Corrigendum to "Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals" [J. JCTE 2 (2015) 55-60].

[This corrects the article DOI: 10.1016/j.jcte.2015.02.003.].

Experiences of transgender and nonbinary physicians during residency training.

Background: Little is known about the experiences of transgender and gender non-binary (TNB) physicians in medical residency training programs. Aim: To identify the self-reported experiences and needs of TNB individuals during medical residency in United States training programs. Methods: An online, anonymous survey of TNB current residents and recent graduates was designed. Results: A total of 26 respondents completed the survey. The most common reported gender identity was non-binary or gender queer (n = 11, 42.3%) and male or transgender man (n = 7, 26.9%). About half of participants (n = 14, 53.8%) had undergone gender affirming interventions prior to residency. Most participants (n = 19, 73.1%) did not know all the gender affirming healthcare benefits offered by their program. The majority (n = 21, 80.8%) also reported 2 hours or less of transgender-related didactics in residency. Respondents were most likely to disclose their gender identity to other residents (n = 19, 73.1%) and faculty (n = 19, 73.1%) and were least likely to disclose their identity to patients (n = 6, 23.1%). Most respondents (n = 15, 57.7%) stated that program faculty and staff communicated support for their gender identity. Most participants (n = 16, 61.5%) reported that they perceived transgender residents to be treated similarly to their non-transgender peers in their training program, while the remainder (n = 7, 26.9%) disagreed or strongly disagreed. Nevertheless, approximately three-quarters of trainees (n = 22, 84.6%) self-reported microaggressions during their training program and non-binary and transfeminine trainees were more likely to report these experiences than transmasculine people. Nearly a quarter of transfeminine and non-binary participants reported macroaggressions, with none of the transmasculine respondents reporting these negative experiences. Most macroaggressions were from program faculty. Discussion: This study highlights that while most physicians in residency report support from their program for their TNB identity, TNB physicians still experience significant barriers and prejudices throughout training and more action is needed among program faculty for support of TNB trainees.

Chest binding in context: stigma, fear, and lack of information drive negative outcomes.

Chest binding or 'binding' is a practice used by many trans and nonbinary people assigned a female sex at birth to achieve a flatter chest contour and affirm their gender. Binding allows individuals to affirm their gender in a temporary, reversible way. While many individuals who bind report negative physical symptoms, binding also often carries significant benefits for mental health and safety. In this commentary, we explain what the data do and do not say about the physical risks of binding and describe how decreasing stigma around binding will substantially reduce physical risks associated with binding and increase the benefits of the practice. As with any intervention, individuals should make an informed decision about the risks and benefits of binding. If negative physical symptoms arise, individuals can consider adjusting their binding practice or working with a healthcare provider to address these concerns.

Experiences of Transgender and Nonbinary Physicians During Medical Residency Program Application.

BACKGROUND: Increasing numbers of transgender and nonbinary (TNB) people seek careers in medicine, but little is known about their experiences and the effect of their gender identity during residency application. OBJECTIVE: This project sought to evaluate the experiences and needs of TNB individuals during the residency application and Match process in order to inform the practice of residency programs. METHODS: An online survey was distributed in 2019 via social media, professional groups, and snowball sampling to TNB persons, who were current residents or recent graduates (within the past 3 years) of a US residency program. RESULTS: Twenty-six eligible respondents from 10 medical specialties completed the survey. Eighteen (69.2%) respondents felt unsafe disclosing their gender identity or discussing it during interviews some or all of the time due to fear of discrimination and how it might affect their match; 26.9% (7 of 26) felt they were ranked lower than their qualifications due to their gender identity. Eleven (42.3%) were misnamed or misgendered some or all of the time during interviews through use of incorrect name and pronouns. Respondents' recommendations for programs included: (1) adopt gender-affirming practices; (2) offer gender-affirming health benefits; (3) advertise nondiscrimination policies; (4) understand experiences of discrimination during medical training; and (5) value resident gender diversity. CONCLUSIONS: TNB residents and recent graduates perceived gender identity discrimination during residency application, including feeling unsafe to disclose their gender identity and being misnamed or misgendered. Suggestions for programs to improve the experience of TNB applicants are included.

Time to First Onset of Chest Binding-Related Symptoms in Transgender Youth.

BACKGROUND AND OBJECTIVES: Most transgender individuals assigned female at birth use chest binding (ie, wearing a tight garment to flatten chest tissue for the purpose of gender expression), often beginning in adolescence, to explore their gender identity. Although binding is often critical for mental health, negative physical side effects, ranging from chronic pain to rib fractures, are common. Time to first onset of symptoms is unknown. METHODS: A community-engaged, online, cross-sectional survey ("The Binding Health Project") enrolled 1800 assigned female at birth or intersex individuals who had ever used chest binding. Lifetime prevalence of 27 pain, musculoskeletal, neurologic, gastrointestinal, generalized, respiratory, and skin or soft tissue symptoms related to binding was assessed. Nonparametric likelihood estimation methods were used to estimate survival curves. RESULTS: More than one-half (56%) of participants had begun binding by age 21, and 30% had begun by age 18. In 18 of 27 symptoms, the majority of people who go on to experience the event will do so within the first binding-year, but several skin-related and rare but serious outcomes (eg, rib fracture) took longer to occur. Pain presents rapidly but continues to rise in intensity over time, peaking at >5 years of binding. CONCLUSIONS: Although many symptoms emerge quickly, others can take years to develop. Individuals and their clinicians can use this information to make informed decisions on how to structure binding practices and top surgery timing while meeting goals related to gender expression and mental health. Access to puberty blockers may delay initiation of binding, preventing binding-related symptoms in youth.

Supporting Transgender and Nonbinary Residents.

Transgender and gender nonbinary (TGNB) individuals experience challenges while applying for and completing residency, although limited research exists. An academic panel reviewed best practices for residency programs who interview and match TGNB residents. Program leadership should identify and utilize the affirming name and pronouns for all applicants, not ask gender identity during an interview unless self-disclosed, and ensure that health insurance covers transition care. Programs should proactively educate all residents, faculty, and staff on knowledge gaps regarding transgender health regardless of the presence of TGNB residents. Future studies are necessary regarding experiences of TGNB residents to investigate their specific needs.

Addressing the Opioid Crisis: Community Partnerships in Primary Care.

INTRODUCTION: New Mexico is currently ranked 17th in the United States for drug overdose death rates. Our project seeks to decrease opioid overdose deaths in a community by increasing the number of patients with naloxone in a local family medicine residency clinic. METHODS: We developed a protocol wherein providers asked patients at risk of opioid overdose about naloxone access. Free naloxone was distributed in partner with the county health department, accompanied by teaching of use. We reviewed patient encounters during a 45-day control and study period to measure naloxone possession among patients at risk. RESULTS: Nearly two-thirds of patients at risk of opioid overdose had no naloxone. A standardized protocol implemented to distribute an opioid reversal agent doubled naloxone prescribed by providers at visits (10.3%) compared to a control period (4.3%), but lacked statistical significance. CONCLUSION: Patients in a family medicine residency clinic who were at risk of opioid overdose overwhelmingly did not have naloxone, and a standardized protocol with a community-based partnership increased access to naloxone. Further project data will have implications for ongoing naloxone distribution programs in primary care.

Chest Binding and Care Seeking Among Transmasculine Adults: A Cross-Sectional Study.

Purpose: Chest binding, or compressing the chest tissue, is a common practice among transmasculine individuals that can promote mental health, but frequently results in negative physical health symptoms. The purpose of this study was to assess the prevalence and correlates of care seeking for binding-related health concerns among transmasculine adults. Methods: Descriptive statistics were calculated and logistic regression models were run using data from the Binding Health Project, a cross-sectional online survey among transgender adults who had practiced chest binding (n=1800). The analysis was restricted to transmasculine individuals who had consistent access to health care and were female assigned at birth or intersex (n=1273). Results: Of 1273 participants, 88.9% had experienced at least one binding-related symptom and 82.3% believed that it was important to discuss chest binding with their health care provider, while 14.8% had sought care related to binding. Participants reporting pain, musculoskeletal, or neurological symptoms had 3.19, 1.85, and 1.72 times the adjusted odds, respectively, of seeking care compared to those who did not report those symptoms (95% confidence intervals [CIs]: 1.38-7.37; 1.12-3.06; 1.10-2.68). Care seeking was associated with feeling safe and comfortable initiating a conversation about binding with one's provider (adjusted odds ratio [AOR]=2.07, 95% CI 1.32-3.24). Care seeking was not significantly associated with feeling comfortable receiving a chest examination (AOR=1.07, 95% CI 0.71-1.62). Conclusion: Low rates of care seeking for binding-related symptoms may be driven by lack of access to a provider with whom patients feel safe and comfortable, rather than by general discomfort with chest examinations. While transmasculine patients may be most likely to present with musculoskeletal, neurological, or pain-related concerns, providers should also assess for other symptoms. Providers should be familiar with the benefits and potential complications of binding and initiate non-stigmatizing positive discussions about binding with their transmasculine patients.

EXOGENOUS TESTOSTERONE DOES NOT INDUCE OR EXACERBATE THE METABOLIC FEATURES ASSOCIATED WITH PCOS AMONG TRANSGENDER MEN.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is a complex condition which can include menstrual irregularity, metabolic derangement, and increased androgen levels. The mechanism of PCOS is unknown. Some suggest that excess production of androgens by the ovaries may cause or exacerbate the metabolic findings. The purpose of this study was to assess the role of increased testosterone on metabolic parameters for individuals presumed to be chromosomally female by examination of these parameters in hormone-treated transgender men. METHODS: In 2015 and 2016, we asked all transgender men who visited the Endocrinology Clinic at Boston Medical Center treated with testosterone for consent for a retrospective anonymous chart review. Of the 36 men, 34 agreed (94%). Serum metabolic factors and body mass index (BMI) levels for each patient were graphed over time, from initiation of therapy through 6 years of treatment. Bivariate analyses were conducted to analyze the impact of added testosterone. RESULTS: Regressions measuring the impact of testosterone demonstrated no significant changes in levels of glycated hemoglobin (HbA1c), triglycerides, or low-density-lipoprotein cholesterol. There was a statistically significant decrease in BMI with increasing testosterone. There was also a statistically significant decrease in high-density lipoprotein levels upon initiation of testosterone therapy. CONCLUSION: Testosterone therapy in transgender men across a wide range of doses and over many years did not result in the dyslipidemia or abnormalities in HbA1c seen with PCOS. Instead, treatment of transgender men with testosterone resulted only in a shift of metabolic biomarkers toward the average physiologic male body. ABBREVIATIONS: BMI = body mass index; HbA1c = glycated hemoglobin; HDL = high-density lipoprotein; LDL = low-density lipoprotein; PCOS = polycystic ovary syndrome.

ESTROGEN LEVELS DO NOT RISE WITH TESTOSTERONE TREATMENT FOR TRANSGENDER MEN.

OBJECTIVE: Existing transgender treatment guidelines suggest that for transmasculine treatment, there is a possible need for estrogen-lowering strategies adjunct to testosterone therapy. Further, guidelines advocate consideration of prophylactic female reproductive tissue surgeries for transgender men to avoid the possibility of estrogen-related health risks. Despite the paucity of objective data, some transgender men seek conversion inhibitors. We sought to determine estradiol levels in transgender men treated with testosterone therapy and the change in those levels with treatment, if any. METHODS: Estradiol levels were extracted from the electronic medical records of 34 anonymized transgender men treated with testosterone therapy at the Endocrinology Clinic at Boston Medical Center. Data were sufficient to observe 6 years of follow-up. RESULTS: With increased testosterone levels in trans-gender men, a significant decrease in estradiol levels was noted. There was a significant negative correlation between testosterone levels and body mass index, which may serve to explain part of the mechanism for the fall in estradiol levels. Even though the fall in estradiol levels was significant statistically, the actual levels remained within the normal male range, even with 6 years of follow-up. CONCLUSION: These data suggest that when exogenous testosterone is used to achieve normal serum male testosterone levels for transgender men, it is converted to normal male levels of estradiol, with some decline in those estradiol levels that might be attributable to a fall in fat mass. There appears to be no role for aromatase conversion inhibitors or other estrogen-reducing strategies in trans-gender men. Abbreviation: BMI = body mass index.

Health impact of chest binding among transgender adults: a community-engaged, cross-sectional study.

Chest binding involves the compression of chest tissue for masculine gender expression among people assigned a female sex at birth, particularly transgender and gender non-conforming individuals. There are no peer-reviewed studies that directly assess the health impacts of chest binding, yet transgender community resources commonly discuss symptoms such as pain and scarring. A cross-sectional 32-item survey was administered online to an anonymous, non-random sample of adults who were assigned a female sex at birth and had had experience of binding (n = 1800). Multivariate regression models were used to identify practices associated with self-reported health outcomes. Of participants, 51.5% reported daily binding. Over 97% reported at least one of 28 negative outcomes attributed to binding. Frequency (days/week) was consistently associated with negative outcomes (22/28 outcomes). Compression methods associated with symptoms were commercial binders (20/28), elastic bandages (14/28) and duct tape or plastic wrap (13/28). Larger chest size was primarily associated with dermatological problems. Binding is a frequent activity for many transmasculine individuals, despite associated symptoms. Study findings offer evidence of how binding practices may enhance or reduce risk. Clinicians caring for transmasculine patients should assess binding practices and help patients manage risk.

Evidence supporting the biologic nature of gender identity.

OBJECTIVE: To review current literature that supports a biologic basis of gender identity. METHODS: A traditional literature review. RESULTS: Evidence that there is a biologic basis for gender identity primarily involves (1) data on gender identity in patients with disorders of sex development (DSDs, also known as differences of sex development) along with (2) neuroanatomical differences associated with gender identity. CONCLUSIONS: Although the mechanisms remain to be determined, there is strong support in the literature for a biologic basis of gender identity.

Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals.

INTRODUCTION: Some providers report concern for the safety of transgender hormone therapy (HT). METHODS: This is a systematic literature review of HT safety for transgender adults. RESULTS: Current literature suggests HT is safe when followed carefully for certain risks. The greatest health concern for HT in transgender women is venous thromboembolism. HT among transgender men appears to cause polycythemia. Both groups experienced elevated fasting glucose. There is no increase in cancer prevalence or mortality due to transgender HT. CONCLUSION: Although current data support the safety of transgender HT with physician supervision, larger, long-term studies are needed in transgender medicine.