Association of Media Coverage of Transgender and Gender Diverse Issues With Rates of Referral of Transgender Children and Adolescents to Specialist Gender Clinics in the UK and Australia

IMPORTANCE

Specialist gender clinics worldwide have witnessed an increase in referrals of transgender and gender diverse (TGD) children and adolescents, but the underlying factors associated with this increase are unknown.

OBJECTIVE

To determine whether increases in TGD young people presenting to specialist gender clinics are associated with related media coverage.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted at 2 publicly funded, pediatric specialist gender services, one located in the UK and the other in Australia. Participants were all children and adolescents aged 0 to 18 years, referred between January 1, 2009, and December 31, 2016, to their respective gender services in the UK and Australia. Data analysis was performed in April 2019.

EXPOSURES

Media coverage of TGD issues.

MAIN OUTCOMES AND MEASURES

Referral rates from each gender service were compared with local TGD-related media coverage during the study period.

RESULTS

Referral data for 5242 TGD young people were obtained (4684 in the UK, of whom 1847 [39.4%] were assigned male at birth and 2837 [60.6%] were assigned female at birth; 558 in Australia, of whom 250 [44.8%] were assigned male at birth and 308 [55.2%] were assigned female at birth), and a total of 2614 news items were identified (UK, 2194; Australia, 420). The annual number of TGD young people referred to both specialist gender clinics was positively correlated with the number of TGD-related local media stories appearing each year (Spearman r = 1.0; P < .001). Moreover, weekly referral rates in both the UK for week 1 (β̂ = 0.16; 95% CI, 0.03-0.29; P = .01) and Australia for week 2 (β̂ = 0.12; 95% CI, 0.04-0.20; P = .003) showed evidence of association with the number of TGD-related media items appearing within the local media. There was no evidence of association between referrals and media items appearing 3 weeks beforehand. Media predominantly focused on TGD issues showed some association with increased referral rates. Specifically, TGD-focused stories showed evidence of association with referral numbers at week 1 (β̂ = 0.16; 95% CI, 0.04-0.28; P = .007) and week 2 (β̂ = 0.23; 95% CI, 0.11-0.35; P < .001) in Australia and with referral numbers at week 1 (β̂ = 0.22; 95% CI, 0.01-0.44; P = .04) in the UK. No evidence of association was found between media peripherally related to TGD issues and referral rates.

CONCLUSIONS AND RELEVANCE

This study found evidence of an association between increasing media coverage of TGD-related topics and increasing numbers of young people presenting to gender clinics. It is possible that media coverage acts as a precipitant for young people to seek treatment at specialist gender services, which is consistent with clinical experiences in which TGD young people commonly identify the media as a helpful source of information and a trigger to seek assistance.

Trend differences in men and women in rural and urban U.S. settings

BACKGROUND

Smoking prevalence is declining at a slower rate in rural than urban settings in the United States (U.S.), and known predictors of smoking do not readily account for this trend difference. Given that socioeconomic and psychosocial determinants of health disparities accumulate in rural settings and that life-course disadvantages are often greater in women than men, we examined whether smoking trends are different for rural and urban men and women.

METHOD

We used yearly cross-sectional data (n = 303,311) from the U.S. National Survey on Drug Use and Health (NSDUH) from 2007 through 2014 to compare cigarette smoking trends in men and women across rural and urban areas. Current smoking status was modelled using logistic regression controlling for confounding risk factors.

RESULTS

Regression derived graphs predicting unadjusted prevalence estimates and 95% confidence bands revealed that whereas the smoking trends of rural men, urban men, and urban women significantly declined from 2007 to 2014, the trend for rural women was flat. Controlling for demographic, socioeconomic and psychosocial predictors of smoking did not explain rural women's significantly different trend from those of the other three groups.

CONCLUSION

Rural women lag behind rural men, urban men and urban women in decreasing smoking, a health disparity finding that supports the need for tobacco control and regulatory policies and interventions that are more effective in reducing smoking among rural women.

A growing geographic disparity: Rural and urban cigarette smoking trends in the United States

Rural areas of the United States have a higher smoking prevalence than urban areas. However, no recent studies have rigorously examined potential changes in this disparity over time or whether the disparity can be explained by demographic or psychosocial characteristics associated with smoking. The present study used yearly cross sectional data from the National Survey on Drug Use and Health from 2007 through 2014 to examine cigarette smoking trends in rural versus urban areas of the United States. The analytic sample included 303,311 respondents. Two regression models were built to examine (a) unadjusted rural and urban trends in prevalence of current smoking and (b) whether differences remained after adjusting for demographic and psychosocial characteristics. Results of the unadjusted model showed disparate and diverging cigarette use trends during the 8-year time period. The adjusted model also showed diverging trends, initially with no or small differences that became more pronounced across the 8-year period. We conclude that differences reported in earlier studies may be explained by differences in rural versus urban demographic and psychosocial risk factors, while more recent and growing disparities appear to be related to other factors. These emergent differences may be attributable to policy-level tobacco control and regulatory factors that disproportionately benefit urban areas such as enforcement of regulations around the sale and marketing of tobacco products and treatment availability. Strong federal policies and targeted or tailored interventions may be important to expanding tobacco control and regulatory benefits to vulnerable populations including rural Americans.

Combined aortic and renal artery surgery. A contemporary experience

PURPOSE

This retrospective study examines results with simultaneous aortic and renal artery repair in 133 consecutive hypertensive patients. These results are compared with consecutive patient groups undergoing aortic reconstruction alone (269 patients) or renal artery reconstruction alone (182 patients).

METHODS

From January 1987 through July 1995, 61 women and 72 men (mean age, 62.5 years) underwent combined repair of renal artery and aortic disease (abdominal aortic aneurysm [AAA]: 47 patients; occlusive disease: 86 patients; both: 12 patients). All patients were hypertensive (mean blood pressure: 194/103 mmHg; mean medications: 2.4). Evidenced by serum creatinine levels > or = 2.0 mg/dL, 46 patients (35%) had significant renal dysfunction (mean serum creatinine level: 3.78 mg/dL; range 2.0-10.6 mg/dL, including 7 dialysis-dependent patients). Aortic replacements (29% tube grafts; 71% bifurcated grafts) were combined with unilateral renal artery repair in 47% of patients; 53% had bilateral repair. Preoperative clinical features and perioperative mortality were compared with those groups having isolated aortic and renal repairs.

RESULTS

There were seven perioperative deaths (5.3%) after combined repair, which differed significantly from isolated aortic repair (mortality: 0.74%; p = 0.005), but did not reach statistical significance when compared with the isolated renal artery group (mortality: 1.65%; p = 0.145). Risk analysis did not reveal a significant association between preoperative clinical features and mortality in either the combined repair group or the groups undergoing renal repair alone or aortic repair alone. Among survivors in the combined group, a favorable hypertension response was observed in 63%. This differed significantly from the group receiving renal repair alone (90% cured/improved; p < 0.001). Based on a 20% decrease in serum creatinine levels, excretory renal function was improved in 33% of patients with combined repair, including four of the seven patients removed from hemodialysis. There were eight late deaths in the combined group.

CONCLUSIONS

Our experience suggest that contemporary perioperative mortality for combined aortic and renal repair has improved compared with earlier reports; however, perioperative mortality for simultaneous reconstruction remains greater than repair of aortic disease alone. Moreover, a lower rate of favorable hypertension response was observed after combined correction compared with renal artery repair alone. These differences suggest that aortic and renal artery repair should only be combined for clinical indications rather than for prophylactic repair of clinically silent disease.

Renal artery fibromuscular dysplasia: results of current surgical therapy

PURPOSE

This retrospective review describes current surgical management of renal artery (RA) fibromuscular dysplasia (FMD) to define contemporary clinical characteristics and surgical results in patients over the age of 21 years.

METHODS

From January 1987 through March 1994, 40 consecutive adults with hypertension had operative RA repair of FMD at our center and form the basis of this report. From histologic and angiographic appearance, FMD was classified with regard to specific type, noting the presence of RA dissections, RA macroaneurysms and branch RA involvement. Associations between blood pressure response to operation and patient age, duration of hypertension, presence of extrarenal atherosclerosis, presence of branch renal artery disease, and primary or secondary procedure were examined. Clinical characteristics and blood pressure response in these contemporary patients were compared with the results reported from an earlier surgical series.

RESULTS

Unilateral RA repair was performed in 34 patients, and bilateral procedures were required in six patients. Branch renal artery repair was performed in 28 instances, including ex vivo RA repair in 11 patients. There were no perioperative or follow-up deaths; however, three RA grafts (7%) failed within 30 days of operation. Initial blood pressure response was considered cured in 33%, improved in 57%, and failed in 10%. Analysis demonstrated that patients older than 45 years of age had a significantly decreased rate of hypertension cure compared with younger patients; among patients younger than 45 years of age, duration of hypertension was inversely related to cure. Compared with earlier surgical series, our current group of patients was significantly older, with more frequent branch renal artery involvement and extrarenal atherosclerosis, and demonstrated decreased rate of hypertension cure.

CONCLUSION

A beneficial blood pressure response is currently observed in most selected patients after surgical correction of RA-FMD. Compared with earlier series, however, the present day patient differs in many respects, including a significantly decreased chance for hypertension cure after surgical repair.

Surgical management of dialysis-dependent ischemic nephropathy

PURPOSE

This retrospective review describes surgical management of dialysis-dependent ischemic nephropathy.

METHODS

From February 1987 through September 1993, 340 patients underwent operative renal artery (RA) reconstruction at our center. A subgroup of 20 patients (6 women; 14 men; mean age 66 years) dependent on hemodialysis immediately before RA repair form the basis of this report. Glomerular filtration rates (EGFR) were estimated from at least three serum creatinine measurements obtained 26 weeks before and after operation. A linear regression model was used to estimate the mean rate of change of EGFR before and after RA repair. Comparative analysis of kidney status and change in EGFR were performed. The influence of function response on follow-up survival was determined by the product-limit method.

RESULTS

Hemodialysis was discontinued in 16 of 20 patients (80%). For these 16 patients, postoperative EGFR ranged from 9.0 to 56.1 ml/min/1.73 m2 (mean 32.4 ml/min/1.73 m2). Two of 16 patients resumed hemodialysis 4 and 6 months after surgery. Discontinuation of dialysis was more likely after bilateral or complete RA repair (15 of 16 patients) versus unilateral repair (one of four patients; p = 0.01). Permanent discontinuation of dialysis was associated with a rapid preoperative rate of decline in EGFR (mean slope log(e) EGFR: -0.1393 +/- 0.0340 without dialysis; -0.0188 +/- 0.0464 with dialysis; p = 0.04, but NS after controlling for multiple comparisons). Immediate increase in EGFR after operation was inversely correlated with the severity of nephrosclerosis (rank correlation: -0.57; 95% confidence interval [-0.83, -0.10]). Follow-up death was associated with dialysis dependence; two deaths occurred among 14 patients not receiving dialysis, whereas five of six patients dependent on dialysis died (p < 0.01).

CONCLUSION

Surgical correction of ischemic nephropathy can retrieve renal function in selected patients dependent on dialysis characterized by a rapid decline in preoperative EGFR in combination with global renal ischemia treated by complete or bilateral renal revascularization. After RA repair, discontinuation of dialysis may be associated with improved survival rates when compared with continued dialysis dependence.