Gender-Diverse Patients' Awareness and Utilization of Gender-Affirming Laryngological Services.

OBJECTIVE: Despite gender-affirming laryngological services (GALS; eg, voice therapy or surgery) being available nationwide, there is a discrepancy between the number of transgender and gender diverse (TGD) people with vocal incongruence and those who pursue services. Primary care is an important setting for accessing gender-affirming care, including learning about GALS. The purpose of this study was to understand the relationship between access to primary care and utilization of GALS. METHODS: An anonymous cross-sectional online survey was developed in REDCap. Between June-November 2022, 187 TGD respondents answered all questions related to this analysis. We assessed the relationship between having a primary care provider (PCP) and use of GALS via logistic regression. RESULTS: Of the 167 individuals who reported having a PCP, 54% reported familiarity with GALS, compared to 45% of individuals without a PCP. Compared to the group without a PCP, a greater proportion of individuals with a PCP had received professional voice therapy (21% vs 5%) and voice surgery (3% vs 0%). Logistic regression models did not demonstrate a significant effect of primary care access on either familiarity with, or use of, GALS. CONCLUSION: Most respondents (89%) were linked to the medical community through a PCP. A greater proportion of respondents with a PCP had accessed professional voice therapy and voice surgery compared with respondents without a PCP, though this difference was not statistically significant. Increased communication between GALS providers and PCPs would raise awareness of available services and may strengthen the referral pipeline to increase access to vocal care. LEVEL OF EVIDENCE: Level III.

Resident Attitudes and Experiences with a Novel Radiology-based Transgender Curriculum: A Qualitative Study.

RATIONALE AND OBJECTIVES: Transgender persons often experience healthcare disparities due to lack of provider knowledge. With increasing gender diversity awareness and prevalence of gender-affirming care, radiologists-in-training need to be aware of the unique health considerations for this patient population. Radiology residents have limited exposure to dedicated teaching on transgender medical care and imaging during training. Development and implementation of a radiology-based transgender curriculum can help close this gap in radiology residency education. The aim of this study was to explore radiology resident attitudes and experiences with a novel radiology-based transgender curriculum, guided by the conceptual framework of reflective practice. MATERIALS AND METHODS: A qualitative approach was employed using semi-structured interviews to explore resident perspectives of a curriculum covering transgender patient care and imaging over 4 monthly sessions. Ten residents at the University of Cincinnati radiology residency participated in interviews consisting of open-ended questions. Interviews were audiotaped, transcribed, and thematic analysis was conducted across all responses. RESULTS: Four themes emerged through the existing framework: 1) impactful/memorable aspects; things learned; increased awareness; and suggestions/feedback. Prominent subthemes included patient panel and stories, physician experts sharing knowledge and experiences, link to radiology and imaging, novel concept, gender-affirming surgeries and anatomy, appropriate radiology reporting, and patient interactions. CONCLUSION: Radiology residents found the curriculum to be an effective novel educational experience that was previously unaddressed during their training. This imaging-based curriculum can be further adapted and implemented in a variety of radiology curricular settings.

Training Mental Health Professionals in Gender-Affirming Care: A Survey of Experienced Clinicians.

Purpose: Transgender and gender nonconforming (TGNC) individuals have difficulty accessing mental health professionals (MHPs) prepared to deliver culturally informed care. This study aims to (1) explore the training experiences that had been available to MHPs who are actively providing care to TGNC individuals, (2) define which opportunities had been most beneficial in TGNC career development, and (3) determine the reasons MHPs sought training when it was absent in graduate curricula. Methods: A voluntary cross-sectional electronic survey was distributed through professional Listservs and public referral lists to interdisciplinary MHPs, who self-identified as having experience in providing care to TGNC individuals. Results: Two hundred eighty-one (n=281) counselors, marriage/family therapists, social workers, psychologists, psychiatrists, or psychiatric nurse practitioners responded to the survey. The two most common motivators for seeking training in gender-affirming care were filling a need in the community (68.8%) and having met a TGNC person in a clinical setting, who requested care (67.2%). Only 20.0% of our sample were exposed to relevant content in a graduate course, and 25.2% during clinical training. The most commonly available training opportunities were professional conferences (76.4%) and mentorship (41.2%). Respondents were most likely to recommend that others in their field be trained through structured clinical experience. Conclusion: This study identifies key strategies for graduate and post-graduate educators to better prepare MHPs to serve TGNC individuals. Wider availability of structured clinical experiences, didactic content delivered during graduate school or at professional conferences, and direct clinical mentorship will increase access to welcome and prepared mental health care providers for the TGNC population.

Case Report of Transgender Patient with Gonadotropic Dysfunction Secondary to Craniopharyngioma: Toward Improving Understanding of Biopsychosocial Dynamics of Gender Identity in Neurosurgical Care.

BACKGROUND: There is a paucity of information in the literature linking possible neuroendocrinologic repercussions of anterior pituitary insufficiency from tumor-associated mass effect with gender identity in transindividuals. The authors present the case of a 26-year-old transgender woman who was found to have a sellar/suprasellar neoplasm after reporting loss of vision in a bitemporal distribution. CASE DESCRIPTION: Magnetic resonance imaging demonstrated a 2.6-cm complex cystic and solid sellar/suprasellar mass, suggestive of craniopharyngioma, intimately associated with the pituitary stalk. Importantly, this radiographic diagnosis was made 2 years following the initiation of gender-affirming hormone therapy (HT). Laboratory testing following radiographic diagnosis demonstrated evidence of diffuse anterior pituitary insufficiency with decreased morning cortisol, free thyroxine, insulin-like growth factor-1, and testosterone. Following optimization with the endocrinology team, the patient was taken to the operating room for expanded endonasal resection of tumor with lumbar drain insertion and nasoseptal flap coverage. Gross total resection was achieved with marked improvement in vision noted following surgery. The patient continued her HT following surgery. CONCLUSIONS: In hindsight, the neuroendocrinologic manifestations of the craniopharyngioma may have influenced distressing pubertal experiences that distanced her from her assigned male sex, as well as the desired effects of feminization HT in this patient, ultimately delaying her presentation to the neurosurgery service and diagnosis of craniopharyngioma. As the first report of the neurosurgical evaluation and treatment of a transgender patient with anterior pituitary insufficiency secondary to craniopharyngioma, this case examines the biopsychosocial interplay between the development of gender identity and the neuroendocrinologic manifestations of craniopharyngioma.

Considerations on medical training for gender-affirming care: Motivations and perspectives.

Background: Many transgender individuals lack access to needed medical care, partially due to a lack of providers with experience in gender-affirming healthcare. Aims: The purpose of this study was to identify professional motivators for medical providers seeking out training in gender-affirming care and to define which training experiences were most beneficial to their career development. By identifying experienced providers' recommendations on which training modalities are most relevant to their practice, we aim to suggest future directions for medical education initiatives to effectively expand the transgender care workforce. Methods: A voluntary cross-sectional electronic survey was distributed through professional listservs and publicly-available referral lists to interdisciplinary providers who self-identified as having experience in providing care to transgender individuals. Results: One hundred and fifty-three (n = 153) physicians, physician assistants, or advance-practice nurses responded to the survey. The majority (96.7%) were located in the United States, representing 37 states. The two most common motivators for seeking out training in gender-affirming care were filling a need in the community (73.0%) and/or having met a transgender-identified person in a clinical setting who requested care (63.8%). While many providers gained skills independently (57.3%), the two most commonly-available training opportunities were professional conferences (57.3%) and mentorship (41.3%). Respondents were most likely to recommend that others in their field be trained via structured clinical experience (e.g., a rotation or longitudinal exposure during training), rather than additional didactic training. Discussion: This study identifies key high-yield training methodologies which could improve access to quality gender-affirming healthcare. Through integration of structured clinical experiences during training, direct clinical mentorship, and professional development at conferences on gender-affirming care, the workforce of welcoming and prepared healthcare providers for transgender patients will increase. This will lead to a tremendous improvement on access to gender-affirming care in our communities.

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.

Are the Contraceptive Recommendations of Family Medicine Educators Evidence-Based? A CERA Survey.

BACKGROUND AND OBJECTIVES: Our study aims were to: (1) describe the scope of contraceptive methods provided by US family medicine educators and (2) assess the extent to which US family medicine educators' recommendations regarding eligibility criteria for contraceptive methods are consistent with Centers for Disease Control and Prevention (CDC) guidelines. METHODS: We contributed survey items as part of the 2014 Council of Academic Family Medicine Educational Research Alliance (CERA) omnibus survey, which is distributed annually to a national cohort of US family medicine educators. We created two summary scales, comprised of clinical scenarios, to assess the extent to which provider recommendations regarding eligibility criteria for oral contraceptive pills (OCPs, six scenarios) and the intrauterine device (IUD, eight scenarios) were consistent with CDC guidelines. RESULTS: Among the 1,054 respondents (33% response rate), 98% prescribe OCPs and 66% insert IUDs. The OCP scale mean was 4.6 ± SD 1.6 (range 0-6), and the IUD scale mean was 4.8 SD ± 2.3 (range 0-8). These scores reflect that 23% of providers' OCP recommendations and 40% of their IUD recommendations were inconsistent with CDC guidelines. CONCLUSIONS: The contraceptive recommendations of this cohort of family medicine educators only partially reflected evidence-based guidelines. More misconceptions were noted regarding eligibility criteria for the IUD than for OCPs. To avoid denying safe and effective contraception to otherwise appropriate candidates and putting women at risk of unintended pregnancy, evidence-based contraceptive recommendations must be improved among family medicine educators.

Emergency contraception: A multispecialty survey of clinician knowledge and practices.

OBJECTIVES: To assess knowledge and provision of emergency contraception (EC), particularly the most effective methods. STUDY DESIGN: A web-based survey was distributed to a cross-sectional convenience sample of healthcare providers across specialties treating reproductive-aged women. The survey was sent to 3260 practicing physicians and advanced practice clinicians in 14 academic centers between February 2013 and April 2014. We analyzed responses by provider specialty using multivariable logistic regression. RESULTS: The final sample included 1684 providers (response rate=51.7%). Ninety-five percent of the respondents had heard of levonorgestrel (LNG) EC. Among reproductive health specialists, 81% provide LNG EC in their practice, although only half (52%) had heard of ulipristal acetate (UPA) and very few provide it (14%). The majority in family medicine (69%) and emergency medicine (74%) provide LNG, in contrast to 42% of internists and 55% of pediatricians. However, the more effective methods [UPA and copper intrauterine device (IUD)] were little known and rarely provided outside of reproductive health specialties; 18% of internists and 14% of emergency medicine providers had heard of UPA and 4% provide it. Only 22% of emergency providers and 32% of pediatricians had heard of the copper IUD used as EC. Among reproductive health specialists, only 36% provide copper IUD as EC in their practice. Specialty, provider type and proportion of women of reproductive age in the practice were related to knowledge and provision of some forms of EC. CONCLUSIONS: Awareness and provision of the most effective EC methods, UPA and the copper IUD (which are provider dependent), are substantially lower than for LNG EC, especially among providers who do not focus on reproductive health. IMPLICATIONS: In our sample of 1684 healthcare providers from diverse specialties who treat reproductive-aged women, knowledge and provision of the most effective forms of EC (UPA and the copper IUD) are far lower than for LNG EC. Women should be offered the full range of EC methods.

Prevention of unintended pregnancy: a focus on long-acting reversible contraception.

This article summarizes the literature regarding the epidemiology and prevention of unintended pregnancy in the United States. Because of the Affordable Care Act and its accompanying contraceptive provision, there is a need for more primary care clinicians to provide family planning services. Office-based interventions to incorporate family planning services in primary care are presented, including clinical tools and electronic health record use. Special attention is paid to long-acting reversible contraceptive methods (the subdermal implant and intrauterine devices); these highly effective and safe methods have the greatest potential to decrease the rate of unintended pregnancy, but have been underused.

Extended use of the intrauterine device: a literature review and recommendations for clinical practice.

There are multiple advantages to "extended use" of the intrauterine device (IUD) use beyond the manufacturer-approved time period, including prolongation of contraceptive and non-contraceptive benefits. We performed a literature review of studies that have reported pregnancy outcomes associated with extended use of IUDs, including copper IUDs and the levonorgestrel intrauterine system (LNG-IUS). Among parous women who are at least 25 years old at the time of IUD insertion, there is good evidence to support extended use of the following devices: the TCu380A and the TCu220 for 12 years, the Multiload Cu-375 for 10 years, the frameless GyneFix® (330 mm²) for 9 years, the levonorgestrel intrauterine system 52 mg (Mirena®) for 7 years and the Multiload Cu-250 for 4 years. Women who are at least 35 years old at the time of insertion of a TCu380A IUD can continue use until menopause with a negligible risk of pregnancy. We found no data to support use of the LNG-IUS 13.5 mg (Skyla®) beyond 3 years. When counseling about extended IUD use, clinicians should consider patient characteristics and preferences, as well as country- and community-specific factors. Future research is necessary to determine the risk of pregnancy associated with extended use of the copper IUD and the LNG-IUS among nulliparous women and women less than 25 years old at the time of IUD insertion. More data are needed on the potential effect of overweight and obesity on the long-term efficacy of the LNG-IUS.

Edema: diagnosis and management.

Edema is an accumulation of fluid in the interstitial space that occurs as the capillary filtration exceeds the limits of lymphatic drainage, producing noticeable clinical signs and symptoms. The rapid development of generalized pitting edema associated with systemic disease requires timely diagnosis and management. The chronic accumulation of edema in one or both lower extremities often indicates venous insufficiency, especially in the presence of dependent edema and hemosiderin deposition. Skin care is crucial in preventing skin breakdown and venous ulcers. Eczematous (stasis) dermatitis can be managed with emollients and topical steroid creams. Patients who have had deep venous thrombosis should wear compression stockings to prevent postthrombotic syndrome. If clinical suspicion for deep venous thrombosis remains high after negative results are noted on duplex ultrasonography, further investigation may include magnetic resonance venography to rule out pelvic or thigh proximal venous thrombosis or compression. Obstructive sleep apnea may cause bilateral leg edema even in the absence of pulmonary hypertension. Brawny, nonpitting skin with edema characterizes lymphedema, which can present in one or both lower extremities. Possible secondary causes of lymphedema include tumor, trauma, previous pelvic surgery, inguinal lymphadenectomy, and previous radiation therapy. Use of pneumatic compression devices or compression stockings may be helpful in these cases.