Designing Implementation Strategies for the Inclusion of Lesbian, Gay, Bisexual, Transgender, Intersex, Queer, and Allied and Key Populations' Content in Undergraduate Nursing Curricula in KwaZulu-Natal, South Africa: Protocol for a Multimethods Research Project.

BACKGROUND: Lesbian, gay, bisexual, transgender, intersex, queer, and allied (LGBTQIA+) individuals encounter challenges with access and engagement with health services. Studies have reported that LGBTQIA+ individuals experience stigma, discrimination, and health workers' microaggression when accessing health care. Compelling evidence suggests that the LGBTQIA+ community faces disproportionate rates of HIV infection, mental health disorders, substance abuse, and other noncommunicable diseases. The South African National Strategic Plan for HIV or AIDS, tuberculosis, and sexually transmitted infections, 2023-2028 recognizes the need for providing affirming LGBTQIA+ health care as part of the country's HIV or AIDS response strategy. However, current anecdotal evidence suggests paucity of LGBTQIA+ and key populations' health content in the undergraduate health science curricula in South Africa. Moreover, literature reveals a general lack of health worker training regarding the health needs of LGBTQIA+ persons and other key populations such as sex workers, people who inject drugs, and men who have sex with men. OBJECTIVE: This study aimed to describe the design of a project that aims at facilitating the inclusion of health content related to the LGBTQIA+ community and other key populations in the undergraduate nursing curricula of KwaZulu-Natal, South Africa. METHODS: A multimethods design encompassing collection of primary and secondary data using multiple qualitative designs and quantitative approaches will be used to generate evidence that will inform the co-design, testing, and scale-up of strategies to facilitate the inclusion of LGBTQIA+ and key populations content in the undergraduate nursing curricula in KwaZulu-Natal, South Africa. Data will be collected using a combination of convenience, purposive, and snowball sampling techniques from LGBTQIA+ persons; academic staff; undergraduate nursing students; and other key populations. Primary data will be collected through individual in-depth interviews, focus groups discussions, and surveys guided by semistructured and structured data collection tools. Data collection and analysis will be an iterative process guided by the respective research design to be adopted. The continuous quality improvement process to be adopted during data gathering and analysis will ensure contextual relevance and sustainability of the resultant co-designed strategies that are to be scaled up as part of the overarching objective of this study. RESULTS: The proposed study is designed in response to recent contextual empirical evidence highlighting the multiplicity of health challenges experienced by LGBTQIA+ individuals and key populations in relation to health service delivery and access to health care. The potential findings of the study may be appropriate for contributing to the education of nurses as one of the means to ameliorate these problems. Data collection is anticipated to commence in June 2024. CONCLUSIONS: This research has potential implications for nursing education in South Africa and worldwide as it addresses up-to-date problems in the nursing discipline as it pertains to undergraduate students' preparedness for addressing the unique needs and challenges of the LGBTQIA+ community and other key populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/52250.

Are cisnormative surveys adequate to assess sexual well-being in trans men post-genital gender-affirming surgery?

INTRODUCTION: For transmasculine spectrum individuals, there is a lack of validated surveys to assess sexual well-being (SWB) post-genital gender-affirming surgery. Currently, either providers are designing their own SWB surveys or surveys designed for cisgender men are being used. OBJECTIVE: This study investigated the applicability of SWB surveys validated for cisgender men to transmasculine spectrum individuals post-genital gender-affirming surgery (TMSX). Recognizing the paucity of validated tools for assessing SWB in transmasculine individuals post-genital gender-affirming surgery (TMSX), we evaluated current surveys for their inclusiveness and relevance to this population. METHODS: Our methodology involved analyzing surveys validated in English-speaking North American cisgender men. We conducted a systematic review, yielding 31 surveys, out of which 12 met our inclusion criteria. These were then assessed against the 10 domains of holistic SWB as identified by Özer et al. Each survey was scored based on its reflection of these domains, thus generating an SWB score. Additionally, we performed a thematic analysis to identify areas needing modification for better applicability to TMSX. RESULTS: Our findings indicate an average SWB score of 5.17 out of 10 across the surveys. The surveys predominantly addressed sexual function, with a marked underrepresentation of domains like quality of life, sexuality, and sexual pleasure. This underscores the tendency of these surveys to focus more on the biological mechanisms of sex, rather than on a nuanced biopsychosocial understanding. Thematic analysis revealed significant gaps, such as the irrelevance of questions about erections and ejaculations for TMSX, and the need for greater emphasis on psychosocial factors. CONCLUSION: Given these gaps and the inadequacy of most cisnormative surveys, we recommend the creation of a novel, validated SWB survey specifically for TMSX. This should be developed in collaboration with a multidisciplinary panel and TMSX community advisory board, ensuring a tool that truly reflects the unique SWB needs of this population.

Comprehending Health of the Transgender Population in India Through Bibliometric Analysis.

Objective: In India research on health issues of transgender populations are very recent and limited though transgenders are an important sub-group of the population. Hence, this study attempts to understand the state of transgender health research in India through a systematic review of literature. Methods: A systematic literature review was conducted using bibliometric analysis. Initially, 132 studies were identified, and only 37 articles meeting selection criteria were subsequently selected for review using PRISMA 2020 guidelines. The research landscape was examined with tools such as Biblioshiny, Arc-GIS (10.1), and Vos-Viewer. Results: The review highlights that existing literature on transgender health in India mainly focuses on sexual health while neglecting their overall health status. It also emphasises the skewed geographical coverage of these studies. Based on the analysis, the interdisciplinary nature of the subject is illustrated in a three-field plot and through term co-occurrence. These indicate the need for culture-specific gender-affirmative services promoting a holistic approach to comprehend the health of transgender populations in India. Conclusion: In India research on transgender health is lopsided and at an initial stage. There is a need to develop diverse research focus on various health issues of transgenders that should also be geographically representative. Future in-depth research on this subject will enable optimizing resource allocation, developing effective gender-inclusive policies, and support holistic planning for better health status of transgender people in India, and other countries with similar socio-cultural background.

Ambulatory facial feminization surgery: a comparative analysis of outcomes and complications.

BACKGROUND: To date, there are no studies investigating the safety and outcomes of facial feminization surgery (FFS) as an outpatient procedure. This is the first study of its kind analyzing the outcomes of ambulatory FFS based on a comparison of complications, post-operative emergency department or urgent care (ED/UC) visits, and readmissions between patients who underwent FFS with admission versus same-day surgery. METHODS: A retrospective analysis was conducted on all patients who underwent FFS in a single integrated healthcare system. Patient charts were reviewed for operative details, complications, post-operative ED/UC visits, readmission, and demographic factors. Major outcomes including complications, readmissions, and ED/UC visits were compared between groups with same-day discharge and post-operative hospital admission. RESULTS: Of 242 patients included in the study, ED/UC visits were comparable between patients discharged same-day (18.2%) and patients admitted post-operatively (21.6%, p = 0.52). Logistic regression showed no significant difference in the composite outcomes of minor complications, major complications, and readmissions (15.6% for ambulatory versus 19.3% for admission, p = 0.46). Temporary nerve palsy, infection, and hematoma were the most common post-operative complications. However, covariates of a lower face procedure and operative time were shown to have significant differences in the composite complication outcome (p = 0.04 and p = 0.045, respectively). CONCLUSION: Ambulatory FFS is a safe practice with no associated increase in adverse outcomes including complications, ED/UC visits, and readmission when compared to post-operative admission. Adoption of same-day FFS should be considered by high-volume gender health centers to potentially benefit from increased scheduling flexibility and efficiency, increased access to care, and lower healthcare costs.

A Holistic Framework for the Evaluation of Kidney Function in a Gender-Diverse Landscape.

The most commonly used equations to estimate glomerular filtration rate incorporate a binary male-female sex coefficient, which has important implications for the care of transgender, gender-diverse, and nonbinary (TGD) people. Whether "sex assigned at birth" or a binary "gender identity" is most appropriate for the computation of estimated glomerular filtration rate (eGFR) is unknown. Furthermore, the use of gender-affirming hormone therapy (GAHT) for the development of physical changes to align TGD people with their affirmed gender is increasingly common, and may result in changes in serum creatinine and cystatin C, the biomarkers commonly used to estimate glomerular filtration rate. The paucity of current literature evaluating chronic kidney disease (CKD) prevalence and outcomes in TGD individuals on GAHT makes it difficult to assess any effects of GAHT on kidney function. Whether alterations in serum creatinine reflect changes in glomerular filtration rate or simply changes in muscle mass is unknown. Therefore, we propose a holistic framework to evaluate kidney function in TGD people. The framework focuses on kidney disease prevalence, risk factors, sex hormones, eGFR, other kidney function assessment tools, and the mitigation of health inequities in TGD people.

A conjoint experiment of three placebo rectal products used with receptive anal sex: results from MTN-035.

INTRODUCTION: End-user perspectives are vital to the design of new biomedical HIV prevention products. Conjoint analysis can support the integration of end-user perspectives by examining their preferences of potential pre-exposure prophylaxis (PrEP) products. The Microbicides Trial Network (MTN) 035 protocol examined three placebo rectal dosage forms (insert, enema and suppository) that could deliver PrEP prior to receptive anal sex (RAS). METHODS: Between April 2019 and July 2020, we enrolled 217 HIV-negative, cisgender men who have sex with men (MSM; n = 172; 79.3%) and transgender people (n = 47; 20.7%) ages 18-35 into a randomized cross-over trial across Malawi, Peru, South Africa, Thailand and the United States. Participants used each product prior to RAS over 4-week periods. Participants completed a conjoint experiment where they selected between random profiles using seven features (dosage form, timing of use before sex, side effects, duration of protection, effectiveness, frequency of use and need for a prescription). RESULTS: Effectiveness was the strongest determinant of choice (30.4%), followed by modality (18.0%), potential side effects (17.2%), frequency of use (10.8%), duration of protection (10.4%), timing of use before sex (7.4%) and need for a prescription (5.9%). Relative utility scores indicated that the most desirable combination of attributes was a product with 95% efficacy, used 30 minutes before sex, offering a 3- to 5-day protection window, used weekly, having no side effects, in the form of an enema and available over-the-counter. CONCLUSIONS: Choice in next-generation PrEP products is highly desired by MSM and transgender people, as no one-size-fits-all approach satisfies all the preferences. MTN-035 participants weighed product features differently, recognizing the need for diverse, behaviourally congruent biomedical options that fit the needs of intended end-users.

Dietary Supplement Use in Transmasculine People: Results of an Online Survey of Volunteer Adults.

INTRODUCTION: Health inequities and disparities in nutrition research exist among transmasculine people. A dearth of evidence on dietary supplement use and motivations exist, partially due to constrained collection of sex and gender identity in national surveys. OBJECTIVE: We sought to investigate common motivations and use of dietary supplements in a voluntary survey of transmasculine people. METHODS: A total of 48 participants completed an online survey detailing dietary supplement use, motivations, and demographic information. RESULTS: 64.5 and 90.0% of participants reported use of 1+ dietary supplement within the past 30-days and during some point in their lifetime, respectively. Top reported product types used included multivitamins (52%), melatonin (52%), vitamin D (46%), vitamin C (35%), fish oil (33%), B-vitamins or B-complex (31%), iron (29%), green tea (29%), biotin (25%), cranberry (23%), zinc (23%), protein powder (23%), probiotics (23%), and calcium (21%). There was no relationship between the number of supplements reported and participant age, BMI, income, or mastectomy status (p > 0.05). Participants reported top motivations being for "improving my overall health" (60.4%), "maintaining health" (54.2%), to "supplement my diet due to not getting enough from food"(41.7%), "mental health" (39.6%), and to "prevent colds, boost immune system" (33.3%). CONCLUSION: Transmasculine people in our study reported a high use of dietary supplements. Differences in the types of products and number of products used, as well as specific motivations for use likely exist within this subpopulation, however, future nationally-representative longitudinal studies are needed to fully elucidate these patterns and for informing evidence-based nutrition guidance.

Experiences of and recommendations for LGBTQ+-affirming substance use services: an exploratory qualitative descriptive study with LGBTQ+ people who use opioids and other drugs.

BACKGROUND: Lesbian, gay, bisexual, transgender, queer, and other LGBTQ populations (LGBTQ+; e.g., asexual individuals) have higher rates of substance use (SU) and disorders (SUD) compared to heterosexual and cisgender populations. Such disparities can be attributed to minority stress, including stigma and discrimination in healthcare settings. LGBTQ+-affirming SU treatment and related services remain limited. The purpose of this exploratory qualitative descriptive study was to characterize LGBTQ+ people's experiences in SU services and recommendations for LGBTQ+- affirming care. METHODS: We conducted demographic surveys (characterized using descriptive statistics) and individual qualitative interviews with N = 23 LGBTQ+ people. We employed flexible coding and a thematic analysis approach to describe participants' experiences with stigma, discrimination, and support within SU services at the patient-, staff-, and organizational-level; and participant recommendations for how to make such services LGBTQ+-affirming. We highlighted components of minority stress and mitigators of adverse stress responses throughout our thematic analysis. RESULTS: Patient-level experiences included bullying, name-calling, sexual harassment, and physical distancing from peers; and support via community-building with LGBTQ+ peers. Staff-level experiences included name-calling, denial of services, misgendering, lack of intervention in peer bullying, and assumptions about participants' sexuality; and support via staff advocacy for LGBTQ+ patients, holistic treatment models, and openly LGBTQ+ staff. Organizational-level experiences included stigma in binary gendered program structures; and support from programs with gender-affirming groups and housing, and in visual cues (e.g., rainbow flags) of affirming care. Stigma and discrimination led to minority stress processes like identity concealment and stress coping responses like SU relapse; support facilitated SU treatment engagement and retention. Recommendations for LGBTQ+-affirming care included non-discrimination policies, LGBTQ+-specific programming, hiring LGBTQ+ staff, routine staff sensitivity training, and gender-inclusive program structures. CONCLUSIONS: LGBTQ+ people experience stigma and discrimination within SU services; supportive and affirming care is vital to reducing treatment barriers and promoting positive health outcomes. The current study offers concrete recommendations for how to deliver LGBTQ+-affirming care, which could reduce SU disparities and drug overdose mortality overall.

Assessing the acceptability of implementing a Screening, Brief Intervention and Referral to Treatment for alcohol use among transgender women in Bangkok, Thailand: A mixed-method pre-implementation study using the Consolidated Framework for Implementation Research.

BACKGROUND AND AIMS: Health inequities related to alcohol use exist for transgender individuals. While the Thailand Ministry of Public Health recently published a clinical guideline to implement a Screening, Brief Intervention and Referral to Treatment (SBIRT) in primary care, there has been no study regarding transgender women's (TGW) alcohol use and the acceptability of implementing SBIRT in a Thai context, a gap this study aimed to fill. DESIGN: A mixed-method approach was used. In the first phase, TGW service users and health-care providers (HCPs) completed a survey on the acceptability of prospective implementation of SBIRT. TGW service users completed the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C). In the second phase, TGW service users, HCPs, clinic administrators and national-level alcohol, HIV and transgender health policymakers participated in in-depth qualitative interviews. SETTING: The Tangerine Clinic, a transgender-led sexual health clinic in Bangkok, Thailand. PARTICIPANTS: In the first phase, TGW service users (n = 100) and HCP (n = 8) were surveyed. In the second phase, 22 stakeholders (n = 10 TGW service users; n = 8 HCP; n = 1 clinic administrator; n = 3 policymakers) were interviewed. MEASUREMENTS: Simple proportions were calculated for each survey item. Differences in acceptability by various demographic factors were calculated using univariate analysis. The qualitative data were coded using thematic analysis and a deductive approach. The results were mapped to the Consolidated Framework for Implementation Research domains and constructs. The quantitative and qualitative results were triangulated to expand understanding. FINDINGS: Fifty per cent of the TGW participants exhibited problematic drinking levels (AUDIT-C ≥ 4). Implementing SBIRT was highly acceptable, as more than 95% of participants reported agreeing or completely agreeing to receive SBIRT for alcohol use. Barriers, such as complexity, time constraint and lack of knowledge and skills, were anticipated. Adaptability, such as tailoring the content of brief intervention to suit TGW health needs and SBIRT to fit with existing clinic procedures, might facilitate successful implementation. CONCLUSION: Screening, Brief Intervention and Referral to Treatment (SBIRT) for alcohol use has the potential to be successfully implemented in transgender-led sexual health clinic settings, with some adaptations to overcome anticipated barriers.

Transgender Care Experiences, Barriers, and Recommendations for Improvement in a Large Integrated Health Care System in the United States.

Purpose: Transgender individuals who pursue gender affirmation medical procedures often need to navigate a complex health system and interact with multiple health care providers in primary and specialty care. We sought to better understand patient, provider, and system level barriers to transgender care in a large integrated health care system in California. Methods: Three 90-min focus groups were conducted with 13 transgender individuals who received specialty care between April and August 2018 in Kaiser Permanente Southern California. Results: Participants cited common adversities such as misgendering and system-wide insensitivity during health care encounters and low levels of understanding of their transgender experience among primary care providers. Provider-patient relationship improvements were recommended for pre- and postsurgical care and service-provider sensitivity training. Suggestions include better care coordination, reducing redundancy in clearance for specialty care services, and enhancing patient support for navigation of gender affirmation services. Participants requested careful consideration when implementing systemwide routine processes such as using pronouns and names when calling patients in for visits or describing procedures on service invoices. Conclusions: Education and training programs for improving transgender care competency and enhancing care coordination between primary care and specialty care for transgender patients are warranted. Including transgender voices with lived-experience as active stakeholders in ongoing efforts such as community advisory boards to identify care gaps may facilitate patient-centered and culturally sensitive transgender care and increased patient satisfaction. Policy Implications: There is a need for systematic training for transgender care competent providers and enhancement of care coordination between primary care and specialty care.

Experiences of and recommendations for LGBTQ+-affirming substance use services: A qualitative study with LGBTQ+ people who use opioids and other drugs.

Background: Lesbian, gay, bisexual, transgender, queer, and other LGBTQ populations (LGBTQ+; e.g., non-binary individuals) have higher rates of substance use (SU) and disorders (SUD) compared to heterosexual and cisgender populations. Such disparities can be attributed to minority stress, including stigma and discrimination in healthcare settings. LGBTQ+-affirming SU treatment and related services remain limited. The purpose of this qualitative study was to characterize LGBTQ + people's experiences in SU services and recommendations for LGBTQ+-affirming care. Methods: We conducted demographic surveys (characterized using descriptive statistics) and individual qualitative interviews with N = 23 LGBTQ + people. We employed a flexible coding approach to describe participants' experiences with stigma, discrimination, and support within SU services; and participant recommendations for how to make such services LGBTQ+-affirming at the patient-, staff-, and organizational-level. We highlighted components of minority stress and mitigators of adverse stress responses throughout our thematic analysis. Results: Patient-level experiences included bullying, name-calling, sexual harassment, and physical distancing from peers; and support via community-building with LGBTQ + peers. Staff-level experiences included name-calling, denial of services, misgendering, lack of intervention in peer bullying, and assumptions about participants' sexuality; and support via staff advocacy for LGBTQ + patients, holistic treatment models, and openly LGBTQ + staff. Organizational-level experiences included stigma in binary gendered program structures; and support from programs with gender-affirming groups and housing, and in visual cues (e.g., rainbow flags) of affirming care. Stigma and discrimination led to minority stress processes like identity concealment and stress coping responses like SU relapse; support facilitated SU treatment engagement and retention. Recommendations for LGBTQ+-affirming care included non-discrimination policies, routine pronoun sharing, LGBTQ+-specific programming, hiring LGBTQ + staff, routine staff sensitivity training, and gender-inclusive program structures. Conclusions: LGBTQ + people experience stigma and discrimination within SU services; supportive and affirming care is vital to reducing treatment barriers and promoting positive health outcomes. The current study offers concrete recommendations for how to deliver LGBTQ+-affirming care, which could reduce SU disparities and drug overdose mortality overall.

The dose-dependent effect of estrogen on bone mineral density in trans girls.

OBJECTIVE: Treatment in transgender girls can consist of puberty suppression (PS) with a gonadotropin-releasing hormone agonist (GnRHa) followed by gender-affirming hormonal treatment (GAHT) with estrogen. Bone mineral density (BMD) Z-scores decrease during PS and remain relatively low during GAHT, possibly due to insufficient estradiol dosage. Some adolescents receive high-dose estradiol or ethinyl estradiol (EE) to limit growth allowing comparison of BMD outcomes with different dosages. DESIGN: Retrospective study. METHODS: Adolescents treated with GnRHa for ≥1 year prior to GAHT followed by treatment with a regular estradiol dose (gradually increased to 2 mg), 6 mg estradiol or 100-200 µg EE were included to evaluate height-adjusted BMD Z-scores (HAZ scores) on DXA. RESULTS: Eighty-seven adolescents were included. During 2.3 ± 0.7 years PS, lumbar spine HAZ scores decreased by 0.69 [95% confidence interval (CI) -0.82 to -0.56)]. During 2 years HT, lumbar spine HAZ scores hardly increased in the regular group (0.14, 95% CI -0.01 to 0.28, n = 59) vs 0.42 (95% CI 0.13 to 0.72) in the 6 mg group (n = 13), and 0.68 (95% CI 0.20 to 1.15) in the EE group (n = 15). Compared with the regular group, the increase with EE treatment was higher (0.54, 95% CI 0.05 to 1.04). After 2 years HT, HAZ scores approached baseline levels at start of PS in individuals treated with 6 mg or EE (difference in 6 mg group -0.20, 95% CI -0.50 to 0.09; in EE 0.17, 95% CI -0.16 to 0.50) but not in the regular group (-0.64, 95% CI -0.79 to -0.49). CONCLUSION: Higher estrogen dosage is associated with a greater increase in lumbar spine BMD Z-scores. Increasing dosage up to 2 mg estradiol is insufficient to optimize BMD and approximately 4 mg may be required for adequate serum concentrations.

Emergency Clinicians' Comfort Levels in Caring for Transgender Patients.

Objective: Transgender individuals report negative experiences in emergency department settings, but little is known about emergency clinicians' barriers to treating transgender patients. The purpose of this study was to explore emergency clinicians' experiences with transgender patients to better understand their comfort with caring for this population. Methods: We conducted a cross-sectional survey of emergency clinicians in an integrated health system in the Midwest. To assess the relationship between each independent variable and the outcome variables (i.e., comfort level generally and comfort level asking transgender patients about their body parts specifically), Mann-Whitney U test or Kruskal-Wallis analysis of variance was conducted for categorical independent variables and Pearson correlations were conducted for continuous independent variables. Results: Most participants (90.1%) were comfortable caring for transgender patients, whereas two-thirds (67.9%) were comfortable asking transgender patients about body parts. Although none of the independent variables was associated with increased clinician comfort level caring for transgender patients in general, White clinicians and those who were unsure how to ask patients about their gender identity or transgender-specific care they had received were less comfortable asking about body parts. Conclusion: Having skills to communicate with transgender patients was associated with emergency clinicians' comfort levels. In addition to offering traditional classroom-based didactics about transgender health care, providing opportunities for clinical rotations that allow clinicians-in-training to treat, and perhaps more importantly, learn from transgender patients will likely be higher yield in bolstering clinician confidence in serving this patient population.

Perioperative Oncology Health Care Providers and Transgender Health: A Single-Institution Survey to Gauge Attitudes, Knowledge, Behaviors, and Education.

Purpose: Patients identifying as transgender report that a lack of access to providers with trans-specific medical knowledge represents one of the largest barriers to equitable health care access. Through an institutional survey, we assessed and analyzed the attitudes, knowledge, behaviors, and education of perioperative clinical staff when caring for transgender patients with cancer. Methods: A web-based survey was distributed to 1100 perioperative clinical staff at the National Cancer Institute (NCI)-Designated Comprehensive Cancer Center in New York City between January 14, 2020, and February 28, 2020, and received 276 responses. The survey instrument consisted of 42 nondemographic questions about attitudes, knowledge, behaviors, and education regarding transgender health care and 14 demographic questions. Questions were presented as a mix of Yes/No, free text response, and a 5-point Likert scale. Results: Certain demographic groups (younger, lesbian, gay, or bisexual [LGB], fewer years employment at the institution) held more favorable attitudes toward the transgender population and were more knowledgeable regarding their health needs. Respondents underreported the rates of mental illness and risk factors for cancer like HIV and substance use among the transgender population. A greater proportion of respondents identifying as LGB endorsed witnessing an interaction wherein a colleague exhibited attitudes/beliefs about the transgender population that were barriers to care. Only 23.2% of respondents were ever trained on the health needs of transgender patients. Conclusion: There is a need for institutions to assess the cultural competency of perioperative clinical staff toward transgender health, especially within certain demographics. This survey may inform quality education initiatives to eliminate biases and knowledge gaps.

The Third Gender in a Third World Country: Major Concerns and the "AIIMS Initiative".

With a population dividend of around 1.3 billion, India is the largest democracy in the world that encompasses "unity in diversity". The kaleidoscope of the socio-cultural fabric comprises the transgender population too, which has a historical context dating back millennia and also plays a vital role as described in Hindu scriptures. The Indian transgender person's community shows a variety of gender identities and sexual orientations, which is unlikely from the West, forming a culturally unique gender group. In India, transgender persons were recognised as the 'third gender' in 2014. The third gender population of India is marginalised to a great extent in every sector. Often, transgender persons have been the subjects of sociology, psychology, and health issues. There was a dearth of data regarding their major health problems including bone health, which has not been reported in India and elsewhere before this study. Through a prospective cross-sectional study design, we aimed to determine the current health status of transgender persons with a special emphasis on bone health. Descriptive statistics were used for data analysis. The preliminary results of the study show poor bone health in the transgender population of India. The majority of transgender persons have low bone mineral density (BMD) at a much young age, even before the achievement of their peak bone mass. The health status of the transgender population in India is poor overall. Transgender persons have many impediments to optimal healthcare that requires holistic care. This study presents the current health challenges of the transgender population with a special emphasis on their bone health status as 'AIIMS initiative'. This study also shows transgender persons human rights needs to be explicitly discussed. The stakeholders of social policies require an urgent attention to unfold the major concerns encompassing transgender persons.

Testosterone Restores Body Composition, Bone Mass, and Bone Strength Following Early Puberty Suppression in a Mouse Model Mimicking the Clinical Strategy in Trans Boys.

Transgender youth increasingly present at pediatric gender services. Some of them receive long-term puberty suppression with gonadotropin-releasing hormone analogues (GnRHa) before starting gender-affirming hormones (GAH). The impact of GnRHa use started in early puberty on bone composition and bone mass accrual is unexplored. It is furthermore unclear whether subsequent GAH fully restore GnRHa effects and whether the timing of GAH introduction matters. To answer these questions, we developed a mouse model mimicking the clinical strategy applied in trans boys. Prepubertal 4-week-old female mice were treated with GnRHa alone or with GnRHa supplemented with testosterone (T) from 6 weeks (early puberty) or 8 weeks (late puberty) onward. Outcomes were analyzed at 16 weeks and compared with untreated mice of both sexes. GnRHa markedly increased total body fat mass, decreased lean body mass, and had a modest negative impact on grip strength. Both early and late T administration shaped body composition to adult male levels, whereas grip strength was restored to female values. GnRHa-treated animals showed lower trabecular bone volume and reduced cortical bone mass and strength. These changes were reversed by T to female levels (cortical bone mass and strength) irrespective of the time of administration or even fully up to adult male control values (trabecular parameters) in case of earlier T start. The lower bone mass in GnRHa-treated mice was associated with increased bone marrow adiposity, also reversed by T. In conclusion, prolonged GnRHa use started in prepubertal female mice modifies body composition toward more fat and less lean mass and impairs bone mass acquisition and strength. Subsequent T administration counteracts GnRHa impact on these parameters, shaping body composition and trabecular parameters to male values while restoring cortical bone architecture and strength up to female but not male control levels. These findings could help guide clinical strategies in transgender care. © 2023 American Society for Bone and Mineral Research (ASBMR).

A Scoping Review of Oral Pre-exposure Prophylaxis for Cisgender and Transgender Adolescent Girls and Young Women: What Works and Where Do We Go from Here?

Adolescent girls and young women (AGYW) are disproportionately affected by HIV, and oral pre-exposure prophylaxis (PrEP) can reduce HIV acquisition. The purpose of this scoping review was to synthesize results from interventions along the PrEP continuum for AGYW to inform research and programs. We searched electronic databases for studies published between January 2012-July 2021 and conducted secondary reference searching. Studies were included if they assessed interventions to increase PrEP interest, uptake, or continuation among AGYW. Results were synthesized narratively. Of 2168 citations identified, 50 studies were eligible for inclusion, and 20 contained AGYW-specific data. Among cisgender and transgender AGYW, studies overall demonstrated a positive impact on PrEP interest and uptake but generally attained suboptimal continuation rates. Results demonstrate feasibility of deploying PrEP across diverse settings-particularly when interventions are layered, tailored to AGYW, and include differentiated delivery-but also highlight knowledge gaps and the need for more holistic metrics of success.

RESUMEN: Las adolescentes y las mujeres jóvenes se ven afectadas de forma desproporcionada por el VIH, y la Profilaxis Pre-Exposición oral (PrEP) puede reducir la adquisición del VIH. El propósito de esta revisión de alcance fue sintetizar los resultados de las intervenciones a lo largo del continuo de la PrEP para las adolescentes y las mujeres jóvenes con el fin de informar la investigación y los programas. Se realizaron búsquedas en bases de datos electrónicas de estudios publicados entre enero 2012 a julio 2021 y se llevó a cabo una búsqueda secundaria de referencias. Los estudios se incluyeron si evaluaban intervenciones para aumentar el interés, la iniciación, o la continuación de la PrEP entre las adolescentes y las mujeres jóvenes. Los resultados se sintetizaron narrativamente. De las 2168 citas identificadas, 50 estudios fueron elegibles para inclusión y 20 contenían datos específicos de las adolescentes y las mujeres jóvenes. Entre las adolescentes y las mujeres jóvenes cisgénero y transgénero, los estudios demostraron un impacto positivo en el interés y la iniciación de la PrEP, pero en general alcanzaron tasas de continuación subóptimas. Los resultados demuestran la viabilidad del despliegue de la PrEP en diversos entornos­en particular cuando las intervenciones son estratificadas, se adaptan a las adolescentes y las mujeres jóvenes, e incluyen una prestación diferenciada­pero también destacan las lagunas de conocimiento y la necesidad de una métrica más holística del éxito.

Implicit and Explicit Spirituality in the Lives of Transgender and Gender Expansive Older Adults.

Religion and spirituality for transgender and gender expansive people (whom we refer to collectively as trans) are complicated by mainstream religions' history of stigmatizing and marginalizing sexual and gender minorities. We conducted an interpretive content analysis of biographical interviews with 88 trans older adults from across the United States, applying six tenets of spiritual psychotherapy to their life narratives. Our findings suggest that some trans older adults' spirituality is experienced both implicitly and explicitly. Implicit spirituality reflects the ways in which meaning, purpose, and connection in one's life are nurtured with respect to one's gender identity. Explicit spirituality reflects the process of consciously renegotiating one's spiritual beliefs and religious practices to validate one's gender identity and place in society. This knowledge is potentially helpful for gerontological social workers who seek to nurture trans people's spirituality and well-being as they age.

Nursing care for the transgender population in primary health care: an integrative review.

OBJECTIVE: To describe the care provided to the transgender population by nursing in Primary Health Care (PHC). METHODS: Integrative literature review performed in the Virtual Health Library (VHL), Medline/PubMed and Web of Science (WoS) databases without a pre-established time frame, using the descriptors "transgender persons", "gender identity", "nursing care" and "primary health care". RESULTS: Eleven articles published between 2008-2021 were included. They were categorized as follows: Embracement and healthcare; Implementation of Public Health Policies; Weaknesses in academic training; Barriers between theory and practice. The articles showed a limited scenario of nursing care for the transgender population. The scarcity of research focused on this theme is an important sign of how care has been incipient or even non- existent in the context of PHC. CONCLUSIONS: Structural and interpersonal stigmas materialized in discriminatory and prejudiced practices perpetrated by managers, professionals and health institutions constitute the greatest challenges to be overcome for comprehensive, equitable and humanized care provided to the transgender population by nursing.

Characterization of ovarian tissue oocytes from transgender men reveals poor calcium release and embryo development, which might be overcome by spindle transfer.

STUDY QUESTION: Can spindle transfer (ST) overcome inferior embryonic development of in vitro matured ovarian tissue oocytes (OTO-IVM) originating from testosterone-treated transgender men? SUMMARY ANSWER: ST shows some potential to overcome the embryo developmental arrest observed in OTO-IVM oocytes from transgender men. WHAT IS KNOWN ALREADY: OTO-IVM is being applied as a complementary approach to increase the number of oocytes/embryos available for fertility preservation during ovarian tissue cryopreservation in cancer patients. OTO-IVM has also been proposed for transgender men, although the potential of their oocytes remains poorly investigated. Currently, only one study has examined the ability of OTO-IVM oocytes originating from transgender men to support embryo development, and that study has shown that they exhibit poor potential. STUDY DESIGN, SIZE, DURATION: Both ovaries from 18 transgender men undergoing oophorectomy were collected for the purposes of this study, from November 2020 to September 2022. The patients did not wish to cryopreserve their tissue for fertility preservation and donated their ovaries for research. All patients were having testosterone treatment at the time of oophorectomy and some of them were also having menses inhibition treatment. PARTICIPANTS/MATERIALS, SETTING, METHODS: Sibling ovaries were collected in either cold or warm medium, to identify the most optimal collection temperature. Cumulus oocyte complexes (COCs) from each condition were isolated from the ovarian tissue and matured in vitro for 48 h. The quality of OTO-IVM oocytes was assessed by calcium pattern releasing ability, embryo developmental competence following ICSI, and staining for mitochondrial membrane potential. In vitro matured metaphase I (MI) oocytes, germinal vesicle (GV) oocytes, and in vivo matured oocytes with aggregates of smooth endoplasmic reticulum (SERa) were donated from ovarian stimulated women undergoing infertility treatment and these served as Control oocytes for the study groups. ST was applied to overcome poor oocyte quality. Specifically, enucleated mature Control oocytes served as cytoplasmic recipients of the OTO-IVM spindles from the transgender men. Embryos derived from the different groups were scored and analysed by shallow whole genome sequencing for copy number variations (CNVs). MAIN RESULTS AND THE ROLE OF CHANCE: In total, 331 COCs were collected in the cold condition (OTO-Cold) and 282 were collected in the warm condition (OTO-Warm) from transgender men. The maturation rate was close to 54% for OTO-Cold and 57% for OTO-Warm oocytes. Control oocytes showed a calcium releasing ability of 2.30 AU (n = 39), significantly higher than OTO-Cold (1.47 AU, P = 0.046) oocytes (n = 33) and OTO-Warm (1.03 AU, P = 0.036) oocytes (n = 31); both values of calcium release were similar between the two collection temperatures. Mitochondrial membrane potential did not reveal major differences between Control, OTO-Warm, and OTO-Cold oocytes (P = 0.417). Following ICSI, 59/70 (84.2%) of Control oocytes were fertilized, which was significantly higher compared to 19/47 (40.4%) of OTO-Cold (P < 0.01) and 24/48 (50%) of OTO-Warm oocytes (P < 0.01). In total, 15/59 (25.4%) blastocysts were formed on Day 5 in the Control group, significantly higher than 0/19 (0%) from the OTO-Cold (P = 0.014) and 1/24 (4.1%) in OTO-Warm oocytes (P = 0.026). Application of ST rescued the poor embryo development, by increasing the Day 5 blastocyst rate from 0% (0/19) to 20.6% (6/29) (P = 0.034), similar to that in the ICSI-Control group (25.4%, 15/59). A normal genetic profile was observed in 72.7% (8/11) of OTO-Cold, 72.7% (8/11) of OTO-Warm and 64.7% (11/17) of Control Day 3-Day 5 embryos. After ST was applied for OTO-IVM oocytes, 41.1% (7/17) of the embryos displayed normal genetic patterns, compared to 57.1% (4/7) among ST-Control Day 3-Day 5 embryos. LARGE SCALE DATA: N/A. LIMITATIONS, REASONS FOR CAUTION: Due to the limited access to human oocytes and ovarian tissue, our results should be interpreted with some caution, as only a limited number of human oocytes and embryos could be investigated. WIDER IMPLICATIONS OF THE FINDINGS: The results of this study, clearly indicate that OTO-IVM oocytes originating from transgender patients are of inferior quality, which questions their use for fertility preservation. The poor quality is likely to be related to cytoplasmic factors, supported by the increased blastocyst numbers following application of ST. Future research on OTO-IVM from transgender men should focus on the cytoplasmic content of oocytes or supplementation of media with factors that promote cytoplasmic maturation. A more detailed study on the effect of the length of testosterone treatment is also currently missing for more concrete guidelines and guidance on the fertility options of transgender men. Furthermore, our study suggests a potentially beneficial role of experimental ST in overcoming poor embryo development related to cytoplasmic quality. STUDY FUNDING/COMPETING INTEREST(S): A.C. is a holder of FWO grants (1S80220N and 1S80222N). A.B. is a holder of an FWO grant (1298722N). B.H. and A.V.S. have been awarded with a special BOF (Bijzonder Onderzoeksfonds), GOA (Geconcerteerde onderzoeksacties) and 2018000504 (GOA030-18 BOF) funding. B.H. has additional grants from FWO-Vlaanderen (Flemish Fund for Scientific Research, G051516N and G1507816N) and Ghent University Special Research Fund (Bijzonder Onderzoeksfonds, BOF funding (BOF/STA/202109/005)), and has been receiving unrestricted educational funding from Ferring Pharmaceuticals (Aalst, Belgium). The authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER: N/A.