Chronic UV radiation-induced RORγt+ IL-22-producing lymphoid cells are associated with mutant KC clonal expansion.

Chronic ultraviolet (UV) radiation exposure is the greatest risk factor for cutaneous squamous cell carcinoma (cSCC) development, and compromised immunity accelerates this risk. Having previously identified that epidermal Langerhans cells (LC) facilitate the expansion of UV-induced mutant keratinocytes (KC), we sought to more fully elucidate the immune pathways critical to cutaneous carcinogenesis and to identify potential targets of intervention. Herein, we reveal that chronic UV induces and LC enhance a local immune shift toward RORγt+ interleukin (IL)-22/IL-17A-producing cells that occurs in the presence or absence of T cells while identifying a distinct RORγt+ Sca-1+ CD103+ ICOS+ CD2+/- CCR6+ intracellular CD3+ cutaneous innate lymphoid cell type-3 (ILC3) population (uvILC3) that is associated with UV-induced mutant KC growth. We further show that mutant KC clone size is markedly reduced in the absence of RORγt+ lymphocytes or IL-22, both observed in association with expanding KC clones, and find that topical application of a RORγ/γt inhibitor during chronic UV exposure reduces local expression of IL-22 and IL-17A while markedly limiting mutant p53 KC clonal expansion. We implicate upstream Toll-like receptor signaling in driving this immune response to chronic UV exposure, as MyD88/Trif double-deficient mice also show substantially reduced p53 island number and size. These data elucidate key immune components of chronic UV-induced cutaneous carcinogenesis that might represent targets for skin cancer prevention.

Use of Geosocial Networking Applications Is Associated With Compulsive Sexual Behavior Disorder in an Online Sample.

BACKGROUND: Geosocial networking applications (GNAs) are relatively new outlets through which individuals may find partners for sexual encounters. There has been a paucity of research on the associations between use of these platforms and measures of mental health and compulsive sexual behavior disorder (CSBD). AIM: To examine associations between use of GNA, anxiety, and CSBD. METHODS: Using data from a large nontargeted Web-based sample (N = 4,203), we examined demographics associated with the use of GNAs. Using multivariable logistic regression adjusting for demographic differences between users and non-users, we examined associations between GNA use, anxiety, and CSBD. OUTCOMES: The outcomes are Generalized Anxiety Disorder-7 and a modified Hypersexual Behavior Inventory-19. RESULTS: The percentage of participants that reported they used GNAs was 12.3%. Those who reported using the applications compared with those who did not were more likely to be young, male, and nonheterosexual. After adjusting for demographic variables, GNAs use was associated with CSBD (adjusted odds ratio = 1.62, 95% confidence interval: 1.09-2.37, P = .015) but not anxiety. CLINICAL IMPLICATIONS: This study is an initial foray into the relationships between GNA and mental health, establishing a relationship between GNA use and CSBD. Future research is needed to better understand the relationships between GNA use, psychopathology, and CSBD. STRENGTHS & LIMITATIONS: Strengths of the study include its large sample size and nontargeted recruitment design, which minimizes confirmation bias. Limitations include the cross-sectional nature of this study, which precludes determination of the direction of causation. CONCLUSION: Use of GNAs was prevalent among our sample and associated with CSBD. GNA use may represent an important platform through which CSBD manifests. Conversely, GNA use may drive CSBD. Turban JL, Passell E, Scheuer L, et al. Use of Geosocial Networking Applications Is Associated With Compulsive Sexual Behavior Disorder in an Online Sample. J Sex Med 2020;17:1574-1578.

Posting Sexually Explicit Images or Videos of Oneself Online Is Associated With Impulsivity and Hypersexuality but Not Measures of Psychopathology in a Sample of US Veterans.

INTRODUCTION: Sending sexually explicit text messages ("sexting") is prevalent among US adults; however, the mental health correlates of this behavior among adults have not been studied adequately. Furthermore, there are few studies examining the related but distinct behavior of posting sexually explicit photos or videos of oneself online (posting sexual images [PSI]) and the mental health correlates of this behavior. AIM: To examine associations between sexting, PSI, impulsivity, hypersexuality, and measures of psychopathology. METHODS: Using a national convenience sample of 283 US post-deployment, post-9/11 military veterans, we evaluated the prevalence of 2 behaviors: sexting and PSI and the associations of these behaviors with psychopathology, suicidal ideation, sexual behaviors, hypersexuality, sexually transmitted infections, trauma history, and measures of impulsivity. MAIN OUTCOME MEASURE: Measures of psychopathology including depression, anxiety, post-traumatic stress disorder, insomnia, substance dependence, hypersexuality, and suicidal ideation, as well as measures of impulsivity, sexual behavior, and trauma. RESULTS: Sexting was found to be common among post-9/11 veterans (68.9%). A smaller number of veterans engaged in PSI (16.3%). PSI veterans were more likely to be younger, male, less educated, and unemployed. After adjusting for covariates, no associations were detected between PSI or sexting and the examined measures of psychopathology. However, PSI was associated with higher levels of impulsivity and hypersexuality, whereas sexting was not associated with these measures. CLINICAL IMPLICATIONS: Results from this study suggest that not all digital sexual behaviors are associated with psychopathology. However, PSI was associated with hypersexuality and impulsivity. Those who engage with PSI may benefit from guidance on how to manage their impulsivity to prevent ego-dystonic sexual behaviors. STRENGTHS & LIMITATIONS: The strengths of this study include differentiating PSI from sexting broadly, highlighting that digital sexual behaviors are heterogeneous. Limitations include the study's cross-sectional design, which limits causal interpretations. More research is also needed in civilian populations. CONCLUSION: PSI was less prevalent than sexting in our sample. This behavior was associated with impulsivity and hypersexuality but not with elevated levels of psychopathology. Sexting was not associated with any of these measures. Turban JL, Shirk SD, Potenza MN, et al. Posting Sexually Explicit Images or Videos of Oneself Online Is Associated with Impulsivity and Hypersexuality but Not Measures of Psychopathology in a Sample of US Veterans. J Sex Med 2020;17:163-167.

Psychological Attempts to Change a Person's Gender Identity From Transgender to Cisgender: Estimated Prevalence Across US States, 2015.

Objectives. To examine exposure to psychological attempts to change a person's gender identity from transgender to cisgender (PACGI) among transgender people in the United States, lifetime and between the years 2010 and 2015, by US state.Methods. We obtained data from the 2015 US Transgender Survey, a cross-sectional nonprobability sample of 27 716 transgender people in the United States, to estimate the percentage exposed to PACGI in each US state.Results. Overall, 13.5% of the sample indicated lifetime exposure to PACGI, ranging across all US states from 9.4% (South Carolina) to 25.0% (Wyoming). The percentage of transgender adults in the United States reporting exposure to PACGI between 2010 and 2015 was 5% overall, and across all states ranged from 1.2% (Alaska) to 16.3% (South Dakota).Conclusions. Despite major medical organizations identifying PACGI as ineffective and unethical, 13.5% of transgender people in the United States reported lifetime exposure to this practice. Findings suggest that this practice has continued in every US state as recently as the period 2010 to 2015.

Identify, Engage, Understand: Supporting Transgender Youth in an Inpatient Psychiatric Hospital.

Transgender adolescents may require for inpatient psychiatric care, and have unique healthcare needs and can face barriers to quality care. This study sought to address limited understanding of the inpatient experience of transgender adolescents. This study uses qualitative methods to gain insight into the experience of transgender adolescents and psychiatric care providers on an adolescent inpatient psychiatric unit in the northeast United States. Semi-structured interviews were conducted with patients (9 total, ages 13-17) and unit care providers (18 total). These interviews were recorded, transcribed, and analyzed using inductive thematic analysis. Patients and providers generally reported a supportive inpatient environment. Factors that contributed to this environment were efforts by care providers to respect patients regardless of gender identity, to use patient's preferred identifiers, and to acknowledge mistakes in identifier use. Barriers to consistently supportive interactions were also identified, including a lack of consistent identification of a patient's transgender identity in a supportive manner during the admission intake, challenges associated with the presence of birth-assigned name and gender within the care system (e.g. in the electronic medical record, identifying wristbands, attendance rosters), and a lack of formal training of care providers in transgender cultural competency. Interviews also provided insight into how providers grapple with understanding the complexities of gender identity. Findings suggest that gender-affirming approaches by providers are experienced as supportive and respectful by transgender adolescent patients, while also identifying barriers to consistently supportive interactions that can be addressed to optimize care.

Research Review: Gender identity in youth: treatment paradigms and controversies.

BACKGROUND: Pediatric gender identity has gained increased attention over the past several years in the popular media, political arena, and medical literature. This article reviews terminology in this evolving field, traditional models of gender identity development and their limitations, epidemiology and natural history of cross-gender identification among children and adolescents, co-occurring conditions and behaviors, research into the biological and psychosocial determinants of cross-gender identification, and research into the options regarding and benefits of clinical approaches to gender incongruent youth. METHODS: Based on a critical review of the extant literature, both theoretical and empirical, that addresses the issue of pediatric gender identity, the authors synthesized what is presently known and what is in need of further research in order to elucidate the developmental trajectory and clinical needs of gender diverse youth. RESULTS: The field of pediatric gender identity has evolved substantially over the past several years. New research suggests that cross-gender identification is prevalent (approximately 1% of youth). These youth suffer disproportionately high rates of anxiety, depression, and suicidality. Although research into the etiology of cross-gender identification is limited, emerging data have shown that affirmative treatment protocols may improve the high rates of mental health difficulties seen among these patients. CONCLUSIONS: The field of pediatric gender identity has evolved dramatically. Emerging data suggest that these patients' high rates of anxiety, depression, and suicidality appear to be improved with affirmative protocols, although future longitudinal data are needed.

Biopsychosocial Assessments for Pubertal Suppression to Treat Adolescent Gender Dysphoria.

Transgender and gender diverse (TGD) adolescents are those whose gender identity is incongruent with societal expectations based on their sex assigned at birth.1 Some TGD adolescents may meet criteria for gender dysphoria, which requires at least 6 months of psychological distress related to gender incongruence.1 Such adolescents may seek pubertal suppression with a gonadotropin-releasing hormone agonist (GnRHa).1 GnRHa temporarily and reversibly suppress endogenous puberty, allowing adolescents to engage with care without puberty-related psychological distress.2 Most patients treated with GnRHa proceed to treatment with gender-affirming hormones (eg, estrogen or testosterone to induce puberty that aligns with their gender identity), whereas a small number choose to stop GnRHa treatment, allowing endogenous puberty to proceed.2 Longitudinal cohort and cross-sectional studies link GnRHa treatment to improved mental health outcomes, when provided in accordance with clinical guidelines.2.

The Importance of Non-Probability Samples in Minority Health Research: Lessons Learned from Studies of Transgender and Gender Diverse Mental Health.

Non-probability sampling methods utilize nonrandom research participant selection, which may generate study samples that are not representative of the general population. Non-probability sample studies are often regarded as inferior due to uncertainty about their generalizability and external validity. In reality, non-probability sampling offers advantages that make this method particularly valuable for minority health research. In this perspective article, we review the strengths and limitations of probability and non-probability samples, examining three landmark survey studies used to study transgender and gender diverse mental health. We conclude that both types of studies provide important and actionable data about mental health inequities experienced by minority populations.

Age of Realization and Disclosure of Gender Identity Among Transgender Adults.

PURPOSE: The "rapid-onset gender dysphoria" (ROGD) hypothesis theorized, based on a parent-report survey, a distinct and more transient form of gender dysphoria in which individuals purportedly come to understand themselves as transgender and/or gender diverse (TGD) suddenly during adolescence. This study evaluated components of ROGD by (1) estimating the prevalence among TGD adults of first realizing one's TGD identity after childhood (i.e., after the onset of puberty), and (2) assessing the median time between realizing one's gender identity and disclosing this to someone else. METHODS: We conducted a secondary analysis of the 2015 US Transgender Survey, a survey of 27,715 TGD adults in the United States. Participants were asked the age at which they first realized their gender identity was different than societal expectations based on their sex assigned at birth and grouped by "childhood realization" (ages ≤ 10 years) and "later realization" (ages > 10). They were also asked the age at which they first shared their gender identity with another person. RESULTS: Of 27,497 participants, 40.8% reported "later realization" of TGD identities. Within the "childhood realization" group, the median age of sharing one's gender identity with another person was 20. In this group, the median time between realization of one's gender identity and sharing this with another person was 14 years. DISCUSSION: A substantial proportion of TGD adults reported realizing their gender identity was different from societal expectations based on their sex assigned at birth during adolescence or later. Several years typically elapsed between participants' TGD identity realization and sharing this with another person. The results of this study do not support the ROGD hypothesis.

Correction: Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults.

[This corrects the article DOI: 10.1371/journal.pone.0261039.].

Legislation restricting gender-affirming care for transgender youth: Politics eclipse healthcare.

In the past two years, in 25 US states, bills have been introduced to restrict access to gender-affirming medical care for minors. Some have already become law. We show how these bills, while purporting to "protect" trans youth, are really an assault on their ability, along with their parents' and physicians', to make healthcare choices and to receive medically necessary care. We discuss the evidence-based guidelines for the care of these patients, the positions taken by major medical societies against these bills, and the landscape of legal challenges that are being brought against these enacted laws.

Sex Assigned at Birth Ratio Among Transgender and Gender Diverse Adolescents in the United States.

OBJECTIVE: Representatives of some pediatric gender clinics have reported an increase in transgender and gender diverse (TGD) adolescents presenting for care who were assigned female sex at birth (AFAB) relative to those assigned male sex at birth (AMAB). These data have been used to suggest that youth come to identify as TGD because of "social contagion," with the underlying assumption that AFAB youth are uniquely vulnerable to this hypothesized phenomenon. Reported changes in the AMAB:AFAB ratio have been cited in recent legislative debates regarding the criminalization of gender-affirming medical care. Our objective was to examine the AMAB:AFAB ratio among United States TGD adolescents in a larger and more representative sample than past clinic-recruited samples. METHODS: Using the 2017 and 2019 Youth Risk Behavior Survey across 16 states that collected gender identity data, we calculated the AMAB:AFAB ratio for each year. We also examined the rates of bullying victimization and suicidality among TGD youth compared with their cisgender peers. RESULTS: The analysis included 91 937 adolescents in 2017 and 105 437 adolescents in 2019. In 2017, 2161 (2.4%) participants identified as TGD, with an AMAB:AFAB ratio of 1.5:1. In 2019, 1640 (1.6%) participants identified as TGD, with an AMAB:AFAB ratio of 1.2:1. Rates of bullying victimization and suicidality were higher among TGD youth when compared with their cisgender peers. CONCLUSION: The sex assigned at birth ratio of TGD adolescents in the United States does not appear to favor AFAB adolescents and should not be used to argue against the provision of gender-affirming medical care for TGD adolescents.

Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults.

OBJECTIVE: To examine associations between recalled access to gender-affirming hormones (GAH) during adolescence and mental health outcomes among transgender adults in the U.S. METHODS: We conducted a secondary analysis of the 2015 U.S. Transgender Survey, a cross-sectional non-probability sample of 27,715 transgender adults in the U.S. Using multivariable logistic regression adjusting for potential confounders, we examined associations between access to GAH during early adolescence (age 14-15), late adolescence (age 16-17), or adulthood (age ≥18) and adult mental health outcomes, with participants who desired but never accessed GAH as the reference group. RESULTS: 21,598 participants (77.9%) reported ever desiring GAH. Of these, 8,860 (41.0%) never accessed GAH, 119 (0.6%) accessed GAH in early adolescence, 362 (1.7%) accessed GAH in late adolescence, and 12,257 (56.8%) accessed GAH in adulthood. After adjusting for potential confounders, accessing GAH during early adolescence (aOR = 0.4, 95% CI = 0.2-0.6, p < .0001), late adolescence (aOR = 0.5, 95% CI = 0.4-0.7, p < .0001), or adulthood (aOR = 0.8, 95% CI = 0.7-0.8, p < .0001) was associated with lower odds of past-year suicidal ideation when compared to desiring but never accessing GAH. In post hoc analyses, access to GAH during adolescence (ages 14-17) was associated with lower odds of past-year suicidal ideation (aOR = 0.7, 95% CI = 0.6-0.9, p = .0007) when compared to accessing GAH during adulthood. CONCLUSION: Access to GAH during adolescence and adulthood is associated with favorable mental health outcomes compared to desiring but not accessing GAH.

Geosocial Networking Application Use Among Sexual Minority Adolescents.

The following clinical scenario is a composite case that illustrates clinically important phenomena based on several patients.

Timing of Social Transition for Transgender and Gender Diverse Youth, K-12 Harassment, and Adult Mental Health Outcomes.

PURPOSE: Many transgender and gender diverse (TGD) youth undergo a social transition in which they change their gender expression to align with their gender identity. Our objective was to examine associations between timing of social transition (during the prepubertal childhood period, adolescence, or adulthood) and adult mental health outcomes. METHODS: We conducted a secondary analysis of the 2015 U.S. Transgender Survey, a cross-sectional nonprobability survey of 27,715 TGD adults in the United States. Based on self-reports, participants were categorized as having undergone social transition during childhood (ages 3-9 years), adolescence (ages 10-17 years), or adulthood (ages ≥18 years). Using multivariable logistic regression, we examined associations between timing of social transition and adult mental health outcomes. RESULTS: After adjusting for demographic and potential confounding variables, childhood social transition was associated with lower odds of lifetime marijuana use (adjusted odds ratio .7, 95% confidence interval = .5-.8, p < .0001) when compared with adult social transition. Before adjusting for K-12 harassment based on gender identity, adolescent social transition was associated with adverse mental health outcomes, including greater odds of lifetime suicide attempts when compared with adult social transition (adjusted odds ratio 1.3, 95% confidence interval = 1.1-1.7, p = .004). These associations were no longer significant after further adjusting for K-12 harassment. CONCLUSIONS: Although past research has shown TGD youth who undergo social transition have favorable mental health outcomes in the short term, they may have worse mental health in adulthood if not protected from K-12 harassment based on gender identity. It is the responsibility of clinicians to emphasize the importance of adolescents having safe and affirming social environments.