Associations Between the Length of Time from Transgender Identity Recognition to Hormone Initiation and Smoking Among Transgender Youth and Young Adults

A Qualitative Examination of Tobacco Use and Smoking Cessation Among Gender Minority Adults

BACKGROUND

Despite the elevated prevalence of smoking among gender minority adults, little is known about the factors that influence their tobacco use and cessation.

PURPOSE

We identified and examined factors that influence tobacco use and cessation for gender minority adults, using a conceptual framework based on the Model of Gender Affirmation and Gender Minority Stress Model.

METHODS

Nineteen qualitative, semi-structured in-depth interviews were conducted with gender minority adults who smoke or no longer smoke and were recruited from the Portland, OR metropolitan area. Interviews were audio-recorded, professionally transcribed, and analyzed utilizing thematic analysis.

RESULTS

Four main themes were generated. Gender minority adults smoke to cope with general and gender minority-specific stressors. Smoking was described as a social behavior that was influenced and sustained by community and interpersonal relationships. Smoking cessation was motivated by health concerns (both general and gender minority-specific) and moderated by conducive life circumstances. Recommendations for tobacco cessation interventions highlighted the importance and role of social support. Participants expressed a strong desire for gender minority-specific tobacco cessation programs. There are unique and complex factors that contribute to the higher prevalence of smoking observed among gender minority adults.

CONCLUSIONS

Tobacco cessation interventions are urgently needed for this population and should be tailored to address the unique factors that impact tobacco use and cessation among gender minority people to increase the likelihood of success.

Stressors Associated with Tobacco Use Among Trans Women

Purpose

Tobacco use is prevalent among sexual and gender minorities (SGM), yet few studies have examined the specific drivers of tobacco use among trans women. The purpose of this study is to examine the impact of proximal, distal, and structural stressors associated with tobacco use among trans women.

Methods

This study is based on a cross-sectional sample of trans women (n=162) living in Chicago and Atlanta. Analyses were conducted to examine the association between stressors, protective factors, and tobacco use using a structural equation modeling framework. Proximal stressors (transgender roles scale, transgender congruence scale, internalized stigma, and internalized moral acceptability) were operationalized as a higher order latent factor, while distal stressors were operationalized as observed variables (discrimination, intimate partner violence, sex work, rape, child sexual abuse, HIV, and violence). Protective factors included social support, trans-related family support, and trans-related peer support. All analyses adjusted for sociodemographic variables (age, race/ethnicity, education, homelessness and health insurance).

Results

The prevalence of smoking among trans women in this study was 42.9%. In the final model, homelessness (odds ratio [OR]: 3.78; 95% confidence interval [CI]: 1.97, 7.25), intimate partner violence (OR: 2.14; 95% CI: 1.07, 4.28), and commercial sex work (OR: 2.22; 95% CI: 1.09, 4.56) were all associated with tobacco use. There was no association between proximal stressors and tobacco use.

Conclusion

Among trans women, tobacco use prevalence was high. Tobacco use was associated with homelessness, intimate partner violence, and commercial sex work. Targeted tobacco cessation programs should account for the co-occurring stressors that trans women face.

"I'm a transgender man… I have to quit smoking for treatment and surgery": Describing the experience of a Latino transgender man during his attempt to quit smoking

OBJECTIVE

To describe the experience of a Latino transgender man during his attempt to quit smoking using a text messaging intervention.

METHODS

A Latino transgender man enrolled in a smoking cessation randomized controlled trial for Latino smokers. The participant was randomized to Decídetexto, a smoking cessation mobile intervention. The participant received a 24-week text messaging intervention. We assessed text messaging interactivity with the program, satisfaction, and self-reported abstinence at Week 12 and Month 6.

RESULTS

During the 24-week intervention period, the participant sent a total of 287 text messages to the program. When analyzing the content of the text messages sent by the participants, four important themes were identified: 1) gender identity, 2) low social support, 3) stressors (e.g., gender dysphoria), and 4) gender affirmation surgery as a reason to quit smoking. At both Week 12 and Month 6, the participant reported being extremely satisfied with the intervention and self-reported cigarette use.

CONCLUSION

A smoking cessation mobile intervention generated high satisfaction and frequent interactivity among a Latino transgender man. This case report provides important insights into the experience of one Latino transgender man during his attempt to quit smoking. There is an urgent need to develop or adapt existing smoking cessation interventions to better meet the needs of transgender people.

Coming Soon: Ability to Orgasm After Gender Affirming Vaginoplasty

BACKGROUND

Many patients have goals related to sexual health when seeking gender-affirming vaginoplasty, and previous investigations have only studied the ability to orgasm at cross-sectional timepoints.

AIM

Our aim is to quantify the time to orgasm postoperative gender-affirming vaginoplasty and describe potential correlative factors, including preoperative orgasm, to improve preoperative counseling.

METHODS

A retrospective chart review was utilized to extract factors thought to influence pre and postoperative orgasm in patients undergoing robotic peritoneal flap vaginoplasty. Mean days to orgasm plus one standard deviation above that mean was used to define the time at which patients would be considered anorgasmic.

OUTCOMES

Orgasm was documented as a categorical variable on the basis of surgeon interviews during pre and postoperative appointments while time to orgasm was measured as days from surgery to first date documented as orgasmic in the medical record.

RESULTS

A total of 199 patients underwent surgery from September 2017 to August 2020. The median time to orgasm was 180 days. 178 patients had completed 1 year or greater of follow-up, and of these patients, 153 (86%) were orgasmic and 25 patients (14%) were not. Difficulty in preoperative orgasm was correlated only with older age (median age 45.9 years vs 31.7, P = .03). Postoperative orgasm was not significantly correlated with preoperative orgasm. The only factor related to postoperative orgasm was smoking history: 12 of 55 patients (21.8%) who had a positive smoking history and sufficient follow-up reported anorgasmia (P-value .046). Interventions for anorgasmic patients include testosterone replacement, pelvic floor physical therapy, and psychotherapy.

CLINICAL IMPLICATIONS

Preoperative difficulty with orgasm improves with gender-affirming robotic peritoneal flap vaginoplasty, while smoking had a negative impact on postoperative orgasm recovery despite negative cotinine test prior to surgery.

STRENGTHS & LIMITATIONS

This investigation is the first effort to determine a timeline for the return of orgasmic function after gender-affirming vaginoplasty. It is limited by retrospective review methodology and lack of long-term follow-up. The association of smoking with postoperative orgasm despite universal nicotine cessation prior to surgery may indicate prolonged smoking cessation improves orgasmic outcomes or that underlying, unmeasured exposures correlated with smoking may be the factor inhibiting recovery of orgasm.

CONCLUSION

The majority of patients were orgasmic at their 6-month follow-up appointments, however, patients continued to become newly orgasmic in appreciable numbers more than 1 year after surgery. Blasdel G, Kloer C, Parker A, et al. Coming Soon: Ability to Orgasm After Gender Affirming Vaginoplasty. J Sex Med 2022;19:781-788.

Psychological Stress Identification and Evaluation Method Based on Mobile Human-Computer Interaction Equipment

Since the 1980s, the research of artificial neural networks in the field of artificial intelligence has become more and more common. It accepts nonlinear parallel processing, has strong learning and flexibility, and can be used for influencing factor analysis. The ideal power values and triggers are obtained in the Hopfield network model using genetic algorithm, which best avoids the drawbacks of the Hopfield network model instillation learning method. Through the BP of mobile human-computer interaction equipment, hereditary, genetic algorithms, and Hi-PLS regression method in the artificial neural network, the psychological pressure of college students is identified, evaluated, and predicted from three dimensions such as learning, life, and personal events. This makes it possible to understand the current physical and mental conditions of the students in a timely manner, guide to relieve anxiety and fear, and reach a safe psychological level. The three test results are less than 1%, which has high research significance and value.

Correlates of Tobacco and Nicotine Use Among Transgender and Gender Diverse People: A Systematic Review Guided by the Minority Stress Model

INTRODUCTION

ransgender and gender diverse (TGD) people have a higher prevalence of tobacco and nicotine use compared to their cisgender peers.

AIMS AND METHODS

Using the minority stress model as a guide, we conducted a systematic review of correlates of tobacco and nicotine use among TGD people. We reviewed the literature from Pubmed, PsycINFO, and CINAHL between April 1, 1995 and April 20, 2021. Article inclusion criteria were the following: written in English, reported empirical data, sampled exclusively or reported separate outcomes for transgender/gender diverse people, and reported correlates of tobacco or nicotine use, broadly defined. The first and second authors reviewed the articles retrieved from the search and from gray literature (relevant listserv solicitations) for inclusion. They then reviewed references of any included articles for additional candidate articles.Results: This resulted in 35 articles for review, which were synthesized in a qualitative fashion. The overall quality of the articles was fair, with the articles ranging from poor to fair quality and using primarily cross-sectional design and survey methods.

CONCLUSIONS

Overall, the literature demonstrated external minority stressors were mostly researched (and supported) correlates of tobacco and nicotine use among TGD people. There is a critical need for higher quality research, such as longitudinal or experimental designs, to improve our understanding and prevention of tobacco and nicotine use in this population.

IMPLICATIONS

This systematic review used the minority stress model as a guide to understand correlates of tobacco and nicotine use among transgender and gender diverse people. Literature of fair quality demonstrated that external minority stressors were the most researched and supported correlates of tobacco and nicotine use within the framework of the minority stress model. This review demonstrated a critical need for higher quality research, such as longitudinal or experimental designs, to improve our understanding and prevention of tobacco and nicotine use in this population. Preliminary findings from the limited literature highlight factors that may be relevant to target with this population, including general/environmental stressors and external minority stressors such as discrimination.

Nicotine/tobacco use disparities among transgender and gender diverse adults: Findings from wave 4 PATH data

BACKGROUND

Transgender and Gender Diverse (TGD) populations have current cigarette/e-cigarette/cigar use rates ranging from 32.6% to 39.7%. Importantly, while some studies have reported tobacco use as significantly higher among TGD versus cisgender individuals in multivariate analyses, others have reported no significant differences. The present study used data from wave 4 of the Population Assessment of Tobacco and Health (PATH) study, a large, nationally representative U.S. study, to examine relationships among sociodemographic characteristics, internal and external factors, and tobacco use behaviors, with a focus on TGD individuals.

METHODS

Data were from 33,628 adults from the PATH study's wave 4 (collected December 2016-January 2018). Multivariable logistic regression models examined differences in current tobacco use (cigarettes, electronic nicotine products, and cigars) between TGD and cisgender individuals through the replication of previous work using PATH data, as well as evaluating the role of other internal and external factors.

RESULTS

TGD individuals were 2-3 times more likely than cisgender individuals to report current nicotine/tobacco use, even after adjustment for potential confounders. TGD individuals tended to have lower income and education and be more likely to endorse a sexual minority identity than their cisgender counterparts; meanwhile, lower income, less education, and lesbian/gay and bisexual identities were significant predictors of nicotine/tobacco use, independent of TGD identity.

CONCLUSIONS

Present findings underscore the high rates of nicotine/tobacco use in the TGNC community and emphasize the necessity of TGD-focused research methods and measures, access to quality medical care, and policy aimed at minimizing marginalization and nicotine/tobacco use disparities experienced by TGD communities.

Tobacco use among transgender and gender non-binary youth in Brazil

Transgender and gender non-binary youth are particularly vulnerable to tobacco smoking and susceptible to smoking adverse health outcomes. That is, they are in special risk to start smoking and, after starting, they may face worse outcomes when comparing to their cisgender peers. Therefore, the present study aims to evaluate factors associated with tobacco use among transgender and gender non-binary youth. Brazilian youth aged 16 to 25 who identify as transgender or gender non-binary answered an online questionnaire. Poisson regression with robust variance was run to predict smoking cigarettes based on individual and environmental factors. 14.1% of 206 youth reported smoking cigarettes daily, whereas 9.3% of participants reported smoking e-cigarettes occasionally. Drug use, lack of social support, deprivation, discrimination, the wait for medical gender-affirming procedures and being outside school were associated with smoking cigarettes. Contextual and individual factors should be further explored in causal analysis and taken into consideration when planning smoking prevention and cessation interventions for transgender and gender non-binary youth.

Smoking Protective and Risk Factors Among Transgender and Gender-Expansive Individuals (Project SPRING): Qualitative Study Using Digital Photovoice

BACKGROUND

Transgender and gender-expansive (TGE) adults are twice as likely to smoke cigarettes than cisgender individuals. There is a critical gap in research on effective and culturally sensitive approaches to reduce smoking prevalence among TGE adults.

OBJECTIVE

This study aims to qualitatively examine the risk and protective factors of cigarette smoking among TGE adults through real-world exemplars.

METHODS

We conducted a digital photovoice study among a purposeful sample of 47 TGE adults aged ≥18 years and currently smoking in the United States (March 2019-April 2020). Participants uploaded photos daily that depicted smoking risk and protective factors they experienced over 21 days on either private Facebook or Instagram groups. Next, we conducted separate focus group discussions to explore the experiences of these factors among a subset of participants from each group. We analyzed participants' photos, captions, and focus group transcripts and generated themes associated with smoking risk and protective factors.

RESULTS

We identified 6 major themes of risk and protective factors of smoking among TGE individuals: experience of stress, gender affirmation, health consciousness, social influences, routine behaviors, and environmental cues. We describe and illustrate each theme using exemplar photos and quotes.

CONCLUSIONS

The findings of this study will inform future community-engaged research to develop culturally tailored interventions to reduce smoking prevalence among TGE individuals.

Mental Healthcare Utilization of Transgender Youth Before and After Affirming Treatment

OBJECTIVE

Transgender and gender-diverse (TGD) adolescents experience increased mental health risk compared to cisgender peers. Limited research suggests improved outcomes following gender-affirmation. This study examined mental healthcare and psychotropic medication utilization among TGD youth compared to their siblings without gender-related diagnoses and explored utilization patterns following gender-affirming care.

METHOD

This retrospective cohort study used military healthcare data from 2010-2018 to identify mental healthcare diagnoses and visits, and psychotropic medication prescriptions among TGD youth who received care for gender dysphoria before age 18, and their siblings. Logistic and Poisson regression analyses compared mental health diagnosis, visits, and psychotropic prescriptions of TGD youth to their siblings, and compared healthcare utilization pre- and post-initiation of gender-affirming pharmaceuticals among TGD adolescents.

RESULTS

3,754 TGD adolescents and 6,603 cisgender siblings were included. TGD adolescents were more likely to have a mental health diagnosis (OR 5.45, 95% CI [4.77-6.24]), use more mental healthcare services (IRR 2.22; 95% CI [2.00-2.46]), and be prescribed more psychotropic medications (IRR = 2.57; 95% CI [2.36-2.80]) compared to siblings. The most pronounced increases in mental healthcare were for adjustment, anxiety, mood, personality, psychotic disorders, and suicidal ideation/attempted suicide. The most pronounced increased in psychotropic medication were in SNRIs, sleep medications, anti-psychotics and lithium. Among 963 TGD youth (M_age: 18.2) using gender-affirming pharmaceuticals, mental healthcare did not significantly change (IRR = 1.09, 95% CI [0.95-1.25]) and psychotropic medications increased (IRR = 1.67, 95% CI [1.46-1.91]) following gender-affirming pharmaceutical initiation; older age was associated with decreased care and prescriptions.

CONCLUSION

Results support clinical mental health screening recommendations for TGD youth. Further research is needed to elucidate the longer-term impact of medical affirmation on mental health, including family and social factors associated with the persistence and discontinuation of mental healthcare needs among TGD youth. Hisle-Gorman E, Schvey NA, Adirim TA, et al. Mental Healthcare Utilization of Transgender Youth Before and After Affirming Treatment. J Sex Med 2021;18:1444-1454.

Progression of Gender Dysphoria in Children and Adolescents: A Longitudinal Study

BACKGROUND AND OBJECTIVES

The progression of gender-expansive behavior to gender dysphoria and to gender-affirming hormonal treatment (GAHT) in children and adolescents is poorly understood.

METHODS

A cohort of 958 gender-diverse (GD) children and adolescents who did not have a gender dysphoria-related diagnosis (GDRD) or GAHT at index were identified. Rates of first GDRD and first GAHT prescription were compared across demographic groups.

RESULTS

Overall, 29% of participants received a GDRD and 25% were prescribed GAHT during the average follow-up of 3.5 years (maximum 9 years). Compared with youth assigned male sex at birth, those assigned female sex at birth were more likely to receive a diagnosis and initiate GAHT with hazard ratio (95% confidence interval) estimates of 1.3 (1.0-1.7), and 2.5 (1.8-3.3), respectively. A progression to diagnosis was more common among those aged ≥15 years at initial presentation compared with those aged 10 to 14 years and those aged 3 to 9 years (37% vs 28% vs 16%, respectively). By using the youngest group as a reference, the adjusted hazard ratios (95% confidence interval) for a GDRD were 2.0 (1.3-3.0) for age 10 to 14 years and 2.7 (1.8-3.9) for age ≥15 years. Racial and ethnic minorities were less likely to receive a diagnosis or be prescribed GAHT.

CONCLUSIONS

This study characterized the progression of GD behavior in children and adolescents. Less than one-third of GD youth receive an eventual GDRD, and approximately one-quarter receive GAHT. Female sex at birth, older age of initial GD presentation to medical care, and non-Hispanic white race and ethnicity increased the likelihood of receiving diagnosis and treatment.

A Scoping Review Examining Social and Legal Gender Affirmation and Health Among Transgender Populations

Purpose: Transgender (trans) populations experience health inequities. Gender affirmation refers to psychological, social, legal, and medical validation of one's gender and is a key social determinant of trans health. The majority of research has focused on medical affirmation; however, less is known about the role of social and legal affirmation in shaping trans health. This review aimed to (1) examine how social and legal gender affirmation have been defined and operationalized and (2) evaluate the association between these forms of gender affirmation and health outcomes among trans populations in the United States. Methods: We conducted a systematic search of LGBT Life, PsycInfo, and PubMed using search strings targeting transgender populations and gender affirmation. This review includes 24 of those articles as well as 1 article retrieved through hand searching. We used a modified version of the National Institute of Health Quality Assessment Tool to evaluate study quality. Results: All studies relied on cross-sectional data. Studies measured and operationalized social and legal gender affirmation inconsistently, and some measures conflated social gender affirmation with other constructs. Health outcomes related to mental health, HIV, smoking, and health care utilization, and studies reported mixed results regarding both social and legal gender affirmation. The majority of studies had serious methodological limitations. Conclusion: Despite conceptual and methodological limitations, social and legal gender affirmation were related to several health outcomes. Study findings can be used to develop valid and reliable measures of these constructs to support future multilevel interventions that improve the health of trans communities.

Sexual and gender minority young adults' smoking characteristics: Assessing differences by sexual orientation and gender identity

INTRODUCTION

Sexual and gender minority (SGM) young adults have higher smoking prevalence than their non-SGM peers. Less is known about differences in smoking characteristics within the SGM community.

METHODS

Participants were SGM young adult smokers age 18-25 (N = 165, M age = 21.8) enrolled in a clinical trial of the Put It Out Project, a Facebook smoking cessation intervention for SGM young adults. Analyses tested differences between 1) sexual orientation groups, and 2) gender identity groups, on the following smoking characteristics: cigarettes/day, daily smoker (yes/no), social smoker (yes/no), years of smoking, number of close friends who smoke (out of 5), age of initiation, age began smoking regularly, time to first cigarette (30 min or less/>30 min), lifetime quit attempts, past-year quit attempts, and stage of change for quitting smoking (precontemplation, contemplation, preparation).

RESULTS

Participants were 56% bi/pansexual, 18% gay, 18% lesbian, 8% other (e.g., asexual, queer). The gender identity of the sample was 52% cisgender, 18% transgender, 30% gender non-binary. Lesbian women began smoking at an older age (M = 18.0, SD = 2.0) than "other" sexual orientation participants (M = 15.7, SD = 2.2), p < .05. Transgender participants smoked the most cigarettes per day (M = 11.3, SD = 6.7), followed by cisgender (M = 8.1, SD = 5.6), then non-binary (M = 5.7, SD = 3.5) participants (p < .001; pairwise comparisons p's < 0.05). No other constructs differed by sexual orientation or gender.

CONCLUSIONS

Smoking characteristics were mostly similar across subgroups of young adult SGM smokers; however, transgender individuals were heavier smokers.