Affirming Care Research Articles

Validating identities: The pharmacist's role in providing affirming care and services to sexual and gender minority patients.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Utilizing interprofessional education to foster diversity, equity, and inclusion concepts related to gender affirming care

Interprofessional education (IPE) is on the rise in healthcare fields for several reasons. IPE teaches the collaborative skills necessary for healthcare students to succeed in an increasingly diverse workforce. IPE also creates space for healthcare organizations to develop diversity, equity, and inclusion (DEI) objectives within curriculum and clinical practice. IPE's focus on diversity is important because recent research indicates a lag in DEI initiatives in healthcare. To better integrate DEI objectives into healthcare curricula, faculty from an OTD and MAT program developed an interprofessional assignment that could be implemented across multiple programs. The assignment was designed to improve DEI and IPE competence in OT and AT education.An OTD and a MAT course were chosen to pilot the IPE assignment. These courses were selected for two reasons: curricular content and logistic feasibility. A virtual synchronous and asynchronous format was determined as the best structure for the assignment. Students were asked to complete assigned readings and review a video about culturally sensitive topics, meet as an interprofessional group to discuss a healthcare encounter between a clinical staff and a transgender individual, and participate in an intraprofessional discussion board activity.The primary student learning outcomes for this assignment were threefold 1) Demonstrate use of interprofessional collaborative skills such as communication and roles responsibilities 2) Analyze how interprofessional collaborative skills might be utilized to care for diverse populations and 3) Integrate the use of DEI constructs within discussions of planned care. A rubric was used to assess students in each of these areas. Additionally, a thematic analysis was generated to understand how students’ use of interprofessional education skills and knowledge could enhance the care of diverse populations.Both groups of students in the pilot scored well. The average overall grade for occupational students was 37.25/40 (93 %) and the average overall grade for the athletic training students was 36/40 (90 %). The assignment analysis identified three improvements in student understanding, specifically enhanced quality of care, decreased knowledge gaps, and greater ability to check biases and accountability.

Just Another Patient? Student Reflections on Providing Mental Health Care to Transgender and Gender Expansive People During Simulated Encounters.

This study analyzed psychiatric-mental health nurse practitioner (PMHNP) students' reflections following a virtual simulated encounter with a patient who identified as transgender or gender expansive (TGE). To reduce mental health disparities, PMHNP students must be prepared to deliver affirming care. Engaging in and reflecting on simulated encounters with standardized patients can improve PMHNP students' affirming care competency. A thematic analysis process was used to analyze student reflections during simulation debriefings. Five themes emerged: application of affirming care principles, recognizing minority stressors, treating all patients the same, desire to learn more, and valuing authentic practice. PMHNP students' reflections on the experience of providing care to a standardized patient who identified as TGE support the use of virtual simulations to prepare future providers to deliver affirming, person-centered care.

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A retrospective review of the use of bicalutamide in transfeminine youth; a single center experience

Background: Androgen blockers are an essential part of gender affirming care in post-pubertal transfeminine patients. Bicalutamide is a highly potent androgen receptor blocker that is used primarily in adults. We aimed to review our experience with the use of bicalutamide in transgender adolescents who were assigned male at birth. Methods: A retrospective review of medical records of transfeminine patients treated with bicalutamide during an 8-year period was conducted. Results: Forty patients, aged 15.5 ± 1.55 years were identified, of whom 21 (53%) were started on bicalutamide alone and 19 were started concurrently on estrogen. In patients on bicalutamide alone, 90.4% reported breast development at their first follow up visit, which occurred at a median of 7.1 months. Patients were treated for 29.4 ± 18.2 months. No episodes of liver toxicity related to bicalutamide were seen. Conclusions: Although these results are preliminary, bicalutamide appears to be a safe option for androgen blockade in transgender girls.

Incidental discovery of seminoma after simple orchiectomy in transgender individuals: A case series

Introduction: Seminoma is a common malignancy reported in young, cisgender men. However, there is sparse literature describing cases of seminoma in the transgender and gender diverse patient population. Case Series: We present two cases of seminoma incidentally discovered after simple bilateral orchiectomy performed as part of genital gender affirming surgery. In both instances, patients had not reported any testicular firmness or abnormality prior to surgery. After a thorough literature review, only two other such cases have been reported. Herein, we discuss our two cases and their implications for surgical management of suspected testicular malignancy intraoperatively, a methodical inspection of testicles removed during gender affirming surgery and providing affirming care when navigating discussions of genitalia with transgender and gender diverse patients. Conclusion: Testicular malignancy such as seminoma may be found incidentally when transgender and gender diverse patients undergo genital gender affirming surgery. Thus, special attention is required to identify suspicious exam findings, adjust surgical techniques as indicated, and properly examine surgical specimens. As there is a significant paucity of literature surrounding testicular malignancies in the transgender and gender diverse patient population, it is crucial to continue to investigate how to provide affirming care in these situations.

Queering a life worth living: A gender affirming care model for suicidal transgender emerging adults

The transgender and gender diverse (TGD) population have suicide rates approximately nine times greater than the general population. The gender affirming care model proposed in this case study is based on college-enrolled emerging adults and derived from the complimentary theories of gender minority stress theory and dialectical behavior therapy to integrate a TGD-centered approach that aims to reduce suicidality while increasing gender congruence. It also highlights how higher education administration and practitioners could be more responsive in their interactions and support for the TGD community to reduce suicidality and improve overall mental health.

Gender-affirming care and endocrine-related cancers.

With the increasing number of transgender and gender diverse (TGD) individuals who are seeking gender-affirming care, there is a clear need for the development and collection of evidence-based data to establish guidelines for patient care. TGD individuals are estimated to represent 0.3 to 4.5% of the world population. Gender-affirming care that includes hormone therapy helps to align the body of a transgender person with their gender identity. Hormone therapy requires monitoring for both safety and efficacy. The extent to which gender-affirming hormone therapy alters cancer risk remains unknown. Because of a lack of comprehensive data collection pertaining to this patient population, endocrine cancer data including incidence and outcomes is limited. Dedicated research is needed to help address the gap in knowledge pertaining to the risk of cancer in the TGD population.

Reaching for T in the South African archives

AbstractThis article proposes a methodology of reaching in historicity. It does so by tracing the technical object of synthetic testosterone as it has been used by trans people for gender affirming care. To show the usefulness of the method, this article employs it first in relation to mentions of synthetic testosterone in the South African Medical Journal as a primer to understanding its relationship to the state and the law in South Africa from 1963 to 2003, reaching an apex in the Cape Town Transsexual/Transgender Groups advocacy for self‐identification, much of which hinged on the role of synthetic testosterone.

Mental Health Provider Training to Improve LGBTQ Competence and Reduce Implicit and Explicit Bias: A Randomized Controlled Trial of Online and In-Person Delivery.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals in most countries face strong stigma and often rely on affirmative mental health care to foster coping and resilience. We tested an LGBTQ-affirmative mental health training for psychologists and psychiatrists by comparing in-person versus online modalities and the added benefit of supervision. Participants were randomized to a two-day training either in-person (n = 58) or via live-stream online broadcast (n = 55). Outcomes were assessed at baseline and 5, 10, and 15 months posttraining. Optional monthly online supervision was offered (n = 47) from months 5 to 15. Given the substantial need for LGBTQ-affirmative expertise in high-stigma contexts, the training took place in Romania, a Central-Eastern European country with some of the highest LGBTQ stigma in Europe. Participants (M age = 35.1) were mostly cisgender female (88%) and heterosexual (85%). Trainees, regardless of whether in-person or online, reported significant decreases from baseline to 15-month follow-up in implicit and explicit bias and significant increases in LGBTQ-affirmative clinical skills, beliefs, and behaviors. LGBTQ-affirmative practice intentions and number of LGBTQ clients did not change. Participants who attended at least one supervision session demonstrated greater reductions in explicit bias and increases in LGBTQ-affirmative behaviors from baseline to 15-month follow-up than participants who did not attend supervision. LGBTQ-affirmative mental health training can efficiently and sustainably improve LGBTQ competence and reduce provider bias in high-stigma contexts. Future research can identify additional ways to encourage mental health providers' outreach to LGBTQ clients in need of affirmative care.

Providing LGBTQ+ affirming care to young adults with inflammatory bowel diseases

Creating an affirming care environment for young adults with IBD in the LGBTQ+ community is an essential part of inflammatory bowel disease (IBD) care. This article summarizes the discussions held during the Roundtable on Young Adults with IBD, which focused on essential information for adult-care providers to successfully navigate the complexities and intricacies of sexuality and gender identity for young adult IBD patients. The Roundtable on Young Adults with IBD is held through the Crohn’s and Colitis Young Adults Network. Key focus areas include establishing effective communication between providers and patients, maintaining patient safety and privacy, emphasizing trauma-informed practices, and building trust-based provider-patient relationships. Addressing these issues will allow providers to more fully and effectively treat LGBTQ+ young adults with IBD, ensuring a better, safer path into successful adult lives.

Exploring Hormone Therapy Effects on Reproduction and Health in Transgender Individuals.

Transgender individuals often face elevated mental health challenges due to gender dysphoria, but gender-affirming treatments such as surgery and hormone therapy have been linked to significant improvements in mental well-being. The potential influence of time and circadian rhythms on these treatments is prevalent. The intricate interplay between hormones, clock genes, and fertility is profound, acknowledging the complexity of reproductive health in transgender individuals. Furthermore, risks associated with gender-affirming hormonal therapy and potential complications of puberty suppression emphasize the importance of ongoing surveillance for these patients and the need of fertility preservation and family-building options for transgender individuals. This narrative review delves into the intricate landscape of hormone therapy for transgender individuals, shedding light on its impact on bone, cardiovascular, and overall health. It explores how hormone therapy affects bone maintenance and cardiovascular risk factors, outlining the complex interplay of testosterone and estrogen. It also underscores the necessity for further research, especially regarding the long-term effects of transgender hormones. This project emphasizes the critical role of healthcare providers, particularly obstetricians and gynecologists, in providing affirming care, calling for comprehensive understanding and integration of transgender treatments. This review will contribute to a better understanding of the impact of hormone therapy on reproductive health and overall well-being in transgender individuals. It will provide valuable insights for healthcare providers, policymakers, and transgender individuals themselves, informing decision-making regarding hormone therapy and fertility preservation options. Additionally, by identifying research gaps, this review will guide future studies to address the evolving healthcare needs of transgender individuals. This project represents a critical step toward addressing the complex healthcare needs of this population. By synthesizing existing knowledge and highlighting areas for further investigation, this review aims to improve the quality of care and support provided to transgender individuals, ultimately enhancing their reproductive health and overall well-being.

Serum Hormone Concentrations in Transgender Youth Receiving Estradiol

ObjectiveThis study aimed to evaluate the serum estradiol levels in gender-diverse youth to compare the efficacy of different estradiol routes in achieving therapeutic blood levels and suppressing serum testosterone levels. MethodsThis was a retrospective chart review of patients who initiated estradiol at an adolescent gender clinic between 2010 and 2019. Data on the route of estradiol administration and antiandrogen use (spironolactone or gonadotropin-releasing hormone agonist) were collected, and laboratory data were analyzed. Scatterplots were used to visualize the relationship between the estradiol dose and testosterone and estradiol laboratory values. ResultsA total of 118 patients were included, with a mean (standard deviation [SD]) age of 17.2 (1.6) years. The most common route of estradiol administration was oral only (62.7%), followed by transdermal only (23.7%), multiple routes excluding subcutaneous (8.5%), and any subcutaneous (5.1%). Notable variability was observed in the serum estradiol levels, with means (SDs) of 131.9 (120.4) pg/mL for those on oral estrogen 6 to 8 mg per day, 62.6 (40.3) pg/mL for those on transdermal estrogen 0.1 to 0.15 mg every 24 hours, and 53.6 (42.4) pg/mL for those on subcutaneous estradiol. In patients who received spironolactone, transdermal estradiol was associated with lower testosterone levels than estradiol administered orally or subcutaneously. ConclusionOral, transdermal, and subcutaneous administrations of estrogen all lead to increased serum estradiol levels and are effective for use in gender-affirming care for youth. Patients on transdermal estrogen tended to have lower serum estradiol levels but also had more suppression of serum testosterone levels.

‘It just feels really nice when people call me by my name’: accounts of gender euphoria among Australian trans young people and their parents

ABSTRACT Gender euphoria refers to positive internal feelings of joy related to gender, and external affirmation when recognized as one’s gender. Euphoria can be an important counter to experiences of gender dysphoria for many trans people. Due to an often damage-centred approach to understanding trans people’s lives, gender euphoria remains an under-researched topic, particularly with trans young people. This paper aims to address this gap by exploring the experiences of pre-pubertal trans young people and their families at the beginning of, or who were waiting to access, gender-affirming medical care, and how this relates to their sense of self, relationships with others, and views about the future. As part of the first wave of the Australian iteration of an international longitudinal study, semi-structured interviews were conducted with 12 families (comprising 12 trans young people, 16 parents, and 2 siblings). The themes developed emphasized that gender euphoria can arise as a product of self-understanding, receiving affirming medical care, close interpersonal relationships, and interactions with people in the broader community. While gender euphoria can be normative in its enactment, it also highlights the unique aspects of being trans, helping with feelings of safety, comfort, and the hope and promise of an imagined future.

Navigating gender journeys: Psychiatric perspectives on transgender sexuality

Over the past few decades, society’s perception of transgender individuals has significantly transformed, leading to increased recognition and acceptance. However, despite these positive changes, transgender people have historically faced numerous challenges and stigmatization. This article delves into psychiatric perspectives on transgender sexuality and its impact on mental health. It emphasizes the importance of integrating psychiatrists into primary care to enhance engagement in outpatient behavioral health services for transgender and nonbinary adults. Gender identity and sexuality are interconnected aspects of human experience, and understanding transgender sexuality is essential for mental health professionals to provide effective support and care. Gender dysphoria, a psychological condition stemming from incongruence between gender identity and assigned sex, profoundly affects the mental health of transgender individuals, emphasizing the necessity of affirming and comprehensive mental health care. The significance of cultural factors and intersectionality in supporting transgender individuals and mental health professionals play a critical role in identity development by creating safe and supportive environments for exploration and self-acceptance. Affirmative approaches and treatment options, such as hormone replacement therapy and gender confirmation surgery, are discussed, stressing the importance of collaborative care involving medical and mental health professionals. Ultimately, this article underscores mental health professionals’ vital role in supporting transgender individuals’ mental well-being, fostering inclusivity, and contributing to more affirming society.

Gender dysphoria: Reconsidering ethical and iatrogenic factors in clinical practice.

To examine the treatment of gender dysphoria described in Bell v Tavistock (UK 2020). Bell documents the treatment and sequelae of a 16-year-old adolescent referred to the Tavistock with gender dysphoria. Her case highlights contrasts between gender affirming care and comprehensive care. Consistent with other western centres, in the 2010s, the Tavistock began treating patients with gender dysphoria under the 'Dutch protocol' for gender affirming care. Bell reveals concerning lapses of clinical governance influenced by activists and linked to patient harm. The recent suspension of a senior child psychiatrist from an Australian public hospital service after questioning the evidence base and ethical foundation of gender affirming care underlines the need to resolve these uncertainties to address the crisis in the treatment of gender dysphoria.

A “hard question”: Gender affirming care and gender distress in a social world

AbstractGender affirming care for youth is currently under political attack across the United States. Critics of affirming care often leverage a biological and fixed notion of gender as assigned at birth, which is at odds with how gender has been theorized academically for decades. Yet for some feminist clinicians, the popularized version of SOCIAL CONSTRUCTION present within rhetoric about the purpose of affirmative intervention also seems to undercut the legitimacy of care. In this article, I track how the difficult problems of the origins of gender itself, problems seemingly exposed by the invocation of the SOCIAL CONSTRUCTION of gender, are managed within the field of gender affirming care. I show how by drawing on the narrative power of very young gender expansive people, and by orienting clinical care away from identity towards DISTRESS, medical providers can align themselves both with feminist desires to change how gender ideology functions in the social world, and with the need to provide interventions that allow youth to embody the gender they desire.

Carrying Trans Forward

What utility does trans hold and carry forward at this politically and ecologically volatile moment, when increasingly prevalent legal restrictions are preventing trans people from accessing gender affirming and reproductive health care and seeking to disallow our presence in public life altogether? Taking an autoethnographic approach to exploring trans life and scholarship across generations, this essay poses trans*plantation as a framework for navigating complex questions about how life comes to be defined and whose lives come to hold value or not over time.

Navigating access to medical gender affirmation in Tasmania, Australia: an exploratory study

Background: Gender affirmation through hormone replacement therapies and surgery can significantly improve the health and wellbeing of some transgender, nonbinary, and gender diverse people. Despite the well-documented benefits of gender affirming care, barriers persist for many trans and gender diverse people, particularly those in rural areas. Aims: This exploratory study aimed to identify the barriers trans and gender diverse people faced when seeking to medically affirm their gender in the rural state of Tasmania, Australia. Methods: This article draws on qualitative data from a mixed-methods online survey of 84 trans and gender diverse Tasmanians aged 18-70. Results: Participants identified financial and geographical barriers, discrimination, and medical gatekeeping as the three key factors that prevented or delayed their gender affirmation. Conclusion: Costly services that require multiple referrals to access limit trans and gender diverse patients’ options, impacting their mental health and wellbeing. Gender affirmation on the basis of informed consent would reduce unnecessary medical gatekeeping and improve trans and gender diverse health and wellbeing.

Medical students' perceptions of LGBTQ+ healthcare in Singapore and the United Kingdom.

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) individuals have an increased scope of healthcare needs and face many barriers to accessing healthcare. However, LGBTQ+ healthcare education remains scarce, and students' understanding of LGBTQ+ healthcare remains largely uncharacterised. This study investigated the knowledge of and attitudes toward LGBTQ+ healthcare among medical students in Singapore and the United Kingdom (UK), two culturally different countries. Medical students in two medical schools, one in Singapore and the other in the UK, completed self-administered cross-sectional surveys using multiple-choice, Likert scale, and free-text questions to explore their ideas, concerns, and expectations about LGBTQ+ healthcare education within their medical curricula. From 330 responses, students' knowledge levels were moderate overall, with pronounced gaps in certain areas, including terminology, sexual health, and conversion therapy. Deficiencies in knowledge were significantly greater among students in Singapore compared to the UK (p < 0.001), whilst LGBTQ+ students and non-religious students had more positive knowledge and attitudes than students not identifying. At least 78% of students had positive attitudes towards LGBTQ+ individuals, but 84% had not received LGBTQ+-specific medical education. Although junior UK students were more satisfied with the adequacy of teaching by their medical school's incorporation of LGBTQ+ inclusive teaching in a newer curriculum, qualitative analyses suggested that students in both countries wanted to receive more training. Students further suggested improvements to the medical curriculum to meet their needs. Students in both schools lacked understanding of commonly-used terminology and topics such as sexual healthcare despite affirming attitudes towards LGBTQ+ healthcare. Although sociolegal contexts may affect students' perspectives, differences were less than thought, and students were equally keen to provide affirmative care to their patients. They emphasised a need for more formal teaching of LGBTQ+ healthcare professions to overcome healthcare disparities in these communities.