Improving access for and experience of transgender and non-binary patients in clinical research: Insights from a transgender patient focus group and targeted literature reviews

Teaching Truth in Turbulent Times: Navigating Politicized Policies on Sex and Gender in Nursing Education

BACKGROUND

Nurse educators are confronted with legislative measures that narrowly define sex and gender, potentially excluding transgender and non-binary identities from nursing curricula. This article examines challenges when federal policy directives conflict with scientific consensus and propose strategies for preserving quality education.

PROBLEM

Restrictive policies threaten academic freedom, undermine scientific rigor, and compromise ethical obligations to deliver inclusive, culturally humble care for diverse patients.

APPROACH

Guided by an intersectional framework encompassing race, gender identity, socioeconomic status, and transformative learning theory, this article proposes curricular strategies that integrate rigorous scientific content on sexual differentiation, practical faculty development, and community engagement. These interventions emphasize case-based learning, gender-affirming communication, and legal/ethical preparedness.

CONCLUSIONS

By maintaining academic integrity and prioritizing nuanced understandings of sex and gender, nurse educators can adapt to politically charged climates while advancing person-centered, compassionate care. These efforts uphold the profession's commitment to dignity and justice for all individuals.

Brief Report: Associations Between Gender and Solicited Adverse Events After Passive Infusion of VRC01 or Placebo in HVTN 704/HPTN 085

BACKGROUND

Realizing the potential of HIV prevention options requires understanding product tolerability across diverse groups vulnerable to HIV acquisition. Gender minority (GM) individuals are understudied in clinical trials.

SETTING

HVTN 704/HIV Prevention Trials Network 085, a phase 2b randomized HIV prevention trial, enrolled MSM and transgender participants from Brazil, Peru, Switzerland, and the United States to receive an infusion every 8 weeks (10 total) of VRC01 30 mg/kg, VRC01 10 mg/kg, or placebo. Solicited adverse events (AEs) were recorded for 3 days after each infusion.

METHODS

Gender was defined by self-report and sex assigned-at-birth. Multivariate mixed logistic models were used to estimate the association between gender (cisgender men [CM] vs. GM participants [transgender women, transgender men, or another gender]) and solicited AE frequency and severity.

RESULTS

GM participants reported more solicited AEs than CM among all participants (adjusted OR 1.59, 95% CI: 1.20 to 2.10, P = 0.001) and among placebo recipients (1.72, 1.05 to 2.81, P = 0.031). The severity of solicited AEs (occurrence of grade 2 and higher event) did not significantly differ overall (1.83, 0.79 to 4.20, P = 0.174) or among placebo recipients (3.05, 0.76 to 12.32, P = 0.112). Grade 2 events were reported after 1% and 2% of total infusions among CM and GM participants, respectively. Grade 3-4 events were rare overall (<0.1%). Completion of 10 infusions was high (78.6%) and slightly higher in CM (79.2%) than GM participants (73%).

CONCLUSIONS

This is the first report of associations between gender and solicited AEs after monoclonal antibody infusion. GM participants reported more events; severity was low. HIV prevention trials must engage and support GM individuals to best evaluate tolerability of novel agents.

Evaluating patient diversity in early phase clinical trials in Australia through a prospective multicenter nonrandomized cohort study

BACKGROUND

Early phase clinical trials continue to have difficulty with enrolling real-world populations with many minorities being underrepresented. Reasons for this include patient or clinician perception as well as cultural, linguistic, or social barriers. In Australia, there is currently no prospective data in the early phase clinical trial space regarding recruitment of priority populations.

METHODS

Patient Diversity in Early Phase Clinical Trials was a multicenter, prospective, cohort study involving 2 major early phase clinical trial centers in Sydney, Australia. All participants who were consented to an early phase clinical trial between August 2023 and August 2024 were enrolled. Participants completed a baseline demographic survey, which included cultural and linguistic status, sexual orientation, socioeconomic status, and regional diversity.

RESULTS

A total of 114 participants were recruited. Median age was 63 years (range = 25-83 years) with predominance for female participants (52%). No participant reported a nonbinary gender. All participants reported their sexuality as heterosexual, with no LGBTQIA+ participants recruited. A total of 34 (30%) participants were identified as culturally diverse, while 28 (25%) were linguistically diverse. One patient identified as Indigenous Australian. Of the participants, 26% were born overseas, with 44% having at least 1 parent born overseas. The majority were living in households with family members, with 8% of participants living alone.

CONCLUSION

Patient Diversity in Early Phase Clinical Trials is the first prospective study that provides granular description of social, cultural, linguistic, economic, and sexual diversity among early phase clinical trial participants. Certain subgroups are underrepresented, including those with sexual diversity, gender diversity, and Indigenous backgrounds. Ongoing efforts to monitor and promote inclusion of diverse populations in clinical trials are vital.

Incorporating transgender and nonbinary participants in phase 1 clinical drug trials: Current knowledge gaps and considerations

Phase 1 clinical drug trials critically depend on the participation of healthy volunteers to evaluate the safety and pharmacokinetics of new medicinal products. Current selection criteria and health definitions often overlook the unique health profiles of transgender and nonbinary individuals, potentially excluding them from participating in these essential early-stage studies. This review aims to identify and discuss current knowledge gaps and considerations regarding the inclusion of transgender and nonbinary participants in phase 1 clinical drug trials. We highlight the need for research on how gender-affirming hormone therapy may affect drug pharmacokinetics and call for the development of inclusive biological reference ranges that account for the physiological effects of hormone therapies.

Transgender people in clinical trials of drugs and biologics: An analysis of ClinicalTrials.gov from 2007 to 2023

AIMS

Transgender people have unmet health needs related to chronic conditions such as dementia, osteoporosis and hypertension. Community-driven advocacy increased transgender representation in phase III trials for pharmacological prevention of HIV, but the extent to which drug trials for other conditions have included transgender people is unknown. We investigated the extent to which trials of drugs and biologics represented transgender people across therapeutic areas on ClinicalTrials.gov.

METHODS

Cross-sectional analysis of trials of drugs and biologics registered on ClinicalTrials.gov from 2007-2023. We included efficacy and effectiveness trials (phase II-IV) with transgender-related terms (e.g. 'transgend*'). We labelled trials as Inclusive or Exclusive of transgender people using the trial eligibility criteria. We compared trials (therapeutic area, trial design, enrolment), summarized trials registered from 2008 onward and characterized participant enrolment for Inclusive trials with primary trial publications. We summarized continuous data using median (range), categorical data using frequencies and percentages and compared trial characteristics using Fisher's exact test.

RESULTS

Ninety-seven trials represented transgender people. Characteristics were similar between 85 Inclusive and 12 Exclusive trials. Among Inclusive trials, 58% focused on infectious diseases (e.g. treatment or prevention of HIV and COVID-19), 15% on mental health (e.g. post-traumatic stress disorder, substance use-related disorders), and the remainder focused on endocrine (9%), pain (5%), digestive system disorders (1%) and neoplasms (1%). Twenty (of 25) trials reported enrolment of transgender participants in primary trial publications or reported results.

CONCLUSION

Transgender-inclusive trials have increased since 2008. Most trials focused on infectious diseases and mental health. Investigators should increase opportunities to include of transgender people in trials of drugs and biologics for chronic diseases.

Contraception Requirements in Clinical Research Consent Forms: Assessing and Supporting Gender Inclusive Practices

Gender-diverse individuals are underserved in clinical research settings. Reliance on gendered language throughout the consent process for clinical research contributes to the marginalization of these populations. The research objective was to assess use of gender-inclusive language used to describe the contraception requirement in consent forms. We categorized and analyzed contraception language in 289 clinical trial consent forms using a deductive and summative content analysis approach. We found that 79% (n = 227) of consent forms contained gender-inclusive language, 80% (n = 231) used terms that fell under the biological sex language, and 91% (n = 264) used gendered language. No consent forms used exclusively gender-inclusive language and the majority 63% (n = 182) featuring a combination of all three language types. There were many consent forms which would have been entirely gender-inclusive language if section headings with references to biological-sex-specific contraceptives were excluded, suggesting that gender-inclusive language may be attainable with minor revisions.

Diversity in pulmonary rehabilitation clinical trials: a systematic review of the literature

BACKGROUND

Underrepresentation of minority groups in clinical trials may hinder the potential benefits of pulmonary rehabilitation (PR) programs for individuals with chronic obstructive pulmonary disease (COPD). The aim of this work was to determine whether participants in PR randomized control trials (RCTs) conducted in the U.S.A., Canada, the UK, and Australia are representative of ethnicity, sex, gender, and sociodemographic characteristics.

RESEARCH DESIGN

A systematic search was performed for relevant literature from inception to December 2022. Titles and abstracts were screened before undergoing a full article review. Relevant data on reporting of age, sex, gender, ethnicity, and sociodemographic characteristics of participants was extracted.

RESULTS

Thirty-six RCTs met the inclusion criteria. Only 6% of publications reported on ethnicity, with ≥90% of participants reported as 'White.' All 36 papers reported on age, with the mean between 60 and 69 years old. Thirty-five studies reported on sex (97%), with the majority (67%) reporting more male than female participants. There was no mention of different genders in any paper. Other sociodemographic factors were reported in 7 (19%) papers.

CONCLUSIONS

Inclusivity and representation in clinical trials are essential to ensure that research findings are generalizable. Clinical trialists need to consider the demographics of today's society during recruitment.

A mini-review of the evidence for cerebrovascular changes following gender-affirming hormone replacement therapy and a call for increased focus on cerebrovascular transgender health

Gender-affirming hormone replacement therapy (gaHRT) is an important step for many in the gender diverse community, associated with increased quality-of-life and lower self-reported scores of depression and anxiety. However, considering the interactions that the involved sex hormones have on vasculature (with oestrogen and testosterone demonstrating vasodilatory and vasoconstricting properties, respectively), it is important for transgender healthcare research to examine how the manipulation of these hormones interact with cerebrovascular structure and functioning. There is a stark lack of research in this area. This mini-review outlines the research suggesting a vascular impact of these sex hormones using evidence from a range of cohorts (e.g., menopause, polycystic ovary syndrome) and discusses the work that has been done into cerebrovascular changes following gaHRT. Finally, recommendations for future research into cerebrovascular health in transgender cohorts following gaHRT are outlined.

Sex and gender in infection and immunity: addressing the bottlenecks from basic science to public health and clinical applications

Although sex and gender are recognized as major determinants of health and immunity, their role is rarely considered in clinical practice and public health. We identified six bottlenecks preventing the inclusion of sex and gender considerations from basic science to clinical practice, precision medicine and public health policies. (i) A terminology-related bottleneck, linked to the definitions of sex and gender themselves, and the lack of consensus on how to evaluate gender. (ii) A data-related bottleneck, due to gaps in sex-disaggregated data, data on trans/non-binary people and gender identity. (iii) A translational bottleneck, limited by animal models and the underrepresentation of gender minorities in biomedical studies. (iv) A statistical bottleneck, with inappropriate statistical analyses and results interpretation. (v) An ethical bottleneck posed by the underrepresentation of pregnant people and gender minorities in clinical studies. (vi) A structural bottleneck, as systemic bias and discriminations affect not only academic research but also decision makers. We specify guidelines for researchers, scientific journals, funding agencies and academic institutions to address these bottlenecks. Following such guidelines will support the development of more efficient and equitable care strategies for all.