Issues in Distinguishing Sex and Gender in Surgical Registries: A NSQIP and VASQIP Analysis.

BACKGROUND: Surgical registries do not have separate sex (the biological construct) and gender identity variables. We examined procedures specific to sexually dimorphic anatomy, such as ovaries, testes, and other reproductive organs, to identify "discrepancies" between recorded sex and the anatomy of a procedure. These "discrepancies" would represent a structural limitation of surgical registries, one that may unintentionally perpetuate health inequities. STUDY DESIGN: Retrospective cohort study using 2015-2019 NSQIP and 2016-2019 VASQIP. Surgeries were limited to procedures pertaining to anatomy that is either specifically male (CPT codes 54000-55899) or female (56405-59899). The sex recorded in the surgical registries, often automatically retrieved from electronic health record data, was compared to the specified anatomy of each procedure to quantify discrepancies. RESULTS: 575,956 procedures were identified specific to sexually dimorphic anatomy (549,411 NSQIP; 26,545 VASQIP). Of those, 2,137 recorded a sex discordant with the anatomy specified by the surgical procedure (rates 0.4% in NSQIP; 0.2% in VASQIP). Procedures specific to female anatomy with recorded male sex were more frequent (82.6% in NSQIP; 98.4% in VASQIP) than procedures specific to male anatomy with recorded female sex. CONCLUSIONS: Discrepancies between recorded sex and the anatomy of a surgical procedure were limited. However, because sex in surgical registries is often directly acquired from electronic health record data, these cases likely represent transgender, gender diverse, or living with a difference of sex development (intersex) patients. As these populations increase and continue to seek healthcare, precise measurement of sex, gender identity, and legal sex is necessary for adequate risk adjustment, risk prediction, and surgical outcome benchmarking for optimal care.

Annual Research Review: Puberty and the development of anhedonia - considering childhood adversity and inflammation.

Anhedonia, or diminished pleasure and motivation, is a symptom of severe mental illness (e.g., depressive disorder, bipolar disorder, schizophrenia) that emerges during adolescence. Anhedonia is a pernicious symptom that is related to social impairments, treatment resistance, and suicide. As the mechanisms of anhedonia are postulated to include the frontostriatal circuitry and the dopamine neuromodulatory system, the development and plasticity of these systems during the vulnerable period of adolescence, as well as their sensitivity to pubertal hormones, suggest that pubertal maturation could play a role in the development of anhedonia. This review takes a developmental perspective, considering the possibility that anhedonia emerges in the context of pubertal maturation and adolescent development, with childhood adversity and chronic inflammation influencing neural reward systems to accelerate anhedonia's progression. Here, we review the relevant extant literature on the components of this model and suggest directions for future research.

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.

Stress proliferation in ethnoracial disparities of mental health among U.S. sexual minority adults.

OBJECTIVE: Non-White sexual minorities experience disproportionate adverse childhood experiences (ACEs) and adulthood discrimination, as compared to their White or heterosexual counterparts. These stressors lead to increased psychological distress and worsened clinical outcomes, including suicidality. Minority stress theory posits that systemic marginalization, as experienced by minoritized individuals, leads to distress. Intersectionality theory suggests that marginalization compounds over time for individuals with intersectional minority identities. Yet, the mechanisms underlying the stress proliferation process for individuals with intersectional minority identities remain largely unexamined. METHOD: The present study used nationally representative data of sexual minority individuals (n = 1,518, Mage = 31 years, ethnoracial minority = 38.7%, female and gender minority = 50.6%) to investigate the relations among ethnoracial minoritization, ACEs, discrimination, distress, and self-injurious/suicidal outcomes. We proposed a novel integration of minority stress, intersectionality, and stress proliferation theories. Via longitudinal mediation, we tested models of stress persistence, stress accumulation, and stress sensitization. RESULTS: Our results confirmed disparities between White versus non-White sexual minorities on ACEs, discrimination experiences, and psychological distress. We found support for the stress persistence and the stress accumulation models, but not the stress sensitization model. Moreover, we found distress and discrimination were associated with future nonsuicidal self-injurious behaviors and suicidal outcomes, highlighting the deleterious consequences of intersectional minority stress proliferation. CONCLUSION: Our results support our proposed theory of intersectional minority stress proliferation where ethnoracial and sexual minoritization intersect and beget disproportionate ACEs, which in turn contribute to accumulation and persistence of psychological distress and discrimination experiences in adulthood. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Affirming Care for Transgender Patients.

Gender identity is a deeply felt internal sense of self, which may correspond (cisgender) or not correspond (transgender) with the person's assigned sex at birth. Transgender, nonbinary, and gender diverse people may choose to affirm their gender in any number of ways including medical gender affirmation. This is a primer on the medical care of transgender individuals which covers an introduction to understanding a common language, history of transgender medical care, creating a welcoming environment, hormone therapy, surgical therapies, fertility considerations, and cancer screening in transgender people.

An Ethics and Social-Justice Approach to Collecting and Using Demographic Data for Psychological Researchers.

The collection and use of demographic data in psychological sciences has the potential to aid in transforming inequities brought about by unjust social conditions toward equity. However, many current methods surrounding demographic data do not achieve this goal. Some methods function to reduce, but not eliminate, inequities, whereas others may perpetuate harmful stereotypes, invalidate minoritized identities, and exclude key groups from research participation or access to disseminated findings. In this article, we aim to (a) review key ethical and social-justice dilemmas inherent to working with demographic data in psychological research and (b) introduce a framework positioned in ethics and social justice to help psychologists and researchers in social-science fields make thoughtful decisions about the collection and use of demographic data. Although demographic data methods vary across subdisciplines and research topics, we assert that these core issues-and solutions-are relevant to all research within the psychological sciences, including basic and applied research. Our overarching aim is to support key stakeholders in psychology (e.g., researchers, funding agencies, journal editors, peer reviewers) in making ethical and socially-just decisions about the collection, analysis, reporting, interpretation, and dissemination of demographic data.

Medial Prefrontal Cortex Activity to Reward Outcome Moderates the Association Between Victimization Due to Sexual Orientation and Depression in Youth.

BACKGROUND: Sexual minority youth (SMY) are 3 times more likely to experience depression than heterosexual peers. Minority stress theory posits that this association is explained by sexual orientation victimization, which acts as a stressor to impact depression. For those vulnerable to the effects of stress, victimization may worsen depression by altering activity in neural reward systems. This study examines whether neural reward systems moderate the influence of sexual orientation victimization, a common and distressing experience in SMY, on depression. METHODS: A total of 81 participants ages 15 to 22 years (41% SMY, 52% marginalized race) reported sexual orientation victimization, depression severity, and anhedonia severity, and underwent a monetary reward functional magnetic resonance imaging task. Significant activation to reward > neutral outcome (pfamilywise error < .05) was determined within a meta-analytically derived Neurosynth reward mask. A univariate linear model examined the impact of reward activation and identity on victimization-depression relationships. RESULTS: SMY reported higher depression (p < .001), anhedonia (p = .03), and orientation victimization (p < .001) than heterosexual youth. The bilateral ventral striatum, medial prefrontal cortex (mPFC), anterior cingulate cortex, and right orbitofrontal cortex were significantly active to reward. mPFC activation moderated associations between sexual orientation victimization and depression (p = .03), with higher depression severity observed in those with a combination of higher mPFC activation and greater orientation victimization. CONCLUSIONS: Sexual orientation victimization was related to depression but only in the context of higher mPFC activation, a pattern observed in depressed youth. These novel results provide evidence for neural reward sensitivity as a vulnerability factor for depression in SMY, suggesting mechanisms for disparities, and are a first step toward a clinical neuroscience understanding of minority stress in SMY.

Knowledge Retention and Clinical Skills Acquisition in Sexual and Gender Minority Health Curricula: A Systematic Review.

PURPOSE: To identify exemplary medical education curricula, operationalized as curricula evaluating knowledge retention and/or clinical skills acquisition, for health care for sexual and gender minoritized (SGM) individuals and individuals born with a difference in sex development (DSD). METHOD: The authors conducted a systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed in PubMed/MEDLINE, The Cochrane Library, Web of Science, ERIC, Embase, PsycINFO, and the gray literature to identify studies that (1) pertained to undergraduate and/or graduate medical education, (2) addressed education on health care of SGM/DSD individuals, and (3) assessed knowledge retention and/or clinical skills acquisition in medical trainees. The final searches were run in March 2019 and rerun before final analyses in June and October 2020. RESULTS: Of 670 full-text articles reviewed, 7 met the inclusion criteria. Five of the 7 studies assessed trainee knowledge retention alone, 1 evaluated clinical skills acquisition alone, and 1 evaluated both outcomes. Studies covered education relevant to transgender health, endocrinology for patients born with DSDs, and HIV primary care. Only 1 study fully mapped to the Association of American Medical Colleges (AAMC) SGM/DSD competency recommendations. Six studies reported institutional funding and development support. No studies described teaching SGM/DSD health care for individuals with multiply minoritized identities or engaging the broader SGM/DSD community in medical education curriculum development and implementation. CONCLUSIONS: Curriculum development in SGM/DSD health care should target knowledge retention and clinical skills acquisition in line with AAMC competency recommendations. Knowledge and skill sets for responsible and equitable care are those that account for structures of power and oppression and cocreate curricula with people who are SGM and/or born with DSDs.

Maternal Response to Positive Affect Moderates the Impact of Familial Risk for Depression on Ventral Striatal Response to Winning Reward in 6- to 8-Year-Old Children.

BACKGROUND: A growing body of research has demonstrated that adolescent offspring of depressed parents show diminished responding in the ventral striatum to reward. More recent work has suggested that altered reward responding may emerge earlier than adolescence in offspring at familial risk for depression, although factors associated with neural alterations in childhood remain poorly understood. METHODS: We tested whether 6- to 8-year-old children, 49% at heightened risk for depression via maternal history, showed altered neural responding to winning reward. We evaluated whether maternal socialization of positive emotion moderated the association between familial risk and child neural response to reward. Participants were 49 children 6 to 8 years of age (24 with a maternal history of recurrent or chronic depression, 25 with no maternal history of any psychiatric disorder). Children underwent functional magnetic resonance imaging while completing the Doors Guessing Task, a widely used reward guessing task. Mothers reported their use of encouraging and dampening responses to child positive affect. RESULTS: Findings demonstrated that children at high familial risk for depression showed lower ventral striatum responding to winning reward relative to low-risk children, but only when mothers used less encouragement or greater dampening responses to their child's positive emotion expressions. CONCLUSIONS: Neural reward alterations in the ventral striatum may emerge earlier than previously thought, as early as 6 to 8 years of age, specifically in the context of maternal discouragement of child positive emotions. Clinical interventions that focus on coaching mothers on how to encourage child positive emotions may be beneficial for supporting child reward-related brain development.

Interpersonal context and desired emotional closeness in neural response to negative visual stimuli: Preliminary findings.

INTRODUCTION: Emotions typically emerge in interpersonal contexts, but the neural circuitry involved remains insufficiently understood. Two key features of interpersonal contexts are interpersonal interactions (e.g., supportive physical touch serving as a form of social regulation) and interpersonal traits. Social regulation research has predominately focused on fear by using physical threat (i.e., electric shock) as the stimulus. Given that social regulation helps with various negative emotions in the real world, using visual stimuli that elicit negative emotions more broadly would also be beneficial. Differing from trait loneliness-which is related to lower recruitment of social circuitry in negative socioaffective contexts-trait desired emotional closeness is related to adaptive outcomes and may demonstrate an opposite pattern. This study investigated the roles of social regulation and desired emotional closeness in neural response to aversive social images. METHODS: Ten pairs of typically developing emerging adult friends (N = 20; ages 18-25) completed a functional magnetic resonance imaging (fMRI) handholding task. Each friend viewed negative and neutral social images in the scanner under two conditions: (a) holding their friend's hand and (b) having their friend in the room. RESULTS: Handholding attenuated response to aversive social images in a region implicated in emotion and inhibitory control (right dorsal striatum/anterior insula/ventrolateral prefrontal cortex). Desired emotional closeness was positively associated with response to aversive social images (in the no handholding condition) in self and social processing (right ventral posterior cingulate cortex) and somatosensory regions (right postcentral gyrus). DISCUSSION: These findings extend previous research on the roles of interpersonal behaviors and tendencies in neural response to aversive stimuli.

Gender Nonconformity and Minority Stress Among Lesbian, Gay, and Bisexual Individuals: A Meta-Analytic Review.

Lesbian, gay, and bisexual (LGB) individuals are less healthy than heterosexual individuals, and minority stress endured by LGB individuals contributes to these health disparities. However, within-groups differences in minority stress experiences among LGB individuals remain underexplored. Individuals are more likely to be categorized as LGB if they exhibit gender nonconformity, so gender nonconformity could influence concealability of sexual orientation among LGB individuals, carrying important implications for the visibility of their stigmatized sexual orientation identity and for how they experience and cope with minority stress. Through a meta-analytic review, we examined how gender nonconformity was associated with minority stress experiences among LGB individuals. Thirty-seven eligible studies were identified and included in analyses. Results indicate gender nonconformity is associated with experiencing more prejudice events, less concealment of sexual orientation, lower internalized homonegativity, and higher expectations of rejection related to sexual orientation among LGB individuals. Gender nonconformity is more strongly associated with experiencing prejudice events among gay and bisexual men than among lesbian and bisexual women. Gender nonconformity is systematically associated with minority stress experiences among LGB individuals, and future research must measure and examine gender nonconformity when investigating the role of minority stress in degraded health outcomes among LGB populations.

Trauma Affects Prospective Relationships Between Reward-Related Ventral Striatal and Amygdala Activation and 1-Year Future Hypo/Mania Trajectories.

BACKGROUND: Trauma exposure is associated with a more severe, persistent course of affective and anxiety symptoms. Markers of reward neural circuitry function, specifically activation to reward prediction error (RPE), are impacted by trauma and predict the future course of affective symptoms. This study's purpose was to determine how lifetime trauma exposure influences relationships between reward neural circuitry function and the course of future affective and anxiety symptoms in a naturalistic, transdiagnostic observational context. METHODS: A total of 59 young adults aged 18-25 (48 female and 11 male participants, mean ± SD = 21.5 ± 2.0 years) experiencing psychological distress completed the study. Participants were evaluated at baseline, 6, and 12 months. At baseline, the participants reported lifetime trauma events and completed a monetary reward functional magnetic resonance imaging task. Affective and anxiety symptoms were reported at each visit, and trajectories were calculated using MPlus. Neural activation during RPE and other phases of reward processing were determined using SPM8. Trauma and reward neural activation were entered as predictors of symptom trajectories. RESULTS: Trauma exposure moderated prospective relationships between left ventral striatum (ß = -1.29, p = .02) and right amygdala (ß = 0.58, p = .04) activation to RPE and future hypo/mania severity trajectory: the interaction between greater trauma and greater left ventral striatum activation to RPE was associated with a shallower increase in hypo/mania severity, whereas the interaction between greater trauma and greater right amygdala activation to RPE was associated with increasing hypo/mania severity. CONCLUSIONS: Trauma exposure affects prospective relationships between markers of reward circuitry function and affective symptom trajectories. Evaluating trauma exposure is thus crucial in naturalistic and treatment studies aiming to identify neural predictors of future affective symptom course.

A Social Affective Neuroscience Model of Risk and Resilience in Adolescent Depression: Preliminary Evidence and Application to Sexual and Gender Minority Adolescents.

Depression is a disorder of dysregulated affective and social functioning, with attenuated response to reward, heightened response to threat (perhaps especially social threat), excessive focus on negative aspects of the self, ineffective engagement with other people, and difficulty modulating all of these responses. Known risk factors provide a starting point for a model of developmental pathways to resilience, and we propose that the interplay of social threat experiences and neural social-affective systems is critical to those pathways. We describe a model of risk and resilience, review supporting evidence, and apply the model to sexual and gender minority adolescents, a population with high disparities in depression and unique social risk factors. This approach illustrates the fundamental role of a socially and developmentally informed clinical neuroscience model for understanding a population disproportionately affected by risk factors and psychopathology outcomes. We consider it a public health imperative to apply conceptual models to high-need populations to elucidate targets for effective interventions to promote healthy development and enhance resilience.

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.

Social and Non-social Reward Processing and Depressive Symptoms Among Sexual Minority Adolescents.

Sexual minority adolescents (SMA) are more likely to suffer from depression, putatively through experiences of social stress and victimization interfering with processing of social reward. Alterations in neural reward networks, which develop during adolescence, confer risk for the development of depression. Employing both social and monetary reward fMRI tasks, this is the first neuroimaging study to examine function in reward circuitry as a potential mechanism of mental health disparities between SMA and heterosexual adolescents. Eight SMA and 38 heterosexual typically developing adolescents completed self-report measures of depression and victimization, and underwent fMRI during monetary and peer social reward tasks in which they received positive monetary or social feedback, respectively. Compared with heterosexual adolescents, SMA had greater interpersonal depressive symptoms and exhibited blunted neural responses to social, but not monetary, reward in socioaffective processing regions that are associated with depressive symptoms. Specifically, compared with heterosexual adolescents, SMA exhibited decreased activation in the right medial prefrontal cortex, left anterior insula (AI), and right temporoparietal junction (TPJ) in response to being liked. Lower response in the right TPJ was associated with greater interpersonal depressive symptoms. These results suggest that interpersonal difficulties and the underlying substrates of response to social reward (perhaps more so than response to monetary reward) may confer risk for development of depressive symptoms in SMA.

Mental Health, Drug, and Violence Interventions for Sexual/Gender Minorities: A Systematic Review.

CONTEXT: Compared with cisgender (nontransgender), heterosexual youth, sexual and gender minority youth (SGMY) experience great inequities in substance use, mental health problems, and violence victimization, thereby making them a priority population for interventions. OBJECTIVE: To systematically review interventions and their effectiveness in preventing or reducing substance use, mental health problems, and violence victimization among SGMY. DATA SOURCES: PubMed, PsycINFO, and Education Resources Information Center. STUDY SELECTION: Selected studies were published from January 2000 to 2019, included randomized and nonrandomized designs with pretest and posttest data, and assessed substance use, mental health problems, or violence victimization outcomes among SGMY. DATA EXTRACTION: Data extracted were intervention descriptions, sample details, measurements, results, and methodologic rigor. RESULTS: With this review, we identified 9 interventions for mental health, 2 for substance use, and 1 for violence victimization. One SGMY-inclusive intervention examined coordinated mental health services. Five sexual minority-specific interventions included multiple state-level policy interventions, a therapist-administered family-based intervention, a computer-based intervention, and an online intervention. Three gender minority-specific interventions included transition-related gender-affirming care interventions. All interventions improved mental health outcomes, 2 reduced substance use, and 1 reduced bullying victimization. One study had strong methodologic quality, but the remaining studies' results must be interpreted cautiously because of suboptimal methodologic quality. LIMITATIONS: There exists a small collection of diverse interventions for reducing substance use, mental health problems, and violence victimization among SGMY. CONCLUSIONS: The dearth of interventions identified in this review is likely insufficient to mitigate the substantial inequities in substance use, mental health problems, and violence among SGMY.

Anhedonia Reduction and the Association Between Left Ventral Striatal Reward Response and 6-Month Improvement in Life Satisfaction Among Young Adults.

Importance: Anhedonia is a symptom of multiple psychiatric conditions in young adults that is associated with poorer mental health and psychosocial function and abnormal ventral striatum reward processing. Aberrant function of neural reward circuitry is well documented in anhedonia and other psychiatric disorders. Longitudinal studies to identify potential biomarkers associated with a reduction in anhedonia are necessary for the development of novel treatment targets. Objective: To identify neural reward-processing factors associated with improved psychiatric symptoms and psychosocial function in a naturalistic, observational context. Design, Setting, and Participants: A longitudinal cohort follow-up study was conducted from March 1, 2014, to June 5, 2018, at the University of Pittsburgh Medical Center after baseline functional magnetic resonance imaging in 52 participants between the ages of 18 and 25 years who were experiencing psychological distress. Main Outcomes and Measures: Participants were evaluated at baseline and 6 months. At baseline, participants underwent functional magnetic resonance imaging during a card-guessing monetary reward task. Participants completed measures of affective symptoms and psychosocial function at each visit. Neural activation during reward prediction error (RPE), a measure of reward learning, was determined using Statistical Parametric Mapping software. Neural reward regions with significant RPE activation were entered as regions associated with future symptoms in multiple linear regression models. Results: A total of 52 young adults (42 women and 10 men; mean [SD] age, 21.4 [2.2] years) completed the study. Greater RPE activation in the left ventral striatum was associated with a decrease in anhedonia symptoms during a 6-month period (ß = -6.152; 95% CI, -11.870 to -0.433; P = .04). The decrease in anhedonia between baseline and 6 months mediated the association between left ventral striatum activation to RPE and improvement in life satisfaction between baseline and 6 months (total [c path] association: ß = 0.245; P = .01; direct [c' path] association: ß = 0.133; P = .16; and indirect [ab path] association: 95% CI, 0.026-0.262). Results were not associated with psychotropic medication use. Conclusions and Relevance: Greater left ventral striatum responsiveness to RPE may serve as a biomarker or potential target for novel treatments to improve the severity of anhedonia, overall mental health, and psychosocial function.

Trauma-associated anterior cingulate connectivity during reward learning predicts affective and anxiety states in young adults.

BACKGROUND: Trauma exposure is associated with development of depression and anxiety; yet, some individuals are resilient to these trauma-associated effects. Differentiating mechanisms underlying development of negative affect and resilience following trauma is critical for developing effective interventions. One pathway through which trauma could exert its effects on negative affect is reward-learning networks. In this study, we examined relationships among lifetime trauma, reward-learning network function, and emotional states in young adults. METHODS: One hundred eleven young adults self-reported trauma and emotional states and underwent functional magnetic resonance imaging during a monetary reward task. Trauma-associated neural activation and functional connectivity were analyzed during reward prediction error (RPE). Relationships between trauma-associated neural functioning and affective and anxiety symptoms were examined. RESULTS: Number of traumatic events was associated with greater ventral anterior cingulate cortex (vACC) activation, and lower vACC connectivity with the right insula, frontopolar, inferior parietal, and temporoparietal regions, during RPE. Lower trauma-associated vACC connectivity with frontoparietal regions implicated in regulatory and decision-making processes was associated with heightened affective and anxiety symptoms; lower vACC connectivity with insular regions implicated in interoception was associated with lower affective and anxiety symptoms. CONCLUSIONS: In a young adult sample, two pathways linked the impact of trauma on reward-learning networks with higher v. lower negative affective and anxiety symptoms. The disconnection between vACC and regions implicated in decision-making and self-referential processes may reflect aberrant regulatory but appropriate self-focused mechanisms, respectively, conferring risk for v. resilience against negative affective and anxiety symptoms.