Unmet Needs, Minority Stress and Mental Health Outcomes Among Transgender Individuals: The Mediating Role of Schema Domains.

Exposure to gender-related minority stressors, the negative experiences and beliefs that stem from anti-trans stigma increases transgender and gender diverse (TGD) people's vulnerability to experiencing poor mental health outcomes. This study examined if the relationships between experiences of minority stress and mental health outcomes were mediated by early maladaptive schemas: mental representations shaping the way people view themselves, others and the world. Drawing from a schema therapy perspective, the study additionally examined if caregivers' failure to meet TGD people's core emotional needs was associated with mental health outcomes and if schemas similarly mediated these relationships. A total of 619 TGD adults completed an online survey about early maladaptive schemas, core emotional needs, gender-related minority stress and psychological distress and wellbeing. Causal mediation analyses indicated that caregivers who did not meet TGD people's core emotional needs and greater experiences of minority stress were associated with increased distress and lower wellbeing. These relationships were mediated by schema severity, particularly the disconnection and rejection and impaired autonomy domains. These findings provide empirical support for the schema therapy model's assumption that unmet core emotional needs are associated with schema formation. For TGD people, maladaptive beliefs about the self, others and world can form in response to manifestations of anti-trans stigma within the individual, their interpersonal relationships, community and broader society. Caregivers' failure to meet needs, plus experiences of minority stress throughout the individual's system, leads to greater distress and lower wellbeing; however, clinical interventions targeting schemas may improve outcomes for this at-risk group.

Characteristics of a transgender and gender-diverse patient population in Utah: Use of electronic health records to advance clinical and health equity research.

Transgender and gender-diverse (TGD) people, individuals whose gender identity differs from their sex assigned at birth, face unique challenges in accessing gender-affirming care and often experience disparities in a variety of health outcomes. Clinical research on TGD health is limited by a lack of standardization on how to best identify these individuals. The objective of this retrospective cohort analysis was to accurately identify and describe TGD adults and their use of gender-affirming care from 2003-2023 in a healthcare system in Utah, United States. International Classification of Disease (ICD)-9 and 10 codes and surgical procedure codes, along with sexual orientation and gender identity data were used to develop a dataset of 4,587 TGD adults. During this time frame, 2,985 adults received gender-affirming hormone therapy (GAHT) and/or gender-affirming surgery (GAS) within one healthcare system. There was no significant difference in race or ethnicity between TGD adults who received GAHT and/or GAS compared to TGD adults who did not receive such care. TGD adults who received GAHT and/or GAS were more likely to have commercial insurance coverage, and adults from rural communities were underrepresented. Patients seeking estradiol-based GAHT tended to be older than those seeking testosterone-based GAHT. The first GAS occurred in 2013, and uptake of GAS have doubled since 2018. This study provides a methodology to identify and examine TGD patients in other health systems and offers insights into emerging trends and access to gender-affirming care.

Disparities in behaviors and experiences among transgender and cisgender high school students - 18 U.S. states, 2021.

PURPOSE: Transgender youth (those whose gender identity differs from their sex assigned at birth) experience stigma and discrimination that can place them at increased risk for poor health outcomes compared with cisgender youth (those whose gender identity aligns with their sex assigned at birth). Limited population-based data exist on disparities among transgender and cisgender youth. METHODS: We examined differences in experiences of violence, substance use, mental health, suicide, sexual behavior, unstable housing, parental monitoring, and school connectedness among 98,174 transgender and cisgender high school students using data from 18 states that included an item to assess transgender identity on their 2021 Youth Risk Behavior Survey. RESULTS: Overall, 2.9% of students identified as transgender and 2.6% questioned whether they were transgender. Among transgender students, 71.5% reported that their mental health was not good, 32.3% had attempted suicide, and 29.0% experienced sexual violence. Transgender students were more likely than cisgender students to report experiences of violence, substance use, poor mental health, suicide risk, some sexual risk behaviors, and unstable housing, and were less likely to report feeling connected to others at school. CONCLUSIONS: Interventions that can address the causes of these adverse outcomes and promote the health and wellbeing of transgender youths are warranted.

Direct and vicarious exposure to healthcare discrimination and erasure among transgender and gender independent individuals: Testing the indirect effect of mistrust in healthcare on utilization behaviors.

RATIONALE: Direct exposure to gender identity-related discrimination and erasure among the transgender and gender independent (TGI) population are associated with healthcare underutilization, which may further exacerbate the health disparities that exist between this population and cisgender individuals in the United States (U.S.). Although the impacts of direct exposure to healthcare discrimination and erasure may have on TGI individuals are known, exposure to such harm vicariously (i.e., through observation or report) is underexplored. OBJECTIVE: The present study examined the relationships among direct and vicarious gender identity-related healthcare discrimination and erasure exposure and past-year healthcare utilization. METHOD: Gender identity-based mistrust in healthcare was also assessed, as a mechanism through which direct and vicarious gender identity-related healthcare discrimination and erasure predict healthcare utilization behaviors among a sample (N = 385) of TGI adults in the U.S., aged 18 to 71 recruited online. RESULTS: Results indicated direct lifetime and vicarious healthcare discrimination and erasure exposure significantly predicted past-year healthcare underutilization when participants anticipated encountering gender identity-related healthcare discrimination. Mediational analyses indicated that higher levels of exposure to direct lifetime and vicarious healthcare discrimination and erasure were related to higher levels of mistrust in healthcare, through which past-year underutilization was significantly related. CONCLUSIONS: These findings are vital to informing healthcare practice and policy initiatives aimed at ensuring the barriers that deleteriously influence the accessibility of healthcare among TGI individuals are ameliorated.

Hospitalizations and transgender patients in the United States.

It is known that transgender people experience health inequalities. Disparities in hospital outcomes impacting transgender individuals have been inadequately explored. We conducted this retrospective cohort study using the National Inpatient Sample (01/2018-12/2019) to compare in-hospital mortality and utilization variables between cisgender and transgender individuals using regression analyses. Approximately two-thirds of hospitalizations for transgender patients (n = 10,245) were for psychiatric diagnoses. Compared to cisgender patients, there were no significant differences in adjusted means differences (aMD) in length of stay (LOS) (aMD = -0.29; p = .16) or total charges (aMD = -$486; p = .56). An additional 4870 transgender patients were admitted for medical diagnoses. Transgender and cisgender individuals had similar adjusted odds ratios (aOR) for in-hospital mortality (aOR = 0.96; p = .88) and total hospital charges (aMD = -$3118; p = .21). However, transgender individuals had longer LOS (aMD = +0.46 days; confidence interval [CI]: 0.15-0.90; p = .04). When comparing mortality and resource utilization between cisgender and transgender individuals, differences were negligible.

Interest in over-the-counter progestin-only pills among transgender, nonbinary, and gender-expansive individuals in the United States.

BACKGROUND: In July 2023, the US Food and Drug Administration approved the first nonprescription oral contraceptive, a progestin-only pill, in the United States. Transgender, nonbinary, and gender-expansive people assigned female or intersex at birth face substantial contraceptive access barriers and may benefit from over-the-counter oral contraceptive access. However, no previous research has explored their perspectives on this topic. OBJECTIVE: This study aimed to measure interest in over-the-counter progestin-only pill use among transgender, nonbinary, and gender-expansive individuals assigned female or intersex at birth. STUDY DESIGN: We conducted an online, cross-sectional survey from May to September 2019 (before the US Food and Drug Administration approval of a progestin-only pill) among a convenience sample of transgender, nonbinary, and gender-expansive people assigned female or intersex at birth who were aged 18 to 49 years from across the United States. Using descriptive statistics and logistic regression analyses, we estimated interest in over-the-counter progestin-only pill use (our outcome) overall and by sociodemographic and reproductive health characteristics (our exposures). We evaluated separate logistic regression models for each exposure. In each model, we included the minimally sufficient adjustment set to control for confounding pathways between the exposure and outcome. For the model for age, we ran a univariable logistic regression model; for all other exposures, we ran multivariable logistic regression models. RESULTS: Among 1415 participants in our sample (median age, 26 years), 45.0% (636/1415; 95% confidence interval, 42.3-47.6) were interested in over-the-counter progestin-only pill use. In separate logistic regression models for each exposure, there were higher odds of interest among participants who were aged 18 to 24 years (odds ratio, 1.67; 95% confidence interval, 1.33-2.10; vs those aged 25-34 years), those who were uninsured (adjusted odds ratio, 1.91; 95% confidence interval, 1.24-2.93; vs insured), those who currently used oral contraceptives (adjusted odds ratio, 1.69; 95% confidence interval, 1.17-2.44; vs non-users), had ≤high school degree (adjusted odds ratio, 3.02; 95% confidence interval, 1.94-4.71; vs college degree), had ever used progestin-only pills (adjusted odds ratio, 2.32; 95% confidence interval, 1.70-3.17; vs never users), and who wanted to avoid estrogen generally (adjusted odds ratio, 1.32; 95% confidence interval, 1.04-1.67; vs those who did not want to avoid estrogen generally) or specifically because they viewed it as a feminizing hormone (adjusted odds ratio, 1.72; 95% confidence interval, 1.36-2.19; vs those who did not want to avoid estrogen because they viewed it as a feminizing hormone). There were lower odds of interest among participants with a graduate or professional degree (adjusted odds ratio, 0.70; 95% confidence interval, 0.51-0.96; vs college degree), those who were sterilized (adjusted odds ratio, 0.31; 95% confidence interval, 0.12-0.79; vs not sterilized), and those who had ever used testosterone for gender affirmation (adjusted odds ratio, 0.72; 95% confidence interval, 0.57-0.90; vs never users). CONCLUSION: Transgender, nonbinary, and gender-expansive individuals were interested in over-the-counter progestin-only pill use, and its availability has the potential to improve contraceptive access for this population.

Evaluation of health status of transgender sex workers in Turkey: A qualitative study.

OBJECTIVE: Sex workers can be disadvantaged in terms of overall health due to challenging living and working conditions. This research aimed to evaluate the health status and experiences related to sexually transmitted infections (STDs) of unregistered transgender sex workers in Turkey. DESIGN: It employed a phenomenological qualitative research design. SITE: Data were collected in Istanbul between March 2021 and November 2021. PARTICIPANTS: Data were collected through in-depth interviews involving 24 people (19 sex workers and 5 physicians). METHODS: Key statements were listed during data analysis, and clusters of meanings were formed based on these statements. The participants' statements were used for contextual and structural descriptions. RESULTS: Sex workers suffer from chronic illnesses such as asthma, chronic obstructive pulmonary disease (COPD), diabetes, allergic diseases, and neurological disorders. Among the health issues affecting them, the most notable ones are STDs, psychological problems, and the risk of suicide. Sex workers also face a dilemma between choosing public hospitals and private hospitals. Majority of sex workers undergo regular testing for STDs, with the frequency varying from person to person. Reasons for not undergoing regular testing include lack of social security coverage, financial constraints, lack of information, and feeling undervalued. Some individuals are being subjected to mandatory testing. CONCLUSIONS: It is recommended that sex workers who seek and request healthcare services should be provided with detailed information and education, particularly regarding psychological problems and STDs.

Assessment of Quality of Life of Transgender and Gender-Diverse Children and Adolescents in Melbourne, Australia, 2017-2020.

Importance: Transgender and gender-diverse (TGD) children and adolescents may experience not only gender dysphoria but also depression and anxiety, all of which are likely to be associated with reduced quality of life (QOL). Despite this, little is known about QOL in this population. Objectives: To identify demographic, social, and clinical characteristics associated with reduced QOL in TGD children and adolescents; compare their QOL with age-matched population-based norms and that of young people with common mental health problems; and evaluate the association between gender dysphoria and QOL. Design, Setting, and Participants: In this cohort study, baseline data were derived from questionnaires completed in a prospective cohort study (Trans20) of TGD children aged 6 to 12 years and adolescents aged 13 to 17 years first seen at the Royal Children's Hospital Gender Service (Melbourne, Australia) between February 2017 and February 2020. Main Outcomes and Measures: The main outcome was QOL, measured using the Child Health Utility 9D instrument (CHU-9D). Data collection included demographic information, social factors (eg, bullying, lack of support, and social transition), and clinical characteristics (eg, gender identity, gender dysphoria, and mental health difficulties). Population norms and CHU-9D data for Australian youths with mental health diagnoses were derived from published literature. Results: The TGD cohort comprised 525 children and adolescents aged 6 to 17 years (median age, 14 years [IQR, 12-16 years]; 364 [69.33%] presumed female at birth). The mean (SD) CHU-9D score was 0.46 (0.26). Compared with population norms, TGD children (0.58 [0.27] vs 0.81 [0.16]; P < .001) and adolescents (0.41 [0.25] vs 0.80 [0.14]; P < .001) had significantly lower scores. Within the TGD cohort, mean (SD) scores were significantly lower in adolescents (0.41 [0.24] vs 0.62 [0.25]; P < .001), those assigned female at birth (0.43 [0.26] vs 0.55 [0.25]; P < .001), those reporting mental health problems (0.37 [0.23] vs 0.57 [0.25]; P < .001) and physical health problems (0.41 [0.26] vs 0.48 [0.26]; P = .04), and those who were bullied (0.38 [0.24] vs 0.52 [0.25]; P < .001). Gender dysphoria alone was associated with a lower mean (SD) CHU-9D score (0.51 [0.23]) than that in control adolescents with serious mental health conditions such as depression (0.64 [0.26]) and anxiety (0.70 [0.24]) and was an independent factor associated with QOL. Conclusions and Relevance: In this cohort study of TGD children and adolescents in Australia, QOL was worse in this population than in age-matched, population-based peers. Quality of life associated with gender dysphoria was substantially worse than that seen in young people with common mental health conditions. These findings emphasize the risk of poor QOL among TGD young people and the need to better support them.

Healthcare Experiences of Gender Diverse Youth Across Clinical Settings.

We explored gender diverse youth's experiences seeking and receiving gender-affirming care in various health system locations. Results provide evidence for system-, clinic-, and provider-level improvements to promote the development of affirming environments and to improve health outcomes for gender diverse youth.

'This family rejection harmed my health as well': Intersections between the meanings of family and health for trans people and family members in a trans healthcare service in Brazil.

Transgender people deal with intense discrimination in every aspect of life. These experiences increase when they face family rejection. The research on social and family environment surrounding gender transition has been largely overlooked. We examine the meanings of family and health, and how these intersect, among trans people and their family members in a health service in Brazil. We conducted a qualitative study (between December 2017 and July 2018), an ethnography with the triangulation of three sources: interviews with 8 transgender men, 8 transgender women and 5 family members; a focus group with another 8 transgender men and approximately 100 h of field observation. Our study shows that family and health are interpreted as ideal protective environments, and seen as causes of disappointment, abandonment and illness. The meanings of family and health are interconnected and constituted in relation to each other. We also found that there are differences within these meanings of family and health when we consider the ethnicity and the economic status of the participants. The participants reported that the society education towards transsexuality is fundamental to improving trans people's quality of life. Our results challenge health services to provide comprehensive healthcare and assure health equity for transgender people.

Barriers to Accessing Health Care in Rural Regions by Transgender, Non-Binary, and Gender Diverse People: A Case-Based Scoping Review.

Research shows an overrepresentation of trans people in vulnerable socioeconomic situations, primarily due to experiences of discrimination. At the same time, rural or suburban living areas often lack specialized trans-related health care, which a majority of trans people rely on to some extent. Taken together, the lack of both socioeconomic resources and access to trans-related health care can exacerbate health-related distress and impairment for trans people. We illustrate this problem using case vignettes of trans people from rural and suburban areas in (Northern) Germany. They are currently participating in an e-health intervention and randomized controlled trial (RCT) called i2TransHealth, whose case vignettes provided the impetus for the scoping review. The scoping review analyzes the impact of place of residence and its intersection with barriers to accessing trans-related health care. PubMed and Web of Science Data bases were searched for relevant studies using a search strategy related to trans people and remote, rural, or suburban residences. 33 studies were selected after full-text screening and supplemented via reference list checks and study team expertise by 12 articles addressing the living conditions of remotely living trans people and describing requirements for trans-related health care. The literature on trans people living remotely reveals intersections of trans mental health with age, race, gender expression, geographic location, community size, socioeconomic status, discrimination experiences, and attitudes towards health care providers. Several structural health care barriers are identified. The role of health care professionals (HCPs) for remotely living trans people is discussed. There is no need assuming that rural life for trans people is inevitably worse for health and well-being than urban life. Nevertheless, some clear barriers and health disparities exist for trans people in remote settings. Empowering trans groups and diversity-sensitive education of remote communities in private and institutional settings are needed for respectful inclusion of trans people. Facilitating access to trans-related health care, such as through video-based e-health programs with HCPs, can improve both the health and socioeconomic situation of trans people.

The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis.

INTRODUCTION: Transgender individuals are at risk for HIV. HIV risks are dynamic and there have been substantial changes in HIV prevention (e.g., pre-exposure prophylaxis [PrEP]). It is thus time to revisit HIV prevalence and burden among transgender individuals. The objective of this systematic review and meta-analysis was thus to examine worldwide prevalence and burden of HIV over the course of the epidemic among trans feminine and trans masculine individuals. METHODS: We conducted an updated systematic review by searching PsycINFO, PubMed, Web of Science, and Google Scholar, for studies of any research design published in in a peer-reviewed journal in any language that reported HIV prevalence among transgender individuals published between January 2000 and January 2019. Two independent reviewers extracted the data and assessed methodological quality. We then conducted a meta-analysis, using random-effects modelling, to ascertain standardized prevalence and the relative burden of HIV carried by transgender individuals by country and year of data collection, and then by geographic region. We additionally explored the impact of sampling methods and pre-exposure prophylaxis (PrEP). RESULTS: Based on 98 studies, overall standardized HIV prevalence over the course of the epidemic, based on weights from each country by year, was 19.9% (95% CI 14.7% - 25.1%) for trans feminine individuals (n = 48,604) and 2.56% (95% CI 0.0% - 5.9%) for trans masculine individuals (n = 6460). Overall OR for HIV infection, compared with individuals over age 15, was 66.0 (95% CI 51.4-84.8) for trans feminine individuals and 6.8 (95% CI 3.6-13.1) for trans masculine individuals. Prevalence varied by geographic region (13.5% - 29.9%) and sampling method (5.4% - 37.8%). Lastly, PrEP effects on prevalence could not be established. CONCLUSION: Trans feminine and trans masculine individuals are disproportionately burdened by HIV. Their unique prevention and care needs should be comprehensively addressed. Future research should further investigate the impact of sampling methods on HIV prevalence, and monitor the potential impact of PrEP.

Centralized and Decentralized Delivery of Transgender Health Care Services: A Systematic Review and a Global Expert Survey in 39 Countries.

Introduction: Transgender health care is delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different medical institutions spread over several locations). However, the health care delivery setting has not gained attention in research so far. Based on a systematic review and a global expert survey, we aim to investigate its role in transgender health care quality. Methods: We performed two studies. In 2019, we systematically reviewed the literature published in databases (Cochrane, MEDLINE, EMBASE, Web of Science) from January 2000 to April 2019. Secondly, we conducted a cross-sectional global expert survey. To complete the evidence on the question of (de-)centralized delivery of transgender health care, we performed a grey literature search for additional information than the systematic review and the expert survey revealed. These analyses were conducted in 2020. Results: Eleven articles met the inclusion criteria of the systematic review. 125 participants from 39 countries took part in the expert survey. With insights from the grey literature search, we found transgender health care in Europe was primarily delivered centralized. In most other countries, both centralized and decentralized delivery structures were present. Comprehensive care with medical standards and individual access to care were central topics associated with the different health care delivery settings. Discussion: The setting in which transgender health care is delivered differs between countries and health systems and could influence different aspects of transgender health care quality. Consequently, it should gain significant attention in clinical practice and future health care research.

Marital status differences in suicidality among transgender people.

The suicide rate for transgender people is among the highest of any group in the United States. Yet, we know little about disadvantages or resources available to transgender people to prevent suicide. The overall purpose of this study is to assess how marital status modifies the risk of suicide among transgender people. We analyzed data from the 2015 U.S. Transgender Survey to predict marital status differences in both suicide ideation and suicide attempt in the past year. The analytic sample for suicide ideation included 17,117 transgender respondents (9,182 transwomen and 7,935 transmen), and the analytic sample for suicide attempt was limited to 8,058 transgender respondents (4,342 transwomen and 3,716 transmen) who reported suicide ideation in the last 12 months. Results from binary logistic regression models suggested that never married and previously married transmen and transwomen, regardless of their partnership status, generally had higher risk of both suicide ideation and attempt than their married transgender counterparts with only one exception: never married transwomen had lower risk of suicide ideation (but not attempt) than their married transwomen counterpart after sociodemographic characteristics were accounted for. These findings draw attention to the heterogeneity of the transgender population, highlighting marital status as a key social factor in stratifying the life experiences of transgender people.

Gender incongruence in Denmark, a quantitative assessment.

INTRODUCTION: The number of persons with gender incongruence referred to health care is increasing, but national data on the incidence of gender incongruence are lacking. The aim of this study was to quantify the development in number of individuals with gender incongruence over time and to estimate the national incidence in Denmark. MATERIAL AND METHODS: Historical descriptive cohort study. Individuals older than 18 years with legal sex-change in their person registration number were achieved from Statistics Denmark, and the National Health Register provided data on contact diagnoses related to gender-identity conditions. By combining these two data sources, we made estimates on incidence and incidence rates for individuals with gender incongruence in Denmark through a 41-year period 1980-2020. RESULTS: Through 1980-2020, the annual number of legal sex-changes increased in individuals assigned female at birth from 5 to approximately 170 and among individuals assigned male at birth from 10 to approximately 150. The cumulative number of legal sex-changes at the end of 2019 was 1275 assigned female at birth and 1422 assigned male at birth and 66% of the legal sex-changes were in individuals below 30 years. Correspondingly, the annual number of contacts with the healthcare system due for gender-identity-related conditions increased from 30 during 1990-1999 to around 500 in 2017 (both genders combined), with a 10-fold increase from 2010 to 2017. CONCLUSIONS: The number of legal sex-changes and healthcare contacts due to gender-identity-related diagnoses increased substantially over the last 40 years with a more than 10-fold increase during the last decade. This calls for research on possible explanations for this increase, for research on the short-term and long-term health consequences of hormonal and surgical treatment regimens and for ensuring adequate healthcare facilities.

Clinical Outcomes Following Acute Residential Psychiatric Treatment in Transgender and Gender Diverse Adolescents.

Importance: Transgender and gender diverse (TGD) individuals, who have a gender identity that differs from their sex assigned at birth, are at increased risk of mental health problems, including depression, anxiety, self-injurious behavior, and suicidality, relative to cisgender peers. Objective: To examine mental health outcomes among TGD vs cisgender adolescents in residential treatment. Design, Setting, and Participants: This cohort study's longitudinal design was used to compare groups at treatment entry and discharge, and 1-month postdischarge follow-up. The setting was an adolescent acute residential treatment program for psychiatric disorders. Participants were TGD or cisgender adolescents enrolled in the treatment program. Statistical analysis was performed October 2019 to March 2021. Exposure: Adolescents participated in a 2-week acute residential treatment program for psychiatric disorders. Main Outcomes and Measures: Primary outcomes were depressive (the Center for Epidemiologic Studies Depression Scale [CES-D]) and anxiety (the Multidimensional Anxiety Scale for Children [MASC]) symptoms, and emotional dysregulation (the Difficulties in Emotion Regulation Scale [DERS]), measured at treatment entry and discharge, and postdischarge follow-up. Age of depression onset, suicidality, self-injury, and childhood trauma also were assessed at treatment entry. Results: Of 200 adolescent participants who completed treatment entry and discharge assessments, the mean (SD) age was 16.2 (1.5) years; 109 reported being assigned female at birth (54.5%), 35 were TGD (17.5%), and 66 (49.3%) completed 1-month follow-up. TGD participants had an earlier mean (SD) age of depression onset (TGD: 10.8 [2.4] years vs cisgender: 11.9 [2.3] years; difference: 1.07 years; 95% CI, 0.14-2.01 years; P = .02), higher mean (SD) suicidality scores (TGD: 44.4 [23.1] vs cisgender: 28.5 [25.4]; difference: 16.0; 95% CI, 6.4-25.5; P = .001), more self-injurious behavior (mean [SD] RBQ-A score for TGD: 3.1 [2.5] vs cisgender: 1.7 [1.9]; difference: 1.42; 95% CI, 0.69-2.21; P = .001) and more childhood trauma (eg, mean [SD] CTQ-SF score for emotional abuse in TGD: 12.7 [5.4] vs cisgender: 9.8 [4.7]; difference: 2.85; 95% CI, 1.06-4.64; P = .002). The TGD group also had higher symptom scores (CES-D mean difference: 7.69; 95% CI, 3.30 to 12.08; P < .001; MASC mean difference: 7.56; 95% CI, 0.46 to 14.66; P = .04; and DERS mean difference: 18.43; 95% CI, 8.39 to 28.47; P < .001). Symptom scores were significantly higher at entry vs discharge (CES-D mean difference, -12.16; 95% CI, -14.50 to -9.80; P < .001; MASC mean difference: -3.79; 95% CI, -6.16 to -1.42; P = .02; and DERS mean difference: -6.37; 95% CI, -10.80 to -1.94; P = .05) and follow-up (CES-D mean difference: -9.69; 95% CI, -13.0 to -6.42; P < .001; MASC mean difference: -6.92; 95% CI, -10.25 to -3.59; P < .001; and DERS mean difference: -12.47; 95% CI, -18.68 to -6.26; P < .001). Conclusions and Relevance: This cohort study found mental health disparities in TGD youth relative to cisgender youth, with worse scores observed across assessment time points. For all participants, primary clinical outcome measures were significantly lower at treatment discharge than at entry, with no significant differences between discharge and 1-month follow-up. Given the substantial degree of mental health disparities reported in TGD individuals, these findings warrant focused clinical attention to optimize treatment outcomes in gender minority populations.

Health and health care access in the US transgender population health (TransPop) survey.

BACKGROUND: Probability and nonprobability-based studies of US transgender persons identify different disparities in health and health care access. OBJECTIVES: We used TransPop, the first US national probability survey of transgender persons, to describe and compare measures of health and health access among transgender, nonbinary, and cisgender participants. We directly compared the results with 2015 US Transgender Survey (USTS) data and with previously published analyses from the Behavioral Risk Factor Surveillance System (BRFSS). METHODS: All participants were screened by Gallup Inc., which recruited a probability sample of US adults. Transgender people were identified using a two-step screening process. Eligible participants completed self-administered questionnaires (transgender n = 274, cisgender n = 1162). We obtained weighted proportions/means, then tested for differences between gender groups. Logistic regression was performed to evaluate associations. Bivariate analyses were conducted using the weighted USTS data set for shared variables in USTS and TransPop. RESULTS: Transgender participants were younger and more racially diverse compared to the cisgender group. Despite equally high insurance coverage, transgender people more often avoided care due to cost concerns. Nonbinary persons were less likely to access transgender-related health care providers/clinics than transgender men and women. Transgender respondents more often rated their health as fair/poor, with more frequently occuring poor physical and mental health days compared to cisgender participants. Health conditions including HIV, emphysema, and ulcer were higher among transgender people. TransPop and USTS, unlike BRFSS-based analyses, showed no differences in health or health access. DISCUSSION: Transgender persons experience health access disparities centered on avoidance of care due to cost beyond insured status. Health disparities correspond with models of minority stress, with nonbinary persons having distinct health/health access patterns. Despite different sampling methods, USTS and TransPop appear more similar than BRFSS studies regarding health/health access. CONCLUSION: Future research should elucidate health care costs for transgender and nonbinary people, while addressing methodology in national studies of transgender health.

Sexual Behavior and Contraceptive Use Among Cisgender and Gender Minority College Students Who Were Assigned Female at Birth.

STUDY OBJECTIVE: Our objective was to describe sexual behavior and contraceptive use among assigned female cisgender and gender minority college students (ie, those whose gender identity does not match their sex assigned at birth). DESIGN: Cross-sectional surveys administered as part of the fall 2015 through spring 2018 administrations of the National College Health Assessment. SETTING: Colleges across the United States. PARTICIPANTS: A total of 185,289 cisgender and gender minority assigned females aged 18-25 years. MAIN OUTCOME MEASURES: Recent vaginal intercourse; number and gender of sexual partners; use of contraception; use of protective barriers during vaginal intercourse. RESULTS: Both gender minority and cisgender students often reported having male sexual partners, but gender minority students were more likely to report having partners of another gender identity (eg, women, trans women). Gender minorities were less likely than cisgender students to report having vaginal intercourse (adjusted odds ratio [AOR]: 0.86; 95% confidence interval [95% CI]: 0.80, 0.93). Gender minorities were less likely than cisgender students to report using any contraceptive methods (AOR: 0.86; 95% CI: 0.73, 1.03), and were less likely to consistently use barrier methods (AOR: 0.72; 95% CI: 0.64, 0.81) or emergency contraception (AOR: 0.56; 95% CI: 0.48, 0.65). However, gender minorities were more likely to use Tier 1 and Tier 3 contraceptive methods than cisgender women. CONCLUSIONS: Providers must be trained to meet the contraceptive counseling needs of cisgender and gender minority patients. Providers should explicitly ask all patients about the sex/gender of the patients' sexual partners and the sexual behaviors in which they engage, to assess sexual risk and healthcare needs.

Gender Identity Disparities in Criminal Victimization: National Crime Victimization Survey, 2017-2018.

Objectives. To estimate the prevalence of personal and household victimizations among transgender people in the United States.Methods. We analyzed pooled 2017 and 2018 data from the National Crime Victimization Survey, the first nationally representative sample that allows identification of transgender respondents.Results. Transgender people experienced 86.2 victimizations per 1000 persons compared with cisgender people's 21.7 per 1000 persons (odds ratio [OR] = 4.24; 90% confidence interval [CI] = 1.49, 7.00). Households that had a transgender person had higher rates of property victimization (214.1 per 1000 households) than households with only cisgender people (108 per 1000 households; OR = 2.25; 90% CI = 1.19, 3.31). Transgender victims whose sex assigned at birth was male were more likely to perceive their victimization as a hate crime than cisgender victims whose sex assigned at birth was male. There were no disparities in reporting victimizations to authorities: only about half of the victimizations of both transgender and cisgender people were reported.Conclusions. Public policy and administration need to consider the unique vulnerabilities transgender people routinely encounter, resulting in disparities in criminal victimization.