Propensity Score Analysis Assessing the Burden of Non-Communicable Diseases among the Transgender Population in the United States Using the Behavioral Risk Factor Surveillance System (2017-2019)

Gender Identity and Cardiovascular Disease Among Adults in the United States

Purpose: The purpose of this study was to examine associations across gender identity subgroups and cardiovascular disease (CVD) subsets including myocardial infarction (MI), stroke, and coronary heart disease/angina. Methods: Nationally representative cross-sectional data from the Behavioral Risk Factor Surveillance System years 2019 and 2021 were analyzed. Multivariable logistic regression was conducted to assess the odds ratios of CVD and disease subsets for transgender women, transgender men, and gender nonconforming individuals compared to cisgender men and cisgender women. Results: In total, 2108 survey participants identified as transgender of which 35.0% were transgender women, 34.1% were transgender men, and 30.9% were gender nonconforming individuals. Compared to cisgender women, transgender men (adjusted odds ratio [aOR]: 1.62; 95% confidence interval [CI]: 1.02-2.58) and cisgender men (aOR: 1.85; 95% CI: 1.76-1.94) had increased odds of CVD. Transgender women (aOR: 2.25; 95% CI: 1.07-4.73), transgender men (aOR: 1.97; 95% CI: 1.06-3.65), gender nonconforming individuals (aOR: 2.47; 95% CI: 1.08-5.61), and cisgender men (aOR: 2.55; 95% CI: 2.37-2.73) all had higher odds of MI when compared to cisgender women. Transgender men (aOR: 2.05; 95% CI: 1.01-4.16) and cisgender men (aOR: 2.07; 95% CI: 1.94-2.21) had higher odds of heart disease/angina than cisgender women. Conclusion: This study revealed variability in self-reported CVD among transgender men, transgender women, and gender nonconforming individuals compared with cisgender men and cisgender women. This emphasizes the need for targeted research and interventions to improve health outcomes in these populations.

Social-Ecological Determinants of Suicidal Ideation Among Sexual and Gender Minority Adults: A Cross-Sectional Study in the United States

Background/Objectives: Sexual and gender minority (SGM) adults are at an increased risk for suicide and suicidal ideation compared with cisgender/heterosexual adults. Due to the complexity of suicidal ideation, individual, social, and systemic factors must be considered. The purpose of this study was to identify determinants of suicidal ideation among SGM adults using constructs from the Social-Ecological Model (SEM). Methods: This was a cross-sectional study of data collected from 1034 SGM adults between 27 January and 7 February 2022, and variables reflected the four constructs of the SEM, including individual, family, community, and societal levels. Hierarchical multiple linear regression was used to enter the variables in blocks. Results: The final model explained 55% of the variance in suicidal ideation, and determinants of suicidal ideation were identified at all four levels. At the individual level, factors were depression (p < 0.001, β = 0.231), anxiety (p < 0.001, β = 0.279), vigilance distress (p = 0.036, β = 0.157), not being out/open (p = 0.046, β = 1.136), having some college education (p = 0.002, β = -1.875), and personal strength (p = 0.012, β = -0.131). Family of origin discrimination distress was significant at the family level (p = 0.016, β = 0.174). Social resources (p < 0.001, β = -0.113), victimization distress (p < 0.001, β = 0.795), and harassment/discrimination distress (p = 0.035, β = 0.179) were significant at the community level. At the social level, SGM protective state law score (p = 0.43, β = -0.35) and having a proposed or enacted transgender sports ban (p = 0.027, β = 1.480) were significant. Conclusions: Understanding the factors across the various levels of the SEM that influence suicidal ideation allows for the development of multi-level, social-ecological suicide prevention programs. Such programs can address the unique needs of SGM individuals and help mitigate suicidal ideation.

Gender Differences in Self-assessed Measures of Health: How Does the Structure of Self-rated Health Compare Across Transgender and Cisgender Groups?

Self-rated health (SRH) is consistently related to mortality and morbidity. Yet, health ratings are subjective and reflect an individual's social context. Prior work has found differences in the structure of SRH-that is, in how self-assessments relate to underlying health conditions-across social groups, including by gender. However, prior work has not included transgender adults despite evidence that widespread interpersonal and structural stigma uniquely shapes their subjective experience of health. This study draws on information about 12 health conditions for a sample of transgender men, transgender women, nonbinary adults, cisgender men, and cisgender women. It examines whether the probabilities of reporting poor or fair SRH are similar among those with various underlying health problems. Findings reveal differences by gender identity and age group. For more than half of the examined conditions, self-rated health is poorer among nonbinary adults and younger transgender men than among other gender groups. These differences likely reflect distinct self-assessment processes that consider minority stress and structural stigma, as well as underlying differences in severity and comorbidity that stem from such stigma processes. SRH remains a useful, holistic measure of well-being, including for transgender groups.

Non-communicable diseases and its risk factors among the transgender population in Kerala: a cross-sectional study

BACKGROUND

Non-communicable diseases (NCDs) are high on the priority list of the Kerala government, and exploring the extent to which transgender and gender diverse (TGD) community members benefit from the services of national programmes for NCDs can provide valuable insights on improving the inclusivity of the health system as it moves towards Universal Health Coverage. This study was conducted to explore the prevalence of NCD risk factors as well as facilitators and barriers to NCD management among the TGD population in Kerala.

METHODS

A multiple methods study, including a cross-sectional survey of 120 self-identifying TGD people that included an adaptation of the WHO STEPS questionnaire, as well as in-depth interviews with thirteen individuals, was conducted in three districts of Kerala to explore the barriers and facilitators to NCD prevention and management.

RESULTS

The results are presented using the key dimensions emerging out of the Diederichsen framework. A range of discrimination faced by TGD people in Kerala traps them in situations of low educational outcomes with consequent disadvantages in the job market when they search for livelihoods. This results in a large proportion of our sample living away from families (69 percent), and finding themselves in precarious jobs including sex work (only 33 percent had a regular job), with all these aforementioned factors converging to marginalise their social position. This social position leads to differential risk exposures such as increased exposure to modifiable risk factors like alcohol (40 percent were current alcohol users) and tobacco use (40.8 percent currently used tobacco) and ultimately metabolic risk factors too (30 and 18 percent were hypertensive and diabetic respectively). Due to their differential vulnerabilities such as the discrimination that TGD people are subjected to (41.7 percent had faced discrimination at a healthcare centre in the past one year), those with higher exposure to risk factors often find it hard to bring about behavioural modifications and are often not able to access the services they require.

CONCLUSIONS

The disadvantaged social position of TGD people and associated structural issues result in exacerbated biological risks, including those for NCDs. Ignoring these social determinants while designing health programmes is likely to lead to sub-optimal outcomes.

The impact of gender-affirming hormone therapy on nutrition-relevant biochemical measures

Gender-affirming hormone therapy carries the potential risk for shifts in biochemical markers that may impact cardiometabolic, hematologic, hepatic, and renal health. The critical evaluation of biochemical data is an integral part of a comprehensive nutrition assessment; therefore, nutrition professionals should be aware of shifts that are expected during the course of masculinizing and feminizing hormone therapy. Changes in important biochemical values along with binary sex-specific standards for interpreting laboratory data can pose significant challenges for nutrition professionals working with transgender and gender-diverse patients who receive gender-affirming hormone therapy. Overall, research on the biochemical impact of masculinizing and feminizing hormone therapy is nascent and limited. Methodologies and outcomes measured are heterogenous across studies, introducing complexities that impede researchers from drawing definitive conclusions. In light of these limitations, this narrative review aims to describe the potential implications of masculinizing and feminizing hormone therapy regimens on biochemical measures that may influence nutrition strategies and interventions to promote optimal health.

Using concept mapping to identify recruitment and engagement strategies for inclusion of LGBTQIA+ populations in Alzheimer's disease and related dementia research

INTRODUCTION

Past Alzheimer's disease and related dementias (ADRD) research has not considered ways to ensure the representation of diverse sexual and gender minorities. This study used concept mapping (CM) to identify strategies for engaging and recruiting LGBTQIA+ older adults living with memory loss and their caregivers into ADRD research.

METHODS

CM, involving brainstorming, thematic analysis, and rating of strategies, was conducted with 46 members from one national and three local community advisory boards. Data was analyzed using The Concept Systems Global MAX™ web platform.

RESULTS

One hundred twenty-two solutions were identified from June through December 2022, and represented five key themes: aging focused, LGBTQIA+ specific, memory loss and caregiving support focused, physical advertisements, and other media. Promising strategies included partnering with LGBTQIA+ health centers, attending social groups for older adults, and increasing community representation in marketing.

DISCUSSION

Tailored strategies, building trust, and community involvement are essential for engaging LGBTQIA+ individuals living with memory loss or ADRD and their caregivers in ADRD-focused research.

Highlights

Innovative ways to ensure the inclusion of LGBTQIA+ older adults in Alzheimer's disease and related dementias (ADRD) research can be bolstered through collaboration with key community stakeholders.Promising strategies for recruitment and engagement include partnering with LGBTQIA+ centers, attending social groups for older adults, and ensuring diverse representation in marketing.Tailored recruitment and engagement strategies are crucial for building trust with LGBTQIA+ populations to increase participation in ADRD research.

Moderated Mediation Analysis of Structural Stigma and Suicidal Ideation and Behaviors Among Sexual and Gender Minority Adults

Purpose: This study aimed to conduct a moderated mediation analysis to understand further the complex pathways through which structural stigma in the form of transgender sports bans was associated with suicidal ideation and behaviors among sexual and gender minority (SGM) adults. Methods: A cross-sectional survey of 1033 adults who identified as SGM from across the 50 U.S. states and Washington, DC was conducted between January 28 and February 7, 2022. Distal discrimination distress was the mediation variable; individual resilience and social resources were the moderation variables. Familiarity with transgender sports bans represented structural stigma. The conditional process analysis was applied to build a moderated mediation model. Both conditional direct and indirect effects were computed by estimated coefficients. All models were based on linear regression. Results: Our final model explained nearly half (46%) of the variation in suicidal ideation and behaviors between those SGM adults familiar and those not familiar with transgender sports bans. Social resources significantly moderated the conditional indirect effect of distal discrimination distress (adjusted estimate = -0.23; 95% confidence interval = -0.37 to -0.08). Conclusion: Both discrimination distress and social resources influenced the association between structural stigma as measured by familiarity with transgender sports bans and suicidal ideation and behaviors among SGM adults. Findings support the need for future research examining the pathway between structural stigma and suicidal ideation and behaviors among SGM adults and how minority stress, social safety, and other constructs shape this pathway.

Sex and gender differences in risk scores for dementia and Alzheimer's disease among cisgender, transgender, and non-binary adults

INTRODUCTION

Few studies have explored dementia risk according to sex and gender including for transgender and non-binary adults. This study evaluated dementia risk factors and risk scores among cisgender, transgender, and non-binary adults.

METHODS

Observational data were drawn from the 2019 Behavioral Risk Factor Surveillance System. A matched-cohort approach was used to develop sex (male, female) and gender identity cohorts (cisgender men, cisgender women, transgender men, transgender women, and non-binary adults) for comparison. Dementia risk scores were calculated using established mid-life and late-life risk score algorithms.

RESULTS

Males had higher overall mid-life dementia risk, and lower late-life Alzheimer's disease risk compared to females. Transgender men, transgender women, and non-binary adults had higher overall late-life risk compared to both cisgender men and women.

DISCUSSION

Future research is needed to build the evidence base for specific risk factors that may be contributing to higher overall risk among understudied and underserved gender groups.

HIGHLIGHTS

Using data from the 2019 Behavioral Risk Factor Surveillance System, this matched-cohort study found that those assigned female at birth had lower overall mid-life dementia risk and higher overall late-life Alzheimer's disease (AD) risk compared to those assigned male at birth. Transgender men, transgender women, and non-binary adults all showed higher overall late-life AD risk compared to cisgender men and cisgender women. Between-group differences were found in the incidence of specific risk and protective factors for dementia and AD.

Hypertension in transgender individuals

Although there has been a dramatic increase in visibility and recognition of transgender and gender-diverse populations, remarkably little has been published on prevalence rates of hypertension within these populations. In addition to summarizing the limited data on prevalence rates, this review compares the prevalence rates with those of cisgender populations and explores whether gender-affirming hormone therapy affects blood pressure and hypertension rates. The studies show that hypertension affects a significant proportion of transgender and gender-diverse people and support the practice of routinely monitoring blood pressure in transgender and gender-diverse people, especially after the initiation of gender-affirming hormone therapy. The two largest studies both found that estrogen plus an antiandrogen was associated with a decrease in systolic blood pressure and that testosterone was associated with an increase in systolic blood pressure.

Investigating the Psychosocial Impact of COVID-19 Among the Sexual and Gender Minority Population: A Systematic Review and Meta-Analysis

Purpose: The purpose of this study was to utilize a systematic review and meta-analysis to assess the existing body of literature to understand the mental health impacts of the coronavirus disease-19 (COVID-19) pandemic among sexual and gender minority (SGM) people. Methods: The search strategy was developed by an experienced librarian and used five bibliographical databases, specifically PubMed, Embase, APA PsycINFO (EBSCO), Web of Science, and LGBTQ+ Source (EBSCO), for studies (published 2020 to June, 2021) examining the psychological impact of the COVID-19 pandemic among SGM people. Articles were screened by two reviewers. The quality of the articles was assessed using the National Institutes of Health quality assessment tool for observational studies. A double extraction method was used for data abstraction. Heterogeneity among studies was assessed by I2 statistic. The random-effects model was utilized to obtain the pooled prevalence. Publication bias was assessed by Funnel plot and Egger's linear regression test. Results: Of a total of 37 studies, 15 studies were included in the meta-analysis with 17,973 SGM participants. Sixteen studies were U.S. based, seven studies were multinational studies, and the remaining studies were from Portugal, Brazil, Chile, Taiwan, the United Kingdom, France, Italy, Canada, and several other countries. A majority of studies used psychometric valid tools for the cross-sectional surveys. The pooled prevalence of anxiety, depression, psychological distress, and suicidal ideation was 58.6%, 57.6%, 52.7%, and 28.8%, respectively. Conclusions: Findings of this study serve as evidence to develop appropriate interventions to promote psychological wellbeing among vulnerable population subgroups, such as SGM individuals.

Epidemiology of non-communicable diseases among transgender population residing in Chennai district, Tamil Nadu

Introduction

There is a paucity of research on non-communicable diseases (NCDs) like diabetes, hypertension and coronary heart diseases among transgenders, with more importance given to diseases like HIV. The study was undertaken to determine the prevalence of NCDs, their risk factors and the associated factors among transgenders residing in Chennai district, Tamil Nadu.

Methodology

This is a descriptive cross-sectional study done among 145 transgenders residing in the Chennai district, Tamil Nadu, selected by snowball sampling method. Data were collected by a pre-tested semi-structured questionnaire, anthropometric data were measured, and blood pressure was measured by a mercury sphygmomanometer using standard protocols. Data were entered in Excel software and analysed by using SPSS version 25.

Results

The mean age of the study participants was 36 ± 4.2 years. Nearly 91% had only up to school education. Around 26.7% suffered from type 2 diabetes mellitus, 15.1% had a history of hypertension, 36.3% were newly diagnosed hypertensives, and 13.9% were overweight/obese. Almost 40% were either current tobacco or alcohol consumers. There was a statistically significant association found between overweight/obesity and education, work, and income of study participants.

Conclusion

The high prevalence of NCDs among the study participants warrants health education among transgenders to get screened for common NCDs. Further research is needed to understand the risks of NCDs among transgenders.

Sexual Orientation and Gender Identity-Related State-Level Policies and Perceived Health Among Lesbian, Gay, Bisexual, and Transgender (LGBT) Older Adults in the United States

ObjectivesWe examined the associations between state-level policies and the health of lesbian, gay, bisexual, and transgender (LGBT) older adults. Methods: Using data from the 2018-2020 Behavioral Risk Factor Surveillance System surveys, we assessed physical and mental health by the tally of points for enacted LGBT-related policies (Low= <0-49.9% of possible points, High= 50-100% of possible points) in 10,032 sexual minority (i.e., lesbian, gay, and bisexual) and 1,072 transgender (non-sexual minority) adults aged 50 and older from 41 states. Results: Sexual minority adults in low tally states had greater odds of reporting fair or poor general health and 14 or more days of poor physical health in the past 30 days. Transgender participants in low tally states also had greater odds of reporting fair or poor general health. Discussion: Lesbian, gay, bisexual, and transgender adults have significantly greater risk of poor health if they live in a state with fewer LGBT anti-discriminatory policies enacted.

Impact of COVID-19 on Sexual and Gender Minority Communities: Focus Group Discussions

BACKGROUND

People who identify as sexual and gender minorities (SGM) experienced disproportionate economic and mental health issues related to COVID-19 when compared to the general population. The purpose of this study was to better understand how COVID-19 has impacted the SGM community and ways to address vaccine hesitancy.

METHODS

Three focus groups were conducted with 21 members of the SGM community between 5 November and 10 December 2020. A thematic analysis using the reflexive approach was applied to the transcripts of the focus groups.

RESULTS

Four themes emerged: (1) Impact of COVID-19 on the Community, (2) Perceptions of Contact Tracing and Testing, (3) Perceptions of a Potential COVID-19 Vaccine, and (4) Decreasing Vaccine Hesitancy. The most relevant subthemes were that social isolation led to anxiety, stress, and fear in the SGM community during COVID-19; resilience and adaptation were positive outcomes of the pandemic; histories of medical racism contributed to hesitancy to get tested; and specific messaging from trusted messengers may be needed to encourage SGM communities to get vaccinated. These findings support other COVID-19 research on the SGM community during the start of the pandemic.

CONCLUSIONS

This study provides insight into the impact of the early stages of COVID-19 on the SGM community, highlighting the unique hurdles faced by SGM individuals with regard to contact tracing and vaccine hesitancy.

Predictive Classifier for Cardiovascular Disease Based on Stacking Model Fusion

The etiology of cardiovascular disease is still an unsolved world problem, and high morbidity, disability, and mortality are the main characteristics of cardiovascular diseases. There is, therefore, a need for effective and rapid early prediction of likely outcomes in patients with cardiovascular disease using artificial intelligence (AI) techniques. The Internet of Things (IoT) is becoming a catalyst for enhancing the capabilities of AI applications. Data are collected through IoT sensors and analyzed and predicted using machine learning (ML). Existing traditional ML models do not handle data inequities well and have relatively low model prediction accuracy. To address this problem, considering the data observation mechanism and training methods of different algorithms, this paper proposes an ensemble framework based on stacking model fusion, from Support Vector Machines (SVM), K-Nearest Neighbor (KNN), Logistic Regression (LR), Random Forest (RF), Extra Tree (ET), Gradient Boosting Decision Tree (GBDT), XGBoost, LightGBM, CatBoost, and Multilayer Perceptron (MLP) (10 classifiers to select the optimal base learners). In order to avoid the overfitting phenomenon generated by the base learners, we use the Logistic Regression (LR) simple linear classifier as the meta learner. We validated the proposed algorithm using a fused Heart Dataset from several UCI machine learning repositories and another publicly available Heart Attack Dataset, and compared it with 10 single classifier models. The experimental results show that the proposed stacking classifier outperforms other classifiers in terms of accuracy and applicability.

Considerations for Transgender Population Health Research Based on US National Surveys

Transgender identities and health are highly politicized in the United States leading to restrictions on relevant data collection in national health surveillance systems. This has serious implications on transgender population health research; an urgent area of study given the systemic discrimination faced by transgender individuals and the resultant social and health inequities. In this precarious political climate, obtaining high-quality data for research is challenging and in recent years, two data sources have formed the foundation of transgender health research in the United States, namely the 2015 United States Transgender Study and the Behavioral Risk Factor Surveillance System (BRFSS) after the launch of the optional Sexual Orientation and Gender Identity Module in 2014. While useful, there are serious challenges to using these data to study transgender health, specifically related to survey weighting methodologies, ascertainment of gender identity, and study design. In this article, we detail these challenges and discuss the strengths and weaknesses of various methodological approaches that have been implemented as well as clarify several common errors that exist in the literature. We feel that this contribution is necessary to provide accurate interpretation of the evidence that currently informs policy and priority setting for transgender population health and will provide vital insights for future studies with these now ubiquitous sources of data in the field.

Physical and Mental Disabilities among the Gender-Diverse Population Using the Behavioral Risk Factor Surveillance System, BRFSS (2017-2019): A Propensity-Matched Analysis

This propensity-matched analysis utilized the publicly available Behavioral Risk Factor Surveillance System (2017–2019) data to compare the burden of disabilities among transgender/non-binary (TGNB) and cisgender groups. The groups were matched (1:1 ratio) on demographic variables using Nearest Neighborhood Matching. Categorical variables were compared among groups using a Chi-square analysis to test differences in the proportions. Multivariate logistic regression analysis was fit to predict the likelihood of the physical and mental disabilities among the TGNB group compared with the cisgender group while controlling for healthcare access factors, income, and employment. Survey weights were included in the model to account for the complex survey design. In a weighted sample of 664,103 respondents, only 2827 (0.4%) self-identified as TGNB. In the matched sample, a higher proportion of the TGNB group belonged to the low-income group (39.5% vs. 29.8%, p < 0.001), were unable to work (12.5% vs. 8.6%, p < 0.001), and delayed care due to cost barriers (19.0% vs. 12.4%, p < 0.001). Compared with the cisgender group, the odds of having difficulty making decisions were 1.94 times higher (95% CI: 1.67–2.27) and odds of difficulty walking were 1.38 times higher (95% CI: 1.19, 1.59) among the TGNB group. Additionally, the TGNB group had 59.8% higher adjusted odds ratio (aOR) (aOR 1.598, 95% Confidence interval (CI): 1.256, 2.034) of experiencing difficulty dressing and 83.3% higher odds (aOR 1.833, 95% CI: 1.533, 2.191) in having difficulty doing things alone. The findings of this study advocate for developing policies and interventions to deliver culturally competent care to the TGNB population with disabilities.