Gender Affirmation and Body Modification Among Transgender Persons in Bogotá, Colombia

Highs, Lows, and Hormones: A Qualitative Metasynthesis of Transgender Individuals' Experiences Undergoing Gender-Affirming Hormone Therapy

Gender Affirming Hormone Therapy (GAHT) is a key therapeutic approach which aims to help trans and gender diverse (or simply "trans") individuals' transition from their sex-presumed-at-birth to their experienced gender identity. Previous reviews have focused on synthesizing quantitative experiences; however, a qualitative lens is important to understand the personal journey of GAHT. This review provides a qualitative meta-synthesis of the experiences of trans people around the world who have undergone GAHT to elicit contextualized understanding of the changes experienced. Systematic searches of eight databases identified an initial 2670 papers, refined to a final 28 papers. Overall, findings suggested that the GAHT journey is unique and elicited a myriad of changes which, whilst challenging at times, were life-changing and brought about positive psychological, physical, and social changes. Other themes explored GAHT not being treated as a fix-all for associated mental health issues, the rules that govern appraisal of physical changes, how privilege and social identity evolve, and the power of affirmation. This work offers important recommendations to improve the care offered to trans people undergoing GAHT. Namely, person-centered support is essential, and peer-navigation may be a useful future direction to explore.

A life course health development model of HIV vulnerabilities and resiliencies in young transgender women in Peru

BACKGROUND

Globally transgender women (TW) are at heightened vulnerability for HIV infection. In Lima Peru, sharp increases in HIV prevalence are seen among TW ages 25 years and older highlighting the need for early HIV prevention efforts for young TW. This study conducted in-depth qualitative interviews to elucidate the social and developmental contexts of HIV vulnerability for young TW in Lima Peru.

METHODS

Between November 2019 and February 2020, young TW ages 16-24 years (n = 21) in Lima Peru were purposively sampled using in-person (e.g., face-to-face outreach) and online (e.g., social media, networking websites) social network-based methods. Interviews were conducted in Spanish and a rapid qualitative analysis was conducted using a modified immersion crystallization methodology to identify themes.

RESULTS

Five themes emerged, informing the conceptualization of a Life Course Health Development Model of HIV Vulnerabilities and Resiliencies: (1) interpersonal contexts (family, school, partners, sexual debut, trans mothers); (2) structural vulnerabilities (poverty, educational constraints, migration, hostile environments, sex work, police violence); (3) concomitant mental health and psychosocial factors (discrimination, violence, depression, suicidality, substance use, life hopes/dreams/future expectations); (4) gender affirmation processes (gender identity development, hormones, surgery, legal name/gender marker change); (5) HIV prevention and treatment barriers (PrEP uptake, HIV care, condom use, risk reduction).

CONCLUSIONS

Young TW experience formidable developmental challenges associated with transphobia, violence, and pre-maturely facing accelerated milestones. Developmentally and culturally appropriate interventions to mitigate HIV vulnerability in Peru are needed, including those that consider co-occurring stigma-related conditions in adolescence and young adulthood.

Supporting Gender-Related Medical Decision Making for Transgender and Gender-Diverse Individuals: A Scoping Review

Purpose

Transgender and gender-diverse (TGD) individuals and their families face numerous challenging decisions. To better understand their decision processes, we conducted a scoping review of the existing literature and of decision-support tools in use at pediatric gender-care clinics.

Methods

We searched PubMed, EMBASE, Scopus CINAHL, PsychINFO, and EBM Reviews for studies that were original research focused on decisions, decision making, or decision support for TGD individuals and/or their families. All studies were reviewed for inclusion by at least two researchers. Additionally, we reviewed clinical tools used to support decision making by TGD youth and their families.

Results

We retrieved 3306 articles. Thirty-two met criteria for data extraction. Studies focused on three major decisions: gender-confirming surgery, fertility preservation, and gender-affirming hormone therapy. Several themes that cut across clinical topics emerged: decision-making processes, decision-making roles, and sources of decision support. Only three articles focused on decision-support interventions, two of which discussed development of support tools and one evaluated a class designed to help with surgical decision making. None of the clinical tools reviewed met criteria for a decision aid.

Conclusions

There is a dearth of studies related to decision support interventions, an absence validated by the resources currently in clinical use. This scoping review suggests an opportunity for the development of tools to aid in the decision-making processes for TGD youth and their families.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Surgical Treatment of Granulomatous Breast Deformities Caused by Injection of Foreign Substances in Transgender Women: A Case Series and Algorithm

SUMMARY

Despite potentially devastating complications, free foreign substance injections for feminizing breast augmentation remain common among transgender women. To date, the literature regarding surgical treatment of these deformities among transgender women remains limited. The authors present a case series of transgender women presenting for surgical management of granulomatous breast deformities secondary to free foreign substance injections between January of 2016 and February of 2020. Seven transgender women presented for surgical management of complications secondary to free foreign substance injections of the breast. These patients ranged in age from 29 to 53 years, all identified as Hispanic/Latinx, and five were primarily Spanish speakers. All were recipients of public insurance. Six of the seven patients received free foreign substance injections outside of the United States, with an average time from initial injections to presentation of 19.3 ± 15.7 years. Three patients presented with a history of prior revisions by other surgeons. Four underwent staged reconstruction at the authors' institutions. Patients were followed for, on average, 10.7 ± 12.6 months after their initial surgery. There were no major complications. The most common minor complication was delayed wound healing. In the present series, the authors illustrate that, with careful consideration and patient selection, it is possible to perform safe and successful breast reconstruction for the management of foreign substance granulomas in transgender women. They also provide an algorithm based on patient-specific factors to guide treatment decisions in this patient population. Further research is needed to determine the generalizability and applicability of this algorithm.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Applying implementation science frameworks to identify factors that influence the intention of healthcare providers to offer PrEP care and advocate for PrEP in HIV clinics in Colombia: a cross-sectional study

Background

Few studies have used implementation science frameworks to identify determinants of PrEP prescription by healthcare providers. In this work, we developed and psychometrically examined a questionnaire using the theoretical domains framework (TDF) and the consolidated framework for implementation research (CFIR). We used this questionnaire to investigate what factors influence the intention of healthcare providers to offer PrEP care and advocate for PrEP.

Methods

We conducted a cross-sectional study in 16 HIV healthcare organizations in Colombia. A 98-item questionnaire was administered online to 129 healthcare professionals. One hundred had complete data for this analysis. We used exploratory factor analysis to assess the psychometric properties of both frameworks, and multinomial regression analysis to evaluate the associations of the frameworks’ domains with two outcomes: (1) intention to offer PrEP care and (2) intention to advocate for PrEP impmentation.

Results

We found support for nine indices with good internal consistency, reflecting PrEP characteristics, attitudes towards population needs, concerns about the use of PrEP, concerns about the role of the healthcare systems, knowledge, beliefs about capabilities, professional role, social influence, and beliefs about consequences. Notably, only 57% of the participants were likely to have a plan to care for people in PrEP and 66.7% were likely to advocate for PrEP. The perception of the need for PrEP in populations, the value of PrEP as a practice, the influence of colleagues, and seeing PrEP care as a priority was related to being less likely to be unwilling to provide or advocate for PrEP care.

Conclusion

Our findings suggested the importance of multilevel strategies to increase the provision of PrEP care by healthcare providers including adquisition of new skills, training of PrEP champions, and strength the capacity of the health system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00278-2.

Filler Use Among Trans Women: Correlates of Feminizing Subcutaneous Injections and Their Health Consequences

Purpose: Subcutaneous injections, or "fillers," are used illicitly and in large quantities by trans women for feminization. They are associated with severe complications, but data on their use are limited, especially in places with widespread access to safe gender-affirming care. Our analysis seeks to assess the prevalence, correlates, and complications of filler use to inform prevention and treatment. Methods: A secondary analysis of cross-sectional survey data from the Trans* National Study conducted from May 2016 to December 2017 of 631 adult trans women in the San Francisco Bay Area, California, recruited using respondent-driven sampling. Results: Around 65/631 participants (10.3%) reported filler use. Filler use was highest among Latinas (21.3% vs. 3.8% among whites, p<0.001), high school graduates (22.6% vs. 1.7% among college graduates, p<0.001), and those with a history of being undocumented (31.7% vs. 16.3% among documented immigrants and 6.4% among U.S. natives, p<0.001). Filler users had higher odds of engaging in sex work ever (odds ratio [OR] 3.3, p<0.001) and in the last 6 months (OR 2.00, p=0.049). The majority of filler users (78.5%) reported a physical complication, including infectious and inflammatory responses, coagulopathies, and neuropathies. Conclusion: Filler use was high among participants, despite availability of gender-affirming care and prevalence of complications. Filler use was highest among those with social, economic, and political vulnerabilities. Thus, filler use might be associated with structural factors that reduce access to safer methods of feminization. Addressing these factors, increasing access to safe gender-affirming care, and developing protocols for filler-related complications are needed.

Self-administration of gender-affirming hormones: a systematic review of effectiveness, cost, and values and preferences of end-users and health workers

Self-administration of quality gender-affirming hormones is one approach to expanding access to hormone therapy for individuals seeking secondary sex characteristics more aligned with their gender identity or expression and can be empowering when provided within safe, supportive health systems. To inform World Health Organization guidelines on self-care interventions, we systematically reviewed the evidence for self-administration compared to health worker-administration of gender-affirming hormones. We conducted a comprehensive search for peer-reviewed articles and conference abstracts that addressed effectiveness, values and preferences, and cost considerations. Data were extracted in duplicate using standardised forms. Of 3792 unique references, five values and preferences articles were included; no studies met the criteria for the effectiveness or cost reviews. All values and preferences studies focused on self-administration of unprescribed hormones, not prescribed hormones within a supportive health system. Four studies from the U.S. (N = 2), Brazil (N = 1), and the U.K. (N = 1) found that individuals seeking gender-affirming hormone therapy may self-manage due to challenges finding knowledgeable and non-stigmatising health workers, lack of access to appropriate services, exclusion, and discomfort with health workers, cost, and desire for a faster transition. One study from Thailand found health worker perspectives were shaped by restrictive legislation, few transgender-specific services or guidelines, inappropriate communication with health workers, and medical knowledge gaps. There is limited literature on self-administration of gender-affirming hormone therapy. Principles of gender equality and human rights in the delivery of quality gender-affirming hormones are critical to expand access to this important intervention and reduce discrimination based on gender identity.

Human rights and legal dimensions of self care interventions for sexual and reproductive health

Understanding the user, the health system, and the environment is key to ensuring that self care interventions for sexual and reproductive health are not only available but safe and empowering for all, say Laura Ferguson and colleagues

Nonsurgical Management of Facial Masculinization and Feminization

BACKGROUND

Transgender patients may seek nonsurgical methods for facial masculinization and feminization as an adjunct or alternative to undergoing surgical procedures.

OBJECTIVES

The authors reviewed the existing literature regarding this topic and provided an overview of nonsurgical techniques for facial masculinization and feminization.

METHODS

A comprehensive literature search of the PubMed and MedLine databases was conducted for studies published through December 2017 for techniques and outcomes of nonsurgical facial masculinization and feminization. Keywords were used in performing the search. Data on techniques, outcomes, complications, and patient satisfaction were collected.

RESULTS

Four articles fit our inclusion criteria. Given the lack of published literature describing facial injectables in transgender patients, data from the literature describing techniques in cisgender patients were utilized to supplement our review.

CONCLUSIONS

Facial feminization can be achieved through injectables such as neurotoxin and fillers for lateral brow elevation, lip augmentation, malar augmentation, and improvement of rhytids. Facial masculinization can be achieved with injectables used for genioplasty, jawline augmentation, and supraorbital ridge augmentation. One must develop best practices for these techniques in the transgender patient population and increase awareness regarding nonsurgical options.

LEVEL OF EVIDENCE: 4

The social context of hormone and silicone injection among Puerto Rican transwomen

This paper draws on ethnographic, qualitative and survey data with transwomen in Puerto Rico to examine the social and political-economic context of lay injection with hormone and silicone - common practices within this community. We describe specific practices of hormone and silicone injection, the actors that govern them, the market for the sale and distribution of syringes and the networks of lay specialists who provide services to a population that is neglected by and largely excluded from biomedical settings. Our data derive from ethnographic observations, sociodemographic questionnaires, surveys and semi-structured interviews conducted with a diverse group of transwomen in metropolitan San Juan, Puerto Rico. Our analysis focuses on four overlapping social domains or processes that shape the practices of lay silicone and hormone injection among transwomen: (1) the circulation of gender transitioning technologies within local and global markets; (2) the tension between the social exclusion of transwomen and their resilient sub-cultural responses; (3) the cultural meanings that shape transwomen's attitudes about injection; and (4) the perceived consequences of injection. We conclude with a discussion of the kinds of intervention and policy changes that would respond to the factors that most endanger transwomen's health.

Stigma-related access barriers and violence against trans women in the Colombian healthcare system

Drawing from qualitative research conducted in a participatory action research framework with 28 transgender women in Colombia, this paper presents the stigma-related barriers to healthcare experienced by trans women and their experiences of multi-level violence within the healthcare system. The authors also discuss how advocacy work was conducted as part of the research process and how trans community leaders were involved throughout the project in order to promote policy-relevance and community-based implementation of findings. The paper concludes with a discussion of how the experiences of violence and stigmatisation within the health care system is linked to broader processes of structural stigma reproduced within Colombian society.

Factors Associated with Gender-Affirming Surgery and Age of Hormone Therapy Initiation Among Transgender Adults

Purpose: Gender-affirming surgeries and hormone therapy are medically necessary treatments to alleviate gender dysphoria; however, significant gaps exist in the research and clinical literature on surgery utilization and age of hormone therapy initiation among transgender adults.

Methods: We conducted a retrospective review of electronic health record data from a random sample of 201 transgender patients of ages 18–64 years who presented for primary care between July 1, 2010 and June 30, 2015 (inclusive) at an urban community health center in Boston, MA. Fifty percent in our analyses were trans masculine (TM), 50% trans feminine, and 24% reported a genderqueer/nonbinary gender identity. Regression models were fit to assess demographic, gender identity-related, sexual history, and mental health correlates of gender-affirming surgery and of age of hormone therapy initiation.

Results: Overall, 95% of patients were prescribed hormones by their primary care provider, and the mean age of initiation of masculinizing or feminizing hormone prescriptions was 31.8 years (SD=11.1). Younger age of initiation of hormone prescriptions was associated with being TM, being a student, identifying as straight/heterosexual, having casual sexual partners, and not having past alcohol use disorder. Approximately one-third (32%) had a documented history of gender-affirming surgery. Factors associated with increased odds of surgery were older age, higher income levels, not identifying as bisexual, and not having a current psychotherapist.

Conclusion: This study extends our understanding of prevalence and factors associated with gender-affirming treatments among transgender adults seeking primary care. Findings can inform future interventions to expand delivery of clinical care for transgender patients.

Integrated and Gender-Affirming Transgender Clinical Care and Research

Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested “best practices” for how to integrate clinical care and research for the field of HIV prevention. Holistic and culturally responsive HIV prevention interventions must be grounded in the lived realities the trans community faces to reduce disparities in HIV infection. HIV prevention interventions will be most effective if they use a structural approach and integrate primary concerns of transgender people (eg, gender-affirmative care and management of gender transition) alongside delivery of HIV-related services (eg, biobehavioral prevention, HIV testing, linkage to care, and treatment).

Gender Affirmation and Resiliency Among Black Transgender Women With and Without HIV Infection

Purpose: Among black transgender women (transwomen) at high risk of HIV acquisition or already living with HIV/AIDS, the study examined whether medical or socially based gender affirming factors may contribute differentially to selected measures of resiliency, perceived stress, and a scale measure of mental health outcomes. This question has implications for clinical care and counseling of this population.

Methods: Seventy-seven black transwomen were recruited to participate in a private, face-to-face structured interview. Two index measures of gender affirmation (GA) were constructed from the data. One comprised medical aspects only and the other comprised social aspects of GA. Assessed outcomes were personal competence and acceptance of self and life (resiliency), perceived stress and recent anxiety, depression, and suicide ideation (mental health). Associations between GA variables and outcomes were first assessed using bivariate level correlations. Significant bivariate associations were then tested in multivariable regression models adjusting for age and HIV status.

Results: Mean age of the sample was 34.5 years. More than one-half of the sample (62.3%) indicated being HIV-infected. None of the bivariate or multivariable associations pertaining to GA medical factors were significant. Conversely, the social GA factors were significant and protective with all four outcomes. In the presence of age and HIV status, greater social GA was significantly associated with greater personal competence, acceptance of self and life, and positive mental health outcome. HIV status had an independent effect on personal competence, acceptance of self and life, with HIV-positive transwomen scoring higher on both measures.

Conclusion: Among black transwomen at high risk of HIV acquisition or already HIV-infected, study findings suggest the possibility that socially based GA may play a prominent role in strengthening the resiliency and mental health of black transwomen. This same protective effect may not occur as a consequence of gender affirming body modification practices.

Gender Affirmation and Resiliency Among Black Transgender Women With and Without HIV Infection

Purpose: Among black transgender women (transwomen) at high risk of HIV acquisition or already living with HIV/AIDS, the study examined whether medical or socially based gender affirming factors may contribute differentially to selected measures of resiliency, perceived stress, and a scale measure of mental health outcomes. This question has implications for clinical care and counseling of this population. Methods: Seventy-seven black transwomen were recruited to participate in a private, face-to-face structured interview. Two index measures of gender affirmation (GA) were constructed from the data. One comprised medical aspects only and the other comprised social aspects of GA. Assessed outcomes were personal competence and acceptance of self and life (resiliency), perceived stress and recent anxiety, depression, and suicide ideation (mental health). Associations between GA variables and outcomes were first assessed using bivariate level correlations. Significant bivariate associations were then tested in multivariable regression models adjusting for age and HIV status. Results: Mean age of the sample was 34.5 years. More than one-half of the sample (62.3%) indicated being HIV-infected. None of the bivariate or multivariable associations pertaining to GA medical factors were significant. Conversely, the social GA factors were significant and protective with all four outcomes. In the presence of age and HIV status, greater social GA was significantly associated with greater personal competence, acceptance of self and life, and positive mental health outcome. HIV status had an independent effect on personal competence, acceptance of self and life, with HIV-positive transwomen scoring higher on both measures. Conclusion: Among black transwomen at high risk of HIV acquisition or already HIV-infected, study findings suggest the possibility that socially based GA may play a prominent role in strengthening the resiliency and mental health of black transwomen. This same protective effect may not occur as a consequence of gender affirming body modification practices.