Development of a Minority Stress Preventive Intervention for Sexual and Gender Minority Youth and Young Adults

Mental health disparities amongst sexual and gender minority (SGM) individuals are spurred by exposure to minority stressors and sustained by mediators of problems with emotion regulation, social support, and cognitive processes. Emerging clinical research suggests empirically supported behavioral health treatments can be culturally adapted to address these mental health disparities, however less work has focused on the prevention of symptoms. The present study developed a brief preventive intervention targeting mediators of the minority stress model for SGM youth and young adults aged 17 to 26. Focus groups with 8 SGM participants informed development to ensure the content and delivery of the intervention was culturally appropriate. Intervention components included psychoeducation on the minority stress model, skills for emotion regulation, compiling lists of local affirming resources, and practice of cognitive restructuring techniques with internalized stigma examples. Twenty-six participants, in 4 cohorts, received the 90-minute intervention in a multiple baseline design trial to establish preliminary feasibility and efficacy. Participants completed measures of internalizing symptoms, emotion regulation, social support, stress appraisal, and internalized stigma every 2 weeks for 5 time-points. Participants rated the intervention as successful, logical, and appropriate for SGM youth and young adults. Limited change was seen in outcome measures at follow-up time-points. Onset of the COVID-19 pandemic necessitated changes to the intervention delivery mode, and along with factors such as limited dosing, may explain lack of improvement on distal outcome measures. With further refinement, this brief preventive intervention can easily be delivered to SGM youth and young adults to provide skills and resources for coping with minority stress. Advisor: Debra A. Hop

The Often‑Circuitous Path to Affirming Mental Health Care for Transgender and Gender‑Diverse Adults

Purpose of Review We describe recent research regarding access to affirming mental health services for transgender and gender-diverse (TGD) adults and explore new resources available for therapists to inform evidence-based practice with TGD clients. Recent Findings Barriers and facilitators at all socioecological levels impact TGD adults’ mental health help-seeking. TGD adults often interface with mental health providers while accessing gender-affirming medical care, though new standards of care are likely to alter this typically common path to mental health services. Efforts to improve therapist education, such as therapy manuals, are increasingly available and a necessary step to increase the number of competent, affirming therapists. Summary More work—both advocacy and research—is needed to fully expand accessible, affirming mental health services for TGD adults. Better understanding factors impacting different steps of the mental health help-seeking process and conducting randomized controlled trials of affirming mental health services are important next steps

First impressions online: The inclusion of transgender and gender nonconforming identities and services in mental healthcare providers’ online materials in the USA

Background: When accessing mental healthcare services, transgender and gender nonconforming (TGNC) individuals face systemic barriers to gender-affirmative care. Initial points of contact, like intake forms, may show limited consideration for the heterogeneity of TGNC identities and can lead to negative consequences prior to face-to-face interaction with providers. Aims: The first aim was to mimic a likely pathway a TGNC individual may follow to seek mental healthcare services in the USA and to describe the extent to which they may encounter enacted stigma or affirmative messages that may impede or facilitate access to care. The second aim was to determine if a positive State legal climate for TGNC people was associated with more affirmative provider materials. Methods: Content analysis was used to examine a national sample of websites and intake forms of mental healthcare providers who advertise online as working with TGNC clients. Intake forms were coded for usage of affirmative language in gender/sex questions and including questions for a client’s pronouns and preferred name. Websites were coded for mentioning a variety of services or resources for TGNC clients. Results: While provider websites were found through Google searches for a “gender therapist,” only 56.6% of websites stated a provider specialty to work with TGNC clients and 32.1% of websites had no mention of services or resources for TGNC people. Additionally, a significantly larger proportion of intake forms from States with legal protections for TGNC people used affirmative language in gender/sex questions and asked for a client’s pronouns than intake forms from States without legal protections. Discussion: Barriers to affirmative healthcare for TGNC people within patient and provider interactions have been identified in previous research and these data show TGNC individuals may face enacted stigma even in their search for a provider, particularly those TGNC people living in States without legal protections

Modeling age-related changes in muscle-tendon dynamics during cyclical contractions in the rat gastrocnemius

Efficient muscle-tendon performance during cyclical tasks is dependent on both active and passive mechanical tissue properties. Here we examine whether age-related changes in the properties of muscle-tendon units (MTUs) compromise their ability to do work and utilize elastic energy storage. We empirically quantified passive and active properties of the medial gastrocnemius muscle and material properties of the Achilles tendon in young (∼6 mo) and old (∼32 mo) rats. We then used these properties in computer simulations of a Hill-type muscle model operating in series with a Hookean spring. The modeled MTU was driven through sinusoidal length changes and activated at a phase that optimized muscle-tendon tuning to assess the relative contributions of active and passive elements to the force and work in each cycle. In physiologically realistic simulations where young and old MTUs started at similar passive forces and developed similar active forces, the capacity of old MTUs to store elastic energy and produce positive work was compromised. These results suggest that the observed increase in the metabolic cost of locomotion with aging may be in part due to the recruitment of additional muscles to compensate for the reduced work at the primary MTU. Furthermore, the age-related increases in passive stiffness coupled with a reduced active force capacity in the muscle can lead to shifts in the force-length and force-velocity operating range that may significantly impact mechanical and metabolic performance. Our study emphasizes the importance of the interplay between muscle and tendon mechanical properties in shaping MTU performance during cyclical contractions

A Systematic Review of Recommendations for Behavioral Health Services for Transgender and Gender Diverse Adults: The Three-Legged Stool of Evidence-Based Practice is Unbalanced

There is a growing literature of clinical recommendations for transgender and gender diverse (TGD) affirming behavioral health care, yet it is unknown to what extent these recommendations are rooted in evidence-based practice (EBP). This systematic review included 65 articles published between 2009 and 2018 with recommendations for behavioral health services with TGD adults, emphasizing general clinical care. Coded variables included type of article, participant demographics, aspects of EBP, and whether care was informed by objective assessment. Most articles did not equally draw from all components of EBP. Recommendations for specific clinical problems are increasingly available and address diversity within TGD communities. More research, including clinical trials adapting established interventions, is needed to inform state-of-the-art TGD-affirmative behavioral health care

Specialists in Name or Practice? The Inclusion of Transgender and Gender Diverse Identities in Online Materials of Gender Specialists

Recommendations for health care providers working with transgender and gender diverse (TGD) individuals emphasize affirming clients’ identities, such as using correct pronouns and name, however it is unknown how often gender specialists adhere to such recommendations. Websites and intake forms of gender specialists were coded for use of affirming language, asking for pronouns and chosen name, and mention of TGD specialties and resources. Most websites identified the provider’s specialty to work with TGD individuals, though much fewer provided additional resources concerning TGD issues and only half of intake forms included affirming language. Given previous research that has demonstrated providers working in states with legal protections for TGD individuals use affirming language more often than providers in locales without protections, association with state legal climate is also examined

The Provider Perspective on Behavioral Health Care for Transgender and Gender NonConforming Individuals in the Central Great Plains: A Qualitative Study of Approaches and Needs

Purpose—Transgender and gender nonconforming (TGNC) individuals interact with mental health care systems at high rates and experience substantial barriers to care. Rural TGNC individuals face additional disparities in accessing appropriate mental health services. Little research has focused on the mental healthcare providers who work with TGNC individuals in underserved areas. The current study sought to describe the mental health care services delivered by providers perceived as affirming by TGNC community members in the Central Great Plains. Methods—We conducted qualitative interviews with 10 providers to understand how providers seek cultural competency and conceptualize and work with their TGNC clients given the barriers to care. Results—Providers held diverse theoretical orientations and described challenges to working with TGNC clients including the impact of stigma and marginalization and financial and structural barriers to care. Emphasis was placed on individualizing care, helping clients manage stigma and build resiliency, connecting clients to resources (when available) and support systems, and navigating the intersections of physical health care and mental health care such as writing letters for medical transition. Providers largely educated themselves on TGNC topics and had previous experience working with marginalized populations. Conclusions—Overall, the providers’ approaches to working with TGNC clients mapped on to models of cultural competency but few providers described their work in the context of an evidence-based model. Implications for increasing the quality and availability of mental health care services for TGNC individuals in underserved areas are discussed. Public Policy Statement—Affirming mental healthcare providers working with transgender and gender nonconforming (TGNC) clients in underserved areas strive towards cultural competency, but lack of resources and structural barriers to care prohibit wide dissemination of affirming evidence-based care. This study highlights the need for increased research and evidence-informed policy regarding the delivery of mental health services to TGNC individuals in underserved areas

A Review of Contemporary Assessment Tools for Use with Transgender and Gender Nonconforming Adults

There is increasing recognition of the need for culturally sensitive services for individuals who identify as transgender and gender nonconforming (TGNC), and only recently have empirical studies appeared in the literature that inform best practices for TGNC people. Competent, culturally appropriate clinical services and research depend upon methodologically sound assessment of key constructs, but it is unclear whether appropriate self-report or clinician-rated assessment tools for adults exist. This article reviewed existing published measures to identify areas of strength as well as existing gaps in the available research. The search strategy for this systematic review identified any published article describing a self-report or clinician-rated scale for assessing transgender-related concerns. Each measure was reviewed for information on its scope, reliability, validity, strengths, limitations, and source. The majority of these questionnaires was developed with the TGNC communities and targeted important factors that affect quality of life for TGNC people. Limitations included limited evidence for validity, reliability, and sensitivity to change. Overall, the field is moving in the direction of TGNC-affirming assessment, and promising measures have been created to monitor important aspects of quality of life for TGNC people. Future research should continue to validate these measures for use in assessing clinical outcomes and the monitoring of treatment progress

Test–Retest Reliability and Sensitivity of a Brief Clinical Monitoring Measure for Transgender and Gender Diverse Adults: The Trans Collaborations Clinical Check-In (TC\u3csup\u3e3\u3c/sup\u3e)

The current study aimed to examine the test–retest reliability and sensitivity of the Trans Collaborations Clinical Check-In (TC3) in a 3-month period with four assessment points at baseline, 1, 2, and 3 months to examine its utility as a clinical progress monitoring measure. This study builds on the initial validation study conducted by Holt et al. (2019). The sample of 32 transgender and gender diverse (TGD) participants were chosen who met screening for at least modest depression and anxiety, and did not have other significant risk factors (e.g., mania, self-harm). Participants completed a battery of measures that assessed mood, well-being, and gender-related constructs at each of the time points in addition to demographic questionnaires. Overall, the TC3 exhibited excellent test–retest reliability. While there was no systematic change in scores, there was some random variation of scores around the mean; and large, within-person correlations between time points. The TC3 also demonstrated convergence with many of the gender-related constructs, and to a lesser degree demonstrated criterion validity with mental health constructs. Further longitudinal study with larger samples in addition to study within intervention frameworks are necessary next steps to understand the utility of the TC3 for assessing systematic change over time. Overall, the current study highlights the initial utility of the TC3 to measure aspects of gender-related well-being across time, such as during health or behavioral health services. Public Significance Statement -- The overall findings of the study suggest that the Trans Collaborations Clinical Check-In (TC3) is a valid and reliable tool for use with transgender and gender diverse (TGD) people in clinical settings, which addresses the dearth of validated, brief TGD-specific assessments that are routine essentials for providing evidence-based care

Keeping the Promise of Community-Based Participatory Research: Integrating Applied Critical Rhetorical Methods to Amplify the Community’s Voice for Trial Development

Community-based participatory research (CBPR) represents an important improvement in the integration of marginalized voices into research programs by including community members in the designs, conduct, and dissemination of studies. CBPR often features a social justice component, generating studies designed to reduce societal disparities and improve outcomes for disenfranchised groups. However, the practical implementation of CBPR usually fails to capitalize on this promise, using the same traditional research methodologies, leadership structures, trial designs, and research questions that inculcate researcher bias. In response to the problem, we propose a new solution: Applied critical rhetorical research (ACRR) integrated into the CBPR approach to clinical health research. ACRR research combines critical/cultural studies and rhetorical methods to amplify the figurative voice of marginalized populations. ACRR can expose how majority power (i.e., hegemony) manifests in social institutions like healthcare and government, where its meanings and subjectivities are absorbed. ACRR analyses enhance CBPR by shaping research in directions that reduce stigma, unintended disenfranchisement, and culturally bound bias, increasing the yield from CBPR for researchers and the community