Transgender people: health at the margins of society.

In this paper we examine the social and legal conditions in which many transgender people (often called trans people) live, and the medical perspectives that frame the provision of health care for transgender people across much of the world. Modern research shows much higher numbers of transgender people than were apparent in earlier clinic-based studies, as well as biological factors associated with gender incongruence. We examine research showing that many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health. They often experience difficulties accessing appropriate health care, whether specific to their gender needs or more general in nature. Some governments are taking steps to address human rights issues and provide better legal protection for transgender people, but this action is by no means universal. The mental illness perspective that currently frames health-care provision for transgender people across much of the world is under scrutiny. The WHO diagnostic manual may soon abandon its current classification of transgender people as mentally disordered. Debate exists as to whether there should be a diagnosis of any sort for transgender children below the age of puberty.

Comparing self- and provider-collected swabbing for HPV DNA testing in female-to-male transgender adult patients: a mixed-methods biobehavioral study protocol.

BACKGROUND: Cervical cancer, nearly all cases of which are caused by one of several high-risk strains of the human papillomavirus (hr-HPV), leads to significant morbidity and mortality in individuals with a cervix. Trans masculine (TM) individuals were born with female reproductive organs and identify as male, man, transgender man, or another diverse gender identity different from their female assigned sex at birth. Routine preventive sexual health screening of TM patients is recommended, including screening for cervical cancer and other sexually transmitted infections (STIs); however, as many as one in three TM patients are not up-to-date per recommended U.S. GUIDELINES: Among cisgender (non-transgender) women, self-swab hr.-HPV DNA testing as a primary cervical cancer screening method and self-swab specimen collection for other STIs have high levels of acceptability. No study has yet been conducted to compare the performance and acceptability of self- and provider-collected swabs for hr.-HPV DNA testing and other STIs in TM patients. METHODS: This article describes the study protocol for a mixed-methods biobehavioral investigation enrolling 150 sexually active TM to (1) assess the clinical performance and acceptability of a vaginal self-swab for hr.-HPV DNA testing compared to provider cervical swab and cervical cytology, and (2) gather acceptability data on self-collected specimens for other STIs. Study participation entails a one-time clinical visit at Fenway Health in Boston, MA comprised of informed consent, quantitative assessment, venipuncture for syphilis testing and HIV (Rapid OraQuick) testing, randomization, collection of biological specimens/biomarkers, participant and provider satisfaction survey, and qualitative exit interview. Participants are compensated $100. The primary study outcomes are concordance (kappa statistic) and performance (sensitivity and specificity) of self-collected vaginal HPV DNA specimens vs provider-collected cervical HPV swabs as a gold standard. DISCUSSION: This study addresses critical gaps in current clinical knowledge of sexual health in TM patients, including comparing alternative strategies for screening and diagnosis of cervical cancer, hr.-HPV, and other STIs. Findings have implications for improving the delivery of sexual health screening to this often overlooked and underserved patient population. Less-invasive patient-centered strategies may also generalize to other at-risk cisgender female populations that face barriers to timely and needed STI and cervical cancer screening. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02401867.

All-Arthroscopic Suprapectoral Versus Open Subpectoral Tenodesis of the Long Head of the Biceps Brachii Without the Use of Interference Screws.

PURPOSE: To compare patient-reported outcomes and healing rates after open subpectoral and all-arthroscopic suprapectoral biceps tenodesis without the use of interference screws in patients with more than 2 years of follow-up. METHODS: Patients with at least 2 years of follow-up who underwent open subpectoral biceps tenodesis or all-arthroscopic suprapectoral biceps tenodesis without concomitant rotator cuff repair, labral repair, or Mumford procedure were considered for enrollment in the study. They were evaluated for visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and satisfaction with function and biceps contour. Ultrasonography was performed to evaluate the integrity of the tenodesis site and measure biceps muscle diameters on each arm. RESULTS: Forty-nine patients were eligible for our study and of these, 38 were able to participate. Twenty-three patients had open subpectoral biceps tenodesis and 15 received all-arthroscopic suprapectoral biceps tenodesis. The average follow-up time was 4.5 years (range 2-9.1 years). There were no significant differences in anterior shoulder pain VAS, ASES scores, or satisfaction rates. The average anterior shoulder VAS was 0.7 ± 1.1 for the open group and 0.9 ± 1.8 for the arthroscopic group (P = .74). The mean ASES score for the open group was 90.6 ± 11.4 and 91.4 ± 13.9 for the arthroscopic group (P = .69). All patients had an intact tenodesis site on ultrasonography and the ratio of operative to nonoperative biceps diameters was 100.2% ± 12.8% for the open group and 99.1% ± 10.8% for the arthroscopic group (P = .66). There were no infections and no brachial plexus injuries in either group. CONCLUSIONS: Open subpectoral biceps tenodesis and all-arthroscopic suprapectoral biceps tenodesis are both successful surgeries with consistently positive outcomes. Tenodesis can be performed in either location without interference screw fixation with durable, reliable results. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

The Proposed ICD-11 Gender Incongruence of Childhood Diagnosis: A World Professional Association for Transgender Health Membership Survey.

ICD-11 (the eleventh edition of the World Health Organization International Statistical Classification of Diseases and Related Health Problems) is due for approval in 2018. For transgender health care, the most important proposals for ICD-11 are as follows: (1) the five ICD-10 diagnoses (most notably Transsexualism and Gender Identity Disorder of Childhood) currently in Chapter 5 (Mental and Behavioural Disorders) will be replaced by two Gender Incongruence diagnoses, one of Adolescence and Adulthood and the other of Childhood (GIC), and (2) these two diagnoses will be located in a new chapter provisionally named Conditions Related to Sexual Health. Debate on the GIC proposal has focused on whether there should be a diagnosis for young children exploring their identity and has drawn on a number of arguments for and against the proposal. The World Professional Association for Transgender Health conducted a survey to examine members' views concerning the GIC proposal, as well as an alternative framework employing non-pathologizing Z Codes. The survey was completed by 241 (32.6 %) out of 740 members. Findings indicated an even split among members regarding the GIC proposal (51.0 % [n = 123] opposing and 47.7 % [n = 115] supporting the proposal). However, non-US members were overall opposed to the proposal (63.9 % [n = 46] opposing, 36.1 % [n = 26] supporting). Across the sample as a whole, and among those expressing a view about Z Codes, there was substantial support for their use in healthcare provision for children with gender issues (35.7 % [n = 86] of the sample supporting vs. 8.3 % [n = 20] rejecting).

Gender-Affirmative Surgery: A Collaborative Approach between the Surgeon and Mental Health Professional.

SUMMARY: Gender incongruence describes a condition in which an individual's gender identity does not align with their sex assigned at birth based on anatomic characteristics. Individuals with gender incongruence may request surgical interventions, and gender-affirmation surgery plays an important role for these individuals. The basis of care derives from principles elucidated in the Standards of Care, international guidelines that help inform clinical decision-making. Historically, mental health care professionals (MHCPs) and surgeons have worked collaboratively to select "appropriate" surgical candidates. However, as understanding of gender identity evolves, so does the relationship between the MHCP and the surgeon. The role of the MHCP has shifted from a requirement to verify an individual's identity to that of supporting and participating in a shared decision-making process between the individual and the health care team. This article discusses the evolution of the relationship between the MHCP and the surgeon and provides insight into the history of this relationship.

Unbending the Light: Changing Laws and Policies to Make Transgender Health Visible; Reflections of an Advocate.

This essay describes an instrumental advocate's development, engagement, and accomplishments in transgender health at the intersection of law and medicine. Reflecting on the evolution of insurance policy reforms in conjunction with the need to increase the availability of clinicians who can understand and respectfully treat transgender patients, the author demonstrates how visibility, tenacity, and ingenuity can create far-reaching change.

Utilization of health care among female-to-male transgender individuals in the United States.

Female-To-Male (FTM) transgender individuals were approached at a conference and several peer support groups in the United States and asked to complete a short questionnaire regarding their medical care. Results from the 122 completed questionnaires indicated that a high number of respondents were taking testosterone (n = 106) and had some gender-confirming surgery (n = 68). Seventy percent of respondents rated their overall quality of health care "good" or "excellent." A surprising finding was the low number (7%) reporting diagnoses of polycystic ovarian syndrome--the incidence of which has been reported elsewhere as high as 50%. Also notable were the high levels of employment, insurance, knowledge of standards of care, and access to providers, contrasting with reports from studies involving predominantly Male-To-Female (MTF) individuals. Finally, FTM's usage of transition-related medical resources can vary, but many within this study are foregoing genital surgery.

Legal issues for transgender people: a review of persistent threats.

Background The legal status of transgender (trans) people is in constant flux. Over the past 70 years, gradually increasing transgender visibility, national and global advocacy, and, more recently, widespread Internet access, communication, and broadening support from allies, have all contributed to successful campaigns that have improved transgender lives and legitimised transgender. Still, traumatic interactions with the legal system or policing agencies remain plentiful. This is a very general overview of the most common legal issues confronting trans people. It aims to inform medical and mental health providers about the trepidation with which their patients and clients must engage legal systems, and the scope of their concerns, which ultimately affect their health. This review relies upon reports generated by advocacy organisations based on population surveys in several countries, the projects undertaken by legal and human rights advocacy groups, the topics most frequently discussed in academic texts examining transgender legal issues, and draws upon the author's personal advocacy experience. The most complicated and persistent issues are identity recognition, family law and relationship issues, adverse discrimination and anti-transgender violence and its aftermath. Criminal law, almost universally, treats trans people according to the lowest common denominator, their genital status, which supposedly supports expediency and "safety". Global legal and human rights efforts remain desperately needed to lift transgender people from the margins of society and provide them with equal opportunities to lead healthy and fulfilling lives. Access to appropriate and meaningful health care is a crucial element necessary to affirm the humanity of any person.

Transsexual Surgery May Be Covered By Medicare.

On May 30, 2014, after accepting evidence that transsexual surgical treatment (i.e., the surgical procedures used for treatment of gender dysphoria) is effective and medically accepted in appropriate cases, the U.S. Department of Health and Human Services (HHS) lifted a longstanding ban on use of Medicare funds for transsexual surgeries. Service provision, though, will be subject to Local Coverage Determination. This is a major step in a decades-long struggle to provide medically necessary care for gender-variant people whose gender dysphoria would be best treated with gender affirming surgical procedures. The term "transsexual surgery" refers to those procedures, and is used in this article for consistency with the language of the HHS decision.

Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group.

Transgender patients have particular needs with respect to demographic information and health records; specifically, transgender patients may have a chosen name and gender identity that differs from their current legally designated name and sex. Additionally, sex-specific health information, for example, a man with a cervix or a woman with a prostate, requires special attention in electronic health record (EHR) systems. The World Professional Association for Transgender Health (WPATH) is an international multidisciplinary professional association that publishes recognized standards for the care of transgender and gender variant persons. In September 2011, the WPATH Executive Committee convened an Electronic Medical Records Working Group comprised of both expert clinicians and medical information technology specialists, to make recommendations for developers, vendors, and users of EHR systems with respect to transgender patients. These recommendations and supporting rationale are presented here.

Regulation of CXCL-8 (interleukin-8) induction by double-stranded RNA signaling pathways during hepatitis C virus infection.

Hepatitis C virus (HCV) infection induces the alpha-chemokine interleukin-8 (CXCL-8), which is regulated at the levels of transcription and mRNA stability. In the current study, CXCL-8 regulation by double-stranded (ds)RNA pathways was analyzed in the context of HCV infection. A constitutively active mutant of the retinoic acid-inducible gene I (RIG-I), RIG-N, activated CXCL-8 transcription. Promoter mutagenesis experiments indicated that NF-kappaB and interferon (IFN)-stimulated response element (ISRE) binding sites were required for the RIG-N induction of CXCL-8 transcription. IFN-beta promoter stimulator 1 (IPS-1) expression also activated CXCL-8 transcription, and mutations of the ISRE and NF-kappaB binding sites reduced and abrogated CXCL-8 transcription, respectively. In the presence of wild-type RIG-I, transfection of JFH-1 RNA or JFH-1 virus infection of Huh7.5.1 cells activated the CXCL-8 promoter. Expression of IFN regulatory factor 3 (IRF-3) stimulated transcription from both full-length and ISRE-driven CXCL-8 promoters. Chromatin immunoprecipitation assays demonstrated that IRF-3 and NF-kappaB bound directly to the CXCL-8 promoter in response to virus infection and dsRNA transfection. RIG-N stabilized CXCL-8 mRNA via the AU-rich element in the 3' untranslated region of CXCL-8 mRNA, leading to an increase in its half-life following tumor necrosis factor alpha induction. The data indicate that HCV infection triggers dsRNA signaling pathways that induce CXCL-8 via transcriptional activation and mRNA stabilization and define a regulatory link between innate antiviral and inflammatory cellular responses to virus infection.

Stability of CXCL-8 and related AU-rich mRNAs in the context of hepatitis C virus replication in vitro.

BACKGROUND: Previous studies have shown that levels of CXCL-8 are elevated in patients with chronic hepatitis C virus (HCV) infection and are highest in nonresponders to interferon (IFN) therapy and that CXCL-8 inhibits IFN antiviral action. CXCL-8 expression involves AU-rich elements (AREs) in 3' untranslated regions that regulate mRNA stability. CXCL-8 mRNA stability was, therefore, investigated in the context of HCV replication in 4 replicon cell lines, Huh7 and Huh7.5 cells, and primary human fetal hepatocytes. METHODS: The half-life of CXCL-8 mRNA was measured by use of real-time reverse-transcription polymerase chain reaction following tumor necrosis factor (TNF)- alpha induction in the presence and absence of inhibitors of transcription and translation. Cellular mRNAs containing AREs were assessed by custom microarray analyses. RESULTS: The half-life of CXCL-8 mRNA increased in 3 of 4 HCV replicon cell lines, particularly after treatment with TNF- alpha , a potent inducer of CXCL-8. CXCL-8 mRNA was superinduced by TNF- alpha in the presence of the protein-synthesis inhibitor cycloheximide. Analysis of >1500 ARE-containing cellular mRNAs, by use of microarrays, revealed that CXCL-8 and other newly identified ARE genes were induced by TNF- alpha in Huh7 cells and were coordinately regulated. CONCLUSION: The data suggest that increased CXCL-8 gene expression in the context of HCV replication involves posttranscriptional events.