Prevalence and Risk Factors for Nonsuicidal Self-Injury in Transgender and Gender-Expansive Youth at a Rural Gender Wellness Clinic.

Purpose: Transgender and gender-expansive (TGE) populations are at increased risk for nonsuicidal self-injury (NSSI). Rural TGE populations are understudied and underserved in terms of mental health services. The purpose of this study was to determine lifetime prevalence of NSSI among TGE youth at a rural gender wellness clinic and identify demographic and clinical characteristics associated with NSSI. Methods: The Gender Wellness Center Pediatric Patient Registry, a comprehensive database of 185 TGE youth ≤25 years of age, provided an estimate of the lifetime prevalence of NSSI. Univariate logistic regression models were utilized to test associations between patient demographic and clinical characteristics and NSSI. Variables that met the threshold for significance in the univariate analyses (p<0.05) were entered into a multivariate logistic regression model. All statistical analyses were conducted in SAS v.9.4. Results: Prevalence of NSSI in the sample was 36.8% (n=68). In unadjusted logistic regression models, risk factors for NSSI included female assigned sex at birth, transmasculine spectrum gender identity, history of mood disorder, history of suicidal ideation (SI) or attempt, and history of abuse (p<0.05). In the adjusted model, variables significantly associated with NSSI included female assigned sex at birth, history of mood disorder, and history of SI or attempt. Conclusion: NSSI was highly prevalent in this sample of rural TGE youth, confirming the need for screening and early interventions that target the unique vulnerabilities of TGE youth. The complex interplay of sex assigned at birth, mood disorders, and NSSI requires further research.

Longitudinal Use of the Consolidated Framework for Implementation Research to Evaluate the Creation of a Rural Center of Excellence in Transgender Health.

BACKGROUND: Transgender people face numerous barriers to accessing care, particularly in rural settings. Transportation, travel time, a lack of providers offering transgender care, and discrimination all contribute to these barriers. The Gender Wellness Center was established in New York State, USA, to fill a gap in rural transgender care and was subsequently awarded a Robert Wood Johnson Foundation grant to establish a Center of Excellence. This study examined the implementation of the Center of Excellence, a complex intervention, to assess barriers and facilitators to implementation over 18 months. METHODS: The Consolidated Framework for Implementation Research (CFIR) was used to develop baseline and follow-up surveys. These were distributed to members of the core implementation team at the Gender Wellness Center at the midpoint and conclusion of the Robert Wood Johnson Foundation grant. Responses were largely open-ended and analyzed qualitatively. RESULTS: Results are presented in terms of CFIR domains and constructs, as well as the relative outlook (positive or negative) of implementation. Overall, there were improvements over time, with more encouraging feedback and examples of success at follow-up. Though true, organizational culture and individual beliefs about the provision of transgender care challenged implementation of the Center of Excellence throughout the project. CONCLUSIONS: This study highlights the importance of organizational culture on implementation efforts, as well as the need for complex, multifaceted interventions to overcome such challenges in order to improve care for marginalized populations.

Health-related quality of life among transgender and gender expansive youth at a rural gender wellness clinic.

PURPOSE: To address a critical gap in the existing Health-Related Quality of Life (HRQOL) literature by quantifying and describing HRQOL among transgender and gender expansive (TG/GE) youth at a rural gender clinic and comparing the HRQOL of these youth to age-stratified United States (U.S.) population standards. METHODS: This cross-sectional study includes results of the baseline HRQOL assessment of 141 TG/GE patients enrolled in the Gender Wellness Center (GWC) Pediatric Patient Registry. HRQOL was assessed using the Child Health Questionnaire-Child Form 87 (CHQ-CF87; ages < 18) and the Short Form-36 (SF-36v2; ages 18-21). Mean subscale scores were compared to the most current U.S. population standards available. RESULTS: On all but one of the CHQ-CF87 subscales, TG/GE youth scored significantly lower than 2015-2016 U.S. general population youth and youth with two chronic conditions. On the SF-36v2, TG/GE youth scored significantly higher than 2009 U.S. standards on all physical health domains but lower on all but one of the mental health domains. CONCLUSIONS: Cross-sectional HRQOL data from a registry of TG/GE youth indicate significantly poorer mental health measures as compared with the U.S. general population. Longitudinal assessments are needed to evaluate whether HRQOL improves with gender-affirming care. Future studies should aim to identify sociocultural factors at the intersection of rurality and health that contribute to diminished HRQOL among rural TG/GE youth.

Building a Pediatric Patient Registry to Study Health Outcomes Among Transgender and Gender Expansive Youth at a Rural Gender Clinic.

Purpose: Significant knowledge gaps regarding outcomes of gender-affirming therapy in transgender (TG) and gender expansive (GE) youth impede an evidence-based approach to these patients. The Gender Wellness Center (GWC) Pediatric Patient Registry was established in 2017 to enable systematic, longitudinal research to describe the physical, mental, and quality-of-life outcomes of these youth. Methods: All TG/GE youth, ages 8-21 years, presenting to the GWC were recruited on site. Ten research questions guided the creation of data fields. The following 131 variables were abstracted from electronic medical records: demographics, weight, height, body mass index, gender identity, sexual orientation, coexisting diagnoses, substance use, Tanner stage, sexual activity, medications, fertility preservation, Gonadotropin Releasing Hormone (GnRH) analog use, hormone therapy, surgery, and related outcomes. Health-related quality of life is assessed using the Child Health Questionnaire-87 for ages <18 and the Short Form-36 for ages 18-21. Results: To date, 139 TG and GE youth (90% white and 93% non-Hispanic), have enrolled in the registry. Average age at enrollment was 17.5 years (±3.1, range: 8-21). Two-thirds of youth identified on the trans masculine spectrum (n=90), 28.8% identified on the trans feminine spectrum (n=40), and 6.5% identified as nonbinary/gender nonconforming (n=9). Nearly, all youth had socially transitioned (n=121, 87.7%) and were medically transitioning (n=123, 89.1%). Conclusion: As one of the first rural-based registries, the GWC Registry has helped to delineate health outcomes attributable to gender-affirming care in a unique patient population of TG/GE youth. Our results will be used to describe treatment outcomes that will contribute to evidence-based guidelines.

Complex Medical Decision-Making for a Trans-Feminine Youth with a BRCA1 Mutation.

The risks of being a cisgender BRCA1/BRCA2 mutation carrier (BRCA1+/BRCA2+) are well documented, and recommendations to mitigate cancer risk in BRCA+ cisgender women are clear. However, there is a lack of guidance for BRCA+ transgender women. In this article, we discuss the case of a trans-feminine youth who presented at a gender clinic for medications for pubertal suppression and was identified as a BRCA1 mutation carrier. We explore principles of bioethics to consider when the potential risks of treatment are unclear. We discuss the unknown risks for a trans-feminine youth with a BRCA1 mutation and the potential benefits and risks of treatment options.

Mammary Myofibroblastoma in a Transgender Patient on Feminizing Hormones: Literature Review and Case Report.

Purpose: Defining the risk of neoplasia associated with gender-affirming hormone therapy (GAHT) is a priority for transgender medical research. The purposes of this article are to present a unique case of breast neoplasia in a transgender individual and to review the existing evidence base on GAHT as a potential risk for breast pathology. Methods: We present the case of a 76-year-old transgender patient who developed an estrogen receptor-positive mammary myofibroblastoma (MFB) after 13 months of treatment on feminizing hormones. To our knowledge, this is the first reported case of MFB occurring in a transgender individual. A literature review was conducted to identify all reported cases of breast neoplasia among transgender individuals receiving feminizing GAHT. Information was abstracted from each of the included cases to describe the existing body of literature and to compare published cases to the case reported in this study. Results: We identified a total of 19 malignant and 3 benign cases of breast neoplasia among transgender women. Ours is the first reported case of MFB in a transgender individual receiving feminizing hormones and the first reported case of breast neoplasia associated with GAHT administered via the estradiol patch. Conclusion: This case reinforces the need for additional reporting of breast neoplasia presenting in transgender individuals treated with feminizing hormones. The relationship between estrogen exposure and breast neoplasia in the transgender population remains poorly defined, and additional research is needed to define risks and inform clinical practice.

A Transgender Woman with Testicular Cancer: A New Twist on an Old Problem.

We present the case of a transgender woman who developed rising testosterone and estradiol levels while on feminizing hormones. After months of uncertainty about the cause of her elevated hormone levels, her physician found a large testicular mass on examination. The patient was diagnosed with a rare virilizing form of testicular cancer. We review the biopsychosocial factors that led to a delay in diagnosis, appropriate screening for patients whose anatomical parts are incongruent with their gender identity, and the difficulty of learning to become a competent provider for transgender patients at a time when resources and educational opportunities are lacking.