Gender Identity, Disability, and Unmet Healthcare Needs among Disabled People Living in the Community in the United States

Disabled adults and transgender people in the United States face multiple compounding and marginalizing forces that result in unmet healthcare needs. Yet, gender identity among disabled people has not been explored, especially beyond binary categories of gender. Using cross-sectional survey data, we explored the rates of disability types and the odds of unmet healthcare needs among transgender people with disabilities compared to cisgender people with disabilities. The rates of disability type were similar between transgender and cisgender participants with two significant differences. Fewer transgender participants identified physical or mobility disability as their main disability compared to cisgender participants (12.31%/8 vs. 27.68/581, p < 0.01), and more transgender participants selected developmental disability as their main disability compared to cisgender participants (13.85%/9 vs. 3.67%/77, p < 0.001). After adjusting for sociodemographic characteristics, the odds of disabled transgender participants reporting an unmet need were higher for every unmet need except for preventative services

Androgenetic alopecia in transgender and gender diverse populations: A review of therapeutics

Androgenetic alopecia (AGA) management is a significant clinical and therapeutic challenge for transgender and gender-diverse (TGD) patients. Although gender-affirming hormone therapies affect hair growth, there is little research about AGA in TGD populations. After reviewing the literature on approved treatments, off-label medication usages, and procedures for treating AGA, we present treatment options for AGA in TGD patients. The first-line treatments for any TGD patient include topical minoxidil 5% applied to the scalp once or twice daily, finasteride 1 mg oral daily, and/or low-level laser light therapy. Spironolactone 200 mg daily is also first-line for transfeminine patients. Second-line options include daily oral minoxidil dosed at 1.25 or 2.5 mg for transfeminine and transmasculine patients, respectively. Topical finasteride 0.25% monotherapy or in combination with minoxidil 2% solution are second-line options for transmasculine and transfeminine patients, respectively. Other second-line treatments for any TGD patient include oral dutasteride 0.5 mg daily, platelet-rich plasma, or hair restoration procedures. After 6-12 months of treatment, AGA severity and treatment progress should be assessed via scales not based on sex; eg, the Basic and Specific Classification or the Bouhanna scales. Dermatologists should coordinate care with the patient\u27s primary gender-affirming clinician(s) so that shared knowledge of all medications exists across the care team

Development and Validation of Urological and Appearance Domains of the Post-Affirming Surgery Form and Function Individual Reporting Measure (AFFIRM) for Transwomen following Genital Surgery

PURPOSE: As feminizing gender-affirming surgery becomes increasingly accessible, functional outcomes are increasingly relevant. We aimed to develop and validate the first patient-reported outcome questionnaire focusing on postoperative symptomatology and quality of life. MATERIAL AND METHODS: Questions were developed from interviews with postoperative transwomen followed by face validation from a multispecialty clinician group. The measure was co-administered with established relevant questionnaires for concurrent validity testing. Participants were asked to complete the questionnaire at baseline and at a 2-week retest interval. RESULTS: The AFFIRM questionnaire is a 33-item patient-reported outcome measure comprising Appearance, Urological and Gynecologic domains, each scored to create a composite AFFIRM score. A total of 102 women participated, with 60% completing the test-retest. The overall Cronbach\u27s α for AFFIRM was 0.79, and domain α for AFFIRM-A, AFFIRM-U and AFFIRM-G was 0.85, 0.87 and 0.42, respectively. Test-retest demonstrated score reliability (z values -1.862 to -0.005, p \u3e0.05) with intraclass coefficients demonstrating moderate to good absolute correlation (0.54 to 0.88). The AFFIRM-A and AFFIRM-U correlated well with the Genital Appearance Satisfaction Measure and Urinary Distress Inventory-6, respectively (ρ 0.556 and 0.618, p \u3c0.001); 89% of participants confirmed congruence between their external genitalia and gender identity, 87.8% reported clitoral sensation and 75.6% expressed satisfaction with vaginal caliber. Reported symptoms included a misdirected urinary stream (68.9%), nocturia (51.3%), urinary frequency (29.7%) and vaginal pain (46.7%). CONCLUSIONS: Transwomen have diverse symptoms not captured by unstructured questions or cisgender questionnaires. The AFFIRM questionnaire is the first tool available to reliably evaluate outcomes following feminizing gender-affirming surgery

Sexual and gender minority health‐related content in geriatric fellowships

Abstract Introduction Despite a growing number of older lesbian, gay, bisexual transgender, and queer (LGBTQ) adults in the United States, education on care for this vulnerable population has historically been inadequate across all levels of training. This research assessed the extent of LGBTQ education in geriatric medicine fellowship curricula across the United States. Methods We designed a survey to anonymously collect information from geriatric medicine fellowship programs on LGBTQ curricular content. Eligible participants included all 160 fellowship directors on record with the American Geriatrics Society. The survey addressed demographics of the fellowship program, current state of inclusion of LGBTQ content in didactic curricula and in clinical settings, and other available training opportunities. Results Out of those contacted, 80 (50%) completed the survey. Of the programs surveyed, 60 (75%) were housed in internal medicine, 19 (24%) were in family medicine, and one was in their own department. Forty‐seven fellowships (59%) reported some formal didactic session (e.g., lecture or case based), with the majority of these programs (72%) featuring 1–2 h of formal instruction. Forty‐five programs (56%) reported offering no formal clinical experiences. There was less than 50% coverage for all surveyed topics in the required curriculum (range 46% for discrimination to 9% for gender affirming care). Time and lack of expertise were cited as the main barriers to content inclusion. Conclusions Curricular content regarding care for LGBTQ older adults is inadequate in geriatric medicine fellowships. Faculty development of current educators and providing standardized guidelines and curricula are steps toward addressing this deficit

Prevalence of HIV preexposure prophylaxis prescribing among persons with commercial insurance and likely injection drug use.

Importance: Although HIV preexposure prophylaxis (PrEP) implementation among persons who inject drugs has been inadequate, national HIV monitoring programs do not include data on PrEP, and specific trends in PrEP use are not well understood. Objective: To estimate HIV PrEP uptake among commercially insured persons with opioid or stimulant use disorder by injection drug use (IDU) status. Design, Setting, and Participants: This cross-sectional study used deidentified data from the MarketScan Commercial Claims and Encounters Database to identify a sample of 547 709 commercially insured persons without HIV but with opioid and/or stimulant use disorder, including 110 592 with evidence of IDU between January 1, 2010, and December 31, 2019. Data were analyzed from November 1, 2020, to July 1, 2021. Persons with opioid and/or stimulant use disorder and evidence of IDU were identified through claims data. Main Outcomes and Measures: The outcome was receipt of tenofovir disoproxil fumarate and emtricitabine for PrEP as identified from filled pharmacy claims. Multivariable logistic regression was used to assess the association of demographic and clinical characteristics with receipt of PrEP. Results: The study cohort included 211 609 (28.6%) females and 336 100 (61.4%) males with a combined mean (SD) age of 34.8 (13.1) years, including 110 592 individuals with evidence of IDU. During the study period, 508 (0.09%) persons with opioid and/or stimulant use disorder, including 170 (0.15%) with evidence of IDU, received PrEP. Receipt of PrEP increased from 0.001 to 0.243 per 100 person-years from 2010 through 2019 among the entire cohort and from 0.000 to 0.295 per 100 person-years among those with IDU. In multivariable analysis, PrEP use was more likely among males (adjusted odds ratio [aOR] 8.72; 95% CI, 6.39-11.89), persons with evidence of IDU (aOR, 1.47; 95% CI, 1.21-1.79), and persons with evidence of sexual risk indications for PrEP (aOR, 23.68; 95% CI, 19.57-28.66). Conclusions and Relevance: In this cross-sectional study of commercially insured persons with opioid and/or stimulant use disorder, HIV PrEP delivery remained low, including among those with evidence of IDU. PrEP should be consistently offered alongside substance use disorder treatment and other harm reduction and HIV prevention services

Health Care Satisfaction in Relation to Gender Identity: Behavioral Risk Factor Surveillance Survey, 20 States (2014-2018)

BACKGROUND: Health care satisfaction is a key component of patient-centered care. Prior research on transgender populations has been based on convenience samples, and/or grouped all gender minorities into a single category. OBJECTIVE: The objective of this study was to quantify differences in health care satisfaction among transgender men, transgender women, gender nonconforming, and cisgender adults in a diverse multistate sample. RESEARCH DESIGN: Cross-sectional analysis of 2014-2018 Behavioral Risk Factor Surveillance System data from 20 states, using multivariable logistic models. SUBJECTS: We identified 167,468 transgender men, transgender women, gender-nonconforming people, cisgender women, and cisgender men and compared past year health care satisfaction across these groups. RESULTS: Transgender men and women had the highest prevalence of being not at all satisfied with the health care they received (14.6% and 8.6%, respectively), and gender-nonconforming people had the lowest prevalence of being very satisfied with their health care (55.7%). After adjustment for sociodemographic characteristics, transgender men were more likely to report being not at all satisfied with health care than cisgender men (odds ratio: 4.45, 95% confidence interval: 1.72-11.5) and cisgender women (odds ratio: 3.40, 95% confidence interval: 1.31-8.80). CONCLUSIONS: Findings indicate that transgender and gender-nonconforming adults report considerably less health care satisfaction relative to their cisgender peers. Interventions to address factors driving these differences are needed

A Cross-sectional Survey of Internal Medicine Resident Knowledge, Attitudes, Behaviors, and Experiences Regarding Pre-Exposure Prophylaxis for HIV Infection

BackgroundPre-exposure prophylaxis (PrEP) for HIV is effective, yet many providers continue to lack knowledge and comfort in providing this intervention. It remains unclear whether internal medicine (IM) residents receive appropriate training in PrEP care and if this affects their future practices.ObjectiveWe sought to evaluate the relationship between current IM residents' prior PrEP training and knowledge, comfort, and practice regarding the provision of PrEP.Design and participantsWe created an online survey to assess IM residents' knowledge, attitudes, and behaviors related to PrEP. The survey was distributed among five IM programs across the USA.Key resultsWe had a 35% response rate. Of 229 respondents, 96% (n = 220) had heard of PrEP but only 25% (n = 51) had received prior training and 11% (n = 24) had prescribed PrEP. Compared with those without, those with prior training reported good to excellent knowledge scores regarding PrEP (80% versus 33%, p &lt; 0.001), more frequent prescribing (28% versus 7%, p = 0.001), and higher comfort levels with evaluating risk for HIV, educating patients, and monitoring aspects of PrEP (75% versus 26%, 56% versus 16%, and 47% versus 8%, respectively; all p values &lt; 0.0001). While only 25% (n = 51) had received prior training, 75% (n = 103) of respondents reported that training all providers at their continuity clinic sites would improve implementation.ConclusionsWe found that prior training was associated with higher levels of self-reported PrEP knowledge, comfort, and prescribing behaviors. Given the significant need for PrEP, IM residents should be trained to achieve adequate knowledge and comfort levels to prescribe it. This study demonstrates that providing appropriate PrEP training for IM residents may lead to an increase in the pool of graduating IM residents prescribing PrEP