario were included in the secondary analysis.

RESULTS

Fifteen primary care practitioner providing care to transgender individuals in Northern Ontario participated in the parent study. Practitioners described their understanding of the effect of the early stages of the COVID-19 pandemic changes on their practice and the care experience for their transgender patients. Two themes were identified and described by participants: (1) a change in the delivery of care; and (2) barriers and facilitators to care.

CONCLUSIONS

Practitioners' primary care experiences in the early waves of COVID suggest the integral use of telehealth in Northern Ontario transgender care. Nurses working in advance practice and nurse practitioners are essential in providing continuity of care for their transgender clients.

CLINICAL RELEVANCE/SIGNIFICANCE

Identification of initial practice changes for the primary care of trans people will illuminate avenues for further research. The urban, rural, and remote practice settings in Northern Ontario provide an opportunity for increasing access for gender diverse people in these areas and for developing increased understanding of uptake of telemedicine practice. Nurses are integral to primary care for transgender patients in Northern Ontario.

Effectiveness and Safety of Different Estradiol Regimens in Transgender Women (TREAT Study): Protocol for a Randomized Controlled Trial

BACKGROUND

Current guidelines for gender-affirming hormone therapy (GAHT) for transgender women are mostly based on clinical experience from experts in the field and treatments used on postmenopausal women. While care is currently provided with the best available evidence, there is a critical gap in knowledge about the safest and most effective estradiol routes of administration for GAHT in transgender women; this statement is supported by the World Professional Association for Transgender Health on their Standards of Care for the Health of Transgender and Gender Diverse People, version 8. Furthermore, the reported rates of cardiometabolic adverse events in transgender women highlight the importance of investigating changes in lipoproteins, glucose, and insulin sensitivity, among other markers while receiving GAHT.

OBJECTIVE

This study aims to evaluate the degree of testosterone suppression achieved at 1, 6, and 12 months in treatment-naive transgender women when randomized to GAHT with estradiol and spironolactone as antiandrogens. As a secondary aim, this study will assess the treatment effect on metabolic and coagulation factors from baseline to 6 and 12 months after initiating GAHT.

METHODS

This is a prospective pilot, open-label, randomized clinical trial conducted at an adult transgender clinic in a tertiary medical center. The 3 treatment arms include once-daily sublingual 17-β estradiol, twice-daily sublingual 17-β estradiol, and transdermal 17-β estradiol. All participants received spironolactone as an antiandrogen. Transgender women aged 18 to 45 years who are being evaluated for the initiation of GAHT with 17-β estradiol and did not have a history of coagulopathy, cigarette smoking, liver disease, dyslipidemia requiring treatment, or use of gonadotropin-releasing hormone agonist were eligible to enroll. The main outcome is the total testosterone suppression at 1 and 6 months after the initiation of GAHT, and the secondary outcome is to assess treatment effect in a lipid panel; homeostatic model assessment for insulin resistance; coagulation factors II, IX, and XI; Von Willebrand factor; activated protein C resistance; protein C; and protein S at baseline, 6 months, and 12 months after therapy is initiated.

RESULTS

This study was funded in March 2022, and enrollment concluded in August 2022. It was concluded in July 2023, and currently, the results are being analyzed for publication.

CONCLUSIONS

The Transgender Estradiol Affirming Therapy (TREAT) study offers a rigorous and reproducible approach to answer important questions regarding GAHT in transgender women, specifically, the most effective 17-β estradiol regimen to suppress testosterone levels to 50 ng/dL, as currently recommended.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05010707; https://clinicaltrials.gov/study/NCT05010707.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53092.

Medical Educators' Perceptions and Experiences of Transgender Curriculum in Barbados

Purpose

This study explored medical educators' understanding of the term transgender and their attitudes and perspectives regarding (1) health system responsiveness to transgender needs and (2) transgender curriculum in medical education.

Methods

The study employed purposive sampling of medical educators responsible for design and delivery of curriculum. Fifteen of 18 eligible educators participated in Zoom focus groups (FG1 n=7, FG2 n=8). FGs averaged 93 min and were recorded, transcribed verbatim, and analyzed using a qualitative interpretivist methodology with deductive and inductive coding assisted by NVivo 12 Pro software.

Results

Educators were knowledgeable about the term transgender and the physical and psychosocial needs of transgender people. Participants viewed transgender care as a significant emerging health area. However, infrequent personal or clinical contact, coupled with constraints in human and other resources, resulted in the perception that transgender content as a stand-alone component of curriculum is difficult to justify. Participants articulated a need for broad-based diversity content, including disabilities, primarily at the undergraduate level. Educators saw transgender health as relevant for undergraduate-level psychiatry and postgraduate medical specializations. Analysis and discussion framed participant perspectives in the context of stigma, discrimination, and medicolegal and health systems that impede access to health care for transgender people.

Conclusion

Participants demonstrated knowledge of transgender and transgender health care needs. Areas for improvements in health care responsiveness were identified, particularly related to structural stigma and discrimination. Although participants expressed interest in including transgender health in the curriculum, this would require pragmatic optimization of teaching resources.

Exploring Mediators of Mental Health Service Use Among Transgender Individuals in Ontario, Canada

OBJECTIVES

To determine if and to what degree neighbourhood-level marginalization mediates mental health service use among transgender individuals.

METHODS

This retrospective cohort study identified 2,085 transgender individuals through data obtained from 4 outpatient community and hospital clinics in 3 large cities in Ontario, which were linked with administrative health data between January 2015 and December 2019. An age-matched 1:5 comparison cohort was created from the general population of Ontario. Outcome measures were analysed from March 2020 to May 2022. The primary outcome was mental health service utilization, which included mental health-related visits to primary care providers, psychiatrists, mental health- and self-harm-related emergency department visits, and mental health hospitalizations. Mediation variables included ethnic concentration, residential instability, dependency, and material deprivation at the neighbourhood level and were derived from the Ontario Marginalization Index.

RESULTS

This study identified 2,085 transgender individuals from participating outpatient community and hospital clinics, who were matched to the general population (n = 10,425). Overall, neighbourhood-level marginalization did not clinically mediate mental health service use. However, transgender individuals were more likely to be exposed to all forms of neighbourhood-level marginalization, as well as having higher rates of health service use across all outcome measures.

CONCLUSIONS

In this study, mental health service use among transgender individuals was not clinically mediated by marginalization at the neighbourhood level. This study highlights the need to explore marginalization and mental health service use at the individual level to better understand the mental health disparities experienced by transgender individuals and to ensure that health-care services are inclusive and affirming.

Knowledge, Attitudes, and Beliefs of Medical Students Toward Transgender Healthcare: A Community-Driven Initiative

Introduction Transgender patients face substantial systemic healthcare barriers and inadequate care from providers who often demonstrate clinical gaps in the medical needs of the transgender community. Providing interventions in which affirming transgender healthcare is explored, is crucial to delivering competent transgender-patient care and building compassionate physician-patient relationships. The Northeast Pennsylvania (NEPA) Trans Health Conference was established to address the growing need for an educational forum where transgender people could voice their narratives. In this educational intervention study, changes in the knowledge, attitudes, and beliefs about the psychosocial and medical needs of the transgender community in first-year undergraduate medical students were examined pre- and post-trans health conference attendance. Materials and methods In the late spring of both 2018 and 2019, first-year medical students attended the NEPA Trans Health Conference, hosted by the Geisinger Commonwealth School of Medicine (GCSOM). Student knowledge, attitudes, and beliefs, regarding the healthcare needs of the transgender community were evaluated prior to and directly after the conference (intervention). Though the surveys shared thematic similarities, the 2018 and 2019 surveys were different and thus were not used comparatively. Results In 2018, 35.24% of first-year medical students (37/105 participants) completed both the pre- and post-survey. Overall, 62.5% (5/8) of survey items yielded significant differences. In 2019, 25.5%, of first-year medical students (28/110 participants) completed both the pre- and post-survey and 47.6% (9/21) of survey items yielded significant results. Overall, although the majority of first-year medical students displayed positive attitudes toward trans people pre-intervention, the students also demonstrated increased knowledge, empathy, and understanding of the transgender healthcare narrative post-intervention. Conclusion Providing medical students with a humanistic intervention within the medical curriculum that is focused on the transgender person, in addition to their past and present healthcare experiences, offers a bridge between academic content and providing inclusive gender-affirming healthcare to all patients.

Exploring Hormone Therapy Effects on Reproduction and Health in Transgender Individuals

Transgender individuals often face elevated mental health challenges due to gender dysphoria, but gender-affirming treatments such as surgery and hormone therapy have been linked to significant improvements in mental well-being. The potential influence of time and circadian rhythms on these treatments is prevalent. The intricate interplay between hormones, clock genes, and fertility is profound, acknowledging the complexity of reproductive health in transgender individuals. Furthermore, risks associated with gender-affirming hormonal therapy and potential complications of puberty suppression emphasize the importance of ongoing surveillance for these patients and the need of fertility preservation and family-building options for transgender individuals. This narrative review delves into the intricate landscape of hormone therapy for transgender individuals, shedding light on its impact on bone, cardiovascular, and overall health. It explores how hormone therapy affects bone maintenance and cardiovascular risk factors, outlining the complex interplay of testosterone and estrogen. It also underscores the necessity for further research, especially regarding the long-term effects of transgender hormones. This project emphasizes the critical role of healthcare providers, particularly obstetricians and gynecologists, in providing affirming care, calling for comprehensive understanding and integration of transgender treatments. This review will contribute to a better understanding of the impact of hormone therapy on reproductive health and overall well-being in transgender individuals. It will provide valuable insights for healthcare providers, policymakers, and transgender individuals themselves, informing decision-making regarding hormone therapy and fertility preservation options. Additionally, by identifying research gaps, this review will guide future studies to address the evolving healthcare needs of transgender individuals. This project represents a critical step toward addressing the complex healthcare needs of this population. By synthesizing existing knowledge and highlighting areas for further investigation, this review aims to improve the quality of care and support provided to transgender individuals, ultimately enhancing their reproductive health and overall well-being.

A prospective comparison study of subcutaneous and intramuscular testosterone injections in transgender male adolescents

OBJECTIVES

This prospective study compares testosterone injection type and effects on biochemical changes, clinical effects, and quality of life amongst transgender and gender diverse (TGD) adolescents assigned female at birth (AFAB) over the first 6 months of subcutaneous (SQ) vs. intramuscular (IM) testosterone injections as part of their gender affirming care.

METHODS

Subjects were testosterone-naïve transgender adolescents, AFAB, ages 14-18 years old. Subjects were either randomized to injection type or selected a preferred injection type. At enrollment, subjects completed baseline labs and PedsQL™ quality of life questionnaire. At 3 month and 6 month follow up, subjects completed peak and trough testosterone levels, PedsQL™, masculinizing effects, and medication experience questionnaires.

RESULTS

Twenty-six subjects participated with a median age 15.5 years. By 6-month follow up, trough testosterone levels were comparable between the two groups. Peak testosterone levels were higher in the IM group at 3-month follow up. Mild adverse effects were rare (12 %, all in SQ subjects) and limited to skin reaction only. Self-reported masculinization effects and quality of life were not statistically different between injection groups. A total of 92 % of participants was self-injecting by 3-month follow up.

CONCLUSIONS

In this prospective study, clinical and biochemical effects are similar between SQ and IM testosterone injections for transgender adolescents. Subjects expressed preference for both injection types. Both SQ and IM injection modalities are safe and effective for TGD youth initiating testosterone and both options should be offered to patients.

Assessment of Medical Education on Transgender Health: A Scoping Literature Review

Little is known about how physician learners are assessed following educational interventions about providing gender-affirming care to transgender and gender diverse (TGD) people. The inclusion of learner assessments with educational interventions is essential to understand and measure health professionals' knowledge and skills. We seek to describe how the medical literature has approached the assessment of learners following educational interventions about TGD health. A scoping literature review was done. The guiding research question was "What are the current learner-assessment practices in medical education pedagogy about TGD health?" A total of 270 manuscripts were reviewed. 17 manuscripts were included for data extraction. Miller's pyramid was used to categorize results. 15 used pre- and post-intervention knowledge questionaries to assess learners. Six used simulated patient encounters to assess learners. Most assessments of TGD knowledge and skills among physician learners are pre- and post-surveys. There is sparse literature on higher level assessment following educational interventions that demonstrate learner skills, behaviors, or impact on patient outcomes. Discrete, one-time interventions that are lecture or workshop-based have yet to rigorously assess learners' ability to provide clinical care to TGD patients that is both culturally humble and clinically astute.

Effects of acute aerobic exercise on arterial stiffness in transgender men

Testosterone replacement therapy (TRT) in transgender men (TM) results in side effects such as elevated triglycerides and increased arterial stiffness. Exercise may be useful to ameliorate such effects, but no studies have examined the effects of acute aerobic exercise in TM. This study aimed to investigate the effects of acute aerobic exercise on arterial stiffness in TM. Thirty-six participants were included, comprising 12 TM (duration of TRT: 57.4 ± 30.3 months), 12 males and 12 females. All participants performed acute aerobic exercise on a treadmill at 50% heart rate reserve for 30 min. Arterial stiffness as measured by brachial-ankle pulse wave velocity (baPWV) was measured before exercise (Pre), 30 min after exercise (Post30), and 60 min after exercise (Post60). Serum sex hormone levels, and serum lipid profile were determined only before exercise. Serum low-density lipoprotein cholesterol (LDL-C) levels before exercise were significantly higher in TM than in males or females (males: p < 0.01; females: p < 0.05). At all points, baPWV in TM was significantly higher than in females (p < 0.05) and significantly lower than in males (p < 0.05). However, when comparing changes in baPWV over time in each group, significant decreases in Post30 and Post60 were seen in males compared to Pre (both p < 0.05), but no significant change after aerobic exercise was seen in TM or females. These results suggest that acute aerobic exercise yield different effects in TM than in males, but is unlikely to reduce arterial stiffness in TM receiving TRT.

A Cross-Sectional Analysis of Self-Reported Needs and Health Service Utilization Among Transgender Women in Lima, Perú

Purpose: Globally, transgender women (TGW) experience wide-ranging barriers to health and care, with disproportionately high risks of infectious and chronic diseases. Yet, research on transgender populations' access to care in low- and middle-income countries remains limited, focused on human immunodeficiency virus (HIV) infection, and assesses TGW as a homogenous group. We analyzed morbidity and health service uptake patterns among TGW in Lima, Perú, to understand health outreach and service needs to inform targeting and design of community-level interventions. Methods: This cross-sectional study surveyed a convenience sample of 301 TGW in metropolitan Lima during September-October 2020. We report descriptive statistics and bivariable and multivariable regression model results as adjusted prevalence ratios (aPRs). Results: Health coverage and access to care were suboptimal. Less education and older age were positively associated with illness and negatively associated with HIV and tuberculosis (TB) testing. In the first study to quantitatively examine health utilization by gender identity subgroup (i.e., woman, trans or transgender, transsexual, "transformista," "travesti," and other) in Perú, TGW who identified as women were more likely to ever test for HIV (aPR = 1.49, 95% confidence interval [CI]: 1.16-1.91) and use pre-exposure prophylaxis (PrEP) (aPR = 2.36, 95% CI: 1.15-4.80). Both awareness and interest regarding PrEP were low, as was usage among those who were interested in taking PrEP. Conclusion: Public health efforts should be tailored to meet TGW's diverse needs, expand TB testing, bridge the gap between PrEP interest and use, and increase insurance coverage and access to trans-friendly services for improved health.

The Importance of Safely Prescribing Hormones in the Transgender Community

The transgender community is rapidly growing, necessitating further education and understanding of their unique healthcare needs. Gender affirmation is a multistep process, which generally begins with transgender individuals socially transitioning by adopting a new name, pronouns, and appearance changes, such as hair and clothing, to express themselves. Additional gender affirmation treatment can be achieved through medical therapy with hormones and surgical intervention. Here, we report the case of an 18-year-old transgender man who presented to his primary care provider for a referral to initiate a medical transition with testosterone therapy. The patient practiced penetrative vaginal sex without contraception. The patient presented to the clinic eight months later with amenorrhea, thick coarse facial and body hair, oily skin, irritable moods, and a 20-lb weight gain. A pregnancy test revealed a positive result. A healthy baby girl was delivered at 40 weeks' gestation. This case demonstrates the importance of addressing contraception during the masculinization process in individuals who continue to practice vaginal intercourse. Healthcare providers should seek to establish a clinical environment free of discrimination and stigma to allow patients to feel comfortable describing potential triggers of gender dysphoria. We encourage medical practitioners to discuss all methods of birth control with transgender male patients and choose the contraceptive that best allows for a seamless medical transition.

Gender-inclusive practice in pregnancy determination for transgender, gender diverse and non-binary patients in medical imaging

In recent years, there has been an increased awareness and understanding of the varying gender identities within our society. Consequently, there has also been a need for healthcare providers to be cognizant of the unique needs of a gender-diverse population. Determining the pregnancy status of transgender, gender-diverse and non-binary patients in medical imaging settings has been poorly handled, and there is a lack of standardisation in the Australian and Aotearoa New Zealand setting. The potential risk of exposing a gender-diverse pregnant patient to ionising radiation increases the need for guidance to ensure potentially pregnant persons are not missed during screening questionnaires. This review article explores various approaches to pregnancy status determination for gender-diverse patients, recognising the complexities involved and emphasising the need for future work to establish a widely accepted solution.

Comparing Sexual Orientation and Gender Identity Documentation Between Adolescent and Pediatric Primary Care Clinics

PURPOSE

Recent literature suggests that sexual orientation and gender identity (SOGI) documentation is poor. We hypothesized that an adolescent clinic would have higher rates of SOGI documentation than a pediatric primary care clinic.

METHODS

We performed a single-center, retrospective, observational study of patients ages 10-26 presenting to the primary care or adolescent medicine clinics of a tertiary care hospital from 2019 to 2021. Electronic medical record (EMR) data were analyzed using Python and Stata/MP 16.1.

RESULTS

Patients in the adolescent clinic were five times more likely to have to have complete SOGI documentation compared to primary care. Gender diverse youth were over six times more likely to have a recorded sexual orientation than cisgender youth across both clinics.

CONCLUSION

Adolescent providers document SOGI more often than primary care providers. Sexual orientation information for cisgender patients remains poor across environments. This study emphasizes the need for ongoing provider education on SOGI documentation.

Preliminary Pilot-Testing of Intimate Partner Violence Screening for Transgender and Gender Diverse (TGD) Individuals in Med-Peds and Family Medicine

INTRODUCTION

Transgender and gender diverse (TGD) individuals, comprised of those whose gender identity does not correspond with the sex they were assigned at birth, represent approximately 1.4 million people in the U.S., with a higher prevalence among those 18-24 years old. TGD individuals experience high levels of intimate partner violence (IPV), which leads to disproportionately negative mental and physical health outcomes for this population. As a result, there is a resounding need to connect TGD populations to health-promoting services, supports and resources. Med-Peds and Family Medicine clinics may be particularly well-positioned to support these efforts due to physicians' focus on transitional-aged youth and young adults under 30.

METHODS

The current manuscript reports on processes and outcomes related to a quality improvement (QI) initiative that aimed to test the feasibility and acceptability of implementing IPV screening within both a Med-Peds and a Family Medicine specialty clinic serving TGD populations in Los Angeles, CA. This QI initiative included screeners that capture IPV in cisgender/non-TGD populations (Humiliation, Afraid, Rape, Kick [HARK]) as well as in TGD populations specifically (IPV-T). We utilized a mixed-methods approach to both quantify and qualify responses to existing IPV screening as well as informal feedback from clinic "champions" in each clinic.

RESULTS

Quantitative and qualitative findings from this QI initiative, featuring both general and TGD-specific IPV screening measures with 140 TGD individuals, elucidated several important processes that can support effective IPV screening and referral to supports and services. These include the importance of interdisciplinary teams, the utility of an iterative approach to screener roll-out, and the essential role of solidifying a referral process in these efforts. This project additionally shed light on the potential utility and challenges of implementing both general and TGD-specific IPV screening measures. Our pilot test did not support the necessity of a TGD-specific IPV screener for identifying and responding to IPV in this population, yet additional data is critical to generate more conclusive recommendations.

CONCLUSION

We recommend larger-scale data collection efforts to evaluate the utility of integrating general and TGD-specific screeners into clinic workflows to ensure optimal health promotion for the TGD population in Med-Peds and Family Medicine clinics.

Social Determinants of Health in Urban Transgender Patients: A Case Report

The social determinants of health (SDOH) are a complex web of factors that influence the health of individuals throughout their lifetime. There are many drivers of health inequities within the SDOH, such as socioeconomic status, education, employment, gender, and race/ethnicity. It is possible that mental illness may develop when these factors negatively affect health. However, current research primarily focuses on SDOH in cisgender individuals leaving a scientific gap in transgender individuals who require unique considerations when providing comprehensive medical care. We present the case of a 20-year-old transgender female who was admitted for suicidal attempts during a methamphetamine overdose, and who had been struggling with mental illness and suicidal gestures since she was a young teenager. The significance of our findings is discussed in the context of the substantial lack of current research on SDOH in transgender individuals to underscore the need for clinical awareness and promote future research.

Trends in transgender healthcare curricula in graduate medical education

Background

Recent studies have shown deficiencies in resident knowledge concerning transgender healthcare. However, there has not been an updated survey examining transgender healthcare training by medical residency directors. We assessed whether accredited residency programs in the United States and Canada were providing education on the healthcare needs of transgender patients.

Methods

We performed an exploratory descriptive survey study in 2022 of residency programs in the United States and Canada to assess residency education on transgender health using program directors listed in the website directory of the Accreditation Council for Graduate Medical Education.

Results

Out of 1680 residency program directors, 160 programs responded (response rate, 10%). Among the residency programs, education in transgender health was taught periodically throughout the curriculum (52.5%), in discrete modules (34.4%), or not taught at all (10.6%). However, 60% of residency program directors who responded reported that their program lacked any clinical rotation in which residents directly work with transgender patients. The most common areas of transgender care omitted from residency education on transgender health were barriers associated with chronic illness and mental health.

Conclusion

There remains a need for robust transgender medical training in residency programs through clinical rotations on transgender health.

Exploring the Relationship between (De-)Centralized Health Care Delivery, Client-Centeredness, and Health Outcomes-Results of a Retrospective, Single-Center Study of Transgender People Undergoing Vaginoplasty

Introduction: Transgender health care interventions (e.g., gender-affirming surgery) support transgender and gender-diverse people to transition to their gender and are delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different institutions spread over several locations). In this exploratory study, we investigated the relationship between centralized and decentralized delivery of transgender health care, client-centeredness, and psychosocial outcomes. Methods: A retrospective analysis of 45 clients undergoing vaginoplasty at one medical center was conducted. Mann-Whitney U tests assessed differences regarding five dimensions of client-centeredness and psychosocial outcomes between the health care delivery groups. To address shortcomings regarding the small sample size, we applied a rigorous statistical approach (e.g., Bonferroni correction) to ensure that we only identified predictors that were actually related to the outcomes. Results: All aspects of client-centered care were scored average or high. Decentralized delivery of care was more client-centered in terms of involvement in care/shared decision-making and empowerment. However, participants from decentralized health care delivery settings scored lower on psychosocial health (p = 0.038-0.005). Conclusions: The factor of (de-)centralized health care delivery appears to have a significant impact on the provision of transgender health care and should be investigated by future research.

How the COVID-19 Pandemic Influenced HIV Care: Are We Prepared Enough for Future Pandemics? An Assessment of Factors Influencing Access, Utilization, Affordability, and Motivation to Engage with HIV Services amongst African, Caribbean, and Black Women

The COVID-19 pandemic resulted in disruption in healthcare delivery for people living with human immunodeficiency virus (HIV). African, Caribbean, and Black women living with HIV (ACB WLWH) in British Columbia (BC) faced barriers to engage with HIV care services prior to the COVID-19 pandemic that were intensified by the transition to virtual care during the pandemic. This paper aims to assess which factors influenced ACB WLWH's access to, utilization and affordability of, and motivation to engage with HIV care services. This study utilized a qualitative descriptive approach using in-depth interviews. Eighteen participants were recruited from relevant women's health, HIV, and ACB organizations in BC. Participants felt dismissed by healthcare providers delivering services only in virtual formats and suggested that services be performed in a hybrid model to increase access and utilization. Mental health supports, such as support groups, dissolved during the pandemic and overall utilization decreased for many participants. The affordability of services pertained primarily to expenses not covered by the provincial healthcare plan. Resources should be directed to covering supplements, healthy food, and extended health services. The primary factor decreasing motivation to engage with HIV services was fear, which emerged due to the unknown impact of the COVID-19 virus on immunocompromised participants.

Coping Strategies as a Moderator for the Association between Intimate Partner Violence and Depression and Anxiety Symptoms among Transgender Women

Evidence suggests that intimate partner violence (IPV) is associated with negative mental health outcomes. There is currently limited research on the impact of IPV on the outcomes of mental health for transgender women. The current study aimed to examine the relationship between intimate partner violence, coping skills, depression, and anxiety in a sample of transgender women. Hierarchical regression analyses were conducted examining the relationship of IPV and depression and anxiety symptoms, where coping skills moderate this relationship. The results suggest that those with experiences of IPV are more likely to have symptoms of depression and anxiety. For individuals with no experiences of IPV and low depression, high levels of emotional processing coping and acceptance coping buffered this relationship. For individuals with more experiences of IPV and more depressive symptoms, coping skills did not show to buffer this relationship. These same coping skills did not show evidence for buffering anxiety symptoms for transgender women with low or high levels of IPV. The results, implications, and limitations of this study and suggestions for further research are discussed.

Vaginal self-lubrication following peritoneal, penile inversion, and colonic gender-affirming vaginoplasty: a physiologic, anatomic, and histologic review

INTRODUCTION

Vaginal self-lubrication is central to the sexual satisfaction and healthy genitourinary function of patients who have undergone gender-affirming vaginoplasty (GAV). Secretory capacities of different neovaginal lining tissues have been variably described in the literature, with little evidence-based consensus on their success in providing a functionally self-lubricating neovagina. We review the existing neovaginal lubrication data and the anatomy, histology, and physiology of penile and scrotal skin, colon, and peritoneum to better characterize their capacity to be functionally self-lubricating when used as neovaginal lining.

OBJECTIVES

The study sought to review and compare the merits of penile and scrotal skin grafts, spatulated urethra, colon, and peritoneal flaps to produce functional lubrication analogous to that of the natal vagina in the setting of GAV.

METHODS

We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Medline, EMBASE, ClinicalTrials.gov, and the Cochrane Library databases were searched for peer-reviewed studies published prior to December 12, 2022, that (1) included data specific to transfeminine individuals; (2) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (3) included specific discussion of vaginal lubrication or fluid secretion following GAV utilizing penile skin, colonic tissue, or peritoneum.

RESULTS

We identified 580 studies, of which 28 met our inclusion criteria. Data on neovaginal lubrication were limited to qualitative clinician observations, patient-reported outcomes, and satisfaction measures. No studies quantifying neovaginal secretions were identified for any GAV graft or flap technique. Anatomically, penile and scrotal skin have no self-lubricating potential, though penile inversion vaginoplasty may produce some sexually responsive secretory fluid when urethral tissue is incorporated and lubricating genitourinary accessory glands are retained. Colonic and peritoneal tissues both have secretory capacity, but fluid production by these tissues is continuous, nonresponsive to sexual arousal, and likely inappropriate in volume, and so may not meet the needs or expectations of some patients. The impact of surgical tissue translocation on their innate secretory function has not been documented.

CONCLUSIONS

None of penile/scrotal skin, colon, or peritoneum provides functional neovaginal lubrication comparable to that of the adult natal vagina. Each tissue has limitations, particularly with respect to inappropriate volume and/or chronicity of secretions. The existing evidence does not support recommending one GAV technique over others based on lubrication outcomes. Finally, difficulty distinguishing between physiologic and pathologic neovaginal fluid secretion may confound the assessment of neovaginal self-lubrication, as many pathologies of the neovagina present with symptomatic discharge.

Providing gender-affirming care to transgender and gender-diverse individuals with and at risk for HIV

Transgender and gender-diverse populations have unique medical and psychosocial needs. It is important that clinicians address these needs with a gender-affirming approach in all aspects of health care for these populations. Given the significant burden of HIV experienced by transgender people, such approaches in providing HIV care and prevention are essential both to engage this population in care and to work toward ending the HIV epidemic. This review presents a framework for practitioners caring for transgender and gender-diverse individuals to deliver affirming, respectful health care in HIV treatment and prevention settings.

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.

Transgender Healthcare and Medical Education: An Inductive Thematic Analysis of Digital Discourse

Introduction Transgender and gender-diverse (TGD) patients face significant healthcare disparities informed by discrimination, social stigma, and socioeconomic inequality. This is further exacerbated by a paucity of transgender health content in medical education, contributing to a large proportion of providers being ill-equipped to manage TGD patients' health concerns. Method This paper uses the framework approach for an inductive thematic analysis of online discussion forums concerning transgender health and medical education. Online text from anonymous participants was chosen for their authentic accounts of healthcare experiences and to ensure responses are less restrained in discussing sensitive topics. Results Three major themes were identified from the data: desire for more knowledgeable providers, negative healthcare experiences and attitudes, and recommendations for transgender health education. Three subcategories emerged from the latter theme that further illuminated participant recommendations for inclusive healthcare. Conclusions As a result of the unique healthcare concerns faced by TGD patients, providing materials to educate students and providers is crucial to meet the needs of the TGD patient population. Participant reports align with previous literature in recommending curricular reforms in medical school, promoting career options for TGD-identifying people in healthcare, and cultivating a more inclusive clinical culture.

Instability in Housing and Medical Care Access: The Inequitable Impacts of the COVID-19 Pandemic on U.S. Transgender Populations

Purpose

To assess whether the COVID-19 pandemic has inequitably impacted key social determinants of health (SDoH), specifically employment, housing, and health care, for U.S. transgender populations.

Methods

Between April 13, 2020 and August 3, 2020, we conducted a national, cross-sectional online survey of sexual and gender minority individuals (N=870). We used logistic regression to calculate both unadjusted and adjusted odds of unemployment, homelessness/housing instability, and interruptions in medical care owing to the pandemic by gender and gender modality. Adjusted models controlled for age, race/ethnicity, and region.

Results

In adjusted models, transgender and gender diverse people had 2.12 times the odds of reporting homelessness/housing instability and 2.88 times the odds of reporting medical care interruptions compared with cisgender peers. Transgender men, women, and nonbinary people had 4.12, 3.29, and 3.48 times the adjusted odds of interruptions in medical care compared with cisgender men, respectively. We did not observe significant differences in employment.

Conclusions

Findings add empirical support to the hypothesis that socioeconomic consequences of COVID-19 are inequitably impacting transgender people. To contextualize our results and support future research in this area, we present a conceptual model of the short- and long-term impacts of COVID-19 on transgender populations using a framework of stigma as a fundamental cause of health inequities. Our findings emphasize that public health professionals must urgently consider-and intervene to address-the pandemic's SDoH-related impacts on transgender populations.

Postoperative adverse events following gender-affirming vaginoplasty: an American College of Surgeons National Surgical Quality Improvement Program study

BACKGROUND

As a part of gender-affirming care, many transgender women undergo vaginoplasty surgery, which is increasingly being performed in the United States. There are considerable knowledge gaps about adverse events associated with vaginoplasty as most published articles report single-center results.

OBJECTIVE

This study aimed to describe severe and overall 30-day adverse events after gender-affirming vaginoplasty using a large multicenter database.

STUDY DESIGN

This was a retrospective cohort study of transgender women who underwent vaginoplasty between 2011 and 2019 using the American College of Surgeons National Surgical Quality Improvement Program database. Cases were initially identified by diagnosis codes for gender identity disorders and procedure codes for male-to-female vaginoplasty. Adverse events at 30 days were identified, including unplanned reoperation or readmission, blood transfusion, wound dehiscence, surgical site infections, thromboembolic disease, sepsis, cerebrovascular or cardiac events, and urinary tract infection. Surgical procedures were further stratified by Clavien-Dindo grade, a standardized classification system for registering surgical complications. A score of 0 is given if there is no adverse event, whereas scores of 1 and 2 refer to deviations from the normal postoperative course, which may include additional pharmacologic treatment, bedside-managed wound complications, and blood transfusions. Clavien-Dindo grades of 3 to 4 include surgical interventions or life-threatening complications requiring intensive care unit management. A Clavien-Dindo grade of 5 is given for any complication resulting in death.

RESULTS

A total of 488 cases were eligible for inclusion in this study. The mean age of the cohort was 37.5 years, and race distribution was as follows: 71.1% White, 15.2% Black, 5.5% Asian or Pacific Islander, and 8.2% other. Of the cohort, 18.6% were Hispanic. Surgeries were performed by plastic surgeons (87.9%), urologists (8.6%), gynecologists (1.8%), and other specialists (1.6%). Concurrent nongenital surgery was performed in 17% of cases. The median operative time for all cases was 271 minutes (interquartile range, 214-344). There was no reported death in the 30-day period (Clavien-Dindo grade 5), and 27 cases (5.5%) had a Clavien-Dindo grade of 3 to 4. On multivariate analysis, body mass index and higher American Society of Anesthesiologists class were associated with higher odds of having a Clavien-Dindo grade of 3 to 4 (adjusted odds ratios, 2.9 [95% confidence interval, 1.32-4.21; P=.01] and 1.23 [95% confidence interval, 0.56-2.57; P=.05], respectively). Wound dehiscence, superficial surgical site infection, or deep surgical site infection occurred in 46 cases (9.0%). The readmission rate was 4.3% (n=21). Several preoperative factors had higher odds of readmission: body mass index (adjusted odds ratio, 9.81; 95% confidence interval, 1.77-22.13; P=.005), higher American Society of Anesthesiologists class (adjusted odds ratio, 3.23; 95% confidence interval, 1.23-9.03; P=.003), diabetes mellitus (adjusted odds ratio, 5.39; 95% confidence interval, 1.42-20.45; P=.006), and hypertension (adjusted odds ratio, 3.63; 95% confidence interval, 1.26-10.47; P=.01). The reoperation rate was 4.7% (n=23), with no significant patient factor associated with this complication. Of the reoperations, 68.2% of cases were due to wound problems, vaginal bleeding, or hematoma.

CONCLUSION

In transgender women undergoing vaginoplasty for gender affirmation, severe postoperative complications were rare, occurring in 1 of 20 patients. Most patients experienced minor complications or no complication after surgery.

'Don't think that we die from AIDS': Invisibilised uncertainty and global transgender health

The invisibilisation of social groups in health research and survey data is a source of medical uncertainty, long seen as a hallmark of the medical field. However, scholarship has not thoroughly assessed how medical uncertainty is structured by state-level processes and global health agendas, especially for people beyond the Global North. This article introduces invisibilised uncertainty as a type of medical uncertainty structured by global organisational and state-level priorities, which can invisibilise social groups and health problems from research and data collection, exacerbating medical uncertainty and health disparities for people worldwide. Based on 14 months of fieldwork in Thailand and in-depth interviews with 62 participants, the article illuminates how state-level processes and global clinical research agendas have structured knowledge gaps and uncertainties for Thai transgender women. As omissions in health research and data collection become embodied on a world scale, the article expands our understandings of how gendered health disparities are structured nationally and globally. It advances a sociology of medical ignorance by analysing the uneven landscape of holistic transgender health research, parsing how institutional dynamics can prioritise or invisibilise people and health issues in research and data, and structure uncertainties.

Non-typhoidal Salmonella soft-tissue infection after gender affirming subcutaneous mastectomy case report

We present a case of a 32-year-old transgender male who underwent chest masculinization, complicated by purulent soft tissue infection of bilateral chest incisions. Cultures tested positive for non-typhoidal Salmonella, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa. Herein, we discuss multiple factors contributing to the complexity of treating this patient's clinical course.

[The suicidal activity and comorbid mental pathology in persons with gender dystrophia]

According to foreign publications, 58% of patients with gender disorders had additional psychiatric diagnosis, 39.3% had at least one suicide attempt. The data of suicidal activity and mental comorbidity in Russian population of transgenders are absent.Purpose of the study is to assess suicidal activity and mental comorbidity in persons with gender disorders.The retrospective analysis of records of patients applied with complains on gender disorders from January 2014 to April 2021 was applied. The demographic characteristics, life anamnesis, comorbid mental pathology at time of appliance, frequency of suicidal attempts, suicidal thoughts and auto-aggressive behavior were examined. The data of 926 patients with gender disorders were included: FtM 515 (55.7%), MtF 411 (44.3%). The median age of patients applied for care appliance was 24 years (13-65 years). In group of transgender patients 75.2% had no mental illness, except gender disorders. At that, there was high prevalence of comorbid mental pathology (24.8% on average). Usually, it was background mental illnesses and reversible mental disorders, which were not causes of gender disorders. The suicide rate in transgender group was 12.5%. For 1 patient with suicidal experience, there were 1.3 suicidal attempts (from 1 to 5). The significant dependence of increased suicidal activity, depression, auto-aggressive behavior and rate of comorbid mental pathology on age of debut of gender disorders was established. The transgender patients with debut of gender dysphoria in puberty age are most vulnerable to development of any mental pathology. The suicidal activity of patients with gender disorders depends on both social causes and presence of comorbid mental pathology. A number of modifiable risk factors for suicidal behavior were identified: support of relatives, external correspondence to associated gender, early steps to "change gender", earlier apply for medical care, background compensated mental illnesses.

Assessing Comfort of Physicians to Provide Transgender-Specific Care

Purpose

Transgender individuals disproportionately face barriers to accessing and receiving health care. This study examines physician comfort in managing and caring for the unique health needs and barriers that transgender patients encounter. We predicted that increased exposure to a transgender person, prior treatment of a transgender patient, and transgender health education would increase comfort in providing care to transgender individuals.

Methods

A Qualtrics® survey link was sent through mail to actively licensed physicians within the state of Nevada. Questions related to perceived comfort level were measured on a 10-point scale (1=lowest level of comfort, 10=highest level of comfort) and dichotomized for analysis (1-5=not comfortable, 6-10=comfortable).

Results

Survey response was 62 of 1620 (4%). Comfort with providing transgender patients routine care (87%) and sex or gender-related care (68%) was high, whereas comfort with providing hormonal treatment (26%) was low. A majority (61%) of respondents either had no training or obtained their training through a nonformal avenue (e.g., self-study and literature review) regarding transgender health issues. Although there was no evidence that knowing a transgender person (p>0.165) or having more education (p>0.489) significantly improved comfortability with treatment, respondents who had previously treated a transgender patient had greater comfort providing routine (p=0.059) and sex or gender-related care (p=0.011).

Conclusion

Although the results show that a majority of physician respondents in Nevada feel comfortable providing routine care to transgender patients, they also reveal a need for education that incorporates experience with transgender patients and a need for widely available guidelines on hormonal treatment of transgender patients.

Review of Health Insurance Policy Inclusivity of Gender Nonconforming and Nonbinary Individuals Seeking Gender-Affirming Health Care

Background

An increasing number of individuals who present to health care professionals identify as transgender, gender nonconforming (GNC), and gender nonbinary (NB). GNC/NB individuals experience higher rates of discrimination in health care settings compared with their binary (e.g., trans male and trans female) counterparts. Outdated language excludes the nuances of gender identity. The goal of this study was to evaluate whether current terminology found in health insurance policies may be a barrier to gender-affirming health care for GNC/NB individuals.

Methods

Health insurance policies for a diverse subset of government (n=4) and private (n=6) payers were obtained in May 2020. Policies were reviewed independently by two members of the research team to determine whether each was supportive or unsupportive to GNC/NB individuals. An arbitrary scoring system was designed that allowed the reviewers to assign a specific number of points to each policy based on the aggregation of mention, coverage, and inclusivity.

Results

Most policies performed poorly as indicated by a support score less than zero. It was also noted that most policies used binary, gendered language, and terminology that excludes the unique gender identities of many GNC/NB individuals.

Conclusions

Most policies currently failed to provide clear, inclusive coverage to GNC/NB individuals for relevant and important aspects of their care. In their current state, these policies are a source of confusion, uncertainty, and discouragement for these individuals, which can present as a barrier to accessing quality, inclusive, gender-affirming health care.

"I Don't Want to Spend the Rest of my Life Only Going to a Gender Wellness Clinic": Healthcare Experiences of Patients of a Comprehensive Transgender Clinic

BACKGROUND

Transgender individuals are less likely to have had a primary care visit in the last year than cisgender individuals. While the importance of multidisciplinary clinics for transgender care has been established, little is known about the healthcare experiences of transgender patients with these clinics.

OBJECTIVE

To describe how patients experience transgender clinics and how these experiences compare to those experiences in other settings.

PARTICIPANTS

Twenty-one adult patients of a gender health program.

DESIGN AND APPROACH

Semi-structured interviews of transgender patients. The interviews focused on two domains: healthcare experiences and relationships with healthcare providers.

KEY RESULTS

Overall, transgender patients expressed a need for healthcare services, particularly for primary care, that are partially met by the comprehensive care clinic model. Limitations in access included the lack of willing providers, where the patients live, and long wait times for appointments. Participants recounted a range of experiences, both positive and negative, with providers outside of the transgender clinic, but only positive experiences to share about providers from the transgender clinic.

CONCLUSION

Outside specialty transgender settings, many patients had negative experiences with providers who were unwilling or unable to provide care. This study speaks to the need for primary care providers who can and will treat transgender patients, as well as the need for healthcare spaces that feel safe to transgender patents.

The Mount Sinai Interdisciplinary Approach to Perioperative Care Improved the Patient Experience for Transgender Individuals

Purpose

Although medical care for transgender and gender nonbinary (TGNB) individuals is rapidly expanding, numerous gaps in the organization of quality care for TGNB individuals remain. In 2018, the Mount Sinai Center for Transgender Medicine and Surgery (CTMS) expanded its unified care approach to integrate services with an interdisciplinary inpatient team for surgical patients as part of the program. The inpatient team connected with the existing interdisciplinary ambulatory team with all pertinent medical and psychosocial information shared between the teams. The format enabled the hospital team to better prepare in advance of a patient's arrival and facilitated discharge planning as well. We sought to assess patient satisfaction with inpatient care after implementation of the interdisciplinary operation.

Methods

The standard Press Ganey survey tool used by the Mount Sinai Health System to measure patient satisfaction with care was queried before and after implementation of the interdisciplinary inpatient care team.

Results

Patient ratings of inpatient care rose dramatically. Relative to other institutions nationally, Press Ganey scores rose into the 98th or 99th percentiles across all domains. The new scores represented a rise of 25% for communication with nurses, 3% for hospital environment, 25% for care transition, and 100% for willingness to recommend. The discharge information score represented a 30-fold improvement.

Conclusion

An interdisciplinary inpatient health care team can significantly improve patient satisfaction for TGNB patients. Such an approach might be considered for other TGNB health care programs along with health care delivery in other areas of medicine.

They "Don't Know How to Deal with People Like Me": Assessing Health Care Experiences of Gender Minorities in Indiana

Purpose

Within the LGBTQ+ community, the transgender and nonbinary (TGNB) population experience a disproportionate amount of discrimination when seeking health care. Such disparities may arise from lack of proper medical training and resources for providers or biases. In this study, we examine the health care experiences of TGNB individuals living in Southern Indiana.

Methods

We analyzed responses from TGNB respondents to an LGBTQ+ health care needs assessment survey in Southern Indiana. Respondents were asked about demographic data, their self-assessed health status, quality of health care received, whether they have a provider with whom they feel comfortable sharing their gender identity with, and if they have to commute to see their provider. Finally, respondents were asked an open-ended question about their health care experiences while living in Southern Indiana. Responses were coded and several themes emerged and were analyzed.

Results

Eighty-five TGNB individuals completed our survey. Less than half of respondents indicated that they had an LGBTQ+-welcoming provider (44.7%). Individuals with an LGBTQ+-welcoming provider were more likely to report their self-assessed health as excellent/good (p=0.02) and quality of health as excellent/very good (p=0.03) compared to individuals without an LGBTQ+-welcoming provider. Five themes emerged from the write-in responses (n=64): discrimination (34.4%), invalidation (32.8%), distrust (28.1%), logistic concerns (35.9%), and positive experiences (35.9%).

Conclusion

The TGNB community living in Southern Indiana reports numerous barriers related to provider attitudes when obtaining health care. Additional training is needed to address provider biases and improve LGBTQ+ community health disparities.

Disordered Eating and Body Dissatisfaction in Transgender and Gender-Expansive Adults: An Evaluation and Integration of the Gender Minority Stress and Resilience and Tripartite Influence Models

Transgender and gender-expansive (TGE) people, including transgender and nonbinary individuals, experience elevated rates of body dissatisfaction and disordered eating compared to cisgender individuals, but little is known about why. To address this research gap, we compared the ability of TGE-specific factors as proposed in the gender minority stress and resilience (GMSR) model, general psychological factors contained in the tripartite influence (TI) model, and an integration of these frameworks to explain body dissatisfaction and disordered eating among TGE individuals. Regression analyses were conducted to test the models' abilities to explain experiences reported in a survey of 93 U.S. TGE adults, including 43 transgender women respondents (46.2%) and 31 transgender men respondents (33.3%). Participants were diverse with regard to age (M = 34.19, SD = 12.02) and ethnoracial background (e.g., 29.0% Hispanic/Latinx, 17.2% Black/African American, 6.5% American Indian/Alaska Native; 5.4% multiracial). Results demonstrated both models' abilities to explain body dissatisfaction and disordered eating independently, except for the relationship between body dissatisfaction and the thinness-oriented TI model. An integration of the models better explained body dissatisfaction and disordered eating compared to either model alone. Notably, some findings did not align with the two frameworks, suggesting existing models may not adequately describe pathways through which disordered eating emerges in TGE populations. Specifically, body dissatisfaction showed no significant relationship with disordered eating and was not well explained by the TI model, and higher gender identity pride was related to greater disordered eating symptoms. Implications for clinical care and future research are discussed.

Intimate Partner Violence (IPV) Screening and Referral Outcomes among Transgender Patients in a Primary Care Setting

Transgender patients are at elevated risk of intimate partner violence (IPV), but national guidelines do not recommend routine screening for this population. This paper explores the feasibility and effectiveness of routine IPV screening of transgender patients in a primary care setting by describing an existing screening program and identifying factors associated with referral and engagement in IPV-related care for transgender patients. An IPV "referral cascade" was created for 1,947 transgender primary care patients at an urban community health center who were screened for IPV between January 1, 2014 to May 31, 2016: (a) Of those screening positive, how many were referred? (b) Of those referred, how many engaged in IPV-specific care within 3 months? Logistic regression identified demographic correlates of referral and engagement. Of the 1,947 transgender patients screened for IPV, 227 screened positive. 110/227 (48.5%) were referred to either internal or external IPV-related services. Of those referred to on-site services, 65/103 (63.1%) had an IPV-related appointment within 3 months of a positive screen. IPV referral was associated with being assigned male at birth (AMAB) versus assigned female at birth (AFAB) (AOR = 2.69, 95% CI 1.52, 4.75) and with nonbinary, rather than binary, gender identity (AOR = 2.07, 95%CI 1.09, 3.73). Engagement in IPV-related services was not associated with any measured demographic characteristics. Similar to published rates for cisgender women, half of transgender patients with positive IPV screens received referrals and two-thirds of those referred engaged in IPV-specific care. These findings support routine IPV screening and referral for transgender patients in primary care settings. Provider training should focus on how to ensure referrals are made for all transgender patients who screen positive for IPV, regardless of gender identity, to ensure the benefits of screening accrue equally for all patients.

Worry and Wisdom: A Qualitative Study of Transgender Elders' Perspectives on Aging

Purpose: While lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) elders face a multitude of barriers to healthy aging, little is known about needs and concerns specific to transgender elders, except that they face many self-perceived challenges to healthy aging, which exist at the individual, community, and institutional levels. To further understand these needs, we explored the perspectives of transgender individuals aged 65 and older on health care, expectations of aging, concerns for the future, and advice for young transgender people. Methods: We performed 19 semistructured interviews with individuals who identify as transgender elders, 10 transgender women and 9 transgender men. Interviews were transcribed and coded by three investigators to generate salient themes via thematic analysis. Results: We identified 7 major themes that exemplify the concerns and experiences of this sample of the aging transgender community: fear of mistreatment in elder care, isolation and loneliness exacerbated by transgender identity, increased vulnerability to financial stressors, perceived lack of agency, health care system and provider inclusivity, giving back to one's community, and embracing self-truth as a path to fulfillment. Conclusion: While some of these concerns, such as fear of mistreatment, are common among elders, the concerns of transgender elders are heightened due to stigma compounded by being both transgender and elderly. Health care providers, nursing home staff, and social workers must be sensitized to these needs and fears to provide appropriate, affirming, and respectful care and support to transgender elders.

"Making a Way Out of No Way:" Understanding the Sexual and Reproductive Health Care Experiences of Transmasculine Young Adults of Color in the United States

Research focusing on the specific and unique sexual and reproductive health care experiences of transmasculine young adults of color are extremely scarce. We conducted five focus group discussions with 19 Black, Latinx, Asian, Native, and other transmasculine individuals of color aged 18-25 years in the greater Boston area. Using thematic analysis, we found that transmasculine young adults of color experienced cissexism, heterosexism, and racism in accessing and utilizing sexual and reproductive health services. These multiple forms of discrimination undermined participants' receipt of high-quality sexual and reproductive health information and care from competent health care providers who shared their lived experiences. Participants relied on support from their lesbian, gay, bisexual, transgender, and queer peers to obtain needed sexual and reproductive health resources and minimize harm during clinical encounters. Multilevel interventions are needed to promote access to person-centered and structurally competent sexual and reproductive health care among transmasculine young adults of color.