The future of sex and gender in research.

Our understanding of sex and gender evolves. We asked scientists about their work and the future of sex and gender research. They discuss, among other things, interdisciplinary collaboration, moving beyond binary conceptualizations, accounting for intersecting factors, reproductive strategies, expanding research on sex-related differences, and sex's dynamic nature.

Science as a tool for justice.

Elle Lett is the winner of the 2021 Rising Black Scientists Award for a post-graduate scholar. For this award, we asked emerging Black scientists to tell us about the experiences that sparked their interest in the life sciences, their vision and goals, and how they want to contribute to a more inclusive scientific community. This is her story.

Use of Artificial Intelligence in Improving Outcomes in Heart Disease: A Scientific Statement From the American Heart Association.

A major focus of academia, industry, and global governmental agencies is to develop and apply artificial intelligence and other advanced analytical tools to transform health care delivery. The American Heart Association supports the creation of tools and services that would further the science and practice of precision medicine by enabling more precise approaches to cardiovascular and stroke research, prevention, and care of individuals and populations. Nevertheless, several challenges exist, and few artificial intelligence tools have been shown to improve cardiovascular and stroke care sufficiently to be widely adopted. This scientific statement outlines the current state of the art on the use of artificial intelligence algorithms and data science in the diagnosis, classification, and treatment of cardiovascular disease. It also sets out to advance this mission, focusing on how digital tools and, in particular, artificial intelligence may provide clinical and mechanistic insights, address bias in clinical studies, and facilitate education and implementation science to improve cardiovascular and stroke outcomes. Last, a key objective of this scientific statement is to further the field by identifying best practices, gaps, and challenges for interested stakeholders.

Getting Precise about Gender and Sex Measurement: A Primer for Epidemiologists.

Accurately measuring gender and sex is crucial in public health and epidemiology. Iteratively reexamining how variables-including gender and sex-are conceptualized and operationalized is necessary to achieve impactful research. Reexamining gender and sex advances epidemiology toward its goals of health promotion and disease elimination. While we cannot reduce the complexities of sex and gender to simply an issue of measurement, striving to capture these concepts and experiences accurately must be an ongoing dialogue and practice-to the benefit of the field and population health. We assert that epidemiology must counteract misconceptions and accurately measure gender and sex in epidemiology. We aim to summarize existing critiques and guiding principles in measuring gender and sex that can be applied in practice.

Inequities in Conversion Practice Exposure at the Intersection of Ethnoracial and Gender Identities.

Objectives. To examine inequities in conversion practice exposure across intersections of ethnoracial groups and gender identity in the United States. Methods. Data were obtained from The Population Research in Identity and Disparities for Equality Study of sexual and gender minority people from 2019 to 2021 (n = 9274). We considered 3 outcomes: lifetime exposure, age of first exposure, and period between first and last exposure among those exposed to conversion practices. We used log-binomial, Cox proportional hazards, and negative binomial models to examine inequities by ethnoracial groups and gender identity adjusting for confounders. We considered additive interaction. Results. Conversion practice prevalence was highest among minoritized ethnoracial transgender and nonbinary participants (TNB; 8.6%). Compared with White cisgender participants, minoritized ethnoracial TNB participants had twice the prevalence (prevalence ratio = 2.16; 95% confidence interval [CI] = 1.62, 2.86) and risk (hazard ratio = 2.04; 95% CI = 1.51, 2.69) of conversion practice exposure. Furthermore, there was evidence of a positive additive interaction for age of first exposure. Conclusions. Minoritized ethnoracial TNB participants were most likely to recall experiencing conversion practices. Public Health Implications. Policies banning conversion practices may reduce the disproportionate burden experienced by minoritized ethnoracial TNB participants. (Am J Public Health. 2024;114(4):424-434. https://doi.org/10.2105/AJPH.2024.307580).

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.

Operationalizing inclusion: moving from an elusive goal to strategic action.

To mitigate the structural and institutional biases that contribute to inequities in health, we need a diverse cadre of individuals to feel included and advance within our field in order to bring a multicultural set of perspectives to the studies we conduct, the science we generate, the health and academic systems we design, and the medical and scientific knowledge we impart. There has been increasing focus on diversity, inclusion, and equity in recent years; however, often these terms are presented without adequate precision and, therefore, the inability to effectively operationalize inclusion and achieve diversity within organizations. This narrative review details several key studies, with the primary objective of presenting a roadmap to guide defining, measuring, and operationalizing inclusion within work and learning environments.

Improving the inclusion of transgender and nonbinary individuals in the planning, completion, and mobilization of cardiovascular research.

Cardiovascular disease is the leading cause of morbidity and mortality globally. Transgender and nonbinary (TNB) individuals face unclear but potentially significant cardiovascular health inequities, yet no TNB-specific evidence-based interventions for cardiovascular risk reduction currently exist. To address this gap, we propose a road map to improve the inclusion of TNB individuals in the planning, completion, and mobilization of cardiovascular research. In doing so, the adoption of inclusive practices would optimize cardiovascular health surveillance and care for TNB communities.

Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations.

PURPOSE OF REVIEW: Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic. RECENT FINDINGS: While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.

Cisheteronormativity and its influence on the psychosocial experience of LGBTQ+ people with cancer: A qualitative systematic review.

OBJECTIVE: Cisheteronormativity refers to the relationship of heterosexual and cisgender privilege stemming from patriarchy. Although studies have shown that cisheteronormativity can impact health outcomes for lesbian, gay, bisexual, transgender, queer and other sexual, gender diverse, and gender nonconforming (LGBTQ+) people, the specific impact on cancer care has not been described. We synthesized the qualitative evidence on how cisheteronormativity impacts the psychosocial experience of LGBTQ+ people with cancer. METHODS: We conducted a historic search in the CINAHL, LGBT+ Health, PsycInfo, and PubMed databases. Qualitative studies that described the psychosocial experience of LGBTQ+ people with cancer were included. After appraising the quality of the publications, 11 articles were included. Then, we conducted inductive nominal coding, taxonomic analysis, and thematic synthesis. RESULTS: Two main themes emerged, (1) Cisheteronormativity as a social determinant of health, and (2) Cancer, sexual orientation, and gender: Associations and introjections. The themes comprise four categories and 13 subcategories that describe the impact of cisheteronormativity on the cancer experience of LGBTQ+ people. CONCLUSION: Cisheteronormativity within the healthcare system impacts the psychosocial experience of LGBTQ+ people with cancer. Understanding how these gender biases, norms, and social expectations impact the cancer experience is necessary to transform social norms and promote health equity.

Community Support Persons and Mitigating Obstetric Racism During Childbirth.

PURPOSE: We undertook a study to assess whether presence of community support persons (CSPs), with no hospital affiliation or alignment, mitigates acts of obstetric racism during hospitalization for labor, birth, and immediate postpartum care. METHODS: We conducted a cross-sectional cohort study, measuring 3 domains of obstetric racism as defined for, by, and with Black birthing people: humanity (violation of safety and accountability, autonomy, communication and information exchange, and empathy); kinship (denial or disruption of community and familial bonds that support Black birthing people); and racism in the form of anti-Black racism and misogynoir (weaponization of societal stereotypes and scripts in service provision that reproduce gendered anti-Black racism in the hospital). We used a novel, validated instrument, the Patient-Reported Experience Measure of Obstetric Racism (the PREM-OB Scale suite), and linear regression analysis to determine the association between CSP presence during hospital births and obstetric racism. RESULTS: Analyses were based on 806 Black birthing people, 720 (89.3%) of whom had at least 1 CSP present throughout their labor, birth, and immediate postpartum care. The presence of CSPs was associated with fewer acts of obstetric racism across all 3 domains, with statistically significant reductions in scores in the CSP group of one-third to two-third SD units relative to the no-CSP group. CONCLUSIONS: Our findings suggest that CSPs may be an effective way to reduce obstetric racism as part of quality improvement initiatives, emphasizing the need for democratizing the birthing experience and birth space, and incorporating community members as a way to promote the safety of Black birthing people in hospital settings.Annals "Online First" article.

The Association of Microaggressions with Depressive Symptoms and Institutional Satisfaction Among a National Cohort of Medical Students.

BACKGROUND: Despite substantial research on medical student mistreatment, there is scant quantitative data on microaggressions in US medical education. OBJECTIVE: To assess US medical students' experiences of microaggressions and how these experiences influenced students' mental health and medical school satisfaction. DESIGN AND PARTICIPANTS: We conducted a cross-sectional, online survey of US medical students' experiences of microaggressions. MAIN MEASURES: The primary outcome was a positive depression screen on the 2-item Patient Health Questionnaire (PHQ-2). Medical school satisfaction was a secondary outcome. We used logistic regression to model the association between respondents' reported microaggression frequency and the likelihood of a positive PHQ-2 screen. For secondary outcomes, we used the chi-squared statistic to test associations between microaggression exposure and medical school satisfaction. KEY RESULTS: Out of 759 respondents, 61% experienced at least one microaggression weekly. Gender (64.4%), race/ethnicity (60.5%), and age (40.9%) were the most commonly cited reasons for experiencing microaggressions. Increased microaggression frequency was associated with a positive depression screen in a dose-response relationship, with second, third, and fourth (highest) quartiles of microaggression frequency having odds ratios of 2.71 (95% CI: 1-7.9), 3.87 (95% CI: 1.48-11.05), and 9.38 (95% CI: 3.71-26.69), relative to the first quartile. Medical students who experienced at least one microaggression weekly were more likely to consider medical school transfer (14.5% vs 4.7%, p<0.001) and withdrawal (18.2% vs 5.7%, p<0.001) and more likely to believe microaggressions were a normal part of medical school culture (62.3% vs 32.1%) compared to students who experienced microaggressions less frequently. CONCLUSIONS: To our knowledge, this is the largest study on the experiences and influences of microaggressions among a national sample of US medical students. Our major findings were that microaggressions are frequent occurrences and that the experience of microaggressions was associated with a positive depression screening and decreased medical school satisfaction.

Conceptualizing, Contextualizing, and Operationalizing Race in Quantitative Health Sciences Research.

Differences in health outcomes across racial groups are among the most commonly reported findings in health disparities research. Often, these studies do not explicitly connect observed disparities to mechanisms of systemic racism that drive adverse health outcomes among racialized and other marginalized groups in the United States. Without this connection, investigators inadvertently support harmful narratives of biologic essentialism or cultural inferiority that pathologize racial identities and inhibit health equity. This paper outlines pitfalls in the conceptualization, contextualization, and operationalization of race in quantitative population health research and provides recommendations on how to appropriately engage in scientific inquiry aimed at understanding racial health inequities. Race should not be used as a measure of biologic difference, but rather as a proxy for exposure to systemic racism. Future studies should go beyond this proxy use and directly measure racism and its health impacts.VISUAL ABSTRACTAppeared as Annals "Online First" article.

Resculpting Professionalism for Equity and Accountability.

Recent controversies over the characteristics of "professionalism" and its enforcement by medical educators underscore the racialized and gendered norms implicit in this practice. In this essay, we describe the ways nebulous definitions of "professionalism" imbue White, cisgender, straight, and able-bodied standards to police the boundaries of belonging in medicine. As such, marginalized trainees remain unfinished sculptures, forced to chisel away dimensions of experience and expression to conform to "professional" standards. We seek to resculpt professionalism in a way that centers patients and trainees currently at the margins. This will strengthen the increasingly diverse workforce and ensure that they can effectively address the needs of patients often excluded from quality care.

Sexual Behaviors Associated with HIV Transmission Among Transgender and Gender Diverse Young Adults: The Intersectional Role of Racism and Transphobia.

HIV prevalence and engagement in sexual behaviors associated with HIV transmission are high among transgender people of color. Per intersectionality, this disproportionate burden may be related to both interpersonal and structural racism and transphobia. The goal of this study was to estimate the association between interpersonal and structural discrimination and sexual behaviors among transgender and gender diverse (TGD) U.S. young adults. We used logit models with robust standard errors to estimate the individual and combined association between interpersonal and structural racism and transphobia and sexual behaviors in a national online sample of TGD young adults of color (TYAOC) aged 18-30 years (N = 228). Racism was measured at the interpersonal and structural level using the Everyday Discrimination Scale and State Racism Index, respectively. Transphobia was measured at the interpersonal and structural level using the Gender Minority Stress Scale and the Gender Identity Tally, respectively. We found that interpersonal racism was associated with transactional sex, and interpersonal transphobia was associated with alcohol/drug consumption prior to sex and transactional sex among TYAOC. We also found evidence of a strong joint association of interpersonal and structural racism and transphobia with alcohol/drug consumption prior to sex (OR 3.85, 95% CI 2.12, 7.01) and transactional sex (OR 3.54, 95% CI 0.99, 12.59) among TYAOC. Racism and transphobia have a compounding impact on sexual behaviors among TYAOC. Targeted interventions that reduce discrimination at both the interpersonal and structural level may help reduce the HIV burden in this marginalized population.

Ethnoracial inequities in access to gender-affirming mental health care and psychological distress among transgender adults.

PURPOSE: Transgender people face known barriers to accessing mental health care generally, and gender-affirming care in particular. However, little research has been done to evaluate the impact of systemic racism on access to gender-affirming mental health care (GAMHC) among transgender people of color (TPOC). METHODS: We conducted a cross-sectional, secondary analysis of data on 20,967 respondents to the 2015 United States Transgender Survey who reported a desire for GAMHC services related to their gender transition. We estimated inequities across ethnoracial groups in access to GAMHC, and measured the association between severe psychological distress and access to GAMHC among TPOC. RESULTS: We found decreased access to GAMHC across all TPOC groups. Inequities in access to GAMHC were most severe among assigned male at birth respondents in the Black/African-American group (aOR 0.51, 95% CI 0.37-0.71), Latino/a/e/Hispanic group (aOR 0.52, 95% CI 0.42-0.65), and Native American group (aOR 0.59, 95% CI 0.38-0.94). Among all respondents, severe psychological distress was highest among Native American respondents (47.4%), Latino/a/e/Hispanic (47.1%) respondents, and other/multiracial respondents (46.7%) and lowest among whites (39.9%). Further, among all TPOC, access to GAMHC was associated with decreased odds of severe psychological distress (aOR 0.74, 95% CI 0.62-0.87). CONCLUSION: These results illustrate the need for research that explicitly addresses the intersectional experiences of transgender communities, and the structural drivers of inequities in access to gender-affirming care.

Syndemic relationship of depressive symptoms, substance use, and suicidality in transgender youth: a cross-sectional study using the U.S. youth risk behavior surveillance system.

PURPOSE: Syndemics are co-occurring epidemics that cluster within populations due to shared socio-structural factors and are often in populations with intersecting forms of vulnerability. Suicide, depression, and substance use all disproportionately affect transgender and gender diverse (TGD) youth. In this study, we test a syndemic model of the relationship between these three mental health conditions in the context of economic deprivation and interpersonal discrimination. METHODS: We used data on substance use, depressive symptoms, suicidality, and social-structural factors from 2680 TGD youth captured in the 2017 and 2019 survey waves of the Youth Risk Behavior Surveillance System. We used a latent class analysis (LCA) to identify groups with distinct patterns of self-reported substance use and depressive symptoms, and regression models to characterize the relationship between substance-use, depressive symptoms, class membership, social-structural factors, and suicidality. RESULTS: A three-class LCA solution identified a subset of student respondents in a "high use" latent class characterized by high self-reported substance use frequency and depressive symptoms compared with other classes. Online bullying (aOR: 1.58; 95% CI: 1.28-1.95) and housing insecurity (aOR: 8.78; 95% CI: 4.35-17.71) were associated with increased odds of "high use" class membership relative to the "no use" class membership. "High use" class membership was associated with increased odds of suicidal ideation (aOR: 2.26; 95% CI: 1.75-2.94), plans (aOR: 2.59; 95% CI: 2.01-3.36), and attempts (aOR: 6.85; 95% CI: 3.17-15.68). CONCLUSION: The co-occurrence of substance use and depressive symptoms is associated with socio-structural factors and may drive risk for suicidality among TGD youth. Meaningful suicide prevention efforts that address disproportionate risk in this population must be attentive to and mitigate the shared determinants of mood symptoms and substance use behavior.

Evaluating ACGME-accredited addiction psychiatry fellowship online content: A critical analysis of addiction psychiatry fellowship program websites in the US.

Introduction: There is an extreme shortage of addiction psychiatrists and a lack of representation of addiction psychiatry (ADP) fellows from racial/ethnic minoritized backgrounds. ADP fellowship websites are integral in engaging potential applicants. It is therefore critical to understand the quality of engagement that trainees are having with ADP fellowship websites. The aim of this study was to investigate the accessibility and content of ADP fellowship program websites in the U.S. Methods: A list of ADP Fellowship programs was obtained from the Accreditation Council for Graduate Medical Education. A critical textual analysis of 42 unique factors within four categories (accessibility, recruitment, education, and health equity) was performed for each ADP fellowship website. Results: Of 51 ADP fellowships, 47 (92.2%) had websites. Information about social media accounts was largely missing from ADP fellowship websites. For recruitment, program description (95.7%) and program director name (76.6%) were most readily available, while interview day (0.00%) and vacation details (10.6%) were least available. For education, a list of rotations (55.3%) and didactics/lectures (40.4%) were most readily available, while post fellowship placement (6.4%), call schedule (4.3%), and responsibility progression (2.1%) were least available. The most prevalent health equity factors were gender-inclusive language (100%) and an absence of stigmatizing addiction language (100%). The least listed were statements of commitment to health equity (0.0%), antiracism training (2.1%), and harm-reduction strategies (4.3%). Conclusions: There are considerable gaps in the amount and types of information provided by ADP fellowship websites. Many existing websites are poorly interfacing with potential leaders in the field. The development of ADP fellowship websites could serve as a low-cost recruitment tool to engage potential addiction specialists. Our findings underscore the need for ADP fellowships to optimize their websites to engage bourgeoning leaders in addiction and optimize access to more comprehensive information.

Health Equity Tourism: Ravaging the Justice Landscape.

As the long-standing and ubiquitous racial inequities of the United States reached national attention, the public health community has witnessed the rise of "health equity tourism". This phenomenon is the process of previously unengaged investigators pivoting into health equity research without developing the necessary scientific expertise for high-quality work. In this essay, we define the phenomenon and provide an explanation of the antecedent conditions that facilitated its development. We also describe the consequences of health equity tourism - namely, recapitulating systems of inequity within the academy and the dilution of a landscape carefully curated by scholars who have demonstrated sustained commitments to equity research as a primary scientific discipline and praxis. Lastly, we provide a set of principles that can guide novice equity researchers to becoming community members rather than mere tourists of health equity.

"We've Got Our Own Beliefs, Attitudes, Myths": A Mixed Methods Assessment of Rural South African Health Care Workers' Knowledge of and Attitudes Towards PrEP Implementation.

South Africa maintains the world's largest HIV prevalence, accounting for 20.4% of people living with HIV internationally. HIV Pre-exposure prophylaxis (PrEP) has demonstrated efficacy; however, there is limited data on PrEP implementation in South Africa, particularly in rural areas. Using grounded theory analysis of semi-structured interviews and exploratory factor analyses of structured surveys, this mixed methods study examines healthcare workers' (HCWs)' beliefs about their patients and the likelihood of PrEP uptake in their communities. The disproportionate burden of HIV among Black South Africans is linked to the legacy of apartheid and resulting disparities in wealth and employment. HCWs in our study emphasized the importance of addressing these structural barriers, including increased travel burden among men in the community looking for work, poor transportation infrastructure, and limited numbers of highly skilled clinical staff in their rural community. HCWs also espoused a vision of PrEP that prioritizes women due to perceived constraints on their sexual agency, and that minimizes the impact of HIV-related stigma on PrEP implementation. However, HCWs' additional concerns for risk compensation may reflect dominant social mores around sexual behavior. In recognition of HCWs' role as both informants and community members, implementation scientists should invite local HCWs to partner as early as the priority-setting stage for PrEP interventions. Inviting leadership from local HCWs may increase the likelihood of delivery plans that account for unique local context and structural barriers researchers may otherwise struggle to uncover.