Assigned Female At Birth Research Articles

SAT-745 Lower Serum Estradiol Levels in Assigned Female at Birth Transgender People with Initiation of Testosterone Therapy: Results from the European Network for the Investigation of Gender Incongruence (ENIGI)

Introduction: Aromatization of exogenous testosterone might result in increased estradiol levels. Concerns have been raised about undesired estrogenic effects in assigned female at birth (AFAB) transgender people. How serum estradiol levels change after initiation of testosterone therapy and if these levels should be monitored, remains unclear. Methods: This prospective cohort study was part of the European Network for the Investigation of Gender Incongruence (ENIGI). Serum levels of sex steroids were assessed in 746 AFAB transgender people during a three-year follow-up period, starting at the initiation of hormone treatment. Results: Estradiol levels decreased from median [P25-P75] 45.5[24.0-102.2]pg/mL to 36.5[25.0-46.2]pg/mL over three years (P<0.001), a change was already noticeable during the first three months (mean - 17.1 pg/mL, 95% CI -23.8 - -10.6, P<0.001). Serum estradiol levels were lower in people without endogenous estradiol production (contraceptive users or post gonadectomy) at baseline and after three months, compared to people with endogenous estradiol production. Using long acting testosterone undecanoate injections resulted in a more prominent decrease in serum estradiol values over twelve months, compared to short acting mixed testosterone esters (P<0.001) or testosterone gel (P=0.001). Changes in serum estradiol were positively correlated to changes in LH (ρ = 0.107, P<0.001) and negatively correlated to changes in FSH levels (ρ=-0.167, P<0.001) and body mass index (ρ=-0.082, P<0.001). Conclusion: Testosterone administration in AFAB transgender people results in decreasing serum estradiol levels. Although an underlying mechanism for the observed decrease in serum estradiol levels remains difficult to fathom, our results suggest that testosterone administration suppresses endogenous estradiol production. The exception found in people without endogenous estradiol production may be attributed to aromatization of exogenous testosterone.

OR27-04 Risk Factors For Low Baseline Bone Mineral Density In Gender Diverse Youth

BackgroundSex steroids such as testosterone and estrogen are necessary for accumulation of bone mass. Transgender youth treated with gonadotropin releasing hormone analogues (GnRHa) to block natal puberty for gender-affirming care are at risk of low bone mineral density (BMD). Previous studies indicate that transfemale patients assigned male at birth (AMAB) have low BMD at baseline, during and after GnRHa treatment despite cross hormone treatment. Transmales assigned female at birth (AFAB), however, have normal BMD at baseline that decreases upon GnRHa treatment, with normalization upon cross hormone therapy. The reason(s) for the low baseline BMD in transfemales is unclear. We aimed to assess the baseline characteristics of transgender youth at a single multidisciplinary gender clinic prior to medical intervention and determine factors associated with BMD.MethodsThis is a retrospective chart review of patients <19 years old evaluated in the gender clinic. Dual-energy x-ray absorptiometry (DXA) scans were obtained prior to initiation of GnRHa or cross-hormone therapy per Endocrine Society guidelines for the treatment of gender dysphoria. We included patients with DXA scans completed prior to initiation of treatment with GnRHa or cross gender hormones and excluded those with concurrent medical diagnoses that may affect bone density. Data collected were bone mineral density (BMD) Z-scores, anthropometric data, vitamin D and calcium levels, and calcium intake. Multivariable linear regression models were used to assess the impact of vitamin D levels, height Z-score, weight Z-score, and BMI Z-score on subtotal body BMD Z-score, adjusted for sex assigned at birth and age.ResultsSixty-four patients were included in our analysis. Of these, 73% were AMAB and 27% AFAB. Gender identity was male in 14%, female in 44%, and non-binary in 42%. Average height Z-score was 0.12, weight Z-score 0.27, and BMI Z-score 0.22 (using sex assigned at birth). Subtotal body BMD Z-scores were greater than zero in 11%, between zero and greater than -2 in 59%, and less than or equal to -2 in 30% of tested patients. AMAB patients had lower BMD Z-scores compared to those AFAB (p<0.05 for all Z-scores). There was a positive association with BMI, height, and weight Z-scores and increasing BMD Z-scores after adjusting for sex assigned at birth and age (p<0.05 for all Z-scores). Patients who consumed <2 servings of calcium per day had lower BMD Z-scores (p<0.05 for all Z-scores). Average vitamin D level was 24 ng/ml (+/- 9.5 SD) with no significant association with BMD Z-scores (adjusted for sex assigned at birth).ConclusionsPatients AMAB and patients with calcium intake of < 2 servings/day are associated with lower baseline BMD in a cohort of adolescents seen in a multidisciplinary gender clinic. Height, weight, and BMI are associated linearly with BMD Z-score, following patterns previously described in other populations.

Gender expansive youth disclosure and mental health: Clinical implications of gender identity disclosure.

Some healthcare providers work with gender expansive youth, and preliminary evidence notes that many of these youth do not disclose their gender identity to all of their healthcare providers. No previous research focused on youth has explored gender identity disclosure to healthcare providers, nor linked youth disclosure to negative mental health outcomes (e.g., symptoms of depression). Data were drawn from the LGBTQ National Teen Survey in order to test the relationship between gender identity disclosure, symptoms of depression, and self-esteem among 5,637 13- to 17-year old (M age = 15.6) participants who identified as transgender boys, transgender girls, non-binary youth who were assigned female at birth (AFAB), or assigned male non-binary youth who were assigned male at birth (AMAB). Transgender boys reported the highest symptoms of depression and the lowest levels of self-esteem in comparison to other groups. Among the full sample, 66.8% had not disclosed their gender identity healthcare providers-non-binary AMAB youth were least likely to disclose (77.6%). Symptoms of depression were the highest and self-esteem was the lowest for transgender boys with mixed levels of disclosure. Transgender girls reported the lowest symptoms of depression - these youth had also disclosed their identities the most. Findings suggest that mixed disclosure to healthcare providers is problematic for gender expansive youth, especially transgender boys. Findings suggest a need to better prepare health professionals to understand not all gender expansive youth may feel comfortable disclosing their gender identities in medical contexts. Future research should explore gender affirmative healthcare as a potential protective factor in combatting negative mental health outcomes.

Lower Serum Estradiol Levels in Assigned Female at Birth Transgender People with Initiation of Testosterone Therapy: Results from the European Network for the Investigation of Gender Incongruence.

Purpose: Concerns have been raised about undesired estrogenic effects in assigned female at birth (AFAB) transgender people on testosterone therapy. How serum estradiol levels change after initiation of testosterone therapy and if these levels should be monitored remain unclear. Methods: This prospective cohort study was part of the European Network for the Investigation of Gender Incongruence. Serum levels of sex steroids were assessed in 746 AFAB transgender people during a 3-year follow-up period, starting at the initiation of hormone treatment. Results: Estradiol levels decreased from median [P25-P75] 45.6 [24.0-102.2] pg/mL to 36.5 [25.0-46.2] pg/mL over 3 years (p < 0.001); a change was already noticeable during the first 3 months (mean -17.1 pg/mL, 95% confidence interval -23.8 to -10.6, p < 0.001). Serum estradiol levels were lower in people without endogenous estradiol production from ovarian source (contraceptive users or post hystero-oophorectomy) at baseline and after 3 months, compared with people with endogenous estradiol production. Using long-acting testosterone undecanoate injections resulted in a more prominent decrease in serum estradiol values over 12 months, compared with short-acting mixed testosterone esters (p < 0.001) or testosterone gel (p = 0.001). Changes in serum estradiol were positively correlated to changes in luteinizing hormone (ρ = 0.107, p < 0.001) and negatively correlated to changes in follicle-stimulating hormone levels (ρ = -0.167, p < 0.001) and body mass index (ρ = -0.082, p < 0.001). Conclusion: Testosterone administration in AFAB transgender people resulted in decreasing serum estradiol levels. Our results suggest that testosterone therapy leads to central suppression of estradiol production, with partial restitution due to aromatization.

Responses to the gender minority stress and resilience scales among transgender and nonbinary youth

Stress arising from the experience of stigma and discrimination around gender identity is known to negatively influence health outcomes for transgender individuals. The Gender Minority Stress and Resilience (GMSR) scale is a validated tool for measuring experiences of minority stress and resilience among transgender individuals. This paper seeks to examine whether there are differences in how youth respond to the GMSR scale. Using data from a sample of 202 transgender and gender nonbinary youth collected online, this analysis compares responses to the GMSR scale between transgender youth with binary and nonbinary gender identities. While reports of non-affirmation were generally high (M = 15.02), and community connectedness for all participants was generally low (M = 7.5), there were no significant differences to scale responses across gender identity. Nonbinary assigned male at birth (AMAB) reported greater rates of threats of physical violence due to gender identity or expression. Nonbinary assigned female at birth (AFAB) reported greater rates of feeling unique in their gender identity or expression. This preliminary analysis suggests that the GMSR scale is a useful tool, however, further research is needed to understand stress and resilience among transgender and gender nonbinary youth and developing specific measures that capture their experience.

Autism trait prevalence in treatment seeking adolescents and adults attending specialist gender services.

To assess the prevalence of autism traits in individuals accessing gender affirming treatments, we conducted a cross-sectional survey in the regional specialist gender services in Northern Ireland. One hundred and twenty-three individuals (38 adolescents and 69 adults) currently attending or who previously attended specialist gender services in Northern Ireland were recruited. Fifty-six individuals assigned male at birth (AMAB) and 66 individuals assigned female at birth (AFAB) took part in the study. Main outcome measures: Autism Quotient (AQ), Cambridge Behavior Scale (EQ), and RAADS-14. Autism trait prevalence rates of 19.5% (AQ); 25.4% (RAADS-14); and 35.8% (poor empathy traits). A combined measure comprising all three provided a prevalence of 17.2%. There were no mean differences in the scores between AMAB (assigned male at birth) individuals and AFAB (assigned female at birth) individuals. Autism traits present additional challenges during the assessment and treatment of individuals with gender dysphoria. Autism screening tools can aid in the identification of individual with additional needs.

Parental desire and fertility preservation in assigned female at birth transgender people living in Belgium

To study the considerations and concerns of transgender people regarding fertility preservation and parental desire in a large, nonclinical sample. Gender-affirming care can reduce fertility. Previous research on fertility in transgender people (mainly focused on people visiting health care professionals) shows low fertility preservation use. A web-based survey on fertility and parenthood. Not applicable. Transgender people assigned female at birth (AFAB) were selected for this analysis (n = 172 or 40.4% of the total sample) of which 116 (67.4%) self-identified as transgender men (TM) and 56 (32.6%) as gender nonbinary (GNB) people. Not applicable. Data on parental desire and fertility preservation were assessed in a large, nonclinical sample of AFAB transgender people. Sixty-seven (39.0%) respondents had a current/future parental desire. Parental desire rates did not differ between TM and GNB persons. Barriers for fulfilling the parental desire (multiple response) included assumed difficulties in the adoption procedure (41.3%), fear of discrimination against the child (38.0%) or being discriminated against as a transgender parent (32.6%), and the cost for using personal genetic material (32.6%). Nine percent had cryopreserved reproductive cells or tissue. Even though parental desire rates in this cohort are in line with earlier research, fertility preservation use was lower in the current study. These numbers reflect the barriers transgender people face when considering fertility options, including cost and the need to postpone hormone therapy. In addition, GNB persons have different needs for gender-affirming treatment and subsequently for fertility preservation.

Being Trans Without Medical Transition: Exploring Characteristics of Trans Individuals from Germany Not Seeking Gender-Affirmative Medical Interventions.

Until recently, trans persons were expected to align their sex characteristics as much as possible with the opposite sex. Today, research and health care, as well as the diagnostic criteria from DSM-5 and ICD-11, reflect a broader understanding of trans individuals. It encompasses diverse identities and treatment requests, including trans individuals not wanting or having decided against gender-affirmative medical interventions (GAMI). The present study explored this insufficiently studied group by (1) reviewing the existing literature regarding trans individuals not seeking GAMI and by (2) exploring their demographic and trans-related characteristics in a non-clinical online convenience sample from Germany. The literature review found one large survey with a single question on trans individuals not seeking GAMI. Beyond that, only community literature addressed the topic. The analyzed sample consisted of 415 trans participants, of whom 220 were assigned female at birth (AFAB) and 195 were assigned male at birth (AMAB). Fourteen (3.4%) reported neither previous nor planned GAMI (AFAB = 9, AMAB = 5). Trans individuals not seeking GAMI were significantly older and more often reported to identify with a non-binary gender. The two interdependent, central reasons for refusing GAMI were the avoidance of transition-related suffering and the lack of necessity for treatment. The diversification of gender, as reflected in the increasing visibility of non-binary or genderqueer gender identities, seems to go hand in hand with a diversification of transition-related treatment, including the option not to seek GAMI.

High Burden of Mental Health Problems, Substance Use, Violence, and Related Psychosocial Factors in Transgender, Non-Binary, and Gender Diverse Youth and Young Adults.

Transgender and gender diverse (TGD) people are disproportionately impacted by various health issues and associated risk factors, but little is known about differences in these outcomes between gender identities within the TGD population. This study characterized the health of a diverse sample of TGD youth and young adults. Data were taken from the baseline visit of two longitudinal studies in the Chicago area, RADAR (N = 1079, M age = 20.8years) and FAB 400 (N = 488, M age = 19.57years), which are cohorts of young sexual and gender minorities assigned male at birth (AMAB) and assigned female at birth (AFAB), respectively. There was a combined sample of 214 TGD (128 AFAB, 86 AMAB) individuals across cohorts. We examined differences between gender identities in self-reported health and related psychosocial variables, and compared TGD youth and their cisgender sexual minority peers from their cohort of origin on all variables. Among TGD youth, we found high rates of depression and suicidality (ideation, plan, attempt), violence (trauma, victimization, childhood sexual abuse), and substance use (cigarette, alcohol, illicit drug use). With the exception of depression, transgender women and non-binary AMAB youth reported worse health outcomes than transgender men and non-binary AFAB youth. Non-binary AMAB youth reported the highest rates of certain outcomes, including traumatic experiences and suicidal ideation. TGD youth generally reported worse outcomes than cisgender sexual minority youth; these differences were less pronounced among AFAB youth. Findings point to the diversity of experiences within the TGD population and critical needs for intervention approaches to mitigate health disparities.

Patient-Provider Sexually Transmitted Infection Prevention Communication among Young Adult Sexual Minority Cisgender Women and Nonbinary Assigned Female at Birth Individuals.

Health care providers are an important source of sexually transmitted infection (STI) prevention information for young adult sexual minority women (SMW). However, very few studies have described patient-provider STI communication in this understudied and underserved population. We explore sexual minority women's experiences communicating with health care providers about sexual health, with particular attention to STI prevention, to inform programs and practices that address their unique needs and concerns. We conducted 29 in-depth interviews with sexual minority cisgender women and nonbinary assigned female at birth (AFAB) individuals aged 18-36years. The sample included White (55%), Asian (31%), Black (17.2%), and Latina (3.4%) participants. We used thematic analysis with deductive and inductive coding to identify themes related to patient-provider STI prevention communication. Heteronormative health care provider assumptions inhibited participants' willingness to disclose their sexual orientation and discuss sexual health issues with providers. Most sexual health conversations focused on pregnancy and contraception, which many felt was irrelevant to them, and limited STI prevention recommendations to condom use. Participants reported that some providers lacked medical knowledge on AFAB-to-AFAB STI transmission and were not able to provide relevant STI prevention information. Providers' bias related to gender identity and race/ethnicity furthered some participants' mistrust generated from providers' heteronormative assumptions. Our study describes several barriers that AFAB sexual minorities felt inhibited their patient-provider sexual health communication. Interventions are needed to improve patient-provider STI prevention conversations with AFAB sexual minorities so they can access the sexual health information they need to effectively protect themselves from STIs.

Human Papillomavirus Risk Perceptions Among Young Adult Sexual Minority Cisgender Women and Nonbinary Individuals Assigned Female at Birth

Some sexual minority women may be less likely than other women to engage in human papillomavirus (HPV) prevention behaviors. Although risk perceptions have been found to be associated with health behaviors, HPV risk perceptions among U.S. sexual minority women have not been examined. In 2016-2017, in-depth interviews were conducted in Boston with 29 sexual minority individuals aged 18-36 who were assigned female at birth (AFAB) and identified as women or nonbinary. Purposive sampling was used to recruit participants online, through community-based and student organizations, and by word of mouth. Thematic analysis was employed to examine participants' HPV risk perceptions. Participants incorrectly linked HPV risk to the exchange of genital fluids, and a hierarchy of perceived risk emerged in relation to sexual orientation: Individuals who engage in penile-vaginal sex with partners who were assigned male at birth (AMAB) were perceived to be at highest risk, and lesbians and individuals with only AFAB partners were perceived to be at low risk. Lesbians and participants with only AFAB partners identified sex with bisexual women or AFAB individuals with AMAB partners as a risk factor for HPV infection. Risk perceptions were shaped by health care providers' linking HPV risk to sex with AMAB individuals, a lack of discussion of HPV with parents and peers, and the exclusion of information on HPV and sexual minority women from school-based sex education. Interventions providing sexual minority AFAB individuals with comprehensive, accurate and tailored information about HPV risk are needed.

Transmasculine Spectrum Parenting: Beyond a Gendered Fatherhood

Little scholarship exists on parenting in the transgender and gender nonconforming (GNC) community, even though a sizable portion of the community is either currently parenting or interested in becoming a parent. This dearth of literature is particularly noticeable among those individuals assigned female at birth (AFAB) who identify as transmasculine. This study examined differences in likelihood of being a transgender or GNC parent across a number of sociocultural factors, as well as some parenting experiences specifically among AFAB transmasculine parents, using data from the National Transgender Discrimination Survey. Characteristics such as being assigned male at birth, identifying as African American/black or bi/multiracial, and having a physical disability were correlated with increased likelihood of being a parent. A curvilinear relationship between age and the likelihood of being a parent was also found. As the research on parenting and fatherhood grows, this population of transgender and GNC individuals clearly needs a dedicated space in the emerging literature to ensure that their voices and experiences are heard.

2148 Understanding the health effects of binding and tucking for gender affirmation

OBJECTIVES/SPECIFIC AIMS: Gender affirmation is a critical aspect of the health and well-being of transgender individuals. For many transgender people, this includes changing one’s physical appearance to align with one’s felt gender. Some gender-affirming body modifications require medical interventions such as hormone therapies and surgeries. Other modifications, such as tucking to create a flat-appearing lower pelvis and binding to create a flat-appearing chest, require no external intervention. The published literature is slowly growing on the health effects of gender affirming medical interventions; however, other body modifications are understudied. As part of our needs assessment of the transgender community, we sought to understand the frequency and health impact of binding and tucking. METHODS/STUDY POPULATION: A quantitative online survey was developed based on qualitative interviews with 20 community-based key informants. The survey was available online, in English, for 6 months. Eligible participants were 18 years of age or older, lived in the Baltimore metropolitan area, and identified as transgender and/or a sex different from what was assigned on their original birth certificate. RESULTS/ANTICIPATED RESULTS: 139 participants provided complete data: 45% were assigned male at birth (AMAB) and 55% were assigned female at birth (AFAB). In total, 54% were Black, 40% White, and 9% Latinx. Of AFAB participants, 80% had bound their chest tissue. Of those who had bound, 51% bound 7 days/week, 62% bound 8+ hours per day, and 68% were concerned about the health effects of binding. The most common symptoms associated with binding were back pain (65%), shortness of breath (48.6%), bad posture (32%), chest pain (30%), and light-headedness (30%). Of AMAB participants, 71% had ever tucked, 85% of those tucked 7 days per week, 79% tucked 8+ hours per day, and 50% were concerned about the health effects of tucking. Most common symptoms included itching (28%), rash (21%), testicular pain (17%), penile pain (14%), and skin infections (12%). DISCUSSION/SIGNIFICANCE OF IMPACT: The majority of transgender participants used binding or tucking for gender-affirming body modification and at least half of them have concerns about associated health effects. Clinicians should ask transgender patients about binding and tucking behaviors and assess for common symptoms. More research is needed to better understand the benefits and risks of gender-affirming binding and tucking behaviors.