What are the barriers to health professionals' training on gender-affirming care from patients' and clinicians' perspectives?

OBJECTIVE: The aim of the study is to identify the barriers to gender-affirming health care education for providers from the perspectives of patients and providers. METHODS: A qualitative study based on grounded theory was conducted. Participants included transgender and gender diverse (TGD) patients seeking care, as well as resident physicians and attending physicians involved in care of patients seeking gender-affirming care. Semi-structured interviews were conducted over Zoom application and telephone calls. The study was conducted in Boston, Massachusetts, USA from November 2022 until February 2023. RESULTS: Nine attending physicians, eight resident physicians, and fifteen patients were interviewed. Attending physicians noted barriers to include lack of formal training in medical school and residency, lack of adequate opportunities for faculty development to appropriately train resident physicians, lack of opportunities for trainees to provide dedicated clinical care, lack of community engagement initiatives, and need for additional training centered on cultural sensitivity and inclusivity. Resident physicians noted a lack of robust and longitudinal didactic curriculum, deficiency in dedicated clinical time, and inadequacy in interprofessional training as major barriers to their training. They noted that they generally felt unprepared to care for TGD patients. Patients' barriers included difficulty building trust in medical providers' knowledge and skills, being addressed with incorrect names and pronouns, lacking a sense of belonging as a patient, as well as difficulty in arranging care due to lack of a centralized care system. CONCLUSION: Barriers to gender-affirming education include lack of adequate and formal training, lack of professional development opportunities, inadequacy in a multidisciplinary approach to treatment and education, and inadequacy in cultural and sensitivity training. Findings of this qualitative study based on interviews may help facilitate addressing such barriers through creation of routine lecture-based didactic opportunities for providers, investment in faculty development, creation of gender-affirming clinics, providing opportunities for trainees to provide longitudinal care to TGD patients, creation of interdisciplinary training modules, community engagement, and implementation of a multidisciplinary care model, which may help improve gender-affirming care in the long-run.

Removing Barriers and Honoring Autonomy: Rethinking Mental Health Professional Assessments in Adolescent Gender-Affirming Medical Care.

ABSTRACT: Adolescents seeking gender-affirming medical care (GAMC) face numerous barriers that may delay or inhibit their access to these services. Such obstacles include mental health professional (MHP) assessment requirements prior to initiating GAMC. MHP letters ultimately carry little benefit for patients. Their formulaic nature discourages nuance, reduces likelihood of capturing gender embodiment goals (beyond a narrow definition of gender dysphoria), and may cause clinicians to overlook presenting mental health concerns. MHP assessment requirements also reinforce the conception of gender dysphoria as a mental health disorder. Moreover, studies have not shown that requiring MHP assessment letters effectively reduces regret among patients. Fortunately, primary clinicians who provide GAMC are most often capable of assessing patients without additional input from an MHP. In this article, we provide an ethical framework for clinicians that prioritizes patient autonomy through an informed assent approach. We discuss Appelbaum's criteria and its application, and contexts in which MHP consultation is appropriate. We also address common questions about informed assent among clinicians, patients, and families. Finally, we advocate for bolstering multidisciplinary support teams involved in GAMC to facilitate the informed assent process. This approach upholds patient autonomy, expands access to GAMC, and utilizes the mental health workforce more effectively.

Strategies for Insurers to Promote Health Among Sexual and Gender Minority People.

This Viewpoint describes strategies for payers to improve health outcomes among sexual and gender minority people.

Systemic Barriers to Fertility Preservation for Sexually and Gender Diverse Populations.

Fertility preservation is the process of collecting and storing oocytes, sperm, or reproductive tissue so that a person may retain their ability to have biologically related children. In instances of infertility caused by medical intervention or an underlying medical condition, this procedure is often sought by affected patient populations. U.S. Title 21 regulations have produced disparities in access, disproportionately restricting services for sexually and gender diverse subpopulations capable of producing sperm. This article examines policies contributing to these disparities, explores how these policies may translate to real-world health care delivery, and proposes policy changes that would increase equitable access to care.

The Role of Psychiatry for Transgender and Gender Diverse Adults.

ABSTRACT: Since the inclusion of gender identity disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry and the broader medical field have made substantial alterations in their recognition of and respect for transgender and gender diverse (TGD) identities. As this recognition continues to expand, psychiatrists should be aware of both historical harm and current best care practices, especially in light of psychiatric morbidity in TGD populations relative to the general population. This article contextualizes the history of psychiatry's engagement with TGD patients and presents the gender minority stress and resilience model to frame the mental health disparities experienced by TGD people. We envision a role for psychiatry that goes beyond gatekeeping gender-affirming hormone therapy and surgeries. Instead, we should invest in equitable care across the continuum of mental health needs. We provide an overview of existing literature to help characterize psychiatric epidemiology for this population, with the goal of offering guidance on how psychiatrists can deliver responsive and high-quality care for TGD people. Some key areas of proposed clinical improvement include culturally tailoring interventions for substance use disorders, reducing medical trauma in acute psychiatric care settings, and better understanding the interplay of psychopharmacology and gender-affirming hormone therapy.

Development of a mentor training curriculum to support LGBTQIA+ health professionals.

While mentors can learn general strategies for effective mentoring, existing mentorship curricula do not comprehensively address how to support marginalized mentees, including LGBTQIA+ mentees. After identifying best mentoring practices and existing evidence-based curricula, we adapted these to create the Harvard Sexual and Gender Minority Health Mentoring Program. The primary goal was to address the needs of underrepresented health professionals in two overlapping groups: (1) LGBTQIA+ mentees and (2) any mentees focused on LGBTQIA+ health. An inaugural cohort (N = 12) of early-, mid-, and late-career faculty piloted this curriculum in spring 2022 during six 90-minute sessions. We evaluated the program using confidential surveys after each session and at the program's conclusion as well as with focus groups. Faculty were highly satisfied with the program and reported skill gains and behavioral changes. Our findings suggest this novel curriculum can effectively prepare mentors to support mentees with identities different from their own; the whole curriculum, or parts, could be integrated into other trainings to enhance inclusive mentoring. Our adaptations are also a model for how mentorship curricula can be tailored to a particular focus (i.e., LGBTQIA+ health). Ideally, such mentor trainings can help create more inclusive environments throughout academic medicine.

A Peer-to-Peer Collaborative Learning Approach for the Implementation of Evidence-Informed Interventions to Improve HIV-Related Health Outcomes.

The nationwide scale-up of evidence-based and evidence-informed interventions has been widely recognized as a crucial step in ending the HIV epidemic. Although the successful delivery of interventions may involve intensive expert training, technical assistance (TA), and dedicated funding, most organizations attempt to replicate interventions without access to focused expert guidance. Thus, there is a grave need for initiatives that meaningfully address HIV health disparities while addressing these inherent limitations. Here, the Health Resources and Services Administration HIV/AIDS Bureau (HRSA HAB) initiative Using Evidence-Informed Interventions to Improve HIV Health Outcomes among People Living with HIV (E2i) piloted an alternative approach to implementation that de-emphasized expert training to naturalistically simulate the experience of future HIV service organizations with limited access to TA. The E2i approach combined the HAB-adapted Institute for Healthcare Improvement's Breakthrough Series Collaborative Learning Model with HRSA HAB's Implementation Science Framework, to create an innovative multi-tiered system of peer-to-peer learning that was piloted across 11 evidence-informed interventions at 25 Ryan White HIV/AIDS Program sites. Four key types of peer-to-peer learning exchanges (i.e., intervention, site, staff role, and organization specific) took place at biannual peer learning sessions, while quarterly intervention cohort calls and E2i monthly calls with site staff occurred during the action periods between learning sessions. Peer-to-peer learning fostered both experiential learning and community building and allowed site staff to formulate robust site-specific action plans for rapid cycle testing between learning sessions. Strategies that increase the effectiveness of interventions while decreasing TA could provide a blueprint for the rapid uptake and integration of HIV interventions nationwide.

Lower levels of social support are associated with risk for future suicide attempts in a clinical sample of transgender and gender diverse adults.

PURPOSE: Transgender and gender diverse (TGD) adults are disproportionately affected by suicide. Social support and connection to the broader TGD community may help lower TGD adults' odds of having a suicide attempt (SA). The current study examined whether baseline levels of social support and community connectedness were associated with TGD adult's prospective odds of having a SA over 12 months of follow-up. METHODS: Longitudinal data for the current study came from a patient cohort of TGD adults enrolled in the LEGACY Project. Descriptive statistics and an attrition analysis were used to examine characteristics of the cohort and missingness over time. Logistic generalized estimating equation models were used to examine factors associated with patients' odds of having a past 6-month SA at 6- or 12-month follow-up. RESULTS: During the 12-month follow-up period, a total of 26 patients (3.1%; N = 830) reported having a SA. The 6-month incidence of SAs was approximately 2% at both 6- and 12-months of follow-up (6 months: N = 830; 12 months: N = 495). Baseline factors associated with increased odds of a future SA included gender identity (transfeminine vs. transmasculine: adjusted odds ratio [aOR] = 3.73, 95% confidence interval [CI] = 1.26-11.08; nonbinary vs. transmasculine: aOR = 3.09, 95% CI = 1.03-9.21), having a prior SA (aOR = 6.44, 95% CI = 2.63-15.79), and having moderate vs. high perceived social support (aOR = 4.25, 95% CI = 1.65-10.90). CONCLUSION: Lower levels of social support are associated with risk for future suicide attempts among TGD adults. Findings may inform screening practices for future suicide risk and the development of interventions to improve mental health outcomes for TGD adults.

Clinical Considerations for Children of Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and All Sexually and Gender Diverse Families.

The visibility of lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexually and gender diverse (LGBTQIA+) families is growing. Anti-LGBTQIA+ rhetoric and actions continue to shape the public discourse, legislation, and health care. This article highlights unique challenges and strengths of children raised by LGBTQIA+ parents. Health care professionals should be cognizant of challenges and resiliencies these children experience in a normative society regarding gender identity, sexual orientation, and sex development. Clinicians can conduct inclusive and nonjudgmental family and social histories in welcoming practices, with careful consideration of unique familial dynamics these children may experience at home.

Training Health Center Staff in the Provision of Culturally Responsive Care for Sexual and Gender Minority Patients: Results of a Randomized Controlled Trial.

Purpose: The study was designed to evaluate whether an educational intervention to train the health center (HC) staff to optimize care for sexual and gender minority (SGM) patients could improve documentation of sexual orientation and gender identity (SOGI) and increase preventive screenings. Methods: Twelve HCs were matched and randomized to either receive a tailored, multicomponent educational intervention or a 1-hour prerecorded webinar. Documentation of SGM status and clinical testing was measured through analysis of data that HCs report annually. Nonparametric statistics were used to assess associations between baseline HC characteristics and outcome measures. Results: The HCs were geographically, racially, and ethnically diverse. In all but one HC, <10% of the patients were identified as SGM. Intervention HCs underwent between 3 and 10 trainings, which were highly acceptable. In 2018, 9 of 12 HCs documented SO and 11 of 12 documented GI for at least 50% of their patients. Five of 6 intervention HCs increased SO documentation by 2020, compared to 3 of 6 control HCs (nonsignificant, NS). Five intervention HCs increased GI documentation, although generally by less than 10%, compared to 2 of the controls (NS). Intervention HCs tended to increase documentation of preventive services more than control HCs, but the changes were NS. Conclusions: An educational intervention designed to train the HC staff to provide culturally responsive services for SGM patients was found to be acceptable, with favorable, but nonsignificant changes. Further refinement of the intervention using a larger sample of HCs might demonstrate the effectiveness of this approach. Clinical trial registration #: NCT03554785.

Variability in Medicaid Coverage for Gender-affirming Surgeries Across U.S. States.

OBJECTIVE: To describe the current Medicaid coverage landscape for gender-affirming surgery across the United States at the procedure level and identify factors associated with coverage. BACKGROUND: Medicaid coverage for gender-affirming surgery differs by state, despite a federal ban on gender identity-based discrimination in health insurance. States that cover gender-affirming surgery also differ in which procedures are included in Medicaid coverage, leading to confusion among patients and clinicians. METHODS: State Medicaid policies in 2021 for gender-affirming surgery were queried for each of the 50 states and the District of Columbia (D.C.). State partisanship, state-level Medicaid protections, and coverage of gender-affirming procedures in 2021 were recorded. The linear correlation between electorate partisanship and total procedures covered was assessed. Pairwise t tests were used to compare coverage based on state partisanship and the presence or absence of state-level Medicaid protections. RESULTS: Medicaid coverage for gender-affirming surgery was covered in 30 states and Washington, D.C. The most commonly covered procedures were genital surgeries and mastectomy (n = 31), followed by breast augmentation (n = 21), facial feminization (n = 12), and voice modification surgery (n = 4). More procedures were covered in Democrat-controlled or leaning states, as well as in states with explicit protections for gender-affirming care in Medicaid coverage. CONCLUSIONS: Medicaid coverage for gender-affirming surgery is patchwork across the United States and is especially poor for facial and voice surgeries. Our study provides a convenient reference for patients and surgeons detailing which gender-affirming surgical procedures are covered by Medicaid within each state.

HIV pre-exposure prophylaxis provision by U.S. health centers in 2021.

OBJECTIVES: The aim of this study was to assess HIV preexposure prophylaxis (PrEP) provision in U.S. health centers. DESIGN: The U.S. Ending the HIV Epidemic (EHE) initiative designated health centers as the main healthcare system through which PrEP scale-up occurs. Health centers offer primary care to over 30 million disproportionately uninsured, racially or ethnically minoritized, and low-income patients. This study is the first to assess PrEP provision across health centers, including characteristics of clinics, patient populations, and policies associated with PrEP prescribing. METHODS: The Health Resources and Services Administration's Uniform Data System contained aggregate data on PrEP prescriptions and patient sociodemographics at health centers from January 1 through December 31, 2021, in 50 U.S. states, the District of Columbia, and eight U.S. territories. We compared patient demographics and availability of Medicaid expansion and PrEP assistance programs at health centers that prescribed vs. those that did not prescribe PrEP. RESULTS: Across 1375 health centers serving 30 193 278 patients, 79 163 patients were prescribed PrEP. Health centers that prescribed any PrEP had higher proportions of sexual, gender, racial, and ethnic minority patient populations compared with health centers that prescribed no PrEP. Compared with health centers that prescribed no PrEP, a higher proportion of health centers that prescribed PrEP were located in designated high-priority jurisdictions of the EHE initiative or states with Medicaid expansion or public PrEP assistance programs. CONCLUSION: Health centers are critical for scaling up PrEP in minoritized populations disproportionately affected by HIV, facilitated through federal and state-level policies. These findings highlight service gaps and inform future interventions to optimize PrEP implementation and support EHE initiative goals.

Decreased Anogenital Gonorrhea and Chlamydia in Transgender and Gender Diverse Primary Care Patients Receiving Gender-Affirming Hormone Therapy.

BACKGROUND: Transgender and gender diverse (TGD) adults in the U.S. experience health disparities, including in anogenital sexually transmitted infections (STI). Gender-affirming hormone therapy (GAHT) is known to be medically necessary and improve health. Few studies have assessed the effect of GAHT on STI diagnoses. OBJECTIVE: To evaluate the effect of GAHT delivered in primary care as an intervention to improve STI outcomes for TGD adults. DESIGN: LEGACY is a longitudinal, multisite cohort study of adult TGD primary care patients from two federally qualified community health centers in Boston, MA, and New York, NY. PARTICIPANTS: Electronic health record data for eligible adult TGD patients contributed to the LEGACY research data warehouse (RDW). A total of 6330 LEGACY RDW patients were followed from 2016 to 2019, with 2555 patients providing STI testing data. MAIN MEASURES: GAHT exposure was being prescribed hormones, and the clinical outcome was anogenital gonorrhea or chlamydia diagnoses. Log-Poisson generalized estimating equations assessed the effect of prescription GAHT on primary outcomes, adjusting for age, race, ethnicity, gender identity, poverty level, health insurance, clinical site, and cohort years. KEY RESULTS: The median age was 28 years (IQR = 13); the racial breakdown was 20.4% Black, 8.1% Multiracial, 6.9% Asian/Pacific Islander, 1.8% Other; 62.8% White; 21.3% Hispanic/Latinx; 47.0% were assigned female at birth, and 16.0% identified as nonbinary. 86.3% were prescribed hormones. Among those tested, the percentage of patients with a positive anogenital STI diagnosis ranged annually from 10.0 to 12.5% between 2016 and 2019. GAHT prescription was associated with a significant reduction in the risk of anogenital STI diagnosis (aRR = 0.75; 95% CI = 0.59-0.96) over follow-up. CONCLUSIONS: GAHT delivered in primary care was associated with less STI morbidity in this TGD cohort over follow-up. Patients may benefit from individualized and tailored clinical care alongside GAHT to optimize STI outcomes.

Exploring gender euphoria in a sample of transgender and gender diverse patients at two U.S. urban community health centers.

Transgender and gender diverse (TGD) people are affected by mental health inequities. Gender euphoria-positive emotions or joy in gender-may be associated with positive mental health. Between February 2019-July 2021, we surveyed 2,165 adult TGD patients (median age = 28 years; 29.2 % people of color; 29.6 % nonbinary; 81.0 % taking hormones) evaluating gender euphoria and mental health. Overall, 35.0 % self-reported gender euphoria, 50.9 % gender dysphoria, 23.5 % alcohol misuse, and 44.5 % resilience. Gender euphoria differed by race, gender, insurance, and hormone use, and was associated with reduced gender dysphoria (adjusted Odds Ratio[aOR] = 0.58; 95 % confidence interval [95 %CI] = 0.47-0.72) and alcohol misuse (aOR = 0.75; 95 %CI = 0.60-0.95), and increased resilience (aOR = 1.31; 95 %CI = 1.07-1.61). The construct of gender euphoria may be a promising mental health target.