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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Heart-Kidney Transplantation in a Transgender Woman.

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

Association of Cumulative Viral Load With the Incidence of Hypertension and Diabetes in People With HIV.

BACKGROUND: HIV induces several metabolic derangements that contribute to cardiovascular disease, but it is unclear if HIV increases diabetes or hypertension risk. Refining longitudinal relationships between HIV-specific factors and cardiovascular disease risk factors across different care settings may help inform cardiovascular disease prevention among people with HIV (PWH). METHODS: We tested the hypothesis that long-term higher cumulative viral load (viremia-copy-year) is associated with higher risk of diabetes and hypertension by analyzing electronic records of PWH from 2 distinct health systems in Chicago (Northwestern Medicine and Howard Brown Health Care) receiving care in 2004 to 2019. We used joint longitudinal-survival models to assess multivariable-adjusted associations. Subgroup analyses per site were also conducted. RESULTS: We observed 230 (3.0%) incident diabetes cases in 7628 PWH without baseline diabetes and 496 (6.7%) hypertension cases in 7450 PWH without baseline hypertension. Pooled analysis showed a direct association of viremia-copy-year with incident hypertension (hazards ratio, 1.20 [95% CI, 1.14-1.26]) but not with diabetes (hazards ratio, 1.03 [95% CI, 0.96-1.10]). However, site-specific differences existed whereby the Northwestern-only analysis demonstrated a significant association of viremia-copy-year with hypertension (hazards ratio, 1.29 [95% CI, 1.08-1.32]). Additionally, higher social deprivation index (both sites) and diagnosis of mental health disorder (Howard Brown Health only) was associated with higher diabetes and hypertension risk. CONCLUSIONS: Cumulative viral load may be associated with incident hypertension among PWH. Associations of HIV control with cardiovascular disease risk factors among PWH may differ by health care system context.

At-School Victimization and Alcohol Use Among Minoritized U.S. Youth, 2009-2017.

INTRODUCTION: Sexual minority and/or racial/ethnic minority youth may use alcohol at school as a form of minority stress-based coping. Polyvictimization is particularly prevalent among sexual minority and/or racial/ethnic minority youth and may be a useful proxy measure for minority stressors. METHODS: Data from local administrations of the Youth Risk Behavior Survey were pooled across 42 jurisdiction years (biennially, 2009-2017) and analyzed in 2022, resulting in a sample of 118,052 U.S. youth. The prevalence of alcohol use at school was examined by sexual identity, race/ethnicity, and their intersections, stratified by sex. Multivariable logistic regression models were built to examine the disparities in alcohol use at school and the impact of school-based polyvictimization. RESULTS: At the intersections of race/ethnicity and sexual identity, 25 of 30 sexual minority and/or racial/ethnic minority subpopulations had greater odds of alcohol use at school than their White heterosexual same-sex peers. Hispanic/Latinx not-sure males (AOR=9.15; 95% CI=5.97, 14.03) and Hispanic/Latinx lesbian females (AOR=11.24; 95% CI=6.40, 19.77) were most likely to report alcohol use at school. After adjusting for polyvictimization, the magnitude of association was attenuated for most sexual minority and/or racial/ethnic minority subpopulations; however, all but 2 significant associations remained. CONCLUSIONS: Sexual minority and/or racial/ethnic minority youth were more likely than White heterosexual peers to use alcohol at school, with the greatest odds among multiply marginalized and polyvictimized youth. Interventions should consider addressing more than school-based victimization alone because disparities persisted, although at a lower magnitude, after accounting for polyvictimization. Future longitudinal studies are warranted to further explore the associations between multiply marginalized identities, school-based polyvictimization, and alcohol use at school.

Sex-Based Differences in Heart Failure: JACC Focus Seminar 7/7.

Sex-based differences exist in risk, symptoms, and management of heart failure (HF). Women have a higher incidence of HF with preserved ejection fraction compared with men. This may be partially caused by the cardiovascular effects of estrogen and sex-specific risk factors (eg, adverse pregnancy outcomes, premature menopause). Key gaps exist in understanding of gender-based differences in HF, which is a distinctly different concept than sex-based differences. Although evidence-based therapies for HF are available, only limited data address sex-specific efficacy, and no data address gender-based efficacy. Persistent shortcomings in representation of women and gender minority participants in clinical trials limit an actionable database. A comprehensive roadmap to close the sex/gender-based gap in HF includes the following: 1) sex/gender-specific personalized prevention; 2) sex/gender-neutral implementation of evidence-based therapies; and 3) sex/gender-appropriate policy-level initiatives to spur research assessing sex/gender-specific causes of HF; enhance sex/gender-specific subgroup reporting; and promote community engagement of these important patient cohorts.