The Relationship Between Tobacco Use and Legal Document Gender-Marker Change, Hormone Use, and Gender-Affirming Surgery in a United States Sample of Trans-Feminine and Trans-Masculine Individuals: Implications for Cardiovascular Health.

PURPOSE: Transgender individuals smoke tobacco at disproportionately higher rates than the general U.S. population, and concurrent use of gender-affirming hormones (estrogen or testosterone) and tobacco confers greater cardiovascular (CV) risk. This study examines the relationship between tobacco use and legal document gender-marker change, and medical/surgical interventions for gender transition. METHODS: Data came from an Internet-based survey of U.S. trans-feminine (n = 631) and trans-masculine (n = 473) individuals. We used multivariable logistic regression to investigate the relationship between past 3-month tobacco use and legal document gender-marker change, hormone use, and gender-affirming surgery controlling for demographic covariates and enacted and felt stigma. RESULTS: Compared to trans-feminine participants, trans-masculine individuals reported significantly higher rates of lifetime (74.4% vs. 63.5%) and past 3-month tobacco use (47.8% vs. 36.1%), and began smoking at an earlier age (14.5 vs. 15.5 years). Trans-feminine smokers reported significantly more frequent and heavier use. Adjusting for demographic covariates and enacted and felt stigma, legal document gender-marker change was associated with lower tobacco-use odds among trans-feminine individuals, whereas gender-affirming surgery predicted lower smoking odds among trans-masculine individuals. There were no significant differences in tobacco use by hormone use status. CONCLUSION: In this study, trans-masculine individuals were more likely to smoke and trans-feminine individuals reported heavier use. It is concerning that individuals receiving hormones did not report lower smoking rates, given the elevated CV risk of this combination. This is a missed opportunity to intervene on a major public health issue and highlights the need for smoking cessation interventions in this population.

An Evaluation of New York City's 2015 Birth Certificate Gender Marker Regulation.

PURPOSE: In 1971, the New York City (NYC) Department of Health and Mental Hygiene amended Section 207.05 of the NYC Health Code to allow individuals who had undergone "convertive surgery" (interpreted by the code to mean genital surgery) to amend the gender on their birth certificates. This surgery requirement was removed in 2015. In a survey evaluating the regulation change, we sought to characterize the transgender population newly eligible to obtain a gender-congruent NYC birth certificate by comparing respondents with and without genital surgery. METHODS: We mailed a 42-question survey with each newly issued birth certificate. We compared respondents across current gender identity, race, Hispanic ethnicity, age, insurance status, income, current general health status, other transition-related care obtained, and healthcare access, stigma, and discrimination. RESULTS: Of 642 applicants, 219 responded and were thus enrolled in our 5-year study (34.1%). Most (n = 158 out of 203 who answered, 77.8%) had not received genital surgery. Compared to respondents with genital surgery, respondents without surgery were significantly more likely to be transgender men (50.0% vs. 20.0%); younger (median age 32 vs. 56.5); on Medicaid (31.6% vs. 11.1%); identify as Hispanic (28.5% vs. 8.9%); and live in households making <$20,000 annually (35.3% vs. 12.8%). CONCLUSIONS: Removing a genital surgery requirement more equitably enables transgender men and those with limited resources to obtain a gender-congruent birth certificate. Jurisdictions with such requirements should consider similar regulation changes to address the inequities that this requirement likely imposes in accessing birth certificates.

Prematuridade e fatores associados em Santa Catarina, Brasil: análise após alteração do campo idade gestacional na Declaração de Nascidos Vivos / Premature birth and associated factors in the Brazilian State of Santa Catarina: an analysis after alteration of the gestational age section of the Live Birth Declarations

Estimar a prevalência de prematuridade e os fatores associados, após a alteração do campo idade gestacional na Declaração de Nascidos Vivos, no Estado de Santa Catarina, Brasil, em 2012.Métodos:estudo seccional com base nos dados do Sistema de Informações de Nascidos Vivos (SINASC). Razões de Prevalência (RP) de prematuridade, brutas e ajustadas, por Regressão de Cox Robusta para o ano de 2012, foram calculadas e os resultados comparados aqueles reportados para 2005.Resultados:as taxas de prematuridade aumentaram de 6,1 por cento, em 2005, para 10,6 por cento em 2012. Ao se comparar os dois anos, maiores diferenças foram encontradas entre as mulheres com menor número de consultas pré-natal, menor nível de escolaridade e de cor não branca. Após o ajuste pelos fatores de confusão, as taxas de prematuridade se mostraram associadas à menor frequência de consultas de pré-natal (RP=2,64; IC95 por cento: 2,58-3,28), menor escolaridade (RP= 1,65; IC95 por cento: 1,11-2,45), idade materna <20 anos (RP= 1,24; IC95 por cento: 1,17-1,31) e maior que 39 anos (RP= 1,32; IC95 por cento: 1,17-1,49) e de cor não branca (RP=1,14; IC95 por cento: 1,07-1,21.)Conclusões:mudanças no campo idade gesta-cional, agora preenchido como semanas completas de gestação, resultaram em medidas mais confiáveis das taxas de prematuridade no Brasil...

To estimate the prevalence of premature birth and associated factors, after alteration of the gestational age section of Live Birth Declarations in the Brazilian State of Santa Catarina, in 2012.Methods:a cross-sectional study was carried out based on data from the Live Births Information System (SINASC). Prevalence rates for premature birth, raw and adjusted by Cox’s robust regression were calculated for the year 2012 and the results compared with those reported for 2005.Results:the prevalence of premature birth rose from 6.1 percent, in 2005, to 10.6 percent in 2012. Comparison of the two years found greater differences among non-Caucasian women and those with fewer prenatal consultations and a lower level of schooling. After adjustment for confounding factors, the prevalence of premature birth was found to be associated with a lower frequency of prenatal consultations (PR=2.64; CI95 percent: 2.58-3.28), lower levels of schooling (PR= 1.65; CI95 percent: 1.11-2.45), maternal age <20 years (PR= 1.24; CI95 percent: 1.17-1.31) and > 39 years (PR= 1.32; CI95 percent: 1.17-1.49) and non-Caucasian (PR=1.14; CI95 percent: 1.07-1.21.)Conclusions:changes in the gestational age section, now recorded as full weeks of gestation, have resulted in more reliable measurement of the preva-lence of premature birth in Brazil...

Affordable Care Act standards for race and ethnicity mask disparities in maternal smoking during pregnancy.

OBJECTIVE: This study compared maternal smoking during pregnancy between the new Patient Protection and Affordable Care Act (ACA) data collection standards and Federal Office of Management and Budget (OMB) standards. METHOD: Data were from the Massachusetts Standard Certificate of Live Births on 1,156,472 babies from 1996 to 2010. A parent reported whether the mother smoked during pregnancy (yes/no), her race (5 options) and, separately, her ethnicity (39 categories). Prenatal smoking rates were compared between the ACA and OMB standards. Detailed ethnicity from the birth certificate was then examined within all broad categories of the ACA standards: White, Black/African American, Other Hispanic, Other Asian/Pacific Islander, and Other categories. RESULTS: For Hispanic/Latina and Asian mothers, the ACA standards captured the variability in smoking across and within racial/ethnic groups more than the OMB standards. However, for White and Black/African American mothers, the broad ACA categories masked striking differences in prenatal smoking. While the overall prevalence among Whites was 10.2%, this ranged from 0.8% for Iranians to 21.0% for Cape Verdeans. Among Black/African Americans (7.6%), this ranged from 0.5% for Nigerians to 12.9% for African Americans. The ACA standards also combined ethnic groups with sizeable populations into Other Hispanics and Other Asian/Pacific Islanders. CONCLUSION: When population health surveys and other reporting tools are being revised, state and federal agencies should consider expanding all race/ethnicity categories to capture detailed ethnicity on everyone.

Avaliação da implantação do Sistema de Informações sobre Nascidos Vivos (Sinasc) em Pernambuco / Evaluation of the Live Birth Information System (SINASC) in the Brazilian State of Pernambuco

Avaliar o estágio de implantação do Sistema de Informações sobre Nascidos Vivos (Sinasc) em Pernambuco. MÉTODOS: trata-se de uma pesquisa avaliativa do tipo análise de implantação, que relaciona o grau de implantação aos resultados. Para aferição do grau de implantação foi realizada uma avaliação normativa, segundo a abordagem de Donabedian (1980). O estudo foi desenvolvido em duas etapas: 1ª) Foi construído o modelo lógico expondo os componentes do sistema, após consulta aos documentos, e elaborada a matriz de indicadores e de julgamento; 2ª) Foram realizadas: entrevistas individuais e observação direta, de acordo com a matriz de indicadores no âmbito estadual e regional; análise dos documentos e do banco de dados do Sinasc. RESULTADOS: os resultados mostraram o Sinasc como implantado (80,8 por cento) no nível central estadual, enquanto no âmbito regional o grau de implantação variou entre parcialmente implantado avançado (69,3 por cento) e parcialmente implantado incipiente (43,3 por cento). CONCLUSÕES: este estudo revelou aspectos organizacionais e operacionais do Sinasc que precisam ser implementados para manter o padrão de cobertura ideal e excelente qualidade das informações...

To evaluate the implantation stage of the Live Birth Information System (Sinasc) in the Brazilian State of Pernambuco. METHODS: an implantation analysis type evaluative study was carried out relating the degree of implantation with the results. The degree of implantation was measured by way of normative assessment, using the approach developed by Donabedian (1980). The study was divided into two stages: 1) a logical model was built up, revealing the components of the system, after consultation of documents and the development of a matrix of indicators and judgments; 2) individual interviews and direct observations were carried out using the matrix of indicators at State and regional level, along with analysis of documents and the SINASC database. RESULTS: the results show the SINASC to be implanted (80.8 percent) at central State level, while at regional level the degree of implantation varies from partial advanced implantation (69.3 percent) to partial initial implantation (43.3 percent). CONCLUSIONS: this study revealed organizational and operational details of the Sinasc that need to be implemented in order to maintain ideal coverage and excellence in the provision of information...

Transsexual legal rights in the United States and United kingdom: employment, medical treatment, and civil status.

Whereas hormonal and surgical sex change have been increasingly refined and accepted medically during the past 40 years, legal protections have only recently received attention. This overview focuses on employment, medical treatment, and civil status as male or female in the United States and the United Kingdom. Employment protection in the UK is assured since a court decision in 1994, but in the U.S. is generally uncertain and inconsistent between states. Health care, including surgery, under the UK National Health Service, is assured since a court decision in 1996. In the U.S., the absence of a national insurance program and the reluctance of private insurers to fund treatment remains an obstacle. Military personnel and prisoners are provided treatment in the UK but there is no military-provided treatment in the U.S. and prison treatment is limited. Change in birth certificate sex status is available in the UK since 2004. This permits heterosexual marriage as a person of the reassigned sex. In the U.S., whereas nearly all states permit birth certificate modification, obstacles remain to recognition across state jurisdictions. Some states forbid marriage for a transsexual as a person of their reassigned sex. This can impact on transsexuals as parents.

Defining, assigning and designing sex.

This article challenges the distinction the law draws between male and female. It focuses on the legal and medical treatment of intersexual people. Analysing the nature and rate of intersexuality it argues that there is a significant number of people who cannot be described as either male or female and instead exhibit a range of sexual characteristics. Until recently the law and medicine have insisted that intersexual people should be categorized as either male or female. Surgery was performed to ensure that they had the appearance assumed to be the 'norm' for a man or woman and the law followed this medical assignment of sex. Over the last couple of years the established medical practice and the legal treatment have been challenged. This article discusses the nature of these challenges and argues that there is a strong case for rejecting the traditional legal and medical approach to intersexual people. Cosmetic surgery on intersexual babies should be delayed until the individual is old enough to be able to choose their own sexual identity, which may be neither male nor female. The insistence that every person must either be male or female is no longer supportable in medical or social terms and a much wider range of sexual identities must be recognized by the law.