Intolerable Fairness: Biotropes and Regime(s) of the Binary in Women’s Sports

An Examination of the Sex-Specific Nature of Nutrition Assessment within the Nutrition Care Process: Considerations for Nutrition and Dietetics Practitioners Working with Transgender and Gender Diverse Clients

To the Editors: The past decade has seen progress toward getting to zero HIV infections in San Francisco overall. New HIV diagnoses dropped from 521 in 2008 to 197 in 2018, a 62% decrease.1 HIV incidence estimated by a CD4 model2 corroborates a parallel, commensurate drop in incident infections, from a projected 330 in 2013 to 190 in 2017.1 Unfortunately, there is insufficient sample size to estimate HIV incidence separately for smaller populations who may have elevated risk. Directly measured rates of HIV seroconversion observed in longitudinal studies are logistically difficult and costly and therefore rare.3 Limitations of sample size and resources are substantial for estimating or measuring HIV incidence among transgender women (hereafter "trans women"), the population with the highest burden of HIV in San Francisco1,4 and in many parts of the world.5 We report results from the TransNational Study in San Francisco, the primary aims of which are to measure the rate of HIV seroconversion and identify predictors of HIV acquisition among trans women. The present analysis focuses on identifying demographic disparities in HIV risk, particularly testing hypotheses on whether HIV incidence is higher among trans women who are young, members of racial/ethnic minority groups, living in poverty, and homeless based on differences in HIV prevalence and recent trends in new diagnoses in San Francisco.1 Trans women were defined by being assigned male sex at birth and currently identify as other than male gender. Trans women were enrolled into the cohort using a long-chain peer-referral method previously used to accrue a cohort of young trans women in San Francisco6 and men who have sex with men (MSM) in Nanjing, China.7 In brief, initial seeds were identified from diverse social networks and instructed to refer other eligible trans women to the study. Participants were interviewed face-to-face on demographics and risk behaviors and tested for HIV. Trans women who tested negative for HIV and were 18 years or older were eligible. Participants were retested and interviewed at 6, 12, and 18 months. Participants who seroconverted were linked to HIV care. We used an incidence density approach (ie, the number of events divided by the person-time of follow-up) to calculate rates of HIV seroconversion. Incidence rate ratios were used to compare differences in rates among subgroups of trans women assuming a Poisson distribution. When a subgroup had zero seroconversions, we calculated 97.5% one-sided confidence intervals (CI) and compared groups using the Z-test. Referrals to HIV prevention programs, including pre-exposure prophylaxis (PrEP), were offered at each visit. Participants were given $55 for completion of the survey and HIV testing at their initial visit, increasing to $70 for the 18-month visit. Participants were given $20 for each eligible referral to the study. The protocol was approved by the Human Research Protection Program of the University of California San Francisco. Participants provided written informed consent. Of 415 who were HIV negative at enrollment and agreed to follow-up, 377 were seen at their 18-month visit and 8 seroconverted by the time of their 18-month visit (92.6% retention). The 8 seroconversions occurred over 604 person-years (py) of follow-up for an incidence rate of 1.3 per 100 py (95% CI: 0.7 to 2.7) (Table 1).TABLE 1.: HIV Incidence Among Trans Women in a Longitudinal Cohort, San Francisco, 2017–2019Several disparities in HIV incidence rates were noted. Trans women aged 18–24 years had a significantly higher HIV incidence (3.7 per 100 py; 95% CI: 1.2 to 11.6) compared with those aged 25 years and older (1.0 per 100 py; 95% CI: 0.4 to 2.3, P = 0.04). Age categories above 25 years were collapsed because they were similar in magnitude. HIV incidence was significantly higher among Latina/x trans women (2.6 per 100 py; 95% CI: 1.1 to 6.1, P = 0.03) and trans women of color (2.2 per 100 py; 95% CI: 1.1 to 4.3, P = 0.01) compared with white trans women. Trans women who had been incarcerated (2.3 per 100 py; 95% CI: 1.1 to 4.8, P = 0.04) and those without health insurance (5.8 per 100 py; 95% CI: 1.5 to 23.2, P = 0.02) also had significantly elevated HIV incidence. Incidence estimates among trans women for comparison are rare. Twenty years ago, HIV incidence was calculated among trans women in San Francisco in a retrospective cohort, arriving at a rate of 7.8 per 100 py (95% CI: 4.6 to 12.3).8 The estimate suggests a substantial decline to the current level. Serial cross-sectional surveys of trans women in San Francisco show HIV infection sustained at high levels over the past several years.4 We recognize the risk in overinterpreting data based on 8 seroconversions. Small numbers may miss true associations in the population. We also acknowledge potential Hawthorne effects. Multiple risk assessments, HIV testing, and referral to prevention programs, such as PrEP, are likely to dampen HIV incidence, underestimating true rates in the population. Other studies note challenges in measuring HIV incidence among trans women. The iPrEx trial of PrEP efficacy was able to enroll 339 trans women among 2499 total participants across 11 sites.9 The researchers cite difficulties in identifying trans women and determining the preventive effects of PrEP specifically for them. Other studies combine MSM with trans women without being able to separate them for analysis.5 For example, a recent analysis of HIV incidence among key populations in Bangkok across 10 years was unable to distinguish between MSM and trans women.10 We concur with these researchers in the strong need for trans-specific longitudinal studies, including benchmark measures of HIV incidence and randomized controlled trials with incident endpoints. On the other hand, the fact that we were able to find significantly elevated HIV incidence for some groups speaks to the potential magnitude of these effects. Significant correlates of HIV incidence found in our cohort echo concerns emerging from citywide surveillance data.1 Despite decreases overall, new HIV diagnoses have increased for black/African Americans and Latina/x people. Prior studies also found significantly higher incidence and prevalence of HIV among trans women of color.4,8 History of incarceration and lack of health insurance point to structural drivers of continued HIV acquisition among trans women that must be addressed. Structural risks of housing instability, low income, and education are risk factors for sex work and incarceration and are more prevalent among trans women of color.11–13 Instability may also preclude trans women from completing the steps required to enroll in health insurance and establish care in the public health system where biomedical HIV prevention is available. Structural factors disproportionately affecting trans women of color are also tied to poor HIV care outcomes and suboptimal access to HIV prevention use.14,15 Such risks are exacerbated in our city, which has wide disparities in wealth, housing, and employment opportunities.16 Perhaps, the most disheartening finding is the elevated HIV incidence among young trans women. The nearly four-fold higher incidence among transgender youth predicts a continuing high burden of infection for years to come. In an era of intensifying efforts to get to zero HIV infections by 2030,17 any incidence rate above 1 per 100 py is a worrisome reminder that the endgame of eliminating new HIV infections may see diminishing returns as the remaining cases occur among our most marginalized communities.

Little is known about how gender identity develops and how it affects gender-affirming hormone therapy (GAHT) utilization among transgender people in China. To investigate gender identity development among Chinese transgender men (TM) and transgender women (TW) and to explore how identity-related factors are associated with GAHT utilization. This cross-sectional study is based on the latest Chinese Transgender Health Survey targeting the transgender population in China conducted from May to December in 2021. Data analysis was completed in December 2024. Participants were recruited online via snowball sampling. The primary outcomes are the timing of gender identity development milestones (first perception of gender incongruence, confirmation, disclosure, and initiating GAHT) and GAHT utilization status. Multivariable binary logistic regression identified factors associated with GAHT-related behaviors and feedback. A total of 4296 transgender people (1462 TM [34.0%] and 2834 TW [66.0%]; median [IQR] age, 21 [18-24] years) were included in the final analysis. The age distribution of first perceived gender incongruence exhibited a bimodal pattern, with peak occurrences at ages 5 to 6 and at 12 years. The median (IQR) ages at gender identity development milestones were all younger for TM than for TW: 6 (4-10) years vs 9 (6-12) years for perception, 14 (11-16) years vs 15 (12-17) years for confirmation, and 16 (14-19) years vs 17 (15-20) years for disclosure, whereas the age of initiating GAHT was older in TM than in TW (median [IQR] age, 19 [17-22] years vs 18 [16-21] years). The demand for GAHT (3759 participants [87.5%]), usage (2247 participants [52.3%]), and the rate of valid prescriptions among hormone users (339 participants [15.1%]) have all increased significantly compared with 2017. Being a TW and without a college education were associated with starting GAHT before age 16 years, while being a TM, having family disclosure of gender identity, and having official prescriptions were associated with positive feedback on GAHT. In this cross-sectional study of Chinese TM and TW, gender identity development differed by gender, with TM recognizing incongruence earlier and TW progressing faster in initiating GAHT. Both groups showed strong demand for GAHT. Despite recent improvements in GAHT service accessibility, challenges persist in medical accessibility. These findings highlight the need for personalized support for transgender youths and underscore the importance of improving formal transgender health care services in China to enhance the well-being of this population.

Nonmedical prescription opioid use is a pressing public health issue in the United States. Transgender youth, including adolescent girls and young women who were assigned male at birth and currently identify as women, female, transgender women, or another diverse gender identity along the transfeminine gender spectrum, are more likely than their cisgender peers to report illicit substance use and meet diagnostic criteria for substance use disorders. However, relatively little is known about the experiences of these populations in the current era of opioid addiction and misuse. To report the prevalence of and risk factors associated with lifetime nonmedical prescription opioid use in a high-risk community sample of transgender adolescent girls and young women who are sexually active. This cross-sectional study used 2012 to 2015 baseline data from Project LifeSkills, a randomized clinical trial of a behavioral intervention to reduce the risk of HIV acquisition and transmission among a diverse sample of transgender adolescent girls and young women recruited from Boston, Massachusetts, and Chicago, Illinois. A total of 297 transgender girls and women aged 16 to 29 years who were sexually active were included in this analysis. Data were analyzed from June 2019 to August 2019. Transgender woman identification. Self-reported lifetime nonmedical prescription opioid use. Among 297 transgender adolescent girls and young women (mean [SD] age, 23.4 [3.5] years), 145 (48.8%) identified as non-Hispanic/Latinx black, 76 (25.6%) identified as non-Hispanic/Latinx white, 37 (12.5%) identified as Hispanic/Latinx, 7 (2.4%) identified as non-Hispanic/Latinx Asian, and 32 (10.8%) identified as multiracial or other race/ethnicity. Thirty-five participants (11.8%) reported lifetime nonmedical prescription opioid use. Young transgender women who smoked cigarettes monthly or less (adjusted odds ratio, 3.92; 95% CI, 1.10-13.89) and who smoked daily (adjusted odds ratio, 5.69; 95% CI, 1.87-17.33) had greater odds of nonmedical prescription opioid use compared with those who did not smoke. Additionally, participants who identified as a sexual orientation other than heterosexual, gay, lesbian, or bisexual had significantly greater odds of lifetime nonmedical prescription opioid use compared with those who identified as heterosexual (adjusted odds ratio, 3.69; 95% CI, 1.07-12.72). These findings suggest that transgender adolescent girls and young women have similar prevalence of lifetime nonmedical prescription opioid use compared with the US general population prevalence of 12.5%. These findings may serve as a call-to-action for public health surveillance studies and evidence-based interventions to be comprehensively tailored to examine and respond to specific trends of substance use, particularly opioid use disorder, among transgender populations.

Book Review| October 01 2021 Review: Transforming Prejudice: Identity, Fear, and Transgender Rights, by Melissa R. Michaelson and Brian F. Harrison Transforming Prejudice: Identity, Fear, and Transgender Rights, by Melissa R. Michaelson and Brian F. Harrison. New York: Oxford University Press, 2020. 256 pages. $29.95 (paper). ISBN: 9780190068899. Isabel Felix Gonzales Isabel Felix Gonzales University of California, Irvine Search for other works by this author on: This Site PubMed Google Scholar National Review of Black Politics (2021) 2 (3-4): 224–227. https://doi.org/10.1525/nrbp.2021.2.3-4.224 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Isabel Felix Gonzales; Review: Transforming Prejudice: Identity, Fear, and Transgender Rights, by Melissa R. Michaelson and Brian F. Harrison. National Review of Black Politics 1 October 2021; 2 (3-4): 224–227. doi: https://doi.org/10.1525/nrbp.2021.2.3-4.224 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentNational Review of Black Politics Search Melissa Michaelson and Brian Harrison’s Transforming Prejudice: Identity, Fear, and Transgender Rights starts from a commonly held notion: that contemporary political discourses surrounding the rights of transgender people in the United States carry within them echoes of political discourses surrounding gays and lesbians in the United States in the late 1980s and 1990s. Throughout their study, Michaelson and Harrison both problematize and build upon this idea, utilizing extant literature about mass attitudes toward gays and lesbians as a means to theorize strategies for building acceptance for transgender people among the wider cisgender public. In drawing from research about mass attitudes toward gays and lesbians to develop their hypotheses, Michaelson and Harrison articulate a new theory that they term Identity Reassurance Theory, a means of “softening the ground” by reassuring ingroups of their own identities, so that they may become more supportive of stigmatized groups (47). Or, as Michaelson and Harrison... You do not currently have access to this content.

As agentic documents, anti-trans policies express a yearning for the queer, the trans, the black, exist through a poetics of silence. In this conceptual manuscript, I discuss voice as a trans woman phenomenon, a phonic movement through which trans women reorganize themselves to the world. The annihilation of trans women’s voice, then, is a realization of transmisogyny, which animates and orients the schooling process. I argue what is needed is not more policy, but a solidarity of the marooned beyond, outside of, and underneath policies that (fore)tell trans girls and women being (in schools).

A Systematic Review of Inflammatory Bowel Disease Epidemiology and Health Outcomes in Sexual and Gender Minority Individuals

This paper considers whether transgender (trans*) women should be permitted to compete in female categories in sports. Trans* women are often criticized for competing in female categories because they are seen as having an unfair advantage. Specifically, they are seen as having high levels of testosterone that unfairly enhance their performance in comparison to cisgender competitors. In this paper, I argue that trans* women should be permitted to compete in female categories. I suggest that if we want to maintain the skill thesis as a guiding principle of sports and allow trans* women to compete in female categories, then we need to take relevant genetic advantages into consideration by introducing a handicap system. I claim that a handicap system should consider both cisgender and transgender women’s effective testosterone levels.

Introduction: Young men who have sex with men (MSM) in Jamaica have the highest HIV prevalence in the Caribbean. There is little information about HIV among transgender women in Jamaica, who are also overrepresented in the Caribbean epidemic. HIV-related stigma is a barrier to HIV testing among Jamaica’s general population, yet little is known of MSM and transgender women’s HIV testing experiences in Jamaica. We explored perceived barriers and facilitators to HIV testing among young MSM and transgender women in Kingston, Jamaica.Methods: We implemented a community-based research project in collaboration with HIV and lesbian, gay, bisexual and transgender (LGBT) agencies in Kingston. We held two focus groups, one with young (aged 18–30 years) transgender women (n = 8) and one with young MSM (n = 10). We conducted 53 in-depth individual semi-structured interviews focused on HIV testing experiences with young MSM (n = 20), transgender women (n = 20), and community-based key informants (n = 13). We conducted thematic analysis to identify, analyze, and report themes.Results: Participant narratives revealed social-ecological barriers and facilitators to HIV testing. Barriers included healthcare provider mistreatment, confidentiality breaches, and HIV-related stigma: these spanned interpersonal, community and structural levels. Healthcare provider discrimination and judgment in HIV testing provision presented barriers to accessing HIV services (e.g. treatment), and resulted in participants hiding their sexual orientation and/or gender identity. Confidentiality concerns included: clinic physical arrangements that segregated HIV testing from other health services, fear that healthcare providers would publicly disclose their status, and concerns at LGBT-friendly clinics that peers would discover they were getting tested. HIV-related stigma contributed to fear of testing HIV-positive; this intersected with the stigma of HIV as a “gay” disease. Participants also anticipated healthcare provider mistreatment if they tested HIV positive. Participants identified individual (belief in benefits of knowing one’s HIV status), social (social support) and structural (accessible testing) factors that can increase HIV testing uptake.Conclusions: Findings suggest the need for policy and practice changes to enhance confidentiality and reduce discrimination in Jamaica. Interventions to challenge HIV-related and LGBT stigma in community and healthcare settings can enhance access to the HIV prevention cascade among MSM and transgender youth in Jamaica.

Fertility preservation rates among transgender women compared with transgender men receiving comprehensive fertility counselling

Introduction and Objective: Research on relationships between obesity and diabetes risk for transgender youth is limited, despite indications of increased risk of transgender youth developing obesity and diabetes. Understanding this relationship is critical in developing affirming and clinically effective care. This study documented the prevalence of obesity and related health factors in adolescents at their initial gender program visit. Methods: A retrospective chart review conducted on 94 patients receiving care at a gender clinic extracted data points of body mass index (BMI) percentiles and z-scores for assigned sex at birth (ASAB) and affirmed gender, as well as psychological and medical comorbidities. Results: The average patient seen in the gender program was 14.7 years old, white (60.64%), non-Hispanic/Latino (56.57%), and transgender male (62.77%). The average ASAB BMI percentile was 69.57 (z-score = 0.84) with transgender males and females having an average BMI of 25.64 and 22.21. Of note, using affirmed gender to determine BMI percentiles and z-scores displayed changes in weight of transgender males (88.14% had increase in z-score; 74.58% had increase in BMI percentile) and transgender females (78.57% had decrease in z-score; 60.71% had decrease in BMI percentile). This population had the following incidence rates: 3.19 pre-diabetes, 31.92 obesity, 60.64 anxiety, and 17.02 asthma. Conclusion: This retrospective chart review found adolescents entering this gender program were at higher ends of normal weight. Upon comparison, transgender males were at potentially increased risk of obesity compared to transgender females prior to initiating gender affirming treatment. Given increasing rates of pediatric obesity for all adolescents, providers should remain vigilant and assess for weight-related comorbidities like diabetes. Future research could explore health behaviors contributing to overall wellbeing, to inform affirming treatment options for transgender youth. Disclosure K. Oyola-Cartagena: None. A. Sharer: None. S. Gedeon: None. C. Finck: Advisory Panel; Harvard regenerative technologies. Other Relationship; Esophadex. M. Santos: None. Funding American Diabetes Association (11-22-ICTSHD-17)

Purpose: Up to 1.8% of youth identify as transgender; many will be treated with a gonadotropin-releasing hormone agonist (GnRHa). The impact of GnRHa on insulin sensitivity and body composition in transgender youth is understudied. We aimed to evaluate differences in insulin sensitivity and body composition in transgender youth on GnRHa therapy compared with cisgender youth. Methods: Transgender participants were matched to cisgender participants on age, body mass index, and sex assigned at birth. Transgender males (n=9, ages 10.1-16.0 years) on GnRHa (mean±standard deviation duration of exposure: 20.9±19.8 months) were compared with cisgender females (n=14, ages 10.6-16.2). Transgender females (n=8, ages 12.6-16.1) on GnRHa (11.3±7 months) were compared with cisgender males (n=17, ages 12.5-15.5). Differences in insulin sensitivity (1/[fasting insulin], homeostatic model of insulin resistance [HOMA-IR]), glycemia (hemoglobin A1C [HbA1c], fasting glucose), and body composition (dual-energy X-ray absorptiometry) were evaluated using a mixed linear regression model. Results: Transgender males had lower 1/fasting insulin and higher HOMA-IR (p=0.031, p=0.01, respectively), fasting glucose (89±4 vs. 79±13 mg/dL, p=0.012), HbA1c (5.4±0.2 vs. 5.2±0.2%, p=0.039), and percent body fat (36±7 vs. 32±5%, p=0.042) than matched cisgender females. Transgender females had lower 1/fasting insulin and higher HOMA-IR (p=0.028, p=0.035), HbA1c (5.4±0.1% vs. 5.1±0.2%, p=0.007), percent body fat (31±9 vs. 24±10%, p=0.002), and lower percent lean mass (66±8 vs. 74±10%, p<0.001) than matched cisgender males. Conclusion: Transgender youth on a GnRHa have lower estimated insulin sensitivity and higher glycemic markers and body fat than cisgender controls with similar characteristics. Longitudinal studies are needed to understand the significance of these changes. Clinical Trial.gov ID: NCT02550431.

Several studies have demonstrated an improvement in body image following gender-affirming hormone treatment (GAHT). In transgender girls, puberty suppression (PS) can be initiated before GAHT to prevent masculinization. The aim of this study is to assess body image, self-esteem and its determinants in trans women who received PS prior to GAHT. Forty-two trans women from a specialized gender clinic who initiated treatment <18years were included in this cross-sectional study of whom 23 initiated PS in early puberty (Tanner stage G2-3), and 19 in late puberty (Tanner stage G4-5). Body Image Scale (BIS) scores, ranging from 1 (very satisfied) to 5 (very dissatisfied), Rosenberg self-esteem scores and anthropometric measurements were collected. Participants were aged 20.1 ± 2.0years and used GAHT for 4.2 ± 1.6years. Mean total BIS score was 2.4 ± 0.6, indicating satisfaction. Height, BMI, foot length, and waist circumference correlated with corresponding BIS items, with smaller measurements being associated with higher satisfaction. Although total BIS scores were comparable between the early and late pubertal group (β0.3, 95% CI -0.05;0.7), most BIS items (24/27) scored lower in the early PS group, particularly voice (β-1.4, 95% CI -1.9;-0.8), Adam's apple (β-0.6 95% CI -1.2;0.001) and weight (β-1.1 95% CI -1.9;-0.4). Self-esteem correlated negatively with BIS scores (β-4.5, 95% CI -6.6;-2.5). This study reports the potential benefits of PS, especially when initiated early in puberty, on body satisfaction, particularly with voice, and self-esteem in trans women. Clinicians should consider these outcomes when counseling on gender-affirming care and its timing, while also addressing many other factors potentially affecting body image and self-esteem, such as mental wellbeing, social support, quality of life, and other physical parameters like obesity. Strengths include systematic data collection and the integration of objective and subjective variables. Limitations include a small sample size and potential selection bias due to exclusion criteria and non-participation, possibly affecting generalizability. Trans women using PS prior to GAHT are overall satisfied with their bodies and have average self-esteem. More feminine anthropometric measurements correspond to higher body satisfaction. Moreover, early start with PS is associated with higher satisfaction with voice, a characteristic strongly influenced by pubertal testosterone exposure.

Transfemininity marks a site of social upheaval, an encounter that sparks discord. Transfemininity is always otherworldly, posing trans girls and women as figures sought out for capture and eradication. In this manuscript, I elucidate the affective contours of what I describe as the spectre of the tranny, which is a technology of capture and dispossession that seeks to confirm the killability of trans women. Mirroring broader social discourses about transfemininity and trans women, the spectre of the tranny haunts the institution of higher education, shaping pedagogical realities for trans women. In this manuscript, I attend to how the spectre of the tranny attenuates pedagogical (im)possibilities for trans women faculty, particularly those who are pre-tenure and/or in contingent roles. Additionally, I gesture towards how trans(girl) sociality may provide a significant site of momentary resistance from the spectre’s haunting absent-presence.

IntroductionTransgender women experience disparities in sport participation that are exacerbated by policies from sport organisations and legislation in the USA regulating the participation of transgender women in the category that...