Concepts and Approaches in the Management of Transgender and Gender-Diverse Patients.

The terms transgender and gender diverse (TGD) describe persons whose gender is different from the sex assigned to them at birth. While TGD persons have experienced a rise in cultural and social visibility in recent decades, they continue to experience significant health inequities, including adverse health outcomes and multiple barriers to accessing medical care. Transgender and gender-diverse persons are at a higher risk for pain conditions than their cisgender counterparts, but research on chronic pain management for TGD persons is lacking. Clinicians from all disciplines must be informed of best practices for managing chronic pain in the TGD population. This includes all aspects of care including history, physical examination, diagnosis, treatment, and perioperative management. Many TGD persons report delaying or avoiding care because of negative interactions with medical practitioners who do not have sufficient training in navigating the specific health care needs of TGD patients. Furthermore, TGD persons who do seek care are often forced to educate their practitioners on their specific health care needs. This paper provides an overview of existing knowledge and recommendations for physicians to provide culturally and medically appropriate care for TGD persons.

Breaking barriers: How transwomen meet their healthcare needs.

BACKGROUND:  Transgender women - individuals assigned male at birth but who identify as female - are disproportionately affected by, among others, human immunodeficiency virus (HIV), other sexually transmitted diseases (STIs) and mental health issues. Studies show that transgender women often encounter discrimination and stigma when seeking healthcare from health facilities. AIM:  This study assessed the healthcare needs of transgender women, their experiences of the mainstream healthcare system and alternative strategies for navigating the healthcare system. SETTING:  The study was carried out in the City of Ekurhuleni Metropolitan Council in South Africa's Gauteng province. METHODS:  A case study design was followed. Participants were purposively selected and included 10 transgender women aged 26-50. Individual semi-structured interviews were conducted over 2 months. RESULTS:  Participants expressed a need for hormone replacement therapy, HIV treatment and prevention and treatment for STIs. Experiences of participants within the healthcare system were predominantly negative, with instances of discrimination, stigma and privacy violations being commonplace. Alternative strategies to meet their healthcare needs included the use of self-medication, consulting traditional healers and utilising non-governmental organisations. CONCLUSION:  There is an urgent need for equitable and inclusive health management of transgender women in South Africa.Contribution: This study provided a first look in a South African context into how and to what extent transwomen employ alternative healthcare strategies such as self-medication and utilising non-governmental organisations when faced with mainstream healthcare access barriers. The use of traditional doctors was identified as a novel, alternative strategy used by transwomen to access healthcare and treatment.

Human Immunodeficiency Virus Preexposure Prophylaxis Awareness and Acceptability among Men Who Have Sex with Men and Transgender Persons in India: Systematic Review and Meta-analysis.

With increasing importance being given to preexposure prophylaxis (PrEP) for human immunodeficiency virus prevention among men who have sex with men (MSM) and transgender persons (TG), we undertook a systematic review and meta-analysis of PrEP awareness and acceptability among these key populations in India, and their sociodemographic and behavioral determinants. The systematic review was registered with PROSPERO (CRD42023390508). Studies were included if they provided quantitative data on PrEP awareness or acceptability among MSM or TG in India. MEDLINE, Scopus, Web of Science, and Embase were searched from inception to February 29, 2024, using keywords and database-specific terms. Relevant websites were also searched. Critical appraisal was done using the Joanna Briggs Institute Checklist for Prevalence Studies. Random-effects meta-analysis was done for common outcomes reported by the studies. Reporting was as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 statement. Ten studies providing cross-sectional data, mostly from South West India, were included for qualitative synthesis. All were conducted in settings where PrEP was not available. The pooled prevalence among MSM and TG was 18.7% (95% confidence interval [CI] 8.7%, 28.7%) for awareness and 79.8% (95% CI 57.4%, 100.0%) for willingness to use daily oral PrEP. This review highlights the felt need for PrEP among MSM and TG in India. Further research is needed to understand user attitudes in different parts of the country.

Gender-Affirming Hormone Treatment and Metabolic Syndrome Among Transgender Veterans.

Importance: Gender-affirming hormone treatment (GAHT) is a common therapy for transgender individuals to reduce gender dysphoria and improve quality of life. Clarifying the long-term effects of GAHT remains a priority in transgender health research. Objective: To explore whether sex hormones (estradiol and testosterone) are associated with the development of metabolic syndrome in transgender veterans compared with cisgender veterans. Design, Setting, and Participants: This retrospective, longitudinal cohort study used International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes for gender dysphoria from the Veterans Health Administration national database to identify transfeminine and transmasculine veterans receiving documented feminizing (estradiol) or masculinizing (testosterone) treatment from January 1, 2006, to December 31, 2019, and for whom the GAHT initiation date and metabolic syndrome component-related data were available. Transgender veterans were matched to cisgender referents. Exposure: Gender-affirming hormone treatment. Main Outcomes and Measures: Metabolic syndrome z-scores were calculated based on body mass index, systolic blood pressure, and levels of high-density lipoprotein cholesterol, triglycerides, and blood glucose. Changes in mean z-scores were compared among the transgender and cisgender groups before and after the index date (corresponding to GAHT initiation) using a repeated-measures analysis of variance model. Results: The cohort included 1290 participants: 645 transgender (494 [38.3%] transfeminine, 151 [11.7%] transmasculine) and 645 cisgender (280 [21.7%] female, 365 [28.3%] male). Mean (SD) age at the index date was 41.3 (13.2) years. Metabolic syndrome z-scores changed significantly over time and differed significantly across groups. Overall, transmasculine veterans had the greatest percentage increase in mean (SEM) z-scores after vs before the index date (298.0% [57.0%]; P < .001), followed by cisgender females (108.3% [27.5%]; P < .001), cisgender males (49.3% [27.5%]; P = .02), and transfeminine persons (3.0% [10.7%]; P = .77). Conclusions and Relevance: In this cohort study, in both cisgender and transgender veterans, estradiol was associated with reduced metabolic syndrome risk, whereas testosterone was associated with increased risk. However, transmasculine individuals had the greatest risk and transfeminine individuals had the lowest risk of metabolic syndrome associated with these hormones. This is relevant for the management of metabolic syndrome risk factors in cisgender and transgender individuals and to potentially predict the risk of atherosclerotic cardiovascular disease, type 2 diabetes, systolic hypertension, insulin resistance, and nonalcoholic fatty liver disease.

A formative evaluation to inform integration of psychiatric care with other gender-affirming care.

BACKGROUND: Transgender, non-binary, and/or gender expansive (TNG) individuals experience disproportionately high rates of mental illness and unique barriers to accessing psychiatric care. Integrating TNG-specific psychiatric care with other physical health services may improve engagement, but little published literature describes patient and clinician perspectives on such models of care. Here we present a formative evaluation aiming to inform future projects integrating psychiatric care with physical health care for TNG individuals. METHODS: In this qualitative pre-implementation study, semi-structured interview guides were developed informed by the Consolidated Framework for Implementation Research to ensure uniform inclusion and sequencing of topics and allow for valid comparison across interviews. We elicited TNG patient (n = 11) and gender-affirming care clinician (n = 10) needs and preferences regarding integrating psychiatric care with other gender-affirming clinical services. We conducted a rapid analysis procedure, yielding a descriptive analysis for each participant group, identifying challenges of and opportunities in offering integrated gender-affirming psychiatric care. RESULTS: Participants unanimously preferred integrating psychiatry within primary care instead of siloed service models. All participants preferred that patients have access to direct psychiatry appointments (rather than psychiatrist consultation with care team only) and all gender-affirming care clinicians wanted increased access to psychiatric consultations. The need for flexible, tailored care was emphasized. Facilitators identified included taking insurance, telehealth, clinician TNG-competence, and protecting time for clinicians to collaborate and obtain consultation. CONCLUSIONS: This health equity pre-implementation project engaged TNG patients and gender-affirming care clinicians to inform future research exploring integration of mental health care with primary care for the TNG community and suggests utility of such a model of care.

Development of a lesbian, gay, bisexual, and transgender cultural competence scale for nurses in South Korea: a methodological study.

PURPOSE: This study was conducted to develop a cultural competence scale for nurses regarding the lesbian, gay, bisexual, and transgender (LGBT) community and to test its validity and reliability. METHODS: The study adhered to the 8-step process outlined by DeVellis, with an initial set of 25 items derived through a literature review and individual interviews. Following an expert validity assessment, 24 items were validated. Subsequently, a preliminary survey was conducted among 23 nurses with experience caring for LGBT patients. Data were then collected from a final sample of 322 nurses using the 24 items. Item analysis, item-total score correlation, examination of construct and convergent validity, and reliability testing were performed. RESULTS: The item-level content validity index exceeded .80, and the explanatory power of the construct validity was 63.63%. The factor loadings varied between 0.57 and 0.80. The scale comprised five factors: cultural skills, with seven items; cultural awareness, with five items; cultural encounters, with three items; cultural pursuit, with three items; and cultural knowledge, with three items; totaling 21 items. Convergent validity demonstrated a high correlation, affirming the scale's validity. Internal consistency analysis yielded an overall reliability coefficient of 0.97, signifying very high reliability. Each item is scored from 1 to 6 (total score range, 21-126), with higher scores reflecting greater cultural competence in LGBT care. CONCLUSION: This scale facilitates the measurement of LGBT cultural competence among nurses. Therefore, its use should provide foundational data to support LGBT-focused nursing education programs.

Advancing Programme Science approaches to understand gaps in HIV prevention programme coverage for key populations in 12 Nigerian states: findings from the 2020 Integrated Biological and Behavioural Surveillance Survey.

INTRODUCTION: Effective HIV prevention programme coverage is necessary to achieve Nigeria's goal of ending the epidemic by 2030. Recent evidence highlights gaps in service coverage and utilization across the country. The Effective Programme Coverage framework is a Programme Science tool to optimize a programme's population-level impact by examining gaps in programme coverage using data generated through programme-embedded research and learning. We apply the framework using Integrated Biological and Behavioural Surveillance Survey (IBBSS) data from Nigeria to examine coverage of four prevention interventions-condoms, HIV testing, and needle and syringe programmes (NSP)-among four key population groups-female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID) and transgender people. METHODS: Data from Nigeria's 2020 IBBSS, implemented in 12 states, were analysed to examine HIV prevention programme coverage among key populations. For each key population group and prevention intervention of interest, weighted IBBSS data were used to retrospectively generate coverage cascades that identify and quantify coverage gaps. Required coverage targets were informed by targets articulated in Nigeria's National HIV/AIDS Strategic Framework or, in their absence, by guidelines from policy normative bodies. Availability-, outreach- and utilization coverage proxy indicators were defined using variables from IBBSS data collection tools. Sankey diagrams are presented to visualize pathways followed by participants between coverage cascade steps. RESULTS: Required coverage targets were missed for HIV testing and NSP among all key population groups. Condom availability coverage surpassed required coverage targets among FSW and MSM, while utilization coverage only among FSW exceeded the 90% required coverage target. Outreach coverage was low for all key population groups, falling below all required coverage targets. CONCLUSIONS: Our findings identify critical gaps in HIV prevention programme coverage for key populations in Nigeria and demonstrate non-linear movement across coverage cascades, signalling the need for innovative solutions to optimize coverage of prevention services. Programme-embedded research is required to better understand how key population groups in Nigeria access and use different HIV prevention services so that programmes, policies and resource allocation decisions can be optimized to achieve effective programme coverage and population-level impact.

Rationale and design of the Self-TI Study protocol: a cross-sectional human papillomavirus self-testing pilot study among transgender adults in England.

INTRODUCTION: Persistent infection with high-risk human papillomavirus (HPV) is the causal agent of several cancers including cervical, anal and oropharyngeal cancer. Transgender men and transmasculine non-binary (TMNB) people with a cervix are much less likely to undergo cervical cancer screening than cisgender women. Transgender women and transfeminine non-binary (TWNB) people assigned male at birth may be at increased risk of HPV. Both TMNB and TWNB people face many barriers to HPV testing including medical mistrust due to stigma and discrimination. METHODS AND ANALYSIS: The Self-TI Study (Self-TI) is a pilot study designed to measure acceptability and feasibility of HPV self-testing among transgender and non-binary people in England. TMNB people aged 25-65 years, with at least 1 year of testosterone, and TWNB people, aged 18 years and over, are eligible to participate. Participants self-collect up to four samples: an oral rinse, a first void urine sample, a vaginal swab (if applicable) and an anal swab. TMNB participants are asked to have an additional clinician-collected cervical swab taken following their routine Cervical Screening Programme sample. TWNB people are asked to take a self-collection kit to perform additional self-collection at home and mail the samples back to the clinic. Acceptability is assessed by a self-administered online survey and feasibility is measured as the proportion of samples returned in the clinic and from home. ETHICS AND DISSEMINATION: Self-TI received ethical approval from the Research Ethics Committee of Wales 4 and ethical review panel within the Division of Cancer Epidemiology and Genetics at the US National Cancer Institute. Self-TI was coproduced by members of the transgender and non-binary community, who served as authors, collaborators and members of the patient and public involvement (PPI) group. Results of this study will be shared with the community prior to being published in peer-reviewed journals and the PPI group will help to design the results dissemination strategy. The evidence generated from this pilot study could be used to inform a larger, international study of HPV self-testing in the transgender and non-binary community. TRIAL REGISTRATION NUMBER: NCT05883111.

HIV and gender identity expression among transfeminine people in the Western Cape, South Africa - a thematic analysis of data from the HPTN 071 (PopART) trial.

INTRODUCTION: Transfeminine people in South Africa have a high HIV risk due to structural, behavioural, and psychosocial factors. Transfeminine people and feminine identifying men who have sex with men (MSM) are often conflated or grouped with transgender or MSM categories in HIV service programming, although they don't necessarily identify as either. We aimed to investigate gender expression among feminine identifying people who were assigned male at birth. We examined how local conceptualizations of sexuality and gender intersect with the key population label of 'transgender' imported into local HIV programming. METHODS: A qualitative cohort nested within the HPTN 071 (PopART) trial included longitudinal, in-depth interviews with eight transfeminine people (four who disclosed as living with HIV). Data were collected approximately every six weeks between January 2016 and October 2017. We used a combination of thematic analysis and case study descriptions to explore gender identification among participants. RESULTS: Of the eight participants, only one accepted 'transgender' as a label, and even she used varying terms at different times to describe her identity. For participants, a feminine identity included dressing in normatively feminine clothes; using feminine terms, pronouns and names; and adopting stereotypically feminine mannerisms. Participants would switch between typically feminine and masculine norms in response to contextual cues and audience. For example, some participants accepted identification as masculine gay men amongst their family members. Among peers, they expressed their identity through typically more effeminate gender characteristics, for example self-identifying as "femgay". With partners they often also took on a feminine identity role, for example identifying as women in sexual and romantic relationships (meaning they viewed and expressed themselves as the feminine partner in the relationship). CONCLUSIONS: Our findings are amongst the first exploratory and descriptive data of transfeminine people in South Africa. We show how transfeminine people navigate fluid gender identities that could pose a challenge for accessing and utilizing HIV services that are currently set up for transgender individuals or MSM. More work needs to be done to understand and respond to the diverse and shifting ways people experience their gender identities in this high HIV burden context.

Observational study of effects of HIV acquisition and antiretroviral treatment on biomarkers of systemic immune activation.

To assess whether biomarkers of systemic inflammation are associated with HIV acquisition or with the timing of ART initiation ("immediate", at diagnosis, versus "deferred", at 24 weeks post-diagnosis) in men-who-have-sex-with-men (MSM) and transgender women, we conducted a retrospective study comparing inflammatory biomarkers in participants' specimens collected before infection and after ≥2 years of effective ART. We measured biomarkers in four longitudinally collected plasma, including two specimens collected from each participant before and two after HIV acquisition and confirmed ART-suppression. Biomarkers were quantified by enzyme-linked immuno-assay or Meso Scale Discovery. When evaluating systematic variation in these markers over time, we found that multiple biomarkers consistently varied across participants' two pre-infection or two post-ART-suppression specimens. Additionally, we compared changes in biomarkers after vs before HIV acquisition. Across 47 participants, the levels of C-reactive protein (CRP), monocyte chemo-attractant protein-1, tumor necrosis factor-α and interferon gamma-induced protein-10 significantly increased while leptin and lipopolysaccharide binding protein (LBP) significantly decreased following HIV infection. Randomization to deferred-ART initiation was associated with greater increases in CRP and no decrease in LBP. Acquisition of HIV appeared to induce systemic inflammation, with elevation of biomarkers previously associated with infections and cardiovascular disease. Initiation of ART during the early weeks of infection tempered the increase in pro-inflammatory biomarkers compared to delaying ART for ~24 weeks after HIV diagnosis. These findings provide insight into potential mediators by which immediate-ART initiation improves health outcomes, perhaps because immediate-ART limits the size of the HIV reservoir or limits immune dysregulation that in turn trigger systemic inflammation.

Capturing the HIV-related social exclusion practices experienced by key populations through photovoice: an interpretative phenomenological study.

BACKGROUND: Key populations are defined as groups that are susceptible to HIV, including Men Sex with Men (MSM), Transgender (TG), Persons who Inject Drug (PID), and Female Sex Worker (FSW). These key populations groups are among the fastest-growing populations in Indonesia. These vulnerable groups are ostracized by society and health services, which makes it difficult to get treatment. This project was carried out to investigate the different experiences and perspectives of these key populations in facing and addressing social and spiritual exclusion. METHODS: A qualitative phenomenological study using photovoice was carried out from July to December 2022. Key populations comprising MSM, TG, PID, and FSW were recruited from community-based peer groups in West Bandung Regency using snowball sampling. This was followed by the Photovoice stages, from workshops to focus group discussions and interviews with audio recordings. Furthermore, thematic data analysis was carried out by interpretative participant narratives and photographs supported by Atlas.ti software. RESULT: Eighteen participants comprising four MSM, five TG, four PIDs, and five FSWs participated in this research. Among these eighteen participants, six were HIV-negative, including 3 PIDs and 3 FSWs, while the remaining were positive. The analysis of the collected data identified four main themes: 1) limited access like unequal treatment, disadvantage, and harassment, 2) social and spiritual impact, 3) coping mechanisms, and 4) self-reflection through photovoice. These results showed that social exclusion occurred in an environment where community values, beliefs, and norms dehumanised these key populations, and where removal of support and care was prominent. Despite these challenges, participant resilience was evidenced by using internal resources and peer support as coping mechanisms. The participants considered photovoice as a tool to foster self-confidence and self-awareness through a reflective process. CONCLUSIONS: The findings of this study highlight the emphasis on participants' openness in sharing their experiences, which can build empathy and promote a more inclusive community in HIV prevention efforts. This research findings can be used to inform HIV policy and practice and inclusion of these key populations in the community. We advocate making the photovoice efforts accessible to a wider audience through exhibitions and various media.

Barriers and facilitators for adherence to antiretroviral therapy, and strategies to address the barriers in key populations, Mumbai-A qualitative study.

BACKGROUND: Even though quantitative studies have described barriers to anti-retroviral therapy (ART), a more exploratory approach will provide in-depth information on these issues, and potential suggestions to address these issues at individual as well as structural level. We designed this qualitative study to examine the barriers and facilitators for antiretroviral therapy adherence in key population (KP) in Mumbai, India. We also wanted to understand the strategies adopted by these groups and get suggestions to improve adherence to ART. METHODS: This is a qualitative analysis of seven focus group discussions (FGDs) conducted with four KP subgroups in Mumbai. We conducted two FGDs each with female sex workers (FSW), men who have sex with men (MSM), male-to-female transgendered people/Hijras (TGH) each, and one FGD with people who inject drugs (IDU). We transcribed the audio-recorded electronic records of these FGDs. We also added the notes of the observers on the group dynamics to the transcribed data. We used the Framework Approach to analyse these data. RESULTS: Some experiences-such as side effects to ART medicines-were common across groups. However, incarceration as a reason for stopping ART was reported by FSWs but not by other KPs. Friends and family (including Guru) are important support systems for HIV infected individuals and adherence to ART. Stigma and discrimination by community members and general community prevent regular access of ART centres and other health care facilities. Additional factors which led to missed doses were mental health issues, alcohol use, and misplacing the ART tablets during police raids or during robbery attempts at the cruising sites. Since a common source of discrimination among peers and the community was the presence of 'Green book' (or their treatment book); the key population wanted the AIDS program to change it to digital cards so that labelling one as 'HIV positive' for being seen with the book can be avoided. CONCLUSIONS: The qualitative study helped us explore the barriers to ART among key population and the community provided specific suggestions to address them. In addition to Key Population centric enhanced adherence counselling, some administrative guidelines and procedures may need to be altered to improve adherence to ART in these populations.

Practice Makes Perfect: Objective Structured Clinical Examinations Across the UME-to-GME Continuum Improve Care of Transgender Simulated Patients.

Background Residents lack confidence in caring for transgender individuals. More exposure and practice throughout training is needed. Objective To explore whether and how prior exposure to transgender health skills during medical school impacted competency with these skills during residency. Methods In 2022, all 101 internal medicine residents at New York University Grossman School of Medicine participated in an objective structured clinical examination (OSCE) station as part of their annual formative assessment where they cared for a standardized patient (SP) who identified as transgender. Three SPs who were members of the transgender community were recruited through online and social media forums. Two resident groups (continuum vs noncontinuum) differed in their prior experiences with transgender OSCEs during medical school. We analyzed SPs' ratings of resident performance using checklist data and SP open-ended feedback to compare performance between groups and resident post-OSCE evaluations to understand residents' perceptions of the educational value of the case. Results Residents with prior experience with transgender SPs (continuum) were more frequently recommended by SPs (88% [21 of 24] vs 70% [54 of 77]) to a family member or friend, were all rated professional (100% [24 of 24] vs 94% [72 of 94]) and scored better in pain information-gathering (92% vs 65%, mean summary score) and gender-affirming care skills (67% vs 52%, mean summary score). Noncontinuum residents lacked experience, missed opportunities to ask about gender identity, and needed work on demonstrating comfort and using proper language. Most residents completing a post-OSCE evaluation (80%, 41 of 51) rated the case as "very valuable." Conclusions Spaced practice and feedback through early exposure to transgender OSCEs were valuable for skill acquisition, giving continuum residents a learning advantage compared to noncontinuum residents.

Community-Derived Recommendations for Improving Gender Affirmation of Black and Latine Transgender/Nonbinary Youth.

BACKGROUND: Gender affirmation is a process by which gender-diverse individuals are supported in their gender identity. Parents are critical in how gender-diverse youth, including Black and Latine transgender/nonbinary youth (BLTY), access various forms of gender affirmation-for example, social and medical transition. Culturally relevant supports are needed to bolster how BLTY and their parents navigate gender affirmation. PURPOSE: This study aimed to explore recommendations for aiding BLTY and parents in navigating the youth's gender journey. METHODS: Semi-structured interviews were conducted with parents of BLTY, BLTY, and BLT young adults (BLTYAs) recruited from clinics, community organizations, and social media. Interviews focused on gender affirmation and recommendations to promote BLTY's gender affirmation. Primary and secondary analysts coded transcripts using a priori and emergent codes. For this analysis, excerpts pertaining to recommended supports were analyzed to identify themes. RESULTS: Ten parents of BLTY, 10 BLTY (14-18 years), and 23 BLTYAs (18-30 years) participated. Participants provided recommendations at different socio-ecological levels. On the societal level, participants recommended improvements in media representation of racial and ethnic minority gender-diverse individuals. For organizations, participants recommended more clinicians who shared minoritized identities, clinicians knowledgeable in gender-affirming care, affordability of gender-affirming services, and school-based education regarding gender diversity. On interpersonal/individual levels, they suggested culturally informed peer support among BLTY and parents, including support groups, peer mentors, and camps with individuals who share their minoritized identities. CONCLUSIONS: Participants provided salient insights to supporting gender affirmation of BLTY, which can inform intervention development for BLTY and their families.

Black and Latine transgender/nonbinary youth (BLTY) have multiple minoritized identities as they are both racial/ethnic minorities and are gender diverse. These youth face unique challenges in being supported in their gender identity, and their parents face barriers to supporting their gender journey. Unfortunately, approaches to assisting BLTY and their parents in navigating this journey are poorly understood. We interviewed 10 BLTY, 10 related parents of the BLTY, and 23 Black and Latine transgender/nonbinary young adults (BLTYAs) recruited from clinics, community organizations, and social media. In this study, we explored their recommendations for better supporting and affirming BLTY. These recommendations targeted different areas of BLTY's lives. On a broader societal level, participants advocated media representation of gender-diverse individuals of color. For medical and mental health organizations, participants recommended more clinicians knowledgeable in supporting gender-diverse youth and more clinicians who share similar backgrounds with BLTY. For interpersonal and individual relationships, they recommended peer support groups and mentors for BLTY and parents of BLTY. These comprehensive recommendations from BLTY, parents, and BLTYAs can be implemented to better support BLTY in their gender identity through culturally based interventions in different domains.

Trans depathologisation and gender identity disorder in Japan: A critical discourse analysis of medical literature, 2010-2022.

Since the depathologisation movement in 2007 to challenge the pathologisation of trans identities in Western psychiatry, significant developments have occurred, including revisions to Standards of Care and diagnostic criteria such as ICD-11's gender incongruence and DSM-5's gender dysphoria, acknowledging gender diversity as an expected part of human development. This paper argues that Japanese medical models reflect global issues but also have unique aspects shaped by cultural and linguistic nuances. Using critical discourse analysis, this paper examines how depathologisation discourses are perceived in the Japanese medical community, focusing on the term seidouitsusei-syogai (gender identity disorder), presenting three ways in which seidouitsusei-syogai is used: psychiatric disorder, syogai/sikkan (impairment/disability/disorder), and diagnostic category. These uses are influenced by legal and social reforms, healthcare access and alignment with international classifications, while the medical profession's authority remains unexamined. Reflecting the structural challenges of diagnostic models in trans medicine, the interpretation of seidouitsusei-syogai differs from the English phrase 'gender identity disorder' due to the specific connotations of syogai in the Japanese context. By examining Japan's approach to depathologisation and medicalisation, this paper enriches the understanding of trans medicine and the impact of depathologisation discourse in Japan.

The lived experiences of transgender and gender-diverse people in accessing publicly funded penile-inversion vaginoplasty in Canada.

BACKGROUND: Canada's health care systems underserve people who are transgender and gender diverse (TGD), leading to unique disparities not experienced by other patient groups, such as in accessing gender-affirmation surgery. We sought to explore the experiences of TGD people seeking and accessing gender-affirmation surgery at a publicly funded hospital in Canada to identify opportunities to improve the current system. METHODS: We used hermeneutic phenomenology according to Max van Manen to conduct this qualitative study. Between January and August 2022, we conducted interviews with TGD people who had undergone penile-inversion vaginoplasty at Women's College Hospital, Toronto, Ontario, since June 2019. We conducted interviews via Microsoft Teams and transcribed them verbatim. We coded the transcripts using NVivo version 12. Using inductive analysis, we constructed themes, which we mapped onto van Manen's framework of lived body, lived time, lived space, and lived human relations. RESULTS: We interviewed 15 participants who had undergone penile-inversion vaginoplasty; they predominantly self-identified as transgender women (n = 13) and White (n = 14). Participants lived in rural (n = 4), suburban (n = 5), or urban (n = 6) locations. Their median age was 32 (range 27-67) years. We identified 11 themes that demonstrated the interconnected nature of TGD peoples' lived experiences over many years leading up to accessing gender-affirmation surgery. These themes emphasized the role of the body in experiencing the world and shaping identity, the lived experience of the body in shaping human connectedness, and participants' intersecting identities and emotional pain (lived body); participants' experiences of the passage of time and progression of events (lived time); environments inducing existential anxiety or fostering affirmation, the role of technology in shaping participants' understanding of the body, and the effect of liminal spaces (lived space); and finally, the role of communication and language, empathy and compassion, and participants' experiences of loss of trust and connection (lived human relations). INTERPRETATION: Our findings reveal TGD patients' lived experiences as they navigated a lengthy and often difficult journey to penile-inversion vaginoplasty. They suggest a need for improved access to gender-affirmation surgery by reducing wait times, increasing capacity, and improving care experiences.

Lived experiences of transgender and nonbinary people in the perioperative context: a qualitative study.

BACKGROUND: Transgender and nonbinary (TNB) people experience obstacles that create barriers to accessing health care, including stigmatization and health inequities. Our intention was to describe the lived experiences of TNB patients and identify potential gaps in the education of health care professionals. METHODS: We conducted a qualitative descriptive study influenced by phenomenology by interviewing with TNB adults who underwent surgery in Canada within the previous 5 years. We recruited participants using purposeful and snowball sampling via online social networking sites. Audio recordings were transcribed. Two authors coded the transcripts and derived the themes. RESULTS: We interviewed 21 participants, with a median interview duration of 49 minutes. Participants described positive and negative health care encounters that led to stress, confusion, and feelings of vulnerability. Major themes included having to justify their need for health care in the face of structural discrimination; fear and previous traumatic experiences; community as a source of support and information; and the impact of interactions with health care professionals. INTERPRETATION: Participants detailed barriers to accessing care, struggled to participate in shared decision-making, and desired trauma-informed care principles; they described strength in community and positive interactions with health care professionals, although barriers to accessing gender-affirming care often overshadowed other aspects of the perioperative experience. Additional research, increased education for health care professionals, and policy changes are necessary to improve access to competent care for TNB people.