The experience of transfeminine adolescents and their parents regarding fertility preservation via testicular sperm extraction (TESE): a qualitative study.

STUDY QUESTION: How do transfeminine adolescents and their parents experience fertility preservation via testicular sperm extraction (TESE)? SUMMARY ANSWER: Participants experienced the TESE process positively when provided with appropriate guidance to navigate the decisional dilemma between preserving future biological parenthood and the pressure to start puberty suppression early. WHAT IS KNOWN ALREADY: Sperm banking through ejaculation is not feasible for all transfeminine adolescents due to genital dysphoria and early puberty; for this group, TESE is the only alternative. However, during early puberty, they must postpone or pause puberty suppression until spermatogenesis is fully developed. STUDY DESIGN, SIZE, DURATION: All consecutive TESE patients in our centre and their parents were invited to participate. Between December 2022 and May 2023, we included 6 adolescents and 10 parents. We used a qualitative approach based on semi-structured interviews to study the experience of the transfeminine adolescents and their parents. PARTICIPANTS/MATERIALS, SETTING, METHODS: Transfeminine adolescents diagnosed with gender dysphoria in early puberty (Tanner stage ≥2) who underwent TESE before the start of puberty suppression or gender-affirming hormones participated in this study. The interviews were recorded, manually transcribed and analysed using reflective thematic analysis focusing on understanding the participants' experiences of puberty and fertility preservation and the various factors and social processes influencing their decision to undergo TESE. MAIN RESULTS AND THE ROLE OF CHANCE: Transfeminine adolescents decide to undergo invasive fertility preservation because of a possible, future desire for parenthood. Parents stressed the importance of preventing future decisional regret. They both saw masturbation to obtain a semen sample as unreachable. Even though TESE is a surgical procedure with possible complications and pain afterwards, this alternative seemed less dysphoric to them.Adolescents had to postpone the start of puberty suppression, waiting for spermatogenesis to complete. Given the unpredictable development of puberty, they felt a lot of stress and anxiety during this period and were primarily concerned about the lowering of their voice. Because of this puberty-related stress, they were constantly balancing their motivations for fertility preservation against the early start of puberty suppression to prevent unwanted irreversible pubertal body changes. To support this decisional dilemma, adolescents and their parents need adequate communication with each other and their healthcare providers to reflect on their stress for pubertal change. Furthermore, close, continuous surveillance of their current mental state by their parents, together with their psychologist and pubertal development by their physicians, is needed. Despite the challenging decision and postponement of puberty suppression, they retrospectively experienced it positively without any regret. LIMITATIONS, REASONS FOR CAUTION: All adolescents successfully underwent TESE, with viable spermatozoa obtained and without complications. This may result in a more positive reflective experience regarding fertility preservation. Furthermore, the perspectives of adolescents with the intention of TESE but who already started with puberty suppression before the preservation were not included. WIDER IMPLICATIONS OF THE FINDINGS: This study helps healthcare providers improve their counselling and guidance of transfeminine adolescents who consider postponing puberty suppression for fertility preservation via TESE. The adolescents and their parents know more clearly what to expect during fertility preservation. Specific peer-support programs may facilitate the decision process for upcoming adolescents. STUDY FUNDING/COMPETING INTEREST(S): No external funding was used for this study. None of the authors have any conflicts of interest. TRIAL REGISTRATION NUMBER: Not applicable.

Anorectal gonorrhoea and chlamydia among transgender women in Brazil: prevalence and assessment of performance and cost of anorectal infection detection and management approaches.

OBJECTIVES: We aimed to determine the prevalence of anorectal Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) among transgender women in Brazil, and to assess the performance and costs of various approaches for the diagnosis and management of anorectal NG/CT. METHODS: TransOdara was a multicentric, cross-sectional STI prevalence study among 1317 transgender women conducted in five capital cities representing all Brazilian regions. Participants aged >18 years were recruited using respondent-driven sampling (RDS), completed an interviewer-led questionnaire, offered an optional physical examination and given choice between self-collected or provider-collected samples for NG/CT testing. Performance and cost indicators of predetermined management algorithms based on the WHO recommendations for anorectal symptoms were calculated. RESULTS: Screening uptake was high (94.3%) and the estimated prevalence of anorectal NG, CT and NG and/or CT was 9.1%, 8.9% and 15.2%, respectively. Most detected anorectal NG/CT infections were asymptomatic (NG: 87.6%, CT: 88.9%), with a limited number of participants reporting any anorectal symptoms (9.1%). Of those who permitted anal examination, few had clinical signs of infection (13.6%). Sensitivity of the tested algorithms ranged from 1.4% to 5.1% (highest for treatment based on the reported anorectal discharge or ulcer and receptive anal intercourse (RAI) in the past 6 months) and specificity from 98.0% to 99.3% (highest for treatment based on the reported anorectal discharge with clinical confirmation or report of RAI). The estimated cost-per-true case of anorectal NG/CT infection treated varied from lowest providing treatment for anorectal discharge syndrome based on the reported RAI ($2.70-4.28), with algorithms including clinical examinations decreasing cost-effectiveness. CONCLUSIONS: High prevalence of mostly asymptomatic anorectal NG and CT was observed among Brazilian transgender women. Multi-site NG/CT screening should be offered to transgender women. Where diagnostic testing capacity is limited, syndromic management for those presenting with anorectal symptoms is recommended.

Hepatitis C virus infection is uncommon at baseline and during follow-up among individuals using PrEP in the Dutch national PrEP programme between 2019 and 2022.

OBJECTIVES: Studies showed that men who have sex with men (MSM), including those using pre-exposure prophylaxis (PrEP), are at increased risk of hepatitis C virus (HCV) infection. We evaluated HCV prevalence and incidence, along with their associated determinants, in a cohort of PrEP-using individuals in the Netherlands. METHODS: In 2019, the Netherlands launched a 5-year national programme that offers subsidised PrEP to eligible individuals. We used prospectively collected data from individuals registered in this programme between 2019 and 2022. Individuals underwent annual testing for HCV antibodies and additional HCV-RNA testing when antibodies were present. We calculated the prevalence of past/current HCV infection at first visit and overall incidence rate (IR) during follow-up. Univariable logistic and Poisson regression models were used to identify determinants associated with past/current prevalent or incident HCV infection, respectively. Behavioural factors referred to those occurring in the previous 6 months. RESULTS: A total of 10 563 (n=10 319, 97.7% MSM) were included. At first visit, 66 of 10 563 (0.6%) had a past/current HCV infection, which was associated with older age [odds ratio (OR) per 10 years=1.57, 95% confidence interval (CI)=1.31 to 1.88], the use of PrEP before first visit (OR=3.03, 95% CI=1.79 to 5.13), receptive condomless anal sex (CAS) (OR=2.73, 95% CI=1.25 to 5.98), chemsex (OR=2.44, 95% CI=1.49 to 3.99) and injecting drug use (IDU) (OR=6.61, 95% CI=2.35 to 18.61). Among 9851 individuals contributing to 17 150 person-years (PYs) of follow-up, 64 incident HCV infections (IR=0.37 per 100 PYs, 95% CI=0.29 to 0.48) were identified. Factors associated with incident HCV infection were receptive CAS [incidence rate ratio (IRR)=2.59, 95% CI=1.12 to 6.02], chemsex (IRR=1.78, 95% CI=1.06 to 2.98), sexually transmitted infection diagnosis (IRR=2.30, 95% CI=1.23 to 4.31) and IDU (IRR=6.15, 95% CI=2.20 to 17.18). CONCLUSIONS: Past/current prevalence and incidence of HCV were low among individuals in the Dutch PrEP programme. Infections were associated with behaviour known to be associated with HCV. Instead of annual HCV testing, as stated in most PrEP care guidelines, testing frequency for HCV could be based on behaviours associated with HCV acquisition.

Uncovering associations between gender nonconformity, psychosocial factors, and mental health in adolescents: a birth cohort study.

BACKGROUND: Little information is available on the association between gender nonconformity during adolescence and subsequent mental health. While the distress related to gender nonconformity may be socially produced rather than attributed to individual-level factors, further research is needed to better understand the role of psychosocial factors in this context. METHOD: We analyzed data from the Tokyo Teen Cohort, obtained through random sampling of adolescents born between 2002 and 2004. We used inverse probability weighting to examine the association of gender nonconformity at ages 12 and 14 as a time-varying variable with subsequent mental health at age 16, while accounting for time-fixed and time-varying confounders. Furthermore, we used a weighting approach to investigate the mediating role of modifiable psychosocial factors in this association, addressing exposure-mediator and mediator-mediator interactions. RESULTS: A total of 3171 participants were analyzed. Persistent gender nonconforming behavior at ages 12 and 14 was associated with subsequent depression (ß = 2.02, 95% confidence interval [CI] 0.85 to 3.19) and psychotic experiences (ß = 0.33, 95% CI 0.14 to 0.52) at age 16. The results remained robust in sensitivity analyses. Approximately 30% of the association between gender nonconformity and depression was consistently mediated by a set of psychosocial factors, namely loneliness, bullying victimization, and relationships with mother, father, and friends. CONCLUSIONS: Persistent gender nonconformity during adolescence is associated with subsequent mental health. Psychosocial factors play a vital mediating role in this association, highlighting the essential need for social intervention and change to reduce stigmatization and ameliorate mental health challenges.

Incidence of breakthrough bleeding in transgender and gender-diverse individuals on long-term testosterone.

BACKGROUND: Little is known about the maintenance of amenorrhea among transgender and gender-diverse individuals with uteri who are using long-term testosterone gender-affirming hormone therapy. Emerging data describe breakthrough bleeding among adolescents on long-term testosterone therapy and among adults who are seeking a gender-affirming hysterectomy. More studies are needed to better understand breakthrough bleeding patterns among transgender and gender-diverse individuals with uteri who are using testosterone, including the frequency, timing, and etiology of bleeding and how these patterns may differ between adults and younger populations. OBJECTIVE: The primary aim of this study was to characterize the incidence and patterns of breakthrough bleeding in a cohort of transgender and gender-diverse individuals who had been on testosterone for longer than 12 months and who had uteri in situ. Secondary aims included identifying the time to first bleed for those who experienced breakthrough bleeding and the risk factors associated with breakthrough bleeding while on testosterone therapy. STUDY DESIGN: This was an institutional review board-approved, single tertiary center, retrospective chart review of transgender and gender diverse individuals who had been on testosterone for at least 1 year. A primary survival analysis that evaluated the incidence of bleeding was combined with descriptive analyses and an evaluation of the factors associated with bleeding. RESULTS: Of the 279 patients included in the analysis, the median age of testosterone initiation was 22 years (interquartile range, 19-41), and the median follow-up time was 34 months (range, 12-278). The absolute proportion of individuals who ever experienced breakthrough bleeding on testosterone was 34% (n=96; 95% confidence interval, 29-40). Patients who experienced breakthrough bleeding initiated testosterone at a younger age (20.5 vs 22.0 years; P=.04), had lower mean serum testosterone levels (389.14 vs 512.7 ng/dL; P=.001), were more likely to have a mean testosterone level <320 ng/dL (52% vs 48%; P=.001), and had higher mean estradiol levels (62% vs 49%; P=.003). Survival analyses estimated a breakthrough bleeding incidence rate of 0.09 per year (95% confidence interval, 0.07-1.0). Although 58 people underwent a hysterectomy during the follow-up period, 64% of the cohort who maintained a uterus eventually experienced breakthrough bleeding. The median time to the initial bleeding episode was 22 months (interquartile range, 12-201) after testosterone initiation. CONCLUSION: These results suggest that a substantial fraction of transgender and gender-diverse individuals who are using testosterone will experience at least 1 episode of breakthrough bleeding even after their initial year of testosterone use. We recommend that clinicians inform all patients that breakthrough bleeding is a common occurrence even after the first year on testosterone therapy.

Identifying Effective Strategies for Improving Engagement in HIV Prevention and Care Among Transgender Persons in the United States: A Systematic Review.

This systematic review synthesized published literature (2000 - 2023) to identify HIV interventions specifically designed for transgender persons in the United States (PROSPERO registration number: CRD42021256460). The review also summarized strategies for improving outcomes related to the four pillars of the Ending the HIV Epidemic (EHE) initiative in the United States: Diagnose, Treat, Prevent, and Respond. A comprehensive search was conducted using the Centers for Disease Control and Prevention's HIV Prevention Research Synthesis Project database, which included over 120,000 citations from routine systematic searches in CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts. Of 23 interventions that met inclusion criteria, 94% focused on transgender women of color and 22% focused on young transgender persons aged 15-29 years old. Most interventions focused on Treat or Prevent, few focused on Diagnosis, and none focused on Respond. Twenty interventions (87%) showed improvement in at least one EHE related outcome and a quarter of these effective interventions were tested with randomized controlled trials. Common strategies observed in effective interventions include the following: engaging the community in intervention development; pilot-testing with the focus population to ensure appropriateness and acceptability; addressing social determinants of health (e.g. stigma, discrimination, violence) through empowerment and gender-affirming approaches; increasing access to care, prevention, and services through co-location and one-stop shop models; and utilizing peer-led counseling, education, support, and navigation. Continuous effort is needed in addressing gaps, including more research for transgender men and rural settings and for how best to adopt and adapt best practices for subgroups of transgender population.

RESUMEN: Esta revisión sistemática sintetizó la literatura publicada (2000 ­ 2023) para identificar intervenciones relacionadas con el VIH diseñadas específicamente para personas transgénero en los Estados Unidos y resumió las estrategias para mejorar los resultados relacionados con los cuatro pilares de la iniciativa Poner fin a la Epidemia del VIH (EHE por sus siglas en inglés). Diagnosticar, Tratar, Prevenir y Responder. Este protocolo de estudio se registró en PROSPERO (CRD42022364101). Se realizó una búsqueda exhaustiva utilizando la base de datos del Proyecto de Síntesis de Investigación sobre Prevención del VIH de los Centros para el Control y la Prevención de Enfermedades, que incluyó más de 120.000 citas de búsquedas sistemáticas de rutina en CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo y Sociological Abstracts. De las 23 intervenciones que cumplieron con los criterios de inclusión, el 94% se centró en mujeres transgénero de color y el 22% se centró en personas transgénero jóvenes de entre 15 y 29 años. La mayoría de las intervenciones se centraron en los pilares Tratar o Prevenir, pocas se centraron en el pilar de Diagnóstico y ninguna se centró en el pilar de Responder. Veinte intervenciones (87%) mostraron una mejora en al menos un resultado relacionado con la EHE; una cuarta parte de estas intervenciones efectivas se probaron con ensayos controlados aleatorios. Las intervenciones efectivas en todos los pilares compartían características comunes, como la participación de la comunidad en el desarrollo de la intervención; la realización de pruebas piloto con la población objetivo para garantizar la idoneidad y la aceptabilidad; el abordaje de los determinantes sociales de la salud (p.e., el estigma, la discriminación, la violencia, los problemas legales, la vulnerabilidad económica, la vivienda, el transporte, la alimentación) mediante enfoques de empoderamiento y afirmación de género; el aumento del acceso a la atención, la prevención y el servicio (p.e., Mediante la co-ubicación, y el sistema de ventanilla única); y el uso de asesoramiento, educación, apoyo y orientación dirigidos por pares. Se necesita un esfuerzo continuo para abordar las brechas, incluida una mayor investigación para los hombres transgénero y los entornos rurales y para determinar cuál es la mejor manera de adoptar y adaptar las mejores prácticas para los subgrupos de la población transgénero.

Exploring Safety in Gender-Affirming Hormonal Treatments: An Observational Study on Adverse Drug Events Using the Food and Drug Administration Adverse Event Reporting System Database.

BACKGROUND: People with gender dysphoria are treated with hormone therapy for gender reassignment. The indication of this therapy was initially for the opposite sex, and information on potential adverse drug reaction (ADR) is lacking. OBJECTIVE: To describe ADR associated with gender transition medication in transgender individuals reported to the US Food and Drug Administration Adverse Event Reporting System (FAERS) database. METHODS: Data from the FAERS database up to June 2023 were examined, focusing on reports of gender transition medication use in the context of gender dysphoria. The ADRs were categorized using the Medical Dictionary for Regulatory Activities at both Preferred Term and System Organ Class (SOC) levels. Descriptive statistics summarized report counts, medication types, indications, and ADR severity. RESULTS: For individuals assigned female at birth undergoing gender transition to male (transgender men), 82 reports (230 ADRs) were analyzed, with an average age of 29.5 years. Transgender hormonal therapy was cited in 72% of reports, predominantly from the United States (67.1%). A striking 88% were categorized as serious ADRs, primarily SOC injury, poisoning, and procedural complications (26.5%), followed by psychiatric disorders (14.8%) and nervous system disorders (12.2%). Among those assigned sex male at birth transitioning to female (transgender women) (81 reports, 237 ADRs), mean age was 33.3 years, with 58% indicating use for gender dysphoria. A significant proportion (53.6%) were serious ADRs, primarily SOC: injury, poisoning, and procedural complications (26.6%). CONCLUSIONS AND RELEVANCE: The FAERS data reveal significant ADRs in transgender individuals using hormone therapy, sometimes unintended for their recipient gender. Population-level studies are crucial to enhance transgender health care. Spontaneous surveillance databases like FAERS illuminate off-label ADRs, urging health care providers to approach hormone therapies with informed caution.

Health care: life stories by trans women in Colombia.

BACKGROUND: In Colombia, health care for people with trans life experiences is characterised by countless barriers to health services and care. Commonly, trans people have experienced stigma and discrimination among health professionals, a lack of services and professionals specialized to guarantee affirmative processes from non-hegemonic gender perspectives, and there exists a marked pathologization and medicalization of services. Therefore, it is necessary to provide affirmative health services to improve health and well-being from the recognition of their needs and experiences. The article describes life narratives about health care for the gender transitions of trans women in Colombia. METHODS: A qualitative narrative study was conducted with 139 trans women in seven cities in Colombia. In-depth interviews and discussion groups were conducted between June 2019 and March 2020. Data were analyzed using thematic analysis and the Atlas Ti cloud program. National and international ethical guidelines were followed in the development of the research. RESULTS: This research provided an overview of the health experiences of Colombian trans women. They reported their experiences of pathologizing approaches to transgender healthcare, stigma, discrimination, and barriers to accessing preventive, specialized, and regular healthcare services. For this reason, they opted for self-medicated gender transition processes and self-management of health care. An important aspect to consider within healthcare is that not all women want binary gender transition processes. CONCLUSION: Participants felt that in Colombia there is a lack of affirmative health care for transgender women and that there are many limitations to care related to the gender transition processes. This exposes them to more situations that violate their rights and influences their lack of confidence and their search for professional health care. In Colombia, it is important to develop strategies for education, information, and communication, as well as a handbook for health workers on specialized healthcare for trans women.

Pelvic Floor Dysfunction in Transgender Men on Gender-affirming Hormone Therapy: A Descriptive Cross-sectional Study.

INTRODUCTION AND HYPOTHESIS: The objective of this research is to explore the effects of hormone therapy using testosterone on pelvic floor dysfunction (PFD) in transgender men. We hypothesize that PFD might be prevalent among transgender men undergoing hormone therapy. Therefore, this study was aimed at verifying the frequency of these dysfunctions. METHODS: A cross-sectional study was conducted between September 2022 and March 2023 using an online questionnaire, which included transgender men over 18 years old who underwent gender-affirming hormone therapy. Volunteers with neurological disease, previous urogynecology surgery, active urinary tract infection, and individuals without access to the internet were excluded. The questionnaire employed validated tools to assess urinary symptoms, such as urinary incontinence (UI), as well as sexual dysfunction, anorectal symptoms, and constipation. The data were analyzed descriptively and presented as frequencies and prevalence ratios with their respective confidence intervals (95% CI), mean, and standard deviation. RESULTS: A total of 68 transgender men were included. Most participants had storage symptoms (69.1%), sexual dysfunction (52.9%), anorectal symptoms (45.6%), and flatal incontinence (39.7%). Participants with UI symptoms reported moderate severity of the condition. CONCLUSIONS: Transgender men on hormone therapy have a high incidence of PFD (94.1%) and experience a greater occurrence of urinary symptoms (86.7%).

Cross-Cultural Adaptation and Face Validation of the Chilean Version of the Operated Male to Female Sexual Function Index.

INTRODUCTION AND HYPOTHESIS: Transgender and gender-diverse people often experience discrimination or even outright exclusion when undergoing medical attention. It has been shown that gender-affirming treatments improve quality of life in transgender patients, and genital-affirming surgery (GAS) is increasingly spreading worldwide. Sexual function after male-to-female GAS has long been evaluated by using tools designed for assigned female at birth (AFAB), resulting in suboptimal assessments. Currently, the operated Male to Female Sexual Function Index (oMtFSFI) is the only validated questionnaire to assess the sexual function of operated transgender women. The current study was aimed at performing cross-cultural adaptation and to test the face validity of the Chilean version of the oMtFSFI. METHODS: We carried out an observational descriptive study. The questionnaire was translated into Spanish, adapted, and face validated in five phases with eight participants. The study was approved by the Universidad del Desarrollo Scientific Ethics Committee. RESULTS: According to participants, the questionnaire was shown to both pertinently and exhaustively evaluate the sexual function of post-feminizing genitoplasty transgender women. The questionnaire was well understood by the participants, except for a difficulty in understanding certain terms. Some participants criticized the perspective of the instrument in terms of the assumption of having a partner or having penetrative intercourse via the neovagina. The amendments to the Italian version of the questionnaire were discussed until an agreement on adaptation considering the patient´s perspective was reached. The present preliminary data support the face validity of the Chilean version of the oMtFSFI in the assessment of sexual function in operated transgender women. CONCLUSIONS: This adapted questionnaire could be a valuable tool for clinicians and researchers.

Correlation between gender-based violence and poor treatment outcomes among transgender women living with HIV in Brazil.

BACKGROUND: Transgender women are disproportionately affected by both HIV and gender-based violence (GBV), defined as physical, sexual, or emotional violence perpetrated against an individual based on their gender identity/expression. While a growing body of evidence demonstrates that GBV leads to poor HIV care and treatment outcomes among cisgender women, less research has examined this association among transgender women. We assessed the impact of lifetime experiences of GBV on subsequent retention in HIV care and laboratory confirmed viral suppression among a sample of transgender women living with HIV (TWH) in Brazil. METHODS: A pilot trial of a peer navigation intervention to improve HIV care and treatment among TWH was conducted in São Paulo, Brazil between 2018 and 2019. TWH were recruited and randomized into the intervention or control arm and participated in a baseline and 9-month follow-up survey and ongoing extraction of clinical visit, prescribing, and laboratory data. Generalized linear model regressions with a Poisson distribution estimated the relative risk (RR) for the association of lifetime physical and sexual violence reported at baseline with treatment outcomes (retention in HIV care and viral suppression) at follow-up, adjusting for baseline sociodemographic characteristics. RESULTS: A total of 113 TWH participated in the study. At baseline, median age was 30 years, and the prevalence of lifetime physical and sexual violence was 62% and 45%, respectively. At follow-up, 58% (n = 66/113) were retained in care and 35% (n = 40/113) had evidence of viral suppression. In adjusted models, lifetime physical violence was non-significantly associated with a 10% reduction in retention in care (aRR: 0.90, 95% CI: 0.67, 1.22) and a 31% reduction in viral suppression (aRR: 0.69; 95% CI: 0.43, 1.11). Lifetime sexual violence was non-significantly associated with a 28% reduction in retention in HIV care (aRR: 0.72, 95% CI: 0.52, 1.00) and significantly associated with a 56% reduction in viral suppression (aRR: 0.44; 95% CI: 0.24, 0.79). CONCLUSION: Our findings are among the first to demonstrate that lifetime experiences with physical and sexual violence are associated with poor HIV outcomes over time among transgender women. Interventions seeking to improve HIV treatment outcomes should assess and address experiences of GBV among this population. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03525340.

Health care needs and barriers to care among the transgender population: a study from western Rajasthan.

BACKGROUND: Transgender people comprise an estimated 0.3-0.5% (25 million) of the global population. The public health agenda focuses on understanding and improving the health and well-being of gender minorities. Transgender (TG) persons often have complex healthcare needs and suffer significant health disparities in multiple arenas. The international literature suggests that this community is at a higher risk of depression, and other mental health problems, including HIV. Many transgender people experience gender dysphoria and seek specific medical needs such as sex reassignment surgeries, implants, hormonal therapies, etc., but are unable to access these services due to financial or social reasons. The objective of this study was to assess the healthcare needs and associated barriers experienced by transgender people in Western Rajasthan. METHODOLOGY: A qualitative study was carried out in which multilevel stakeholder interviews were conducted using interview and focus group discussion guides. Data was analyzed using the qualitative thematic analysis technique. RESULTS: Findings reveal that transgender people have expressed their need to access health services for general health needs, including but not limited to mental health, non-communicable diseases, and infectious diseases. Barriers to healthcare services were identified on 3 levels: health system, social and personal. Health system barriers include policy, accessibility, affordability, and acceptability issues. Social factors such as inadequate housing, education, and job opportunities also play an important role in affecting the individual's health-seeking behavior. The knowledge of healthcare providers in this context was also limited in context of health insurance schemes, package of services available for transgenders and the importance of gender sensitive healthcare. CONCLUSION: Transgender people expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified at various levels ranging from absence of targeted policies to individual behavior.

Erasure of the young trans person: A critical discursive review of contemporary health care literature.

INTRODUCTION: Trans youth experience significantly higher rates of societal violence and ill-health compared to their cisgender peers. Although recent clinical guidelines for trans young people in health have paved the way for revolutionizing care, many trans young people still experience adversity in clinical settings. This discursive literature review provides a novel approach in exploring why trans young people experience violence in health care despite the availability of evidence-based resources and guidelines. DESIGN: Databases (CINAHL and Scopus) were systematically searched to identify qualitative literature on the experiences of trans young people (<18 years) in health care settings. METHOD: Rather than synthesizing and presenting the literature, Fairclough's (2001) CDA methodology was used to critically analyze the literature as texts in a data corpus. The authors engaged with the data from a critical social theory perspective. RESULTS: Fifteen qualitative articles and one report (n = 16) on the experiences of trans young people (3-24 years) in health care settings were included. Two key discourses were identified in the literature. First, discourses that constituted the trans young person were identified in the definitions of 'trans' as a pathological incongruence and as alternate, self-determined ways of being. Further discourses were identified in the constitution of trans young people as victims, extra-pathological, and alternatively problematised as socially dysphoric. Second, discourses in health provider responses were identified in dismissive, gatekeeping, regulatory, and respectful practices. DISCUSSION: The discursive constitution of the trans young person as incongruent, vulnerable, and pathological is constituted and generated by dismissive, gatekeeping, and regulatory practices of health care providers. The analysis reveals how trans young people are considered pathological and deemed treatable (at the site of the body), in the interest of 'protecting' them from a perceived abject future of trans adulthood. The logic and violence of cisgenderism is uncovered as the foundation of these dominant discourses, whereby growing up cisgender is often presented as the only option in health care settings. The dominant discourses that constitute the trans young person in health care as incongruent, pathological, and vulnerable, alongside the reifying health care responses of dismissal, gatekeeping, and regulation contribute to the erasure of the young trans person. CONCLUSION: This paper identified key discourses in the literature in how trans young people are constituted and regulated in health care. This review highlights an urgent need for further critical scholarship in trans health by trans researchers, from critical perspectives. Furthermore, it provides a starting point for critical reflection of health care provider and researcher practices and the re-imagination of trans-futurity for all young people in health care. CLINICAL RELEVANCE: Nurses are situated at the forefront of health care delivery and play a crucial role in the advocacy and provision of culturally safe care. With this ideal proximity to clients, nurses can powerfully affect change through better understanding and reflecting on how regulatory practices constitute and position trans young people in health care. Nursing knowledge, such as cultural safety, can offer novel approaches in working towards safer ways of meeting the needs of trans young people.

Social-ecological barriers and facilitators to seeking inpatient psychiatric care among transgender and nonbinary people: A qualitative descriptive study.

AIM(S): To assess barriers and facilitators to seeking inpatient psychiatric treatment among transgender and nonbinary people. DESIGN: Qualitative interview study. METHODS: Semi-structured interviews were conducted from March 2019 to June 2022 with transgender and nonbinary people admitted to an inpatient psychiatric hospital in the United States during the past 5 years. Data were analysed using thematic analysis and constructed within a modified social-ecological model of stigma. Standards for Reporting Qualitative Research were used for this study. RESULTS: Participants (N = 15) described barriers and facilitators across all three social-ecological levels. i) Individual themes included distrust of the mental healthcare system, feeling unsafe, loss of autonomy, minimizing one's own mental health needs, and feelings of accountability to others. ii) Interpersonal themes included: lack of support for transgender/nonbinary identity, limited transgender/nonbinary knowledge among mental healthcare professionals, and allyship. iii) Structural themes included: carceral setting, financial costs, and availability of non-profit treatment options. CONCLUSION: Multi-level themes were identified as barriers and facilitators to seeking inpatient psychiatric care for transgender and nonbinary people, providing opportunities among inpatient settings to improve care delivery and engagement. Greater health equity can be achieved by addressing barriers to care. IMPLICATIONS: Incorporating inclusive and affirming practices in inpatient psychiatric services presents an opportunity to reduce barriers to seeking care. IMPACT: The present study describes the experiences of transgender and nonbinary people as they determine whether to voluntarily seek inpatient psychiatric treatment. This perspective allows nurses, health systems, and policymakers to integrate transgender and nonbinary people's needs to improve healthcare delivery. PATIENT/PUBLIC CONTRIBUTION: Transgender and nonbinary participants were recruited in collaboration with community organizations. Members of the transgender and nonbinary community participated in study design development and analysis and were part of the study team.

Physiological impact of Tabata exercise on cardiometabolic and cardiorespiratory parameters in transgender people of Multan.

Objective: To investigate factors directly related to cardiometabolic and cardiorespiratory fitness in transgender people. METHODS: The cross-sectional, experimental study was conducted at the Government Girls Comprehensive Higher Secondary School, Multan, Pakistan, from January to February 2023, after approval from the ethics review committee of the Muhammad Institute of Medical and Allied Sciences, Multan, and comprised transgender people aged 17-28 years. Data was collected using the physical activity readiness questionnaire. All the participants were subjected to Tabata sessions for 4 weeks. Standard cardiometabolic and cardiorespiratory fitness values were noted at baseline and post-intervention. Data was analysed using SPSS 23. RESULTS: Of the 44 participants, 26(59%) were trans-men, 18(40.9%) were trans-women, 16(36.3%) were aged 17-19 years, and 10(22.7%) had other transgender individuals in their families. Cardiorespiratory and cardiometabolic parameters showed significant improvement post-intervention compared to baseline values (p<0.05). Conclusion: Tabata exercises were found to be useful in maintaining cardiorespiratory and cardiometabolic parameters as well in increasing the participants' motor performance.

Navigating Gender Identity and Dementia in Transgender Older Adults: Ethical Challenges and Patient-Centered Care.

OBJECTIVES: As transgender individuals age, they are at risk for neurocognitive disorders which pose not only medical but also bioethical questions. We present a case study of a transgender older adult with dementia who experienced changes in gender identity and explore the bioethical implications of identity over time, including end-of-life care. METHODS: We reviewed clinical notes and relevant medical history to describe the transition and detransition process and examined ethical frameworks related to autonomy, psychological continuity, and transgender care. RESULTS: The individual transitioned as a transgender woman in mid-life but detransitioned shortly before being diagnosed with dementia. This case highlighted conflicts between precedent autonomy and current gender identity in the context of neurocognitive decline and end-of-life care. CONCLUSIONS: The case underscores the complexity of managing gender identity in transgender older adults with dementia, emphasizing the need for personalized and ethically sound care plans. CLINICAL IMPLICATIONS: Clinicians should be vigilant about the impact of neurocognitive disorders on gender identity, balancing respect for patients' prior decisions with their current values, and develop personalized end-of-life care plans that honor the evolving identities and preferences of transgender individuals with dementia.

Action framework for reproductive health promotion: Analysis of contemporary French public policies using a critical lexicometric approach and a transgender perspective / Cadre d'action de promotion de la santé reproductive : analyse critique lexicométrique et trans des politiques publiques françaises contemporaines.

INTRODUCTION: In France, since 2017 the law has allowed people to change the gender marker on their civil status documents without having undergone medical treatment and sterilization surgery. However, no legislative framework has been provided to ensure their right to family, leaving those who wish to become parents in a space of social, political, and legal uncertainty that is inconsistent with international and human rights. In parallel, France has developed an arsenal of health strategies that constrain actors working in the field. PURPOSE OF THE RESEARCH: This study examines the possibilities available to public health actors for promoting reproductive health in the absence of legislation and in the context of political and legislative adversity. To this end, it relies on a participatory, critical, and lexicometric analysis of national strategies for sexual and reproductive health and parenthood support. RESULTS: Governance strategies make no mention of parentality among transgender people. Sexual and reproductive health policies focus on tackling sexually transmitted infections, on health pathways, and on violence and discrimination. The analysis also highlights a lack of awareness on this topic. CONCLUSIONS: Shortcomings in the legislative framework and public health strategies raise ethical questions about the promotion of reproductive health and the potentially non-inclusive approach of actors in the field. These issues force communities to carry out actions outside the scope of ordinary regulations, and they highlight the political positioning of the public-health field in France.

Introduction: Depuis 2017, la loi française a mis fin à la nécessité d'intervention médicale et de stérilisation des personnes faisant modifier leur sexe administratif à l'état civil. Pour autant, aucun cadre législatif n'a été prévu pour garantir leur droit à la famille, ancrant leurs projets parentaux dans un aléa social, politique et juridique contraire aux droits humains et internationaux. Parallèlement, l'État français s'est doté d'un arsenal de stratégies de santé contraignant la place et le rôle des actrices et acteurs de terrain. But de l'étude: Cette étude interroge les possibilités des actrices et acteurs de santé publique à promouvoir la santé reproductive des personnes en l'absence de toute législation et dans un contexte d'adversité politique et législative. Pour cela, elle s'appuie sur une analyse participative, critique et lexicométrique des stratégies nationales de santé sexuelle et reproductive et de soutien à la parentalité. Résultats: La parentalité des personnes trans est absente des stratégies de gouvernance. Les politiques de santé sexuelle et reproductive se centrent autour de la lutte contre les infections sexuellement transmissibles, les parcours de santé et les discriminations et violences. L'analyse fait également ressortir la méconnaissance de cet enjeu. Conclusions: Les manquements du cadre législatif et des stratégies de santé publique interrogent les possibilités éthiques pour les actrices et acteurs de terrain de promouvoir la santé reproductive de manière non inclusive. Ce constat condamne les communautés à mener des actions en dehors du droit commun et pose la question de la place politique du champ de la santé publique en France.

Intergenerational sex and early sexual debut are associated with HIV infection among transgender women in Paraguay.

INTRODUCTION: HIV prevalence among transgender women is high worldwide. The objectives of the present study were to estimate the current prevalence of HIV and identify factors associated with high HIV burden among transgender women in Paraguay. METHODS: Transgender women aged ≥15 years in four regions of Paraguay were recruited by Starfish sampling between February and March 2021. RESULTS: In total, 322 transgender women were included. Mean age was 31 years (range 15-67), and 102 had positive HIV test results (31.7%, 95% confidence interval [CI] 26.6-37.1). In multivariable analysis, factors associated with HIV infection were age at first intercourse ≤17 years (adjusted odds ratio [aOR] 5.47; 95% CI 1.05-28.42), >10 years difference in age with the last sexual partner (aOR 1.60; 95% CI 1.04-2.46), substance use (mostly cocaine) (aOR 3.00; 95% CI 1.47-6.12), higher risk perception (aOR 3.08; 95% CI 1.53-6.17), not testing for HIV (aOR 1.23; 95% CI 1.09-1.39), and accessed by a peer educator (aOR 3.86; 95% CI 1.77-8.38). CONCLUSIONS: Sexual debut as a minor and a large age difference with sexual partners are associated with high burden of HIV among transgender women in Paraguay. Our study corroborates the finding of cocaine use during sex as a risk factor for HIV. Prevention programmes must address structural and social vulnerabilities to stem the tragically high burden of HIV among transgender women.

Behavioural survey and street-based HIV and HCV rapid testing programme among transgender sex workers.

BACKGROUND: Transgender women sex workers (TGW-SW) are disproportionally affected by HIV and have reduced access to testing. Moreover, information regarding their behaviours and health needs is scarce. METHODS: A behavioural survey and a targeted testing programme in prostitution sites were conducted in Milan and Monza areas. The non-profit organisation 'ALA Milano Onlus' and 'San Gerardo' Hospital (Monza) implemented a mobile HIV testing unit involving a TGW peer educator, four physicians, a counsellor, a psychologist and a cultural mediator. All TGW-SW were offered anonymous HIV and hepatitis C virus (HCV) oral testing and asked to fill a questionnaire on sexual habits, drug abuse, and knowledge and attitudes towards HIV and STDs. RESULTS: Between May and July 2017, 130 TGW-SW, predominantly migrants, were contacted during 15 street visits; among them, 78 (60%) were interviewed. HIV and HCV testing were accepted by 53 (42%) and 67 (52%) TGW-SW, respectively. Twenty-five (19.8%) subjects who reported already established HIV infection were not retested. Seven patients received a new diagnosis of HIV, while nobody tested positive for HCV. Overall, HIV prevalence was 13.2% (25% including those with already known HIV infection). Recent arrival in Italy and young age were associated with risk of undiagnosed HIV infection. Inconsistent condom use was commonly reported during commercial sex (27%) and with non-commercial partners (64%). Alcohol and cocaine abuse were common problems which facilitated risky behaviours. CONCLUSIONS: Oral rapid HIV and HCV testing for TGW-SW in outreach settings were feasible and acceptable and led to a considerable number of new diagnoses. Interventions tailored to TGW-SW, focused on HIV prevention, testing and engagement in care, are fundamental.

Vaginal gonorrhoea in a transgender man reporting no vaginal sex.

We present a case of a transgender man symptomatic of vaginal Neisseria gonorrhoeae infection despite reporting no receptive vaginal sex in his recent history.