A Contemporary Paradigm: Integrating Spirituality in Advance Care Planning.

In the 25 years since advance care planning first drew the attention of the national healthcare and legal systems, gains in the rate of advance care directive completion have been negligible despite the effort of researchers, ethicists, and lawmakers. With the benefit of sophisticated healthcare technology, patients are living longer. Despite the benefits of increased longevity, it is widely acknowledged that enough has not been done to adequately address end-of-life care decisions at the crossroads between medical futility and quality of life. To arrive at a solution, researchers have focused on patient self-reflection, provider attitudes, health literacy, communication and the logistics of surrogacy, setting, payment, and documentation. However, a survey of the literature reveals one conspicuously absent theme. It is a phenomenon one would expect in the context of end-of-life discussion and decision making, that of spiritual inquiry. This article explores the history leading up and past approaches to advance care planning and then suggests the use of a theoretical model and a body of work concerning spiritual care as a new tack in the ongoing development of advance care planning.

Coming out for a third time: transmen, sexual orientation, and identity.

Female-to-male (FTM) transgender persons are often assumed to have been lesbian in sexual orientation prior to transition and to have maintained a primary attraction for women after transition. However, limited research and anecdotal information from clinicians who work with FTM have indicated that many identify as gay men post-transition. This article described the results of a qualitative study that employed interviews with 17 FTM in order to understand their experience of transition and sexual orientation. Of the 17 participants, seven identified as lesbian prior to transition, three as heterosexual, and seven as bisexual or queer. After transition, 10 identified as gay men and the remaining seven identified as bisexual or queer. Four patterns of sexual behavior emerged from the data and were described and discussed. These patterns were named steadfast, aligned, shifted, and fluid. These findings bring additional options to the belief that there are two distinct types of transgender: a homosexual subtype and a nonhomosexual subtype.

Initiation of HIV pre-exposure prophylaxis in adolescents and young adults: Barriers and opportunities.

BACKGROUND: Adolescents and young adults (AYA) ages 13 to 24 years comprise a quarter of the new HIV diagnoses in the United States. Lack of access to HIV-preventive biomedical tools such as pre-exposure prophylaxis (PrEP) reduces opportunities to prevent HIV infection in this population. Initiating PrEP in AYA significantly reduces the negative health outcomes of HIV, but many providers are still reluctant to initiate PrEP in their AYA patients based on perceived threats and barriers. OBJECTIVES: This review aims to highlight the barriers and opportunities for initiating PrEP services in AYA and provides recommendations for PrEP services in this population. DATA SOURCES: Ten scholarly articles rated levels IIA through IIIB were identified using the Johns Hopkins Evidence-Based Practice ratings. These included quasi-experimental and nonexperimental publications. Both quantitative and qualitative data contributed to identifying perceived barriers, opportunities, and recommendations for increased PrEP access and prescription in AYA. CONCLUSIONS: Pre-exposure prophylaxis is a vital component of a robust HIV prevention program. Themes that emerged hindering optimal PrEP utilization in AYA included provider-related barriers (e.g., knowledge deficit, lack of familiarity with PrEP guidelines, and protocols), patient-related barriers (e.g., lack of awareness, confidentiality issue, and HIV stigma), and structure-related barriers (e.g., lack of AYA-friendly clinics and insurance coverage). IMPLICATIONS FOR PRACTICE: Providers in any setting should be able identify at-risk AYA and prescribe PrEP accordingly. Nurse practitioners should make PrEP accessible to AYA by addressing the barriers to PrEP utilization, prescribing, and continuity of care. Nurse practitioner curriculum, training, and continuing education should include PrEP for AYA.

Effect of cross-sex hormones on the quality of life, depression and anxiety of transgender individuals: a quantitative systematic review.

OBJECTIVE: The objective of the review was to evaluate the effectiveness of cross-sex hormone use in improving quality of life and the related measures of depression and anxiety in transgender individuals. INTRODUCTION: Transgender medicine as a specialty is still in its infancy and is beginning to attract more primary care providers. The use of hormones to aid in gender transition is expected to provide benefit with regard to quality of life, but there have been few high-quality studies. Two previous systematic reviews were found. One review included studies where participants had gender-affirming surgery, and the other review considered only prospective studies. Both reviews found a benefit with the use of hormones, despite the lack of high-quality studies. To describe outcomes specifically associated with hormone therapy, this review focused on patients who had not yet had surgical interventions, with an aim to inform primary care providers who are considering providing gender transition related-care in their office or clinic. INCLUSION CRITERIA: Eligible studies included participants who were transgender (trans) women, trans men or who did not identify with the gender binary and were using cross-sex hormones. This review only considered studies where hormone use was under medical supervision. Studies that included participants who already had any form of gender-affirming surgery were excluded, as were studies that did not use a validated tool to measure quality of life, depression or anxiety. METHODS: A comprehensive database search of PubMed, CINAHL, Embase and PsycINFO was conducted in August and September of 2017. The search for unpublished studies and gray literature included Google, the New York Academy of Medicine and the World Professional Association for Transgender Health (WPATH) Conference Proceedings. No date limits were used in any part of the search. Study selection, critical appraisal and data extraction were conducted by two independent reviewers using the JBI protocols, standardized critical appraisal and data extraction tools. RESULTS: Seven observational studies met the inclusion criteria for this review. The total number of transgender participants in all the included studies was 552. Population sizes in the studies ranged from 14 to 163. In general, the certainty of the findings was low to very low due to issues with imprecision and indirectness. The use of cross-sex hormones was associated with improved quality of life, depression and anxiety scores, although no causation can be inferred. CONCLUSIONS: Transgender participants who were prescribed cross-sex hormones had statistically significant scores demonstrating improvement on the validated scales that measured quality of life, anxiety and depression when compared to transgender people who had enrolled in a sex-reassignment clinic but had not yet begun taking cross-sex hormones. However, because the certainty of this evidence was very low to low, recommendations for hormone use to improve quality of life, depression and anxiety could not be made. High-quality research on this issue is needed, as is the development of a quality-of-life tool specific to the transgender population.

Attitudes, Beliefs, and Barriers to PrEP Among Trans Men.

The study examined the attitudes and knowledge of transgender men (trans men) regarding pre-exposure prophylaxis (PrEP) for HIV. Three focus groups of trans men were conducted with a trans male facilitator for a total of 21 participants. Six themes were identified; the range of information about PrEP and possible side effects, the economic realities for trans men, finding a trans-competent provider, trans male sexuality, the importance of contraception, and condom use. Despite identified risk and some information that has been disseminated, many trans men still lack adequate information regarding PrEP. There exist significant barriers to PrEP access for trans men. Participants commented that many providers avoid important discussions regarding sexuality and contraception. The education of health care professionals must include competency in working with transgender populations. More research is needed with regard to interactions between PrEP, testosterone, and hormonal contraception.

Provision of Patient-Centered Transgender Care.

INTRODUCTION: Transgender individuals have unique health care needs and experience health disparities. There is an increased need for transgender health care services and primary care for this underserved population. However, provision of appropriate health care services for transgender persons requires cultural competency and skill on the part of the health care provider, and providers need specific skills to address the needs of this population. METHODS: A review of the literature was performed by accessing CINAHL, PsycINFO, and PubMed databases. Pertinent research was extracted and reviewed for relevance. References in these publications were reviewed to identify additional publications that address primary prevention, secondary prevention, and tertiary care of transgender individuals. Articles that include prevention, screening, and treatment of health problems of transgender persons were identified. RESULTS: Research on the health needs of the transgender population is limited. Whenever available, research findings that address this unique population should be incorporated into clinical practice. When research evidence is not available to address the unique needs of transgender individuals, research and clinical care guidelines from the general population may be applied for health screening and maintenance. DISCUSSION: This article provides information about primary care services for transgender individuals and seeks to improve awareness of the health disparities this underserved population experiences. Simple solutions to modify clinical settings to enhance care are provided.

PrEP: A case study.

PURPOSE: The purpose of this case study is to present information and raise awareness about the provision of pre-exposure prophylaxis (PrEP) to those individuals who are at risk for HIV infection. DATA SOURCES: PubMed, CINAHL, government websites, press releases, and the author's clinical experiences. CONCLUSIONS: PrEP is the latest tool available for HIV prevention that has been approved by the FDA. It involves taking the HIV medication TDF/FTC on a daily basis. Documented side effects are minimal but renal monitoring is recommended because of possible kidney damage. PrEP may provide as much as 90% protection against HIV infection, but this is dependent upon patient compliance. IMPLICATIONS FOR PRACTICE: Nurse practitioners are in an ideal position to be the gatekeepers for information and access to PrEP. However, this requires that they engage in thorough risk assessments with their patients. This includes both a comprehensive sexual history and drug use history. The case study demonstrates the importance of intervention in and recognition of high-risk stigmatized populations such as transgender individuals and that prompt action may prevent future HIV infections.

Factors Related to Homophobia Among Nursing Students.

A convenience sample of 90 nursing students participated in an online survey measuring homophobia or sexual prejudice. Significantly higher scores were seen among those who endorsed the belief that being gay was a matter of personal choice, did not have a friend or family member who was gay or lesbian, and endorsed religiosity. A significantly higher level of sexual prejudice was seen among those who identified as non-Catholic Christians when compared to other religions. Asian/Pacific Islanders showed significantly higher scores on the scales compared to non-Hispanic Caucasian students. Nursing education should focus on those aspects of homophobia amenable to change.

Transmen: the HIV risk of gay identity.

Many female-to-male transgender individuals, or transmen, are situated within the gay community, one of the highest risk communities for HIV, yet there has been little research regarding the experience of risk for these transmen. Seventeen transmen were interviewed regarding their sexuality and HIV risk behavior. Fourteen of the 17 reported having non-trans gay men as sexual partners. Risk behaviors included not using condoms with multiple partners who were HIV-positive, or of unknown HIV status. Aspects of risk included the unfamiliarity of the gay community and the lack of safe sex negotiating skills. The dynamics of acceptance and rejection between transmen and non-trans gay men impacted risk by compromising safety. Incorrect assumptions regarding transmen, non-trans gay men, and risk included beliefs that neither person could be at risk. Other aspects included the impact of testosterone on sexual behavior, the changed bodies of transmen, and sex work.

Safe sex fatigue, treatment optimism, and serosorting: new challenges to HIV prevention among men who have sex with men.

As the HIV epidemic enters its third decade in the United States, there have been few changes in the demographics of the populations most affected by HIV. Twenty years of HIV has resulted in changing attitudes toward prevention and infection in the population of men who have sex with men (MSM). This article presents a review of the recent research regarding HIV risks and attitudes among MSM and reports on several trends that have repeatedly emerged from the literature. Concepts such as safe sex, treatment optimism, and serosorting have recently become common among MSM communities and present a challenge to all who work in HIV prevention. Suggestions are made regarding implications for nursing and areas for future research.