Functional Neurological Disorder Among Sexual and Gender Minority People

Cerebrovascular Health Among Sex- and Gender-Diverse People: A Narrative Review

Purpose of Review

Sex and gender diversity includes people who are intersex, transgender, and nonbinary. Americans are identifying as sex and gender diverse (SGD) in increasing numbers. Although data are limited on the diagnosis and management of stroke in SGD communities, the current literature suggests that there may be unique health needs among these marginalized populations.

Recent Findings

Health disparities and community-specific stressors may influence the frequency of stroke and traditional cerebrovascular disease risk factors among SGD people. In addition, transgender and gender-diverse people have higher rates of atypical stroke risk factors, such as sexually transmitted infections and an increased mental health burden. The adverse effects of some gender-affirming therapies can increase the rates of stroke, particularly in transfeminine people who use long-term estrogen as part of their medical gender transition. Decisions to discontinue hormonal therapy after stroke should be weighed against the psychological risks of doing so. In addition, some commonly prescribed medications for stroke prevention could interact with gender-affirming hormone therapies. Neurologists should collaborate with primary care providers and endocrinologists to screen for and manage cerebrovascular disease risk factors for the primary and secondary prevention of stroke. Limited evidence suggests intersex people may be at higher risk of cerebrovascular disease, particularly those with congenital adrenal hyperplasia (CAH). People diagnosed with CAH have unique risk factors of stroke including treatment with stress-dose corticosteroids or polycythemia due to hyperandrogenism.

Summary

Creating affirming environments and increasing knowledge of health care for SGD communities may lead to improved equitable treatment of SGD patients with stroke by increasing community trust in health providers and incorporating use of best practices in clinical care and research settings. Limited data exist on stroke clinical presentations and how stroke is experienced and treated among SGD people, particularly among those with multiple marginalized identities, those presenting with acute stroke, and those requiring secondary stroke prevention.

The Relationship Between Functional Seizures, Dissociation, and Gender Dysphoria: A Case Report and Review

Psychogenic non-epileptic seizures (PNES), also known as functional seizures, clinically mimic seizure-like activity without the presence of brain wave abnormalities on electroencephalogram (EEG). PNES, among other functional neurological disorders, demonstrates an increased prevalence among transgender and non-binary individuals, particularly those with ongoing gender dysphoria. It is established that PNES episodes can be triggered by states of severe distress and that mirror-gazing may cause distress in individuals with gender dysphoria. Herein, we review the available research on the pathophysiology of PNES. We also describe a 16-year-old non-binary patient with gender dysphoria, initially admitted following a suicide attempt, who experienced multiple PNES episodes upon entering their bathroom. Once bathroom access was restricted and the patient was supervised with a bedside commode, they experienced no further episodes on the unit. With no other potential triggers identified, we hypothesized that the patient's symptoms were evoked by their reflection in the bathroom mirror, causing such great distress that it resulted in dissociation and PNES. This is a case of mirror-gazing potentially inducing PNES in a non-binary patient.

Prevalence of Epilepsy in People of Sexual and Gender Minoritized Groups

Importance

Epilepsy is a highly treatable condition for many people, but there are large treatment gaps with suboptimal seizure control in minoritized groups. The sexual and gender minority (SGM) community is at risk for health disparities, yet the burden of epilepsy in this community is not known.

Objective

To estimate the prevalence of active epilepsy among SGM people in the United States.

Design, Setting, and Participants

This was a cross-sectional, nationally representative survey study of community-dwelling US adults who answered questions about epilepsy, sexual orientation, and gender identity in the 2022 National Health Interview Survey (NHIS).

Exposure

Self-identification of transgender or gender-diverse identity, or sexual orientation including gay, lesbian, bisexual, or other orientation, excluding straight (ie, heterosexual).

Main Outcomes and Measures

Participants self-reported epilepsy status, medical treatment, seizure frequency, demographic characteristics, sexual orientation, and gender identity. Logistic regression was used to estimate the association of epilepsy with SGM identification.

Results

A total of 27 624 participants (15 050 [54%] women; 3231 [12%] Black; mean [SD] age, 48.2 [18.5] years) completed the NHIS and were included. Active epilepsy was present in 1.2% (95% CI, 1.0%-1.3%) of the population. A higher proportion of SGM adults than non-SGM adults reported active epilepsy (2.4% [95% CI, 1.4%-3.3%] vs 1.1% [95% CI, 1.0%-1.3%], respectively). After adjusting for age, race, ethnicity, income, and education, SGM people were more than twice as likely to report active epilepsy than were non-SGM adults (adjusted odds ratio, 2.14; 95% CI, 1.35-3.37).

Conclusions and Relevance

The findings suggest that SGM adults in the United States have a disproportionate prevalence of epilepsy. The reasons for this disparity are likely complex and may be associated with biological and psychosocial determinants of health unique to this population; as such, these individuals are in need of protected access to medical care.

Increase in Functional Tic Presentations in Sexual Orientation and Gender Identity Minority Youth During Coronavirus Disease 2019

BACKGROUND

Functional tic disorders are among the least common functional movement disorders, but their prevalence rose during the coronavirus disease 2019 (COVID-19) pandemic. Although female adolescents develop functional neurological disorders at higher rates than males, investigations into sexual orientation and gender identity (SOGI) status of these patients are limited.

METHODS

We completed a retrospective, cross-sectional time series examining the incidence of new-onset functional tic disorders in youth presenting to the Massachusetts General Hospital Movement Disorder clinics before and during the COVID-19 pandemic. Data were collected by searching for relevant International Classification of Diseases (ICD)-10 diagnostic codes in youth aged nine to 26 years using a hospital-wide data repository. Individual cases were reviewed for inclusion based on clinical criteria and expert consensus.

RESULTS

The prevalence of functional tic presentations in youth rose 8.6-fold from pre- to postpandemic levels (Fisher exact test P < 0.001), whereas the prevalence of developmental tic presentations pre- and postpandemic remained stable (114 vs 112). SOGI minority youth comprised 37% of those with functional tics (total n = 19). Ninety five percent of patients with functional tics identified as female, with 10% of these identifying as transgender.

CONCLUSIONS

Our data confirm previously demonstrated dramatic rises in functional tic presentations during the COVID-19 pandemic and, more notably, reveal a strong association with SOGI minority status. We highlight the potential link between functional tic disorders and SOGI minority status. Providing a safe and supportive clinical environment and addressing stress linked to SOGI minority status may help to improve patient prognosis.

Symptom Severity and Health Impacts of Functional Tic-Like Behaviors in Youth

BACKGROUND

We performed this study to improve understanding of the relationship between functional tic-like behaviors (FTLBs) and quality of life, loneliness, family functioning, anxiety, depression, and suicidality.

METHOD

This cross-sectional study assessed self-reported quality of life, disability, loneliness, depression, anxiety, family functioning, tic severity, and suicide risk in age- and birth-sex matched youth with FTLBs, Tourette syndrome (TS), and neurotypical controls. We performed specific subanalyses comparing individuals with FTLBs who identified as transgender/gender diverse (TGD) with cisgender individuals.

RESULTS

Eighty-two youth participated (age range 11 to 25, 90% female at birth), including 35 with FTLBs, 22 with TS, and 25 neurotypical controls. A significantly higher proportion of participants with FTLB identified as TGD (15 of 35) than TS (two of 22) and neurotypical control (three of 25) participants. Compared with neurotypical controls, individuals with FTLBs had significantly lower quality of life, greater disability, loneliness, social phobia, anxiety symptoms, depressive symptoms, and suicidality. Compared with individuals with TS, individuals with FTLBs had more school/work absences due to tics, had more depressive symptoms, were more likely to be at high risk for suicidality, and had disability in self-care and life activity domains. There were no significant differences between cisgender and TGD participants with FTLB in any of the domains assessed.

CONCLUSIONS

Youth with FTLB have unique health care needs and associations with anxiety, depression, sex, and gender.

Topical Review: Acute and Chronic Pain Experiences in Transgender and Gender-Diverse Youth

OBJECTIVE

To provide an overview of the existing literature on gender diversity in pediatric acute and chronic pain, propose an ecological systems model of understanding pain in transgender and gender-diverse (TGD) youth, and identify a direction for future work that will address the key knowledge gaps identified.

METHODS

Relevant literature on pain and gender diversity was reviewed, drawing from adult literature where there was insufficient evidence in pediatric populations. Existing relevant models for understanding minority stress, gender and pain, and pain experiences within marginalized groups were considered with the reviewed literature to develop a pain model in TGD youth.

RESULTS

While there is an abundance of literature pointing to increased risk for pain experiences amongst TGD youth, there is comparably little empirical evidence of the rates of pain amongst TGD youth, prevalence of TGD identities in pain care settings, effective pain treatments for TGD youth and unique considerations for their care, and the role intersectional factors in understanding TGD youth identities and pain.

CONCLUSION

Pediatric psychologists are well-positioned to advance the research on acute and chronic pain in TGD youth, make evidence-based adaptations to clinical care for TGD youth with pain, including pain related to gender affirmation, and support colleagues within the medical system to provide more inclusive care.