Invisibilização e preconceitos velados: barreiras para o acesso aos serviços de atenção básica pela população trans / Invisibilization and veiled prejudices: barriers to access to primary care services for the transgender population / Invisibilización y prejuicios velados: barreras para el acceso de la población trans a los servicios de atención primaria

Introdução: No processo de edificação da Política Nacional de Saúde Integral LGBT+, a Atenção Básica ganha importante destaque, pois deveria funcionar como o contato preferencial dos usuários transgênero (trans). Objetivo: Investigar quais as percepções dos profissionais da Atenção Básica quanto às situações de vulnerabilidade enfrentadas pelas pessoas trans, bem como pesquisar os impedimentos que eles consideram existir na busca dessa população por acesso a esses serviços. Métodos: Utilizou-se uma abordagem qualitativa por meio de entrevistas semiestruturadas com 38 profissionais de saúde atuantes das Estratégias Saúde da Família de dois municípios do interior do estado de São Paulo. O material obtido foi submetido à análise de conteúdo de Bardin. Resultados: Os resultados apontaram para o desconhecimento quanto aos reais empecilhos que dificultam o acesso e seguimento de pessoas trans nos serviços de saúde. Observou-se ainda a manutenção de preconceitos e ideias que reforçam estereótipos ligados ao tema e que se estendem ao exercício da profissão. Isso se relaciona diretamente com a falta da abordagem de assuntos relacionados à sexualidade humana na graduação desses profissionais, além da falta de atualização quanto ao tema, o que impacta a qualidade do serviço que é ofertado à população em estudo. Conclusões: As normativas e portarias já existentes precisam ser efetivamente postas em prática, fazendo-se imperativas a ampliação e difusão do conhecimento a respeito da temática trans no contexto dos serviços públicos de saúde, o que pode servir como base para subsidiar a formação dos profissionais que atuam nesse setor, bem como políticas públicas efetivas.

Introduction: In the process of creating the National LGBT+ Comprehensive Health Policy, primary care has important prominence as it must work as the preferential contact of transgender (trans) users. Objective: To investigate the perceptions of primary care professionals about the vulnerability situations faced by trans persons and also hindrances they consider existing in this population's search for access to these services. Methods: A qualitative approach was used through semi-structured interviews with 38 health care professionals working in the Family Health Strategy of two cities in the countryside of the state of São Paulo. The material obtained was submitted to analysis of Bardin content. Results: The results pointed to a lack of knowledge about real hindrances that obstruct the access to and follow-up by health services for trans persons. It was also observed the maintenance of prejudices and ideas that reinforce stereotypes connected to the matter and extend to the practice of professionals. It is directly related to the lack of approach of issues related to human sexuality in the education of those professionals, in addition to lack of update about it, which impacts the quality of service offered to the population under study. Conclusions: The standards and ordinances already existing need to be effectively practiced, being crucial the extension and spread of knowledge about trans matters in the context of public health services. It can be the basis for subsidizing the education of professionals who work in this field, as well as effective public policies.

Introducción: En el proceso de edificación de la Política Nacional de Salud Integral LGBT+, la Atención Básica tiene importante destaque, pues debería funcionar como contacto preferente de los usuarios transgénero (trans). Objetivo: Investigar las percepciones de los profesionales de Atención Básica sobre las situaciones de vulnerabilidad que enfrentan las personas trans, así como investigar los impedimentos que consideran que existe en la búsqueda de esta población por el acceso a estos servicios. Métodos: Se utilizó un abordaje cualitativo por medio de entrevistas semiestructuradas con 38 profesionales de salud actuantes de las Estrategias de Salud de la Familia de dos municipios del interior del estado de São Paulo. El material obtenido fue sometido a análisis de contenido de Bardin. Resultados: Los resultados apuntaron al desconocimiento sobre los reales obstáculos que dificultan el acceso de personas trans a los servicios, además del segmento de los cuidados en las unidades. Se observó además que se mantienen los prejuicios e ideas que refuerzan estereotipos vinculados al tema y que se extienden al ejercicio de la profesión. Esto se relaciona directamente a la falta da abordaje de asuntos relacionados a la sexualidad humana en la graduación de estos profesionales, además de la falta de actualización sobre el tema, lo que impacta en la calidad del servicio que se ofrece a la población en estudio. Conclusiones: Las normas y ordenanzas ya existentes deben ser efectivamente puestas en práctica, por lo que es imperativo ampliar y difundir el conocimiento sobre la temática trans en el contexto de los servicios públicos de salud, que pueda servir de base para apoyar la formación de profesionales que actúan en este sector, así como políticas públicas efectivas.

Racial and Ethnic Differences in Mobile App Use for Meeting Sexual Partners Among Young Men Who Have Sex With Men and Young Transgender Women: Cross-Sectional Study.

Background: Young men who have sex with men and young transgender women (YMSM-YTW) use online spaces to meet sexual partners with increasing regularity, and research shows that experiences of racism online mimics the real world. Objective: We analyzed differences by race and ethnicity in web-based and mobile apps used to meet sexual partners as reported by Chicago-based YMSM-YTW in 2016-2017. Methods: A racially and ethnically diverse sample of 643 YMSM-YTW aged 16-29 years were asked to name websites or mobile apps used to seek a sexual partner in the prior 6 months, as well as provide information about sexual partnerships from the same period. We used logistic regression to assess the adjusted association of race and ethnicity with (1) use of any website or mobile apps to find a sexual partner, (2) use of a "social network" to find a sexual partner compared to websites or mobile apps predominantly used for dating or hookups, (3) use of specific websites or mobile apps, and (4) reporting successfully meeting a sexual partner online among website or mobile app users. Results: While most YMSM-YTW (454/643, 70.6%) used websites or mobile apps to find sexual partners, we found that Black non-Hispanic YMSM-YTW were significantly less likely to report doing so (comparing White non-Hispanic to Black non-Hispanic: adjusted odds ratio [aOR] 1.74, 95% CI 1.10-2.76). Black non-Hispanic YMSM-YTW were more likely to have used a social network site to find a sexual partner (comparing White non-Hispanic to Black non-Hispanic: aOR 0.20, 95% CI 0.11-0.37), though this was only reported by one-third (149/454, 32.8%) of all app-using participants. Individual apps used varied by race and ethnicity, with Grindr, Tinder, and Scruff being more common among White non-Hispanic YMSM-YTW (93/123, 75.6%; 72/123, 58.5%; and 30/123, 24.4%, respectively) than among Black non-Hispanic YMSM-YTW (65/178, 36.5%; 25/178, 14%; and 4/178, 2.2%, respectively) and Jack'd and Facebook being more common among Black non-Hispanic YMSM-YTW (105/178, 59% and 64/178, 36%, respectively) than among White non-Hispanic YMSM-YTW (6/123, 4.9% and 8/123, 6.5%, respectively). Finally, we found that while half (230/454, 50.7%) of YMSM-YTW app users reported successfully meeting a new sexual partner on an app, Black non-Hispanic YMSM-YTW app users were less likely to have done so than White non-Hispanic app users (comparing White non-Hispanic to Black non-Hispanic: aOR 2.46, 95% CI 1.50-4.05). Conclusions: We found that Black non-Hispanic YMSM-YTW engaged with websites or mobile apps and found sexual partners systematically differently than White non-Hispanic YMSM-YTW. Our findings give a deeper understanding of how racial and ethnic sexual mixing patterns arise and have implications for the spread of sexually transmitted infections among Chicago's YMSM-YTW.

Transgender-Specific Differentiated HIV Service Delivery Models in the South African Public Primary Health Care System (Jabula Uzibone): Protocol for an Implementation Study.

BACKGROUND: Almost 60% of transgender people in South Africa are living with HIV. Ending the HIV epidemic will require that transgender people successfully access HIV prevention and treatment. However, transgender people often avoid health services due to facility-based stigma and lack of availability of gender-affirming care. Transgender-specific differentiated service delivery (TG-DSD) may improve engagement and facilitate progress toward HIV elimination. Wits RHI, a renowned South African research institute, established 4 TG-DSD demonstration sites in 2019, with funding from the US Agency for International Development. These sites offer unique opportunities to evaluate the implementation of TG-DSD and test their effectiveness. OBJECTIVE: The Jabula Uzibone study seeks to assess the implementation, effectiveness, and cost of TG-DSD for viral suppression and prevention-effective adherence. METHODS: The Jabula Uzibone study collects baseline and 12-month observation checklists at 8 sites and 6 (12.5%) key informant interviews per site at 4 TG-DSD and 4 standard sites (n=48). We seek to enroll ≥600 transgender clients, 50% at TG-DSD and 50% at standard sites: 67% clients with HIV and 33% clients without HIV per site type. Participants complete interviewer-administered surveys quarterly, and blood is drawn at baseline and 12 months for HIV RNA levels among participants with HIV and tenofovir levels among participants on pre-exposure prophylaxis. A subset of 30 participants per site type will complete in-depth interviews at baseline and 12 months: 15 participants will be living with HIV and 15 participants will be HIV negative. Qualitative analyses will explore aspects of implementation; regression models will compare viral suppression and prevention-effective adherence by site type. Structural equation modeling will test for mediation by stigma and gender affirmation. Microcosting approaches will estimate the cost per service user served and per service user successfully treated at TG-DSD sites relative to standard sites, as well as the budget needed for a broader implementation of TG-DSD. RESULTS: Funded by the US National Institutes of Mental Health in April 2022, the study was approved by the Human Research Ethics Committee at University of Witwatersrand in June 2022 and the Duke University Health System Institutional Review Board in June 2023. Enrollment began in January 2024. As of July 31, 2024, a total of 593 transgender participants have been enrolled: 348 are living with HIV and 245 are HIV negative. We anticipate baseline enrollment will be complete by August 31, 2024, and the final study visit will take place no later than August 2025. CONCLUSIONS: Jabula Uzibone will provide data to inform HIV policies and practices in South Africa and generate the first evidence for implementation of TG-DSD in sub-Saharan Africa. Study findings may inform the use of TG-DSD strategies to increase care engagement and advance global progress toward HIV elimination goals. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/64373.

Evaluating the Risk of Venous Thromboembolism in Transfeminine and Gender Diverse People: A Retrospective Analysis.

OBJECTIVE: The risk of venous thromboembolism (VTE) with feminizing gender-affirming hormone therapy is an area of concern. This analysis aimed to assess whether gender-affirming hormone therapy and other potential risk factors are associated with VTE in transfeminine and gender diverse individuals. METHODS: We conducted a chart review of 2126 transfeminine and gender diverse adults receiving care within a large urban health system. The primary outcomes were the prevalence of VTE and odds ratios for the association of VTE with insurer, use of estrogen, and select comorbidities. RESULTS: A history of VTE was documented in 0.8% of the cohort. Those with a history of VTE were older (P < .001), more often self-identified as Hispanic or Black compared to White or Asian (P < .05) and were more likely to have Medicaid or Medicare (P < .01) when compared to those without a history of VTE. The prevalence of hyperlipidemia (P < .001), diabetes mellitus (P < .05), and hypercoagulable conditions (P < .001) were all greater in the positive VTE group. Hyperlipidemia (P < .001), diabetes mellitus (P < .05), and insurer (P < .05) were associated with increased odds of VTE in univariate analyses. None of the exposure variables analyzed were associated with VTE when controlling for age, race, and the number of comorbidities. CONCLUSIONS: The prevalence of VTE in our cohort was lower than previously observed. VTE was not associated with any one risk factor, including estrogen use, when controlling for age, race, and the number of comorbidities. Those of advanced age and those with multiple cardiometabolic comorbidities may benefit from increased surveillance and mitigation of modifiable risk factors.

Induced lactation in a transgender woman: case report.

BACKGROUND: Breastfeeding offers significant health benefits, but its practice and success can vary. While research on induced lactation in cisgender women has been documented, there is limited research on lactation induction in transgender women. CASE PRESENTATION: A 50-year-old transgender woman undergoing hormone therapy and living with a pregnant partner sought to co-feed using induced lactation. After approval by the hospital ethics committee, a regimen of estradiol, progesterone, and domperidone was initiated, accompanied by nipple stimulation. Lactation was successfully induced and maintained, with milk composition analysis indicating high levels of protein and other key nutrients. This case, the seventh reported, highlights the complexity of lactation induction in transgender women, considering factors such as age, obesity, and insulin resistance. The nutrient profile of the milk suggests its suitability for infant feeding, despite some differences from typical human milk. CONCLUSIONS: Induced lactation is feasible in transgender women, expanding the understanding of non-puerperal lactation and its potential in diverse family structures. Further research is warranted to optimize lactation induction protocols in transgender women.

Gender-affirming hormone treatment modalities for transfemale & non-binary transfeminine individuals: A UK perspective.

Gender incongruence and the number of people seeking gender affirming hormone treatment has dramatically risen in the last two decades. In the UK, transgender women and non-binary transfeminine individuals are typically treated with simultaneous suppression of endogenous testosterone production through anti-androgens and exogenous oestradiol replacement. Oestrogen replacement comes in different forms and is primarily given as transdermal (gel or patch) or oral preparations in the UK. Decisions around preparation choice are based on a combination of individual preference and/or mitigating the chance of complications based on individual risk profiles. Time frames to achieve female physical changes are largely predictable and managing expectations of individuals prior to commencing treatment is highly important. Common complications include venous thromboembolism, liver dysfunction and effects on fertility, thus individuals should be thoroughly counselled prior to commencing treatment. This article provides an overview of the management and considerations of gender-affirming hormone treatment in transgender women and non-binary transfeminine individuals.

Acoustic Analysis of Mandarin-Speaking Transgender Women.

OBJECTIVES: This study aims to investigate the speech characteristics and assess the potential risk of voice fatigue and voice disorders in Chinese transgender women (TW). METHODS: A case-control study was conducted involving TW recruited in Shanghai, China. The participants included 15 TW, 20 cisgender men (CISM), and 20 cisgender women (CISW). Acoustic parameters including formants (F1, F2, F3, F4), cepstral peak prominence (CPP), jitter, shimmer, harmonic-to-noise ratio (HNR), noise-to-harmonics (NHR), fundamental frequency (f0), and intensity, across vowels, passages, and free talking. Additionally, the Voice Handicap Index-10 (VHI-10) and the Voice Fatigue Index were administered to evaluate voice-related concerns. RESULTS: (1) The F1 of TW was significantly higher than that of CISW for the vowels /i/ and /u/, and significantly higher than that of CISM for the vowels /a/, /i/, and /u/. The F2 of TW was significantly lower than CISW for the vowels /i/, significantly higher than CISW for the vowels /u/, and significantly higher than CISM for the vowels /a/ and /u/. F3 was significantly lower in TW than in CISW for the vowels /a/ and /i/. The F4 formant was significantly lower in TW than in CISW for the vowels /a/ and /i/, but significantly higher than in CISM for the vowel /u/. (2) The f0 of TW was significantly lower than that of CISW for the vowels /a/, /i/, /u/, during passage reading, and in free speech, but was significantly higher than CISM during passage reading and free talking. Additionally, TW exhibited significantly higher intensity compared with CISW for the vowel /a/ and during passage reading. (3) Jitter in TW was significantly higher than in CISW for the vowels /i/ and /u/, and significantly lower than in CISM during passage reading and free talking. Shimmer was significantly higher in TW compared with both CISW and CISM across the vowels /a/, /i/, during passage reading, and in free talking. The HNR in TW was significantly lower than in both CISW and CISM across all vowels, during passage reading, and in free talking. The NHR was significantly higher in TW than in CISW across all vowels, during passage reading, and in free talking, and significantly higher than in CISM for the vowels /a/, /i/, during passage reading, and in free talking. The CPP in TW was significantly lower than in CISW during passage reading and free talking, and significantly lower than in CISM across all vowels, during passage reading, and in free speech. (4) The VHI-10 scores were significantly higher in TW compared with both CISM and CISW. CONCLUSIONS: TW exhibit certain acoustic parameters, such as f0 and some of the formants, that fall between those of CISW and CISM without undergoing phonosurgery or voice training. The findings suggest a potential risk for voice fatigue and the development of voice disorders as TW try to modify their vocal characteristics to align with their gender identity.

The association between microaggressions and mental health among UK trans people: a cross-sectional study.

PURPOSE: Epidemiological studies investigating the mental health impacts of microaggressions in the trans population have tended to have methodological limitations, including a lack of validated measures, raising concerns about the validity of their findings. To address this evidence gap, we investigated the associations between microaggressions and poor mental health (depression; anxiety; non-suicidal self-harm [NSSH]; suicidal thoughts; suicide attempt) amongst trans people. METHODS: We conducted a cross-sectional survey of 787 trans adults in the UK, measuring mental health and exposure to microaggressions using the Gender Identity Microaggressions Scale (GIMS). Using univariable and multivariable linear and logistic regression models we tested for an association of microaggressions with depressive symptoms (PHQ-9), anxiety symptoms (GAD-7), lifetime NSSH, lifetime suicidal thoughts, and lifetime suicide attempt. RESULTS: Of the 787 participants, 574 (73%) provided complete data. Microaggressions were a common experience, affecting 97.6% of participants over their lifetime. In adjusted analyses, using sociodemographic and clinical variables, increased microaggression scores were associated with increased depressive symptoms (adjusted coefficient: 1.86 (95%CI = 1.35 to 2.36)), anxiety symptoms (adjusted coefficient: 1.57 (95%CI = 1.09 -2.05)) and with increased odds of NSSH (Odds Ratio [OR]adj 1.83 (95%CI = 1.45 -2.30)), suicidal thoughts (ORadj 2.18, (95%CI = 1.52 -3.13)), and suicide attempt (ORadj, 1.59, (95%CI = 1.32 -1.92)). In exploratory analyses different GIMS subscales were associated with these various outcomes. CONCLUSIONS: There was evidence of associations between microaggressions and adverse mental health outcomes, as well as to support specific microaggressions being associated with specific outcomes, emphasizing the importance of public health interventions that target microaggressions directed at trans adults. Longitudinal studies are needed to investigate the temporality of the associations between microaggressions and mental health outcomes.

A Cautionary Tale: Digital Clinical Trial Implementation of a Couples-Based HIV Prevention Study among Transgender Women and Their Partners in the United States.

This study investigates baseline differences in couples enrolled in the "It Takes Two" HIV prevention intervention for transgender women and their partners, comparing in-person participation pre-COVID-19 and digital participation during the pandemic. Among 52 couples (40% in-person, 60% digital), bivariate analyses revealed that in-person participants were more likely to be African American, have cisgender male partners, report higher unemployment, incarceration histories, greater relationship stigma, and lower relationship quality. The findings highlight the limitations of digital modalities in engaging transgender women of color and those with structural vulnerabilities. The study emphasizes that reliance on digital methods in HIV research jeopardizes the inclusion of those lacking technological access and literacy, especially communities disproportionately impacted by HIV. Researchers must incorporate hybrid or in-person options and engage communities to ensure equity and inclusion, thus overcoming barriers and ensuring comprehensive population reach in HIV prevention studies.

Understanding risk of chronic pain development and related mental health disparities among transgender people: A review of current literature and future directions.

Biomedical and clinical research has traditionally focused on binary sex assignments as opposed to gender identity. This oversight has resulted in other gender minority populations being understudied. As a result, there is limited literature on chronic pain and mental health in transgender populations. These socially vulnerable individuals may be at increased risk for chronic pain development and related mental health disorders. Transgender individuals experience higher rates of social stigma and discrimination than their cisgender counterparts, and these factors have been linked to an increased prevalence of chronic pain, depression, and stress. Beyond chronic pain and mental health research, large overall health disparities and differences exist for transgender people compared to their cisgender peers. Therefore, it is crucial to include transgender individuals, as well as other gender minority people, in research in order to fully understand the impact of gender minority status on pain and quality of life. PERSPECTIVE: This review explores the intersectional impact of stress and mental health on chronic pain development and the unequal risk for transgender individuals. Promoting inclusion of gender minority individuals in research is a critical step to understanding the factors contributing to minority stress.

Approaching the Concepts of Gender and Sex in Family Planning Research.

Gender and sex are distinct constructs that shape family planning related experiences, outcomes, and opportunities. This commentary provides guidance to clinical and social science researchers on: 1) current definitions of gender and sex; 2) when and why capturing information about gender, sex, or both is relevant to family planning studies; 3) recommended language for each stage of the research process to accurately and affirmingly recruit participants, collect and analyze data, and disseminate findings; and 4) approaches for engaging with already collected data or published research. Failing to address gender and sex with clarity and intention in family planning research can lead to biased samples, biased instruments, and biased data, consequently limiting scholarly knowledge of family planning desires, abilities, experiences, outcomes, and preferences.

Pharmacy barriers for transgender and gender diverse young adults.

BACKGROUND: Transgender and gender diverse (TGD) individuals face substantial physical and mental health care barriers. Community pharmacies are one of the most accessible healthcare settings; however, concern for discrimination at the pharmacy has been reported. It is important to gain a better understanding of TGD individual's perspectives and experiences at the pharmacy to ensure optimal and inclusive care. OBJECTIVE: To identify TGD individual experiences and barriers at the pharmacy. METHODS: This IRB-approved qualitative study recruited TGD young adults in the United States between ages 18-29 years old for semi-structured focus group discussions. Questions focused on barriers to obtaining medications at the pharmacy and negative or positive experiences with pharmacists. Interviews were recorded, transcribed, and transcripts were analyzed for common themes amongst participants. RESULTS: Nine 1.5-2-hour focus groups were conducted and included 30 participants (2-6 participants in each group). All participants reported having been prescribed medications by a physician or mental health provider. Participants self-reported issues at pharmacies and with pharmacy personnel. Major themes included issues accessing medications and supplies (needles, syringes), questioning of prescription validity and patient identity, and lack of education or understanding of TGD individuals by pharmacy staff. CONCLUSION: TGD individuals experience barriers at the pharmacy and concerning issues with pharmacy staff. Education, structural competency, and improvements in gender-related data management are necessary for pharmacists and pharmacy staff to provide equitable and inclusive care for TGD individuals.

"They're not feeling the love they need to feel": HIV stigma and other intersecting stigmas among Black gay and bisexual men and transgender women in House and Ball Communities.

Introduction: Stigma negatively influences engagement in HIV prevention and care. This study explores how young Black gay and bisexual men and transgender women (GBT) in the House and Ball Community (HBC) experience HIV and other intersecting stigmas. Method: We conducted phenomenological analysis of interviews with 60 young Black GBT HBC members and 30 older leaders of the HBC. Result: Participants described experiences of enacted, perceived, and internalized HIV stigma and intersecting stigmas related to race, ethnicity, sexuality, gender identity, gender expression, and body size, as well as their responses to HIV stigma. Intersecting stigmas shaped and reinforced one another, leading to isolation and increased HIV vulnerability. Conclusion: Interventions to ameliorate intersectional stigma and its effects are needed to improve primary and secondary HIV prevention in the HBC.

Genital gender-affirming surgery trends in Germany: Total population data with 19,600 cases from 2006 to 2022.

PURPOSE: To delineate the current trends regarding gender-affirming surgeries (GAS) in Germany. METHODS: Analysis of German hospital quality reports from 2006 to 2022 was conducted using the reimbursement.info tool. The German procedure classification (OPS) codes 5-646.0 for masculinizing- and 5-646.1 for feminizing surgery were assessed to identify GAS. Linear regression models were utilized for the analysis and depiction of current trends. RESULTS: A total of 19,632 gender-affirming procedures were performed during the study period with an exponential increase over the years. Masculinizing surgeries increased from 246 in 2006 to 1291 cases in 2022 (increase by 424%; p < 0.001). The highest annual increase of 37.2% in numbers was from 2018 to 2019 (from 1235 to 1694 cases). Feminizing surgeries increased from 180 cases in 2006 to 799 procedures in 2022 (increase by 343%; p < 0.001). The cases increased most between 2015 and 2016 from 277 to 502 cases (81.2%). The number of hospitals offering these surgeries expanded from 24 in 2006 to 29 in 2022 (21% increase; p < 0.001). CONCLUSION: This study demonstrates an exponential growth in numbers feminizing and masculinizing of GAS performed each year in Germany. Furthermore, a discernible trend emerges with a propensity for concentration of procedures within selected high-caseload centers across Germany.

Effect of spironolactone and cyproterone acetate on breast growth in transgender people: a randomized clinical trial.

CONTEXT: Transgender people with sex recorded male at birth desiring feminization commonly use cyproterone acetate or spironolactone as anti-androgens with estradiol, but the optimal anti-androgen is unclear. OBJECTIVE: To assess the effect of anti-androgens on breast development. We hypothesized this would be greater in those treated with cyproterone acetate than spironolactone due to more potent androgen receptor antagonism and suppression of serum total testosterone concentrations. DESIGN: Randomised clinical trial 2020-2022. SETTING: Outpatient endocrinology clinic. PARTICIPANTS: Transgender people aged 18+ years old commencing feminizing gender affirming hormone therapy. INTERVENTIONS: Standardized estradiol therapy plus either spironolactone 100mg daily or cyproterone acetate 12.5mg daily for six months. MAIN OUTCOME MEASURES: Primary outcome was breast development as measured by the breast chest distance. Secondary outcomes included estimated breast volume, suppression of serum total testosterone concentration <2nmol/L and Gender Preoccupation and Stability Questionnaire (GPSQ). RESULTS: Sixty-three people (median age 25 years) were enrolled, randomized and included in intention-to-treat analysis (cyproterone acetate n=32, spironolactone n=31). At six months, there was no between-group difference in breast chest distance (mean difference 0.27 cm, 95% CI -0.82 to 1.35, p=0.6) or estimated breast volume (mean difference 17.26 mL, 95% CI -16.94 to 51.47, p=0.3). Cyproterone acetate was more likely to suppress serum testosterone concentration to <2 nmol/L (odds ratio 9.01, 95% CI 1.83 to 4.44, p=0.008). Changes in GPSQ were similar between groups. CONCLUSION: Anti-androgen choice should be based on clinician and patient preference with consideration of side effects. Further research is needed to optimize breast development in transgender people.

Use of Telemedicine Services Is Associated with Longer Time to Initiation of Hormone Therapy in Transgender Teens and Young Adults.

Purpose: This is a retrospective chart review examining factors, which may contribute to timing of receipt of prescription for testosterone or estrogen-based interventions for transgender adolescents and young adults who do not receive such a prescription at their first medical appointment. Methods: A total of 176 patient records were available; of this a minority received a prescription for hormone therapy at first medical appointment. Of the remaining 108 unique individuals, 49 received a prescription at a subsequent medical. Results: Participants seen through virtual health care had a significantly longer time in care prior to receipt of estrogen or testosterone prescription (331 days vs. 220 days, p = 0.046). No other significant relationships were found. Conclusion: Patients who utilize telemedicine services for gender-related health care purposes and who did not receive a prescription for estrogen or testosterone at their initial medical encounter have a longer lead time to receipt of hormone therapy.

Assessment of sociodemographic and psychiatric characteristics of transgender adults seen at a Midwest tertiary medical center.

Background: The National Academy of Medicine has formally identified transgender adults as an understudied population in critical need of health research. While national surveys, like the US Transgender survey, have characterized higher rates of depression, anxiety, suicidality and socioeconomic need in the transgender community, studies have not examined the impact of sociodemographic and clinical characteristics on mental health related outcomes. Objective: To describe the sociodemographic and mental health characteristics of transgender adults seen at a large Midwest transgender clinic and to determine factors associated with self-reported mental health conditions. Methods: Descriptive, retrospective, cross-sectional study of new transgender patients 18 years and older seen at a large Midwest transgender clinic between December 2019 and June 2022. Results: A total of 482 charts were reviewed. During their initial evaluation, 11.6% (56/482) reported having a history of suicide attempt and 81.3% (392/482) reported a mental health diagnosis with the most common being depression, anxiety, attention deficit disorder, and post-traumatic stress disorder. Multivariable logistic regression results show no single factor was significantly associated with mental health diagnosis after adjusting for the effect of age and race. Patients who were new to gender affirming hormone therapy (54%, 254/468) are 2.0 (95% CI 1.4-2.9) times more likely to report having a mental health care provider than patients who were seen for continuation of therapy (46%, 214/468). Ten records with race not disclosed, 3 records with gender identity "other" and 2 records with gender identity not disclosed were excluded from analysis. Conclusion: This study reinforces the finding that transgender adults have an increased lifetime prevalence of mental health conditions. The higher prevalence of mental health conditions in our clinic was not associated with sociodemographic factors included in the study. Furthermore, transgender patients are less likely to have seen mental healthcare providers after initiation of gender affirming hormone therapy.

Differences in Drug Poisonings Among Those Who Identify as Transgender Compared to Cisgender: An Analysis of the Toxicology Investigators Consortium (ToxIC) Core Registry, United States 2017-2021.

PURPOSE: In this manuscript, the abbreviation TG is defined as persons who identify as transgender, GNC is defined as persons who identify as gender nonconforming, and CG is defined as persons who identify as cisgender. TG and GNC (e.g., nonbinary), are those whose gender identity and sex assigned at birth do not align, as opposed to CG. This study describes drug poisonings among TG, GNC, and CG captured in the Toxicology Investigators Consortium (ToxIC) Core Registry during 2017-2021. METHODS: Authors conducted a secondary data analysis of medical toxicology physician consultations involving intentional exposures (i.e., use with the knowledge of the exposed person) within the ToxIC Core Registry from 2017 through 2021. Demographic characteristics, exposure intent, and reported drug classes are reported by gender identity and sex assigned at birth. FINDINGS: From a total of 15,800 medical toxicology consultations, 213 (1.3%) involved both TG (n = 187, 1.2%) and GNC (n = 26, 0.2%), and 15,587 (98.7%) involved CG. Among TG, 128 (68.8%) were transgender men, 58 (31.2%) transgender women. Sixty-two percent of TG/GNC (n = 132) and 34.8% of CG (n = 5,428) were aged ≤18 years. Reported intent for exposure (i.e., self-harm and misuse/harmful use) differed proportionally across both sexes assigned at birth and gender identity among transgender men and cisgender men. IMPLICATIONS: In the ToxIC Core Registry, the consultations varied proportionally by age group across TG/GNC and CG, with more than half of TG/GNC aged ≤18 years. The proportion of consultations also varied by intent across TG/GNC and CG. Further research to delineate differences between TG/GNC and CG could increase knowledge in prevention, assessment, and treatment of drug poisonings in this population.

'A void in our community': exploring the complexities of delivering and implementing primary care services for transgender individuals in Northern Ontario.

AIM: To understand how the implementation of primary care services for transgender individuals is undertaken and delivered by practitioners in Northern Ontario. BACKGROUND: Northern Ontario, Canada, has a shortage of primary care health practitioners, and of these, there are a limited number providing transgender primary care. Transgender people in Northern Ontario must also negotiate a lack of allied and specialty services related to transgender health and travel over long distances to access those services that do exist. METHODS: A convergent mixed methods design was guided by normalization process theory (NPT) to explore transgender primary care delivery and implementation by nurses, nurse practitioners, physicians, social workers, and psychotherapists. A survey measuring implementation processes was elaborated through qualitative interviews with participants. Analysis of key themes emerging using the NPT framework informed understanding of primary care successes, barriers, and gaps in Northern Ontario. FINDINGS: Key themes included the need for more education on transgender primary care practice, increased need for training and awareness on transgender resources, identification of unique gaps and barriers to access in Northern Ontario transgender care, and the benefits of embedding and normalizing transgender care in clinical practice to practitioners and transgender patients. These findings are key to understanding and improving access and eliminating healthcare barriers for transgender people in Northern Ontario.

Gender Minority Stressors and Psychological Distress Among Chinese Transgender and Gender Diverse People: Variable-Centered, Person-Centered, and Psychological Network Approaches.

Mental health disparities in transgender and gender diverse (TGD) populations call for more research examining gender minority stressors (GMS) as antecedents to their psychological distress, especially for the long-underrepresented groups living in conservative societies towards gender minorities. Furthermore, some questions remain underexamined, including the relative, independent influences of various GMS on TGD people's mental well-being (i.e., uniqueness of each stressor); how these stressors would configurate with each other in distinctive patterns to characterize subgroups of TGD people (i.e., beyond-average heterogeneity); and how these stressors would constitute a psychological network and vary in their centrality in that network (i.e., holistic complexity). To narrow such gaps, we examined the links between GMS and TGD people's psychological distress, using survey data collected in 2023 from 410 Chinese TGD people (Meanage = 22.33 years, SD = 4.27; 306 transgender, 70 non-binary/gender-queer/gender-fluid, 26 agender/gender-neutral, 3 intersex, and 5 others). We approached such links from three perspectives. First, variable-centered analyses indicated that while different GMS were considered simultaneously, internalized transphobia, preoccupation with gender dysphoria, and gender-related victimization were uniquely associated with psychological distress. Second, person-centered analyses yielded a 3-profile solution. Psychological distress varied systematically across profiles. Last, network analyses revealed a 3-cluster structure: Distal, Proximal Internal, and TGD-Specific Stressors. Preoccupation with gender dysphoria was the most central node. These findings contribute to a more nuanced understanding of the implications of GMS for TGD people's mental well-being. GMS related to internal struggles with gender identity might be among the central intervention targets to prevent/reduce TGD people's psychological distress.