Gender-Affirming Facial Feminization Surgery at a Public, Safety-Net Hospital: A Single-Center Early Experience.

BACKGROUND: Facial feminization surgery (FFS) remains inaccessible to many transgender patients. Zuckerberg San Francisco General Hospital (ZSFG) was among the first public, safety-net hospitals to perform FFS. The purpose of this study is to examine the postoperative outcomes of patients who underwent FFS at ZSFG and describe barriers to providing FFS in a public hospital setting. METHODS: A retrospective review identified patients who underwent FFS at ZSFG. Demographic data, comorbidity profiles, postoperative outcomes, and hospital utilization data were collected from the medical records. FACE-Q modules (scored 0-100) were used to survey patient satisfaction at least 1 year postoperatively. RESULTS: Seventeen patients underwent comprehensive FFS surgery at ZSFG. The median age was 41 years [interquartile range (IQR): 38-55], median body mass index was 26.4 (IQR: 24.1-31.3). Patients underwent a median of 9 procedures, the most common of which included frontal cranioplasty (n=13, 77%), open brow lift (n=13, 77%), rhinoplasty (n=12, 71%), and mandible contouring (n=12, 71%). There were no complications, readmissions, or reoperations within 30 days. Patients reported high satisfaction with the surgical outcome (median: 87, IQR: 87-100), excellent postoperative psychological functioning (median: 100, IQR: 88-100), and low levels of appearance-related distress (median: 3, IQR: 0-35). An estimated 243 operating room hours and 51 inpatient bed days were required to cover all FFS procedures. CONCLUSIONS: Performing FFS in a public, safety-net hospital was associated with zero postoperative complications, few revision procedures, and excellent patient satisfaction. Limited operating room hours and inpatient availability represented barriers to providing FFS in this setting.

"I Have to Ask": A Mixed-Methods Study on the Collection of Sexual Orientation and Gender Identity Data Within the San Francisco County COVID-19 Case Investigation and Contact Tracing Program.

OBJECTIVE: To understand how the San Francisco (SF) COVID-19 case investigation and contact tracing (CICT) workforce documented sexual orientation and gender identity (SOGI) data, as well as a qualitative assessment of the workforce's capacity to successfully collect that data. METHODS: This mixed-methods project analyzed data from 2 sources: SOGI item completeness among adult completed/partially completed interviews in the SF digital CICT COVID-19 database, and a secondary data analysis of qualitative data from 16 semistructured 90-minute virtual interviews with the SF CICT workforce, between November 14, 2020, and April 14, 2021. RESULTS: Among 15 416 COVID-19 cases and 7836 close contacts, sexual orientation data are missing from 20% of cases and 17% of contacts. The proportion of transgender/nonbinary individuals was 0.32% and 0.5%, respectively. The SF CICTs participants discussed challenges in collecting SOGI data, not understanding SOGI measure rationale, and feeling uncomfortable asking the questions. CONCLUSION: Qualitative interviews with the COVID-19 CICT workforce and quantitative data on SOGI parameters in COVID-19 surveillance suggest that these data may have been underreported. Our results strongly suggest that comprehensive training is crucial in the collection of SOGI data among COVID-19 cases and their close contacts. If SOGI data are not collected accurately, the true impact of COVID-19 among lesbian, gay, bisexual, transgender, and queer populations remains unknown, preventing data-driven allocation of COVID-19 funds to lesbian, gay, bisexual, transgender, and queer communities.

Expanding the Pie-Differentiated PrEP Delivery Models to Improve PrEP Uptake in the San Francisco Bay Area.

BACKGROUND: Pre-exposure prophylaxis (PrEP) uptake among trans people to date has been low. Recommendations implemented in San Francisco to offer PrEP with feminizing hormones have not led to improvement of PrEP uptake in trans communities. New delivery models may be needed. The aim of this study was to examine whether a PrEP-only clinic was more likely to serve trans people at highest risk of HIV than trans-affirming primary care clinics. METHODS: Participants were recruited between 2017 and 2019 as part of a PrEP demonstration project in the San Francisco Bay Area. Survey data including sociodemographics, HIV-related risk behavior, barriers to PrEP, and self-reported PrEP adherence were collected at baseline, 3 months, and 6 months for all participants. Bivariable Poisson regression models were used to examine differences between participants in the primary care clinics and PrEP-only clinic delivered to participants. RESULTS: Baseline survey data were collected from 153 participants. Those with a higher number of sexual partners were significantly more likely to use the PrEP-only clinic rather than the primary care clinics. Participants with higher perceived HIV risk and those who engaged in sex work were also more likely to use the PrEP-only clinic compared with the primary care clinic. Medical mistrust was higher at baseline among participants of the PrEP-only clinic. PrEP adherence was not significantly different by delivery model. Few participants identified PrEP barriers, such as interactions with feminizing hormones, to be determinants of PrEP uptake. CONCLUSIONS: A PrEP-only delivery model could improve PrEP uptake and may better meet the needs of trans people who could most benefit from PrEP.

Systematic Collection of Sexual Orientation and Gender Identity in a Public Health System: The San Francisco Health Network SO/GI Systems-Change Initiative.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals experience disparate outcomes within health care that are often unacknowledged by health systems due to lack of systematic collection of sexual orientation/gender identity (SO/GI) data. METHODS: This article describes a San Francisco Department of Public Health (SFDPH) initiative to standardize SO/GI data collection for every patient/client utilizing SFDPH services, as well as the training development and implementation around this initiative. This initiative incorporated community engagement throughout and had an aim of meeting new regulatory requirements, improving patient experience and, ultimately, equipping staff with the needed data to uncover and reduce health disparities. RESULTS: Upon completion of the first wave of training (May 2019), a total of 5618 (69.1%) staff completed the online training and 2189 (26.7%) staff completed the optional in-person training. As of June 2020, SO/GI was collected in 35.0 percent of empanelled primary care patients and in 26.8 percent of the unique patient encounters overall throughout the health network. CONCLUSIONS: This initiative demonstrated the feasibility of implementing SO/GI data collection as an inclusive and community-driven culture change initiative, fully integrated with the complexities of operational change in a diverse public health network. Next steps include providing ongoing training and support for clinicians, staff, and patients, implementing SO/GI data collection for pediatric patients/clients, and identifying health disparities within the network to create targeted interventions and improve the care experience for our LGBTQ+ patients/clients.

Moderation and mediation of the relationships between masculinity ideology and health status.

OBJECTIVE: The purpose of this study was to assess the direct and indirect relationships between the endorsement of traditional masculinity ideology (TMI) and self-reported health status through potential mediating variables of expectations of benefits from health risk behaviors and actual health risk behaviors. In addition, the objective was to test the moderating effect of gender identity, broadly defined (including cisgender and transgender men and women and nonbinary persons). METHOD: Participants (N = 1233; 34.3% transgender) participated in an online survey, responding to measures of TMI, expectations of benefits, health behaviors, health status, and demographics. Data were analyzed using conditional process modeling. RESULTS: TMI was positively and directly associated with general health status for self-identified men (regardless of their sex assigned at birth), and with mental health for both men and women, but was not associated with physical health for persons of any gender identity. TMI was positively and directly associated with expectations of benefits for both men and women. Expectations of benefits from engaging in health risk behaviors was positively associated with health risk behaviors, and health risk behaviors had a large negative association with health status, for people of all gender identities. CONCLUSIONS: TMI may be a general and mental health protective factor for self-identified men, and a mental health protective factor for women, regardless of assigned sex at birth. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Advancing Ego Development in Adulthood Through Study of the Enneagram System of Personality.

A rapidly growing number of working professionals, academic communities, and businesses have applied the Enneagram personality system of nine types to enhance psychological growth in their personal and professional lives. However, there are no existing studies that measure the effects of the application of Enneagram training programs to promote ego development. This study examined if ego development took place among individuals enrolled in Enneagram training programs in the Narrative Tradition. Two groups of participants (N = 122) were assessed using the Washington University Sentence Completion Test (WUSCT) at baseline (pretest) before the training began and then again 18 months later (posttest); one of the groups participated in Enneagram Intensive training programs (n = 73) and the other group participated in introductory Enneagram trainings (n = 49). Data revealed an advancement in ego development among some of the participants who received at least 40-50 h of training. The findings suggest that Enneagram Intensive trainings may be beneficial for promoting psychological growth and ego development. Clinical applications and future research directions are discussed.

Longitudinal Associations of Sexual Fluidity and Health in Transgender Men and Cisgender Women and Men.

Research has just begun to study associations between sexual fluidity and health among cisgender individuals; only one cross-sectional study examined these links among transgender individuals. The goals of the current study were to prospectively examine fluidity in sexual attractions and fluidity in sexual orientation identity, and associations with health-related outcomes. Participants were a community-based sample of 45 transgender men, ages 16-51 years, who had recently begun testosterone, and 95 cisgender individuals (53 women, 42 men), ages 18-55 years, who completed surveys either in-person or via mail. Analyses tested for group differences in sexual fluidity, sociodemographic predictors of sexual fluidity among transgender men, and associations between sexual fluidity and health across the three groups. As hypothesized, transgender men reported more fluidity in sexual attractions and sexual orientation identity than did cisgender individuals. Contrary to our hypotheses, testosterone use was not significantly associated with sexual fluidity, although less education was. As hypothesized, fluidity in sexual orientation identity was associated with more adverse mental health outcomes among transgender men (depression and anxiety) and cisgender women (anxiety and stress), as well as decreased vitality among transgender men and cisgender women, and decreased social functioning among cisgender women. In contrast, fluidity in sexual attractions was only associated with less depression among cisgender women, but was not significantly associated with any other health-related outcomes. This study increases knowledge about sexual fluidity among transgender men and implications for health and can inform clinical work with this population.

Are rash impulsive and reward sensitive traits distinguishable? A test in young adults.

Adolescents and young adults are characterized as prone to risky behavior with a wide range of traits identified as predictors of individual differences in this behavior. Here we test a crucial difference between traits that reflect rash impulsivity, the tendency to engage in risky behavior without consideration of consequences, versus reward sensitivity, the tendency to be attracted to novel and rewarding experience. To test the validity of this distinction, we examined the factorial structure of eight risk-related traits in a sample of 899 18 to 22 year-olds. We predicted that rash impulsive traits would be separable in structure from reward sensitive traits and would uniquely predict relatively maladaptive risk-taking (e.g., drug use). In addition, we predicted that reward sensitive traits would be related to both adaptive (e.g., entering competitions) and maladaptive risk behaviors. Results revealed a factorial structure that distinguished these traits, with rash impulsive and reward sensitive traits uniquely predictive of different forms of risk-taking. The results suggest that it is possible to distinguish traits that reflect these two forms of risk-taking with implications for the measurement and interpretation of risk propensities in youth.

Testosterone treatment and MMPI-2 improvement in transgender men: a prospective controlled study.

OBJECTIVE: Most transgender men desire to receive testosterone treatment in order to masculinize their bodies. In this study, we aimed to investigate the short-term effects of testosterone treatment on psychological functioning in transgender men. This is the 1st controlled prospective follow-up study to examine such effects. METHOD: We examined a sample of transgender men (n = 48) and nontransgender male (n = 53) and female (n = 62) matched controls (mean age = 26.6 years; 74% White). We asked participants to complete the Minnesota Multiphasic Personality Inventory (2nd ed., or MMPI-2; Butcher, Graham, Tellegen, Dahlstrom, & Kaemmer, 2001) to assess psychological functioning at baseline and at the acute posttreatment follow-up (3 months after testosterone initiation). Regression models tested (a) Gender × Time interaction effects comparing divergent mean response profiles across measurements by gender identity; (b) changes in psychological functioning scores for acute postintervention measurements, adjusting for baseline measures, comparing transgender men with their matched nontransgender male and female controls and adjusting for baseline scores; and (c) changes in meeting clinical psychopathological thresholds. RESULTS: Statistically significant changes in MMPI-2 scale scores were found at 3-month follow-up after initiating testosterone treatment relative to baseline for transgender men compared with female controls (female template): reductions in Hypochondria (p < .05), Depression (p < .05), Hysteria (p < .05), and Paranoia (p < .01); and increases in Masculinity-Femininity scores (p < .01). Gender × Time interaction effects were found for Hysteria (p < .05) and Paranoia (p < .01) relative to female controls (female template) and for Hypochondria (p < .05), Depression (p < .01), Hysteria (p < .01), Psychopathic Deviate (p < .05), Paranoia (p < .01), Psychasthenia (p < .01), and Schizophrenia (p < .01) compared with male controls (male template). In addition, the proportion of transgender men presenting with co-occurring psychopathology significantly decreased from baseline compared with 3-month follow-up relative to controls (p < .05). CONCLUSIONS: Findings suggest that testosterone treatment resulted in increased levels of psychological functioning on multiple domains in transgender men relative to nontransgender controls. These findings differed in comparisons of transgender men with female controls using the female template and with male controls using the male template. No iatrogenic effects of testosterone were found. These findings suggest a direct positive effect of 3 months of testosterone treatment on psychological functioning in transgender men.

Substance Use to Cope with Stigma in Healthcare Among U.S. Female-to-Male Trans Masculine Adults.

PURPOSE: Enacted and anticipated stigma exist within healthcare settings for transgender people, but research has yet to examine the effects of these forms of stigma on the substance use behaviors of female-to-male (FTM) trans masculine people. METHODS: Data were analyzed from the cross-sectional U.S. National Transgender Discrimination Survey, a convenience sample of transgender adults purposively sampled in 2008. Trans masculine respondents (n=2,578) were identified using a two-step method: Step 1, Assigned birth sex; Step 2, Current gender identity. A gender minority stress model of substance use was tested to examine the relation of enacted and anticipated stigma with substance use to cope with mistreatment. RESULTS: Overall, 14.1% of the sample reported having been refused care by a provider (enacted stigma), 32.8% reported delaying needed medical care when sick/injured, and 39.1% delayed routine preventive care (anticipated stigma). Having been refused care was significantly associated with avoidance of healthcare, including delaying needed medical care when sick/injured and delaying routine preventive medical care. Substance use to cope with mistreatment was self-reported by 27.6% of the sample. Enacted stigma by providers was associated with self-reported substance use to cope. Delays in both needed and preventive care (anticipated stigma) were highly associated with substance use, and attenuated the effect of enacted stigma. CONCLUSION: Gender minority-related stressors, particularly enacted and anticipated stigma in healthcare, should be integrated into substance use and abuse prevention and intervention efforts with this underserved population.

Measures of clinical health among female-to-male transgender persons as a function of sexual orientation.

The present study examined the sexual orientation classification system that was used in the DSM-IV-TR for categorizing those who met the Gender Identity Disorder diagnostic criteria in order to determine the extent to which female-to-male transgender persons (FTMs) differ on psychological variables as a function of sexual orientation. Participants were 605 self-identified FTMs from 19 different countries (83 % U.S.) who completed an internet survey assessing their sexual orientation, sexual identity, symptoms of depression and anxiety, stress (Depression Anxiety Stress Scales), social support (Multidimensional Scale of Perceived Social Support), and health related quality of life (SF-36v2 Health Survey). Over half the sample (52 %) reported sexual attractions to both men and women. The most common sexual identity label reported was "queer." Forty percent of FTMs who had begun to transition reported a shift in sexual orientation; this shift was associated with testosterone use. Overall, FTMs ranged from normal to above average on all psychological measures. FTMs did not significantly differ by sexual attraction on any mental health variables, except for anxiety. FTMs attracted to both men and women reported more symptoms of anxiety than those attracted to men only. Results from the present study did not support a sexual orientation classification system in FTMs with regard to psychological well-being.

A tool for the culturally competent assessment of suicide: the Cultural Assessment of Risk for Suicide (CARS) measure.

Despite important differences in suicide presentation and risk among ethnic and sexual minority groups, cultural variations have typically been left out of systematic risk assessment paradigms. A new self-report instrument for the culturally competent assessment of suicide, the Cultural Assessment of Risk for Suicide (CARS) measure, was administered to a diverse sample of 950 adults from the general population. Exploratory factor analysis yielded a 39-item, 8-factor structure subsumed under and consistent with the Cultural Theory and Model of Suicide (Chu, Goldblum, Floyd, & Bongar, 2010), which characterizes the vast majority of cultural variation in suicide risk among ethnic and sexual minority groups. Psychometric properties showed that the CARS total and subscale scores demonstrated good internal consistency, convergent validity with scores on other suicide-related measures (the Suicide Ideation Scale, the Beck Depression Inventory suicide item, and the Beck Hopelessness Scale), and an ability to discriminate between participants with versus without history of suicide attempts. Regression analyses indicated that the CARS measure can be used with a general population, providing information predictive of suicidal behavior beyond that of minority status alone. Minorities, however, reported experiencing the CARS cultural risk factors to a greater extent than nonminorities, though effect sizes were small. Overall, results show that the CARS items are reliable, and the instrument identifies cultural suicide risk factors not previously attended to in suicide assessment. The CARS is the first to operationalize a systematic model that accounts for cultural competency across multiple cultural identities in suicide risk assessment efforts.

Individual Differences in Numeracy and Cognitive Reflection, with Implications for Biases and Fallacies in Probability Judgment.

Despite evidence that individual differences in numeracy affect judgment and decision making, the precise mechanisms underlying how such differences produce biases and fallacies remain unclear. Numeracy scales have been developed without sufficient theoretical grounding, and their relation to other cognitive tasks that assess numerical reasoning, such as the Cognitive Reflection Test (CRT), has been debated. In studies conducted in Brazil and in the USA, we administered an objective Numeracy Scale (NS), Subjective Numeracy Scale (SNS), and the CRT to assess whether they measured similar constructs. The Rational-Experiential Inventory, inhibition (go/no-go task), and intelligence were also investigated. By examining factor solutions along with frequent errors for questions that loaded on each factor, we characterized different types of processing captured by different items on these scales. We also tested the predictive power of these factors to account for biases and fallacies in probability judgments. In the first study, 259 Brazilian undergraduates were tested on the conjunction and disjunction fallacies. In the second study, 190 American undergraduates responded to a ratio-bias task. Across the different samples, the results were remarkably similar. The results indicated that the CRT is not just another numeracy scale, that objective and subjective numeracy scales do not measure an identical construct, and that different aspects of numeracy predict different biases and fallacies. Dimensions of numeracy included computational skills such as multiplying, proportional reasoning, mindless or verbatim matching, metacognitive monitoring, and understanding the gist of relative magnitude, consistent with dual-process theories such as fuzzy-trace theory.

Mothers' Differentiation and Depressive Symptoms among Adult Children.

Parents' differentiation has been linked to negative psychological and behavioral outcomes in children, adolescents, and young adults. This line of research, however, has not been extended to families in later life. In this article, we use data from 671 mother-child dyads in 275 families in the greater Boston area to explore whether mothers' differentiation among their children is related to psychological well-being among offspring. We examined actual and perceived maternal differentiation in the domains of closeness, expectations for care, and conflict. We hypothesized that depressive symptoms would be higher when mothers differentiated among their children and when adult children perceived differentiation. Although the specific patterns varied somewhat by mothers' and children's reports, the findings indicated that across all three domains, maternal differentiation was related to higher depression scores.

The Role of Perceived Maternal Favoritism in Sibling Relations in Midlife.

Data were collected from 708 adult children nested within 274 later-life families from the Within-Family Differences Study to explore the role of perceived maternal favoritism in the quality of sibling relations in midlife. Mixed-model analyses revealed that regardless of which sibling was favored, perceptions of current favoritism and recollections of favoritism in childhood reduced closeness among siblings. Recollections of maternal favoritism in childhood were more important than perceptions of current favoritism in predicting tension among adult siblings, regardless of age. Taken together, the findings from this investigation are consistent with childhood studies showing that siblings have better relationships when they believe that they are treated equitably by their parents.