HIV/Pre-Exposure Prophylaxis Knowledge and Acceptability of Rapid HIV Testing Among Transgender Adolescents in a Multidisciplinary Gender Clinic.

Purpose: The objectives of this study were to assess the knowledge of HIV and pre-exposure prophylaxis (PrEP) in transgender adolescents and young adults (AYAs) and to test the acceptability of rapid HIV testing among transgender adolescents in a multidisciplinary gender clinic. Methods: Participants enrolled on the same day as their mental health or medical appointment in a multidisciplinary gender clinic. They completed survey questions regarding HIV and PrEP knowledge and were also offered an optional same-day, rapid, fourth-generation HIV test. Participants who had an HIV test answered additional questions about their testing experience. Results: We enrolled 61 participants; just over half (n=31) were assigned female at birth. Less than a third (n=20, 32.8%) scored 80% or above regarding HIV knowledge. Nearly half of the participants (n=29, 47.5%) were not interested in PrEP. Forty-one percent of participants chose to have a rapid HIV test; all were "satisfied" with the testing experience. There were no positive HIV results. Conclusions: Transgender AYAs have gaps in their understanding of HIV acquisition and transmission. Rapid HIV testing in the setting of gender care is well received by those who desire testing and may be a way to increase knowledge of transgender AYA HIV status.

Development of a mentor training curriculum to support LGBTQIA+ health professionals.

While mentors can learn general strategies for effective mentoring, existing mentorship curricula do not comprehensively address how to support marginalized mentees, including LGBTQIA+ mentees. After identifying best mentoring practices and existing evidence-based curricula, we adapted these to create the Harvard Sexual and Gender Minority Health Mentoring Program. The primary goal was to address the needs of underrepresented health professionals in two overlapping groups: (1) LGBTQIA+ mentees and (2) any mentees focused on LGBTQIA+ health. An inaugural cohort (N = 12) of early-, mid-, and late-career faculty piloted this curriculum in spring 2022 during six 90-minute sessions. We evaluated the program using confidential surveys after each session and at the program's conclusion as well as with focus groups. Faculty were highly satisfied with the program and reported skill gains and behavioral changes. Our findings suggest this novel curriculum can effectively prepare mentors to support mentees with identities different from their own; the whole curriculum, or parts, could be integrated into other trainings to enhance inclusive mentoring. Our adaptations are also a model for how mentorship curricula can be tailored to a particular focus (i.e., LGBTQIA+ health). Ideally, such mentor trainings can help create more inclusive environments throughout academic medicine.

Disordered eating and considerations for the transgender community: a review of the literature and clinical guidance for assessment and treatment.

BACKGROUND: It has been well established that individuals who identify as lesbian, gay, bisexual, transgender, and queer are at increased risk for mental health pathology, including eating disorders/disordered eating behaviors (ED/DEB). However, less is understood about the unique experiences of transgender and gender diverse (TGD) people who struggle with ED/DEB. AIMS: The purpose of this literature review is to examine the literature regarding the unique risk factors for TGD individuals who experience ED/DEB through a lens informed by the minority stress model. Additionally, guidance around the assessment and clinical management of eating disorders for TGD individuals will be presented. RESULTS: TGD people are at increased risk for developing ED/DEB due to a number of factors including: gender dysphoria, minority stress, the desire to pass, and barriers to gender affirming care. CONCLUSION: While guidance around assessment and treatment of ED/DEB for TGD individuals is still limited, adhering to a gender affirmative care model is essential.

People who identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ) are more likely to have mental health difficulties, including eating disorders/disordered eating behaviors (ED/DEB). Much of the existing literature has focused on LGBTQ populations and not on the unique experiences of transgender and gender diverse (TGD) people. This literature review seeks to examine the unique risk factors for TGD people who experience ED/DEB. The minority stress model is used to better understand these risk factors, which include gender dysphoria, minority stress, the desire to pass, and barriers to gender affirming care. Research offering guidance for assessing and treating ED/DEB with TGD people is still limited but it is clear that a gender affirmative care model provides robust support for this population.

COVID-19 impacts and videoconference healthcare preferences in relation to depression and sexual risk behaviors among young adults assigned female at birth: a cross-sectional study.

Background: Due to decreased access to sexual and reproductive health (SRH) services and an increase in depressive symptoms, the coronavirus disease 2019 (COVID-19) pandemic has exacerbated the risk of unsafe sexual behaviors among already vulnerable young adults assigned female at birth (AFAB). Despite its potential for improving SRH outcomes, little is known about how young adults view virtual SRH counseling. We designed a survey to examine these perspectives and further characterize pandemic-associated changes in mood and healthcare access in young adults AFAB. Methods: Patients of a Midwest family planning organization who were AFAB and aged 21-24 years were recruited via convenience sampling between May and September 2021. Participants answered survey questions about how they perceived that the pandemic had affected their mood and healthcare access. The Patient Health Questionnaire (PHQ)-8 assessed depressive symptoms. Additional questions probed SRH risk behaviors and experience with and opinions on virtual healthcare and research. Non-responses to questions were not included in analyses. Associations among these variables were analyzed using non-parametric bivariate tests (chi-square and Mann-Whitney U). Results: One hundred twenty people participated in the survey. Participants had a median age of 22 years and self-identified predominantly as female and White. Three-quarters of respondents reported their mood worsened as a result of the pandemic and more than 3 in 10 had depression. Those reporting pandemic-worsened mood had more severe depressive symptoms than those who did not (U=722.500, P=0.005). Most reported sexual intercourse in the past 3 months, nearly all of whom reported at least one SRH risk. Pandemic mood impacts were not associated with SRH risk. One in four participants reported pandemic-associated difficulty accessing healthcare, which was not associated with depression or SRH risk. Most reported comfort with videoconference healthcare, including technology, speaking with a provider, and having enough privacy. Conclusions: The COVID-19 pandemic has increased depression and SRH risk among young adults AFAB and, at the same, impeded their access to healthcare. The study findings suggest that no matter the degree of depression or presence of SRH risk, videoconferencing may be an acceptable option for advancing research and addressing unmet SRH needs in this population.

Adapting a Counseling-Plus-mHealth Intervention for the Virtual Environment to Reduce Sexual and Reproductive Health Risk Among Young Women with Depression.

MARSSI (Momentary Affect Regulation - Safer Sex Intervention) is a counseling-plus-mobile health (mhealth) intervention to reduce sexual and reproductive health (SRH) risks for women with depression and high-risk sexual behavior. Due to the COVID-19 pandemic limiting in-person care, we sought to develop the counseling and mhealth app onboarding for virtual implementation. A team with SRH, adolescent medicine, motivational interviewing, cognitive behavioral therapy, and technology expertise adapted the counseling through an iterative consensus process. We identified essential aspects of the counseling, specified the content so the counseling could be delivered in person or virtually with fidelity, and considered best practices for telehealth for the focus population. Virtual counseling retained key elements from in-person counseling while including enhancements with engaging visual and audio-video aids. Instructions and programming were developed to support virtual counseling delivery and onboarding for the mhealth app component of MARSSI. After testing the virtual format in mock sessions, we implemented a small-scale feasibility study in an adolescent medicine clinic with women with depressive symptoms and high-risk sexual behavior age 18-24 years (N = 9). Participants experienced minimal technical difficulties and expressed satisfaction with the virtual format, and all were able to complete app onboarding successfully. Expanding delivery options for SRH interventions to include virtual can improve access, particularly for populations with psychological and environmental barriers to care.

Integrating LGBTQIA + Community Member Perspectives into Medical Education.

ProblemLGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minorities) people have unique health care needs related to their sexual orientation, gender identity and expression, and sex development. However, medical education has historically excluded LGBTQIA + health-related content in formal curricula. It is common for medical students to interact with diverse patient populations through clinical rotations; however, access to and knowledge about LGBTQIA + patients is inconsistently prioritized in medical schools. This is especially true for LGBTQIA + patients with intersecting historically marginalized identities, such as people of color and people with disabilities. Learning from and listening to medically underserved community members can help both medical students and educators better understand the unique health needs of these communities, and address implicit biases to improve health care and outcomes for their patients. Intervention: To address the lack of LGBTQIA + health-related content in medical education and improve access to and knowledge about LGBTQIA + patients, LGBTQIA + community members' perspectives and lived experiences were integrated into undergraduate medical education via four primary methods: Community Advisory Groups, community panel events, standardized patients, and community member interviews. Context: LGBTQIA + community members' perspectives and lived experiences were integrated into medical education at Harvard Medical School (HMS) as part of the HMS Sexual and Gender Minority Health Equity Initiative. Impact: LGBTQIA + community members' perspectives and lived experiences were successfully integrated into multiple aspects of medical education at HMS. During this process, we navigated challenges in the following areas that can inform similar efforts at other institutions: representation of diverse identities and experiences, meeting and scheduling logistics, structural barriers in institutional processes, and implementation of community member recommendations. Lessons Learned: Based on our experiences, we offer recommendations for integrating LGBTQIA + community members' perspectives into medical education. Engaging community members and integrating their perspectives into medical education will better enable medical educators at all institutions to teach students about the health care needs of LGBTQIA + communities, and better prepare medical students to provide affirming and effective care to their future patients, particularly those who are LGBTQIA+.

Retrospective Review of Sexual and Reproductive Health Conversations During Initial Visits of Adolescents Seeking Gender-Affirming Testosterone.

STUDY OBJECTIVE: To use a retrospective review of sexual and reproductive health (SRH) counseling that occurred during initial visits of adolescents seeking testosterone gender-affirming hormone therapy to determine the feasibility of using such visits to manage SRH DESIGN: Retrospective chart review SETTING: Children's hospital, multidisciplinary gender clinic PARTICIPANTS: Transgender male and nonbinary patients assigned female at birth (TGD-M) aged 15-17 seen for initiation of testosterone between January 1, 2010, and December 31, 2019 INTERVENTIONS: Not applicable MAIN OUTCOME MEASURE(S): Counseling on (1) testosterone impact on fertility and (2) fertility preservation; assessment of (3) desire for gender-affirming surgery, (4) sexual activity, (5) sexual orientation, and (6) human papilloma virus vaccination as documented during the initial visit. RESULTS: Of 195 patients who met the inclusion criteria, only 3 (1.5%) had all 6 measures addressed. The median number addressed was 4 out of 6 (IQR = 2-5/6), with fertility counseling (95.9%, n = 187) being most common, followed by assessment of surgery desire (74.4%, n = 145), sexual orientation (69.2%, n = 135), and sexual activity (69.2%, n = 135). The odds of being asked about sexual orientation were 5.3 times higher in patients who endorsed sexual activity than in those who did not (P < .001; 95% CI, 9.8-10.3). CONCLUSION: Providers of adolescent gender-affirming hormone therapy regularly assess and counsel on certain aspects of SRH as part of their initial visits for those seeking testosterone. Our data suggest that these initial visits for patients seeking testosterone represent an opportunity to expand SRH assessment and counseling among TGD-M adolescents.

A Digital Platform to Support HIV Case Management for Youth and Young Adults: Mixed Methods Feasibility Study.

BACKGROUND: Advances in medical treatments in recent years have contributed to an overall decline in HIV-related opportunistic infections and deaths in youth; however, mortality and morbidity rates in perinatally and nonperinatally infected adolescents and young adults (AYA) living with HIV remain relatively high today. OBJECTIVE: The goal of this project was to assess the use, utility, and cost-effectiveness of PlusCare, a digital app for HIV case management in AYA living with HIV. The app supports routine case management tasks, such as scheduling follow-up visits, sharing documents for review and signature, laboratory test results, and between-visit communications (eg, encouraging messages). METHODS: We conducted a single-group mixed methods pre-post study with HIV case management programs in 2 large urban hospitals in the Boston metro area. Case management staff (case managers [CMs], N=20) and AYA living with HIV participants (N=45) took part in the study with access to PlusCare for up to 15 and 12 months, respectively. RESULTS: The CMs and AYA living with HIV reported mean System Usability Scale scores of 51 (SD 7.9) and 63 (SD 10.6), respectively. Although marginally significant, total charges billed at 1 of the 2 sites compared with the 12 months before app use (including emergency, inpatient, and outpatient charges) decreased by 41% (P=.046). We also observed slight increases in AYA living with HIV self-reported self-efficacy in chronic disease management and quality of life (Health-Related Quality of Life-4) from baseline to the 12-month follow-up (P=.02 and P=.03, respectively) and increased self-efficacy from the 6- to 12-month follow-up (P=.02). There was no significant change in HIV viral suppression, appointment adherence, or medication adherence in this small-sample pilot study. CONCLUSIONS: Although perceived usability was low, qualitative feedback from CMs and use patterns suggested that direct messaging and timely, remote, and secure sharing of laboratory results and documents (including electronic signatures) between CMs and AYA living with HIV can be particularly useful and have potential value in supporting care coordination and promoting patient self-efficacy and quality of life. TRIAL REGISTRATION: ClinicalTrials.gov NCT03758066; https://clinicaltrials.gov/ct2/show/NCT03758066.

Harvard Medical School's Sexual and Gender Minority Health Equity Initiative: Curricular and Climate Innovations in Undergraduate Medical Education.

PROBLEM: Sexual and gender minority (SGM) populations face numerous health disparities. Medical school curricula lack adequate educational content preparing students for serving SGM patients, and medical students typically do not experience welcoming, inclusive educational environments conducive to learning about SGM health care. APPROACH: In 2018, Harvard Medical School (HMS) launched the 3-year Sexual and Gender Minority Health Equity Initiative to integrate SGM health content throughout the longitudinal core medical curriculum and cultivate an educational climate conducive for engaging students and faculty in SGM health education. The initiative employed innovative strategies to comprehensively review existing SGM health curricular content and climate; integrate content across courses and clerkships; lead with LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minorities) community engagement; adopt an intersectional approach that centers racial equity; cultivate safe, affirming educational environments for LGBTQIA+ and non-LGBTQIA+ students and staff; ensure all graduating students are prepared to care for SGM patients; enhance faculty knowledge, skills, attitudes, and confidence teaching SGM health; evaluate effectiveness and impact of SGM health curricular innovations; prioritize sustainability of curricular innovations; and publicly share and disseminate SGM health curricular products and tools. OUTCOMES: Key outcomes of the initiative focused on 5 areas: development of 9 SGM health competencies, stakeholder engagement (HMS students and faculty, national SGM health experts, and LGBTQIA+ community members), student life and educational climate (increased LGBTQIA+ student matriculants, enhanced mentorship and support), curriculum development (authentic LGBTQIA+ standardized patient experiences, clerkship toolkit design), and faculty development (multimedia curriculum on content and process to teach SGM health). NEXT STEPS: In addition to refining curricular integration, evaluating interventions, and implementing comprehensive antiracist and gender-affirming educational policies, the next phase will involve dissemination by translating best practices into feasible approaches that any school can adopt to meet local needs with available resources.

Bone density and bone marrow composition in transgender girls prior to pubertal blockade: A case series.

PURPOSE: To determine bone mineral density (BMD) of transgender girls before pubertal blockade, and correlate with lifestyle and clinical variables. METHODS: Six transfemale peri-pubertal girls had knee magnetic resonance imaging (MRI) with T1-weighted images and single-voxel proton magnetic resonance spectroscopy (MRS). BMD measurements were obtained via dual-energy X-ray absorptiometry. Questionnaires about physical activity, diet, and the Eating Attitudes Test (EAT-26) were completed. The T2 relaxation rate of water (R2 = 1/T2 in s -1) was correlated with scores on surveys. RESULTS: Three participants (50 %) had a low bone mineral density for age based on total body less head Z-score less than -2; two participants (33 %) had a low BMD for age at lumbar spine. All had EAT-26 scores below threshold for clinical concern. All participants self-reported regular exercise. Bone marrow MR variables (T1, fat fraction, unsaturation index and R2 of water) were not correlated with DXA measures. CONCLUSIONS: Participants had low BMD on beginning pubertal blockade. Clinicians should consider monitoring BMD among youth AMAB, a group at potential risk for poor bone health.

The interaction of sexual orientation and provider-patient communication on sexual and reproductive health in a sample of U.S. women of diverse sexual orientations.

OBJECTIVE: Our goal was to examine associations among provider-patient communication, past-year contraceptive use and lifetime sexually transmitted infection. METHODS: Data were analyzed cross-sectionally from 22,554 women in the Growing Up Today Study and Nurses' Health Study 3 between the follow-up period of 1996-2020. We used multivariable Poisson regression models adjusted for race/ethnicity, age in years, study cohort, and region of residence to obtain risk ratio (RR) associations and 95% confidence intervals (CI). RESULTS: Provider-patient communication was associated with higher likelihood of using all methods of past-year contraceptive use (RRs ranging from 1.11 to 1.63) and lifetime STI diagnosis (RRs ranging from 1.18 to 1.96). Completely heterosexual women with no same-sex partners (referent) were 13% more likely than lesbians and 4% less likely than other groups to report a provider ever discussed their SRH. Significant interactions emerged between sexual minority status and provider-patient communication. Sexual minority women whose providers discussed their SRH were less likely to report contraceptive non-use in the past year (p < .0001). CONCLUSION: Provider-patient communication may benefit sexual minority women's contraceptive practices and engagement with STI testing. PRACTICE IMPLICATIONS: Differences in provider-patient SRH discussion by sexual orientation indicate lesbian women are not receiving the same attention in clinical encounters.

Eating disorder screening and treatment experiences in transgender and gender diverse young adults.

Transgender and gender diverse (TGD) young adults have elevated risk for disordered eating, unhealthy weight control behaviors, and eating disorders (EDs). Little is known about TGD young adult experiences with ED screening and treatment; this qualitative study aimed to address this gap. This study used data from eight asynchronous online focus groups, a dynamic online bulletin board method (N = 66). Participants posted responses to moderator-posed questions over a 4-day period. Participants were TGD young adults ages 18-30 years old, were recruited using social media and outreach to community organizations, and resided in 25 US states. We conducted inductive thematic analysis of all focus group excerpts that described experiences with ED screening or treatment (n = 32). Participants were of diverse gender identities (25% transgender woman, 41% transgender man, 28% non-binary, 6% another gender) and racial/ethnic identities (62% White, 13% Latinx, 13% Multiracial, 6% Asian, 6% Black). Three major themes emerged from the analysis: (1) Barriers to ED screening/treatment; (2) Complexity of the relationship between EDs and gender dysphoria; (3) Need for provider education in gender affirming care practices for ED screening and treatment. Results indicate an ongoing need for gender affirming care for TGD young adults in ED screening and treatment. Health care systems must address barriers to screening and treatment for TGD young adults, including enhancing understanding of the intersection of gender dysphoria and eating disorders as well as improvements in health care provider training.

Primary Care for Transgender Adolescents and Young Adults in Rhode Island: An Analysis of the all Payers Claims Database.

PURPOSE: Structural stigma has shaped disparities across several domains of health for transgender relative to cisgender (nontransgender) adolescents in the United States. Research on transgender health has largely overlooked the role of preventive care, especially for adolescents. METHODS: We used ICD-9 and ICD-10 codes to identify transgender adolescents in the Rhode Island All Payers Claims Database (APCD) from 2011 to 2017 based on a diagnosis for gender identity disorder (GID). We evaluated differences in the use of preventive care services between transgender and cisgender adolescents. We compared the frequency of sexually transmitted infection and HIV screening and the percentage prescribed pre-exposure prophylaxis among transgender and cisgender adolescents using t-tests and chi-square tests. We used logistic regression to evaluate the association between attending regular physical exams and receiving preventive health services. RESULTS: There was no significant difference in the proportion of transgender and cisgender adolescents who received regular influenza vaccinations, physical exams, and HPV vaccinations. Transgender adolescents were significantly more likely to receive regular cholesterol and BMI screenings compared to cisgender adolescents. While there was a significant positive association between having regular physical exams and receiving most preventive screenings in the cisgender population, in the transgender population, regular physical exams were only significantly positively associated with STI screening. CONCLUSIONS: Transgender adolescents accessing the healthcare system received similar, if not greater, levels of preventive health services compared to their cisgender peers. Because regular physical exams were not associated with receiving most preventive services among transgender adolescents, these services may be delivered outside of primary care settings.

DXA in Children and Adolescents.

DXA plays a critical role in assessing skeletal health and disease, as well as, fat and muscle status in children and adolescents. Quality DXA requires training, expertise and attention to details, as in adults, but there are key differences in performing and interpretations in children. These include choice of measurement site, skills required, reference data and software, and considerations for indications and underlying disorders to facilitate correct interpretation. The International Society for Clinical Densitometry (ISCD) has been pivotal in establishing official positions and training for people who are interested in performing or interpreting such examinations, and guiding clinicians who may request such studies. However training in the performance and interpretation of scans of individuals with more complex needs falls outside the scope of this review, and consideration should be given to refer such examinations to a specialist pediatric DXA unit. Others may be scanned and reported by those with expertise in densitometry, as long as due diligence is paid to standard quality procedures, as well as knowledge of the special circumstances and training required for this field. In this invited review we outline some of these considerations, highlight key messages, and provide some appropriate references to help guide clinicians, technologists and scientists involved or interested in DXA use in children and adolescents.

Gender Expression, Peer Victimization, and Disordered Weight-Control Behaviors Among U.S. High School Students.

PURPOSE: The purpose of this study is to examine the association between gender expression, peer victimization, and disordered weight-control behaviors (DWCBs) in four population-based samples of U.S. high school students. METHODS: Analyses include data from 5,488 U.S. high school students from the 2013 Youth Risk Behavior Surveys in four jurisdictions (Broward County, FL; Chicago, IL; Los Angeles, CA; San Diego, CA). Participants were 56% Hispanic/Latino, 21% black/African American, and 14% white. Two items asked about perceived gender expression; responses were classified into three groups: highly gender conforming (e.g., very masculine boys), moderately gender conforming, gender nonconforming (e.g., feminine boys). Sex-stratified multivariable logistic regression models were used to examine the association between gender expression, peer victimization, and DWCBs in previous month (fasting, using diet pills/liquids/powders, and purging [vomiting or using laxatives]), controlling for potential confounders. RESULTS: Overall, 12% of respondents reported fasting, 6% reported diet pill use, and 5% reported purging, with significantly higher prevalence among gender nonconforming than among gender conforming male students (p < .001). In adjusted models, gender nonconforming male students had greater odds of fasting (odds ratio [95% confidence interval]: 3.0 [2.0-4.7]), diet pill use (6.1 [3.7-9.9]), and purging (7.2 [3.6-14.8]), relative to moderately conforming males. No significant associations were found among female students. Adding peer victimization to models modestly attenuated the association between gender nonconformity and DWCBs for male students. CONCLUSIONS: In probability samples of U.S. high school students, we observed marked differences by gender expression in DWCBs among male students but not among female students. Gender expression-related stigma should be addressed within clinical and school-based interventions to prevent DWCBs.