Levels of depression in transgender people and its predictors: Results of a large matched control study with transgender people accessing clinical services

One size does not fit all: notable individual variation in brain activity correlates of antidepressant treatment response

Introduction

To date, no robust electroencephalography (EEG) markers of antidepressant treatment response have been identified. Variable findings may arise from the use of group analyses, which neglect individual variation. Using a combination of group and single-participant analyses, we explored individual variability in EEG characteristics of treatment response.

Methods

Resting-state EEG data and Montgomery-Åsberg Depression Rating Scale (MADRS) symptom scores were collected from 43 patients with depression before, at 1 and 12 weeks of pharmacotherapy. Partial least squares (PLS) was used to: 1) identify group differences in EEG connectivity (weighted phase lag index) and complexity (multiscale entropy) between eventual medication responders and non-responders, and 2) determine whether group patterns could be identified in individual patients.

Results

Responders showed decreased alpha and increased beta connectivity, and early, widespread decreases in complexity over treatment. Non-responders showed an opposite connectivity pattern, and later, spatially confined decreases in complexity. Thus, as in previous studies, our group analyses identified significant differences between groups of patients with different treatment outcomes. These group-level EEG characteristics were only identified in ~40-60% of individual patients, as assessed quantitatively by correlating the spatiotemporal brain patterns between groups and individual results, and by independent raters through visualization.

Discussion

Our single-participant analyses suggest that substantial individual variation exists, and needs to be considered when investigating characteristics of antidepressant treatment response for potential clinical applicability.

Clinical trial registration

https://clinicaltrials.gov, identifier NCT00519428.

Transcriptional signatures of early-life stress and antidepressant treatment efficacy

Individuals with a history of early-life stress (ELS) tend to have an altered course of depression and lower treatment response rates. Research suggests that ELS alters brain development, but the molecular changes in the brain following ELS that may mediate altered antidepressant response have not been systematically studied. Sex and gender also impact the risk of depression and treatment response. Here, we leveraged existing RNA sequencing datasets from 1) blood samples from depressed female- and male-identifying patients treated with escitalopram or desvenlafaxine and assessed for treatment response or failure; 2) the nucleus accumbens (NAc) of female and male mice exposed to ELS and/or adult stress; and 3) the NAc of mice after adult stress, antidepressant treatment with imipramine or ketamine, and assessed for treatment response or failure. We find that transcriptomic signatures of adult stress after a history of ELS correspond with transcriptomic signatures of treatment nonresponse, across species and multiple classes of antidepressants. Transcriptomic correspondence with treatment outcome was stronger among females and weaker among males. We next pharmacologically tested these predictions in our mouse model of early-life and adult social defeat stress and treatment with either chronic escitalopram or acute ketamine. Among female mice, the strongest predictor of behavior was an interaction between ELS and ketamine treatment. Among males, however, early experience and treatment were poor predictors of behavior, mirroring our bioinformatic predictions. These studies provide neurobiological evidence for molecular adaptations in the brain related to sex and ELS that contribute to antidepressant treatment response.

Collective self-understanding: A linguistic style analysis of naturally occurring text data

Understanding what groups stand for is integral to a diverse array of social processes, ranging from understanding political conflicts to organisational behaviour to promoting public health behaviours. Traditionally, researchers rely on self-report methods such as interviews and surveys to assess groups' collective self-understandings. Here, we demonstrate the value of using naturally occurring online textual data to map the similarities and differences between real-world groups' collective self-understandings. We use machine learning algorithms to assess similarities between 15 diverse online groups' linguistic style, and then use multidimensional scaling to map the groups in two-dimensonal space (N=1,779,098 Reddit comments). We then use agglomerative and k-means clustering techniques to assess how the 15 groups cluster, finding there are four behaviourally distinct group types - vocational, collective action (comprising political and ethnic/religious identities), relational and stigmatised groups, with stigmatised groups having a less distinctive behavioural profile than the other group types. Study 2 is a secondary data analysis where we find strong relationships between the coordinates of each group in multidimensional space and the groups' values. In Study 3, we demonstrate how this approach can be used to track the development of groups' collective self-understandings over time. Using transgender Reddit data (N= 1,095,620 comments) as a proof-of-concept, we track the gradual politicisation of the transgender group over the past decade. The automaticity of this methodology renders it advantageous for monitoring multiple online groups simultaneously. This approach has implications for both governmental agencies and social researchers more generally. Future research avenues and applications are discussed.

Mental Health of Transmasculine Adults Receiving Gender-Affirming Hormone Therapy in Thailand

Purpose

Many studies have shown conflicting results regarding mental health among transmasculine adults or transgender men (TM). This study aimed to identify the prevalence of depression among Thai TM receiving gender-affirming hormone therapy (GAHT).

Methods

All TM, over 18 years of age, who received GAHT for at least three consecutive months were invited to complete a self-report questionnaire that covered participants' demographic and clinical data. Mental health, including depression, anxiety, and quality of life (QoL), was assessed. We reported the prevalence of mental illnesses and examined the correlations between mental health scores and other associated data.

Results

A total of 84 TM were included in the analysis. Major depression and generalized anxiety disorder were detected in 14.3% and 3.6%, respectively. Depression severity was negatively associated with age and QoL. Depression and anxiety severity were found to be positively associated.

Conclusions

Compared with the general Thai population, the prevalence of mental health problems among Thai TM receiving GAHT was higher. Age of maturity may be a potential mental health protective factor, and assessment in younger individuals may benefit mental health.

Depression, Anxiety, and Stress among the Malay Muslim Transgender Women in Northern Malaysia: A Mixed-Methods Study

The study aimed to determine the prevalence and associated factors of depression, anxiety, and stress among the Malay Muslim transgender women in the northwestern states of Peninsular Malaysia. This mixed-method, quantitative and qualitative, study was conducted in collaboration with a nongovernmental organization that works incognito to advocate and help transgender women. Participants were recruited using a snowball method. A self-administered questionnaire was used that included information related to the demographic background of participants, and the Depression, Anxiety and Stress Scale and Oslo-3 Social Support Scale. For the qualitative part of the study, 13 in-depth interviews were conducted using a semi-structured interview guide in the Malay language. The study showed the prevalence of depression, anxiety, and stress was 33.3% (n = 47), 48.2% (n = 68), and 26.2% (n = 37), respectively. Difficulty in finding employment was significantly associated with depression, anxiety, and stress, whereas a history of physical abuse was also significantly associated with anxiety, and being ostracized by friends was significantly associated with depression. During in-depth interviews, suicidal thoughts were mentioned by several respondents and many lamented poor support from family and cisgender friends, and they complained of societal pressure. In addition to being physically and verbally abused, some also complained about cyberbullying. There is an urgent need to identify those with mental distress among transgender women in Malaysia to enable early interventions. More research is needed to identify mental health issues among transgender women and highlight these issues to sensitize the general public to their problems.

Detransition Narratives Trouble the Simple Attribution of Madness in Transantagonistic Contexts: A Qualitative Analysis of 16 Canadians' Experiences

Emerging evidence suggests that transgender individuals are more likely than cisgender peers to receive a diagnosis with a primary mental disorder. Attributions of madness, though, may serve the social function of dismissing and discrediting transgender individual's self-perceptions. The narratives of individuals who stop or reverse an initial gender transition who also identify as living with mental health conditions can sometimes amplify these socio-political discourses about transgender people. Through a critical mental health lens, this article presents a qualitative analysis of 16 individuals who stopped or reversed a gender transition and who also reported a primary mental health condition. Semi-structured, virtual interviews were conducted with people living in Canada. Applying constructivist grounded theory methodology, and following an iterative, inductive approach to analysis, we used the constant comparative method to analyse these 16 in-depth interviews. Results show rich complexity such that participants narrated madness in nuanced and complex ways while disrupting biased attitudes that madness discredited their thoughts and feelings, including prior gender dysphoria. Instead, participants incorporated madness into expanding self-awareness and narrated their thoughts and feelings as valid and worthy. Future research must consider provider's perspectives, though, in treating mad individuals who detransitioned, since alternate gender-affirming care models may better support the identification and wellness of care-seeking individuals who may be identified (in the past, present, or future) as mad.

Gender-affirming treatment and mental health diagnoses in Danish transgender persons: a nationwide register-based cohort study

IMPORTANCE

Gender affirming treatment aims to improve mental health.

OBJECTIVE

To investigate longitudinal mental health outcomes in Danish transgender persons.

DESIGN

National register-based cohort study in Danish transgender persons with diagnosis code of "gender identity disorder" during the period 2000-2021.

PARTICIPANTS

Five age-matched controls of the same sex at birth and five age-matched controls of the other sex at birth were included for each transgender person.

MAIN OUTCOMES

Diagnosis codes of mental and behavioral disorders and/or prescription of psychopharmacological agents until June 2022.

RESULTS

The cohort included 3812 transgender persons with median age (interquartile range) 19 (15; 24) years for persons assigned female at birth (AFAB, N = 1993) and 23 (19; 33) years for persons assigned male at birth (AMAB, N = 1819) and 38 120 controls. Follow up duration was up to 10 years with mean (standard deviation) 4.5 (4.3) years. In transgender persons AFAB compared to control women, the odds ratio (OR) (95% confidence interval) for mental and behavioral disorders was 6.7 (5.5; 8.1) before the index date, 9.9 (8.4; 11.7) at 1 year, 5.8 (4.4; 7.7) at 5 years, and 3.4 (2.1; 7.5) at 8 years follow up. In transgender persons AMAB compared to control men, corresponding ORs were 5.0 (4.0; 6.4), 11.3 (9.3; 13.7), 4.8 (3.5; 6.5), and 6.6 (4.2; 10.3) at 8 years follow up (all P < .001).

CONCLUSION

The OR for mental health disorders was higher in transgender persons compared to controls and remained elevated throughout follow up, especially in transgender persons AMAB.

Insights Into the Cardiomodulatory Effects of Sex Hormones: Implications in Transgender Care

Transgender individuals that undergo gender-affirming hormone therapy may experience discrimination in the health care setting with a lack of access to medical personnel competent in transgender medicine. Recent evidence suggests that gender-affirming hormone therapy is associated with an increased risk of cardiovascular diseases and cardiovascular risk factors. A recent statement from the American Heart Association reinforces the importance of cardiovascular-focused clinical management and the necessity for more research into the impact of gender-affirming hormone therapy. With this in mind, this review will highlight the known cardiovascular risk factors associated with gender-affirming hormone therapy and identify potential molecular mechanisms determined from the limited animal studies that explore the role of cross-sex steroids on cardiovascular risk. The lack of data in this understudied population requires future clinical and basic research studies to inform and educate clinicians and their transgender patient population to promote precision medicine for their care to improve their quality of life.

Depression and HIV: a scoping review in search of neuroimmune biomarkers

People with HIV are at increased risk for depression, though the neurobiological mechanisms underlying this are unclear. In the last decade, there has been a substantial rise in interest in the contribution of (neuro)inflammation to depression, coupled with rapid advancements in the resolution and sensitivity of biomarker assays such as Luminex, single molecular array and newly developed positron emission tomography radioligands. Numerous pre-clinical and clinical studies have recently leveraged these next-generation immunoassays to identify biomarkers that may be associated with HIV and depression (separately), though few studies have explored these biomarkers in co-occurring HIV and depression. Using a systematic search, we detected 33 publications involving a cumulative N = 10 590 participants which tested for associations between depressive symptoms and 55 biomarkers of inflammation and related processes in participants living with HIV. Formal meta-analyses were not possible as statistical reporting in the field was highly variable; future studies must fully report test statistics and effect size estimates. The majority of included studies were carried out in the United States, with samples that were primarily older and primarily men. Substantial further work is necessary to diversify the geographical, age, and sex distribution of samples in the field. This review finds that alterations in concentrations of certain biomarkers of neuroinflammation (interleukin-6, tumour necrosis factor-α, neopterin) may influence the association between HIV and depression. Equally, the chemokines monocyte chemoattractant protein-1 (MCP-1) and interleukin-8 (IL-8) or the metabolic index kynurenine:tryptophan (Kyn:Trp), which have been the focus of several studies, do not appear to be associated with depressive symptoms amongst people living with HIV, as all (MCP-1) or most (IL-8 and Kyn:Trp) available studies of these biomarkers reported non-significant associations. We propose a biomarker-driven hypothesis of the neuroimmunometabolic mechanisms that may precipitate the increased risk of depression among people with HIV. Chronically activated microglia, which trigger key neuroinflammatory cascades shown to be upregulated in people with HIV, may be the central link connecting HIV infection in the central nervous system with depressive symptoms. Findings from this review may inform research design in future studies of HIV-associated depression and enable concerted efforts towards biomarker discovery.

Measuring Geographic Access to Transgender Hormone Therapy in Texas: A Three-step Floating Catchment Area Analysis

While the extant literature has established that transgender people face significant barriers to accessing healthcare, no studies to date have offered an explicitly spatial analysis of their access to trans-specific care. This study aims to fill that gap by providing a spatial analysis of access to gender-affirming hormone therapy (GAHT) using Texas as a case study. We used the three-step floating catchment area method, which relies on census tract-level population data and location data for healthcare facilities to quantify spatial access to healthcare within a specific drive-time window, in our case 120 min. For our tract-level population estimates we adapt estimates of the rates of transgender identification from a recent data source, the Household Pulse Survey, and use these in tandem with a spatial database of GAHT providers of the lead author's creation. We then compare results of the 3SFCA with data on urbanicity and rurality, as well as which areas are deemed medically underserved. Finally, we conduct a hot-spot analysis that identifies specific areas where health services could be planned in ways that could improve both access to GAHT for trans people and access to primary care for the general population. Ultimately, we conclude that our results illustrate that patterns of access to trans-specific medical care, like GAHT, do not neatly follow patterns of access to primary care for the general population and that therefore trans communities' access to healthcare warrants specific, further investigation.

Blood Pressure Challenge Reduces Hematomas in Gender-Affirming Mastectomy: A Retrospective Chart Review of 92 Consecutive Patients

BACKGROUND

Gender-affirming mastectomy is a common surgery for the treatment of gender incongruence and gender dysphoria and improves quality of life. Hematoma rates for gender-affirming double incision mastectomies are between 2.8% and 8.1%. This study aims to investigate the utility of a blood pressure challenge, whereby the patient's blood pressure is medically increased intraoperatively to reveal bleeding vessels that can be addressed with additional hemostasis before skin closure, to reduce postoperative hematoma.

METHODS

A retrospective chart review of patients who underwent gender-affirming double incision mastectomies over a 6-year period by a single surgeon was conducted. Surgeries were separated into a blood pressure challenge experimental group and a non-blood pressure challenge control group. Demographics, surgical characteristics, and postoperative complications were compared between the 2 cohorts using Pearson χ2, Fisher exact, t tests, univariate logistic regression, and multivariable logistical regression. Significance was established at P < 0.05.

RESULTS

A total of 92 patients (184 breasts) were included with 32 patients (64 breasts) in the control group and 60 (120 breasts) in the blood pressure challenge group. In the control group, there were 5 hematomas (7.81%) compared with 1 (0.83%) in the blood pressure challenge group (P = 0.02). On univariate logistical regression analysis, blood pressure challenge was the only variable significantly associated with hematoma (odds ratio, 0.1; 95% confidence interval, 0.01-0.63; P = 0.04). On multivariable logistical regression, after controlling for age, body mass index, smoking status, and mass of excised breast tissue, patients who underwent blood pressure challenge demonstrated lower hematoma rates (odds ratio, 0.08; 95% CI, 0.004-0.59; P = 0.04).

CONCLUSIONS

Using an intraoperative blood pressure challenge was associated with reduced hematoma rates. Guidelines for blood pressure challenge goals should be established to standardize care and reduce complications in gender-affirming mastectomies.

The Effect of Gender-Affirming Hormones on Gender Dysphoria, Quality of Life, and Psychological Functioning in Transgender Individuals: A Systematic Review

Gender-affirming hormone therapy (GAHT) is an essential part of gender affirmation for many transgender (including people with binary and nonbinary identities) individuals and although controlled studies are unethical, there remains limited evidence on the impact of GAHT on gender dysphoria, quality of life (QoL), and psychological functioning. Some clinicians and policy makers use the lack of evidence to argue against providing gender-affirming care. The aim of this review is to systematically and critically assess the available literature on the influence of GAHT on improving gender- and body-related dysphoria, psychological well-being, and QoL. Using Preferred Reporting Items for Systematic Review and Meta-analysis guidelines, we searched Ovid MEDLINE®, Embase®, and Ovid PsycINFO® from inception to March 6, 2019 to assess the influence of GAHT on (1) gender dysphoria, (2) body uneasiness, (3) body satisfaction, (4) psychological well-being, (5) QoL, (6) interpersonal and global functioning, and (7) self-esteem. Our search strategy found no randomized controlled trials. Ten longitudinal cohort studies, 25 cross-sectional studies, and 3 articles reporting both cross-sectional and longitudinal data were identified. While results are mixed, the majority of studies demonstrate that GAHT reduces gender dysphoria, body dissatisfaction, and uneasiness, subsequently improving psychological well-being and QoL in transgender individuals. However, all current researches are of low to moderate quality comprising longitudinal cohort studies and cross-sectional studies, making it difficult to draw clear conclusions and do not reflect external social factors unaffected by GAHT, which significantly impact on dysphoria, well-being, and QoL.

A Longitudinal Study Exploring the Role of Mental Health Symptoms and Social Support Regarding Life Satisfaction 18 Months after Initiation of Gender-Affirming Hormone Treatment

While positive changes in mental health have been found following gender-affirming hormone treatment (GAHT), it is unclear how pre-GAHT mental health and social support can influence treatment outcomes. To address this, a retrospective longitudinal design was used in which 137 participants completed measures of social support, anxiety, and depression prior to GAHT (T0) and a measure of life satisfaction 18 months after GAHT (T1). The data showed no significant differences in life satisfaction at T1 based on T0 caseness of anxiety or depression. It was also found that T1 life satisfaction was not predicted by levels of anxiety, depression, or social support at T0. The lack of significant differences in life satisfaction at 18 months post-GAHT based on pre-GAHT mental health, coupled with no evidence for the predictive role social support suggest that these factors are not central to long-term life satisfaction. For many, lower mental wellbeing may be part of the experience of awaiting GAHT and should not be regarded as indicative of longer-term issues. Instead, facilitation of social support connections and mental health support should be offered both concurrently with, and for those awaiting, GAHT.

Gender-affirming hormone therapy, mental health, and surgical considerations for aging transgender and gender diverse adults

As the transgender and gender diverse (TGD) population ages, more transfeminine and transmasculine individuals present to clinic to initiate or continue their gender-affirming care at older ages. Currently available guidelines on gender-affirming care are excellent resources for the provision of gender-affirming hormone therapy (GAHT), primary care, surgery, and mental health care but are limited in their scope as to whether recommendations require tailoring to older TGD adults. Data that inform guideline-recommended management considerations, while informative and increasingly evidence-based, mainly come from studies of younger TGD populations. Whether results from these studies, and therefore recommendations, can or should be extrapolated to aging TGD adults remains to be determined. In this perspective review, we acknowledge the lack of data in older TGD adults and discuss considerations for evaluating cardiovascular disease, hormone-sensitive cancers, bone health and cognitive health, gender-affirming surgery, and mental health in the older TGD population on GAHT.

Systematic mapping on availability, extent and distribution of mental health research in Malawi

Background

Mental health research is essential in the implementation of evidence-based interventions. This can be impeded by unavailability or limited access to local evidence in low- and middle-income countries (LMICs) such as Malawi.

Aim

The aim of this systematic mapping was to describe the availability, extent and distribution of mental health research conducted in Malawi.

Setting

The study was conducted at Kamuzu University of Health Sciences in Malawi.

Methods

A systematic search of four electronic databases from inception to September 2021 was carried out. All published and unpublished mental health studies in all languages were eligible for inclusion. Studies were screened against inclusion and exclusion criteria, and data were extracted, analysed and presented in tables and as a narrative synthesis.

Results

Cross-sectional studies (33.6%, n = 76) were found to be the most common study design for mental health research in Malawi. More studies were conducted on women (21.2%, n = 48) compared to men (1.3%, n = 3). Mental health research was concentrated in the southern region of the country (44.8%, n = 120) and in the three cities of Lilongwe (17.9%, n = 48), Blantyre (16.4%, n = 44) and Zomba (9.0%, n = 24).

Conclusion

This systematic mapping suggests that there are few studies on mental health in Malawi which are not equally distributed across the country. There is a pressing need to conduct more mental health research using robust designs across disciplines.

Contribution

Research on mental health is urgently needed to produce culturally acceptable data in Malawi.

Mental health among sexual and gender minorities: A Finnish population-based study of anxiety and depression discrepancies between individuals of diverse sexual orientations and gender minorities and the majority population

Substantial empirical evidence suggests that individuals who belong to sexual and gender minorities experience more anxiety and depression than heterosexual and cisgender people. Many previous studies have not, however, used population-based samples. There is also a shortage of evidence about certain sexual and gender minorities (e.g., nonbinary individuals). We examined differences in levels of anxiety and depression within sexual and gender minorities, as well as compared to the heterosexual and cisgender majority in a population-based Finnish sample (N = 8,589). We also explored if individuals who belong to both a gender and a sexual minority (double minority) reported higher rates of anxiety and depression than individuals who hold either a gender or a sexual minority status (single minority). Individuals who belonged to either a sexual or a gender minority overall experienced significantly higher rates of anxiety and depression than cisgender and heterosexual individuals. Among the different sexual and gender minorities, bisexual, emerging identity, and nonbinary individuals reported the highest rates of anxiety and depression. We found no differences in anxiety and depression between single minority and double minority individuals. Our results suggest that even though Finland is a country with an inclusive social climate, sexual and gender minorities are, nevertheless, disproportionately affected by mental health issues. The present study gives further support to the claim that individuals holding a sexual or gender minority status experience higher levels of depression and anxiety compared to cisgender and heterosexual individuals and pinpoints the need to acknowledge these issues both in the context of health care and in the society at large.

Gender identity and transition: relationships with sleep disorders in US youth

STUDY OBJECTIVES

Transgender or gender-nonconforming (TGNC) identity is associated with higher burden of sleep disorders relative to cisgender identity. However, the role of gender-affirming therapy (GAT) in sleep disorders is poorly understood. This study examined relationships between TGNC identity, transition, and sleep disorders among TGNC and cisgender youth.

METHODS

This retrospective cross-sectional study utilized a large US-based administrative claims database (deidentified Optum Clinformatics Data Mart Database) to identify youth aged 12-25 years who obtained a diagnosis of TGNC identity and those who pursued GAT. Descriptive statistics estimated distributions of demographic and health characteristics by gender identity. Unadjusted and age-adjusted logistic regression models were used to examine associations between TGNC identity, GAT, and sleep disorders.

RESULTS

This study included 1,216,044 youth, of which 2,603 (0.2%) were identified as TGNC. Among the 1,387 TGNC who pursued GAT, 868 and 519 were identified as transmasculine and transfeminine, respectively. Adjusted analysis showed increased odds of insomnia (odds ratio = 5.4, 95% confidence interval 4.7, 6.2), sleep apnea (odds ratio = 3.0, 95% confidence interval 2.3, 4.0), and other sleep disorders (odds ratio = 3.1, 95% confidence interval 2.5, 3.9) in TGNC relative to cisgender youth. Decreased odds of any sleep disorder were observed in the TGNC youth on GAT (odds ratio = 0.5, 95% confidence interval 0.4, 0.7) relative to those not on GAT.

CONCLUSIONS

This study demonstrated a high burden of sleep disorders in TGNC youth in comparison to cisgender. However, GAT may confer a protective effect on sleep disorders among TGNC youth. Longitudinal assessments of sleep disorders prior to and post-GAT are needed to uncover their temporal relationships.

CITATION

Gavidia R, Whitney DG, Hershner S, Selkie EM, Tauman R, Dunietz GL. Gender identity and transition: relationships with sleep disorders in US youth. J Clin Sleep Med. 2022;18(11):2553-2559.

Predictors of mood or anxiety problems among transgender individuals seeking hormone therapy

BACKGROUND

Mental health needs of transgender individuals can be complex with individual, social, and medical factors impacting symptoms. This study examines predictors of mood or anxiety problems among transgender individuals seeking hormone therapy (HT).

METHODS

A retrospective chart review was conducted at 2 clinics providing gender-affirming HT. Cross-sectional data from initial patient encounters (N = 311) were used in this study. Bivariate correlations and multiple logistic regression analyses were carried out.

RESULTS

Transgender women (TW) were 2.2 times more likely to have mood or anxiety problems while transgender men (TM) were 2.6 times more likely as the number of medical comorbidities increased. For both TW and TM, White race significantly increased the likelihood of mood or anxiety problems. Neither previous nor current HT were associated with mood or anxiety problems for TW and TM. However, receiving multiple gender-affirming procedures decreased the likelihood of mood or anxiety problems for TM.

CONCLUSIONS

Gender-affirming care and addressing comorbidities can be important aspects of mental health needs for transgender individuals.

Factors that drive mental health disparities and promote well-being in transgender and nonbinary people

Transgender (or trans) is an umbrella term for individuals who experience their gender differently from what is associated with the sex they were assigned at birth. Individuals who are nonbinary experience their gender outside binary conceptions of gender. Although research has predominantly focused on negative mental health outcomes for transgender and non-binary (TNB) individuals, an emergent literature has begun to explore protective and health-promoting factors and dimensions of psychological well-being. In this Review, we discuss the sociocultural context for TNB people, beginning with a brief history of TNB identity before highlighting frameworks for understanding the higher prevalence of certain mental health concerns among TNB individuals. Next, we summarize the predictive factors associated with higher rates of depression, anxiety, suicidality, trauma-related concerns, disordered eating behaviours and substance use. We also review TNB coping, resilience and resistance to anti-trans stigma, as well as psychological well-being, flourishing and gender euphoria. Tying these topics together, we discuss affirming interventions for reducing mental health disparities and promoting psychological health in TNB individuals and communities. We conclude by discussing future research directions.

Individuals who are transgender or nonbinary experience a higher prevalence of certain mental health concerns, including depression, anxiety and disordered eating behaviours. In this Review, Tebbe and Budge discuss these disparities along with factors that protect these individuals from negative outcomes and promote well-being.

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.

Mental health service utilisation among transgender women sex workers who are at risk of mental health problems in Shenyang, China: An application of minority stress theory

Transgender women sex workers (TGSW), as a highly stigmatised population, are at substantial risk for mental health problems but lack access to mental health care. This study investigated factors of mental health service utilisation (MHSU) behaviour and related behavioural intention among TGSW who were at risk of mental health problems in the past year [subsample 1: scored above the cut-off for probable depression or probable anxiety or had suicidal ideation (N = 126); subsample 2: perceived needs for mental health services (N = 109)]. A cross-sectional survey was conducted among TGSW in Shenyang, China during 2017-2018. Data on minority stress, coping, mental health and MHSU were collected. 10.3% of participants in subsample 1 and 14.7% in subsample 2 had sought help from mental health professionals in the last year. Unwillingness to disclose minority identity and gender non-affirmation were negatively associated with MHSU. Factors for behavioural intention of MHSU included unwillingness to disclose minority identity and social support for both subsamples and adaptive coping for subsample 2. Confidentiality concern, discrimination and cost were the most frequently endorsed barriers to mental health services. Interventions should promote gender affirmation, social support and adaptive coping as well as remove stigma to increase health service access and utilisation among minority populations.

Epilepsy Care in Transgender Patients

PURPOSE OF REVIEW

The goal of this review is to outline the main considerations when treating transgender patients with epilepsy. Points to be addressed include the gender affirming hormone therapy regimens and how they interact with anti-seizure medications and seizure control, as well as common co-morbidities in the transgender epilepsy population.

RECENT FINDINGS

Gender affirming hormone therapy (GAHT) may affect seizure control directly, due to proconvulsant or anticonvulsant properties. GAHT may interact with anti-seizure medications; most notably, estrogen will decrease serum concentration of lamotrigine. Enzyme-inducing anti-seizure medications may decrease hormone levels, potentially interfering with goals of GAHT. Transgender epilepsy patients are at risk for co-morbidities such as decreased bone mineral density and depression. There are minimal direct studies on treatment or outcomes in the transgender epilepsy population. Providers must be knowledgeable about the bi-directional interactions between gender affirming hormone therapy and anti-seizure medications, as well as direct hormonal influences on seizure control. Future research should directly evaluate outcomes in transgender epilepsy patients with regard to seizure control, success of hormone therapy, and management of co-morbidities, to further educate providers and patients how to best manage their healthcare.

Substance Use in the Transgender Population: A Meta-Analysis

(1) Background: This meta-analysis aimed to assess the relationship between identifying as transgender and substance use. (2) Methods: We searched for relevant studies in PubMed, Scopus, the Web of Science, and PsycINFO on 21 July 2021. (3) Results: Twenty studies comparing transgender and cisgender people were included in this work, accounting for a total of 2,376,951 participants (18,329 of whom were transgender). These articles included data on current tobacco use, current tobacco use disorder, current alcohol use, current alcohol use disorder, lifetime substance (all) use, current substance use (excluding tobacco and alcohol), current use of specific substances (excluding tobacco and alcohol and including cocaine, amphetamines, methamphetamines, ecstasy, stimulants, heroin, opiates, cannabis, marijuana, LSD, hallucinogens, steroids, inhalants, sedatives, Ritalin or Adderall, diet pills, cold medicine, prescription medications, polysubstance, other club drugs, and other illegal drugs), and current substance use disorder (excluding tobacco and alcohol). We used the ORs and their 95% CIs to state the association between identifying as transgender and those variables. The control reference category used in all cases was cisgender. We employed a random-effects model. Transgender people were more likely to use tobacco (odds ratio (OR) = 1.65; 95% CI [1.37, 1.98]), have used substances throughout their lives (OR = 1.48; 95% CI [1.30, 1.68]), and present current use of specific substances (OR = 1.79; 95% CI [1.54, 2.07]). When current alcohol and substance use in general and tobacco, alcohol, and substance use disorders specifically were considered, the likelihood did not differ from that of cisgender people. (4) Conclusions: The presence of substance use disorders did not differ between transgender and cisgender people. Considering this population as consumers or as addicted may be a prejudice that perpetuates stigma. Nonetheless, transgender people were more likely to use tobacco and other substances, but not alcohol. Hypothetically, this might be an emotional regulation strategy, a maladaptive mechanism for coping with traumatic experiences, or could respond to minority stress, produced by stigma, prejudice, discrimination, and harassment. It is of particular importance to implement policies against discrimination and stigmatisation and to adapt prevention and treatment services so that they are inclusive of the 2SLGBTQIA+ community.

Evaluation of Mental Health and Satisfaction Following Transfeminine Gender-Affirming Surgery in Thailand

Purpose

Although many studies have shown that transgender women (TW) tend to have more depressive symptoms compared with the general population, the exact prevalence of major depressive disorder and contributing risk factors have not yet been studied, especially in those who have undergone gender-affirming genital surgery (GAS).

Methods

Every TW aged 20-60 years attending transgender clinics in the Thai Red Cross Society for postoperative checkup were invited to complete a self-report questionnaire, including (1) demographic data, (2) the Thai Patient Health Questionnaire 9 (PHQ-9), (3) satisfaction with psychosocial factors (relationship in family, friends, and society), sexual experiences and outcomes of gender-affirming treatments before and after GAS, and (4) contributing factors to depressive symptoms. Correlations between demographic data and depressive scores were tested. Paired t-test was used to compare pre- and post-GAS data.

Results

A total of 97 TW were analyzed, with 22.7% considered to have "major depression" (PHQ-9≥9) after GAS. Postoperative improvement in satisfaction with psychosocial factors and gender-affirming treatment outcomes were observed, especially in sexual experience. Depression severity was found to be negatively correlated with age and sexual satisfaction. Notably, presence of male characteristics before surgery, poor social support and understanding, and postoperative surgical complications were greatly considered as factors contributing to depressive symptoms.

Conclusion

Compared with non-GAS TW, depression among those who underwent GAS in Thailand was lower but still significant and was linked to younger age and poor postoperative sexual experiences. These findings were supported by the number of qualitative assessments in the psychosexual domain and postoperative treatment outcomes. Clinical Trial Registration Number - TCTR20190904003.

Sex Hormone Suppression and Physical Activity: Possible Implications for Transgender Individuals

Purpose

Transgender individuals tend to be less physically active than cisgender individuals, and the primary focus of these physical activity barriers have been psychosocial in nature. Very little attention has been given to the role that changes in the sex hormone milieu (such as that occurring during gender-affirming hormone therapy) play on physical activity. The purpose of this study was to explore the effects of sex hormone suppression using a gonadotropin-releasing hormone agonist (GnRHa) on physical activity levels and patterns.

Methods

Female and male rats received 4 weeks of sex hormone suppression using the GnRHa goserelin acetate (GA) or received a placebo as a control (CON). Animals were then allowed free access to voluntary running wheels, and activity was recorded throughout the treatment period.

Results

Female rats receiving GA (F GA) had a significantly lower total wheel running distance than female CON (F CON, 53±11 km vs. 113±28 km, respectively, p=0.042), and male rats receiving GA (M GA) had a significantly lower total wheel running distance when compared with male CON (M CON, 31±7 km vs. 69±18 km, respectively, p=0.037). Differences in daily wheel running distances were first observed at day 18 between F GA and F CON (p=0.037) and at day 2 between M GA and M CON (p=0.021).

Conclusion

Reduced sex hormone availability reduced wheel running activity in female and male rats. Understanding the role that sex hormone manipulation has on physical activity may be an important consideration in promoting physical activity in transgender individuals receiving treatments that reduce sex hormone availability.

Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: Systematic review and meta-analysis

Minority stress theory posits that transgender and gender diverse (TGD) individuals exhibit greater rates of depression and suicidality due to internal (proximal) and external (distal) stressors related to their TGD identity. Yet, the magnitude of the relationship between minority stress processes and mental health outcomes has not been quantitatively summarized. The current research meta-analyzed the relationship between minority stress constructs and depression, suicidal ideation, and suicide attempt. Results from 85 cross-sectional quantitative studies indicate that distal stress, expectations of rejection, internalized transphobia, and concealment are significantly associated with increased depression, suicidal ideation, and suicide attempt. Greater effect sizes were observed for expectations of rejection and internalized transphobia when compared to distal stress and concealment. Future research on the relationship between minority stress, depression, and suicide would benefit from longitudinal designs and more diverse and representative samples of TGD individuals.

Factors associated with suicidal ideation among travestis and transsexuals receiving assistance from transgender organizations

The aim of this study was to determine the prevalence of suicidal ideation and explore associated factors among travestis and transsexuals. A cross-sectional study was conducted between 2015 and 2016 with 22 travestis and 36 transsexuals who were members of the four transgender organizations operating in the state of Rio Grande do Norte, Brazil. Associations between suicidal ideation and the categorical variables were measured using the chi-squared test, Fisher's exact test, and likelihood ratios. Multivariate analysis was performed using robust Poisson regression. The suicidal ideation prevalence rate was 41.4% (95%CI 41.3-54.51%): 13.79% among travestis (95%CI 4.91-22.66%) and 27.61% in transsexuals (95%CI 16.08-39.08%). The prevalence of suicidal ideation was higher among respondents who reported suffering violence at school (PR = 2.05; 95%CI 1.08-3.87) and those experiencing moderate/severe depression (PR = 3.86; 95%CI 1.51-9.83). The findings suggest that unfavorable school contexts and the presence of depression compromise mental health and contribute to suicidal ideation among travestis and transsexuals.

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.

Examining the elevated risk of COVID-19 in transgender communities with an intersectional lens

COVID-19 has presented unique and unprecedented struggles for all people, yet they tend to be magnified among marginalized communities. Indeed, in the United States, transgender (trans) people experience oppression in many facets of their lives, which places them at an increased risk for both COVID-19 exposure and complications. This oppression can be broadly categorized into two distinct, yet interrelated categories: health disparities (e.g., decreased immune health) and structural barriers (e.g., employment discrimination, policing). Recent scholarship has examined trans people’s risk for COVID-19 exposure and mortality, however few articles examine intersectional identities, and, to our knowledge, none have interrogated oppressive power structures (e.g., the prison industrial complex). We aim to fill these critical gaps and argue that it is imperative for cisgender people to partner with trans communities to dismantle these harmful systems, positively impacting the lives of trans individuals during the pandemic and beyond. We make several key recommendations for researchers, policymakers, healthcare workers, and allies to do so.

Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review

BACKGROUND

UK adult gender identity clinics (GICs) are implementing a new streamlined service model. However, there is minimal evidence from these services underpinning this. It is also unknown how many service users subsequently 'detransition'.

AIMS

To describe service users' access to care and patterns of service use, specifically, interventions accessed, reasons for discharge and re-referrals; to identify factors associated with access; and to quantify 'detransitioning'.

METHOD

A retrospective case-note review was performed as a service evaluation for 175 service users consecutively discharged by a tertiary National Health Service adult GIC between 1 September 2017 and 31 August 2018. Descriptive statistics were used for rates of accessing interventions sought, reasons for discharge, re-referral and frequency of detransitioning. Using multivariate analysis, we sought associations between several variables and 'accessing care' or 'other outcome'.

RESULTS

The treatment pathway was completed by 56.1%. All interventions initially sought were accessed by 58%; 94% accessed hormones but only 47.7% accessed gender reassignment surgery; 21.7% disengaged; and 19.4% were re-referred. Multivariate analysis identified coexisting neurodevelopmental disorders (odds ratio [OR] = 5.7, 95% CI = 1.7-19), previous adverse childhood experiences (ACEs) per reported ACE (OR = 1.5, 95% CI = 1.1-1.9), substance misuse during treatment (OR = 4.3, 95% CI = 1.1-17.6) and mental health concerns during treatment (OR = 2.2, 95% CI 1.1-4.4) as independently associated with accessing care. Twelve people (6.9%) met our case definition of detransitioning.

CONCLUSIONS

Service users may have unmet needs. Neurodevelopmental disorders or ACEs suggest complexity requiring consideration during the assessment process. Managing mental ill health and substance misuse during treatment needs optimising. Detransitioning might be more frequent than previously reported.

Mental Health Disparities at the Intersections of Gender Identity, Race, and Ethnicity

Purpose: Very little research has examined mental health among transgender people of color using population-based data. The objective of this study was to use large-scale data to examine mental health disparities at the intersections of gender identity, race, and ethnicity. Methods: Data for this study came from transgender (n = 4024) and cisgender (n = 935,793) adults aged 18 years and older in the 2014-2018 Behavioral Risk Factor Surveillance System. We estimated and compared frequent mental distress and lifetime depression diagnoses using multivariable logistic regression models. Regression results are presented as adjusted odds ratios (AORs) with 95% confidence intervals (CIs). Results: After controlling for sociodemographic characteristics and compared with cisgender White adults, transgender White adults (AOR = 1.81; 95% CI = 1.49-2.21), transgender American Indian or Alaska Native (AIAN) adults (AOR = 8.06; 95% CI = 2.03-32.00), and transgender adults of other/multiple races and ethnicities (AOR = 3.15; 95% CI = 1.78-5.59) had higher odds of exhibiting frequent mental distress. Transgender White adults (AOR = 2.07; 95% CI = 1.75-2.46), transgender AIAN adults (AOR = 3.61; 95% CI = 1.06-12.32), and transgender adults of other/multiple races and ethnicities (AOR = 2.37; 95% CI = 1.41-4.01) had higher odds of reporting a lifetime depression diagnosis compared with White cisgender adults. Conclusion: This study serves as a reminder that LGBT health should be analyzed through an intersectional lens as some individuals with multiple marginalized identities may have worse health as a result of double discrimination. Public health practitioners and health care providers should be mindful of the diversity within the transgender population in their work.

Socioeconomic status in Danish transgender persons: a nationwide register-based cohort study

BACKGROUND

Gender dysphoria could be associated with low socioeconomic status (SES). SES could be modified by age, ethnic background, and medical morbidity.

AIM

To determine SES in a national study population including transgender persons in Denmark.

METHODS

National register-based cohort study in Danish transgender persons and age-matched controls. The transgender study cohort included persons with ICD-10 diagnosis code of 'gender identity disorder' and/or persons with legal sex change and persons who fulfiled the inclusion criteria during 2000-2018. The main outcome measure was SES including personal income, occupational status, and education.

RESULTS

The cohort included 2770 transgender persons and 27,700 controls. In the transgender study cohort, 1437 were assigned male at birth (AMAB), median age (interquartile range, IQR) 26.0 (17.3) years, and 1333 were assigned female at birth (AFAB), median age 22.5 (10.3) years. Adjusting for age and sex, the relative risk ratio (RRR) of low vs high personal income was 5.6 (95% CI: 4.9; 6.3) in transgender persons compared to controls. The RRR of low vs high income was 6.9 (5.8; 8.3) in persons AMAB compared to control males and 4.7 (3.9; 5.6) in persons AFAB compared to control females. The RRR of low vs high income was 3.7 (3.2; 4.3) in transgender persons of Danish origin compared to controls. The Charlson comorbidity index was comparable in transgender persons vs controls.

CONCLUSIONS

Being transgender was negatively associated with SES. In transgender persons, the risk of low vs high income could be more pronounced in transgender persons of foreign origin.

Childhood adversities are common among trans people and associated with adult depression and suicidality

Trans people suffer from increased rates of depression and suicidality even after gender-affirming medical interventions. The present study aims to examine the prevalence of childhood adversities in patients with gender dysphoria and to analyze its impact on adult depression and suicidality. Participants meeting diagnostic criteria of Gender Dysphoria were recruited in a cross-sectional multicenter study at four German health-care centers. Childhood adversities were assessed with the Childhood Trauma Questionnaire (CTQ) and additional single items for other childhood adversities. Associations between childhood adversities and adult depression and suicidality were calculated using regression analyses. A large majority of participants reported childhood adversities, and only 7% endorsed no adversities in the CTQ. Over 30% reported severe to extreme childhood adversities. One-fourth reported parents exhibiting violent behavior while bullying by peers was experienced by 70%. These adversities were associated with an increased risk for adult depression and suicidality. Time since beginning of hormonal therapy did not show a significant influence neither on depression nor on suicidality. Childhood adversities are common and associated with adult depression and suicidality in trans people. Adequately addressing these childhood adversities and providing trauma-informed mental health care might ameliorate the mental health burden in trans people.

Buffering against Depressive Symptoms: Associations between Self-Compassion, Perceived Family Support and Age for Transgender and Nonbinary Individuals

Transgender and gender nonbinary (TGNB) individuals often report higher levels of depression compared to cisgender individuals. Higher levels of depression in TGNB populations may be partially attributed to a lack of family support, which may be particularly salient for younger individuals. However, two possible protective factors that may mitigate depressive symptoms are self-compassion, defined as an attitude of kindness and understanding towards one's own imperfections, and perceived support, especially from family. The present study aimed to explore whether self-compassion was negatively associated with self-reported depressive symptoms, and whether perceived family support moderated this association, especially for younger individuals. Participants who were (1) at least 18 years of age, (2) identified as TGNB, and (3) experienced gender dysphoria were eligible for this study. Cross-sectional data from 148 individuals were collected online during May 2020. In support of the hypotheses, self-compassion was negatively associated with depressive symptoms, and perceived family support furthered this association. Additionally, results showed that younger participants (ages 18-24) with lower family support reported the highest levels of depressive symptoms. Taken together, these results suggest that self-compassion and perceived family support may be significant protective factors against depressive symptoms for TGNB individuals, although longitudinal research is needed. Taking a strengths-based perspective, mental health clinicians working with TGNB individuals may consider interventions geared toward increasing self-compassion in daily life and working with clients' families to increase support.

Anxiety and Depression Among Transgender People: Findings from a Cross-Sectional Online Survey in Russia

Purpose: As we still do not know enough about the mental health concerns of gender minority people in Russia, there is a need to initiate research on these issues. We aimed to examine the frequency of anxiety and depression symptoms in a Russian sample of transgender people. Methods: The study consisted of a structured online survey and was conducted throughout November 2019. The Hospital Anxiety and Depression Scale was used for online screening of anxiety and depression symptoms. A total of 588 transgender adults living in all Federal Districts of Russia (mean age 24.0 ± standard deviation 6.7) was included in the final analysis. Results: It was found that 45.1% (n = 265) and 24.0% (n = 141) of transgender people had clinically significant levels of anxiety and depression, respectively. No statistically significant differences in the prevalence of anxiety and depression were found among those who identified as a transgender man, a transgender woman, or other transgender identities. The anxiety and depression mean scores in the sample were statistically significantly higher than in the general Russian population (p < 0.001). No statistically significant differences were found in the level of depression and anxiety symptoms among respondents in Moscow, St. Petersburg, and other Russian cities. Conclusions: We found high rates of clinical symptoms of depression and anxiety among transgender people, consistent with international research. The study highlights the need for further research on the psychological well-being and mental health of transgender people, and the availability of psychiatric care to transgender people living in Russia.

Gender-Affirming Mastectomy in Transmasculine Patients: Does Obesity Increase Complications or Revisions?

BACKGROUND

Obesity can often be a barrier to gender-affirming top surgery in transmasculine patients because of concern for increased surgical site complications.

STUDY DESIGN

All adult patients (N = 948) within an integrated health care system who underwent gender-affirming mastectomy from 2013 to 2018 were retrospectively reviewed to evaluate the relationship between obesity and surgical site complications or revisions.

RESULTS

One third of patients (n = 295) had obese body mass index (BMI), and those patients were further stratified into obesity class I (BMI of 30-34.9 kg/m2, 9.4%), class II (BMI of 35-39.9 kg/m2, 8.9%), and class III (BMI of ≥40 kg/m2, 2.9%). A majority of patients across BMI categories underwent double incision surgery. There were no significant differences in complications or revisions between patients with obesity versus those with normal BMI, when BMI was treated as a categorical or continuous variable and when evaluating only patients who underwent double incision surgery.

CONCLUSIONS

Obesity alone should not be considered a contraindication for gender-affirming mastectomy. Attention should be given to several modifiable risk factors identified in this study, including lesser incision surgical techniques, tobacco use, and testosterone use. Further research is needed to understand risks associated with the highest BMI (≥40 kg/m2) patients and to assess patient satisfaction with surgical outcome.

Characterization of the 1H-MRS Metabolite Spectra in Transgender Men with Gender Dysphoria and Cisgender People

Much research has been conducted on sexual differences of the human brain to determine whether and to what extent a brain gender exists. Consequently, a variety of studies using different neuroimaging techniques attempted to identify the existence of a brain phenotype in people with gender dysphoria (GD). However, to date, brain sexual differences at the metabolite level using magnetic resonance spectroscopy (1H-MRS) have not been explored in transgender people. In this study, 28 cisgender men (CM) and 34 cisgender women (CW) and 29 transgender men with GD (TMGD) underwent 1H-MRS at 3 Tesla MRI to characterize common brain metabolites. Specifically, levels of N-acetyl aspartate (NAA), choline (Cho), creatine (Cr), glutamate and glutamine (Glx), and myo-inositol + glycine (mI + Gly) were assessed in two brain regions, the amygdala-anterior hippocampus and the lateral parietal cortex. The results indicated a sex-assigned at birth pattern for Cho/Cr in the amygdala of TMGD. In the parietal cortex, a sex-assigned at birth and an intermediate pattern were found. Though assessed post-hoc, exploration of the age of onset of GD in TMGD demonstrated within-group differences in absolute NAA and relative Cho/Cr levels, suggestive for a possible developmental trend. While brain metabolite levels in TMGD resembled those of CW, some interesting findings, such as modulation of metabolite concentrations by age of onset of GD, warrant future inquiry.

Gender Dysphoria and Perceived Social Support: A Matched Case-Control Study

BACKGROUND

In people diagnosed with Gender Dysphoria (GD), low perceived social support from their families and society has been suggested to be associated with poor quality of life and mental well-being.

AIM

To compare the perceived social support in individuals with GD with that in individuals without GD matched for age and gender.

METHODS

The study group (n = 50) consisted of individuals diagnosed with GD via psychiatric evaluation. A control group (n = 50) was created by matching volunteers without GD by age and gender. Sociodemographic data form, Structured Clinical Interview Form for DSM-IV TR Axis I Disorders (SCID-I), and Multidimensional Scale of Perceived Social Support (MSPSS) were used to gather data from participants.

OUTCOMES

comparing the perceived social support, the total and subscale MSPSS scores of groups were calculated.

RESULTS

The presence of at least 1 psychiatric disorder was significantly higher in the GD group than in the control group, either lifetime or during evaluation (P < .001 and P = .025, respectively). The total MSPSS and family support subscale scores were found to be significantly lower in the GD group than in the control group (P = .001 and P ≤ .001, respectively). When the groups formed on the basis of gender identity (32 trans men vs 32 cis men and 18 trans women vs 18 cis women) were compared, only the family support subscale score was found to be lower in trans men than cis men (P = .005). In addition, comparisons within the groups formed based on sex assigned-at-birth revealed lower total, friend, and family support in those assigned female-at-birth and lower total and family support in those assigned male-at-birth in the GD group. A multiple linear regression analysis revealed that the presence of GD was significantly associated with total and family support MSPSS subscale scores.

CLINICAL IMPLICATIONS

The findings show that perceived social support in people diagnosed with GD is lower, even when the presence of psychiatric disorders is included in the analysis.

STRENGTHS AND LIMITATIONS

The matched case-control design was the major study strength, whereas the sample size was the major limitation.

CONCLUSION

Clinical care of people diagnosed with GD should include the evaluation of diverse sources of social support, efforts to strengthen family and friend support, maintenance of interpersonal relationships, and support of mental well-being. Kaptan S, Cesur E, Başar K, et al. Gender Dysphoria and Perceived Social Support: A Matched Case-Control Study. J Sex Med 2021;18:812-820.

Differences in mental health symptom severity and care engagement among transgender and gender diverse individuals: Findings from a large community health center

Mental health disparities among transgender and gender diverse (TGD) populations have been documented. However, few studies have assessed differences in mental health symptom severity, substance use behavior severity, and engagement in care across TGD subgroups. Using data from the electronic health record of a community health center specializing in sexual and gender minority health, we compared the (1) severity of self-reported depression, anxiety, alcohol use, and other substance use symptoms; (2) likelihood of meeting clinical thresholds for these disorders; and (3) number of behavioral health and substance use appointments attended among cisgender, transgender, and non-binary patients. Participants were 29,988 patients aged ≥18 who attended a medical appointment between 2015 and 2018. Depression symptom severity (F = 200.6, p < .001), anxiety symptom severity (F = 102.8, p < .001), alcohol use (F = 58.8, p < .001), and substance use (F = 49.6, p < .001) differed significantly by gender. Relative to cisgender and transgender individuals, non-binary individuals are at elevated risk for depression, anxiety, and substance use disorders. Gender was also associated with differences in the number of behavioral health (χ2 = 51.5, p < .001) and substance use appointments (χ2 = 39.3, p < .001) attended. Engagement in treatment among certain gender groups is poor; cisgender women and non-binary patients assigned male at birth were the least likely to have attended a behavioral health appointment, whereas transgender men and cisgender women had attended the lowest number of substance use appointments. These data demonstrate the importance of (1) assessing gender diversity and (2) addressing the barriers that prevent TGD patients from receiving affirming care.

Predicting outcomes of cross-sex hormone therapy in transgender individuals with gender incongruence based on pre-therapy resting-state brain connectivity

Individuals with gender incongruence (GI) experience serious distress due to incongruence between their gender identity and birth-assigned sex. Sociological, cultural, interpersonal, and biological factors are likely contributory, and for some individuals medical treatment such as cross-sex hormone therapy and gender-affirming surgery can be helpful. Cross-sex hormone therapy can be effective for reducing body incongruence, but responses vary, and there is no reliable way to predict therapeutic outcomes. We used clinical and MRI data before cross-sex hormone therapy as features to train a machine learning model to predict individuals' post-therapy body congruence (the degree to which photos of their bodies match their self-identities). Twenty-five trans women and trans men with gender incongruence participated. The model significantly predicted post-therapy body congruence, with the highest predictive features coming from the cingulo-opercular (R² = 0.41) and fronto-parietal (R² = 0.30) networks. This study provides evidence that hormone therapy efficacy can be predicted from information collected before therapy, and that patterns of functional brain connectivity may provide insights into body-brain effects of hormones, affecting one's sense of body congruence. Results could help identify the need for personalized therapies in individuals predicted to have low body-self congruence after standard therapy.

ESHRE guideline: female fertility preservation

STUDY QUESTION

What is the recommended management for women and transgender men with regards to fertility preservation (FP), based on the best available evidence in the literature?

SUMMARY ANSWER

The ESHRE Guideline on Female Fertility Preservation makes 78 recommendations on organization of care, information provision and support, pre-FP assessment, FP interventions and after treatment care. Ongoing developments in FP are also discussed.

WHAT IS KNOWN ALREADY

The field of FP has grown hugely in the last two decades, driven by the increasing recognition of the importance of potential loss of fertility as a significant effect of the treatment of cancer and other serious diseases, and the development of the enabling technologies of oocyte vitrification and ovarian tissue cryopreservation (OTC) for subsequent autografting. This has led to the widespread, though uneven, provision of FP for young women.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 November 2019 and written in English were included in the review.

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

This guideline aims to help providers meet a growing demand for FP options by diverse groups of patients, including those diagnosed with cancer undergoing gonadotoxic treatments, with benign diseases undergoing gonadotoxic treatments or those with a genetic condition predisposing to premature ovarian insufficiency, transgender men (assigned female at birth), and women requesting oocyte cryopreservation for age-related fertility loss.The guideline makes 78 recommendations on information provision and support, pre-FP assessment, FP interventions and after treatment care, including 50 evidence-based recommendations-of which 31 were formulated as strong recommendations and 19 as weak-25 good practice points and 3 research only recommendations. Of the evidence-based recommendations, 1 was supported by high-quality evidence, 3 by moderate-quality evidence, 17 by low-quality evidence and 29 by very low-quality evidence. To support future research in the field of female FP, a list of research recommendations is provided.

LIMITATIONS REASONS FOR CAUTION

Most interventions included are not well studied in FP patients. As some interventions, e.g. oocyte and embryo cryopreservation, are well established for treatment of infertility, technical aspects, feasibility and outcomes can be extrapolated. For other interventions, such as OTC and IVM, more evidence is required, specifically pregnancy outcomes after applying these techniques for FP patients. Such future studies may require the current recommendations to be revised.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in female FP, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in FP.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. R.A.A. reports personal fees and non-financial support from Roche Diagnostics, personal fees from Ferring Pharmaceuticals, IBSA and Merck Serono, outside the submitted work; D.B. reports grants from Merck Serono and Goodlife, outside the submitted work; I.D. reports consulting fees from Roche and speaker's fees from Novartis; M.L. reports personal fees from Roche, Novartis, Pfizer, Lilly, Takeda, and Theramex, outside the submitted work. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at  www.eshre.eu/guidelines.) ^†ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.