Transgender Health Dilemmas: An Intersectional Analysis of the Therapeutic Itineraries of Transgender Communities in the Philippines.

This study leverages an intersectional lens to characterize the therapeutic itineraries of local transgender (trans) communities vis-à-vis salient cisnormative and capitalist structures in Philippine society that produce trans health inequities. Interpretative phenomenological analysis of online interviews with thirteen (13) self-identified trans Filipinos reveals how the inaccessibility of trans-responsive care in the Philippines fosters trans health dilemmas, or the dilemmatic decision-making circumstances and processes that force trans Filipinos to choose between their trans-specific health needs and other needs. Such dilemmas valorize the deprioritization of trans health, disengagement with the health system, and the pursuit of alternative pathways to care oftentimes at the expense of their overall well-being. Addressing these dilemmas entails research, policy, and advocacy work that contend with the implicated structures of domination through systemic interventions initiated in partnership with local trans communities.

Effect of testosterone therapy on breast tissue composition and mammographic breast density in trans masculine individuals.

BACKGROUND: The effect of gender-affirming testosterone therapy (TT) on breast cancer risk is unclear. This study investigated the association between TT and breast tissue composition and breast tissue density in trans masculine individuals (TMIs). METHODS: Of the 444 TMIs who underwent chest-contouring surgeries between 2013 and 2019, breast tissue composition was assessed in 425 TMIs by the pathologists (categories of lobular atrophy and stromal composition) and using our automated deep-learning algorithm (% epithelium, % fibrous stroma, and % fat). Forty-two out of 444 TMIs had mammography prior to surgery and their breast tissue density was read by a radiologist. Mammography digital files, available for 25/42 TMIs, were analyzed using the LIBRA software to obtain percent density, absolute dense area, and absolute non-dense area. Linear regression was used to describe the associations between duration of TT use and breast tissue composition or breast tissue density measures, while adjusting for potential confounders. Analyses stratified by body mass index were also conducted. RESULTS: Longer duration of TT use was associated with increasing degrees of lobular atrophy (p < 0.001) but not fibrous content (p = 0.82). Every 6 months of TT was associated with decreasing amounts of epithelium (exp(ß) = 0.97, 95% CI 0.95,0.98, adj p = 0.005) and fibrous stroma (exp(ß) = 0.99, 95% CI 0.98,1.00, adj p = 0.05), but not fat (exp(ß) = 1.01, 95%CI 0.98,1.05, adj p = 0.39). The effect of TT on breast epithelium was attenuated in overweight/obese TMIs (exp(ß) = 0.98, 95% CI 0.95,1.01, adj p = 0.14). When comparing TT users versus non-users, TT users had 28% less epithelium (exp(ß) = 0.72, 95% CI 0.58,0.90, adj p = 0.003). There was no association between TT and radiologist's breast density assessment (p = 0.58) or LIBRA measurements (p > 0.05). CONCLUSIONS: TT decreases breast epithelium, but this effect is attenuated in overweight/obese TMIs. TT has the potential to affect the breast cancer risk of TMIs. Further studies are warranted to elucidate the effect of TT on breast density and breast cancer risk.

Gender-affirming surgeries for transgender and gender diverse individuals and associated health outcomes.

Gender-affirming care is treatment that recognizes and affirms the gender identity of transgender and gender-diverse (TGD) individuals. Though not all TGD people choose to surgically transition, gender-affirming surgeries (GAS) are an important part of many TGD people's transition. GAS can include a wide array of procedures aimed at aligning an individual's physical characteristics and gender identity. This review describes the most common procedures considered to be GAS, detailing important relevant considerations for each procedure. These include transfeminine procedures (i.e., breast augmentation, penile inversion vaginoplasty, orchiectomy, tracheal shave, and facial feminization); transmasculine procedures (i.e., chest masculinization, hysterectomy, phalloplasty, and metoidioplasty); and other procedures (i.e., fertility preservation and hair removal). Patient outcomes and the legal landscape for GAS are also discussed to contextualize these procedures within largest discourses surrounding gender-affirming care.

Gender in Health: Addressing Transgender-Related Stigma and Health Disparities in Southeast Asia.

This paper advocates for robust regional research to gain a comprehensive understanding of the specific healthcare requirements of transgender populations, particularly in Association of Southeast Asian Nations (ASEAN), where empirical data is limited. It underscores the importance of acknowledging and mitigating gender minority stress, addressing the pervasive stigma surrounding transgender individuals, ensuring equal access to healthcare, reforming policies to protect the rights of transgender individuals, and promoting supportive community organizations. Through the adoption of these measures, ASEAN can move toward improving the pressing issue of transgender health disparities, thereby safeguarding the well-being of transgender individuals within their region.

Gut-Directed Hypnotherapy May Pose Specific Challenges in Gender-Diverse Patients: A Review of 3 Patients.

Disorders of gut-brain interaction are common and often characterized by chronic symptom courses. While gut-directed hypnotherapy is effective for refractory disorders of gut-brain interaction, the required internal awareness and vulnerability may be challenging. Driven by our own clinical experiences, we conducted qualitative interviews with patients who identified as transgender or gender diverse and who had discontinued gut-directed hypnotherapy. Four main themes were generated from these interviews related to distress resulting from body awareness, difficulty with vulnerability, the importance of gender-affirming supports, and external barriers. Providers are encouraged to consider gender diversity, and more broadly body image, in discussion of hypnosis treatment.

Gender-affirming hormone therapy and cardiovascular health in transgender adults.

A growing number of people identify as transgender and gender non-binary in the USA and worldwide. Concomitantly, an increasing number of patients are receiving gender-affirming hormone therapy (GAHT) to achieve gender congruence. GAHT has far-ranging effects on clinical and subclinical markers of cardiovascular risk. Transgender patients also appear to be at higher risk for cardiovascular diseases compared to their cisgender peers and the impact of gender-affirming therapy on cardiovascular health is unclear. Studies on the effect of GAHT on cardiovascular outcomes are confounded by differences in GAHT regimens and methodological challenges in a diverse and historically hard-to-reach population. Current cardiovascular guidelines do not incorporate gender identity and hormone status into risk stratification and clinical decision-making. In this review, we provide an overview on the cardiometabolic impact and clinical considerations of GAHT for cardiovascular risk in transgender patients.

Sameness across Difference: A Postcolonial Feminist Analysis of Gender-Affirming Health Care in Thailand and the United States.

Joining a growing body of research calling for the integration of social analysis and postcolonial theory, recent work in medical sociology has analyzed health, illness, and medicine from a postcolonial lens. In this article, I argue for a postcolonial feminist approach to medical sociology that builds on this extant work while challenging methodological nationalism and cultural essentialism. Based on an analysis of gender-affirming health care for transgender and gender diverse (TGD) people in Thailand and the United States, I propose "sameness across difference" as a framework to analyze commonalities in the health care experiences of marginalized populations across nations as the products of imperial legacies. Drawing on 83 interviews with health care providers, TGD patients, and TGD activists, I demonstrate the role of imperialism in sustaining barriers to gender-affirming health care through the uneven geographic distribution of care across rural and urban areas and the reinforcement of racial and class hierarchies within cities.

Gender diversity among adolescents with obesity in a weight management programme.

Gender dysphoria (GD) and obesity share commonalities, including associations with mental health comorbidities, disordered eating, body dissatisfaction and may intensify with physical and developmental changes during adolescence. While associations of obesity and gender diversity have been identified, rates of gender diversity among adolescents with obesity remain unclear. The aim was to examine gender diversity among adolescents with obesity in a weight management programme. A single-centre cross-sectional questionnaire study was conducted. Eligible adolescents received the Gender Identity/GD Questionnaire for Adolescents and Adults (GIDYQ-AA), a validated instrument measuring gender diversity and GD. Gender identities, sexual orientations, questionnaire scores, and frequency of GD (GIDYQ-AA score <3) were determined. The relationship of GIDYQ-AA scores and BMI Z-score (BMIz) was assessed. Of 72 consenting youth, 29 assigned females (AF) and 17 assigned males (AM) completed GIDYQ-AA and demographic questions. Seventeen (59%) AF reported non-heterosexual orientations, and 6 (21%) reported non-cisgender identities. One (6%) AM reported non-cisgender identity. Two (4%) AF individuals had GD based on GIDYQ-AA scores. GIDYQ-AA scores did not correlate with BMIz. In conclusion, adolescents with obesity, particularly AF with non-heterosexual orientation, reported high rates of non-cisgender identity and GD. Routine screening for gender-related concerns in weight management settings may be warranted.

Toward a Better Understanding of Cardiovascular Risk in the Transgender and Gender-Diverse Community: A Global Call to Action.

On World Heart Day 2022, the Mexican Society of Cardiology, the Inter-American Society of Cardiology, and the World Heart Federation collaborated on a public call to action regarding the increased risk of adverse cardiovascular health outcomes in transgender and gender diverse (TGD) individuals. The aim of this article is to unpack the numerous factors that contribute to this, such as the social stigma faced by members of the TGD community, their reduced access to clinical care, and the scarcity of research regarding the unique needs of their community, which makes it difficult for clinicians to provide individualized medical care. Decreasing the incidence of adverse cardiovascular events among TGD individuals requires interventions such as educational reform in the medical community, an increase in inclusive research studies, and broader social initiatives intended to reduce the stigma faced by TGD individuals.

Exploring Safety in Gender-Affirming Hormonal Treatments: An Observational Study on Adverse Drug Events Using the Food and Drug Administration Adverse Event Reporting System Database.

BACKGROUND: People with gender dysphoria are treated with hormone therapy for gender reassignment. The indication of this therapy was initially for the opposite sex, and information on potential adverse drug reaction (ADR) is lacking. OBJECTIVE: To describe ADR associated with gender transition medication in transgender individuals reported to the US Food and Drug Administration Adverse Event Reporting System (FAERS) database. METHODS: Data from the FAERS database up to June 2023 were examined, focusing on reports of gender transition medication use in the context of gender dysphoria. The ADRs were categorized using the Medical Dictionary for Regulatory Activities at both Preferred Term and System Organ Class (SOC) levels. Descriptive statistics summarized report counts, medication types, indications, and ADR severity. RESULTS: For individuals assigned female at birth undergoing gender transition to male (transgender men), 82 reports (230 ADRs) were analyzed, with an average age of 29.5 years. Transgender hormonal therapy was cited in 72% of reports, predominantly from the United States (67.1%). A striking 88% were categorized as serious ADRs, primarily SOC injury, poisoning, and procedural complications (26.5%), followed by psychiatric disorders (14.8%) and nervous system disorders (12.2%). Among those assigned sex male at birth transitioning to female (transgender women) (81 reports, 237 ADRs), mean age was 33.3 years, with 58% indicating use for gender dysphoria. A significant proportion (53.6%) were serious ADRs, primarily SOC: injury, poisoning, and procedural complications (26.6%). CONCLUSIONS AND RELEVANCE: The FAERS data reveal significant ADRs in transgender individuals using hormone therapy, sometimes unintended for their recipient gender. Population-level studies are crucial to enhance transgender health care. Spontaneous surveillance databases like FAERS illuminate off-label ADRs, urging health care providers to approach hormone therapies with informed caution.

Two Gender Medicine: Provider-Side Barriers to Caring for Transgender and Gender Diverse Patients.

Experienced and anticipated discrimination during health care visits result in lower health care utilization rates, which contribute to persistent health disparities between transgender and gender diverse (TGD) individuals and the general population. Most strategies for improving health care delivery to TGD patients place the responsibility on providers, overlooking the role of medical systems and institutions in creating the environments where negative health care experiences occur. Relying on the inhabited institutionalism framework, this study explores system- and institutional-level barriers to the provision of quality care to TGD patients identified by health care providers and administrators, including relevant contextual details of, and interactions between, these barriers. Based on interview data from health care providers and administrators from a variety of practices across Texas, we identified two overarching themes and six subthemes. We demonstrate how our interviewees' responses reveal an institutional logic of "two-gender medicine," which creates barriers to health care provision in both formal medical education and training and throughout the managed care model of practice. We also illustrate how health care workers find ways to resist this logic in the course of their practice. Addressing these barriers to delivering competent and compassionate care to TGD patients that providers encounter could make long overdue strides toward addressing health disparities.

Compelling care: A grounded theory of transmasculine self-defense and collective protection at the clinic.

Despite formidable inequities in health care systems, transgender people are accessing clinical services in record numbers and gaining recognition as a patient population. This article examines how transgender people are negotiating their care and, in so doing, challenging patterns of marginalization and exclusion. Interviews with twenty-six transmasculine adults were collected and analyzed in the context of a community-led initiative foregrounding low-income people and people of color in Los Angeles County using a constructivist grounded theory approach. Participants gained agency in clinical settings by compelling care, a grounded theory that explains how patients contest medical authority and shift power through everyday acts to defend themselves and future patients. Histories of mistreatment and unequal social power drive patients to engage with health care providers judiciously and with a sense of social responsibility. In tracing seemingly decentralized acts of self-defense (e.g., vetting providers, disrupting gender norms, directing treatment), the study shows how patients rely on community resources and marshal collective protection. The theory recasts patients as constitutive actors in a changing landscape of care and as integral to, and one of many fronts of, collective struggle. In turn, the study lends theoretical insights to anti-racist understandings of medical mistrust andoffers a depathologized framework toward the development of community-building health equity interventions.

Ethical considerations for the nursing care of Transgender patients in the Intensive Care Unit.

There is more discussion than ever surrounding the health and care needs of Transgender communities. However, there is limited research on the care of Transgender patients in the Intensive Care Unit which can contribute to knowledge gaps, inconsistencies and uncertainties surrounding health care practices. This article is not intended to address all of the specific needs of Transgender patients in ICU, but to explore the ethical considerations for caring for a Transgender woman in the ICU. In doing so, this article will explore some specific considerations around gender affirming care, challenging discrimination, physiological changes, and systems change to enhance care.

Mediational pathways exploring the link between adverse childhood experiences and physical health in a transgender population.

BACKGROUND: Adverse childhood experiences (ACEs) consist of instances of abuse, neglect, or household dysfunction occurring before adulthood. Prevalence rates of ACEs are higher among specific populations, including gender minorities. In addition to ACEs, transgender individuals (TG) face many personal, social, and structural factors that have the potential to negatively impact their physical health. OBJECTIVE: This study examines exploratory mediational pathways between ACEs and two health outcomes (i.e., general health and days physically ill) in TG. Mediators include everyday discrimination, social support, gender non-affirmation, and mental distress. METHODS: Cross-sectional data from the U.S. Transgender Population Health Survey (TransPop) was used to conduct a serial/parallel mediation analysis. The TransPop survey included a total of 274 TG. RESULTS: For both outcome variables, the same three indirect pathways were significant. First, ACEs were associated with increased mental distress, which was associated with a decrease in general health and an increase in days physically ill. Second, ACEs were associated with increased discrimination, which was associated with increased mental distress, and this was associated with a decrease in general health and an increase in days physically ill. Finally, ACEs were associated with discrimination, which was associated with increased gender non-affirmation which was associated with increased mental distress, and this was associated with a decrease in general health and an increase in days physically ill. CONCLUSION: Interventions focused on reducing discrimination, gender non-affirmation, and poor mental health may be vital to improving the health of TG and to mitigating the indirect role of ACEs on TG health.

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.

Attitudes of Spanish mental health professionals towards trans people: A cross-sectional study.

WHAT IS KNOWN ABOUT THE SUBJECT?: The trans community perceives barriers to the mental health services in the form of professionals' transphobia, lack of knowledge, and cultural sensitivity in healthcare. The attitudes of health professionals are mediated by their social context, which can determine their behaviour or attitude towards users. WHAT DOES THE ARTICLE ADD TO EXISTING KNOWLEDGE?: The attitudes of mental health professionals towards trans people are related to variables such as the professional's age, gender, political ideology and religious beliefs. Mental health nursing, psychology and social work are the professions that present more favourable attitudes towards trans people. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The inclusion of a professional perspective that understands sexual and gender diversity among mental health professionals is required. It is necessary to train professionals to promote socio-healthcare based on respect and free from prejudice, discrimination and stigma. ABSTRACT: Introduction The trans community perceives barriers to the mental health services in the form of professionals' transphobia, lack of knowledge and cultural sensitivity in healthcare. Aim Evaluation of the attitudes towards trans people of the professionals who work in the different Spanish mental health services. Method A cross-sectional design was used with a sample of professionals from different professional groups working in mental health units, hospitals and outpatient settings throughout Spain. Results Gender differences were found, with higher values in genderism and sexism among males. Negative attitudes and sexism have also been associated with age and religious beliefs. Mental health nursing, psychology and social work presented more favourable attitudes towards trans people than other mental health professionals. Discussion/Implications for Practice The inclusion of a professional perspective that understands sexual and gender diversity and the acquisition of professional attitudes based on evidence and patient-centred model are basic aspects to promote socio-healthcare based on respect and free from prejudices, discrimination and stigma.

Primary care in Northern Ontario for transgender people in the context of the COVID-19 pandemic: A qualitative secondary analysis.

PURPOSE: To examine changes to primary care practice for transgender clients resulting from government mandated public health measures in response to COVID-19 in Northern Ontario. DESIGN: Secondary analysis of qualitative data using interview transcripts from a dataset that included 15 interviews conducted between October 2020 and April 2021. METHODS: The dataset came from a convergent mixed method study exploring the delivery of primary care services to transgender individuals in Northern Ontario. Qualitative interviews with primary care practitioners including nurse practitioners, nurses, physicians, social workers, psychotherapists, and pharmacists providing care for transgender people in Northern Ontario were included in the secondary analysis. RESULTS: Fifteen primary care practitioner providing care to transgender individuals in Northern Ontario participated in the parent study. Practitioners described their understanding of the effect of the early stages of the COVID-19 pandemic changes on their practice and the care experience for their transgender patients. Two themes were identified and described by participants: (1) a change in the delivery of care; and (2) barriers and facilitators to care. CONCLUSIONS: Practitioners' primary care experiences in the early waves of COVID suggest the integral use of telehealth in Northern Ontario transgender care. Nurses working in advance practice and nurse practitioners are essential in providing continuity of care for their transgender clients. CLINICAL RELEVANCE/SIGNIFICANCE: Identification of initial practice changes for the primary care of trans people will illuminate avenues for further research. The urban, rural, and remote practice settings in Northern Ontario provide an opportunity for increasing access for gender diverse people in these areas and for developing increased understanding of uptake of telemedicine practice. Nurses are integral to primary care for transgender patients in Northern Ontario.

Quantitative approaches to measuring structural cisgenderism.

There is rapidly growing interest in understanding the impacts of structural cisgenderism on health and health inequities for transgender and nonbinary populations. This growing interest has led to an influx of novel measures of structural cisgenderism. In this commentary, we discuss and identify gaps in existing measures and offer considerations for the development of future measures. Developing and utilizing valid measures of structural cisgenderism is crucial to quantify its impacts on health and health inequities, and to inform public health interventions, laws, and policies to eliminate gender identity and modality-based health inequities.

Erythrocytosis Is Rare With Exogenous Testosterone in Gender-Affirming Hormone Therapy.

CONTEXT: Studies have found a variable incidence of erythrocytosis among people using testosterone as part of gender-affirming hormone therapy (GAHT). OBJECTIVE: To examine the effect of using exogenous testosterone as GAHT on hematocrit in a large North American cohort. METHODS: We conducted a cross-sectional analysis of testosterone and hematocrit laboratory values in 6670 patients who were prescribed testosterone through Plume, a national provider of GAHT. The prevalence of erythrocytosis, the mean hematocrit at predetermined testosterone thresholds and with varying routes of testosterone administration were assessed. RESULTS: Among 6670 individuals, 560 (8.4%) had a hematocrit ≥50%, 182 ≥ 52% (2.7%), and 60 ≥ 54% (0.9%). There was significant variation (P < .001) in hematocrit between different clinically relevant testosterone thresholds (T < 50 vs T 50-299 vs T 300-999 vs T ≥ 1000 ng/dL) and when comparing serum testosterone in increments of 50 ng/dL within the target range for males (300-1000 ng/dL) (P < .001). Mean hematocrit ranged from 41.84% (T < 50 ng/dL) to 45.68% (T 900-949 ng/dL). Patients on intramuscular testosterone had a higher mean hematocrit than those on transdermal testosterone (44.96% vs 43.41%, P < .001). Both route of administration (P < .001) and testosterone level (P < .001) had statistically significant associations with hematocrit when controlling for each other. CONCLUSION: While the magnitude of change in hematocrit with serum level and route of administration of testosterone was statistically significant, the absolute levels were within the normal range, unlikely to be clinically meaningful. These findings, along with the low prevalence of erythrocytosis, should help allay concerns about the use of testosterone as GAHT.