Coping with Gender Dysphoria in a Rural Environment during Adolescence

Gender dysphoria is socially more visible and discussed today, but still underdiagnosed. It refers to distress and/or impaired function caused by inconsistency between the sex assigned at birth and gender identification. Clinical manifestations are variable. Lack of training and investment in gender issues make the diagnosis and management in primary care complex, particularly in conservative and isolated communities, with poor access to information and specialized health services. We describe the diagnosis of gender dysphoria and use of a patient centered multidisciplinary and family approach in a 12-year-old rural born adolescent, assigned female at birth. Our aim is to raise awareness of early symptoms and signs of gender dysphoria and problems faced by transgender people and their families during childhood, leading to gender dysphoria, and we hope our successful approach might improve healthcare provision for these patients, particularly in rural areas.

Supporting autonomy in young people with gender dysphoria: psychotherapy is not conversion therapy

Opinion is divided about the certainty of the evidence base for gender-affirming medical interventions in youth. Proponents claim that these treatments are well supported, while critics claim the poor-quality evidence base warrants extreme caution. Psychotherapy is one of the only available alternatives to the gender-affirming approach. Discussion of the treatment of gender dysphoria in young people is generally framed in terms of two binary approaches: affirmation or conversion. Psychotherapy/exploratory therapy offers a treatment option that lies outside this binary, although it is mistakenly conflated with conversion therapies. Psychotherapy does not impose restrictive gender stereotypes, as is sometimes claimed, but critically examines them. It empowers young people to develop creative solutions to their difficulties and promotes agency and autonomy. Importantly, an exploratory psychotherapeutic process can help to clarify whether gender dysphoria is a carrier for other psychological or social problems that may not be immediately apparent. Psychotherapy can therefore make a significant contribution to the optimal, ethical care of gender-dysphoric young people by ensuring that patients make appropriate, informed decisions about medical interventions which carry risks of harm and have a contested evidence base.

Assessing Patient Goals for Gender-Affirming Hormone Therapy: A Standardized Patient Case for Medical Students

Introduction

Inadequate coverage of transgender and gender-diverse (TGD) health in the UME curriculum contributes to the scarcity of competent physicians to care for TGD patients. Increasing TGD health skills-based curricula in UME can help address TGD health disparities. We developed a standardized patient (SP) case to assess TGD health skills-based competencies and attitudes among medical students.

Methods

An interdisciplinary team, including individuals with lived TGD experience, developed the SP case that was completed by second-year medical students at the University of Pittsburgh School of Medicine in January 2020. After the TGD SP session, students and faculty completed a postsession survey to assess the degree to which the case met the learning objectives. Students were assessed via self-reports, faculty reports, and SP video evaluations.

Results

Seventy second-year medical students, 30 faculty facilitators, and eight SPs participated in 2020. Students reported being significantly more prepared to care for TGD patients (Z = -5.68, p < .001) and to obtain a gender history (Z = -5.82, p < .001). Both faculty and students felt that skills for caring for TGD patients were important in medical education and agreed the case should remain in the curriculum.

Discussion

The case effectively honed and assessed students' ability to collect a gender history and discuss goals for hormone therapy with TGD patients. It should complement ongoing curricula to effectively train medical students in TGD health care. Developing these skills in students directly addresses the barriers that many TGD patients experience in health care settings.

[Dysphoria and psychiatric comorbidity in transgender people seeking medical care for somatic transition]

Gender dysphoria is the diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, which refers to the marked incongruence that exists between the gender that is felt or expressed and the one assigned at birth. The discomfort generated by the incongruity can cause gender affirmation to be requested through hormonal treatment or surgical sex reassignment, which is expected to disappear such discomfort. However, not all people with gender incongruence manifest discomfort and when the discomfort exists it is not always of psychopathological characteristics (dysphoria), which for some authors represents gender affirmation for aesthetic purposes (correct the incongruity). There are reports of increased medical care for transgender people who request somatic transition, but in Mexico there are no standardized protocols for their care; it is only recommended to promote access to hormonal treatment and mental health services to transgender people who request it. The eventual inclusion of surgical management in the Mexican guidelines will require clarity of concepts and unification of criteria to select the cases that should enter the health system for treatment, which is why health personnel must be prepared to identify those who can benefit from the somatic transition. The presence of dysphoria and psychiatric comorbidity may be key elements when the evaluation is carried out.

Gender Differences in the Risk of Depression in Community-Dwelling Stroke Survivors Compared to the General Population without Stroke

This study examined the gender-specific association between stroke status and depression in South Korea. A total of 5,746 men and 7,608 women aged ≥30 years who participated in the 2014, 2016, and 2018 Korea National Health and Nutrition Examination Survey were included in the analysis. The cross-sectional surveys targeted the general population consisting of nationally representative adults (≥19 years) residing in Korea. A 9-item Patient Health Questionnaire score of 10 or more was regarded as depression. A higher risk of depression in stroke survivors compared to the non-stroke population was not observed in men (odds ratio [OR], 1.51; 95% confidence intervals [CI], 0.82-2.81), while it was observed in women (OR, 2.49; 95% CI, 1.64-3.77). Compared to non-stroke women, women stroke survivors with a younger age at diagnosis (<60 years) (OR, 4.05; 95% CI, 2.28-7.20) and stroke with duration of ≥10 years (OR, 3.12; 95% CI, 1.63-5.97) had a higher risk for depression. Gender aspects should be more intensively considered in the association between stroke status and depression in community settings.

Myocardial Protection in Isolated Coronary Artery Bypass Grafting: Del Nido versus Blood Cardioplegia

INTRODUCTION

Our study aimed to examine the impacts of blood cardioplegia (BC) and del Nido cardioplegia (DNC) solutions - which we used in isolated coronary artery bypass grafting (CABG) - on early mortality and major adverse events (MAE).

METHODS

We retrospectively analyzed 329 consecutive patients who underwent CABG in our clinic between January 2016 and January 2020. Myocardial infarction, reoperation, cardiac tamponade, stroke, renal failure, extracorporeal membrane oxygenation requirement, and cardiopulmonary resuscitation were defined as MAE. The group in which DNC was used was Group D (181 [55%] patients), and the group in which BC was used was Group B (141 [45%] patients).

RESULTS

No statistically significant difference was determined between the groups regarding age, weight, body surface area, gender, or European System for Cardiac Operative Risk Evaluation score (P=0.615, P=0.560, P=0.934, P=0.365, P=0.955, respectively). Although there was no statistically significant difference between the groups in terms of aortic cross-clamping time (P=0.712), cardiopulmonary bypass duration was longer in Group B (P=0.001). Even though the incidence of stroke was higher in Group B (P=0.030), no statistically significant difference was observed between the groups regarding total incidence of MAE, mortality, mechanical ventilation time, length of stay in the intensive care unit, or length of hospital stay (P=0.153, P=0.130, P=0.689, P=0.710, P=0.613, respectively).

CONCLUSION

We found no significant difference in MAE, mortality, duration of mechanical ventilation, intensive care unit stay, or hospital stay between the DNC and BC groups. We believe that both solutions can be used safely for cardiac protection in the adult patient population.

Assessing widening disparities in HbA1c and systolic blood pressure retesting during the COVID-19 pandemic in an LGBTQ+-focused federally qualified health center in Chicago: a retrospective cohort study using electronic health records

INTRODUCTION

To assess disparities in retesting for glycated hemoglobin (HbA1c) and systolic blood pressure (SBP) among people with diabetes mellitus (DM) and hypertension (HTN), respectively, we analyzed medical records from a lesbian, gay, bisexual, transgender, queer-specialized federally qualified health center with multiple sites in Chicago.

RESEARCH DESIGN AND METHODS

We identified people with DM seen in 2018 and 2019 then assessed if individuals had HbA1c retested the following year (2019 and 2020). We repeated this using SBP for people with HTN. Rates of retesting were compared across gender, sexual orientation, and race and ethnicity and across the 2 years for each categorization with adjustment for socioeconomic indicators.

RESULTS

Retesting rates declined from 2019 to 2020 for both HbA1c and SBP overall and across all groups. Cisgender women and transgender men with DM (vs cisgender men) and straight people (vs gay men) had significantly lower odds of HbA1c retesting for both years. There was evidence of widening of HbA1c retesting disparities in 2020 between gay men and other orientations. Cisgender women, straight people, and black people (vs white) with HTN had significantly lower odds of SBP retesting for both years. There was evidence of narrowing in the retesting gap between black and white people with HTN, but this was due to disproportionate increase in no retesting in white people rather than a decline in no retesting among black people with HTN.

CONCLUSIONS

Disparities in DM and HTN care according to gender, race, ethnicity, and sexual orientation persisted during the pandemic with significant widening according to sexual orientation.

Disability: leaning away from the curve

This response to Evans et al encourages broader consideration of what constitutes disability, extending beyond a protagonist's capabilities toward society's fuller chorus. Three avenues are submitted to encourage this. First, Engel's biopsychosocial paradigm of health can be helpfully applied to the question of identity in general, and disability in particular. Second, the philosophy of language (and of naming) gives useful insight into the pitfalls of trying to define disability via descriptions of capability. Third, Kennedy's critique 'Unmasking Medicine' offers a sociopolitical view that builds on Foucault and Illich allowing us to recognise that it matters who judges who, as disabled, and on what grounds. Alongside this, I suggest alternative views first, on the authors' liberal use of bell curves in the depiction of disability and second, on their terminology of capacity spaces.

Prevalence of Gender Dysphoria by Gender and Age in Japan: A Population-Based Internet Survey Using the Utrecht Gender Dysphoria Scale

BACKGROUND

Several studies have attempted to estimate the prevalence of gender dysphoria (GD) from a general population sample. However, no previous studies used reliable questionnaires.

AIM

To estimate the prevalence of GD in Japan by gender and age using the Utrecht Gender Dysphoria Scale (UGDS).

METHODS

A cross-sectional observational study was conducted with 20,000 respondents between the ages of 20 and 69 who were registered with an internet research company. The study consisted of two phases. First, the participants were asked to self-identify their gender on two 5-point Likert scales. Second, the screened participants completed the UGDS.

OUTCOMES

Self-identified gender and GD were defined as follows: ambivalent gender (equally feeling like the birth gender and another gender), incongruent gender (a stronger sense of the latter vs the former), narrow GD (incongruent gender + UGDS score ≥ 41), and broad GD (ambivalent or incongruent gender + UGDS score ≥ 41).

RESULTS

Among the eligible participants, the age-adjusted proportions of those classified as male (n = 7827) and female (n = 8903) at birth were 6.0% and 5.9%, respectively, for ambivalent gender, and 0.93% and 1.0%, respectively, for incongruent gender. The age-adjusted prevalence of GD was 0.27% (95% confidence interval, 0.18-0.42) and 0.35% (95% confidence interval, 0.25-0.50) for narrow GD and 0.87% (95% confidence interval, 0.69-1.1) and 1.1% (95% confidence interval, 0.86-1.3) for broad GD, respectively. No significant gender differences were found within the age groups, except for broad GD in respondents in their 50s (P = .016). However, for both genders, significant differences were found between age groups such that GD was more prevalent in younger vs older respondents, except for broad GD in respondents classified as female at birth (P = .063).

CLINICAL IMPLICATIONS

Clinicians should be aware that the prevalence of GD is not negligible and that it varies with age. GD should be assessed in detail from various perspectives in addition to self-identified gender.

STRENGTHS & LIMITATIONS

This study used a reliable questionnaire to examine the prevalence of GD in a large population. However, the participants did not represent the general population because this was an internet survey.

CONCLUSION

The prevalence of GD was much higher than previously estimated by clinic-based studies, and was more frequently associated with participant age vs gender. Oshima Y, Matsumoto Y, Terada S, et al. Prevalence of Gender Dysphoria by Gender and Age in Japan: A Population-based Internet Survey Using the Utrecht Gender Dysphoria Scale. J Sex Med 2022;19:1185-1195.

Prescription Patterns and Testosterone Concentrations Achieved With AndroForte 5% Testosterone Cream in Transgender and Gender Diverse Individuals

BACKGROUND

Masculinizing hormone therapy with testosterone is used to align an individual's physical characteristics with their gender identity in trans and gender diverse individuals. Standard testosterone doses and formulations recommended for hypogonadal cisgender men are typically administered. 100 mg AndroForte 5% testosterone cream is the recommended starting dose in hypogonadal cisgender men but there are no data evaluating the use of AndroForte 5% testosterone cream in gender-affirming hormone therapy regimens.

AIM

To assess the prescription patterns and serum total testosterone concentrations achieved with AndroForte 5% testosterone cream in trans and gender diverse individuals.

METHODS

A retrospective analysis was undertaken of trans and gender diverse individuals at a primary and secondary care clinic in Melbourne, Australia. Seventy-two individuals treated with AndroForte 5% testosterone cream to the torso were included.

OUTCOMES

Testosterone dose and serum total testosterone concentration.

RESULTS

Median age was 26 years (IQR 22-30) and median duration of testosterone therapy was 14 months (7-24). Fifty (69%) individuals had a non-binary gender identity. Initial median testosterone dose was 50 mg (50-100) daily. Thirty-eight (53%) commenced doses <100 mg daily, the recommended starting dose for hypogonadal cisgender men. Median total testosterone concentration achieved from 186 individual laboratory results was 11.9 nmol/L (8.1-16.4). Polycythemia was documented in 5 (7%) individuals.

CLINICAL IMPLICATIONS

AndroForte 5% testosterone cream can be used in individuals with a binary and/or non-binary gender identity seeking masculinization. It can be commenced at a lower dose than that administered to hypogonadal cisgender men for individuals seeking slow masculinization goals.

STRENGTHS & LIMITATIONS

Limitations include the retrospective study design, lack of clinical end points and lack of standardization of timing of laboratory tests in relation to the last dose. This is the first study to evaluate AndroForte 5% testosterone cream in trans and gender diverse individuals and provides insights into prescription patterns in individuals with a non-binary gender identity.

CONCLUSION

AndroForte 5% testosterone cream represents an alternative formulation of testosterone administration for trans and gender diverse individuals seeking masculinization. Nolan BJ, Zwickl S, Locke P, et al. Prescription Patterns and Testosterone Concentrations Achieved With AndroForte 5% Testosterone Cream in Transgender and Gender Diverse Individuals. J Sex Med 2022;19:1049-1054.

Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy

BACKGROUND

Recently, the variability and heterogeneity of gender presentations in transgender youths have gained significant attention worldwide. Alongside this, specialized gender services have reported an increase in referrals of youths reporting non-binary identities. In Italy, studies investigating gender identity and expression in gender non-conforming youths are lacking, as are data regarding the non-binary population.

AIM

The present study aimed at dimensionally exploring how transgender and non-binary Italian adolescents identify and express their gender.

OUTCOMES

Gender expression in trans binary youths and non-binary youths.

METHODS

The Gender Diversity Questionnaire (GDQ; Twist & de Graaf, 2019) was used to investigate gender identity, gender fluidity, and gender expression in a sample of 125 adolescent patients from the Gender Identity Development Service (SAIFIP) in Rome and the Gender Incongruence Unit of the Careggi Hospital in Florence, between April 2019-June 2021.

RESULTS

The majority of participants (74.4%) identified as trans* binary and the remaining (25.6%) participants identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity across time and contexts. Almost all participants rated external appearance as important to their gender expression, yet trans binary participants attributed more importance to the body in this respect. Body discomfort and pubertal stage emerged as the most influential factors in participants' experiences of gender. Participants who were assigned male at birth expressed significantly more desire for puberty blockers, whereas those who were assigned female at birth had a stronger desire to engage in breast/chest surgery. Non-binary participants sought different medical interventions relative to trans binary participants.

CLINICAL IMPLICATIONS

These results may be useful for clinicians working with transgender youths as they provide awareness regarding the features of young people who identify within and outside of binary constructions of gender.

STRENGTHS & LIMITATIONS

This study provides useful data in gaining insight into understanding the variety of experiences and challenges of gender non-conforming youths. However as the sample was recruited from specialized services, it may not represent the entire gender non-conforming population in Italy.

CONCLUSION

The results describe the range of gender identities and expressions among gender non-conforming youths attending gender specialized services in Italy, thereby improving our understanding of the variety of identities experienced and the specific medical needs of both trans binary and non-binary adolescents. Mirabella M, Piras I, Fortunato A, et al. Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy. J Sex Med 2022;19:1035-1048.

Gender-Affirming Care With Transgender and Genderqueer Patients: A Standardized Patient Case

Introduction

Transgender and gender-diverse (TGD) patients experience health disparities and bias in health care settings. To improve care for TGD patients, medical trainees can practice gender-affirming care skills such as inclusive communication and discussing hormone therapy through patient simulation. Systematically evaluating these simulation outcomes also helps educators improve training on gender-affirming care.

Methods

A standardized patient case with a patient establishing primary care was developed for rising third-year medical students. The case featured multiple patient iterations to portray individuals with the same health history but a different gender identity and/or sex assigned at birth. Each student was randomly assigned to one patient encounter. Gender-affirming care skills were assessed through standardized patient checklists, postencounter notes, and preventive care recommendations.

Results

Over 2 years, 286 students participated in the simulation. Transgender men and women, cisgender men and women, and genderqueer patients were portrayed. Performance gaps such as misgendering patients and incorrect cancer screening recommendations based on perceived gender identity (rather than sex assigned at birth) were documented. Ninety-eight percent of students agreed that the encounter helped them practice clinical skills needed to see actual patients, and students described the case as challenging but important.

Discussion

This case served dual roles for medical training: (1) Students working with TGD patients practiced skills for gender-affirming care, and (2) portraying TGD patients along with cisgender patients allowed educators to identify biased recommendations that necessitated additional training. The outcomes further highlighted the importance of students routinely practicing gender-inclusive communication with all patients during simulation.

A Novel Compound Heterozygous Mutation of HSD17B3 Gene Identified in a Patient With 46,XY Difference of Sexual Development

INTRODUCTION

Deficiency of the 17β-hydroxysteroid dehydrogenase type 3 (17 β-HSD3) is a rare autosomal recessive 46,XY Difference of sex development (DSD), resulting from pathogenetic variants in the HSD17B3 gene, which lead to absent or reduced ability to convert Δ4-androstenedione to testosterone in the fetal testes.

AIM

This study aimed to present the clinical and genetic characteristics of an Italian patient receiving a diagnosis of 17 β-HSD3 deficiency in adulthood. The patient was raised as female and underwent early surgical interventions to correct virilized genitalia, leading to a significant sexual distress.

METHODS

At the time of the referral, a 20-gene Next Generation Sequencing custom-panel for DSD was performed on patient's genomic DNA.

RESULTS

A novel compound heterozygous mutation in HSD17B3 gene was identified, detecting a new variant (c.257_265delAGGCCATTG, p.) CONCLUSION: Novel genotype causing 17 β-HSD3 deficiency is presented. Furthermore, the patient's clinical history stresses the importance to actively involve these individuals in the decision-making process avoiding surgical intervention when the patient is not able to give fully informed consent. Cocchetti C, Baldinotti F, Romani A, et al. A Novel Compound Heterozygous Mutation of HSD17B3 Gene Identified in a Patient With 46,XY Difference of Sexual Development. Sex Med 2022;10:100522.

Gender affirming hormonal treatment in Danish transgender persons. A nationwide register-based study

BACKGROUND

Gender affirming hormonal treatment (GAHT) is a cornerstone in transgender care. National data are sparse regarding use of hormonal treatment by transgender persons.

AIM

To assess use of GAHT in transgender persons.

DESIGN

National register-based cohort study in Danish transgender persons followed from 2000 until 2018. The main outcome measure was prescription and purchase of GAHT. Persons with ICD-10 diagnosis code of "gender identity disorder" (CGI-cohort) and persons with legal sex change but without diagnosis (CPR-cohort) were included. In the CGI-cohort, transgender women were defined by prescription of estrogen and/or cyproterone acetate and/or testosterone-5-alpha reductase inhibitors and transgender men were defined by prescription of testosterone after study inclusion. Discontinuation of GAHT was defined as no purchase of GAHT ≥ 13 months or shift from feminizing to masculinizing hormone treatment, or vice versa.

RESULTS

The cohort included 2789 transgender persons (n = 1717, CGI-cohort and n = 1072, CPR-cohort). The median age (interquartile range) at study inclusion was 26.1 (17.7) years for persons assigned male at birth (n = 1447) and 22.5 (10.5) years for persons assigned female at birth (n = 1342). In the CGI-cohort, the event rate for GAHT in transgender women increased from 4.0 (95% CI: [3.1; 5.2]) events per 100 person in year 2000-2005 to 20.6 [17.8; 23.7] between 2014 -2018. In transgender men, the event rate of GAHT increased from 4.2 [2.8; 6.2] to 18.8 [16.4; 21.6]. The rate of discontinuation of GAHT was 0.06 (95% CI 0.049; 0.071) per person year.

CONCLUSIONS

The event rate of GAHT increased during 2000-2018. Our data suggested high adherence to GAHT. This article is protected by copyright. All rights reserved.

Talking About Sexuality With Youth: A Taboo in Psychiatry?

BACKGROUND

Young people who have psychiatric problems are more likely than their peers to endure difficulties during their sexual and gender identity development.

AIM

This study aims to examine the communication between mental health care providers and their patients about the topics of relations, sexuality and gender identity, including a description of professionals' attitudes toward these topics and the factors that contribute to and inhibit communication.

METHODS

Study participants (n = 242, response rate = 31%) were a representative sample of a large multicenter cohort of 768 mental health care professionals (eg, medical doctors, psychiatrists, psychologists, group counselors, parent counselors) of 7 institutions and 5 solo practices in the Netherlands, who completed a survey on communication about sexuality and gender identity with their young patients (age 12-21 years).

OUTCOMES

Sexuality and gender identity are infrequently discussed by mental health care providers with their young patients or their patients' parents.

RESULTS

Of the study sample, 99.5 % valued sexuality as an important topic to discuss with their patients. However, only 17.1% of the professionals reported that they discussed sexuality-related issues with the majority (>75%) of their patients (adolescents: 19.9%, parents: 14.4%) Additionally, only 2.3 % of the participants discussed gender nonconformity regularly with patients. Information about sexual side effects of prescribed medication was infrequently (20.3%) provided: antidepressants (40.0%), antipsychotics (34.0%), benzodiazepines (5.1%) and stimulants (2.4%). The most frequently cited reasons for not discussing these topics were a lack of awareness, own feelings of discomfort, and the patients' supposed feelings of shame. There was no gender differences observed.

CLINICAL IMPLICATIONS

Recommendations for professionals include to be aware of these topics, initiating age-appropriate conversation and use inclusive language.

STRENGTHS AND LIMITATIONS

The present study included a diverse and representative group of mental health care professionals. Frequency of sexual communication was based on self-report, which brings a risk of bias.

CONCLUSION

Despite a recognized need to engage in age-appropriate communication about sexuality and gender identity in youth mental health care, mental health providers seem to remain hesitant to discuss such topics. Bungener SL, Post L, Berends I, et al. Talking About Sexuality With Youth: A Taboo in Psychiatry?. J Sex Med 2022;19:421-429.

An Exploration of the Experiences of Physical Therapists Who Identify as LGBTQIA+: Navigating Sexual Orientation and Gender Identity in Clinical, Academic, and Professional Roles

OBJECTIVE

The purpose of this study was to explore physical therapy through the stories of physical therapists who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other related identities (LGBTQIA+) to consider how the profession enacts and constructs gender and sexual orientation.

METHODS

Physical therapists with clinical, academic, and professional roles who identify as LGBTQIA+ were recruited from Australia, the United Kingdom, Canada, and the United States. In-depth data were collected via narrative interviews. An iterative group discourse analysis was used to examine key discourses underpinning interview narratives and how these relate to the physical therapy profession.

RESULTS

Twenty-two physical therapists were interviewed. Participants had between 1.5 and 40 years of experience across various clinical areas and settings. Participants identified with varying sexual orientations and gender identities. Analysis identified discourses discussed under the following headings: (1) normativity, which related to hetero-normative assumptions about sexual orientation and cisnormative assumptions about gender identity and the intersectionality among sexual orientation, gender identity, and other forms of marginalization; (2) stress and labor, which explored the stress experienced by physical therapists who are LGBTQIA+ (due to fear of discrimination or actual discrimination) and additional emotional and other types of labor or work done in the workplace to hide aspects of their lives to feel safe, educate colleagues, and be a role model; and (3) professionalism, which related to the heterosexual/cisnormative (and other) "norms" that comprised participants' ideas of presenting as "professional" and positioning physical therapists who are LGBTQIA+ as "unprofessional."

CONCLUSION

Findings suggest that cultural norms may need to be reconceptualized in physical therapy to promote inclusion and belonging of individuals who identify as LGBTQIA+. Approaches to upskill new and existing physical therapists may include elements such as individual and institutional reflexivity, learning and implementing appropriate terminology, displaying indicators of inclusivity, and cultural safety training. These elements may provide the first steps to promote inclusive and culturally safe environments for individuals who identify as LGBTQIA+ within the profession.

IMPACT

This is the first known study to explore the lived experiences of those who identify as LGBTQIA+ in the physical therapy profession. The findings highlight how prevailing normative discourses in Western society are also present in physical therapy and impact those who identify as LGBTQIA+.

Is My Femininity a Liability? Longitudinal Associations between Girls' Experiences of Gender Discrimination, Internalizing Symptoms, and Gender Identity

Gender discrimination is a common experience for adolescent girls and has implications for their mental health and identity development. Guided by Phenomenological Variant of Ecological Systems Theory (PVEST; Spencer et al. 1997), this study examined the longitudinal and bidirectional associations between adolescent girls’ experiences of gender discrimination, their internalizing symptoms, and gender identity. The sample was 161 adolescent girls (ages 14–17; M_age = 15.90) from across the United States (51% White; 17% African American, 11% Hispanic/Latina) who participated in a short-term longitudinal study of adolescent development. The results showed a reciprocal, longitudinal association between discrimination and internalizing symptoms. Discrimination also predicted longitudinal declines in gender identity, which was explained indirectly through internalizing symptoms. The findings implicate gender discrimination as a distinct risk factor during girls’ developmental years, and underscore the importance of helping girls learn adaptive responses to sexism, while also reducing actual occurrence and exposure.

The relationship between sexual and gender stigma and suicide attempt and ideation among LGBTQI + populations in Thailand: findings from a national survey

PURPOSE

Thailand has one of the highest suicide rates in Southeast Asia; yet, little is known about suicidality among lesbian, gay, bisexual, trans, queer, intersex, and other gender and sexually diverse (LGBTQI +) people living in the region, who may experience elevated risk for suicide. We sought to identify the prevalence of lifetime suicidal attempts and ideation among a nationally recruited sample of LGBTQI + people in Thailand. We further examined the relationship between levels of sexual/gender stigma and suicidal attempt and ideation.

METHODS

Data were derived from a national online survey of Thai LGBTQI + individuals between January and March 2018. Multivariable logistic regression was used to examine the relationship between sexual/gender stigma scales, adapting a previously validated instrument, and suicide attempt and ideation.

RESULTS

Among 1,290 LGBTQI + participants, the median age was 27 years. The prevalence of suicide attempt and ideation was 16.8% and 50.7%, respectively. In multivariable analyses, after adjusting for potential confounders, experiences of perceived and enacted sexual/gender stigma were independently and positively associated with suicide attempt (adjusted odds ratio [AOR] = 1.25; 95% confidence interval CI:1.10-1.41 and AOR = 1.31; 95% CI:1.11-1.55, respectively) and ideation (AOR = 1.30; 95% CI:1.17-1.43 and AOR = 1.34; 95% CI:1.14-1.58, respectively).

CONCLUSION

One-sixth of the sample reported a suicide attempt, while a half reported ever contemplating suicide. Both experiences of perceived and enacted sexual/gender stigma were associated with lifetime suicide attempt and ideation. Multi-level interventions are needed to decrease stigma and in turn suicide among LGBTQ + people in Thailand, including anti-discrimination policies and support for mental health and well-being.

Biochemical Changes During the First Year of Feminizing Hormone Therapy in Transfeminine Individuals

BACKGROUND

Persons with assigned male sex at birth (AMAB) might wish to obtain feminization and/or demasculinization according to the person's gender identity and are therefore treated with estradiol and/or antiandrogens.

AIM

The aim was to evaluate biochemical changes and side effects in AMAB individuals treated with guideline-based feminizing hormone treatment (FHT).

METHODS

Medical charts of 99 AMAB individuals ≥ 18 years referred to the Center for Gender Identity; Aalborg University hospital, Denmark, between January 2017 and July 2019 were reviewed to identify adverse side effects. Furthermore, data from the laboratory information system (Labka II) were retrieved to obtain biochemical parameters. Biochemical plasma concentrations after initiation of FHT were compared to concentrations prior to FHT and to existing guidelines.

OUTCOMES

After 11-19 months, 29% of the trans feminine individuals had plasma estradiol concentrations within the treatment target.

RESULTS

The plasma concentration of estradiol varies greatly during FHT. Plasma levels of estrogen were within the treatment target after 11-19 months of treatment, whereas 100% had concentrations within the reference range for premenopausal cis-women. Furthermore, plasma concentrations of lipids and hematological parameters approached female reference ranges after 11 months of FHT.

CLINICAL IMPLICATIONS

The target levels of plasma estradiol concentrations during FHT could be expanded, making the wanted physiological changes easier to obtain.

STRENGTHS & LIMITATION

This cohort study included 99 AMAB individuals and biochemical evaluation was possible in 67 individuals. Only one individual was lost during follow-up. However, the follow-up period was limited making evaluation of long-term side effects impossible.

CONCLUSION

Plasma concentration of estradiol varies greatly during guideline based FHT, making plasma estradiol levels within the target level difficult to attain. JA Hojbjerg, AD Højgaard, A-M Hvas. Biochemical Changes During the First Year of Feminizing Hormone Therapy in Transfeminine Individuals. Sex Med 2021;10:100472.

Understanding the Lived Experiences of Hispanic Sexual Minority Youth and their Parents

Disclosure of sexual identity and/or gender orientation is difficult for youth and is associated with elevated adverse health risks, particularly when there is parental rejection. There are limited studies conducted with Hispanic sexual minority youth (HSMY) and their families to understand the disclosure process, how the family unit changes and adapts following disclosure, and the implications for preventive interventions for HSMY and their families. This paper explores the lived experiences of youth and parents throughout the disclosure process. A phenomenological approach was used to interview 15 parent-youth dyads (N = 30) to understand what it means for Hispanic youth to disclose their sexual identity and/or gender orientation. Three themes that best described the experience emerged from the participant interviews; the experience of disclosing included intrapersonal challenges, navigating disclosure, and conceptualizing acceptance. The authors highlight implications for preventive interventions that can help these families undergoing the unique process of disclosure.

Psychological Wellbeing and Perceived Social Acceptance in Gender Diverse Individuals

BACKGROUND

Over the last few years, the gender binary has been questioned, highlighting the existence of gender diverse people, who identify as neither (exclusively) male nor female.

AIM

The present study evaluated the possible differences in terms of psychological wellbeing between binary and gender diverse individuals, as well as the role of perceived social acceptance and religious fundamentalism as possible mediators of psychopathology in gender diverse people. Furthermore, the diversity of gender-affirming hormonal treatment requests according to gender identification was investigated.

METHODS

A sample of 563 transgender people aged 18-70 was enrolled (n = 264 assigned female at birth, AFAB and n = 299 assigned male at birth, AMAB), all individuals referring to several Italian gender clinics. A subdivision of the study population based on the gender identity visual analog scale (GI-VAS) median was performed, in order to distinguish between gender diverse and binary transgender individuals. Moreover, a linear regression analysis was performed entering logarithmically transformed GI-VAS (Log GI-VAS) into the models with psychometric scales.

OUTCOMES

Psychometric and sociodemographic data, as well as information regarding requests for gender-affirming treatments, were extrapolated from the clinical interviews conducted during the first referral.

RESULTS

Gender diverse individuals showed significantly less intense gender dysphoria and higher levels of depression and anxiety compared to binary ones; accordingly, a less binary gender identity correlated with higher levels of depression and anxiety and lower levels of gender dysphoria. The depressive symptomatology in gender diverse people was partially mediated by perceived discrimination and humiliation. Moreover, gender diverse AMAB people sought a non-standard hormonal treatment more often than their binary counterpart.

CLINICAL IMPLICATIONS

The present study highlights the importance for transgender health professionals, when planning gender-affirming hormonal treatments, to offer flexible interventions, tailored on the patient's needs and goals.

STRENGTHS & LIMITATIONS

Strengths included exploring whether and how perceived discrimination may affect mental health in gender diverse people. Limitations included the enrolled sample of people referring to different gender clinics, which is not fully representative of the transgender population.

CONCLUSION

This study highlights the importance of evaluating each individual's unique health care needs, exploring each single request and its underlying reasons. Romani A., Mazzoli F., Ristori J., et al. Psychological Wellbeing and Perceived Social Acceptance in Gender Diverse Individuals. J Sex Med 2021;18:1933-1944.

The influence of minority stress on indicators of suicidality among lesbian, gay, bisexual and transgender adults in Thailand

WHAT IS KNOWN ON THE SUBJECT?: Established research from the United States and other Western countries has found that lesbian, gay, bisexual and transgender (LGBT) populations are at an elevated risk for suicide. Suicidality among LGBT individuals is understudied in Thailand and other Asian countries, warranting additional research to better understand risk factors and to create effective treatment and suicide prevention interventions. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The study examined rates and predictors of suicidality in Thai LGBT adults. Study findings suggest that general (e.g. stress and loneliness) and minority stressors (e.g. discrimination and victimization) played important roles in predicting lifetime and past-year suicidal ideation, while socio-demographic and health-related factors (e.g. living in high poverty area and having chronic diseases) were associated with suicide attempts among LGBT individuals. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Changes in the nursing curriculum and continuing education resources are needed to improve knowledge and core competencies in the mental health and treatment needs of LGBT individuals in Thailand. Among LGBT serving practitioners, routine assessment of suicidality is needed to increase the early identification and treatment of individual at risk for suicidal behaviours. Standardized measures of sexual orientation and gender identity should be included in all patient intake forms. In conducting research on strategies to improve mental health outcomes among LGBT populations, standardized measures of sexual orientation/gender identity and minority-specific stressors should be used. Suicide prevention interventions aimed at reducing general and minority stress among LGBT populations should be a priority in mental health nursing.

ABSTRACT

INTRODUCTION: A large and rigorous body of research in the United States has demonstrated that lesbian, gay, bisexual and transgender (LGBT) populations are at an elevated risk for suicide. However, scant research aimed at understanding the rates and predictors for suicidality among Thai LGBT individuals exists.

AIM

To examine rates and predictors of suicidality among Thai LGBT adults (N = 411).

METHOD

Data collection was conducted via online and in-person surveys. Guided by the Minority Stress Model, standardized measures of demographics, health-related factors, general and minority-specific stressors and suicidality were completed.

RESULTS

Thirty-nine per cent of participants reported lifetime suicidal ideation, 19.0% past 12-month suicidal ideation and 13.1% lifetime suicide attempts. Lifetime suicidal ideation was associated with higher levels of social discrimination, stress, loneliness and chronic disease (OR = 1.12, 1.16, 2.75, and 1.46, p ≤ .05, R² = 0.327). Past-year suicidal ideation was associated with victimization, stress, loneliness and being a former smoker (OR = 1.52, 1.20, 2.34, and 4.89, p < .05, R²  = 0.345). Suicide attempts were associated with internalized homophobia, poverty, chronic disease, alcohol use and physical health (OR = 1.44, 1.06, 1.59, 1.45 and 0.95, p ≤ 0.05, R²  = 0.187).

DISCUSSION

General and minority-specific stressors negatively impacted suicidality among LGBT participants.

IMPLICATION FOR PRACTICE

Study findings have implications for nursing education, practice and research. Nursing education should include information about the influence of sexual orientation and gender identity on mental health outcomes. Further, systematic screening for suicidality should be conducted by LGBT serving psychiatric and mental health nurses. Finally, research is needed to determine best practices for interventions aimed at reducing suicidality risk among LGBT individuals.

Validation of the Chinese Version of the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults

BACKGROUND

The number of individuals with potential gender dysphoria (GD) being referred to specialized gender identity clinics or programs is increasing internationally; these cases are initially screened using the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA).

AIM

The current study aimed to assess the psychometric properties of the GIDYQ-AA in a sample of adolescents and young adults from China.

METHODS

A cross-sectional study was conducted in October 2020. Sociodemographic information of the participants was first collected. Participants then completed the GIDYQ-AA, the Generalized Anxiety Disorder-7 scale, the Patient Health Questionnaire-9, and a suicidal ideation assessment. A total of 2,533 participants with a mean age of 19.30 (SD = 1.19) years were recruited. Of the participants, 841 (33.2%) were cis men, 1,589 (62.7%) were cis women, 66 (2.6%) self-identified as transgender, 17 (0.7%) self-identified as non-binary, and 20 (0.8%) self-identified as gender queer.

RESULTS

The GIDYQ-AA had high internal consistency with a Cronbach's alpha = 0.89. Exploratory factor analysis showed that the GIDYQ-AA had a four-factor structure in China. The GIDYQ-AA was significantly correlated with anxiety symptoms (r = -0.32, P < .01), depressive symptoms (r = -0.33, P < .01), and suicidal ideation (r = -0.20, P < .01).

CLINICAL TRANSLATION

The Chinese version of GIDYQ-AA is a useful measurement with high practical value, which could promote the assessment and research of GD across China or among Chinese migrants in other countries.

STRENGTHS AND LIMITATIONS

This is the first study assessing the psychometric properties of the GIDYQ-AA in Chinese adolescents and young adults. The convergent and divergent validity of the GIDYQ-AA were not examined due to the unavailability of data. Also, the sample did not have an equal distribution of male to males and female to females.

CONCLUSION

The Chinese version of GIDYQ-AA is a useful measure, which could promote both the assessment and research of GD in the Chinese population. Wang Y, Feng Y, Su D, et al. Validation of the Chinese Version of the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. J Sex Med 2021;18:1632-1640.

[Gender Distribution in Medical Leadership Roles in Portugal: The Example of Candidacy to Bodies of the Portuguese Medical Association 2017-2019]

INTRODUCTION

Gender equality is one of the sustainable development goals. Low participation of women in leadership roles is an example of gender inequality. In Portugal, there are few studies regarding gender inequality in medical leadership roles. Therefore, we aimed to analyse gender distribution of candidates to regional bodies of the Portuguese Medical Association.

MATERIAL AND METHODS

We extracted data from the candidates to the regional bodies of the Portuguese Medical Association (2017 - 2019 mandate) from the Association's magazine (issue number 175). We calculated the percentage of women candidates, overall and stratified by list, region and roles. We obtained observed-vs-expected ratios overall and by region, and respective 95% confidence intervals, assuming a Poisson distribution. Finally, we conducted a sensitivity analysis, excluding substitute candidates.

RESULTS

Women accounted for 37% of the candidates (regional variation: 29% - 51%). The national observed-vs-expected ratio was 0.74 (95% confidence interval: 0.58; 0.92), mainly driven by the ratio from the South Region: 0.58 (95% confidence interval: 0.41; 0.80). Women ran mainly for alternate candidates and secretary positions (56% and 54% respectively).

DISCUSSION

Gender differences were identified, particularly in the South, regarding the frequency and type of candidacy. Previous works have identified maternity, the social role of women and perceptions regarding the leadership roles as possible reasons to explain such differences. Our analysis is limited to specific leadership roles and an election moment; further studies should be pursued.

CONCLUSION

We identified a lower than expected participation of women in the elections for the Portuguese Medical Association. When they run, women are found mainly in less relevant positions or with less potential to be elected (secretary or alternate candidate). A deeper understanding and measures to fight gender inequality in leadership roles are required.

Teaching Sexual Orientation and Gender Identity in Pediatric Clinical Settings: A Training Workshop for Faculty and Residents

INTRODUCTION

Health disparities for the lesbian, gay, bisexual, transgender, queer, intersex, asexual, all other genders, sexes, and sexualities (LGBTQIA+) population are striking. Yet, deliberate efforts to integrate sexual orientation and gender identity in pediatric education settings remain lacking. The type of formal training that pediatric educators currently have for teaching of sexual orientation and gender identity is unclear and limited, which led to the development and implementation of this curriculum.

METHODS

A 2-hour workshop was developed to address gaps in knowledge, equip faculty and resident educators with skills to apply key concepts in teaching activities, and motivate them to examine challenges and opportunities in teaching sexual orientation and gender identity principles in their routine duties in pediatric settings across the undergraduate and graduate education spectrum. Learning strategies of the workshop included learner activation, a didactic, and clinical cases with role-play opportunities. Participants completed evaluations at the end of the workshop.

RESULTS

The workshop was implemented in three varied educational settings in 2019. All 65 participants enrolled in the workshop completed the evaluations. Evaluations ranged from 4.6 to 4.9 on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Participants reported workshop strengths and anticipated impact on their own teaching and clinical practice.

DISCUSSION

Stark health disparities for the LGBTQIA+ population and gaps in relevant curricula demand a training intervention for pediatric educators. We demonstrated the successful implementation of a training workshop, with evidence of feasibility and generalizability, that addressed knowledge gaps and teaching and clinical skills.

Early Intervention for LGBTQ Health: A 10-Hour Curriculum for Preclinical Health Professions Students

INTRODUCTION

Individuals who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) face significant health disparities and barriers to accessing care. Patients have reported provider lack of knowledge as one of the key barriers to culturally responsive, clinically competent care. Many US and Canadian medical schools still offer few curricular hours dedicated to LGBTQ-related topics, and medical students continue to feel unprepared to care for LGBTQ patients.

METHODS

We developed a 10-hour LGBTQ health curriculum for preclinical medical and physician assistant students. The curriculum included lectures and case-based small-group discussions covering LGBTQ terminology, inclusive sexual history taking, primary care and health maintenance, and transition-related care. It also included a panel discussion with LGBTQ community members and a small-group practice session with standardized patients. Students were surveyed before and after completing the curriculum to assess for increases in confidence and knowledge related to LGBTQ-specific care.

RESULTS

Forty first- and second-year medical students completed the sessions and provided valid responses on pre- and postcourse surveys. Nearly all students initially felt unprepared to sensitively elicit information, summarize special health needs and primary care recommendations, and identify community resources for LGBTQ individuals. There was significant improvement in students' confidence in meeting these objectives after completion of the five sessions. Knowledge of LGBTQ health issues increased minimally, but there was a significant increase in knowledge of LGBTQ-related terminology.

DISCUSSION

Our 10-hour LGBTQ health curriculum was effective at improving medical students' self-confidence in working with LGBTQ patients but was less effective at increasing LGBTQ-related medical knowledge.

Evaluating gender bias in an eating disorder risk assessment questionnaire for athletes

Due to stigma, eating disorders are under-researched, underdiagnosed and undertreated among men. This is particularly pertinent among athletes, as athletic goals are a major risk factor for disordered eating in men. This gender stereotype may be reinforced by eating disorder risk assessment tools that better reflect female symptoms. We examine an eating disorder risk assessment questionnaire in a population of athletes to assess both (1) gender bias in individual items and (2) gender differences on a cognitive and behavioral subscale, identified through a factor analysis. Controlling for eating disorder risk, we found that female gender significantly predicted high risk scores on four items; male gender significantly predicted high risk scores on four other items. We also found that women were more likely to score above the median on a cognitive subscale than men with the same level of eating disorder risk, while men were more likely to score above the median on a behavioral subscale. These results may be applied practically to allow eating disorder risk assessment tools to better capture eating disorder risk independent of gender. These methods may be applied to other questionnaires and other social identities, to expand the scope of eating disorder research and treatment.

"Sex Can Be a Great Medicine": Sexual Health in Oncology Care for Sexual and Gender Minority Cancer Patients

Purpose of review

Until recently, sexual and gender minority (SGM) people have been largely invisible in health care and health services research. However, understanding the needs and experiences of SGM cancer patients is critical to providing high-quality care, including needs and experiences related to sexual health. In this narrative review, we highlight that the literature on sexual health for SGM people with cancer is lacking, summarize existing literature on disparities affecting SGM patients with cancer, and discuss factors associated with these disparities. We conclude with recommendations and suggestions for future research in this area.

Recent Findings

Emerging evidence suggests that SGM people are at a higher risk for breast, cervical, endometrial, HPV-related, and lung cancers, as well as poor cancer outcomes, due to behavioral risk factors and health care system factors (e.g. lower access to health care insurance, discrimination in non-affirming care settings, negative health care interactions with providers). Additional research suggests that lack of clear guidelines for cancer screening in SGM patients, particularly for transgender and gender diverse patients, negatively impacts cancer screening uptake among SGM people. A growing number of studies have suggested greater sexual challenges following cancer treatment for sexual minority men with prostate cancer, while other studies highlight positive outcomes for sexual minority women following cancer treatment, such as benefit finding and resilience. Research on transgender and gender diverse patients is lacking.

Summary

Collection of sexual orientation and gender identity data across clinical enterprises and population-based surveys, mandatory health care provider training on cultural and clinical competency with SGM patients, and additional research inclusive of and focused on SGM cancer patients are key strategies to advance evidence-based clinical cancer care for diverse SGM populations.

Rainbows and "Ready for Residency": Integrating LGBTQ Health Into Medical Education

INTRODUCTION

To provide appropriate and sensitive care for lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) youth, providers must learn specific skills and guidelines. Most medical schools lack formal education on LGBTQ health, particularly for adolescent patients.

METHODS

We developed an Introduction to LGBTQ Health course for fourth-year medical students as part of a monthlong Ready for Residency curriculum in March and April of their graduating year. The course addressed guidelines recommended in the care of LGBTQ individuals utilizing problem-based learning methodology. Through learner-led discussion, students worked in small groups to research case-based scenarios and reported their findings to the larger group, followed by teaching points from a facilitator. The course was evaluated on curricular perception using a 5-point Likert scale and open-ended feedback.

RESULTS

One hundred forty-six students participated in the curriculum; 103 completed the session evaluation. Mean total scores were 4.6 out of 5 in March and 4.7 out of 5 in April after changes were made based on student feedback, namely, increasing the session from 50 to 80 minutes and decreasing session size from 72 students to 36. Students felt the session was well planned and run, engaging, and relevant; appropriately integrated evidence-based medicine; and taught them what they hoped to learn.

DISCUSSION

Many medical schools lack curricula dedicated to LGBTQ health care. Implementing this mandatory LGBTQ health course was well received and highly rated by almost all students regardless of anticipated specialty. The session could be easily replicated at medical schools across the country.

Teaching Intersectionality of Sexual Orientation, Gender Identity, and Race/Ethnicity in a Health Disparities Course

Introduction

Intersectionality considers how different identities simultaneously affect an individual's experiences. Those of multiple minority statuses may experience effects of intersecting systems of oppression. Most health disparities curricula do not focus on intersectionality. We studied the impact of an innovative module teaching intersectionality of sexual orientation, gender identity, and race/ethnicity issues in the required Pritzker School of Medicine course Health Care Disparities: Equity and Advocacy.

Methods

A short lecture reviewed sexual and gender minority (SGM) health disparities, intersectionality, minority stress, and shared decision making (SDM) to establish shared language among 83 first-year medical students. Students then viewed four videos of SGM patients of color (POC) describing their health care experiences, each followed by moderated discussion about how compounded minority stress affects lived experiences and health and how to improve SDM for SGM POC. One video interviewee attended the session and answered students' questions. Evaluation was performed using pre- and postsurveys.

Results

Feeling somewhat/completely confident in defining intersectionality increased from 57% to 96%. Prior to the session, 62% of respondents reported feeling somewhat/completely confident in identifying barriers to care for SGM patients, and 92% after. Thirty-three percent felt somewhat/completely confident in asking SGM patients about their identities before the session, and 81% after. Eighty-four percent rated the session as very good or excellent.

Discussion

The session was well received, improved student knowledge of intersectionality, and improved confidence in communicating with and caring for SGM patients. Future iterations could include condensing the lecture and including a patient panel and/or small-group discussion.

The Case of Sean Smith: A Three-Part Interactive Module on Transgender Health for Second-Year Medical Students

INTRODUCTION

While great strides have been made in favor of the LGBT community overall, transgender individuals are still facing many legal challenges and suffer from more marked health issues and disparities compared to other members of the LGBT community. Our multimodal transgender curriculum was designed in accordance with the Kern model to address educational gaps in the area of transgender health.

METHODS

This three-part module consists of: (1) a didactic PowerPoint presentation reviewing unique health issues and disparities experienced by transgender patients, (2) a small-group session viewing and analyzing a pair of videos showcasing competent and poor communication between a provider and a transgender patient, and (3) a large-group patient panel featuring members of the transgender community.

RESULTS

One hundred and sixty-one students returned pre- and postworkshop surveys with 123 matched pairs. When comparing participants reported pre- and postworkshop confidence levels, the mean rating increased significantly for all three learning objectives. Based on a 5-point Likert scale (1 = poor, 5 = excellent), participants' mean ratings were highest for the patient panel at 4.5, compared to 3.9 for the large-group didactic lecture, and 3.8 for the small-group video session.

DISCUSSION

The use of this multimodal approach using a didactic session, video-based case discussion, and patient panel provided a strong foundation and primer for transgender health and resulted in an increase in learner confidence in module objectives regarding care for the transgender community.

Role of Common Variables: Age, Gender, BMI, Rhinosinusitis, and Smoking among Asthmatic and Severe Asthmatic Patients

BACKGROUND

This study was done to determine the role of common variables, including age, gender, body mass index (BMI), rhinosinusitis, and smoking among a group of asthmatic and severe asthmatic patients in 2016.

MATERIALS AND METHODS

This retrospective study was carried out from mid-June to the end of September 2016. Of 678 patients with asthma referred to private asthma clinics in Tehran, 163 subjects were selected. Severe asthma (SA) cases were diagnosed according to the SA definition (severe shortness of breath, chest tightness or pain, and coughing or wheezing, low peak expiratory flow (PEF) using a peak flow meter, and more than two days of wheezing and coughing per week). Patients with the presence of concomitant diseases, such as gastroesophageal reflux disease, sleep apnea, hypo- and hyperthyroidism, as well as users of nonsteroidal anti-inflammatory drugs (NSAIDs) were excluded.According to the signs and symptoms and classic criteria of asthma, the subjects with SA were assigned to the case group and subjects with asthma to the control group. Besides, general information, including age, gender, BMI, smoking history, and the presence of Rhinosinusitis was collected.

RESULTS

Of 163 subjects, 92 patients (56.4%) were in the control, and 71 patients (43.6%) in the case group. The rate of SA among 678 patients was 10.47%. The mean age of the case group was 49.08 ±11.66 and the control group was 50.05 ±15.65 years. There was a significant difference in BMI between the case and control groups (p=0.034), especially among females in the case group (p=0.001). BMI was significantly higher in females than in males (p=0.002). Also, smoking status was not significant between the case and control groups (p=0.751). Rhinosinusitis was significantly higher in the case groups compared with the control groups (p= .014).

CONCLUSION

Rhinosinusitis was higher in SA patients (case group). SA was more observed among females than males and those who were more overweight. It seems that rhinosinusitis and obesity are more important risk factors. Moreover, obese female patients require more serious attention.

[Argentinian women and the uses of drugs: A sociohistorical analysis of female drug use in Argentina (1860-1930)]

This article describes cases presented by experts from the legislative and medical-legal fields regarding the use of psychoactive substances among Argentinian women from 1878 to 1930. Background information is presented regarding the relationship between women and the use different drugs, medical interventions on the female body where psychoactive substances were used are analyzed, and experts' descriptions of cases of female drug users are detailed. Experts' discourses during this period did not attempt to comprehend the specificities of female consumption, but were rather used to position the issue of drug use as a social problem. This was done using three prototypes: the victim of a sick husband; the prostitute who encourages drug use among the weak in spirit (natural-born criminals); and the virtuous young woman who succumbs to drug addiction in spite of her father's rule. Each figure reinforces the need for state intervention and increased social control.

Addressing Needs of Transgender Patients: The Role of Family Physicians

There are approximately 1 million transgender and gender-diverse adults in the United States. Despite increased awareness and acceptance, they frequently encounter medical settings that are not welcoming and/or health care providers who are not knowledgeable about their health needs. Use of correct terminology, following best practices for name and pronoun use, and knowledge of gender-affirming interventions can create office environments that are welcoming to transgender clients. Health disparities faced by transgender patients that impact access to care include higher rates of mental health issues, substance use disorders, violence, and poverty. Transgender women are at greater risk for HIV acquisition and are less likely to achieve viral suppression compared with cisgender (nontransgender) individuals. Medical providers can facilitate HIV prevention efforts by offering pre- and postexposure prophylaxis to transgender patients at risk for HIV infection. Improving health outcomes requires attention to cultural competency and an understanding of lived experiences and priorities of transgender people.

Upper urinary tract stone compositions: the role of age and gender

Objective:

To analyze the compositions of upper urinary tract stones and investigate their distributions in different gender and age groups.

Materials and Methods:

Patients diagnosed with upper urinary tract stone disease between December 2014 and March 2018 were retrospectively reviewed. Patient's age, gender, BMI, comorbidities, stone event characteristics, and compositions were collected, and proportions of stone components in different gender and age groups were analyzed.

Results:

A total of 1532 stone analyses were performed (992 from males and 540 from females). The mean age was younger in males (p <0.001). Males included more cases with larger BMI, hyperuricemia, and obesity, while females had more urinary tract infections. Multiple components were present in 61.8% of stones. Calcium oxalate (CaOx) (67.0%) was the most common component, followed by uric acid (UA) (11.8%), infection stone (11.4%), calcium phosphate (CaP) (8.0%), cystine (1.1%), brushite (0.4%), and 2, 8-dihydroxyadenine (0.2%). Men contributed with more CaOx stones than women at age 30-49 years (all p <0.01) and more UA stones at 30-59 years (all p <0.05). Women contributed with more infection stones than men in age groups 30-49 and 60-69 years (all p <0.05), and more CaP stones at 30-49 years. The prevalence peak was 50-59 years in men and 60-69 years in women. Both genders had the lowest prevalence in adolescence. Prevalence of UA stones increased while that of infection stones decreased with aging in both genders.

Conclusions:

Age and sex had a strong association with distribution of stone compositions in this Chinese cohort.

Comprehensive Curriculum for Internal Medicine Residents on Primary Care of Patients Identifying as Lesbian, Gay, Bisexual, or Transgender

INTRODUCTION

Significant gaps remain in the training of health professionals regarding the care of individuals who identify as lesbian, gay, bisexual, and transgender (LGBT). Although curricula have been developed at the undergraduate medical education level, few materials address the education of graduate medical trainees. The purpose of this curriculum was to develop case-based modules targeting internal medicine residents to address LGBT primary health care.

METHODS

We designed and implemented a four-module, case-based, interactive curriculum at one university's internal medicine residency program. The modules contained facilitator and learner guides and addressed four main content areas: understanding gender and sexuality; performing a sensitive history and physical examination; health promotion and disease prevention; and mental health, violence, and reproductive health. Knowledge, perceived importance, and confidence were assessed before and after each module to assess curricular effectiveness and acceptability. General medicine faculty delivered these modules.

RESULTS

Perceived importance of LGBT topics was high at baseline and remained high after the curricular intervention. Confidence significantly increased in many areas, including being able to provide resources to patients and to institute gender-affirming practices (p < .05). Knowledge improved significantly on almost all topics (p < .0001). Faculty felt the materials gave enough preparation to teach, and residents perceived that the faculty were knowledgeable.

DISCUSSION

This resource provides an effective curriculum for training internal medicine residents to better understand and feel confident addressing LGBT primary health care needs. Despite limitations, this is an easily transferable curriculum that can be adapted in a variety of curricular settings.

Promoting Affirmative Transgender Health Care Practice Within Hospitals: An IPE Standardized Patient Simulation for Graduate Health Care Learners

INTRODUCTION

Transgender patients frequently experience discrimination within health care settings due to provider lack of knowledge and bias resulting in poor service delivery. Team-based interprofessional collaboration is becoming a best practice for health professionals to improve patient-centered care and address these health disparities.

METHODS

A team-based interprofessional education simulation activity was developed as a teaching activity at a university for graduate health care learners in medicine, nursing, occupational therapy, physical therapy, physician assistant, social work, and health care administration programs over 2 years (N = 494). The simulation focused on a transgender patient brought to the emergency department (ED) after a workplace assault. Students were placed in interprofessional teams and asked to critique the initial ED interaction with the patient and then complete a team huddle and discharge planning meeting with a standardized patient. Student preparedness to engage in the Interprofessional Education Collaborative (IPEC) competencies was assessed through a posttest measure.

RESULTS

Student learners reacted overwhelmingly positively to the activities of the workshop. The averaging of 2 years of data yielded students responses of strongly agree and agree at 90% or higher for all IPEC core competencies, as well as for educational objectives of the workshop.

DISCUSSION

Reducing the structural, interpersonal, and individual stigma experienced by transgender patients requires institutions to offer experiential learning opportunities for future health care providers. This interprofessional education simulation experience focusing on transgender patients calls attention to the negative impact of stigma while also promoting competency in interprofessional practice.

Designed Strategies and Adaptation of a Master Patient Index for Transgender Patients in a Tertiary Care Hospital

Transgender people experience their gender identity as different from the sex assigned to them at birth and/or those listed on their legal identification. A Master Patient Index (MPI) is a centralized index of all patients in a health care system. The objective of this work was to describe the designed strategies and adapting of a MPI that contemplates transgender patient registration needs as regards as health and legal context.

The feminist perspective of intersectionality in the field of public health: a narrative review of the theoretical-methodological literature

The intersectionality approach emerged in the late 1990s in the field of black feminist activism in the USA, as a critique of one-dimensional analyses of social inequalities. This descriptive-analytical narrative review presents the current state of theoretical-methodological inclusion of intersectionality in public health. Seven scientific literature databases were consulted: Web of Science, Embase, Cinahl, Scopus, Sociological Abstracts, Lilacs, and Medline, resulting in 1763 papers. After duplicates were eliminated and the titles and abstracts screened, 30 papers produced in five countries between 2006 and 2017 were selected. The analysis, structured into three central themes (theoretical-methodological debates, social markers - gender, race, ethnicity and sexual orientation - and health policies and practices), shows intersectionality to be a promising analytical resource for understanding and facing the global challenge of inequalities in health.

Affirming Gender Identity of Patients With Serious Mental Illness

Transgender people who experience serious mental illness represent a uniquely vulnerable population. Because of limited research, however, recommendations for treating this population are scarce. In this article, the authors describe the challenge of recognizing gender dysphoria in people with serious mental illness. They then discuss why existing evidence and clinical experience support provision of gender-affirming medical and surgical treatments for transgender people who have serious mental illness and also demonstrate capacity to make informed medical decisions. More research is needed to develop evidence-based treatments and programs for transgender people with serious mental illness.

Mentoring Across Differences

INTRODUCTION

Effective mentoring can contribute to wellness and career growth and satisfaction. However, the same social forces and interpersonal dynamics affecting all relationships can compromise mentoring relationships. This is especially true when there are issues that are compounded by structural disadvantage due to racism, gender bias, social class, and other discriminatory factors. The Mentoring Across Differences (MAD) sessions are a workshop designed to develop and nurture skills, tools, self-awareness, and mindful practice in mentors and mentees. The workshop encourages participants to gain confidence in navigating differences across a variety of domains.

METHODS

We designed interactive sessions for faculty as part of a nine-part training series on mentoring in an academic setting. Teaching methods drew from adult learning theory. We used cases distilled from real teaching and mentoring experiences to trigger discussion and activate emotion and intrinsic motivation. Participants' prior knowledge and experience were drawn on to cocreate knowledge through small-group peer learning.

RESULTS

As part of a course, 167 participants completed the sessions; several hundred more people participated in them in faculty development venues. Participants highly rated the open discussions regarding differences and enhanced awareness of their assumptions, specifically highlighting knowledge and tools addressing bias in their roles as mentors and teachers.

DISCUSSION

The MAD sessions function both as an important module in a comprehensive mentoring curriculum and as stand-alone sessions. They fill a critical need of faculty and training institutions to explore difference in order to foster diversity and inclusion.

Strategies for Effectively Documenting Sexual Orientation and Gender Identity in Electronic Health Record

In this communication we identify strategies for effectively documenting Sexual Orientation and Gender Identity in Electronic Health Records. For this review a multidisciplinary group composed by three physicians, a nurse, an engineer and a lawyer analyzed the evidence in bibliography related to the topic and summarized the results. After analyzing the information, we summarized and classified them into three major topics: To request, to store and to display and access to the information. How to standardize those data and where data specifically will be populated in EHRs have not been answered yet. The target of all of these efforts should be: to be sensitive with the needs of the patient and to ensure high quality of care.

Gender Identity in Patients with Congenital Adrenal Hyperplasia

BACKGROUND

Sex assignment in infancy for patients with disorder of sex development (DSD) is a challenging problem. Some of the patients with congenital adrenal hyperplasia (CAH) have DSD that may affect their gender identity.

OBJECTIVES

The study aimed to assess gender identity in patients with CAH.

METHODS

In this study, 52 patients with CAH, including 22 prepubertal children and 30 adolescents and adults, were assessed using two separate gender identity questionnaires for children and adults based on the criteria of diagnostic and statistical manual of mental disorders, 5th edition.

RESULTS

In the children group, compatibility was seen between gender identity and rearing gender. In the adult group, there were three cases of mismatching between gender identity and sex assignment composed of two females with poor control and one male with good control with 21-hydroxylase deficiency (21-OHD). Three girls with 11-hydroxylase deficiency (11-OHD) were reared as boy. Two of them with late diagnosis at 5 and 6 years of age had pseudoprecocious puberty. Parents and children did not accept to change the gender. One of them is 36 years old now, is depressed and unsatisfied with her gender, another girl is still child and has male sexual identity. One girl with 11-OHD and early diagnosis at birth with Prader 5 virilization but with good hormonal control was changed to female gender at 12 years of age when female sexual characteristics appeared; she is 34-years-old now, married, and with two children, and she is satisfied with her gender.

CONCLUSIONS

In patients with CAH, gender identity disorder is a rare finding. Hormonal control, social, familial, and religious beliefs have impacts on gender identity of these patients.

Transgender Medicine Curriculum: Integration Into an Organ System-Based Preclinical Program

INTRODUCTION

There is a recognized and articulated need for health professionals to understand the definitions, health disparities, and medical management of transgender patients. This recognition comes organically from students requesting more information, and top-down from governing bodies such as the AAMC or the Liaison Committee on Medical Education. Surveys of North American medical schools indicate that training in transgender medicine (specifically, the process of transition) is infrequent and inadequate. One problem underlying this trend may be the lack of resources to help conceptualize and roll out a transgender medicine curriculum.

METHODS

Here, we report the integration of training in transgender medicine into the organ system-based course Endocrine-Reproduction. This transgender curriculum includes coverage of basic science, clinical management, ethics, and clinical skills. The curriculum leverages an already existing, health care disparity-focused curriculum but adds (1) a didactic component for dissemination and discussion of basic science principles applied to transgender patients and (2) a mock initial encounter between a physician and patient with gender dysphoria.

RESULTS

Following the first-time implementation of the transgender curriculum, students were surveyed, with a large majority reporting feeling more prepared to care for transgender patients.

DISCUSSION

We conclude that including a multidisciplinary transgender medicine curriculum in medical school advances the goal of creating safe, effective physicians by providing fundamental knowledge about an underserved population of patients, as well as exampled application of that knowledge.

Sexual Sensation Seeking, Sexual Compulsivity, and Gender Identity and Its Relationship With Sexual Functioning in a Population Sample of Men and Women

INTRODUCTION

Despite awareness of the importance of psycho-affective factors in the development of sexual problems, there is a lack of studies exploring the relation of sexual sensation seeking (SSS) and sexual compulsivity (SC) to sexual functioning. Because sex differences in SSS and SC have been reported, gender identity (GI; an individual's own experience of his or her gender that is unrelated to the actual biological sex) might act as a moderator in this relation.

AIM

To understand the role of SSS and SC for men and women's sexual functioning and to explore whether these potential associations are moderated by GI.

METHODS

A population-based cross-sectional online survey targeted 279 individuals (69.2% women, 30.8% men; mean age = 32 years). Validated questionnaires, including the Sexual Sensation Seeking Scale, the Sexual Compulsivity Scale, the Female Sexual Function Index, the Premature Ejaculation Diagnostic Tool, and the International Index of Erectile Function, were applied.

MAIN OUTCOME MEASURES

Variations in SSS and SC and their association with sexual functioning were investigated using Spearman rank correlation. Moderation analyses were conducted using regression models in which the interaction terms between SSS and GI and between SCS and GI as predictors of sexual functioning were included.

RESULTS

A statistically significant correlation between SSS and SC could be detected in men and women (r = 0.41 and 0.33, respectively; P < .001 for the two comparisons). In women, higher levels of SSS were associated with higher levels of desire, arousal, lubrication, and orgasm and less sexual pain (P < .05 for all comparisons). No moderating effect of GI could be detected. In men, GI was a significant moderator in the relation between SC and erectile function (β = 0.47; P < .001) and between SSS and erectile and ejaculatory function (β = -0.41 and 0.30; P < .001 for the two comparisons).

CONCLUSION

The present study is the first to show a link between SSS and SC and sexual functioning. The results might have important clinical implications and can provide useful information for programs aimed at sexual health enhancement.

Educational inequalities in hypertension: complex patterns in intersections with gender and race in Brazil

Background

Hypertension is a major public health issue worldwide, but knowledge is scarce about its patterns and its relationship to multiple axes of social disadvantages in Latin American countries. This study describes the educational inequality in the prevalence of hypertension in Brazil, including a joint stratification by gender and race.

Methods

We analyzed interview-based data and blood pressure measurements from 59,402 participants aged 18 years or older at the 2013 Brazilian National Health Survey (PNS). Sociodemographic characteristics analyzed were gender (male, female), racial self-identification (white, brown, black), age (5-years intervals), and educational attainment (pre-primary, primary, secondary, tertiary). Hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, and/or self-reported use of antihypertensive medications in the last 2 weeks. We used logistic regression to evaluate the age-adjusted prevalences of hypertension (via marginal modeling), and pair-wise associations between education level and odds of hypertension. Further, the educational inequality in hypertension was summarized through the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). All analyses considered the appropriate sampling weights and intersections with gender, race, and education.

Results

Age-adjusted prevalence of hypertension was 34.0 % and 30.8 % among men and women, respectively. Black and brown women had a higher prevalence than whites (34.5 % vs. 31.8 % vs. 29.5 %), whereas no racial differences were observed among men. White and brown, but not black women, showed graded inverse associations between hypertension and educational attainment; among men, non-statistically significant associations were observed in all racial strata. The RII and SII estimated inverse gradients among white (RII = 2.5, SII = 18.1 %) and brown women (RII = 2.3, SII = 14.5 %), and homogeneous distributions of hypertension in educational subgroups among black women and among men.

Conclusion

In this representative sample of Brazilian adults, the association between educational attainment and hypertension was influenced by gender and race – a topic still poorly understood. Our findings highlight the importance of assessing intersections of multiple sociodemographic characteristics in health inequalities research. The use of comprehensive measures of inequality, such as RII and SII, provide useful insights for monitoring health inequalities in an intersectional perspective.