Concepts and Approaches in the Management of Transgender and Gender-Diverse Patients.

The terms transgender and gender diverse (TGD) describe persons whose gender is different from the sex assigned to them at birth. While TGD persons have experienced a rise in cultural and social visibility in recent decades, they continue to experience significant health inequities, including adverse health outcomes and multiple barriers to accessing medical care. Transgender and gender-diverse persons are at a higher risk for pain conditions than their cisgender counterparts, but research on chronic pain management for TGD persons is lacking. Clinicians from all disciplines must be informed of best practices for managing chronic pain in the TGD population. This includes all aspects of care including history, physical examination, diagnosis, treatment, and perioperative management. Many TGD persons report delaying or avoiding care because of negative interactions with medical practitioners who do not have sufficient training in navigating the specific health care needs of TGD patients. Furthermore, TGD persons who do seek care are often forced to educate their practitioners on their specific health care needs. This paper provides an overview of existing knowledge and recommendations for physicians to provide culturally and medically appropriate care for TGD persons.

How Do Prescribing Clinicians Obtain Consent to Initiate Gender-Affirming Hormones?

Purpose: Multiple consent models exist for initiating gender-affirming hormone therapy (GAHT). Our study aim was to examine the variety of approaches utilized by clinicians. Methods: Online and in-person recruitment of clinicians involved in gender-affirming care was undertaken from June 2019 through March 2020. Participants completed an online survey. Results: Of the 175 respondents, 148 prescribed GAHT. Sixty-one (41.2%) prescribed to adults only, 11 (7.4%) to minors only, and 76 (51.4%) prescribed to adults and minors. Of those who prescribed to adults, more than half (n=74, 54.4%) utilized a written consent model, one-fourth only verbal consent (n=33, 24.3%), and one-fifth required an additional mental health assessment (MHA) (n=29, 21.3%). Of those prescribing to minors, most required either written consent (n=39, 44.8%) or an additional MHA (n=35, 40.2%). Only 11 (12.6%) utilized only verbal consent for minors. Rationales provided for requiring an additional MHA in adults included protection from litigation, lack of competence in assessing psychosocial readiness for GAHT, and believing that this is the best way to ensure the patient has processed the information. Practicing in multidisciplinary clinics was associated with not requiring an MHA for adult GAHT. Conclusion: Clinicians across fields are utilizing different models to provide the same treatment, with varying rationales for the same model. As a result, patients receive nonstandard access to care despite similar clinical presentations. Our study highlights an important area for further improvement in GAHT care.

Breast Cancer Screening Recommendations for Transgender and Gender Diverse Patients: A Knowledge and Familiarity Assessment of Primary Care Practitioners.

Breast cancer screening recommendations for transgender and gender diverse (TGD) patients have only been recently developed and many primary care practitioners (PCPs) are unaware of these specific recommendations. The aim of this study is to assess the level of familiarity and knowledge PCPs have with breast cancer screening recommendations for TGD patients. An anonymous survey was distributed to primary care physicians, primary care advanced practice practitioners, and internal medicine and family medicine residents at three academic medical systems in the United States (Mayo Clinic, University of Michigan, University of Texas - Medical Branch). Survey questions assessed the familiarity and knowledge base of TGD breast cancer screening recommendations, training and experience with TGD patients, and basic demographics of the practitioners. Of the 95 survey respondents, only 35% of respondents were aware that breast cancer screening recommendations for TGD patients existed. PCPs who had increased transgender specific health care training and direct clinical exposure to TGD patients demonstrated significantly higher levels of screening recommendation awareness. Two-thirds of respondents received TGD specific medical education during training or medical career and those who had increased transgender specific medical education or direct clinical exposure to TGD patients demonstrated significantly higher levels of screening recommendation awareness. Awareness of breast cancer screening recommendations for TGD patients is low among PCPs and varied based on the practitioner's prior TGD education and experience. Up-to-date breast cancer screening recommendations for TGD patients should be readily available across multiple platforms, target key audiences, and integrated into transgender health educational curriculums to maximize awareness of these important recommendations.

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

OBJECTIVE: Accumulating evidence demonstrates that gender affirming hormone therapy (GAHT) improves mental health outcomes in transgender persons. Data specific to the risks associated with GAHT for transgender persons continue to emerge, allowing for improvements in understanding, predicting, and mitigating adverse outcomes while informing discussion about desired effects. Of particular concern is the risk of venous thromboembolism (VTE) in the context of both longitudinal GAHT and the perioperative setting. Combining what is known about the risk of VTE in cisgender individuals on hormone therapy (HT) with the evidence for transgender persons receiving HT allows for an informed approach to assess underlying risk and improve care in the transgender community. OBSERVATIONS: Hormone formulation, dosing, route, and duration of therapy can impact thromboembolic risk, with transdermal estrogen formulations having the lowest risk. There are no existing risk scores for VTE that consider HT as a possible risk factor. Risk assessment for recurrent VTE and bleeding tendencies using current scores may be helpful when assessing individual risk. Gender affirming surgeries present unique perioperative concerns, and certain procedures include a high likelihood that patients will be on exogenous estrogens at the time of surgery, potentially increasing thromboembolic risk. CONCLUSIONS AND RELEVANCE: Withholding GAHT due to potential adverse events may cause negative impacts for individual patients. Providers should be knowledgeable about the management of HT in transgender individuals of all ages, as well as in the perioperative setting, to avoid periods in which transgender individuals are off GAHT. Treatment decisions for both anticoagulation and HT should be individualized and tailored to patients' overall goals and desired outcomes, given that the physical and mental health benefits of gender affirming care may outweigh the risk of VTE.

"Invisible in the Most Tragic of Ways": Exploring Internalized Transphobia and Coping Through Photovoice.

Transgender and gender diverse (TGD) individuals experience minority stress that includes internalizing the negative attitudes that exist in society about those whose identities rest outside of the gender binary. The purpose of this study was to gain a better understanding of the experience of internalized stigma and associated coping methods among six TGD adults utilizing photovoice. Thematic and iconographic analysis of 35 works produced by the participants revealed themes involving metaphors for internalized transphobia, internalized social messages, the psychological debt or emotional cost of internalized transphobia, and a range of coping strategies. Specifically, invisibility was a common metaphor used to suggest that a TGD person's experience may be associated with actively hiding, masking their identity, or failing to be seen as their true self. Participants expressed concern with being accepted by others and noted anxiety about outward expressions of their gender and personal characteristics. The results also revealed that participants experienced loneliness, fear of rejection, and low self-esteem related to internalized transphobia and their TGD identities. Participants reported receiving messages that TGD individuals are often viewed negatively and generally lack support from society and close relations. Coping strategies utilized by participants included withdrawing from others, hiding their TGD identity to avoid rejection or violence, self-exploration, accepting self and others, and connecting to a community of TGD persons and/or allies. Focus group feedback revealed benefits to participants, including an enhanced sense of community and self-esteem, as well as recommendations for future group structure. Implications and future research directions are discussed.

Affirmative neuropsychological practice with transgender and gender diverse individuals and communities.

Objective: To provide guidance and resources on how to practice culturally safe and humble neuropsychology with transgender and gender diverse (TGD) individuals and communities. Methods: We gathered a multidisciplinary team of clinicians with relevant professional and/or lived experience to review pertinent literature, discuss important concepts, and identify key resources. From this process, we outline practical steps to advance gender affirmative neuropsychological practice. Results: Professional awareness and knowledge regarding how to gather context-relevant, gender identity information is critical. TGD individuals form a heterogenous group; a one-size-fits-all approach is not adequate. It is incumbent upon neuropsychologists to engage in clinical and research practices in a manner that does not perpetuate gender minority stress and trauma. Creating an open, safe environment of care requires intentionality and careful thinking to determine what information is relevant for a particular referral question. We provide recommendations and resources for neuropsychologists. Conclusion: When neuropsychologists are proactive, responsible, and intentional, they can better provide individualized, person-centered, and trauma-informed care to TGD individuals.