Needs of transgender children and adolescents presenting to an urban gender health program.

BACKGROUND: Youth who identify as transgender and gender diverse (TGD) are increasingly presenting to pediatric providers. Gender-affirming surgery is often delayed until after a patient reaches the age of majority; however, patients may desire surgery at a younger age. OBJECTIVE: We explore the specific clinical needs of this vulnerable population, including surgical requests. STUDY DESIGN: We present a cross-sectional study of patient intake interviews at time of presentation to our gender health program from 2017 to 2020. We summarize patient demographics, medical histories, and gender-affirming care needs by gender identity and age of presentation. RESULTS: Of 92 patients analyzed, those included were 19 trans girls, 55 trans boys, and 18 non-binary individuals. The median age of our sample was 15 (range 5-17). The median age (IQR) while first questioning gender was 10 (7-12). Sexual orientation was variable with 28 (43%) not sure/unknown. The majority of patients present for primary care services (grade schoolers 75%, early teens 78%, and late teens 77%, p = 0.97) and hormone management (grade schoolers 42%, early teens 62%, and late teens 77%, p = 0.06). Late teens were more likely to present for surgical services (49%) compared to grade schoolers (25%) and early teens (11%), p = 0.001. Prior psychiatric diagnoses were common in all age groups. Trans girls were interested in a variety of affirming procedures whereas trans boys and non-binary individuals primarily sought chest surgery (see summary figure). CONCLUSION: Pediatric gender affirming care needs are varied and multidisciplinary within our center. By age 16, about half of TGD individuals are seeking surgical services. On average, there was a 4-5 year delay from age at first questioning one's gender and presenting to our gender health program. Primary care physicians in particular may prepare to serve this complex population by familiarizing themselves with treatment needs, including developing a network of competent surgical referrals.

A Call for Updates to Hormone Therapy Guidelines for Gender-Diverse Adults Assigned Male at Birth.

Gender-affirming hormone therapy for assigned male at birth (AMAB) individuals with gender incongruence typically consists of estradiol with or without an anti-androgen to achieve physical changes and psychological benefits. However, prescribed hormone regimens vary considerably, and high-quality research in this area is extremely limited. Additional evidence-based research evaluating patient-reported outcome measures (PROMs) is needed to fill current knowledge gaps and create a personalized therapeutic approach for AMAB individuals. This editorial provides a critical description of current treatment options, discusses their variability, reviews some discrepancies in guideline-based dosing recommendations, and recommends areas for further study.

Resolution of metabolic dysfunction-associated steatohepatitis with estradiol in a transgender female: A case report.

A 16-year-old trans female patient presented to our Gender Health Program for gender-affirming care. Her intake evaluation revealed signs of hepatocellular injury and fibrosis concerning for metabolic dysfunction-associated steatohepatitis (MASH) and she was referred to a Pediatric Hepatologist. Subsequent delays in initiating hormone therapy caused a decline in her mental health, and she began experiencing suicidal ideations. Gender-affirming hormone therapy has been shown to significantly reduce depressive symptoms and suicidal ideations in transgender and gender diverse youth, and studies in animal models suggest improvement in hepatic steatosis in response to estrogen. A multidisciplinary meeting with Gender Health, Psychiatry, and Hepatology appropriately weighed the benefits of life-saving hormone therapy and the possibility of an improvement in her comorbid liver condition with the risk of further liver damage from estrogen therapy. The teams and the patient agreed to start estradiol with subsequent resolution of laboratory and radiographic evidence of MASH.

Priorities for efficacy trials of gender-affirming hormone therapy with estrogen: collaborative design and results of a community survey.

PURPOSE: Treatment guidelines for gender-affirming hormone therapy with estrogen (GAHT-E) recommend specific dosing regimens based on limited data. Well-controlled efficacy trials are essential to tailoring treatment to patient goals as the guidelines recommend. The goal of this study was to take a foundational step toward designing community-centered effectiveness trials for gender-diverse individuals seeking GAHT-E. METHODS: Our team developed a cross-sectional survey based on broad clinical experience and consultation with our community advisory board. The survey included 60 items covering demographics, transition history, goals and priorities for treatment, indicators of treatment success, sexual function goals, and future research priorities. The survey was distributed during the summer of 2021, primarily through social networks designed for gender-expansive individuals seeking treatment with estrogen. RESULTS: A total of 1270 individuals completed the survey. Overall treatment goals most frequently rated "extremely important" or "very important" were the following: (1) improved satisfaction with life (81%), (2) appearing more feminine (80%), (3) appearing less masculine (77%), (4) improved mental health (76%), and (5) being seen as your true gender by others (75%). The three body characteristics most frequently rated "highest priority" or "high priority" among changes were the following: (1) facial hair (85%), (2) breast shape or size (84%), and (3) body shape (80%). The highest-rated research priority was comparing feminization with different routes of estrogen administration. CONCLUSION: The goals and experiences of individuals seeking GAHT-E are diverse. Future clinical trials of GAHT-E should be grounded in the needs and priorities of community stakeholders.

Gender-Affirming Mastectomy: Psychosocial and Surgical Outcomes in Transgender Adults.

BACKGROUND: Limited literature exists examining the effects of gender-affirming mastectomy on transmasculine and nonbinary patients that is prospective and uses validated survey instruments. STUDY DESIGN: The psychosocial functioning of transmasculine and nonbinary patients was compared between patients who underwent gender-affirming mastectomy and those who had not yet undergone surgery. Participants were enrolled in a single-site, combined study of surgical and psychosocial outcomes, including a cross-sectional cohort of preoperative and postoperative patients, as well as separate prospective cohort. Participants completed the BREAST-Q psychosocial and sexual well-being modules, the BODY-Q satisfaction with chest and nipples modules, the Body Image Quality of Life Inventory, the Transgender Congruence Scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7 scale before and after surgery. We also examined how patient demographic factors correlated with postoperative surgical and psychosocial outcomes. RESULTS: A total of 111 transmasculine and nonbinary patients 18 to 63 years of age (mean ± SD 26.5 ± 8) underwent mastectomy and were included in the study. All were included in the cross-sectional cohort, and 20 were enrolled in the prospective cohort. More than one-third (34.2%) of patients were nonbinary. After surgery, psychosocial and sexual well-being, satisfaction, body image-related quality of life, and gender congruence were increased (p < 0.001) in both cohorts, and depression (p < 0.009 cross-sectional), and anxiety (p < 0.001 cross-sectional) were decreased. The most common adverse event was hypertrophic scarring, which occurred in 41 (36.9%) participants. CONCLUSIONS: In this study of transmasculine and nonbinary adults, gender-affirming mastectomy was followed by substantial improvements in psychosocial functioning.

Preliminary Pilot-Testing of Intimate Partner Violence Screening for Transgender and Gender Diverse (TGD) Individuals in Med-Peds and Family Medicine.

INTRODUCTION: Transgender and gender diverse (TGD) individuals, comprised of those whose gender identity does not correspond with the sex they were assigned at birth, represent approximately 1.4 million people in the U.S., with a higher prevalence among those 18-24 years old. TGD individuals experience high levels of intimate partner violence (IPV), which leads to disproportionately negative mental and physical health outcomes for this population. As a result, there is a resounding need to connect TGD populations to health-promoting services, supports and resources. Med-Peds and Family Medicine clinics may be particularly well-positioned to support these efforts due to physicians' focus on transitional-aged youth and young adults under 30. METHODS: The current manuscript reports on processes and outcomes related to a quality improvement (QI) initiative that aimed to test the feasibility and acceptability of implementing IPV screening within both a Med-Peds and a Family Medicine specialty clinic serving TGD populations in Los Angeles, CA. This QI initiative included screeners that capture IPV in cisgender/non-TGD populations (Humiliation, Afraid, Rape, Kick [HARK]) as well as in TGD populations specifically (IPV-T). We utilized a mixed-methods approach to both quantify and qualify responses to existing IPV screening as well as informal feedback from clinic "champions" in each clinic. RESULTS: Quantitative and qualitative findings from this QI initiative, featuring both general and TGD-specific IPV screening measures with 140 TGD individuals, elucidated several important processes that can support effective IPV screening and referral to supports and services. These include the importance of interdisciplinary teams, the utility of an iterative approach to screener roll-out, and the essential role of solidifying a referral process in these efforts. This project additionally shed light on the potential utility and challenges of implementing both general and TGD-specific IPV screening measures. Our pilot test did not support the necessity of a TGD-specific IPV screener for identifying and responding to IPV in this population, yet additional data is critical to generate more conclusive recommendations. CONCLUSION: We recommend larger-scale data collection efforts to evaluate the utility of integrating general and TGD-specific screeners into clinic workflows to ensure optimal health promotion for the TGD population in Med-Peds and Family Medicine clinics.

Assessing Child Life Specialists' Management of Challenging Behaviors in Autistic Pediatric Patients.

Given that autistic children are hospitalized at higher rates than neurotypical peers, it is important to understand the autism-specific preparedness of healthcare providers. Certified Child Life Specialists (CCLSs) play a crucial role in pediatric hospitalizations by providing socioemotional support and coping strategies. The present study assessed perceived competency and comfort levels among 131 CCLSs regarding the management of challenging behaviors exhibited by autistic pediatric patients, including aggression and self-injury. All participants reported experiences providing care to autistic children who exhibited challenging behaviors, but very few reported both high perceived competency and high comfort in managing these behaviors. Autism-specific training positively correlated with perceived competency and comfort. These results have implications for providing autistic children high quality hospital care.

Lactation Induction in a Transgender Woman: Macronutrient Analysis and Patient Perspectives.

INTRODUCTION: Induction of lactation in a non-gestational parent has numerous potential benefits including parent-child bonding, optimal nutrition, and health benefits to the child and breast- or chest-feeding parent. For transgender women and nonbinary people on estrogen-based, gender-affirming hormone therapy, the ability to nourish their infants through production of their own milk may also be a profoundly gender-affirming experience. Two prior case studies have been published describing induced lactation in transgender women, but analysis of the nutritional quality of the milk produced has not been previously described. MAIN ISSUE: Here we describe the experience of a transgender woman who underwent successful induction of lactation in order to breastfeed her infant, who was gestated by her partner. MANAGEMENT: Through modification of exogenous hormone therapy, use of domperidone as a galactogogue, breast pumping, and ultimately direct breastfeeding, the participant was able to co-feed her infant for the first 4 months of life. We provide a detailed description and timeline of the medications used, laboratory and electrocardiographic measurements, results of the participant's milk analysis showing robust macronutrient content, and description of the participant's experience in her own words. CONCLUSION: These findings provide reassurance about the adequacy of nutrition from human milk produced by non-gestational transgender female and nonbinary parents on estrogen-based, gender-affirming hormone therapy, and support the importance of this experience on a personal level.

Gender Affirming Surgery in Nonbinary Patients: A Single Institutional Experience.

Background An increasing number of nonbinary patients are receiving gender-affirming procedures due to improved access to care. However, the preferred treatments for nonbinary patients are underdescribed. The purpose of this study was to investigate the goals and treatments of nonbinary patients. Methods A retrospective study of patients who self-identified as nonbinary from our institutional Gender Health Program was conducted. Patient demographics, clinical characteristics, surgical goals, and operative variables were analyzed. Results Of the 375 patients with gender dysphoria, 67 (18%) were nonbinary. Over half of the nonbinary patients were assigned male at birth ( n = 57, 85%) and nearly half preferred the gender pronoun they/them/theirs ( n = 33, 49%). A total of 44 patients (66%) received hormone therapy for an average of 2.5 ± 3.6 years, primarily estrogen ( n = 39). Most patients ( n = 46, 69%) received or are interested in gender-affirming surgery, of which, almost half were previously on hormone therapy ( n = 32, 48%). The most common surgeries completed or desired were facial feminization surgery ( n = 15, 22%), vaginoplasty ( n = 15, 22%), mastectomy ( n = 11, 16%), and orchiectomy ( n = 9, 13%). Nonbinary patients who were assigned male at birth (NB-AMAB) were more often treated with hormones compared to nonbinary patients assigned female at birth (NB-AFAB) (72% vs. 30%, p = 0.010). Conversely, patients who were AFAB were more likely to complete or desire surgical intervention than those who were AMAB (100% vs. 63.0%, p < 0.021). Conclusion Majority of nonbinary patients were assigned male at birth. NB-AFAB patients all underwent surgical treatment, whereas NB-AMAB patients were predominantly treated with hormone therapy.

Effect of Gender-affirming Facial Feminization Surgery on Psychosocial Outcomes.

OBJECTIVE: This study investigates the effect of gender-affirming facial feminization surgery (FFS) on psychosocial outcomes in patients with gender dysphoria. BACKGROUND: Comprehensive analyses of psychosocial outcomes after gender-affirming FFS are absent in the literature resulting in a paucity of information on the impact of FFS on quality of life as well as ramifications in health insurance coverage of FFS. METHODS: Scores from 11 validated, quantitative instruments from the Patient-Reported Outcomes Measurement Information System (PROMIS) assessing anxiety, anger, depression, global mental health, global physical health, satisfaction with sex life, positive affect, emotional support, social isolation, companionship, and meaning and purpose. Patients within the preoperative group (pre-FFS) were evaluated >30 days before surgery and patients within the postoperative group (post-FFS) were evaluated ≥10 weeks after surgery. RESULTS: A total of 169 patients [mean (SD) age, 33.5 (10.8) years] were included. Compared with the pre-FFS group (n=107), the post-FFS group (n=62) reported improved scores anxiety (56.8±8.8 vs 60.1±7.9, P =0.01), anger (47.4±7.6 vs 51.2±9.6, P =0.01), depression (52.2±9.2 vs 57.0±8.9, P =0.001), positive affect (46.6±8.9 vs 42.9±8.7, P =0.01), meaning and purpose (49.9±10.7 vs 46.2±10.5, P =0.03), global mental health (46.7±7.6 vs 43.1±9.2, P =0.01), and social isolation (52.2±7.5 vs 55.4±7.4, P =0.01). Multivariable analysis to account for the effects of other gender-affirming surgeries, hormone therapy duration, preexisting mental health diagnoses, socioeconomic disparities, and patient-reported quality of social relationships on psychosocial functioning demonstrated that completion of FFS was independently predictive of improved scores. CONCLUSIONS: Gender-affirming FFS improves the quality of life by multiple psychosocial domains in transfeminine patients.

Breast Cancer Among Transgender and Nonbinary Patients: Paradigms for Improving Data Collection and Inclusion in Breast Imaging Settings.

Breast cancer incidence among transgender and nonbinary (TGNB) individuals is not well characterized owing to the absence of robust data collection among this patient population. Consequently, breast cancer risks are largely unknown, and screening guidelines are not based on robust evidence. Additionally, TGNB patients experience barriers to access health care. A first step in improving data collection, research, and ultimately care of TGNB individuals is the identification of group members and demonstration to patients that our breast imaging centers are champions of LGBTQ+ health. At our institution, patients who present for breast imaging complete an iPad-administered breast imaging history and breast cancer risk assessment survey. Using the modified Tyrer-Cuzick model, the lifetime risk of developing breast cancer is estimated, and additional key history that may impact breast care and future breast imaging is collected. Under the previous clinic workflow, patients are identified as either "male" or "female" and complete a corresponding gender-specific survey. To improve care, we revised the survey using gender-inclusive language and developed four versions to allow patients to separately self-report their sex assigned at birth and gender identity. Relevant queries relating to hormone use and gender-affirming chest/breast surgery that are concordant with six gender-identity groups were added. Long-term collection of these inclusive data by imaging centers has the potential to enhance the data set available to improve breast care and better understand breast cancer risk and outcomes among TGNB populations.

Early childhood hospitalization and problematic behaviors: A propensity score analysis.

Existing research suggests that children who experience poverty and hospitalization in early childhood are at risk of developing behavior problems. We examined whether the association between early childhood hospitalization and children's internalizing and externalizing behaviors were moderated by family poverty status and child sex. Participants included 224 children from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. There was no direct association between hospitalization and problematic behaviors. Poverty status during early childhood, but not child sex, significantly moderated the association between hospitalization and externalizing problems. Findings support the need for community programs that promote an integrative approach to healthcare for families experiencing poverty.

Initial Clinical Needs Among Transgender and Non-binary Individuals in a Large, Urban Gender Health Program.

BACKGROUND: Transgender and gender-diverse individuals are particularly vulnerable to healthcare discrimination and related health sequelae. OBJECTIVE: To demonstrate diversity in demographics and explore variance in needs at the time of intake among patients seeking care at a large, urban gender health program. DESIGN: We present summary statistics of patient demographics, medical histories, and gender-affirming care needs stratified by gender identity and sexual orientation. PARTICIPANTS: We reviewed all intake interviews with individuals seeking care in our gender health program from 2017 to 2020. MAIN MEASURES: Clients reported all the types of care in which they were interested at the time of intake as their "reason for call" (i.e., establish primary care, hormone management, surgical services, fertility services, behavioral health, or other health concerns). KEY RESULTS: Of 836 patients analyzed, 350 identified as trans women, 263 as trans men, and 223 as non-binary. The most prevalent sexual identity was straight among trans women (34%) and trans men (38%), whereas most (69%) non-binary individuals identified as pansexual or queer; only 3% of non-binary individuals identified as straight. Over half of patients reported primary care, hormone management, or surgical services as the primary reason for contacting our program. Straight, transgender women were more likely to report surgical services as their primary reason for contacting our program, whereas gay transgender men were more likely to report primary care as their reason. CONCLUSIONS: Individuals contacting our gender health program to establish care were diverse in sexual orientation and gender-affirming care needs. Care needs varied with both gender identity and sexual orientation, but primary care, hormone management, and surgical services were high priorities across groups. Providers of gender-affirming care should inquire about sexual orientation and detailed treatment priorities, as trans and gender-diverse populations are not uniform in their treatment needs or goals.

Perceptual Access Reasoning (PAR) in Developing a Representational Theory of Mind.

An important part of children's social and cognitive development is their understanding that people are psychological beings with internal, mental states including desire, intention, perception, and belief. A full understanding of people as psychological beings requires a representational theory of mind (ToM), which is an understanding that mental states can faithfully represent reality, or misrepresent reality. For the last 35 years, researchers have relied on false-belief tasks as the gold standard to test children's understanding that beliefs can misrepresent reality. In false-belief tasks, children are asked to reason about the behavior of agents who have false beliefs about situations. Although a large body of evidence indicates that most children pass false-belief tasks by the end of the preschool years, the evidence we present in this monograph suggests that most children do not understand false beliefs or, surprisingly, even true beliefs until middle childhood. We argue that young children pass false-belief tasks without understanding false beliefs by using perceptual access reasoning (PAR). With PAR, children understand that seeing leads to knowing in the moment, but not that knowing also arises from thinking or persists as memory and belief after the situation changes. By the same token, PAR leads children to fail true-belief tasks. PAR theory can account for performance on other traditional tests of representational ToM and related tasks, and can account for the factors that have been found to correlate with or affect both true- and false-belief performance. The theory provides a new laboratory measure which we label the belief understanding scale (BUS). This scale can distinguish between a child who is operating with PAR versus a child who is understanding beliefs. This scale provides a method needed to allow the study of the development of representational ToM. In this monograph, we report the outcome of the tests that we have conducted of predictions generated by PAR theory. The findings demonstrated signature PAR limitations in reasoning about the mind during the ages when children are hypothesized to be using PAR. In Chapter II, secondary analyses of the published true-belief literature revealed that children failed several types of true-belief tasks. Chapters III through IX describe new empirical data collected across multiple studies between 2003 and 2014 from 580 children aged 4-7 years, as well as from a small sample of 14 adults. Participants were recruited from the Phoenix, Arizona metropolitan area. All participants were native English-speakers. Children were recruited from university-sponsored and community preschools and daycare centers, and from hospital maternity wards. Adults were university students who participated to partially fulfill course requirements for research participation. Sociometric data were collected only in Chapter IX, and are fully reported there. In Chapter III, minor alterations in task procedures produced wide variations in children's performance in 3-option false-belief tasks. In Chapter IV, we report findings which show that the developmental lag between children's understanding ignorance and understanding false belief is longer than the lag reported in previous studies. In Chapter V, children did not distinguish between agents who have false beliefs versus agents who have no beliefs. In Chapter VI, findings showed that children found it no easier to reason about true beliefs than to reason about false beliefs. In Chapter VII, when children were asked to justify their correct answers in false-belief tasks, they did not reference agents' false beliefs. Similarly, in Chapter VIII, when children were asked to explain agents' actions in false-belief tasks, they did not reference agents' false beliefs. In Chapter IX, children who were identified as using PAR differed from children who understood beliefs along three dimensions-in levels of social development, inhibitory control, and kindergarten adjustment. Although the findings need replication and additional studies of alternative interpretations, the collection of results reported in this monograph challenges the prevailing view that representational ToM is in place by the end of the preschool years. Furthermore, the pattern of findings is consistent with the proposal that PAR is the developmental precursor of representational ToM. The current findings also raise questions about claims that infants and toddlers demonstrate ToM-related abilities, and that representational ToM is innate.

Survey of Spanish Language Neuropsychological Test Use in the Assessment of Hispanic Americans/Latino/as/x.

OBJECTIVE: To identify the Spanish language neuropsychological tests most frequently used in the evaluation of Hispanic Americans/Latino/as/x across eight neuropsychological domains. To compare these with previously surveyed most frequently used English language tests in the US/Canada. To describe the norms used with Spanish language tests. METHOD: An anonymous, uncompensated, 12-min survey was emailed to 169 members of the American Academy of Clinical Neuropsychology, Hispanic Neuropsychological Society, and National Academy of Neuropsychology who self-identified as providing neuropsychological evaluations in Spanish via organizational websites. RESULTS: The response rate was 36%. Respondents were all licensed U.S. psychologists with the majority fluent in Spanish, conducting less than half their evaluations in Spanish. There was an overlap between the versions of the three most frequently used Spanish versus English neuropsychological tests, but it varied by domain with 3/3 similar for visual-spatial/visuoconstructional skills and sensory/motor functioning domains and 2/3 similar for all other domains except memory (0/3). English language norm use predominated within the mood/personality and sensory/motor functioning domains. In all other domains, Spanish language norms collected in the continental US were preferred to those from foreign Spanish-speaking countries. The most frequently used foreign norms were from Mexico. CONCLUSION: Except for the memory domain, there was a sizeable overlap between the three most frequently used Spanish and English language neuropsychological tests in the US. Spanish language tests are primarily interpreted with Spanish norms collected in the continental US except within the mood/personality and sensory/motor functioning domains where English language norms predominate.

Access, barriers, and decisional regret in pursuit of fertility preservation among transgender and gender-diverse individuals.

OBJECTIVE: To query transgender and gender-diverse individuals on their desire for fertility preservation, perceived barriers to access care, and decisional regret. DESIGN: Cross-sectional. SETTING: Not applicable. PATIENT(S): A total of 397 gender-diverse individuals undergoing intake to the University of California Los Angeles Gender Health Program from January 2018 to March 2019. Seventy participated in a follow-up survey from September to October 2019 clarifying reproductive desires or intentions. INTERVENTION: Multiple-choice questionnaire. MAIN OUTCOME MEASURE(S): Perceived barriers to access fertility preservation and decisional regret surrounding choice to pursue fertility preservation as measured with the use of the validated Decision Regret Scale (scored 0 to 100). RESULT(S): Barriers to accessing care were primarily cost of treatment (36%), discontinuation/delay of hormonal therapy (19%), or worsening of gender dysphoria with treatment/pregnancy (11%). Respondents indicated that their family planning goals were addressed by primary care providers and/or medical endocrinologists (multiple responses allowed), but 37% stated that their family planning goals were not adequately addressed. Those who had made a firm decision to pursue or not pursue fertility treatment had mild decisional regret. Moderate-to-severe decisional regret was noted in those who were undecided regarding the pursuit of fertility perseveration before transition and in those who were interested in referral to reproductive endocrinology. CONCLUSION(S): Consultation with a reproductive endocrinologist may reduce decisional regret as well as clarify perceived barriers to fertility preservation in transgender and gender-diverse individuals interested in fertility preservation.

Specificity rates for non-clinical, bilingual, Mexican Americans with California Verbal Learning Test3, verbal fluency, and Rey 15-IR performance validity measures.

Objective: To measure failure rates among non-clinical, Mexican American, bilinguals on embedded performance validity measures from the California Verbal Learning Test3 and verbal fluency and the stand-alone Rey 15-item test plus recognition (Rey 15-IR) using valid/invalid performance cut scores developed for monolingual, English-speakers. Method: Participants were 60 consecutive recruits, aged between 18 and 75 years, with ≤16 years of education who self-identified as bilingual (confirmed via formal assessment) and chose the language of assessment, Spanish or English, for the performance validity tests. Results: The only performance validity measure studied with a higher failure rate (19%) than that for monolingual, English-speakers (9%) was semantic fluency administered in Spanish. Conclusions: Valid/invalid performance cut scores derived for monolingual English-speakers generated comparable or lower failure rates among Mexican American bilinguals on CVLT3 forced-choice recognition, CVLT3 yes-no recognition hits, letter fluency, semantic fluency in English, and the Rey 15-IR.

Transgender Care in the Primary Care Setting: A Review of Guidelines and Literature.

For patients who desire transgender care, providers must use appropriate language, know the basics of cross-sex hormone therapy, and understand the risks and adverse effects of treatment options.

Specificity rates for non-clinical, bilingual, Mexican Americans on three popular performance validity measures.

OBJECTIVE: To measure specificity as failure rates for non-clinical, bilingual, Mexican Americans on three popular performance validity measures: (a) the language format Reliable Digit Span; (b) visual-perceptual format Test of Memory Malingering; and (c) visual-perceptual format Dot Counting, using optimal/suboptimal effort cut scores developed for monolingual, English-speakers. METHODS: Participants were 61 consecutive referrals, aged between 18 and 65 years, with <16 years of education who were subjectively bilingual (confirmed via formal assessment) and chose the language of assessment, Spanish or English, for the performance validity tests. RESULTS: Failure rates were 38% for Reliable Digit Span, 3% for the Test of Memory Malingering, and 7% for Dot Counting. For Reliable Digit Span, the failure rates for Spanish (46%) and English (31%) languages of administration did not differ significantly. CONCLUSIONS: Optimal/suboptimal effort cut scores derived for monolingual English-speakers can be used with Spanish/English bilinguals when using the visual-perceptual format Test of Memory Malingering and Dot Counting. The high failure rate for Reliable Digit Span suggests it should not be used as a performance validity measure with Spanish/English bilinguals, irrespective of the language of test administration, Spanish or English.

Development of constructivist theory of mind from middle childhood to early adulthood and its relation to social cognition and behavior.

Two studies examined the development of constructivist theory of mind (ToM) during late childhood and early adolescence. In Study 1, a new measure was developed to assess participants' understanding of the interpretive and constructive processes embedded in memory, comprehension, attention, comparison, planning, and inference. Using this measure, Study 2 tested a mediational model in which prosocial reasoning about conflict mediated the relation between constructivist ToM and behavior problems in high school. Results showed that the onset of constructivist ToM occurs between late childhood and early adolescence and that adolescents who have more advanced constructivist ToM have more prosocial reasoning about conflict, which in turn mediated the relation with fewer serious behavior problems in high school, after controlling for academic performance and sex. In both studies, girls showed more advanced constructivist ToM than boys in high school.