Transgender Care Research Articles

Which U.S. States’ Medicaid Programs Provide Coverage for Gender-Affirming Hormone Therapy and Gender-Affirming Genital Surgery for Transgender Patients?: A State-by-State Review, and a Study Detailing the Patient Experience to Confirm Coverage of Services

BackgroundTo date, a comprehensive state-by-state assessment of transgender transition-related health care coverage for gender-affirming hormone therapy (GAHT) and genital gender-affirming surgery (GAS) has not been reported. AimsThe aims of this study were 1) to verify which U.S. states’ Medicaid systems do/do not cover GAHT and GAS; 2) to assess the ease/difficulty for patients to determine whether GAHT and GAS are Medicaid-covered benefits; and 3) to understand possible state-related predictors of Medicaid coverage for gender-affirming care. MethodsWe reviewed the official Medicaid Handbook and website for all 51 states (+D.C.) and 5 territories to confirm whether GAHT and GAS are covered benefits. When indeterminate, we called the Medicaid office in each state, and for many, Medicaid managed care organizations (MCOs), and individual in-state providers, to confirm coverage. We recorded our experiences, number of, and duration of phone calls to confirm coverage. OutcomesThe main outcome was a definitive answer from the state/territory's Medicaid program or MCOs regarding whether GAHT and GAS are/are not covered benefits. Secondary outcome measures included responses we received and the total number/duration of phone calls necessary to confirm coverage. ResultsOnly 12 of 51 states and 0 of 5 territories featured their policy regarding coverage for GAHT in their Medicaid Handbook/webpages. We confirmed that 34 of 51 state Medicaid programs do cover GAHT, whereas 9 of 51 states' and 2 of 5 territories’ do not. We could not confirm coverage of GAHT in 8 of 51 states and 3 of 5 territories.Only 26 of 51 states and 0 of 5 territories featured their policy regarding coverage for GAS in their Medicaid Handbook/webpages. We confirmed that 25 of 51 state Medicaid programs do cover GAS, whereas 22 of 51 states' and 3 of 5 territories’ do not. We could not confirm coverage of GAS in 4 of 51 states and 2 of 5 territories. Up to 12 calls, lasting up to 125 minutes, were required to confirm coverage for GAHT/GAS. Clinical ImplicationsOur findings indicate that important health care access barriers/disparities exist today and warrant improvement. Strengths & LimitationsTo our knowledge, this is the most comprehensive assessment of transgender transition-related health care coverage. Limitations include possible bias, as it could be that we were more persistent than actual patients would be to determine service coverage, and a lack of specificity regarding which specific hormone formulations or procedures are/are not covered. ConclusionOur findings show that only 34 of 51 (67%) states’ Medicaid programs include GAHT and 25 of 51 (49%) include GAS as covered benefits. Our experience suggests that the process to confirm coverage can be especially time-consuming and frustrating for patients.Zaliznyak M, Jung EE, Bresee C, et al. Which U.S. States’ Medicaid Programs Provide Coverage for Gender-Affirming Hormone Therapy and Genital Gender-Affirming Surgery for Transgender Patients?: A State-by-State Review, and a Study Detailing the Patient Experience to Confirm Coverage of Service. J Sex Med 2021;18:410–422.

Pharmacists' role in transgender healthcare: A scoping review.

Transgender patients have unique healthcare needs, providing pharmacists with the opportunity to play an important role in transgender care through addressing the healthcare disparities observed in this patient group. This scoping review aimed to explore the role of pharmacists in transgender healthcare. Six databases were searched from inception: Emcare, Informit, MEDLINE (Ovid), PubMed, Scopus, and Web of Science. The first author performed screening and data extraction in consensus with co-authors. Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) was utilised to report this review. Themes related to the role of pharmacists in transgender healthcare were identified. A total of 356 studies were identified; however, only 15 studies, all from the USA met the selection criteria and were included in this review. Study types included empirical research, practice reports and opinion pieces such as commentaries, editorials, and reports. Pharmacists were found to practise in two different care settings: community and interdisciplinary clinics, performing various roles in transgender healthcare, including patient education and counselling, management of cross-sex hormonal therapy, patient advocacy and provision of preventative care. They were also responsible for the provision of culturally sensitive care in an inclusive and welcoming environment. Although pharmacists considered their role important, they lacked confidence in their knowledge to provide appropriate care to this patient group. This review has highlighted that there is a need for education in transgender care for both pharmacists and pharmacy students, so that they are both confident and comfortable to play a meaningful role in transgender care. Pharmacists' involvement in addressing the health disparities experienced will contribute to improving the overall health outcomes for this group.

How Kerala transgenders are faring amidst the COVID-19 pandemic.

Dear Editor, We read the article by Asadi[1] with great interest where the authors have described how an empowered transgender community gains the ability to handle adversities. The transgenders are a vulnerable group in this pandemic. The 2011 census and 2015 Kerala transgender survey estimates 3,902[2] and 25,000[3] self revealed transgenders, respectively, in Kerala. With a high literacy rate of 94%,[2] the transgenders in Kerala depict a strong community with empowered members who actively voice their rights and needs. An article by Madhavan[4] and other literature[5] reveal transgenders have high prevalence and risk factors for non-communicable, communicable diseases, HIV, high tobacco consumption and other conditions, which makes them prone to COVID-19 adversities. Older transgenders are at a higher risk due to weaker immunity, possible presence of comorbidities, emotional and financial issues. The pandemic scenario would leave many on hormone replacement therapy and with scheduled gender reassignment surgeries unable to continue with it. Lack of familial support, stress about COVID and non-COVID conditions including post-surgical care are major issues. Majority mostly rely on daily wage/unsteady jobs including begging and paid sex. The pandemic has impinged drastically on their outdoor work and income generation. Their stay in overcrowded circumstances makes social distancing difficult posing high transmission threat. Inability to pay rents during such periods of non-earning makes secure shelter difficult. However, Kerala became the first state to provide relief in the form of temporary housing and food facilities to transgenders who had registered with the government during the lockdown. This falls in line with the State Policy for Transgenders in Kerala, 2015[3] which noted inclusiveness of transgenders in the socio-economic and political spectrum as pivotal; and The Transgender Persons (Protection of Rights) Act, 2019 which has a component of access to welfare measures including healthcare. The Transgender cell,[3] a first in the country, functioning under the Social Justice Department caters to this population’s needs including operating a 24 × 7 distress counselling helpline. Many live together in large households and such clusters might need more provisions than an average household. Those who choose temporary shelters like lodges find cooking facilities inaccessible even after receiving raw materials. Steps to provide cooked food are taken in transgender care homes. Special arrangements for vaccinating transgenders and providing kits containing sanitizers and masks are under process to ensure coverage in the second wave. Kerala’s Kudumbashree system (Women Self Help Group) has empowered transgender ‘neighbourhood groups’ in eight districts that enthusiastically worked towards public service during COVID-19. Augmentation of such groups across the state and country can prove highly effective. The government welcomed 0.015% transgenders who enrolled in as COVID-19 volunteers in the pandemic control activities of the state.[6] Transgender identity options are being included in all Kerala government application forms to aid in identification and improve service coverage to the invisible pocket-sects of this populace. Health workers may be motivated further to give equitable care by promoting provision for essential primary medical and advanced care through telemedicine services, addressing mental health issues to provide psychosocial support amidst the pandemic scare and infection. Financial support and sponsorship SHSRC-K Conflicts of interest There are no conflicts of interest.

The lesbian, gay, bisexual and transgender communities' mental health care needs and experiences of mental health services: An integrative review of qualitative studies.

INTRODUCTION: The lesbian, gay, bisexual and transgender (LGBT) communities are a minority population that experience a range of health disparities, including mental health. Because these groups have higher rates of mental disorder than the general population it is, therefore, pertinent to identify their specific mental health needs and their experiences when accessing mental health care. To identify the mental health needs of the LGBT communities and their experiences of accessing mental health care. An integrative review of qualitative studies was conducted. A total of fourteen studies were selected for this review. The studies identified that participants' experiences of accessing mental health care were related to (a) experiencing stigma and (b) staff's lack of knowledge and understanding of LGBT people's needs. They identified a need for mental health care that promotes the principles of equity, inclusion and respect for diversity. The LGBT communities while not a homogenous group, face unique challenges when dealing with their mental health needs. Services that promote health equity and self-acceptance are important for this group. It is vital that mental health nursing education incorporate models that promote equity, inclusion and respect for diversity regarding this group of people.

Longitudinal Use of the Consolidated Framework for Implementation Research to Evaluate the Creation of a Rural Center of Excellence in Transgender Health.

Background: Transgender people face numerous barriers to accessing care, particularly in rural settings. Transportation, travel time, a lack of providers offering transgender care, and discrimination all contribute to these barriers. The Gender Wellness Center was established in New York State, USA, to fill a gap in rural transgender care and was subsequently awarded a Robert Wood Johnson Foundation grant to establish a Center of Excellence. This study examined the implementation of the Center of Excellence, a complex intervention, to assess barriers and facilitators to implementation over 18 months. Methods: The Consolidated Framework for Implementation Research (CFIR) was used to develop baseline and follow-up surveys. These were distributed to members of the core implementation team at the Gender Wellness Center at the midpoint and conclusion of the Robert Wood Johnson Foundation grant. Responses were largely open-ended and analyzed qualitatively. Results: Results are presented in terms of CFIR domains and constructs, as well as the relative outlook (positive or negative) of implementation. Overall, there were improvements over time, with more encouraging feedback and examples of success at follow-up. Though true, organizational culture and individual beliefs about the provision of transgender care challenged implementation of the Center of Excellence throughout the project. Conclusions: This study highlights the importance of organizational culture on implementation efforts, as well as the need for complex, multifaceted interventions to overcome such challenges in order to improve care for marginalized populations.

“Gender Dysphoria”: Therapist Negotiations of Oppressive Practices

It has long been demonstrated that psychological and psychiatric fields pathologise and discipline certain bodies. However, few have explored practitioners’ resistance to, and critiques of, gender oppressive practices. Drawing from theoretical frameworks of transgender studies and queer theory, this paper reports on qualitative data gathered from semi-structured interviews with six therapists in Sydney, Australia. Case studies highlight the ruptures, dissonances, and possibilities of transgender and gender diverse (TGD) mental health care in practice. Thematic analysis of therapist case studies demonstrates how notions of “allyship” are inadequate in problematising power dynamics, binary gender, and cisgenderism, as therapists engaged in problematic discourses and practices in relation to their TGD clients. Exploring the limitations of traditional gatekeeping models, the paper situates counselling and psychotherapy practices within an Australian context as holding unique opportunities to engage in anti-oppressive practice with TGD clients. The research makes clear that active frameworks for challenging oppression in the lives of clients are essential to ethical, client-centred work.

Characterisation of testicular function and spermatogenesis in transgender women.

Does gender-affirming treatment prevent full spermatogenesis in transgender women (TW)? Adequate hormonal therapy (HT) leads to complete suppression of spermatogenesis in most TW, if serum testosterone levels within female reference ranges are obtained. Gender-affirming treatment in transgender individuals may involve gender-affirming HT. The effects on spermatogenesis in TW remain unclear. In order to add information from a referral centre for transgender care, we wish to compare results of earlier studies with our population of TW who received a standard hormone treatment. This was a prospective cohort study part of the European Network for the Investigation of Gender Incongruence (ENIGI), conducted between 15 February 2010 and 30 September 2015. There were 162 TW were included in the ENIGI study at the Ghent University Hospital in Belgium. Participants are included in ENIGI when they first start HT, and follow-up visits occur over the next 3 years. The study included 97 TW who initiated HT with cyproterone acetate (CPA) plus oestrogens and proceeded with gonadectomy at the Ghent University Hospital. Testicular tissue retrieved during gonadectomy was processed and stained for four different germ cell markers by the Biology of the Testis lab at the Vrije Universiteit Brussel. Subsequent immunohistochemical staining was performed for melanoma-associated antigen A4 (MAGE-A4, marker for spermatogonia and early spermatocytes), boule homologue, RNA-binding protein (BOLL, marker for secondary spermatocytes and round spermatids), cAMP-responsive element modulator (CREM, marker for round spermatids) and acrosin (marker for acrosome visualization). Serum levels of sex steroids were measured prior to surgery. Suppressed testosterone levels (<50 ng/dl) were found in 92% of the participants prior to surgery. The mean time between initiation of HT and surgery was 685 days. In 88% (85/97) of the sections, MAGE-A4 staining was positive. Further staining could not reveal complete spermatogenesis in any participant. Testicular function of the participants prior to initiation of HT was not assessed, although all participants presented with cisgender male serum testosterone values before initiation of HT. The current study only reports on people using CPA at a fixed dose and may therefore not be applicable to all TW. HT leads to complete suppression of spermatogenesis in most TW, if serum testosterone levels within female reference ranges are obtained. Serum testosterone levels are associated with the sperm maturation rate. It is important to discuss sperm preservation before the start of hormone therapy. If serum testosterone levels remain higher, spermatogenesis may still occur. D.V.S. is a post-doctoral fellow of the Fonds Wetenschappelijk Onderzoek (FWO; 12M2819N). Processing of the testis specimens was funded by the Biology of The Testes (BITE) research group (Department of Reproduction, Genetics and Regenerative medicine at Vrije Universiteit Brussel (VUB)). There are no competing interests. N/A.

Fertility Preservation: A Tale of Two Testicles

The transgender population has long been marginalized by society. Societal stigmata, fear to seek care, and dearth of provider knowledge regarding transgender health issues has caused disparities to widen. The purpose of this case study is to call to attention the often-overlooked aspect of transgender care: the importance of fertility preservation prior to undergoing therapy. 13 and 16-year old genetically XY patients presented to a tertiary care facility for gender affirmation. Both self-identified as female since a young age and successfully socially transitioned. Impending onset and/or progression of puberty prompted patients to seek hormonal therapy. Fortunately, physicians in transgender clinic were aware of fertility struggles after undergoing hormone therapy and referred for consultation. Sperm cryopreservation via open gonadal biopsy, tissue cryopreservation, and semen sample were discussed. Though invasive, biopsy relieves patients of the psychological impact of sample production and is indicated in pubertal immaturity. After further discussion with patients and parents, the 13-year-old decided to undergo testicular biopsy while the 16-year old opted for semen sample. Both patients had success and their genetic material was cryopreserved for future assisted reproduction. Gender affirming procedures and hormone therapy affect the long-term reproductive potential of transgender individuals. While cost concerns and insurance coverage regarding oncofertility is a prominent area of discussion, the transgender community is often excluded. With more individuals beginning medical and surgical therapy at a younger age, fertility preservation discussions are essential but often overlooked, depriving these individuals the joy of becoming a biological parent.

Understanding Male to Female Transgender Surgery and Associated Complications—a Comprehensive Review

Recent social, legal, and medical advances have significantly increased transgender visibility and the need for widely available access to care for these patients. The past decade has seen an increase in the literature providing insight into the demographics, access to care, and surgical techniques related to transgender care. This review attempts to offer a basic overview of male-to-female transgender surgery, with insights into the major complications that may occur intraoperatively or postoperatively. Overall, the field of transgender reconstructive surgery is relatively nascent, and with increasing advances in surgical techniques and postoperative management, some of these complications may be addressed and avoided.

The Ethical Justification for Conscience Clauses in Nurse-Midwifery Practice: Context, Power, and a Changing Landscape.

In the last century, conscientious objection has moved from objection to conscripted military service to include health care providers who have moral concerns about participation in specific aspects of health care. Although guidance for the use of conscientious objection has developed in both nursing and midwifery, changes in the political landscape may be creating a source of conflict between providers and the use of conscientious objection. Particularly in aspects of sexual and reproductive care like abortion, contraception, and lesbian, gay, bisexual, transgender, or queer health care, the ethical requirement for prompt referral is becoming increasingly difficult to meet in many contexts. Changes to federal regulations protecting conscience clauses have tilted strongly in favor of the rights of providers in recent years; this challenges the delicate balance of patient and provider rights that has developed over the years. These may now represent an unavoidable conflict between different aspects of the ethical obligations of providers, in particular the obligation to seek justice, and bring into question whether the current status of conscientious objection is sustainable. In this article, we examine these conflicts in the context of the current political climate.

Variation in sensitivity and rate of change in body composition: steps toward individualizing transgender care.

Transgender individuals sometimes report a lack of physical change during hormone treatment, such as alterations in muscle tone or fat distribution. Identifying characteristics of this subgroup could be a step toward individualizing hormone therapy in transgender individuals. Therefore, we study the variation of changes in body composition and characteristics associated with a lack of change. Body composition measures were recorded in 323 transmen and 288 transwomen at every visit from the start of hormone therapy to a maximum of 24 months follow-up. Absence of change was defined as transmen with a decrease in lean body mass or transwomen with a decrease in fat percentage. A lack of change at 24 months was observed in 19 of 94 (20.2%) transmen and in 9 of 96 (9.4%) transwomen. The risk of not achieving change in body composition was related to lower testosterone levels and less suppression of LH in transmen (OR: 0.67, 95% CI: 0.48-0.94 per SD increase in testosterone and OR: 1.36, 95% CI: 1.01-1.83 per SD increase in LH). There is a large variation in body composition changes during hormone therapy, with a substantial proportion of individuals with no measurable effects. In transmen, serum testosterone and LH were associated with a lack of change, but serum hormone levels were not associated with body composition changes in transwomen. The results provide a rationale for individualizing hormone therapy in transmen, by considering individual effects rather than solely relying on a standardized dosage of hormone therapy.

Military transgender care.

Transgender individuals have a long-standing history of honorable service in the United States Military. However, politics have had an impact on their ability to openly serve in uniform as policies continually change rapidly with each new administration. This article describes the shifting political landscape of policies related to whether (or not) transgender individuals can serve in the military, and how this has affected the health care experiences of transgender individuals and the ability for nurse practitioners to provide quality health care to the transgender population serving on active duty.

Principles of Transgender Care for the Primary Care Physician

The term transgender includes people whose gender identity differs from their sex assigned at birth. People identified as male at birth but possess a female gender identity are called transwomen and people identified as female at birth but experience a male gender identity are called transmen. Transgender individuals may also identify outside the binary norm.&#x0D; The prevalence of transgender people who seek medical treatment has dramatically increased in recent years. Transgender individuals have a higher prevalence of mental health problems, suicidality and premature mortality risk versus the general population. However, many transgender persons avoid medical care due to perceived stigma, in conjunction with transgender-specific knowledge deficits among health care providers.&#x0D; Integral to understanding transgender health is the concept of gender dysphoria. This refers to the internal conflict individuals experience due to incongruence between their birth sex and their self-perceived gender. For these individuals, the inconsistency causes significant internal conflict, often to the point that it interferes with functioning.&#x0D; To address gender dysphoria, many transgender people elect to transition to a gender role that is consistent with their gender identity. These individuals opt for medical and/or surgical interventions to do so. Medical therapy incorporates the use of cross-sex hormones to facilitate the acquisition of secondary sexual characteristics consistent with the individual’s internalized identity. Many transgender people choose to undergo gender-confirming surgeries in conjunction with hormonal therapy.&#x0D; Health care is transgender-affirming when it supports the patient’s inherent identity. Educating providers about this population’s unique needs can help reduce health disparities and promote respectful transgender care.

Feminizing Genital Gender-affirmative Surgery in Centralized and Decentralized Health Care Settings - The Hamburg TransCare study

Gender Dysphoria (GD, formerly known as transsexualism) describes distress and impairment in an individual caused by the incongruence between the experienced gender and the sex assigned at birth (Gender Incongruence: GI). Transgender health care focusses on gender-affirmative treatments (e. g., hormone therapy) and associated needs (e. g., psychotherapy). Moreover, genital surgery is considered an effective treatment to reduce GI/GD and improve mental health and quality of life. Interdisciplinary cooperation between the associated medical facilities is regarded as evidence-based health care. To date, THC is delivered in zwei different health care settings: interdisciplinary and centralized from one medical institution vs. decentralized, spread over several medical institutions. In Germany, individuals with GI/GD access health care mostly in decentralized structures. The consequences of feminizing genital surgery carried out in centralized and decentralized health care structures in terms of quality and effectiveness have not been investigated so far. The goal of the TransCare study is to prospectively examine individuals with GI/GD seeking feminizing genital surgery regarding demographics and clinical characteristics as well as to analyze the influence of centralized and decentralized health care settings on the psychosocial and clinical outcome. To recruit a valid and comprehensive sample, participants were questioned prospectively. The results of the study should help gain new insights into the influence of centralized and decentralized health care settings carrying out feminizing genital surgery on psychosocial and clinical outcomes for the patients. Based on the TransCare study, we suggest that health care should be improved according to individual patient needs.

The effect of early puberty suppression on treatment options and outcomes in transgender patients.

In the past 10-15 years, paediatric transgender care has emerged at the forefront of several general practice and subspecialty guidelines and is the topic of continuing medical education for various medical disciplines. Providers in specialties ranging from family medicine, paediatrics and adolescent medicine to endocrinology, gynaecology and urology are caring for transgender patients in increasing numbers. Current and evolving national and international best practice guidelines recommend offering a halt of endogenous puberty for patients with early gender dysphoria, in whom impending puberty is unacceptable for their psychosocial health and wellness. Pubertal blockade has implications for fertility preservation, transgender surgical care and psychosocial health, all of which must be considered and discussed with the patient and their family and/or legal guardian before initiation.

Considerations for Providing Pediatric Gender-Affirmative Care During the COVID-19 Pandemic

Considerations for Providing Pediatric Gender-Affirmative Care During the COVID-19 Pandemic

Athletic Trainers' Competence, Education, and Perceptions Regarding Transgender Student-Athlete Patient Care.

Transgender student-athletes are increasingly participating in sport, requiring athletic trainer (AT) preparedness to care for their needs. To measure ATs' (1) perceived definition of transgender, (2) comfort and competence working with transgender student-athletes, (3) sources of education, (4) perceived legal concerns, and (5) perception of competitive advantage. Cross-sectional study. Mixed-methods survey. Collegiate or university ATs (n = 5537) received an email invitation to participate; the data of 667 ATs were included in the analysis. A multipart 43-item questionnaire addressing the primary objectives of the study, with other factors that were explored in relation to these objectives to uncover potential influences on their responses. We calculated descriptive statistics, and for open-ended responses, we used the consensual qualitative research tradition. About half (48.1%, n = 321) of the participants agreed they were competent in treating transgender patients, but only 36.0% (n = 240) believed they were competent in practicing collaboratively with an endocrinologist in the drug-screening processes. Fewer than half (45.6%, n = 304) of participants felt they were competent in using appropriate terminology relating to transgender patients. The ATs disagreed when asked if they were competent regarding counseling transgender patients about the effects of hormone replacement therapy on sport participation (48.1%, n = 321) or on mental health concerns (40.3%, n = 269). Participants learned most frequently from media outlets (35.2%, n = 235) or personal experiences with family, friends, or themselves (33.7%, n = 225), yet 35.1% (n = 243) received no education in caring for transgender patients. Many ATs (41.2%, n = 278) believed that transgender female student-athletes had a competitive advantage. In contrast, 6.6% (n = 44) of participants indicated that transgender male student-athletes had a competitive advantage. Although collegiate ATs generally felt competent in treating transgender patients, they did not feel capable of addressing specific aspects of transgender patients' health care needs. Regardless of the resulting perceived unfair advantage, ATs must be aware of the regulations and therapeutic effects associated with hormone-related therapy for transgender student-athletes.

Primary Care Considerations for Transgender and Gender-Diverse Youth.

1. Jason R. Rafferty, MD, MPH, EdM*,†,‡ 2. Abigail A. Donaldson, MD†,‡ 3. Michelle Forcier, MD, MPH†,‡ 1. *Thundermist Health Centers, Woonsocket, RI 2. †Rhode Island Hospital/Hasbro Children’s Hospital, Providence, RI 3. ‡Warren Alpert Medical School of Brown University, Providence, RI * Abbreviations: FDA: : Food and Drug Administration GnRH: : gonadotropin-releasing hormone HEEADSSS: : Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Safety, Suicide, Strengths PPCP: : pediatric primary care provider TGD: : transgender and gender diverse Pediatric primary care providers must recognize that developmentally appropriate, gender-affirming approaches to the care of transgender and gender-diverse youth are necessary to reduce comorbidities, including high rates of suicide. After completing this article, readers should be able to: 1. Describe the developmental context for emerging gender identity in children. 2. Identify ways in which clinicians can explore gender development as a part of routine pediatric care. 3. Recognize that early identification and affirmation of gender identity is essential to engaging supports and promoting positive mental health outcomes. 4. Describe approaches and options for care available to transgender and gender-diverse youth and their families. 5. Recognize the potential medical and mental health disparities and risks faced by this historically marginalized population. Pediatric primary care providers (PPCPs) establish care with patients at birth and manage individuals throughout childhood, adolescence, and young adulthood. Thus, pediatricians are uniquely situated to screen, identify, and care for transgender and gender-diverse (TGD) youth. Large, systematic prevalence studies of TGD identity in children have not been conducted. (1) A 2016 national survey estimated that 0.6% of adults in the United States identify as transgender. This is approximately 1.5 million people and is twice the prevalence found a decade earlier. (2) Estimates suggest that today’s adolescents identify as transgender more often than adults. (1) As children and adolescents become increasingly aware of gender diversity, PPCPs should be attentive to physical and emotional cues that point to gender-related distress. Early identification of potential distress, supported exploration of identity, and affirmation foster healthy growth and development in a particularly vulnerable …

The Desire and Status of Gender-Affirming Hormone Therapy and Surgery in Transgender Men and Women in China: A National Population Study

BackgroundGender-affirming hormone therapy and surgery are important medically necessary approaches to transgender care. However, few related data exist in China. AimTo understand the desire and access of transgender cares in the Chinese transgender men and women population. MethodsA cross-sectional self-selecting survey targeting the Chinese transgender population was conducted in 2017 using a snowball sampling method. Participants completed an online questionnaire anonymously. Gender identity was verified by specifically designed questions. Data analysis of this study was performed in 2019. OutcomesThe main outcome was the status of receiving transgender medical care, including the desire vs actual state of receiving gender-affirming hormone treatment and gender-affirmation surgery, methods of accessing hormonal therapy and surgery, and risky behaviors associated with obtaining treatments. ResultsOf the total 2060 valid questionnaires, there were 1,304 transgender individuals (626 transgender men and 678 transgender women), with a median age of 22 (interquartile range, 19–26) years. Among them, 1,036 (79.4%) expressed desires for hormonal therapy, but of 1,036, 741 (71.5%) considered it difficult to obtain medications from doctors. Of 1,036 individuals, 275 (26.5%) and 172 (16.6%) had thoughts or behaviors of self-injury, respectively, when lacking access to hormone therapy. Of 1,036 individuals, 602 (58.1%) had used hormones. Of those 602 hormone users, 407 (67.6%) had ever obtained medications from informal drug dealers, and 372 (61.8%) of them did not perform regular monitoring. 868 of 1,303 (66.6%) participants had received or wanted to undergo gender-affirming surgeries, but 710 of 868 (81.8%) considered the surgery resources not adequate or very scarce. Clinical ImplicationsThe transgender medical resources in China are scarce, and many transgender individuals have engaged in high-risk activities to access care. Strengths & LimitationsThis is the first study to focus on the current status of gender-affirming hormone therapy and surgery in the Chinese transgender population, providing valuable and real-world data for understanding the need for transgender health care in China. But, the online questionnaire could not provide the prevalence and other epidemiologic information about transgender individuals in China, and the survey did not address specific medication regimens, dosages, sex hormone levels, and specific hormone therapy–related or surgery-related adverse events. ConclusionSignificant improvement in access to gender-affirming medical and surgery care is needed in China.Liu Y, Xin Y, Qi J, et al. The Desire and Status of Gender-Affirming Hormone Therapy and Surgery in Transgender Men and Women in China: A National Population Study. J Sex Med 2020;17:2291–2298.

Theory and practice of integrative clinical ethics support: a joint experience within gender affirmative care

BackgroundClinical ethics support (CES) aims to support health care professionals in dealing with ethical issues in clinical practice. Although the prevalence of CES is increasing, it does meet challenges and pressing questions regarding implementation and organization. In this paper we present a specific way of organizing CES, which we have called integrative CES, and argue that this approach meets some of the challenges regarding implementation and organization.MethodsThis integrative approach was developed in an iterative process, combining actual experiences in a case study in which we offered CES to a team that provides transgender health care and reflecting on the theoretical underpinnings of our work stemming from pragmatism, hermeneutics and organizational and educational sciences.ResultsIn this paper we describe five key characteristics of an integrative approach to CES; 1. Positioning CES more within care practices, 2. Involving new perspectives, 3. Creating co-ownership of CES, 4. Paying attention to follow up, and 5. Developing innovative CES activities through an emerging design.ConclusionsIn the discussion we compare this approach to the integrated approach to CES developed in the US and the hub and spokes strategy developed in Canada. Furthermore, we reflect on how an integrative approach to CES can help to handle some of the challenges of current CES.