Forced to adapt: Structural constraints and healthcare trade-offs among transgender and gender-diverse populations in the United States

Transgender and nonbinary peoplehave been identified as vulnerable and clinically underserved and experience health disparities. Lack of health care provider knowledge about transgender and gender diverse populations is a barrier to care, impacting health outcomes. The aim of this project was to develop, implement, and evaluate a simulation learning activity for midwifery and women's health nurse practitioner students and obstetrics and gynecology residents to interact with transgender and nonbinary individuals, with the goal of enhancing health history taking comfort and skills. A partnership was formed among University faculty and simulation educators, a community clinic providing gender-affirming care, and members of transgender and gender diverse populations who served as patient-teachers. Two cases frequently encountered in clinics providing care to transgender individuals were developed for the simulation. Learners were divided into interprofessional groups of 3 and completed one of 2 case scenarios with a patient-teacher. Learners and patient-teachers debriefed after the simulation to discuss and reflect on the experience. Thirty-three learners participated in the simulation, 12 midwifery students, 16 women's health nurse practitioner students and 5 obstetrics and gynecology residents. Significant differences were observed for all comfort and skills questions, showing increased perceived comfort and skills from pre- to postsimulation. There were no significant differences in attitude responses. We successfully created and implemented a new sexual and reproductive history taking skills simulation in partnership with community clinic staff and transgender and nonbinary persons. The session was well received by learners and patient-teachers. Learners demonstrated significant improvements in comfort and skills in history taking in this setting and provided favorable feedback about the experience. This simulation can serve as a guide to others providing education to future midwives, women's health nurse practitioners, and obstetrician-gynecologists.

Correlates of body dissatisfaction and eating disorder symptoms in transgender and gender diverse populations: A systematic review.

Introduction Little is known about sleep health among transgender and gender diverse populations. Even less is known about sleep among transgender women of color, a population that experiences considerable health disparity. Methods Interim baseline data were analyzed from the TURNNT (Trying to Understand Relationships, Networks and Neighborhoods among Transgender women of color) Study, an ongoing cohort of 350 HIV-negative transgender women of color in New York City. At baseline, items from the widely-used Pittsburgh Sleep Quality Index (PSQI) were used to measure typical sleep duration and subjective sleep quality. For example, typical sleep duration was measured with the PSQI item, “During the past month, how many hours of actual sleep did you get each night?”. Participant responses were analyzed descriptively; the Mann-Whitney U test was used to assess bivariate associations. Results As of November 2019, there were n=31 participants enrolled in TURNNT. Nearly half of participants earned less than $30,000 per year (48%) and in the 6 months before participation 61% had experienced food insecurity and 13% reported being unstably housed. Participants reported typically receiving 2-12 hours of sleep per night (median=6 hours). With short sleep defined as <7 hours per night, 55% reported this during the month prior to participation in the study, while 29% of participants rated their overall sleep quality as poor. Typical sleep duration was equivalent among participants with lower or higher incomes (5.5 vs 7 hours, p=0.3), but those who faced food insecurity reported less sleep (5 vs 7 hours, p<0.05) as did those who experienced housing instability (3.5 vs 7 hours, p<0.05). Conclusion Poor sleep health was common among our sample of transgender women of color, especially among those experiencing food insecurity and housing instability. Future research should examine multi-level correlates of poor sleep health such as network structures and neighborhood environments. Support The TURNNT (Trying to Understand Relationships, Networks and Neighborhoods among Transgender women of color) Study is funded through grants from the National Institute on Minority Health and Health Disparities (Grant Numbers: R01MD013554 and 3R01MD013554-02S1; Principal Investigator: Dustin T. Duncan, ScD).

Androgenetic alopecia incidence in transgender and gender diverse populations: A retrospective comparative cohort study

The implementation of telepsychology soared in response to the 2019 novel coronavirus (COVID-19) pandemic. For most health service psychologists, this surge preceded formal training in telepsychology. Transgender and gender diverse (TGD) individuals reported significant vulnerabilities and health disparities during the COVID-19 pandemic. To ensure the health and well-being of adult transgender and gender diverse individuals during the COVD-19 pandemic and beyond, it is critical to promote the delivery of gender-affirming telepsychology. This article highlights clinical issues observed by health service psychologists at a high-volume gender clinic during the COVID-19 pandemic. The authors provide anticipatory guidance and recommendations to promote gender-affirming telepsychology.

A systematic review of sexuality measurement in transgender and gender diverse populations.

Existing data is often used for reproductive research and quality improvement. Electronic health records (EHRs) with a single data field for sex and gender conflate sex assigned at birth, genotype, gender identity, and the presence of anatomic tissue and organs. This is problematic for inclusion of transgender and gender-diverse populations in research. This article discusses considerations with a single-item sex and gender variable drawn from EHR records and describes an audit to determine variable validity as a criterion for inclusion or exclusion in perinatal research. Individuals with a live birth at a large academic medical center from 2010 to 2022 were identified via electronic query, and records with male demographic information were reviewed to validate (1) the patient's date of birth and delivery date in the EHR matched the medical record number, (2) male sex and gender demographic information, and (3) male gender terms in EHR notes. All health records of male birthing individuals (n = 8) had EHR evidence of giving birth within the health system during the timeframe, and the date of birth matched the medical record number of the EHR. All had male gender in the EHR demographic information. Six patients did not have any male gender terms in available EHR notes, only female gender terms. Two records had recent notes using male gender terms. Current EHRs may not have reliable data on the gender and sex of gender-diverse individuals. A single sex and gender variable drawn from EHRs should not be used as inclusion or exclusion criteria for health research or quality improvement without additional record review. EHRs can be updated to collect more data on sex, gender identity, and other relevant variables to improve research and quality improvement.

Application of Cisgender Anesthesia Clinical Scoring Systems in the Transgender and Gender-Diverse Populations.

Hormones have been shown to affect the pathophysiology of rosacea, however, the prevalence of rosacea in transgender and gender diverse (TGD) patients on gender affirming hormone therapy (GAHT) has never been studied. Our retrospective cohort study showed a significantly decreased prevalence TGD patients on feminizing GAHT compared to cisgender men, women, and TGD not on GAHT. Our results suggest that estrogen and/or anti-androgenetic agents may play a protective role in the development or course of rosacea.

Transgender and gender-diverse (TGD) individuals face barriers to cancer screening and HPV vaccination, as many programs rely on legal sex, and systemic issues such non-inclusive records and lack of provider training persist, leading to low uptake. Inclusive guidelines are essential to ensure equitable cancer prevention, but their global availability remains limited. This systematic review aimed to identify and describe national guidelines on cancer prevention addressing TGD populations. The search was conducted in Sept. 2024 using Overton, supplemented by citation mining and manual searches. Documents were classified by service and document type (official guideline vs recommendation). Thirty-seven documents from 11 countries were identified. For breast cancer screening, 9 guidelines from Australia, Canada, US, UK, Ireland, Netherlands and 7 recommendations, from these countries and Italy, were retrieved. For cervical cancer screening 6 guidelines (Australia, Canada, US, UK, Ireland, Netherlands) and 9 recommendations, including from Italy, Belgium and France were identified. Colorectal cancer screening was addressed by the UK and Ireland, but specific TGD adaptations were limited. For anal cancer, 1 Italian society statement addressed high-risk groups. For prostate cancer, 3 recommendation from the US, UK and Ireland were identified. Over 47 countries have implemented gender-neutral HPV vaccination policies, indirectly covering many TGD individuals. Seven guidelines (Canada, US, UK, Sweden), and 6 recommendations including from Italy and Spain, addressed TGD populations specifically. Across all services, only few documents from Canada, the UK, and Ireland provided detailed operational instructions for eligibility, invitations and procedures. Despite growing awareness, most cancer prevention policies inadequately address the needs of TGD populations. Anatomy-based screening pathways and standardized national guidelines are urgently needed to achieve equitable access.Key messages• Few countries have issued cancer screening or HPV vaccination guidelines fully inclusive of transgender and gender-diverse individuals, with major gaps across all services.• Standardized, anatomy-based eligibility and clear invitation protocols are urgently needed to improve equitable cancer prevention for transgender and gender-diverse populations worldwide.

Gender diversity, especially pertaining to transgender and gender-diverse (TGD) populations, is often stigmatized. A small but not insignificant number of adults in the United States identify as TGD, including transgender, nonbinary, and other gender identities than cisgender. Accessing health care remains a significant challenge for TGD individuals because many health care systems adhere to a gender binary model and many TGD individuals experience negative interactions when interfacing with health care. There is also a scarcity of literature addressing their unique health care needs, limiting our current understanding of breast cancer risks and screening recommendations for TGD patients. This article reviews important considerations when providing care to TGD patients. It covers background information on gender identity and sexuality, explores gender-affirming care, discusses histopathologic findings of breast biopsy specimens, examines breast cancer risks, and presents current breast cancer screening recommendations for TGD patients. Education on TGD breast cancer risks and screening and creating a standardized screening protocol for TGD patients who may receive gender-affirming care through hormonal and surgical therapies could help improve their health care equity and access.

The extent to which violent victimization may explain higher rates of suicidality for transgender and gender diverse (TGD) populations is not well-understood. We identified likely-TGD patients using 2008-2019 electronic health record data and compared them with non-TGD patients to characterize differences in suicide attempt, ideation, and violent victimization. TGD patients (n = 916) had more suicide attempts (5.2 vs. 0.4 percent), ideation (20.5 vs. 1.8 percent), and violent victimization (5.4 vs. 1.7 percent, all p < .001) than non-TGDs (n = 511,026). Violent victimization and TGD cohort were independent predictors of suicide attempt (odds ratios [ORs], 7.23 and 10.84) and ideation (ORs, 6.83 and 11.03, all p < .001). We did not observe a differential impact of violent victimization for gender minorities. TGD patients are at higher baseline risk for suicidality, which is higher still for those experiencing violent victimization. Routine screening for both outcomes, including in primary care settings, may improve treatment.

The purpose of this review is to summarize the current knowledge base for sex-trait related cancer risks and screening guidelines as applied in transgender and gender diverse (TGD) populations with an emphasis on the potential impact of gender-affirming hormonal and surgical therapies. Additionally, this review will address access to screening services and patient-friendly adaptations to screening approaches for this population. While breast cancer incidence is higher among transfeminine persons relative to genotypic males, it still remains significantly lower than that of genotypic females. As chest masculinization surgery performed in transmasculine persons may leave behind breast tissue, there is still a cancer risk. Mammography may not be feasible in a contoured chest and alternative approaches should be considered. Endometrial and ovarian cancers do not appear to have increased incidence in transmasculine persons who receive testosterone. Gender-affirming hormone therapy may be protective in prostate cancer risk in transfeminine persons. Lastly, prevalent societal constraints and outright discrimination of TGD persons in health care settings may limit patients from seeking necessary screening examinations. Some may opt out of screening because of emotional or physical discomfort associated with incongruence between screened anatomy and gender identity. Overall, the incidence of sex steroid–influenced cancers among TGD persons appears to be low, but gender-affirming therapies may influence cancer risk. Additionally, the patient experience and potential barriers in access should also be considered in the development of TGD-specific screening guidelines.

Background:Findings from previous population-based studies are in conflict regarding the relative use of tobacco products among transgender populations compared with their cisgender counterparts. The purpose of this study was to estimate the prevalence of current tobacco use among transgender persons in the United States and evaluate differences in relative use between transgender and cisgender respondents.Methods:This was a secondary analysis of data from the Population Assessment of Tobacco and Health (PATH) Study Wave 2 (October 2014 and October 2015). Differences in current use of cigarettes, e-cigarettes, and cigars were examined between self-identified transgender (n = 154) and cisgender (n = 27 788) respondents.Results:In multivariable analyses, transgender identity was not associated with any of the 3 tobacco behaviors or the summary measure of tobacco use (ie, any current use of cigarettes, e-cigarettes, or cigars). In each of the models, female binary sex (compared with male), older age, Hispanic ethnicity (compared with non-Hispanic white), higher household income, and higher educational attainment were independently associated with lower odds of current use of cigarettes, e-cigarettes, or cigars, whereas sexual minority identity (ie, gay/lesbian or bisexual) was independently associated with higher odds of use.Conclusions:The prevalence of the use of cigarettes, e-cigarettes, and cigar use was statistically equivalent between transgender and cisgender populations in this national study of adults in the United States, which differs from previous research showing higher rates of tobacco use among transgender individuals. Differences in tobacco use that were identified were fully explained by sociodemographic characteristics (eg, income and education) between the transgender and cisgender populations.

Transgender and gender-diverse (TGD) populations are identified as high-risk for negative healthcare outcomes. Limited data exists on experiences of TGD youths in healthcare. The review aim is to systematically review literature on healthcare experiences of TGD youths. Seven electronic databases were systematically searched for relevant studies. Pre-determined eligibility criteria were used for inclusion with a double-screening approach. Sixteen studies were included. Studies included were quality appraised, data were extracted, and findings were synthesized narratively. Four narratives were identified including experiences of: accessing care, healthcare settings and services, healthcare providers, and healthcare interventions. Long waiting times, lack of competent providers, and fear were reported as challenges to accessing gender-affirming care. Negative experiences occurred in mental health services and primary care, while school counseling and gender clinics were affirming. Puberty blockers and hormone-replacement therapy were identified as protective factors. TGD youths are at risk of negative health outcomes due to an under resourced healthcare system. Further research is needed to assess interventions implemented to improve TGD youth’s experiences.