Getting Precise about Gender and Sex Measurement: A Primer for Epidemiologists.

Accurately measuring gender and sex is crucial in public health and epidemiology. Iteratively reexamining how variables-including gender and sex-are conceptualized and operationalized is necessary to achieve impactful research. Reexamining gender and sex advances epidemiology toward its goals of health promotion and disease elimination. While we cannot reduce the complexities of sex and gender to simply an issue of measurement, striving to capture these concepts and experiences accurately must be an ongoing dialogue and practice-to the benefit of the field and population health. We assert that epidemiology must counteract misconceptions and accurately measure gender and sex in epidemiology. We aim to summarize existing critiques and guiding principles in measuring gender and sex that can be applied in practice.

The future of sex and gender in research.

Our understanding of sex and gender evolves. We asked scientists about their work and the future of sex and gender research. They discuss, among other things, interdisciplinary collaboration, moving beyond binary conceptualizations, accounting for intersecting factors, reproductive strategies, expanding research on sex-related differences, and sex's dynamic nature.

Inequities in Conversion Practice Exposure at the Intersection of Ethnoracial and Gender Identities.

Objectives. To examine inequities in conversion practice exposure across intersections of ethnoracial groups and gender identity in the United States. Methods. Data were obtained from The Population Research in Identity and Disparities for Equality Study of sexual and gender minority people from 2019 to 2021 (n = 9274). We considered 3 outcomes: lifetime exposure, age of first exposure, and period between first and last exposure among those exposed to conversion practices. We used log-binomial, Cox proportional hazards, and negative binomial models to examine inequities by ethnoracial groups and gender identity adjusting for confounders. We considered additive interaction. Results. Conversion practice prevalence was highest among minoritized ethnoracial transgender and nonbinary participants (TNB; 8.6%). Compared with White cisgender participants, minoritized ethnoracial TNB participants had twice the prevalence (prevalence ratio = 2.16; 95% confidence interval [CI] = 1.62, 2.86) and risk (hazard ratio = 2.04; 95% CI = 1.51, 2.69) of conversion practice exposure. Furthermore, there was evidence of a positive additive interaction for age of first exposure. Conclusions. Minoritized ethnoracial TNB participants were most likely to recall experiencing conversion practices. Public Health Implications. Policies banning conversion practices may reduce the disproportionate burden experienced by minoritized ethnoracial TNB participants. (Am J Public Health. 2024;114(4):424-434. https://doi.org/10.2105/AJPH.2024.307580).

Use of Artificial Intelligence in Improving Outcomes in Heart Disease: A Scientific Statement From the American Heart Association.

A major focus of academia, industry, and global governmental agencies is to develop and apply artificial intelligence and other advanced analytical tools to transform health care delivery. The American Heart Association supports the creation of tools and services that would further the science and practice of precision medicine by enabling more precise approaches to cardiovascular and stroke research, prevention, and care of individuals and populations. Nevertheless, several challenges exist, and few artificial intelligence tools have been shown to improve cardiovascular and stroke care sufficiently to be widely adopted. This scientific statement outlines the current state of the art on the use of artificial intelligence algorithms and data science in the diagnosis, classification, and treatment of cardiovascular disease. It also sets out to advance this mission, focusing on how digital tools and, in particular, artificial intelligence may provide clinical and mechanistic insights, address bias in clinical studies, and facilitate education and implementation science to improve cardiovascular and stroke outcomes. Last, a key objective of this scientific statement is to further the field by identifying best practices, gaps, and challenges for interested stakeholders.

Resilience is an Adverse Event: A Critical Discussion of Resilience Theory in Health Services Research and Public Health.

Resilience, the individual trait of being able to persist and cope with, often recurrent, negative experiences, has experienced an explosion in recent years as a topic of study. In this commentary, we critique this surge and problematize the co-occurring development of the "resilience as treatment" paradigm. We show that resilience is an expectation foisted primarily on historically and contemporarily oppressed and excluded populations often in response to systemic and structural forms of discrimination. We argue that this represents a fundamental mismatch of intervention and problem; offering an individual-level solution to a structural toxin. In doing so, we re-contextualize resilience as an adverse event, more analogous to scar tissue than a reliable treatment paradigm. Our essay concludes with offering alternatives to resilience that originate with the holistic trauma and liberation health frameworks. These paradigms are united in that, in contrast to resilience, they emphasize healing from structural violence, rather than adapting to it.

Computational phenotyping within electronic healthcare data to identify transgender people in the United States: A narrative review.

PURPOSE: With the expansion of research utilizing electronic healthcare data to identify transgender (TG) population health trends, the validity of computational phenotype (CP) algorithms to identify TG patients is not well understood. We aim to identify the current state of the literature that has utilized CPs to identify TG people within electronic healthcare data and their validity, potential gaps, and a synthesis of future recommendations based on past studies. METHODS: Authors searched the National Library of Medicine's PubMed, Scopus, and the American Psychological Association PsycInfo's databases to identify studies published in the United States that applied CPs to identify TG people within electronic healthcare data. RESULTS: Twelve studies were able to validate or enhance the positive predictive value (PPV) of their CP through manual chart reviews (n = 5), hierarchy of code mechanisms (n = 4), key text-strings (n = 2), or self-surveys (n = 1). CPs with the highest PPV to identify TG patients within their study population contained diagnosis codes and other components such as key text-strings. However, if key text-strings were not available, researchers have been able to find most TG patients within their electronic healthcare databases through diagnosis codes alone. CONCLUSION: CPs with the highest accuracy to identify TG patients contained diagnosis codes along with components such as procedural codes or key text-strings. CPs with high validity are essential to identifying TG patients when self-reported gender identity is not available. Still, self-reported gender identity information should be collected within electronic healthcare data as it is the gold standard method to better understand TG population health patterns.

Effects of Race and Gender Classifications on Atherosclerotic Cardiovascular Disease Risk Estimates for Clinical Decision-Making in a Cohort of Black Transgender Women.

Introduction: Despite their dynamic, socially constructed, and imprecise nature, both race and gender are included in common risk calculators used for clinical decision-making about statin therapy for atherosclerotic cardiovascular disease (ASCVD) prevention. Methods and Materials: We assessed the effect of manipulating six different race-gender categories on ASCVD risk scores among 90 Black transgender women. Results: Risk scores varied by operationalization of race and gender and affected the proportion for whom statins were recommended. Discussion: Race and gender are social constructs underpinning racialized and gendered health inequities. Their rote use in ASCVD risk calculators may reinforce and perpetuate existing inequities.

Intersectional Disparities in Emergency Medicine Residents' Performance Assessments by Race, Ethnicity, and Sex.

Importance: Previous studies have demonstrated sex-specific disparities in performance assessments among emergency medicine (EM) residents. However, less work has focused on intersectional disparities by ethnoracial identity and sex in resident performance assessments. Objective: To estimate intersectional sex-specific ethnoracial disparities in standardized EM resident assessments. Design, Setting, and Participants: This retrospective cohort study used data from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education Milestones (Milestones) assessments to evaluate ratings for EM residents at 128 EM training programs in the US. Statistical analyses were conducted in June 2020 to January 2023. Exposure: Training and assessment environments in EM residency programs across comparison groups defined by ethnoracial identity (Asian, White, or groups underrepresented in medicine [URM], ie, African American/Black, American Indian/Alaska Native, Hispanic/Latine, and Native Hawaiian/Other Pacific Islander) and sex (female/male). Main Outcomes and Measures: Mean Milestone scores (scale, 0-9) across 6 core competency domains: interpersonal and communications skills, medical knowledge, patient care, practice-based learning and improvement, professionalism, and system-based practice. Overall assessment scores were calculated as the mean of the 6 competency scores. Results: The study sample comprised 128 ACGME-accredited programs and 16 634 assessments for 2708 EM residents of which 1913 (70.6%) were in 3-year and 795 (29.4%) in 4-year programs. Most of the residents were White (n = 2012; 74.3%), followed by Asian (n = 477; 17.6%), Hispanic or Latine (n = 213; 7.9%), African American or Black (n = 160; 5.9%), American Indian or Alaska Native (n = 24; 0.9%), and Native Hawaiian or Other Pacific Islander (n = 4; 0.1%). Approximately 14.3% (n = 386) and 34.6% (n = 936) were of URM groups and female, respectively. Compared with White male residents, URM female residents in 3-year programs were rated increasingly lower in the medical knowledge (URM female score, -0.47; 95% CI, -0.77 to -0.17), patient care (-0.18; 95% CI, -0.35 to -0.01), and practice-based learning and improvement (-0.37; 95% CI, -0.65 to -0.09) domains by postgraduate year 3 year-end assessment; URM female residents in 4-year programs were also rated lower in all 6 competencies over the assessment period. Conclusions and Relevance: This retrospective cohort study found that URM female residents were consistently rated lower than White male residents on Milestone assessments, findings that may reflect intersectional discrimination in physician competency evaluation. Eliminating sex-specific ethnoracial disparities in resident assessments may contribute to equitable health care by removing barriers to retention and promotion of underrepresented and minoritized trainees and facilitating diversity and representation among the emergency physician workforce.

Translating Intersectionality to Fair Machine Learning in Health Sciences.

Fairness approaches in machine learning should involve more than assessment of performance metrics across groups. Shifting the focus away from model metrics, we reframe fairness through the lens of intersectionality, a Black feminist theoretical framework that contextualizes individuals in interacting systems of power and oppression.

Gender-Related Health Care Discrimination and Human Papillomavirus Vaccination Among Transgender and Nonbinary Young Adults in the United States.

Although transgender and nonbinary (TNB) people can acquire human papillomavirus (HPV), research examining HPV vaccination in these populations is scarce. TNB individuals experience high levels of gender-related health care discrimination, which may undermine HPV vaccine uptake. Using data from a national online survey (N=716), we found a negative association between gender-related health care discrimination and HPV vaccination among transgender women and nonbinary individuals who were assigned male at birth (AMAB; odds ratio [OR]=0.52; 95% confidence interval [CI]: 0.29-0.93). Addressing gender-related health care discrimination may facilitate HPV vaccination and help prevent HPV-related cancers among transgender women and nonbinary AMAB individuals.

Fair admission risk prediction with proportional multicalibration.

Fair calibration is a widely desirable fairness criteria in risk prediction contexts. One way to measure and achieve fair calibration is with multicalibration. Multicalibration constrains calibration error among flexibly-defined subpopulations while maintaining overall calibration. However, multicalibrated models can exhibit a higher percent calibration error among groups with lower base rates than groups with higher base rates. As a result, it is possible for a decision-maker to learn to trust or distrust model predictions for specific groups. To alleviate this, we propose proportional multicalibration, a criteria that constrains the percent calibration error among groups and within prediction bins. We prove that satisfying proportional multicalibration bounds a model's multicalibration as well its differential calibration, a fairness criteria that directly measures how closely a model approximates sufficiency. Therefore, proportionally calibrated models limit the ability of decision makers to distinguish between model performance on different patient groups, which may make the models more trustworthy in practice. We provide an efficient algorithm for post-processing risk prediction models for proportional multicalibration and evaluate it empirically. We conduct simulation studies and investigate a real-world application of PMC-postprocessing to prediction of emergency department patient admissions. We observe that proportional multicalibration is a promising criteria for controlling simultaneous measures of calibration fairness of a model over intersectional groups with virtually no cost in terms of classification performance.

Association of Racial and Ethnic Identity With Attrition From MD-PhD Training Programs.

This cohort study analyzes the attrition rates of students from MD-PhD training programs by race and ethnicity.

A mixed-methods assessment of off-duty police shootings in a media-curated database.

OBJECTIVE: The aim of this study was to examine rates of killings perpetrated by off-duty police and news coverage of those killings, by victim race and gender, and to qualitatively evaluate the contexts in which those killings occur. DATA SOURCES AND STUDY SETTING: We used the Mapping Police Violence database to curate a dataset of killings perpetrated by off-duty police (2013-2021, N = 242). We obtained data from Media Cloud to assess news coverage of each off-duty police-perpetrated killing. STUDY DESIGN: Our study used a convergent mixed-methods design. We examined off-duty police-perpetrated killings by victim race and gender, comparing absolute rates and rates relative to total police-perpetrated killings. [Correction added on 26 June 2023, after first online publication: 'policy-perpetrated' has been changed to 'police-perpetrated' in the preceding sentence.] We also conducted race-gender comparisons of the frequency of news media reporting of these killings, and whether reporting identified the perpetrator as an off-duty officer. We conducted thematic analysis of the narrative free-text field that accompanied quantitative data using grounded theory. PRINCIPAL FINDINGS: Black men were the most frequent victims killed by off-duty police (39.3%) followed by white men (25.2%), Hispanic men (11.2%), white women (9.1%), men of unknown race (9.1%), and Black women (4.1%). Black women had the highest rate of off-duty/total police-perpetrated killings relative to white men (rate = 12.82%, RR = 8.32, 95% CI: 4.43-15.63). There were threefold higher odds of news reporting of a police-perpetrated killing and the off-duty status of the officer for incidents with Black and Hispanic victims. Qualitative analysis revealed that off-duty officers intervened violently within their own social networks; their presence escalated situations; they intentionally obscured information about their lethal violence; they intervened while impaired; their victims were often in crisis; and their intervention posed harm and potential secondary traumatization to witnesses. CONCLUSIONS: Police perpetrate lethal violence while off duty, compromising public health and safety. Additionally, off-duty police-perpetrated killings are reported differentially by the news media depending on the race of the victim.

Transgender/nonbinary young adults' exposure to cissexism-related social stressors: Variation across gender groups.

BACKGROUND: Young adults who are transgender and/or nonbinary (TNB) experience discrimination, violence, and other social stressors as a result of cissexism, the system of power relations that marginalizes people whose genders diverge from sociocultural expectations for the sex they were assigned at birth. However, variation in TNB young adults' exposure to social stressors across gender groups, particularly specific nonbinary gender groups (e.g., agender, genderqueer), has not been well characterized. METHODS: We analyzed data from an online cross-sectional survey of U.S. TNB young adults (N = 667; ages 18-30 years; 44% White, 24% multiracial, 14% Black, 10% Latinx, 7% Asian, 1% another race/ethnicity), assessing gender non-affirmation; cissexist discrimination, rejection, and victimization; general discrimination; sexual assault victimization; and psychological, physical, and sexual abuse in childhood/adolescence. We used generalized linear models to test for variation in stressors across six gender groups (transgender woman [n = 259], transgender man [n = 141], agender [n = 36], gender fluid [n = 30], genderqueer [n = 51], nonbinary [n = 150]) and compare each group to the full sample. We performed similar analyses among nonbinary gender groups. RESULTS: Exposure to stressors was considerable in all groups. Several stressors (e.g., past-year cissexist discrimination) did not vary significantly by gender group. Compared to the full sample, transgender women reported greater lifetime cissexist rejection and lifetime and past-year cissexist victimization. Compared to the full sample, transgender men and women reported greater lifetime cissexist discrimination and lower past-year gender non-affirmation. No stressors varied significantly across nonbinary gender groups. CONCLUSION: Among TNB young adults, women, men, and nonbinary people experience distinct patterns of some (though not all) stigma-related stressors. Decisions about (dis)aggregating research participants by gender group, or providing gender-tailored services for TNB people, should account for patterning of pertinent stressors. Efforts to eliminate structural cissexism should address intersections with other systems of power relations, including sexism and binary normativity.

Operationalizing inclusion: moving from an elusive goal to strategic action.

To mitigate the structural and institutional biases that contribute to inequities in health, we need a diverse cadre of individuals to feel included and advance within our field in order to bring a multicultural set of perspectives to the studies we conduct, the science we generate, the health and academic systems we design, and the medical and scientific knowledge we impart. There has been increasing focus on diversity, inclusion, and equity in recent years; however, often these terms are presented without adequate precision and, therefore, the inability to effectively operationalize inclusion and achieve diversity within organizations. This narrative review details several key studies, with the primary objective of presenting a roadmap to guide defining, measuring, and operationalizing inclusion within work and learning environments.

Cisheteronormativity and its influence on the psychosocial experience of LGBTQ+ people with cancer: A qualitative systematic review.

OBJECTIVE: Cisheteronormativity refers to the relationship of heterosexual and cisgender privilege stemming from patriarchy. Although studies have shown that cisheteronormativity can impact health outcomes for lesbian, gay, bisexual, transgender, queer and other sexual, gender diverse, and gender nonconforming (LGBTQ+) people, the specific impact on cancer care has not been described. We synthesized the qualitative evidence on how cisheteronormativity impacts the psychosocial experience of LGBTQ+ people with cancer. METHODS: We conducted a historic search in the CINAHL, LGBT+ Health, PsycInfo, and PubMed databases. Qualitative studies that described the psychosocial experience of LGBTQ+ people with cancer were included. After appraising the quality of the publications, 11 articles were included. Then, we conducted inductive nominal coding, taxonomic analysis, and thematic synthesis. RESULTS: Two main themes emerged, (1) Cisheteronormativity as a social determinant of health, and (2) Cancer, sexual orientation, and gender: Associations and introjections. The themes comprise four categories and 13 subcategories that describe the impact of cisheteronormativity on the cancer experience of LGBTQ+ people. CONCLUSION: Cisheteronormativity within the healthcare system impacts the psychosocial experience of LGBTQ+ people with cancer. Understanding how these gender biases, norms, and social expectations impact the cancer experience is necessary to transform social norms and promote health equity.

Mapping Community-Engaged Implementation Strategies with Transgender Scientists, Stakeholders, and Trans-Led Community Organizations.

PURPOSE OF REVIEW: Pre-exposure prophylaxis (PrEP) represents one of the most effective methods of prevention for HIV, but remains inequitable, leaving many transgender and nonbinary (trans) individuals unable to benefit from this resource. Deploying community-engaged PrEP implementation strategies for trans populations will be crucial for ending the HIV epidemic. RECENT FINDINGS: While most PrEP studies have progressed in addressing pertinent research questions about gender-affirming care and PrEP at the biomedical and clinical levels, research on how to best implement gender-affirming PrEP systems at the social, community, and structural levels remains outstanding. The science of community-engaged implementation to build gender-affirming PrEP systems must be more fully developed. Most published PrEP studies with trans people report on outcomes rather than processes, leaving out important lessons learned about how to design, integrate, and implement PrEP in tandem with gender-affirming care. The expertise of trans scientists, stakeholders, and trans-led community organizations is essential to building gender-affirming PrEP systems.

Community Support Persons and Mitigating Obstetric Racism During Childbirth.

PURPOSE: We undertook a study to assess whether presence of community support persons (CSPs), with no hospital affiliation or alignment, mitigates acts of obstetric racism during hospitalization for labor, birth, and immediate postpartum care. METHODS: We conducted a cross-sectional cohort study, measuring 3 domains of obstetric racism as defined for, by, and with Black birthing people: humanity (violation of safety and accountability, autonomy, communication and information exchange, and empathy); kinship (denial or disruption of community and familial bonds that support Black birthing people); and racism in the form of anti-Black racism and misogynoir (weaponization of societal stereotypes and scripts in service provision that reproduce gendered anti-Black racism in the hospital). We used a novel, validated instrument, the Patient-Reported Experience Measure of Obstetric Racism (the PREM-OB Scale suite), and linear regression analysis to determine the association between CSP presence during hospital births and obstetric racism. RESULTS: Analyses were based on 806 Black birthing people, 720 (89.3%) of whom had at least 1 CSP present throughout their labor, birth, and immediate postpartum care. The presence of CSPs was associated with fewer acts of obstetric racism across all 3 domains, with statistically significant reductions in scores in the CSP group of one-third to two-third SD units relative to the no-CSP group. CONCLUSIONS: Our findings suggest that CSPs may be an effective way to reduce obstetric racism as part of quality improvement initiatives, emphasizing the need for democratizing the birthing experience and birth space, and incorporating community members as a way to promote the safety of Black birthing people in hospital settings.Annals "Online First" article.