Corrigendum: Clinicians in the Veterans Health Administration initiate gender-affirming hormone therapy in concordance with clinical guideline recommendations.

[This corrects the article DOI: 10.3389/fendo.2024.1086158.].

Suicide prevention providers' perspectives on addressing social determinants of health for at-risk Veterans.

OBJECTIVE: Suicide prevention is a top clinical priority within the Department of Veterans Affairs (VA). While research consistently shows that suicide risk is associated with adverse social determinants of health (SDH, e.g., housing instability, unemployment, justice involvement), less is known about the extent to which suicide prevention staff are aware of and able to address these risk factors. This study aimed to understand the experiences of VA Suicide Prevention Coordinators (SPCs) with referring Veterans at risk of suicide to services that address SDH. METHOD: In January-February 2022, 171 VA SPCs completed a questionnaire about their experiences connecting Veterans with SDH-focused services. Descriptive statistics summarized closed-response items and a thematic analysis was conducted for open-ended responses. RESULTS: The majority of SPCs agreed that adverse SDH contribute to suicide risk and that services to address SDH could reduce suicide risk for Veterans. While most SPCs were aware of on-site SDH services, many reported barriers to connecting Veterans with those services including insufficient resources, lack of staff time, and eligibility criteria. CONCLUSION: Changes at the organizational and policy levels are needed to provide comprehensive suicide prevention services that connect at-risk Veteran with services to address adverse SDH.

Gender as a moderator of associations between military sexual trauma and posttraumatic stress disorder treatment utilization.

The present study sought to investigate whether gender moderates the relationship between military sexual trauma (MST) and posttraumatic stress disorder (PTSD) treatment utilization, among veterans with clinically significant PTSD symptoms. Participants were 2,664 veterans with probable PTSD from a nationwide, population-based survey. Participants reported sociodemographic information, history of MST (including military sexual harassment and military sexual assault), and lifetime receipt of PTSD psychotherapy and medication treatment. We found that gender significantly moderated relationships between (a) military sexual harassment and PTSD psychotherapy, (b) military sexual assault and PTSD psychotherapy, and (c) military sexual harassment and PTSD medication. For women, MST was associated with a greater likelihood of receiving treatment, but for men, MST was not associated with PTSD treatment. Future research is needed to better understand gender differences in how experiences of MST may affect engagement in PTSD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Trauma exposure, mental health, and mental health treatment among LGBTQ+ veterans and nonveterans.

OBJECTIVE: The purpose of the study was to compare lesbian, gay, bisexual, transgender, queer+ (LGBTQ+) veterans' and nonveterans' prevalence of potentially traumatic events (PTEs) and other stressor exposures, mental health concerns, and mental health treatment. METHOD: A subsample of veterans and nonveterans who identified as LGBTQ+ (N = 1,291; 851 veterans; 440 nonveterans) were identified from a national cohort of post-9/11 veterans and matched nonveterans. Majority of the sample identified as White (59.7%), men (40.4%), and gay or lesbian (48.6%). Measures included PTEs and other stressors, depression, anxiety, posttraumatic stress disorder (PTSD), and receipt of mental health treatment. Logistic regressions compared the likelihood of experiencing PTEs and other stressors, self-reported mental health diagnoses, and mental health treatment between LGBTQ+ veterans and nonveterans. RESULTS: Compared with LGBTQ+ nonveterans, LGBTQ+ veterans were more likely to report financial strain, divorce, discrimination, witnessing the sudden death of a friend or family member, and experiencing a serious accident or disaster. LGBTQ+ veterans reported greater depression, anxiety, and PTSD symptom severity than LGBTQ+ nonveterans. However, LGBTQ+ veterans were only more likely to receive psychotherapy for PTSD and did not differ from nonveterans in the likelihood of receiving any other types of mental health treatment. CONCLUSIONS: The study was the first to demonstrate that LGBTQ+ veterans have a greater prevalence of PTEs and other stressors and report worse mental health symptoms. These findings suggest that LGBTQ+ veterans may have unmet mental health treatment needs and need interventions to increase engagement in needed mental health services, especially for depression and anxiety. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

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.

Clinicians in the Veterans Health Administration initiate gender-affirming hormone therapy in concordance with clinical guideline recommendations.

Background: Gender-affirming hormone therapy (GAHT) is a common medical intervention sought by transgender and gender diverse (TGD) individuals. Initiating GAHT in accordance with clinical guideline recommendations ensures delivery of high-quality care. However, no prior studies have examined how current GAHT initiation compares to recommended GAHT initiation. Objective: This study assessed guideline concordance around feminizing and masculinizing GAHT initiation in the Veterans Health Administration (VHA). Methods: The sample included 4,676 veterans with a gender identity disorder diagnosis who initiated feminizing (n=3,547) and masculinizing (n=1,129) GAHT between 2007 and 2018 in VHA. Demographics and health conditions on veterans receiving feminizing and masculinizing GAHT were assessed. Proportion of guideline concordant veterans on six VHA guidelines on feminizing and masculinizing GAHT initiation were determined. Results: Compared to veterans receiving masculinizing GAHT, a higher proportion of veterans receiving feminizing GAHT were older (≥60 years: 23.7% vs. 6.3%), White non-Hispanic (83.5% vs. 57.6%), and had a higher number of comorbidities (≥7: 14.0% vs. 10.6%). A higher proportion of veterans receiving masculinizing GAHT were Black non-Hispanic (21.5% vs. 3.5%), had posttraumatic stress disorder (43.0% vs. 33.9%) and positive military sexual trauma (33.5% vs.16.8%; all p-values<0.001) than veterans receiving feminizing GAHT. Among veterans who started feminizing GAHT with estrogen, 97.0% were guideline concordant due to no documentation of contraindication, including venous thromboembolism, breast cancer, stroke, or myocardial infarction. Among veterans who started spironolactone as part of feminizing GAHT, 98.1% were guideline concordant as they had no documentation of contraindication, including hyperkalemia or acute renal failure. Among veterans starting masculinizing GAHT, 90.1% were guideline concordant due to no documentation of contraindications, such as breast or prostate cancer. Hematocrit had been measured in 91.8% of veterans before initiating masculinizing GAHT, with 96.5% not having an elevated hematocrit (>50%) prior to starting masculinizing GAHT. Among veterans initiating feminizing and masculinizing GAHT, 91.2% had documentation of a gender identity disorder diagnosis prior to GAHT initiation. Conclusion: We observed high concordance between current GAHT initiation practices in VHA and guidelines, particularly for feminizing GAHT. Findings suggest that VHA clinicians are initiating feminizing GAHT in concordance with clinical guidelines. Future work should assess guideline concordance on monitoring and management of GAHT in VHA.

Patient Characteristics Associated with Receiving Gender-Affirming Hormone Therapy in the Veterans Health Administration.

Purpose: This study aimed to examine patient characteristics associated with receipt of gender-affirming hormone therapy in the Veterans Health Administration (VHA). Methods: This cross-sectional study included a national cohort of 9555 transgender and gender diverse (TGD) patients with TGD-related diagnosis codes who received care in the VHA from 2006 to 2018. Logistic regression models were used to determine the association of health conditions and documented social stressors with receipt of gender affirming hormone therapy. Results: Of the 9555 TGD patients, 57.4% received gender-affirming hormone therapy in the VHA. In fully adjusted models, patients who had following characteristics were less likely to obtain gender-affirming hormones in the VHA: Black, non-Hispanic versus white (adjusted odds ratio [aOR]: 0.61; 95% confidence interval [CI]: 0.52-0.72), living in the Northeast versus the West (aOR: 0.72; 95% CI: 0.62-0.84), a documented drug use disorder (aOR: 0.56; 95% CI: 0.47-0.68), ≥3 versus no comorbidities (aOR: 0.44; 95% CI: 0.34-0.57), and ≥3 versus no social stressors (aOR: 0.42; 95% CI: 0.30-0.58; all p<0.001). Younger patients aged 21-29 years were almost 3 times more likely to receive gender affirming hormone therapy in the VHA than those aged ≥60 (aOR: 2.98; 95% CI: 2.55-3.47; p<0.001). Conclusion: TGD individuals who were older, Black, non-Hispanic, and had more comorbidities and documented social stressors were less likely to receive gender-affirming hormone therapy in the VHA. Further understanding of patient preferences in addition to clinician- and site-level determinants that may impact access to gender-affirming hormone therapy for TGD individuals in the VHA is needed.

Sexual and Gender Minority Status and Suicide Mortality: An Explainable Artificial Intelligence Analysis.

Objectives: Suicide risk is elevated in lesbian, gay, bisexual, and transgender (LGBT) individuals. Limited data on LGBT status in healthcare systems hinder our understanding of this risk. This study used natural language processing to extract LGBT status and a deep neural network (DNN) to examine suicidal death risk factors among US Veterans. Methods: Data on 8.8 million veterans with visits between 2010 and 2017 was used. A case-control study was performed, and suicide death risk was analyzed by a DNN. Feature impacts and interactions on the outcome were evaluated. Results: The crude suicide mortality rate was higher in LGBT patients. However, after adjusting for over 200 risk and protective factors, known LGBT status was associated with reduced risk compared to LGBT-Unknown status. Among LGBT patients, black, female, married, and older Veterans have a higher risk, while Veterans of various religions have a lower risk. Conclusion: Our results suggest that disclosed LGBT status is not directly associated with an increase suicide death risk, however, other factors (e.g., depression and anxiety caused by stigma) are associated with suicide death risks.

Sex, gender diversity, and brain structure in early adolescence.

There remains little consensus about the relationship between sex and brain structure, particularly in early adolescence. Moreover, few pediatric neuroimaging studies have analyzed both sex and gender as variables of interest-many of which included small sample sizes and relied on binary definitions of gender. The current study examined gender diversity with a continuous felt-gender score and categorized sex based on X and Y allele frequency in a large sample of children ages 9-11 years old (N = 7195). Then, a statistical model-building approach was employed to determine whether gender diversity and sex independently or jointly relate to brain morphology, including subcortical volume, cortical thickness, gyrification, and white matter microstructure. Additional sensitivity analyses found that male versus female differences in gyrification and white matter were largely accounted for by total brain volume, rather than sex per se. The model with sex, but not gender diversity, was the best-fitting model in 60.1% of gray matter regions and 61.9% of white matter regions after adjusting for brain volume. The proportion of variance accounted for by sex was negligible to small in all cases. While models including felt-gender explained a greater amount of variance in a few regions, the felt-gender score alone was not a significant predictor on its own for any white or gray matter regions examined. Overall, these findings demonstrate that at ages 9-11 years old, sex accounts for a small proportion of variance in brain structure, while gender diversity is not directly associated with neurostructural diversity.

Non-affirmation minority stress, internalized transphobia, and subjective cognitive decline among transgender and gender diverse veterans aged 45 years and older.

OBJECTIVES: To examine the associations of two measures of minority stress, non-affirmation minority stress and internalized transphobia, with subjective cognitive decline (SCD) among transgender and gender diverse (TGD) veterans. METHOD: We administered a cross-sectional survey from September 2022 to July 2023 to TGD veterans. The final analytic sample included 3,152 TGD veterans aged ≥45 years. We used a generalized linear model with quasi-Poisson distribution to calculate prevalence ratios (PR) and 95% confidence intervals (CIs) measuring the relationship between non-affirmation minority stress and internalized transphobia and past-year SCD. RESULTS: The mean age was 61.3 years (SD = 9.7) and the majority (70%) identified as trans women or women. Overall, 27.2% (n = 857) reported SCD. Adjusted models revealed that TGD veterans who reported experiencing non-affirmation minority stress or internalized transphobia had greater risk of past-year SCD compared to those who did not report either stressor (aPR: 1.09, 95% CI: 1.04-1.15; aPR: 1.19, 95% CI: 1.12-1.27). CONCLUSION: Our findings demonstrate that proximal and distal processes of stigma are associated with SCD among TGD veterans and underscore the need for addressing multiple types of discrimination. Above all, these results indicate the lasting sequelae of transphobia and need for systemic changes to prioritize the safety and welfare of TGD people.

Effects of cannabis use on cigarette smoking cessation in LGBTQ+ individuals.

OBJECTIVE: Sexual and gender minority individuals are more likely to use tobacco and cannabis and have lower cigarette cessation. This study examined cannabis use associations with daily cigarettes smoked in sexual and gender minority individuals before and during a quit attempt. METHOD: Participants included dual smoking same-sex/gender couples from California that were willing to make a quit attempt (individual n = 205, 68.3% female sex). Participants reported baseline past 30-day cannabis use and number of cigarettes smoked and cannabis use (yes/no) during 35 nightly surveys. Individuals with current cannabis use reported baseline cannabis use and/or nightly survey cannabis use. Multilevel linear models predicted number of cigarettes smoked by cannabis use. RESULTS: Number of cigarettes decreased from before to during a quit attempt, but this decrease was smaller in individuals with current cannabis use compared to no current cannabis use (p < .001). In individuals with current cannabis use, number of cigarettes smoked was greater on days with cannabis use (p < .001). Furthermore, cannabis use that day increased overall number of cigarettes in those with relatively high overall cannabis use but only during a quit attempt in those with relatively low cannabis use (Within-Subject Cannabis Use × Between-Subject Cannabis Use × Quit Attempt interaction; p < .001). CONCLUSIONS: Sexual and gender minority individuals with cannabis and cigarette use may have a harder time quitting smoking than those who do not use cannabis. For those with cannabis use, guidance on not using cannabis during a quit attempt may improve cigarette cessation outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Limitations of Sexual Orientation and Gender Identity Information as Reported in the National Violent Death Reporting System.

The National Violent Death Reporting System (NVDRS) is a Centers for Disease Control and Prevention (CDC) restricted-access database detailing precipitating circumstances to U.S. violent deaths. In 2013 and 2015, the CDC added codes denoting sexual orientation and gender identity (SOGI) and sex of partner. In the past decade, researchers have leveraged NVDRS data to document SOGI-related patterns and characteristics of violent death including suicide. Yet, there are substantial limitations to NVDRS SOGI information that should be considered in responsible reporting by researchers and informed assessment by reviewers. In this perspective, we summarize some of these challenges and offer recommendations for using NVDRS SOGI data responsibly.

Causes of Death of Transgender and Gender Diverse Veterans.

INTRODUCTION: Transgender and gender diverse (TGD) veterans face numerous challenges due to stigma and marginalization, which have a significant impact on their health and well-being. However, there is insufficient data on cause-specific mortality in TGD veteran populations in the U.S. The purpose of this study was to describe the leading causes of death in a sample of TGD veterans who received care from the Veterans Health Administration. METHODS: A secondary data analysis was conducted using Veterans Health Administration electronic health record data matched with death certificate records from the National Death Index from October 1, 1999 to December 31, 2019. Using record axis codes from National Death Index data, the 25 most frequent underlying and all causes of death were summarized. RESULTS: Deaths occurred in 1,415 TGD veterans. Ranking by any mention on the death certificate, mental and behavioral disorders due to psychoactive substance use (17.2%), conduction disorders and cardiac dysrhythmias (15.3%), chronic obstructive pulmonary disease (15.1%), diabetes mellitus (13.9%), and chronic ischemic heart disease (13.3%) were the top five causes of death. Three distinct methods of suicide appeared as the 7th (firearms), 17th (self-poisoning), and 24th (hanging) underlying causes of death for TGD veterans. CONCLUSIONS: Targeted prevention efforts or interventions to reduce the frequency and severity of causes of death, particularly mental and behavioral health disorders and metabolic disorders, could prevent premature mortality among TGD adults.

Which veterans with PTSD are most likely to report being told of their diagnosis?

Veterans who do not know about their posttraumatic stress disorder (PTSD) diagnosis experience a fundamental barrier to accessing effective treatment. Little is known about the characteristics that influence veterans' PTSD diagnosis knowledge (i.e., report of being told they have a PTSD diagnosis by a healthcare provider). Veterans who met probable and provisional criteria for PTSD on the self-report PTSD checklist for DSM-5 were identified from the Comparative Health Assessment Interview Research Study (n = 2335). Weighted logistic regression was performed to identify demographic variables, clinical characteristics, and social determinants of health (e.g., economic instability, homelessness, healthcare coverage) associated with PTSD diagnosis knowledge among post-9/11 veterans. Approximately 62% of veterans with probable and provisional PTSD had PTSD diagnosis knowledge. Predictors with the strongest associations included another mental health diagnosis (OR = 6.10, CI95:4.58,8.12) and having Veterans Affairs (VA) healthcare coverage (OR = 2.63, CI95:1.97,3.51). Veterans with combat or sexual trauma were more likely to have PTSD diagnosis knowledge than those with different trauma types. Results suggest veterans with VA healthcare coverage and military-related trauma are more likely to be informed by a healthcare professional about a PTSD diagnosis. Further research is needed to improve PTSD diagnosis knowledge for those with non-military-related trauma and those without VA healthcare coverage.

Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration.

BACKGROUND: Transgender and gender diverse (TGD) veterans have a greater prevalence of suicide morbidity and mortality than cisgender veterans. Gender-affirming surgery (GAS) has been shown to improve mental health for TGD veterans. In 2021, the Veterans Health Administration (VHA) announced the initiation of a rulemaking process to cover GAS for TGD patients. OBJECTIVE: This study explores patients' and providers' perspectives about access to GAS and other gender-affirming medical interventions not offered in the VHA including barriers, facilitators, and clinical and policy recommendations. PARTICIPANTS: TGD patients (n = 30) and VHA providers (n = 22). APPROACH: Semi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data. KEY RESULTS: VHA policy exclusions were the most cited barrier to GAS. Additional barriers included finding information about GAS, traveling long distances to non-VHA surgeons, out-of-pocket expenses, post-surgery home care, and psychological challenges related to the procedure. Factors facilitating access included surgical care information from peers and VHA providers coordinating care with non-VHA GAS providers. Pre- and post-operative care through the VHA also facilitated receiving surgery; however, patients and providers indicated that knowledge of these services is not widespread. Respondents recommended disseminating information about GAS-related care and resources to patients and providers to help patients navigate care. Additional recommendations included expanding access to TGD mental health specialists and establishing referrals to non-VHA GAS providers through transgender care coordinators. Finally, transfeminine patients expressed the importance of facial GAS and hair removal. CONCLUSIONS: A policy change to include GAS in the VHA medical benefits package will allow the largest integrated healthcare system in the United States to provide evidence-based GAS services to TGD patients. For robust and consistent policy implementation, the VHA must better disseminate information about VHA-provided GAS-related care to TGD patients and providers while building capacity for GAS delivery.

Identifying suicide documentation in clinical notes through zero-shot learning.

Background and Aims: In deep learning, a major difficulty in identifying suicidality and its risk factors in clinical notes is the lack of training samples given the small number of true positive instances among the number of patients screened. This paper describes a novel methodology that identifies suicidality in clinical notes by addressing this data sparsity issue through zero-shot learning. Our general aim was to develop a tool that leveraged zero-shot learning to effectively identify suicidality documentation in all types of clinical notes. Methods: US Veterans Affairs clinical notes served as data. The training data set label was determined using diagnostic codes of suicide attempt and self-harm. We used a base string associated with the target label of suicidality to provide auxiliary information by narrowing the positive training cases to those containing the base string. We trained a deep neural network by mapping the training documents' contents to a semantic space. For comparison, we trained another deep neural network using the identical training data set labels, and bag-of-words features. Results: The zero-shot learning model outperformed the baseline model in terms of area under the curve, sensitivity, specificity, and positive predictive value at multiple probability thresholds. In applying a 0.90 probability threshold, the methodology identified notes documenting suicidality but not associated with a relevant ICD-10-CM code, with 94% accuracy. Conclusion: This method can effectively identify suicidality without manual annotation.

Factors associated with receipt of minimally adequate psychotherapy for PTSD at the Veterans Health Administration.

BACKGROUND: Despite Veterans Health Administration (VHA) efforts, many Veterans do not receive minimally adequate psychotherapy (MAP) for posttraumatic stress disorder (PTSD). It is important to understand factors associated with receipt of PTSD MAP (at least eight sessions) so that we may tailor efforts to increase treatment utilization for those who experience the greatest barriers to care. METHODS: Participants were 2008 post-9/11 Veterans who participated in a nationwide survey and had a PTSD diagnosis documented in the VHA electronic health record (EHR) before 2018. Participants self-reported sociodemographic information and trauma history. Service utilization data (e.g., PTSD MAP) were obtained from EHR. Logistic regression was used to model factors associated with PTSD MAP. RESULTS: Only 24% of Veterans (n = 479) received PTSD MAP. Veterans who reported that they were not employed and had reported history of military sexual trauma were more likely to have received PTSD MAP. CONCLUSIONS: Understanding and addressing barriers to PTSD care for Veterans who are employed could help improve PTSD treatment utilization for this group.

Association between Services to Address Adverse Social Determinants of Health and Suicide Mortality among Veterans with Indicators of Housing Instability, Unemployment, and Justice Involvement.

Suicide among Veterans continues to be a priority issue addressed by the U.S. Department of Veterans Affairs (VA). In addition to a variety of services specifically intended to prevent suicide, VA also offers a number of services to address Veterans' social determinants of health (SDH), several of which may be associated with elevated risk for suicide. For the present study, we assessed whether participation in services to address adverse SDH is associated with a reduction in risk of suicide mortality among Veterans using secondary data from VA datasets (1/1/2014-12/31/2019) for Veterans with an indicator of housing instability, unemployment, or justice involvement. Logistic regressions modeled suicide mortality; use of services to address SDH was the primary predictor. There was not a statistically significant association between services use and suicide mortality; significant correlates included race other than African American, low or no compensation related to disability incurred during military service, and suicidal ideation/attempt during observation period. Suicide is a complex outcome, difficult to predict, and likely the result of many factors; while there is not a consistent association between services use related to adverse SDH and suicide mortality, providers should intervene with Veterans who do not engage in SDH-focused services but have risk factors for suicide mortality.

Sex, gender diversity, and brain structure in children ages 9 to 11 years old.

There remains little consensus about the relationship between sex and brain structure, particularly in childhood. Moreover, few pediatric neuroimaging studies have analyzed both sex and gender as variables of interest - many of which included small sample sizes and relied on binary definitions of gender. The current study examined gender diversity with a continuous felt-gender score and categorized sex based on X and Y allele frequency in a large sample of children ages 9-11 years-old (N=7693). Then, a statistical model-building approach was employed to determine whether gender diversity and sex independently or jointly relate to brain morphology, including subcortical volume, cortical thickness, gyrification, and white matter microstructure. The model with sex, but not gender diversity, was the best-fitting model in 75% of gray matter regions and 79% of white matter regions examined. The addition of gender to the sex model explained significantly more variance than sex alone with regard to bilateral cerebellum volume, left precentral cortical thickness, as well as gyrification in the right superior frontal gyrus, right parahippocampal gyrus, and several regions in the left parietal lobe. For mean diffusivity in the left uncinate fasciculus, the model with sex, gender, and their interaction captured the most variance. Nonetheless, the magnitude of variance accounted for by sex was small in all cases and felt-gender score was not a significant predictor on its own for any white or gray matter regions examined. Overall, these findings demonstrate that at ages 9-11 years-old, sex accounts for a small proportion of variance in brain structure, while gender diversity is not directly associated with neurostructural diversity.