Characterization of the literature informing health care of transgender and gender-diverse persons: A bibliometric analysis.

BACKGROUND AND OBJECTIVE: Transgender and gender-diverse (TGD) persons experience health inequities compared to their cisgender peers, which is in part related to limited evidence informing their care. Thus, we aimed to describe the literature informing care provision of TGD individuals. DATA SOURCE, ELIGIBILITY CRITERIA, AND SYNTHESIS METHODS: Literature cited by the World Professional Association of Transgender Health Standards of Care Version 8 was reviewed. Original research articles, excluding systematic reviews (n = 74), were assessed (n = 1809). Studies where the population of interest were only caregivers, providers, siblings, partners, or children of TGD individuals were excluded (n = 7). Results were synthesized in a descriptive manner. RESULTS: Of 1809 citations, 696 studies met the inclusion criteria. TGD-only populations were represented in 65% of studies. White (38%) participants and young adults (18 to 29 years old, 64%) were the most well-represented study populations. Almost half of studies (45%) were cross-sectional, and approximately a third were longitudinal in nature (37%). Overall, the median number of TGD participants (median [IQR]: 104 [32, 356]) included in each study was approximately one third of included cisgender participants (271 [47, 15405]). In studies where both TGD and cisgender individuals were included (n = 74), the proportion of TGD to cisgender participants was 1:2 [1:20, 1:1]. Less than a third of studies stratified results by sex (32%) or gender (28%), and even fewer included sex (4%) or gender (3%) as a covariate in the analysis. The proportion of studies with populations including both TGD and cisgender participants increased between 1969 and 2023, while the proportion of studies with study populations of unspecified gender identity decreased over the same time period. CONCLUSIONS: While TGD participant-only studies make up most of the literature informing care of this population, longitudinal studies including a diversity of TGD individuals across life stages are required to improve the quality of evidence.

Transgender and Nonbinary Individuals' Perceptions Regarding Gender-Affirming Hormone Therapy and Cardiovascular Health: A Qualitative Study.

BACKGROUND: Transgender and nonbinary individuals face substantial cardiovascular health uncertainties. The use of gender-affirming hormone therapy can be used to achieve one's gender-affirming goals. As self-rated health is an important predictor of health outcomes, an understanding of how this association is perceived by transgender and nonbinary individuals using gender-affirming hormone therapy is required. The objective of this research was to explore transgender and nonbinary individuals' perceptions of cardiovascular health in the context of using gender-affirming hormone therapy. METHODS: In this qualitative study, English-speaking transgender and nonbinary adults using gender-affirming hormone therapy for 3 months or more were recruited from across Canada using purposive and snowball sampling methods. Semistructured interviews were conducted through videoconference to explore transgender and nonbinary individuals' perceptions of the association between gender-affirming hormone therapy and cardiovascular health between May and August 2023. Data were transcribed verbatim, and transcripts were analyzed independently by 3 reviewers using thematic analysis. RESULTS: Twenty-one participants were interviewed (8 transgender women, 9 transgender men, and 3 nonbinary individuals; median [range] age, 27 [20-69] years; 80% White participants). Three main themes were identified: cardiovascular health was not a primary concern in the decision-making process with regard to gender-affirming hormone therapy, the improved well-being associated with gender-affirming hormone therapy was felt to contribute to improved cardiovascular health, and health care provider knowledge and attitude facilitate the transition process. CONCLUSIONS: Gender-affirming hormone therapy in transgender and nonbinary individuals is perceived to improve cardiovascular health. Given the positive associations between care aligned with patient priorities, self-rated health, and health outcomes, these findings should be considered as part of shared decision-making and person-centered care.

Exercise to Prevent Accelerated Vascular Aging in People Living With HIV.

Given advances in antiretroviral therapy, the mortality rate for HIV infection has dropped considerably over recent decades. However, people living with HIV (PLWH) experience longer life spans coupled with persistent immune activation despite viral suppression and potential toxicity from long-term antiretroviral therapy use. Consequently, PLWH face a cardiovascular disease (CVD) risk more than twice that of the general population, making it the leading cause of death among this group. Here, we briefly review the epidemiology of CVD in PLWH highlighting disparities at the intersections of sex and gender, age, race/ethnicity, and the contributions of social determinants of health and psychosocial stress to increased CVD risk among individuals with marginalized identities. We then overview the pathophysiology of HIV and discuss the primary factors implicated as contributors to CVD risk among PLWH on antiretroviral therapy. Subsequently, we highlight the functional evidence of premature vascular dysfunction as an early pathophysiological determinant of CVD risk among PLWH, discuss several mechanisms underlying premature vascular dysfunction in PLWH, and synthesize current research on the pathophysiological mechanisms underlying accelerated vascular aging in PLWH, focusing on immune activation, chronic inflammation, and oxidative stress. We consider understudied aspects such as HIV-related changes to the gut microbiome and psychosocial stress, which may serve as mechanisms through which exercise can abrogate accelerated vascular aging. Emphasizing the significance of exercise, we review various modalities and their impacts on vascular health, proposing a holistic approach to managing CVD risks in PLWH. The discussion extends to critical future study areas related to vascular aging, CVD, and the efficacy of exercise interventions, with a call for more inclusive research that considers the diversity of the PLWH population.

Changes to Sexual Identity Response Options in the Youth Risk Behavior Survey.

This survey study discusses changes in the proportion of youths who selected "not sure" among other response options to questions about their sexual identity in the National Youth Risk Behavior Survey between 2019 and 2021 and recommends measures to inclusively reflect sexual identities.

Building a Cohort of Transgender and Nonbinary Patients from the Electronic Medical Record.

Purpose: Sexual orientation, gender identity, and sex recorded at birth (SOGI) have been routinely excluded from demographic data collection tools, including in electronic medical record (EMR) systems. We assessed the ability of adding structured SOGI data capture to improve identification of transgender and nonbinary (TGNB) patients compared to using only International Classification of Diseases (ICD) codes and text mining and comment on the ethics of these cohort formation methods. Methods: We conducted a retrospective chart review to classify patient gender at a single institution using ICD-10 codes, structured SOGI data, and text mining for patients presenting for care between March 2019 and February 2021. We report each method's overall and segmental positive predictive value (PPV). Results: We queried 1,530,154 EMRs from our institution. Overall, 154,712 contained relevant ICD-10 diagnosis codes, SOGI data fields, or text mining terms; 2964 were manually reviewed. This multipronged approach identified a final 1685 TGNB patient cohort. The initial PPV was 56.8%, with ICD-10 codes, SOGI data, and text mining having PPV of 99.2%, 47.9%, and 62.2%, respectively. Conclusion: This is one of the first studies to use a combination of structured data capture with keyword terms and ICD codes to identify TGNB patients. Our approach revealed that although structured SOGI documentation was <10% in our health system, 1343/1685 (79.7%) of TGNB patients were identified using this method. We recommend that health systems promote patient EMR documentation of SOGI to improve health and wellness among TGNB populations, while centering patient privacy.

Suicidality by Sexual Identity and Correlates Among American Indian and Alaska Native High School Students.

PURPOSE: This study aims to determine the prevalence of suicidality among American Indian and Alaskan Native (AI/AN) adolescents. Additionally, we measured suicidality, stratified by sex, and its association with sexual identity, sexual violence, and binge drinking. METHODS: We pooled data from the Youth Risk Behavior Survey from 2005 to 2019 to analyze the prevalence of sexual minorities, forced sex, and binge drinking, and their association with suicidality using basic descriptive statistics followed by adjusted odds ratios stratified by sex among AI/AN youth. RESULTS: 19% of AI/AN participants reported having suicidal thoughts and 14% reported having a previous suicide attempt. More than 17% of AI/AN participants identified as sexual minority youth (SMY). Compared to AI/AN heterosexual youth, AI/AN bisexual youth had significantly higher odds of reporting suicidal thoughts (aOR = 16.01), planning (aOR = 12.4), and previous attempts (aOR = 7.73). This pattern was also significantly demonstrated for AI/AN gay/lesbian youth. 43% of all AI/AN participants reported being forced into sexual intercourse. The presence of binge drinking was associated with higher odds of suicidal thoughts for both females and males compared to those who did not binge drink. DISCUSSION: At the intersection of multiple marginalization, AI/AN SMY have a high mental health burden, demonstrating the need for culturally informed, community-led, and targeted mental health support focused on SMY AI/AN. Though this study fails to capture the heterogeneity within the AI/AN community, as nuances exist at the tribal level, these results demonstrate work needs to be done to support the health burden that AI/AN youth carry.

The Association of Depression, Social Determinants and PrEP Uptake Among Black Sexual Minority Men in the Deep South.

Despite its known efficacy in reducing HIV acquisition, pre-exposure prophylaxis (PrEP) uptake and utilization remains alarmingly low among key populations, including Black sexual minority men (SMM). Additionally, research has shown that SMM are at elevated risk of adverse mental health outcomes, including depression, anxiety, illegal drug use, and suicidality. However, there is limited data examining the impact of depression on PrEP uptake among Black SMM. This study analyzes survey data obtained from the ViiV ACCELERATE! Initiative between January 2016 and September 2017 to examine the association between depressive symptoms and uptake of PrEP among a sample of HIV-negative Black SMM ages 18-65 years (N=170) residing in Mississippi, the poorest state in the USA. We found that PrEP-eligible Black SMM reporting depressive symptoms were 60% less likely to take PrEP (aOR = 0.40, CI: 0.18-0.74, p = 0.05). Similarly, PrEP-eligible men lacking health insurance were 63% less likely to start PrEP (aOR = 0.37; CI: 0.17-0.94; p = 0.035). Given the low uptake of PrEP among Black SMM, there is an urgent need for the development and implementation of combination HIV prevention interventions that incorporate access to mental health services among this highly stigmatized and marginalized population.

Sexual Minority Status Disparities in Life's Essential 8 and Life's Simple 7 Cardiovascular Health Scores: A French Nationwide Population-Based Study.

Background A higher burden of cardiovascular disease risk factors has been reported in sexual minority populations. Primordial prevention may therefore be a relevant preventative strategy. The study's objectives are to estimate the associations of Life's Essential 8 (LE8) and Life's Simple 7 (LS7) cardiovascular health scores with sexual minority status. Methods and Results The CONSTANCES is a nationwide French epidemiological cohort study that recruited randomly selected participants older than 18 years in 21 cities. Sexual minority status was based on self-reported lifetime sexual behavior and categorized as lesbian, gay, bisexual, or heterosexual. The LE8 score includes nicotine exposure, diet, physical activity, body mass index, sleep health, blood glucose, blood pressure, and blood lipids. The previous LS7 score included 7 metrics without sleep health. The study included 169 434 cardiovascular disease-free adults (53.64% women; mean age, 45.99 years). Among 90 879 women, 555 were lesbian, 3149 were bisexual, and 84 363 were heterosexual. Among 78 555 men, 2421 were gay, 2748 were bisexual, and 70 994 were heterosexual. Overall, 2812 women and 2392 men declined to answer. In multivariable mixed effects linear regression models, lesbian (ß=-0.95 [95% CI, -1.89 to -0.02]) and bisexual (ß=-0.78 [95% CI, -1.18 to -0.38]) women had a lower LE8 cardiovascular health score compared with heterosexual women. Conversely, gay (ß=2.72 [95% CI, 2.25-3.19]) and bisexual (ß=0.83 [95% CI, 0.39-1.27]) men had a higher LE8 cardiovascular health score compared with heterosexual men. The findings were consistent, although of smaller magnitudes for the LS7 score. Conclusions Cardiovascular health disparities exist in sexual minority adults, particularly lesbian and bisexual women, who may represent a priority population for primordial cardiovascular disease prevention.

Intersectionality-informed analysis of durable viral suppression disparities in people with HIV.

OBJECTIVE: The aim of this study was to examine drivers of durable viral suppression (DVS) disparities among people with HIV (PWH) using quantitative intersectional approaches. DESIGN: A retrospective cohort analysis from electronic health records informed by intersectionality to better capture the concept of interlocking and interacting systems of oppression. METHODS: We analyzed data of PWH seen at a LGBTQ federally qualified health center in Chicago (2012-2019) with at least three viral loads. We identified PWH who achieved DVS using latent trajectory analysis and examined disparities using three intersectional approaches: Adding interactions, latent class analysis (LCA), and qualitative comparative analysis (QCA). Findings were compared with main effects only regression. RESULTS: Among 5967 PWH, 90% showed viral trajectories consistent with DVS. Main effects regression showed that substance use [odds ratio (OR) 0.56, 0.46-0.68] and socioeconomic status like being unhoused (OR: 0.39, 0.29-0.53), but not sexual orientation or gender identity (SOGI) were associated with DVS. Adding interactions, we found that race and ethnicity modified the association between insurance and DVS ( P for interaction <0.05). With LCA, we uncovered four social position categories influenced by SOGI with varying rates of DVS. For example, the transgender women-majority class had worse DVS rates versus the class of mostly nonpoor white cisgender gay men (82 vs. 95%). QCA showed that combinations, rather than single factors alone, were important for achieving DVS. Combinations vary with marginalized populations (e.g. black gay/lesbian transgender women) having distinct sufficient combinations compared with historically privileged groups (e.g. white cisgender gay men). CONCLUSION: Social factors likely interact to produce DVS disparities. Intersectionality-informed analysis uncover nuance that can inform solutions.

A Single Center Review of COVID-19 Testing and Vaccination in the Transgender and Nonbinary Population.

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected transgender and nonbinary (TGNB) persons. We evaluated COVID-19 testing and vaccination rates among TGNB patients at our institution. Methods: We compared COVID-19 testing and vaccination rates between TGNB patients and a cisgender population matched by age, race, and ethnicity. Data were collected through September 22, 2021. Demographic variables, testing rates, and vaccination rates were collected. Descriptive statistics were calculated, and regression was performed on outcomes of interest: any vaccination dose, at least one test, and at least one positive test. Gender modality was the exposure of interest. Results: There were 5050 patients: 1683 cisgender men, 1682 cisgender women, and 1685 TGNB individuals. TGNB patients were more likely to be on Medicaid/Medicare and more likely to be single. The number of patients with at least one test was similar between TGNB (n = 894, 53.1%) and cisgender (n = 1853, 55.1%) groups. The number of patients who had at least one positive test was higher among cisgender patients (n = 238, 7.1%) compared with TGNB patients (n = 73, 4.3%). Vaccination rates were significantly greater among TGNB patients. Compared with cisgender patients, TGNB patients had greater odds of vaccination (adjusted odds ratio [aOR] = 1.25 [95% confidence interval; CI 1.06-1.48]). Compared with cisgender patients, TGNB patients had lower odds of having at least one positive COVID-19 test (aOR = 0.51 [95% CI 0.36-0.72]). Conclusion: Our institutional experience found that vaccination rates for TGNB patients were higher and COVID-19 positivity lower than for cisgender patients.

Instability in Housing and Medical Care Access: The Inequitable Impacts of the COVID-19 Pandemic on U.S. Transgender Populations.

Purpose: To assess whether the COVID-19 pandemic has inequitably impacted key social determinants of health (SDoH), specifically employment, housing, and health care, for U.S. transgender populations. Methods: Between April 13, 2020 and August 3, 2020, we conducted a national, cross-sectional online survey of sexual and gender minority individuals (N=870). We used logistic regression to calculate both unadjusted and adjusted odds of unemployment, homelessness/housing instability, and interruptions in medical care owing to the pandemic by gender and gender modality. Adjusted models controlled for age, race/ethnicity, and region. Results: In adjusted models, transgender and gender diverse people had 2.12 times the odds of reporting homelessness/housing instability and 2.88 times the odds of reporting medical care interruptions compared with cisgender peers. Transgender men, women, and nonbinary people had 4.12, 3.29, and 3.48 times the adjusted odds of interruptions in medical care compared with cisgender men, respectively. We did not observe significant differences in employment. Conclusions: Findings add empirical support to the hypothesis that socioeconomic consequences of COVID-19 are inequitably impacting transgender people. To contextualize our results and support future research in this area, we present a conceptual model of the short- and long-term impacts of COVID-19 on transgender populations using a framework of stigma as a fundamental cause of health inequities. Our findings emphasize that public health professionals must urgently consider-and intervene to address-the pandemic's SDoH-related impacts on transgender populations.

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

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

Disparities in HIV Testing, Condom Use, and HIV Education Between Transgender and Not Transgender High School-Aged Youth: Findings From the 2019 Youth Risk Behavior Survey.

Transgender individuals are disproportionately affected by HIV in the United States. Given increased risk of HIV among youth, there is a need to understand HIV risk and protective factors among transgender individuals who are 18 years and younger. Patterns of HIV testing, HIV education, and condom use have known associations with HIV outcomes among youth in general, but are understudied among transgender youth. This study assessed these outcomes by developing a series of sex-stratified multivariable logistic regression models using pooled Youth Risk Behavior Survey data. Results indicate female and male transgender youth as well as males who were not sure they were transgender were more likely have tested for HIV compared with their not transgender peers. Male transgender youth were significantly less likely to have received HIV education compared with not transgender males. Females not sure if they were transgender and male transgender youth were significantly less likely to have used condoms compared with, respectively, not transgender female and not transgender male counterparts. In sum, condom use and HIV education both remain lower among transgender individuals relative to their not-transgender peers. This highlights the need for the promotion of culturally appropriate HIV education and HIV prevention supports among transgender youth.

Physical Inactivity and the Role of Bullying Among Gender Minority Youth Participating in the 2017 and 2019 Youth Risk Behavior Survey.

PURPOSE: Evidence from small-scale studies suggests that transgender youth are less physically active than nontransgender youth, putting them at risk for worse health outcomes. This study examined the relationship between gender modality and participation in physical activity, physical education (PE), and sports teams in a multistate sample of high school youth and assessed whether bullying impacted this relationship. METHODS: Multiple regression was used to analyze data from the state and local Youth Risk Behavior Survey from 2017 to 2019 to examine the relationship between the gender modality and participation in physical activity, PE, and sports teams. The sample was stratified by sex and adjusted for demographics and in-school and online bullying victimization. RESULTS: Transgender participants who reported a male or female sex, respectively, reported lower odds of physical activity (adjusted odds ratio [aOR] 0.46, p < .001; aOR 0.46, p < .001, respectively) but similar odds of PE participation. Female transgender students were less likely to participate in sports (aOR 0.55, p = .007); however, this relationship was not seen in adjusted models. Adjusting for demographics, male transgender students were significantly more likely to participate in sports (aOR 2.1, p = .002). Adjusting for bullying experiences did not significantly change these results. DISCUSSION: Transgender youth are less likely to participate in physical activity but participate similarly or more than cisgender peers in PE and sports. Factors other than bullying may limit physical activity among transgender youth, and the Youth Risk Behavior Survey may not capture experiences of trans-specific victimization. Increased inclusion and safety may help increase physical activity and amplify its benefits for transgender students.

Trends in heroin use and injection drug use among high school students in five urban school districts in the US (2005-2017).

Background. We describe the prevalence of and changes in heroin use and injection drug use (IDU) among high school students in five large, urban school districts in the US (2005-2017); nearly three-fourths of the students were Black and/or Hispanic/Latino.Methods. Data are from the Centers for Disease Control and Prevention's "Youth Risk Behavior Survey" program, which includes biennial surveys in urban school districts. We pooled data across districts and survey years, and then generated weighted prevalence estimates (and 95% CIs) for any lifetime heroin use and IDU. Joinpoint regression modeling was used to estimate changes in prevalence over the study period.Results. Biennial prevalence estimates (2005-2017) for heroin use and IDU were above 1.8% for all seven timepoints. In 2017, prevalence of heroin use and IDU were 2.9% and 2.5%, respectively. Both heroin use and IDU were higher among boys than girls. There were statistically significant increases in heroin use and IDU among girls from 2005-2009, whereas changes over time were stable among boys.Conclusions. High school students in large, urban school districts may have higher rates of heroin use and IDU than US high school students in general, and there is little evidence of increases since 2009. This study suggests that adolescence may be a critical period for initiation of heroin use among adolescents in large urban school districts, the majority of whom are Black and/or Latino.Supplemental data for this article is available online at https://doi.org/10.1080/15332640.2021.1992327 .

Heart-Kidney Transplantation in a Transgender Woman.

We describe the care of a transgender woman with heart failure who underwent heart-kidney transplantation. Perioperative management of hormone therapy, considerations for future gender-affirming surgeries, and psychosocial aspects of care are discussed. Interdisciplinary collaboration is essential in the treatment of patients with advanced heart failure in the setting of gender-affirming therapies. (Level of Difficulty: Advanced.).