Gender minority stress and diurnal cortisol profiles among transgender and gender diverse people in the United States.

The field of behavioral neuroendocrinology has only begun to explore the lived experiences of transgender and gender diverse (TGD) people exposed to stigma. In light of escalating attacks and legislation targeting TGD people in the United States, it is crucial to examine the physiological pathways through which gender minority stressors become embodied, impact health, and contribute to health inequities. The Trans Resilience and Health Study included baseline data collection from fall 2019 to spring 2020 from a sample of 124 TGD people, reflecting a diversity of gender identities (e.g., trans masculine, trans feminine, and nonbinary) and ages (range = 19-70 years old; M = 34.10), living in Michigan, Nebraska, Oregon, and Tennessee. These analyses examine experiences of gender-related enacted stigma in association with hypothalamic-pituitary-adrenal (HPA)-axis functioning. Among those experiencing the highest levels of enacted stigma, findings show a blunted cortisol awakening response and sluggish daily decline that resulted in elevated concentrations at bedtime compared to those experiencing less enacted stigma. These results of flattened diurnal activity are consistent with an emergent literature on discrimination as a social determinant of potential stress pathophysiology. In contrast, community connectedness was associated with a larger, more dynamic cortisol awakening response. These findings emphasize the importance of incorporating gender-minority stress and resilience measures when studying HPA-axis functioning among TGD people.

The Often-Circuitous Path to Affirming Mental Health Care for Transgender and Gender-Diverse Adults.

PURPOSE OF REVIEW: We describe recent research regarding access to affirming mental health services for transgender and gender-diverse (TGD) adults and explore new resources available for therapists to inform evidence-based practice with TGD clients. RECENT FINDINGS: Barriers and facilitators at all socioecological levels impact TGD adults' mental health help-seeking. TGD adults often interface with mental health providers while accessing gender-affirming medical care, though new standards of care are likely to alter this typically common path to mental health services. Efforts to improve therapist education, such as therapy manuals, are increasingly available and a necessary step to increase the number of competent, affirming therapists. More work-both advocacy and research-is needed to fully expand accessible, affirming mental health services for TGD adults. Better understanding factors impacting different steps of the mental health help-seeking process and conducting randomized controlled trials of affirming mental health services are important next steps.

Differences in Health Care Access, Utilization, and Experiences Among LGBTQ+ Subgroups in the Southern United States.

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) individuals experience health inequities and barriers to accessing appropriate, affirming care. Little is known about differing health care experiences within the LGBTQ+ population, particularly among individuals living in underserved areas. This study explored health care experiences and utilization among LGBTQ+ subgroups: lesbian and gay cisgender individuals (n = 258), bisexual+ cisgender individuals (n = 71), and transgender and gender-diverse individuals (n = 80). Participants were recruited from a geographic region in South Carolina and Georgia and completed an online survey regarding negative health care experiences, barriers to care, and utilization of different health care venues and services. Results revealed significant differences between LGBTQ+ subgroups, with transgender and gender-diverse participants reporting more discriminatory experiences and greater barriers to care. Bisexual+ cisgender individuals also experienced some disparities compared with lesbian and gay cisgender individuals. Most participants endorsed a need for more competent providers. Findings and recommendations are considered within the context of the Southeastern United States for addressing access and utilization disparities among LGBTQ+ communities.

Barriers to Mental Health Care Identified by Sexual and Gender Minority Individuals in Georgia and South Carolina.

OBJECTIVE: Geographic location can affect access to appropriate, affirming mental health care for sexual and gender minority (SGM) individuals, especially for those living in rural settings. Minimal research has examined barriers to mental health care for SGM communities in the southeastern United States. The objective of this study was to identify and characterize perceived barriers to obtaining mental health care for SGM individuals living in an underserved geographic area. METHODS: Drawing from a health needs survey of SGM communities in Georgia and South Carolina, 62 participants provided qualitative responses describing barriers they encountered to accessing mental health care when needed in the previous year. Four coders used a grounded theory approach to identify themes and summarize the data. RESULTS: Three themes of barriers to care emerged: personal resource barriers, personal intrinsic factors, and healthcare system barriers. Participants described barriers that can inhibit access to mental health care regardless of one's sexual orientation or gender identity, such as finances or lack of knowledge about services, but several of the identified barriers intersect with SGM-related stigma or may be magnified by participants' location in an underserved region of the southeastern United States. CONCLUSIONS: SGM individuals living in Georgia and South Carolina endorsed several barriers to receiving mental health services. Personal resource and intrinsic barriers were the most common, but healthcare system barriers were present as well. Some participants described simultaneously encountering multiple barriers, illustrating that these factors can interact in complex ways to affect SGM individuals' mental health help seeking.

Transgender and gender diverse adults' self-reported mental health diagnoses, engagement in mental health services, and perceptions of therapists.

OBJECTIVE: Transgender and gender diverse (TGD) people face various challenges when seeking therapy. Given this, we wanted to understand more about TGD people's perceptions of providers and how these compare to researcher ratings of providers on metrics of affirming practice. METHOD: The sample included 158 TGD adults (Mage = 33.06); 57.6% were in therapy. Participants completed measures about mental health, resilience, and therapy. We systematically coded provider websites and intake forms. RESULTS: Participants in therapy were older, had higher depression, and lower resilience than participants not in therapy. Non-binary/genderqueer participants rated providers as less knowledgeable compared to trans feminine participants. Overall, participants appeared satisfied (71.4% extremely satisfied) and viewed providers as at least moderately knowledgeable (89.1%). Provider coding revealed variation across the markers of affirmation; 66.04% identified a TGD-specialty and only 26.42% shared provider pronouns. Higher frequency of inclusivity (via coding) was related to higher ratings of provider knowledge and more of a focus on gender, however, there was not a significant association with satisfaction. CONCLUSIONS: Providers who engaged in more affirming practices were more knowledgeable compared to those who engaged in fewer affirming practices. This may influence the content of therapy and whether clients feel comfortable discussing gender.

Trade-offs in muscle physiology in selectively bred high runner mice.

A trade-off between locomotor speed and endurance occurs in various taxa, and is thought to be underpinned by a muscle-level trade-off. Among four replicate high runner (HR) lines of mice, selectively bred for voluntary wheel-running behavior, a negative correlation between average running speed and time spent running has evolved. We hypothesize that this trade-off is due to changes in muscle physiology. We studied the HR lines at generation 90, at which time one line (L3) is fixed for the mini-muscle phenotype, another is polymorphic (L6) and the others (L7, L8) lack mini-muscle individuals. We used in situ preparations to quantify the contractile properties of the triceps surae muscle complex. Maximal shortening velocity varied significantly, being lowest in mini-muscle mice (L3 mini=25.2 mm s-1, L6 mini=25.5 mm s-1), highest in normal-muscle mice L6 and L8 (40.4 and 50.3 mm s-1, respectively) and intermediate in normal-muscle L7 mice (37.2 mm s-1). Endurance, measured both as the slope of the decline in force and the proportion of initial force that could be sustained, also varied significantly. The slope was shallowest in mini-muscle mice (L3 mini=-0.00348, L6 mini=-0.00238), steepest in lines L6 and L8 (-0.01676 and -0.01853), and intermediate in L7 (-0.01145). Normalized sustained force was highest in mini-muscle mice (L3 mini=0.98, L6 mini=0.92) and lowest in L8 (0.36). There were significant, negative correlations between velocity and endurance metrics, indicating a muscle-level trade-off. However, this muscle-level trade-off does not seem to underpin the organismal-level speed and endurance trade-off previously reported as the ordering of the lines is reversed: the lines that run the fastest for the least time have the lowest muscle complex velocity and highest endurance.

Bridging the Gap Between Practice Guidelines and the Therapy Room: Community-Derived Practice Adaptations for Psychological Services with Transgender and Gender Diverse Adults in the Central United States.

Individuals who identify as transgender or gender diverse (TGD) are presenting at mental health clinicians' offices with increasing frequency. Many TGD clients are seeking care related to affirming their gender identity but also may present with anxiety, depression, trauma, substance abuse, or other problems for which a clinician may commonly provide services. Some clinicians may hesitate to accept TGD clients into their practice if they have little specialized training to work with this population in an affirming manner, especially in more underserved areas where a generalist practice is the norm. Numerous professional associations and experts have developed guidelines for affirmative behavioral health care for TGD people. However, what is needed are community informed recommendations to bridge from the official guidelines to clinicians' in-session activities. The Trans Collaborations Practice Adaptations for Psychological Interventions for Transgender and Gender Diverse Adults are derived from iterative interviews with TGD community members and affirming mental health clinicians in the Central United States. The 12 practice adaptations are intended to guide clinicians to adapt their usual treatment approach to be TGD affirming, especially in underserved and rural areas. The practice adaptations cover numerous aspects of practice including the office setting and paperwork, understanding gender identity and incorporating it into the case conceptualization, therapist's self-awareness, and referrals. The Trans Collaborations Practice Adaptations will help clinicians work confidently and competently with adult TGD clients, regardless of the presenting problem, to ensure TGD communities receive the best interventions for their behavioral health concerns.

Perceived Barriers and Preliminary PTSD Outcomes in an Open Pilot Trial of Written Exposure Therapy With Latinx Immigrants.

Latinx immigrants experience substantial disparities in mental health treatment access, particularly for posttraumatic stress disorder (PTSD). The availability of brief, flexible interventions in Spanish may assist in reducing these disparities. Written Exposure Therapy (WET) is a five-session PTSD intervention that appears as effective as longer, gold-standard interventions, but has yet to be tested among Latinx immigrants. To test the acceptability and preliminary effectiveness of WET, 20 Spanish-speaking, Latinx immigrants conducted structured interviews at pretreatment, were offered WET, and completed posttreatment structured interviews. Open thematic coding of pre- and posttreatment interview questions examined perceived barriers and benefits of WET. Quantitative components examined symptom change across PTSD (PCL-IV-C) and depression (PHQ-9). Quantitative results indicated clinically meaningful and statistically significant change in PTSD symptoms using intent-to-treat analyses (Mdiff = 17.06, SDdiff = 9.97, range = 0-29, t(15) = 6.84, p < .001). Open thematic coding identified four barrier-related themes and three benefit-related themes at pretreatment. At posttreatment, three barrier-related themes and two benefit-related themes were identified. Qualitative results largely suggested that perceived barriers were common to other PTSD interventions (e.g., exposure components). Only one participant identified barriers specific to WET. Results suggested WET may reduce PTSD symptoms among Latinx immigrants. WET also appeared to be acceptable and primarily viewed as beneficial among this population. WET is a promising intervention with Latinx immigrants and warrants further testing larger trials, including testing implementation strategies that may improve access to care.

The Multi-Scale, Three-Dimensional Nature of Skeletal Muscle Contraction.

Muscle contraction is a three-dimensional process, as anyone who has observed a bulging muscle knows. Recent studies suggest that the three-dimensional nature of muscle contraction influences its mechanical output. Shape changes and radial forces appear to be important across scales of organization. Muscle architectural gearing is an emerging example of this process.

Unmet Expectations in Health Care Settings: Experiences of Transgender and Gender Diverse Adults in the Central Great Plains.

Transgender and gender diverse (TGD) individuals face a long-term, multifaceted process if they choose to begin a gender affirmation journey. Decisions to go on hormone therapy and/or have a surgical procedure necessitate the TGD individual to set up an appointment with a health care provider. However, when TGD patients interact with health care practitioners, problems can arise. This article documents and categorizes the types of unmet expectations that are common in the TGD patient-health care provider social dynamic in the Central Great Plains of the United States. Utilizing a community-based participatory research model, qualitative in-depth interviews were conducted with 27 TGD individuals about their health care experiences. From this, the researchers identified four main themes of unmet expectations: probing, gatekeeping, stigmatizing stance, and misgendering/deadnaming. Steps that can be taken by both the health care provider and the TGD individual to have a more successful encounter are discussed.

In vivo force-length and activation dynamics of two distal rat hindlimb muscles in relation to gait and grade.

Muscle function changes to meet the varying mechanical demands of locomotion across different gait and grade conditions. A muscle's work output is determined by time-varying patterns of neuromuscular activation, muscle force and muscle length change, but how these patterns change under different conditions in small animals is not well defined. Here, we report the first integrated in vivo force-length and activation patterns in rats, a commonly used small animal model, to evaluate the dynamics of two distal hindlimb muscles (medial gastrocnemius and plantaris) across a range of gait (walk, trot and gallop) and grade (level and incline) conditions. We use these data to explore how the pattern of force production, muscle activation and muscle length changes across conditions in a small quadrupedal mammal. As hypothesized, we found that the rat muscles show limited fascicle strains during active force generation in stance across gaits and grades, indicating that these distal rat muscles generate force economically but perform little work, similar to patterns observed in larger animals during level locomotion. Additionally, given differences in fiber type composition and variation in motor unit recruitment across the gait and grade conditions examined here for these muscles, the in vivo force-length behavior and neuromuscular activation data reported here can be used to validate improved two-element Hill-type muscle models.

Tumescent anaesthesia: its applications and well tolerated use in the out-of-operating room setting.

PURPOSE OF REVIEW: Tumescent anaesthesia is a method of administering dilute local anaesthetic into the subcutaneous tissue. Many anaesthesiologists are unfamiliar with the technique, its applications and potential risks. RECENT FINDINGS: The maximum safe dose of lidocaine with epinephrine in tumescent anaesthesia for liposuction is probably between 35 and 55 mg/kg. Without liposuction, the maximum dose of lidocaine with epinephrine should be no more than 28 mg/kg. After tumescent infiltration for liposuction, serum lidocaine concentrations peak between 12 and 16 h after injection. When tumescent lidocaine without epinephrine is used for endovenous laser therapy, peak serum lidocaine concentrations are observed much earlier, between 1 and 2 h after injection. Slow administration of more dilute concentrations of local anaesthetic decreases the risk of local anaesthetic systemic toxicity. SUMMARY: Although appealing because of its ability to provide prolonged analgesia, high doses of local anaesthetic are frequently administered using the tumescent technique, and absorption of local anaesthetic from the subcutaneous tissue is variable. When caring for patients having procedures in which tumescent anaesthesia is used, the risk of local anaesthetic toxicity should be acknowledged and lipid emulsion should be available for prompt treatment if needed.

Stuck in gear: age-related loss of variable gearing in skeletal muscle.

Skeletal muscles power a broad diversity of animal movements, despite only being able to produce high forces over a limited range of velocities. Pennate muscles use a range of gear ratios, the ratio of muscle shortening velocity to fiber shortening velocity, to partially circumvent these force-velocity constraints. Muscles operate with a high gear ratio at low forces; fibers rotate to greater angles of pennation, enhancing velocity but compromising force. At higher forces, muscles operate with a lower gear ratio; fibers rotate little so limiting muscle shortening velocity, but helping to preserve force. This ability to shift gears is thought to be due to the interplay of contractile force and connective tissue constraints. In order to test this hypothesis, gear ratios were determined in the medial gastrocnemius muscles of both healthy young rats, and old rats where the interaction between contractile and connective tissue properties was assumed to be disrupted. Muscle fiber and aponeurosis stiffness increased with age (P<0.05) from 19.1±5.0 kPa and 188.5±24.2 MPa, respectively, in young rats to 39.1±4.2 kPa and 328.0±48.3 MPa in old rats, indicating a mechanical change in the interaction between contractile and connective tissues. Gear ratio decreased with increasing force in young (P<0.001) but not old (P=0.72) muscles, indicating that variable gearing is lost in old muscle. These findings support the hypothesis that variable gearing results from the interaction between contractile and connective tissues and suggest novel explanations for the decline in muscle performance with age.

The energetic benefits of tendon springs in running: is the reduction of muscle work important?

The distal muscle-tendon units of cursorial species are commonly composed of short muscle fibres and long, compliant tendons. It is assumed that the ability of these tendons to store and return mechanical energy over the course of a stride, thus avoiding the cyclic absorption and regeneration of mechanical energy by active muscle, offers some metabolic energy savings during running. However, this assumption has not been tested directly. We used muscle ergometry and myothermic measurements to determine the cost of force production in muscles acting isometrically, as they could if mechanical energy was stored and returned by tendon, and undergoing active stretch-shorten cycles, as they would if mechanical energy was absorbed and regenerated by muscle. We found no detectable difference in the cost of force production in isometric cycles compared with stretch-shorten cycles. This result suggests that replacing muscle stretch-shorten work with tendon elastic energy storage and recovery does not reduce the cost of force production. This calls into question the assumption that reduction of muscle work drove the evolution of long distal tendons. We propose that the energetic benefits of tendons are derived primarily from their effect on muscle and limb architecture rather than their ability to reduce the cyclic work of muscle.

What drives activation-dependent shifts in the force-length curve?

Skeletal muscles are rarely recruited maximally during movement. However, much of our understanding of muscle properties is based on studies using maximal activation. The effect of activation level on skeletal muscle properties remains poorly understood. Muscle optimum length increases with decreased activation; however, the mechanism responsible is unclear. Here, we attempted to determine whether length-dependent calcium effects, or the effect of absolute force underpin this shift. Fixed-end contractions were performed in frog plantaris muscles at a range of lengths using maximal tetanic (high force, high calcium), submaximal tetanic (low force, high calcium) and twitch (low force, low calcium) stimulation conditions. Peak force and optimum length were determined in each condition. Optimum length increased with decreasing peak force, irrespective of stimulation condition. Assuming calcium concentration varied as predicted, this suggests that absolute force, rather than calcium concentration, underpins the effect of activation level on optimum length. We suggest that the effect of absolute force is due to the varying effect of the internal mechanics of the muscle at different activation levels. These findings have implications for our understanding of in vivo muscle function and suggest that mechanical interactions within muscle may be important determinants of force at lower levels of activation.

Preoperative depression symptom severity and its impact on adherence to preoperative beta-blocker therapy.

OBJECTIVES: To test the association among depression symptoms, distressed personality type, and preoperative beta-blocker nonadherence and to estimate the prevalence of untreated major depression in this population. DESIGN: Prospective observational study. SETTING: A veterans hospital. PARTICIPANTS: One hundred twenty patients on outpatient beta-blocker therapy presenting for surgery. INTERVENTIONS: The Patient Health Questionnaire (PHQ)-9, the D-Scale-14 (DS14), and Modified Morisky Scale (MMS) questionnaires. MEASUREMENTS AND MAIN RESULTS: Of 99 participants who presented for surgery, the incidence of preoperative nonadherence was 14.1% (95% confidence interval 7%-21%), consistent with prior research. Nonadherence was 9.5% among those with no depression, 27.8% among those with mild depression, and 28.6% among those with moderate-to-severe depression (Cochran-Armitage test for trend p = 0.03). Distressed personality type was found in 35% of the cohort (95% confidence interval 26-45%) and was not associated with beta-blocker nonadherence (Fisher's exact test, p = 0.24). Among participants with symptoms of major depressive disorder (n = 25, 25.3%), more than half (n = 14, 56%) had no indication of depression listed at their most recent primary care visit. CONCLUSIONS: Patients with symptoms of depression on chronic beta-blocker therapy are susceptible to medication nonadherence on the day of surgery. Most surgical patients with symptoms of major depression lack a diagnosis of depression. Preoperative depression screening may thus (1) identify a population at increased risk of beta-blocker withdrawal, and (2) identify patients who may benefit from anesthesiologist-initiated referral for this treatable condition.

Trends in healthcare and the role of the anesthesiologist in the perioperative surgical home - the US perspective.

PURPOSE OF REVIEW: Although advances in science are important, changes in population structure and developments in health policy have equally critical roles in shaping the future of anesthesia practice. Therefore, it is important for anesthesiologists to be aware of these trends and their implications. RECENT FINDINGS: As in other industrialized nations, population aging implies that patients presenting for elective surgery in future decades will be older and sicker. Nevertheless, in part for economic reasons, the fraction of surgeries performed in the ambulatory environment will continue to increase. Furthermore, the gradual elimination of fee-for-service care in favor of bundled payments will place additional risk on providers to prevent costly complications. In the USA, the American Society of Anesthesiologists has offered the 'surgical home' as a new model for perioperative care delivery in which the anesthesiologist serves as the coordinator of care from the preoperative through the postoperative phase. The purpose is not only to increase patient-centeredness but also to find opportunities for cost savings and increased efficiencies. SUMMARY: Global demographic and health policy trends are calling for new models of healthcare delivery. Anesthesiologists have much experience in the fields of risk assessment and quality improvement. They are well positioned to become leaders in the perioperative care environment of the future.

The effect of muscle ultrastructure on the force, displacement and work capacity of skeletal muscle.

Skeletal muscle powers animal movement through interactions between the contractile proteins, actin and myosin. Structural variation contributes greatly to the variation in mechanical performance observed across muscles. In vertebrates, gross structural variation occurs in the form of changes in the muscle cross-sectional area : fibre length ratio. This results in a trade-off between force and displacement capacity, leaving work capacity unaltered. Consequently, the maximum work per unit volume-the work density-is considered constant. Invertebrate muscle also varies in muscle ultrastructure, i.e. actin and myosin filament lengths. Increasing actin and myosin filament lengths increases force capacity, but the effect on muscle fibre displacement, and thus work, capacity is unclear. We use a sliding-filament muscle model to predict the effect of actin and myosin filament lengths on these mechanical parameters for both idealized sarcomeres with fixed actin : myosin length ratios, and for real sarcomeres with known filament lengths. Increasing actin and myosin filament lengths increases stress without reducing strain capacity. A muscle with longer actin and myosin filaments can generate larger force over the same displacement and has a higher work density, so seemingly bypassing an established trade-off. However, real sarcomeres deviate from the idealized length ratio suggesting unidentified constraints or selective pressures.

Previous mental health care and help-seeking experiences: Perspectives from sexual and gender minority survivors of near-fatal suicide attempts.

Sexual and gender minority (SGM) populations face heightened risk of suicide compared to their heterosexual and cisgender counterparts, and a previous suicide attempt is among the strongest predictors of suicide mortality. Despite this increased risk, limited research has explored mental health help-seeking behavior and previous mental health care experiences of SGM individuals among the highest risk for suicide-individuals with a recent, near-fatal suicide attempt. This study presents thematic analysis results of interviews with 22 SGM individuals who reported at least one near-fatal suicide attempt in the past 18 months. Identified themes were (a) factors that affect help-seeking for SGM individuals with a recent, near-fatal suicide attempt, including previous mental health care experiences, support systems, and structural barriers and facilitators; (b) hospitalization is not a one-size fits all solution; and (c) recommendations for improving care for this population. Findings demonstrate that anti-SGM stigma may magnify existing barriers to mental health care across all socioecological levels. Notably, participants cited a fear of loss of autonomy from inpatient hospitalization and previous discriminatory experiences when seeking mental health care as hampering help-seeking. Given increased risk for suicide mortality, this patient population is a necessary stakeholder in suicide prevention and intervention development and policy discussions affecting mental health care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).