Transgender Health

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth living in foster care or unstable housing are at greater risk for mental health problems, victimization, and getting into fights at school, compared with LGBTQ youth in stable housing and heterosexual youth in foster care, reported Laura Baums, PhD, of the University of Texas at Austin and her coauthors.

This was the finding of analyses of nested data of more than 493,000 students aged 10-18 years from the cross-sectional California Healthy Kids Survey for 2013-2015; 13% identified as LGBTQ. The analyses published in Pediatrics showed LGBTQ youth also were overrepresented in those living situations as compared with the general population.

Less than 1% of the overall sample was in foster care, but 30% of those youth identified as LGBTQ. About 4% of the overall sample lived in unstable housing, and 25% of those youth identified as LGBTQ. So the proportion of LGBTQ youth in foster care or unstable housing was two to three times greater than would be expected than the estimates of LGBTQ youth in nationally representative adolescent samples (that is 11%), Dr. Baums and her associates said.

LGBTQ youth in unstable housing reported lower grades, higher substance/alcohol abuse, higher rates of absenteeism, more fights in school, and more victimization, compared with heterosexual youth in unstable housing and LGBTQ youth in stable housing. Both LGBTQ youth in unstable housing and those in foster care reported higher rates of depression and suicidality in the past year, but the rates for depression were not different from LGBTQ youth in stable housing. Furthermore, African American LGBTQ youth in unstable housing showed poorer outcomes than non-Hispanic white LGBTQ youth in unstable housing, they said.

“LGBTQ youth, in general, showed poor outcomes, which was exacerbated when they lived in unstable housing or foster care,” concluded Dr. Baums and her associates. “The findings of this study point to the need for care that is affirming and respectful of youth’s sexual orientation and gender identity.”

The authors reported no relevant financial disclosures. The study was funded by a Eunice Kennedy Shriver National Institute of Child Health and Human Development grant and supported by the Communities for Just Schools Fund and the Priscilla Pond Flawn Endowment at the university.

[email protected]

SOURCE: Baum L et al. Pediatrics. 2019 Feb 11. doi: 10.1542/peds.2017-4211.

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth living in foster care or unstable housing are at greater risk for mental health problems, victimization, and getting into fights at school, compared with LGBTQ youth in stable housing and heterosexual youth in foster care, reported Laura Baums, PhD, of the University of Texas at Austin and her coauthors.

This was the finding of analyses of nested data of more than 493,000 students aged 10-18 years from the cross-sectional California Healthy Kids Survey for 2013-2015; 13% identified as LGBTQ. The analyses published in Pediatrics showed LGBTQ youth also were overrepresented in those living situations as compared with the general population.

Less than 1% of the overall sample was in foster care, but 30% of those youth identified as LGBTQ. About 4% of the overall sample lived in unstable housing, and 25% of those youth identified as LGBTQ. So the proportion of LGBTQ youth in foster care or unstable housing was two to three times greater than would be expected than the estimates of LGBTQ youth in nationally representative adolescent samples (that is 11%), Dr. Baums and her associates said.

LGBTQ youth in unstable housing reported lower grades, higher substance/alcohol abuse, higher rates of absenteeism, more fights in school, and more victimization, compared with heterosexual youth in unstable housing and LGBTQ youth in stable housing. Both LGBTQ youth in unstable housing and those in foster care reported higher rates of depression and suicidality in the past year, but the rates for depression were not different from LGBTQ youth in stable housing. Furthermore, African American LGBTQ youth in unstable housing showed poorer outcomes than non-Hispanic white LGBTQ youth in unstable housing, they said.

“LGBTQ youth, in general, showed poor outcomes, which was exacerbated when they lived in unstable housing or foster care,” concluded Dr. Baums and her associates. “The findings of this study point to the need for care that is affirming and respectful of youth’s sexual orientation and gender identity.”

The authors reported no relevant financial disclosures. The study was funded by a Eunice Kennedy Shriver National Institute of Child Health and Human Development grant and supported by the Communities for Just Schools Fund and the Priscilla Pond Flawn Endowment at the university.

[email protected]

SOURCE: Baum L et al. Pediatrics. 2019 Feb 11. doi: 10.1542/peds.2017-4211.

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth living in foster care or unstable housing are at greater risk for mental health problems, victimization, and getting into fights at school, compared with LGBTQ youth in stable housing and heterosexual youth in foster care, reported Laura Baums, PhD, of the University of Texas at Austin and her coauthors.

This was the finding of analyses of nested data of more than 493,000 students aged 10-18 years from the cross-sectional California Healthy Kids Survey for 2013-2015; 13% identified as LGBTQ. The analyses published in Pediatrics showed LGBTQ youth also were overrepresented in those living situations as compared with the general population.

Less than 1% of the overall sample was in foster care, but 30% of those youth identified as LGBTQ. About 4% of the overall sample lived in unstable housing, and 25% of those youth identified as LGBTQ. So the proportion of LGBTQ youth in foster care or unstable housing was two to three times greater than would be expected than the estimates of LGBTQ youth in nationally representative adolescent samples (that is 11%), Dr. Baums and her associates said.

LGBTQ youth in unstable housing reported lower grades, higher substance/alcohol abuse, higher rates of absenteeism, more fights in school, and more victimization, compared with heterosexual youth in unstable housing and LGBTQ youth in stable housing. Both LGBTQ youth in unstable housing and those in foster care reported higher rates of depression and suicidality in the past year, but the rates for depression were not different from LGBTQ youth in stable housing. Furthermore, African American LGBTQ youth in unstable housing showed poorer outcomes than non-Hispanic white LGBTQ youth in unstable housing, they said.

“LGBTQ youth, in general, showed poor outcomes, which was exacerbated when they lived in unstable housing or foster care,” concluded Dr. Baums and her associates. “The findings of this study point to the need for care that is affirming and respectful of youth’s sexual orientation and gender identity.”

The authors reported no relevant financial disclosures. The study was funded by a Eunice Kennedy Shriver National Institute of Child Health and Human Development grant and supported by the Communities for Just Schools Fund and the Priscilla Pond Flawn Endowment at the university.

[email protected]

SOURCE: Baum L et al. Pediatrics. 2019 Feb 11. doi: 10.1542/peds.2017-4211.

TRANSforming Gynecology is a column about the ways in which ob.gyns. can become leaders in addressing the needs of the transgender/gender-nonconforming population. We hope to provide readers with some basic tools to help open the door to this marginalized population. We will lay the groundwork with an article on terminology and the importance of language before moving onto more focused discussions of topics that intersect with medical care of gender-nonconforming individuals. Transgender individuals experience among the worst health care outcomes of any demographic, and we hope that this column can be a starting point for providers to continue affirming the needs of marginalized populations in their everyday practice.

Josve05a/Getty Images

We live in a society in which most people’s gender identities are congruent with the sex they were assigned at birth based on physical characteristics. Transgender and gender-nonconforming people – often referred to as trans people, broadly – feel that their gender identity does not match their sex assigned at birth. This gender nonconformity, or the extent to which someone’s gender identity or expression differs from the cultural norm assigned to people with certain sexual organs, is in fact a matter of diversity, not pathology.

To truly provide sensitive care to trans patients, medical providers must first gain familiarity with the terminology used when discussing gender diversity. Gender identity, for starters, refers to an individual’s own personal and internal experience of themselves as a man, woman, some of both, or neither gender.¹ It is only possible to learn a person’s gender identity through direct communication because gender identity is not always signaled by a certain gender expression. Gender expression is an external display usually through clothing, attitudes, or body language, that may or may not fit into socially recognized masculine or feminine categories.¹ A separate aspect of the human experience is sexuality, such as gay, straight, bisexual, lesbian, etc. Sexuality should not be confused with sexual practices, which can sometimes deviate from a person’s sexuality. Gender identity is distinct from sexuality and sexual practices because people of any gender identity can hold any sexuality and engage in any sexual practices. Tied up in all of these categories is sex assigned at birth, which is a process by which health care providers categorize babies into two buckets based on the appearance of the external genitalia at the time of birth. It bears mentioning that the assignment of sex based on the appearance of external genitalia at the time of birth is a biologically inconsistent method that can lead to the exclusion of and nonconsensual mutilation of intersex people, who are individuals born with ambiguous genitalia and/or discrepancies between sex chromosome genotype and phenotype (stay tuned for more on people who are intersex in a future article).

A simplified way of remembering the distinctions between these concepts is that gender identity is who you go to bed as; gender expression is what you were wearing before you went to bed; sexuality is whom you tell others/yourself you go to bed with; sexual practice is whom you actually go to bed with; and sex assigned at birth is what you have between your legs when you are born (generally in a bed).

It is pivotal that medical providers understand that a person’s sex assigned at birth, gender identity, gender expression, sexuality, sexual practice, and romantic attraction can vary widely along a spectrum in each distinct category.² For example, the current social norm dictates that someone born with a penis and assigned male at birth (AMAB) will feel that he is male, dress in a masculine fashion, and be both sexually and romantically attracted to someone born with a vagina who was assigned female at birth (AFAB), feels that she is female, dresses femininely, and likewise is sexually and romantically attracted to him. One possible alternative reality is a person who was born with a vagina that was therefore AFAB that experiences a masculine gender identity while engaging in a feminine gender expression in order to conform to social norms. In addition, they may be sexually attracted to people whom they perceive to be feminine while engaging in sexual activity with people who were AMAB. Informed medical care for trans persons starts with the basic understanding that an individual’s gender identity may not necessarily align with their gender expression, sex assigned at birth, sexual attraction, or romantic attraction.

As obstetrician-gynecologists, we are tasked by the American College of Obstetricians and Gynecologists to provide nondiscriminatory care to all patients, regardless of gender identity.³ We must be careful not to assume that all of our patients are cisgender women who use “she/hers/her” pronouns. By simply asking patients what names or pronouns they would like us to use before initiating care, we become more sensitive to variations in gender identity. Many providers may feel uncertain about how to initiate or respond to this line of questioning. One way that health care practices can begin to respectfully access information around gender identity is to create intake forms that include more than two options for gender or to alter their office visit note templates to include a section that prompts the provider to include a discussion surrounding gender identity. By offering these opportunities for inclusion, we become more welcoming of gender minorities like transgender men seeking cervical cancer screening.

There are a number of reasons that trans persons have limited access to the health care system, but the greatest barrier reported by transgender patients is the paucity of knowledgeable providers.⁴Learning the common terminology used by the trans population is a logical first step for physicians seeking to provide more affirming care to an already marginalized patient population. Familiarity with this terminology normalizes the idea of gender diversity and subsequently reduces the risk of providers making assumptions about patients that contributes to suboptimal care.

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no financial disclosures.

1. Lancet. 2016 Jul 23;388(10042):390-400.

2. www.genderbread.org/resource/genderbread-person-v4-0.

3. Obstet Gynecol. 2011 Dec;118(6):1454-8.

4. Curr Opin Endocrinol Diabetes Obes. 2016 Apr 1;23(2):168-71.

TRANSforming Gynecology is a column about the ways in which ob.gyns. can become leaders in addressing the needs of the transgender/gender-nonconforming population. We hope to provide readers with some basic tools to help open the door to this marginalized population. We will lay the groundwork with an article on terminology and the importance of language before moving onto more focused discussions of topics that intersect with medical care of gender-nonconforming individuals. Transgender individuals experience among the worst health care outcomes of any demographic, and we hope that this column can be a starting point for providers to continue affirming the needs of marginalized populations in their everyday practice.

Josve05a/Getty Images

We live in a society in which most people’s gender identities are congruent with the sex they were assigned at birth based on physical characteristics. Transgender and gender-nonconforming people – often referred to as trans people, broadly – feel that their gender identity does not match their sex assigned at birth. This gender nonconformity, or the extent to which someone’s gender identity or expression differs from the cultural norm assigned to people with certain sexual organs, is in fact a matter of diversity, not pathology.

To truly provide sensitive care to trans patients, medical providers must first gain familiarity with the terminology used when discussing gender diversity. Gender identity, for starters, refers to an individual’s own personal and internal experience of themselves as a man, woman, some of both, or neither gender.¹ It is only possible to learn a person’s gender identity through direct communication because gender identity is not always signaled by a certain gender expression. Gender expression is an external display usually through clothing, attitudes, or body language, that may or may not fit into socially recognized masculine or feminine categories.¹ A separate aspect of the human experience is sexuality, such as gay, straight, bisexual, lesbian, etc. Sexuality should not be confused with sexual practices, which can sometimes deviate from a person’s sexuality. Gender identity is distinct from sexuality and sexual practices because people of any gender identity can hold any sexuality and engage in any sexual practices. Tied up in all of these categories is sex assigned at birth, which is a process by which health care providers categorize babies into two buckets based on the appearance of the external genitalia at the time of birth. It bears mentioning that the assignment of sex based on the appearance of external genitalia at the time of birth is a biologically inconsistent method that can lead to the exclusion of and nonconsensual mutilation of intersex people, who are individuals born with ambiguous genitalia and/or discrepancies between sex chromosome genotype and phenotype (stay tuned for more on people who are intersex in a future article).

A simplified way of remembering the distinctions between these concepts is that gender identity is who you go to bed as; gender expression is what you were wearing before you went to bed; sexuality is whom you tell others/yourself you go to bed with; sexual practice is whom you actually go to bed with; and sex assigned at birth is what you have between your legs when you are born (generally in a bed).

It is pivotal that medical providers understand that a person’s sex assigned at birth, gender identity, gender expression, sexuality, sexual practice, and romantic attraction can vary widely along a spectrum in each distinct category.² For example, the current social norm dictates that someone born with a penis and assigned male at birth (AMAB) will feel that he is male, dress in a masculine fashion, and be both sexually and romantically attracted to someone born with a vagina who was assigned female at birth (AFAB), feels that she is female, dresses femininely, and likewise is sexually and romantically attracted to him. One possible alternative reality is a person who was born with a vagina that was therefore AFAB that experiences a masculine gender identity while engaging in a feminine gender expression in order to conform to social norms. In addition, they may be sexually attracted to people whom they perceive to be feminine while engaging in sexual activity with people who were AMAB. Informed medical care for trans persons starts with the basic understanding that an individual’s gender identity may not necessarily align with their gender expression, sex assigned at birth, sexual attraction, or romantic attraction.

As obstetrician-gynecologists, we are tasked by the American College of Obstetricians and Gynecologists to provide nondiscriminatory care to all patients, regardless of gender identity.³ We must be careful not to assume that all of our patients are cisgender women who use “she/hers/her” pronouns. By simply asking patients what names or pronouns they would like us to use before initiating care, we become more sensitive to variations in gender identity. Many providers may feel uncertain about how to initiate or respond to this line of questioning. One way that health care practices can begin to respectfully access information around gender identity is to create intake forms that include more than two options for gender or to alter their office visit note templates to include a section that prompts the provider to include a discussion surrounding gender identity. By offering these opportunities for inclusion, we become more welcoming of gender minorities like transgender men seeking cervical cancer screening.

There are a number of reasons that trans persons have limited access to the health care system, but the greatest barrier reported by transgender patients is the paucity of knowledgeable providers.⁴Learning the common terminology used by the trans population is a logical first step for physicians seeking to provide more affirming care to an already marginalized patient population. Familiarity with this terminology normalizes the idea of gender diversity and subsequently reduces the risk of providers making assumptions about patients that contributes to suboptimal care.

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no financial disclosures.

1. Lancet. 2016 Jul 23;388(10042):390-400.

2. www.genderbread.org/resource/genderbread-person-v4-0.

3. Obstet Gynecol. 2011 Dec;118(6):1454-8.

4. Curr Opin Endocrinol Diabetes Obes. 2016 Apr 1;23(2):168-71.

TRANSforming Gynecology is a column about the ways in which ob.gyns. can become leaders in addressing the needs of the transgender/gender-nonconforming population. We hope to provide readers with some basic tools to help open the door to this marginalized population. We will lay the groundwork with an article on terminology and the importance of language before moving onto more focused discussions of topics that intersect with medical care of gender-nonconforming individuals. Transgender individuals experience among the worst health care outcomes of any demographic, and we hope that this column can be a starting point for providers to continue affirming the needs of marginalized populations in their everyday practice.

Josve05a/Getty Images

We live in a society in which most people’s gender identities are congruent with the sex they were assigned at birth based on physical characteristics. Transgender and gender-nonconforming people – often referred to as trans people, broadly – feel that their gender identity does not match their sex assigned at birth. This gender nonconformity, or the extent to which someone’s gender identity or expression differs from the cultural norm assigned to people with certain sexual organs, is in fact a matter of diversity, not pathology.

To truly provide sensitive care to trans patients, medical providers must first gain familiarity with the terminology used when discussing gender diversity. Gender identity, for starters, refers to an individual’s own personal and internal experience of themselves as a man, woman, some of both, or neither gender.¹ It is only possible to learn a person’s gender identity through direct communication because gender identity is not always signaled by a certain gender expression. Gender expression is an external display usually through clothing, attitudes, or body language, that may or may not fit into socially recognized masculine or feminine categories.¹ A separate aspect of the human experience is sexuality, such as gay, straight, bisexual, lesbian, etc. Sexuality should not be confused with sexual practices, which can sometimes deviate from a person’s sexuality. Gender identity is distinct from sexuality and sexual practices because people of any gender identity can hold any sexuality and engage in any sexual practices. Tied up in all of these categories is sex assigned at birth, which is a process by which health care providers categorize babies into two buckets based on the appearance of the external genitalia at the time of birth. It bears mentioning that the assignment of sex based on the appearance of external genitalia at the time of birth is a biologically inconsistent method that can lead to the exclusion of and nonconsensual mutilation of intersex people, who are individuals born with ambiguous genitalia and/or discrepancies between sex chromosome genotype and phenotype (stay tuned for more on people who are intersex in a future article).

A simplified way of remembering the distinctions between these concepts is that gender identity is who you go to bed as; gender expression is what you were wearing before you went to bed; sexuality is whom you tell others/yourself you go to bed with; sexual practice is whom you actually go to bed with; and sex assigned at birth is what you have between your legs when you are born (generally in a bed).

It is pivotal that medical providers understand that a person’s sex assigned at birth, gender identity, gender expression, sexuality, sexual practice, and romantic attraction can vary widely along a spectrum in each distinct category.² For example, the current social norm dictates that someone born with a penis and assigned male at birth (AMAB) will feel that he is male, dress in a masculine fashion, and be both sexually and romantically attracted to someone born with a vagina who was assigned female at birth (AFAB), feels that she is female, dresses femininely, and likewise is sexually and romantically attracted to him. One possible alternative reality is a person who was born with a vagina that was therefore AFAB that experiences a masculine gender identity while engaging in a feminine gender expression in order to conform to social norms. In addition, they may be sexually attracted to people whom they perceive to be feminine while engaging in sexual activity with people who were AMAB. Informed medical care for trans persons starts with the basic understanding that an individual’s gender identity may not necessarily align with their gender expression, sex assigned at birth, sexual attraction, or romantic attraction.

As obstetrician-gynecologists, we are tasked by the American College of Obstetricians and Gynecologists to provide nondiscriminatory care to all patients, regardless of gender identity.³ We must be careful not to assume that all of our patients are cisgender women who use “she/hers/her” pronouns. By simply asking patients what names or pronouns they would like us to use before initiating care, we become more sensitive to variations in gender identity. Many providers may feel uncertain about how to initiate or respond to this line of questioning. One way that health care practices can begin to respectfully access information around gender identity is to create intake forms that include more than two options for gender or to alter their office visit note templates to include a section that prompts the provider to include a discussion surrounding gender identity. By offering these opportunities for inclusion, we become more welcoming of gender minorities like transgender men seeking cervical cancer screening.

There are a number of reasons that trans persons have limited access to the health care system, but the greatest barrier reported by transgender patients is the paucity of knowledgeable providers.⁴Learning the common terminology used by the trans population is a logical first step for physicians seeking to provide more affirming care to an already marginalized patient population. Familiarity with this terminology normalizes the idea of gender diversity and subsequently reduces the risk of providers making assumptions about patients that contributes to suboptimal care.

Dr. Joyner is an assistant professor at Emory University, Atlanta, and is the director of gynecologic services in the Gender Center at Grady Memorial Hospital in Atlanta. Dr. Joyner identifies as a cisgender female and uses she/hers/her as her personal pronouns. Dr. Joey Bahng is a PGY-1 resident physician in Emory University’s gynecology & obstetrics residency program. Dr. Bahng identifies as nonbinary and uses they/them/their as their personal pronouns. Dr. Joyner and Dr. Bahng reported no financial disclosures.

1. Lancet. 2016 Jul 23;388(10042):390-400.

2. www.genderbread.org/resource/genderbread-person-v4-0.

3. Obstet Gynecol. 2011 Dec;118(6):1454-8.

4. Curr Opin Endocrinol Diabetes Obes. 2016 Apr 1;23(2):168-71.

Gay men who become fathers still commonly experience barriers and stigma, but those living in states that offer legal protections experienced less stigma and fewer barriers, according to Ellen C. Perrin, MD, of Tufts Medical Center in Boston and her associates.

Juanmonino/iStock/Getty Images

A total of 732 fathers living in 47 states, with 1,316 children (average age, 13 years), responded to a survey, they wrote in Pediatrics. More than 80% had a male partner, 64% had earned a bachelor degree or higher, and 81% were white and non-Hispanic.

In 35% of cases, children entered a family through adoption and/or foster care, 14% through the assistance of a pregnancy carrier or surrogate, and 39% through a heterosexual relationship. Families in states with fewer legal protections were more likely to have been formed through heterosexual relationships (odds ratio, 1.42; 95% confidence interval, 1.11-1.81), while families in states with a greater equality rating were more likely to have been formed through a pregnancy surrogate (OR, 1.41; 95% CI, 1.08-1.84). A total of 41% of fathers reported facing barriers to adoption, and 33% reported having difficulty arranging custody of children born in a heterosexual relationship.

Nearly two-thirds of fathers reported having experienced stigma, and just over half had actively avoided a situation for fear of stigma in the past year. Active stigma experienced by the fathers was most commonly experienced in a religious setting, reported by 35%, with other common sources including neighbors (28%), service providers (26%), family members (24%), gay friends (24%), the child’s school (18%), the workplace (16%), and in health care (11%). Children most often experienced active stigma by their friends (33%), followed by a religious setting (17%), school (16%), neighbors (15%), family (11%), and in health care settings (4%).

Active and avoidant stigma was more likely in states with a low equality rating, especially in religious settings and among family members and neighbors, the investigators noted.

“Given their important role as leaders in the community’s support for all families, pediatricians caring for children and their gay fathers should recognize the likelihood that stigma may be a part of the family’s experience and help both families and communities to counteract it. Pediatricians also have the opportunity to be leaders in opposing discrimination in religious and other community institutions,” Dr. Perrin and her associates wrote.

The study received funding from the Gil Foundation, the Arcus Foundation, and private donations. The study authors reported no relevant financial disclosures or conflicts of interest.

[email protected]

SOURCE: Perrin EC et al. Pediatrics. 2019 Jan 14. doi: 10.1542/peds.2018-0683.

Gay men who become fathers still commonly experience barriers and stigma, but those living in states that offer legal protections experienced less stigma and fewer barriers, according to Ellen C. Perrin, MD, of Tufts Medical Center in Boston and her associates.

Juanmonino/iStock/Getty Images

A total of 732 fathers living in 47 states, with 1,316 children (average age, 13 years), responded to a survey, they wrote in Pediatrics. More than 80% had a male partner, 64% had earned a bachelor degree or higher, and 81% were white and non-Hispanic.

In 35% of cases, children entered a family through adoption and/or foster care, 14% through the assistance of a pregnancy carrier or surrogate, and 39% through a heterosexual relationship. Families in states with fewer legal protections were more likely to have been formed through heterosexual relationships (odds ratio, 1.42; 95% confidence interval, 1.11-1.81), while families in states with a greater equality rating were more likely to have been formed through a pregnancy surrogate (OR, 1.41; 95% CI, 1.08-1.84). A total of 41% of fathers reported facing barriers to adoption, and 33% reported having difficulty arranging custody of children born in a heterosexual relationship.

Nearly two-thirds of fathers reported having experienced stigma, and just over half had actively avoided a situation for fear of stigma in the past year. Active stigma experienced by the fathers was most commonly experienced in a religious setting, reported by 35%, with other common sources including neighbors (28%), service providers (26%), family members (24%), gay friends (24%), the child’s school (18%), the workplace (16%), and in health care (11%). Children most often experienced active stigma by their friends (33%), followed by a religious setting (17%), school (16%), neighbors (15%), family (11%), and in health care settings (4%).

Active and avoidant stigma was more likely in states with a low equality rating, especially in religious settings and among family members and neighbors, the investigators noted.

“Given their important role as leaders in the community’s support for all families, pediatricians caring for children and their gay fathers should recognize the likelihood that stigma may be a part of the family’s experience and help both families and communities to counteract it. Pediatricians also have the opportunity to be leaders in opposing discrimination in religious and other community institutions,” Dr. Perrin and her associates wrote.

The study received funding from the Gil Foundation, the Arcus Foundation, and private donations. The study authors reported no relevant financial disclosures or conflicts of interest.

[email protected]

SOURCE: Perrin EC et al. Pediatrics. 2019 Jan 14. doi: 10.1542/peds.2018-0683.

Gay men who become fathers still commonly experience barriers and stigma, but those living in states that offer legal protections experienced less stigma and fewer barriers, according to Ellen C. Perrin, MD, of Tufts Medical Center in Boston and her associates.

Juanmonino/iStock/Getty Images

A total of 732 fathers living in 47 states, with 1,316 children (average age, 13 years), responded to a survey, they wrote in Pediatrics. More than 80% had a male partner, 64% had earned a bachelor degree or higher, and 81% were white and non-Hispanic.

In 35% of cases, children entered a family through adoption and/or foster care, 14% through the assistance of a pregnancy carrier or surrogate, and 39% through a heterosexual relationship. Families in states with fewer legal protections were more likely to have been formed through heterosexual relationships (odds ratio, 1.42; 95% confidence interval, 1.11-1.81), while families in states with a greater equality rating were more likely to have been formed through a pregnancy surrogate (OR, 1.41; 95% CI, 1.08-1.84). A total of 41% of fathers reported facing barriers to adoption, and 33% reported having difficulty arranging custody of children born in a heterosexual relationship.

Nearly two-thirds of fathers reported having experienced stigma, and just over half had actively avoided a situation for fear of stigma in the past year. Active stigma experienced by the fathers was most commonly experienced in a religious setting, reported by 35%, with other common sources including neighbors (28%), service providers (26%), family members (24%), gay friends (24%), the child’s school (18%), the workplace (16%), and in health care (11%). Children most often experienced active stigma by their friends (33%), followed by a religious setting (17%), school (16%), neighbors (15%), family (11%), and in health care settings (4%).

Active and avoidant stigma was more likely in states with a low equality rating, especially in religious settings and among family members and neighbors, the investigators noted.

“Given their important role as leaders in the community’s support for all families, pediatricians caring for children and their gay fathers should recognize the likelihood that stigma may be a part of the family’s experience and help both families and communities to counteract it. Pediatricians also have the opportunity to be leaders in opposing discrimination in religious and other community institutions,” Dr. Perrin and her associates wrote.

The study received funding from the Gil Foundation, the Arcus Foundation, and private donations. The study authors reported no relevant financial disclosures or conflicts of interest.

[email protected]

SOURCE: Perrin EC et al. Pediatrics. 2019 Jan 14. doi: 10.1542/peds.2018-0683.

As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.¹Among homeless youth, a disproportionate number of these youth identify as lesbian, gay, bisexual, or transgender (LGBT). The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.

bodnarchuk/Getty Images

According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”² Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.

Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,³ about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.

Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.⁴ Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.⁵ As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.^6,7

There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.⁴ Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.⁸

Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.⁴ Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.⁹

Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”¹⁰ Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.

Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.

Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.

Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.

2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.

3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.

4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.

5. Sex Roles. 2013 Jun;68(11-12):690-702.

6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.

7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.

8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.

9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.

10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.

As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.¹Among homeless youth, a disproportionate number of these youth identify as lesbian, gay, bisexual, or transgender (LGBT). The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.

bodnarchuk/Getty Images

According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”² Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.

Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,³ about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.

Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.⁴ Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.⁵ As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.^6,7

There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.⁴ Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.⁸

Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.⁴ Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.⁹

Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”¹⁰ Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.

Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.

Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.

Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.

2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.

3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.

4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.

5. Sex Roles. 2013 Jun;68(11-12):690-702.

6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.

7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.

8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.

9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.

10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.

As winter settles in for most of the United States, there are some people who do not have access to adequate shelter from the cold. Currently, there are an estimated 700,000 homeless youth in the United States, which is roughly 1 out of 30 youth.¹Among homeless youth, a disproportionate number of these youth identify as lesbian, gay, bisexual, or transgender (LGBT). The reasons for these disparities are complex, although stigma and discrimination are major factors. Despite the major challenges faced by this population, medical providers can play a role in addressing homelessness among LGBT youth.

bodnarchuk/Getty Images

According to the Department of Education, homeless youth are defined as youth “who lack a fixed, regular, and adequate nighttime residence.”² Although the image of a person sleeping on a bench at a park covered with newspapers comes to mind, it may not be obvious that a youth may be homeless. Sometimes, youth may be sleeping in their cars at night and others may be staying the night at one house and then staying the next night at another house (known as “couch surfing”). Many will be utilizing homeless shelters to sleep in.

Homelessness among LGBT youth is a major problem in the United States. Although LGB (sexual minority) people comprise 2%-7% of the population,³ about one-third of homeless youth identify as LGB or questioning. Additionally, about 4% of homeless youth identify as transgender, compared with 1% of the general youth population in the United States. LGBT youth are at a higher risk for homelessness than are cisgender (gender identity matches with the assigned sex at birth), heterosexual youth. There are even disparities within LGBT youth.

Why are LGBT youth at high risk for homelessness? The most common reason is family rejection of their sexual orientation and/or gender identity.⁴ Some are directly kicked out by their families. Whereas others leave because relationships with their families have become so strained after the child has come out that the environment is no longer tolerable to live in. However, poverty and race may play a significant role in this phenomenon. There is a misperception that families of color are more homophobic or transphobic (disliking or having a prejudice against transsexual or transgender people) than white families because there is a higher proportion of LGBT homeless youth of color. However, what most likely increases the likelihood of family rejection is the strain of poverty, which people of color are more likely to experience. Chronic unemployment or unstable housing makes it very difficult for families to utilize the important skills to accept and support their LGBT child. Whenever a child comes out to their parents, it is a stressful event for the family. Family with stable physical resources (decent income, stable housing) also are more likely to have psychological resources (family cohesiveness, open communication, good parent-child relationships) to manage these types of stress. However, for those with unstable resources, they are unable to tap into their psychological resources to handle the stress of a child coming out to them.⁵ As a result, they resort to rejection. Many parents believe that rejecting their child’s sexual orientation or gender identity will protect them from stigma and discrimination, and they do not realize that rejection can harm their child.^6,7

There are other reasons LGBT youth become homeless. One is untreated mental illness and substance use, mostly likely a result from experiencing stigma and discrimination. Another is that some age out of the foster care system.⁴ Finally, some LGBT youth run away from home because of abuse from their parents, and unfortunately, LGBT youth are more likely to experience abuse from a parent than are heterosexual, cisgender youth.⁸

Furthermore, although there are homeless shelters for youth, many LGBT youth avoid going to homeless shelters out of fear for their own safety. Many homeless shelters are ill equipped to work with LGBT youth, especially in managing other homeless youth who may harass or assault another youth on the basis of their sexual orientation or gender identity.⁴ Additionally, many homeless shelters arrangements are gendered, making it difficult for transgender youth to find a shelter as they may be forced to live with people of their assigned sex of birth, putting them at an increased risk for harassment and violence.⁹

Despite the many challenges faced by homeless LGBT youth, medical providers can play a role in promoting their health and well-being. Screening for homelessness can create opportunities for medical providers to offer resources for immediate needs. Three good questions are: “During the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?” “In the past 12 months, how many places [have you] lived?” and “What type of housing do you currently live in?”¹⁰ Resources for such youth would include the National Coalition for the Homeless, which contains a list of homeless shelters that are equipped to address the needs of LGBT homeless youth.

Medical providers must address some of the root causes of homelessness among LGBT youth. One of them is family rejection. Medical providers can counsel parents of LGBT youth in the importance of family support in protecting their LGBT child from adverse health outcomes. One good resource is the Family Acceptance Project, which teaches parents skills to support their LGBT child. Additionally, medical providers can work with homeless shelters and help them develop best practices for working with LGBT youth. A good place to start is Lambda Legal’s National Recommended Best Practices for Serving LGBT Homeless Youth.

Educating both families and homeless shelters are key in both preventing homelessness and mitigating the effects of homelessness on the health of LGBT youth.

Dr. Montano is assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

References

1. “Missed opportunities: Youth homelessness in America,” Chapin Hall at the University of Chicago, 2017. voicesofyouthcount.org.

2. Homelessness & Runaway Youth. Federal Definitions. youth.gov.

3. MMWR Surveill Summ. 2016. doi: 10.15585/mmwr.ss6509a1.

4. “Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender and Questioning Youth Experiencing Homelesness,” The Williams Institute with True Colors Fund, June 2015.

5. Sex Roles. 2013 Jun;68(11-12):690-702.

6. “Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children,” Family Acceptance Project, San Francisco State University, 2009.

7. Pediatrics. 2009 Jan. doi: 10.1542/peds.2007-3524.

8. Am J Public Health. 2011. doi: 10.2105/AJPH.2009.190009.

9. Am J Orthopsychiatry. 2014. doi: 10.1037/h0098852.

10. Pediatrics. 2018. doi: 10.1542/peds.2017-2199.

Despite clinical practice guidelines,^1,2 the lack of informed providers remains the greatest barrier to optimal transgender medical care, notable even with improvement with regard to other barriers to care.³ Barriers accessing appropriate care play a significant role in the persistent health disparities experienced by transgender individuals, such as increased rates of certain cancers, substance abuse, mental health concerns, infections, and chronic diseases.

In the United States, transgender people make up an estimated 0.6% of the population.⁴ Transgender individuals have unique health needs. However, when surveyed, most members of the medical community report that they are not adequately trained to address those needs.⁵ There is a need for health care providers to be comfortable treating, as well as versed in the health needs of, transgender patients. Physicians and medical students report having knowledge gaps in transgender health care because of insufficient education and exposure.

For medical students, the Association of American Medical Colleges (AAMC) launched a guide for medical schools in 2014 regarding the integration of LGBT-related curricula. Still, in a survey of 4,262 medical students from 170 medical schools in Canada and the United States, 67% of students rated their LGBT-related curriculum as “very poor,” “poor,” or “fair.”⁶

Data that are transgender specific are scarce. In a transgender medicine education–specific survey done among 365 Canadian medical students attending English-language medical schools, only 24% of them reported that transgender health was proficiently taught and only 6% reported feeling sufficiently knowledgeable to care for transgender individuals.⁷ Additionally, a survey among 341 United States medical students at a single institution reported that knowledge of transgender health lagged behind knowledge of other LGB health.⁸

Park et al. reported on the expanded Boston University School of Medicine (BUSM) transgender medical education model which supplemented the AAMC framework with evidence based, transgender-specific medical–education integrated throughout the medical curriculum.⁹ Beyond the AAMC-suggested program, first-year BUSM students in physiology learn about the biologic evidence for gender identity.¹⁰ In the following year, BUSM students are taught both the classic treatment regimens and monitoring requirements for transgender hormone therapy as part of the standard endocrinology curriculum.¹¹ Following the first 2 years, students reported a significant increase in willingness to care for transgender patients and a 67% decrease in discomfort with providing care to transgender patients.

However, the relative comfort with transgender-specific care still lagged behind the comfort for LGB care in general. In 2014, BUSM expanded its transgender programming further to include an experiential component with a clinical elective for 4th-year medical students.⁹ The transgender medicine elective included direct patient care experiences with transgender individuals in adult primary care, pediatrics, endocrinology, and surgery. Direct patient contact has been demonstrated to facilitate greater confidence in providing transgender medical care for other medical trainees.¹²

A mechanism for the national adoption of the BUSM approach should be instituted for all medical schools. Such a move could easily result in a significant improvement in reported comfort among students. After that, the goal should be to leverage opportunities to mandate experiential components in transgender medical education.

While aspects of health care for transgender individuals have improved significantly, education among healthcare providers still lags and remains the largest barrier to care for transgender individuals. With the identified transgender population continuing to expand, the gap remains large in the production and training of sufficient numbers of providers proficient in transgender care. Although data for effectiveness are only short term, several interventions among medical students have been shown to be effective and seem logical to adopt universally.
 

Dr. Safer is executive director, Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine, New York.

References

1. Coleman E et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend. 2012;13:165.

2. Hembree WC et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:3869-903.

3. Safer JD et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168-71.

4. Flores AR et al. How many adults identify as transgender in the United States? The Williams Institute. 2017 Jun. Los Angeles, Calif. (Accessed on Oct. 30, 2018).

5. Irwig MS. Transgender care by endocrinologists in the United States. Endocr Pract. 2016 Jul;22:832-6.

6. White W et al. Lesbian, gay, bisexual, and transgender patient care: Medical students’ preparedness and comfort. Teach Learn Med. 2015 Jul 9;27:254-63.

7. Chan B et al. Gaps in transgender medicine content identified among Canadian medical school curricula. Transgend Health. 2016 Jul 1;1:142-50.

8. Liang JJ et al. Observed deficiencies in medical student knowledge of transgender and intersex health. Endocr Pract. 2017 Aug;23:897-906.

9. Park JA et al. Clinical exposure to transgender medicine improves students’ preparedness above levels seen with didactic teaching alone: A key addition to the Boston University model for teaching transgender healthcare. Transgend Health. 2018 Jan 1;3:10-6.

10. Eriksson SE et al. Evidence-based curricular content improves student knowledge and changes attitudes towards transgender medicine. Endocr Pract. 2016 Jul;22:837-41.

11. Safer JD et al. A simple curriculum content change increased medical student comfort with transgender medicine. Endocr Pract. 2013 Jul-Aug;19:633-7.

12. Morrison SD et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017 Apr;9:178-83.

Despite clinical practice guidelines,^1,2 the lack of informed providers remains the greatest barrier to optimal transgender medical care, notable even with improvement with regard to other barriers to care.³ Barriers accessing appropriate care play a significant role in the persistent health disparities experienced by transgender individuals, such as increased rates of certain cancers, substance abuse, mental health concerns, infections, and chronic diseases.

In the United States, transgender people make up an estimated 0.6% of the population.⁴ Transgender individuals have unique health needs. However, when surveyed, most members of the medical community report that they are not adequately trained to address those needs.⁵ There is a need for health care providers to be comfortable treating, as well as versed in the health needs of, transgender patients. Physicians and medical students report having knowledge gaps in transgender health care because of insufficient education and exposure.

For medical students, the Association of American Medical Colleges (AAMC) launched a guide for medical schools in 2014 regarding the integration of LGBT-related curricula. Still, in a survey of 4,262 medical students from 170 medical schools in Canada and the United States, 67% of students rated their LGBT-related curriculum as “very poor,” “poor,” or “fair.”⁶

Data that are transgender specific are scarce. In a transgender medicine education–specific survey done among 365 Canadian medical students attending English-language medical schools, only 24% of them reported that transgender health was proficiently taught and only 6% reported feeling sufficiently knowledgeable to care for transgender individuals.⁷ Additionally, a survey among 341 United States medical students at a single institution reported that knowledge of transgender health lagged behind knowledge of other LGB health.⁸

Park et al. reported on the expanded Boston University School of Medicine (BUSM) transgender medical education model which supplemented the AAMC framework with evidence based, transgender-specific medical–education integrated throughout the medical curriculum.⁹ Beyond the AAMC-suggested program, first-year BUSM students in physiology learn about the biologic evidence for gender identity.¹⁰ In the following year, BUSM students are taught both the classic treatment regimens and monitoring requirements for transgender hormone therapy as part of the standard endocrinology curriculum.¹¹ Following the first 2 years, students reported a significant increase in willingness to care for transgender patients and a 67% decrease in discomfort with providing care to transgender patients.

However, the relative comfort with transgender-specific care still lagged behind the comfort for LGB care in general. In 2014, BUSM expanded its transgender programming further to include an experiential component with a clinical elective for 4th-year medical students.⁹ The transgender medicine elective included direct patient care experiences with transgender individuals in adult primary care, pediatrics, endocrinology, and surgery. Direct patient contact has been demonstrated to facilitate greater confidence in providing transgender medical care for other medical trainees.¹²

A mechanism for the national adoption of the BUSM approach should be instituted for all medical schools. Such a move could easily result in a significant improvement in reported comfort among students. After that, the goal should be to leverage opportunities to mandate experiential components in transgender medical education.

While aspects of health care for transgender individuals have improved significantly, education among healthcare providers still lags and remains the largest barrier to care for transgender individuals. With the identified transgender population continuing to expand, the gap remains large in the production and training of sufficient numbers of providers proficient in transgender care. Although data for effectiveness are only short term, several interventions among medical students have been shown to be effective and seem logical to adopt universally.
 

Dr. Safer is executive director, Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine, New York.

References

1. Coleman E et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend. 2012;13:165.

2. Hembree WC et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:3869-903.

3. Safer JD et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168-71.

4. Flores AR et al. How many adults identify as transgender in the United States? The Williams Institute. 2017 Jun. Los Angeles, Calif. (Accessed on Oct. 30, 2018).

5. Irwig MS. Transgender care by endocrinologists in the United States. Endocr Pract. 2016 Jul;22:832-6.

6. White W et al. Lesbian, gay, bisexual, and transgender patient care: Medical students’ preparedness and comfort. Teach Learn Med. 2015 Jul 9;27:254-63.

7. Chan B et al. Gaps in transgender medicine content identified among Canadian medical school curricula. Transgend Health. 2016 Jul 1;1:142-50.

8. Liang JJ et al. Observed deficiencies in medical student knowledge of transgender and intersex health. Endocr Pract. 2017 Aug;23:897-906.

9. Park JA et al. Clinical exposure to transgender medicine improves students’ preparedness above levels seen with didactic teaching alone: A key addition to the Boston University model for teaching transgender healthcare. Transgend Health. 2018 Jan 1;3:10-6.

10. Eriksson SE et al. Evidence-based curricular content improves student knowledge and changes attitudes towards transgender medicine. Endocr Pract. 2016 Jul;22:837-41.

11. Safer JD et al. A simple curriculum content change increased medical student comfort with transgender medicine. Endocr Pract. 2013 Jul-Aug;19:633-7.

12. Morrison SD et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017 Apr;9:178-83.

Despite clinical practice guidelines,^1,2 the lack of informed providers remains the greatest barrier to optimal transgender medical care, notable even with improvement with regard to other barriers to care.³ Barriers accessing appropriate care play a significant role in the persistent health disparities experienced by transgender individuals, such as increased rates of certain cancers, substance abuse, mental health concerns, infections, and chronic diseases.

In the United States, transgender people make up an estimated 0.6% of the population.⁴ Transgender individuals have unique health needs. However, when surveyed, most members of the medical community report that they are not adequately trained to address those needs.⁵ There is a need for health care providers to be comfortable treating, as well as versed in the health needs of, transgender patients. Physicians and medical students report having knowledge gaps in transgender health care because of insufficient education and exposure.

For medical students, the Association of American Medical Colleges (AAMC) launched a guide for medical schools in 2014 regarding the integration of LGBT-related curricula. Still, in a survey of 4,262 medical students from 170 medical schools in Canada and the United States, 67% of students rated their LGBT-related curriculum as “very poor,” “poor,” or “fair.”⁶

Data that are transgender specific are scarce. In a transgender medicine education–specific survey done among 365 Canadian medical students attending English-language medical schools, only 24% of them reported that transgender health was proficiently taught and only 6% reported feeling sufficiently knowledgeable to care for transgender individuals.⁷ Additionally, a survey among 341 United States medical students at a single institution reported that knowledge of transgender health lagged behind knowledge of other LGB health.⁸

Park et al. reported on the expanded Boston University School of Medicine (BUSM) transgender medical education model which supplemented the AAMC framework with evidence based, transgender-specific medical–education integrated throughout the medical curriculum.⁹ Beyond the AAMC-suggested program, first-year BUSM students in physiology learn about the biologic evidence for gender identity.¹⁰ In the following year, BUSM students are taught both the classic treatment regimens and monitoring requirements for transgender hormone therapy as part of the standard endocrinology curriculum.¹¹ Following the first 2 years, students reported a significant increase in willingness to care for transgender patients and a 67% decrease in discomfort with providing care to transgender patients.

However, the relative comfort with transgender-specific care still lagged behind the comfort for LGB care in general. In 2014, BUSM expanded its transgender programming further to include an experiential component with a clinical elective for 4th-year medical students.⁹ The transgender medicine elective included direct patient care experiences with transgender individuals in adult primary care, pediatrics, endocrinology, and surgery. Direct patient contact has been demonstrated to facilitate greater confidence in providing transgender medical care for other medical trainees.¹²

A mechanism for the national adoption of the BUSM approach should be instituted for all medical schools. Such a move could easily result in a significant improvement in reported comfort among students. After that, the goal should be to leverage opportunities to mandate experiential components in transgender medical education.

While aspects of health care for transgender individuals have improved significantly, education among healthcare providers still lags and remains the largest barrier to care for transgender individuals. With the identified transgender population continuing to expand, the gap remains large in the production and training of sufficient numbers of providers proficient in transgender care. Although data for effectiveness are only short term, several interventions among medical students have been shown to be effective and seem logical to adopt universally.
 

Dr. Safer is executive director, Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine, New York.

References

1. Coleman E et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend. 2012;13:165.

2. Hembree WC et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:3869-903.

3. Safer JD et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168-71.

4. Flores AR et al. How many adults identify as transgender in the United States? The Williams Institute. 2017 Jun. Los Angeles, Calif. (Accessed on Oct. 30, 2018).

5. Irwig MS. Transgender care by endocrinologists in the United States. Endocr Pract. 2016 Jul;22:832-6.

6. White W et al. Lesbian, gay, bisexual, and transgender patient care: Medical students’ preparedness and comfort. Teach Learn Med. 2015 Jul 9;27:254-63.

7. Chan B et al. Gaps in transgender medicine content identified among Canadian medical school curricula. Transgend Health. 2016 Jul 1;1:142-50.

8. Liang JJ et al. Observed deficiencies in medical student knowledge of transgender and intersex health. Endocr Pract. 2017 Aug;23:897-906.

9. Park JA et al. Clinical exposure to transgender medicine improves students’ preparedness above levels seen with didactic teaching alone: A key addition to the Boston University model for teaching transgender healthcare. Transgend Health. 2018 Jan 1;3:10-6.

10. Eriksson SE et al. Evidence-based curricular content improves student knowledge and changes attitudes towards transgender medicine. Endocr Pract. 2016 Jul;22:837-41.

11. Safer JD et al. A simple curriculum content change increased medical student comfort with transgender medicine. Endocr Pract. 2013 Jul-Aug;19:633-7.

12. Morrison SD et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017 Apr;9:178-83.

It has been known for decades that sex and gender cannot be determined solely by birth anatomy and chromosomes.¹ Over the past decade, the medical community has been able to better understand the biologic underpinnings of gender identity, and we are gaining a better appreciation for the diversity of gender identities and gender expressions that exist.

Gender expression can be defined as the manner in which an individual chooses to present their gender to others through physical appearance and behaviors, such as style of hair or dress, voice or movement.² Gender nonconformity (GNC) is when an individual’s gender expression does not fully conform with societal expectations often based on an individual’s sex assigned at birth. It is important to note that gender expression is independent of gender identity and may or may not align with gender identity. For example, a person whose sex assigned at birth is female may adopt hairstyles and clothing that are considered more masculine and enjoy activities that are typically associated with masculinity (for example, sports) yet identify as female. The majority of research to date focuses most on transgender individuals, broadly defined as those whose gender identity does not fully align with the sex assigned at birth.^3,4 As our understanding of gender expression and GNC expands, more research is emerging on the prevalence of gender nonconformity in youth and potential associations with various health outcomes.

Stigma, discrimination, and harassment are known to have documented effects on health. GNC youth have been shown to experience discrimination and harassment at rates higher than their gender conforming peers.^5,6 A recent study by Lowry et al. sought to examine the association between GNC and indicators of mental distress and substance use in adolescents.⁷ The authors analyzed a subset of cross-sectional data from more than 6,000 youth who had participated in the Youth Risk Behavior Surveillance–United States, 2015 (YRBS) in three large urban school districts (two in California and one in Florida). In addition to the standard YRBS questions, students at these three school districts were asked about their gender expression using the following question: “A person’s appearance style, dress, or the way they walk or talk may affect how people describe them. How do you think people at your school would describe you?” Based on responses, youth were categorized on a 7-point GNC scale with 1 being most gender conforming (a very feminine female student or very masculine male student) to 7 being most GNC (a very masculine female student or a very feminine male student). The study sample was ethnically diverse with 16% of students identifying as white non-Hispanic, 19% identifying as black non-Hispanic, and 55% identifying as Hispanic of any race.

In the study population, approximately one in five students reported either moderate (students who described themselves as equally feminine and masculine) or high (female students who described themselves as very/mostly/somewhat masculine or male students who described themselves as very/mostly/somewhat feminine) levels of GNC. Among female students, moderate GNC was significantly associated with feeling sad and hopeless, seriously considering attempting suicide, and making a suicide plan. However, in female students substance use was not associated with GNC. Among male students, suicidal thoughts, plans, and attempts all demonstrated a linear increase with GNC, with the greatest prevalence occurring in male students expressing high levels of GNC. Prevalence of substance use, specifically nonmedical use of prescription drugs, cocaine use, methamphetamine use, heroin use, and intravenous drug also was associated with high GNC in male students. Study authors hypothesize that these differences occur because GNC male youth experience more overt harassment, compared with GNC female youth, but further study is needed.

Our understanding of the diversity of gender expressions present in youth populations continues to evolve. Findings from this study add to a growing body of evidence demonstrating a relatively high prevalence of GNC in youth populations, and potential health disparities these youth may face. This study underscores the need for continued study in this area. Family support and acceptance have been demonstrated to be strong protective factors for transgender-, lesbian-, and gay-identified youth. Studies identifying protective factors for GNC youth are needed.⁴

As health care providers, we need to continue to ask patients and families about gender identity and be aware of gender expression. When youth present as GNC, we should recognize that they may be at increased risk and, in addition to assessing overall mental health and risk for substance use, also assess for degree of social/familial support and potential stressors.4 We also should continue to advocate for support systems within schools sensitive to the needs of GNC students, as these may be a potential avenue to improve overall mental health for students. It is important to continue to expand our understanding of the diverse gender identities and expressions of the youth we serve. This hopefully will allow us to identify not only potential risk factors and health disparities, but also protective factors that can help better inform the development of effective interventions so all youth can reach their full potential.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. Email her at [email protected].

References

1. “WPATH (World Professional Association of Transgender Health) Board Responds to Federal Effort to Redefine Gender,” press release, Oct. 23, 2018.

2. “LGBTQ+ Definitions” at Trans Student Educational Resources.3. J Sex Res. 2013;50(3-4):299-317.

4. JAMA Pediatr. 2018 Nov 1;172(11):1010-1.

5. Psychol Sex Orientat Gend Divers. 2016 Dec;3(4):489-98.

6. J Adolesc Health. 2016; 58(2)(supple):S1-2.

7. JAMA Pediatr. 2018 Nov;172(11):1020-8.

It has been known for decades that sex and gender cannot be determined solely by birth anatomy and chromosomes.¹ Over the past decade, the medical community has been able to better understand the biologic underpinnings of gender identity, and we are gaining a better appreciation for the diversity of gender identities and gender expressions that exist.

Gender expression can be defined as the manner in which an individual chooses to present their gender to others through physical appearance and behaviors, such as style of hair or dress, voice or movement.² Gender nonconformity (GNC) is when an individual’s gender expression does not fully conform with societal expectations often based on an individual’s sex assigned at birth. It is important to note that gender expression is independent of gender identity and may or may not align with gender identity. For example, a person whose sex assigned at birth is female may adopt hairstyles and clothing that are considered more masculine and enjoy activities that are typically associated with masculinity (for example, sports) yet identify as female. The majority of research to date focuses most on transgender individuals, broadly defined as those whose gender identity does not fully align with the sex assigned at birth.^3,4 As our understanding of gender expression and GNC expands, more research is emerging on the prevalence of gender nonconformity in youth and potential associations with various health outcomes.

Stigma, discrimination, and harassment are known to have documented effects on health. GNC youth have been shown to experience discrimination and harassment at rates higher than their gender conforming peers.^5,6 A recent study by Lowry et al. sought to examine the association between GNC and indicators of mental distress and substance use in adolescents.⁷ The authors analyzed a subset of cross-sectional data from more than 6,000 youth who had participated in the Youth Risk Behavior Surveillance–United States, 2015 (YRBS) in three large urban school districts (two in California and one in Florida). In addition to the standard YRBS questions, students at these three school districts were asked about their gender expression using the following question: “A person’s appearance style, dress, or the way they walk or talk may affect how people describe them. How do you think people at your school would describe you?” Based on responses, youth were categorized on a 7-point GNC scale with 1 being most gender conforming (a very feminine female student or very masculine male student) to 7 being most GNC (a very masculine female student or a very feminine male student). The study sample was ethnically diverse with 16% of students identifying as white non-Hispanic, 19% identifying as black non-Hispanic, and 55% identifying as Hispanic of any race.

In the study population, approximately one in five students reported either moderate (students who described themselves as equally feminine and masculine) or high (female students who described themselves as very/mostly/somewhat masculine or male students who described themselves as very/mostly/somewhat feminine) levels of GNC. Among female students, moderate GNC was significantly associated with feeling sad and hopeless, seriously considering attempting suicide, and making a suicide plan. However, in female students substance use was not associated with GNC. Among male students, suicidal thoughts, plans, and attempts all demonstrated a linear increase with GNC, with the greatest prevalence occurring in male students expressing high levels of GNC. Prevalence of substance use, specifically nonmedical use of prescription drugs, cocaine use, methamphetamine use, heroin use, and intravenous drug also was associated with high GNC in male students. Study authors hypothesize that these differences occur because GNC male youth experience more overt harassment, compared with GNC female youth, but further study is needed.

Our understanding of the diversity of gender expressions present in youth populations continues to evolve. Findings from this study add to a growing body of evidence demonstrating a relatively high prevalence of GNC in youth populations, and potential health disparities these youth may face. This study underscores the need for continued study in this area. Family support and acceptance have been demonstrated to be strong protective factors for transgender-, lesbian-, and gay-identified youth. Studies identifying protective factors for GNC youth are needed.⁴

As health care providers, we need to continue to ask patients and families about gender identity and be aware of gender expression. When youth present as GNC, we should recognize that they may be at increased risk and, in addition to assessing overall mental health and risk for substance use, also assess for degree of social/familial support and potential stressors.4 We also should continue to advocate for support systems within schools sensitive to the needs of GNC students, as these may be a potential avenue to improve overall mental health for students. It is important to continue to expand our understanding of the diverse gender identities and expressions of the youth we serve. This hopefully will allow us to identify not only potential risk factors and health disparities, but also protective factors that can help better inform the development of effective interventions so all youth can reach their full potential.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. Email her at [email protected].

References

1. “WPATH (World Professional Association of Transgender Health) Board Responds to Federal Effort to Redefine Gender,” press release, Oct. 23, 2018.

2. “LGBTQ+ Definitions” at Trans Student Educational Resources.3. J Sex Res. 2013;50(3-4):299-317.

4. JAMA Pediatr. 2018 Nov 1;172(11):1010-1.

5. Psychol Sex Orientat Gend Divers. 2016 Dec;3(4):489-98.

6. J Adolesc Health. 2016; 58(2)(supple):S1-2.

7. JAMA Pediatr. 2018 Nov;172(11):1020-8.

It has been known for decades that sex and gender cannot be determined solely by birth anatomy and chromosomes.¹ Over the past decade, the medical community has been able to better understand the biologic underpinnings of gender identity, and we are gaining a better appreciation for the diversity of gender identities and gender expressions that exist.

Gender expression can be defined as the manner in which an individual chooses to present their gender to others through physical appearance and behaviors, such as style of hair or dress, voice or movement.² Gender nonconformity (GNC) is when an individual’s gender expression does not fully conform with societal expectations often based on an individual’s sex assigned at birth. It is important to note that gender expression is independent of gender identity and may or may not align with gender identity. For example, a person whose sex assigned at birth is female may adopt hairstyles and clothing that are considered more masculine and enjoy activities that are typically associated with masculinity (for example, sports) yet identify as female. The majority of research to date focuses most on transgender individuals, broadly defined as those whose gender identity does not fully align with the sex assigned at birth.^3,4 As our understanding of gender expression and GNC expands, more research is emerging on the prevalence of gender nonconformity in youth and potential associations with various health outcomes.

Stigma, discrimination, and harassment are known to have documented effects on health. GNC youth have been shown to experience discrimination and harassment at rates higher than their gender conforming peers.^5,6 A recent study by Lowry et al. sought to examine the association between GNC and indicators of mental distress and substance use in adolescents.⁷ The authors analyzed a subset of cross-sectional data from more than 6,000 youth who had participated in the Youth Risk Behavior Surveillance–United States, 2015 (YRBS) in three large urban school districts (two in California and one in Florida). In addition to the standard YRBS questions, students at these three school districts were asked about their gender expression using the following question: “A person’s appearance style, dress, or the way they walk or talk may affect how people describe them. How do you think people at your school would describe you?” Based on responses, youth were categorized on a 7-point GNC scale with 1 being most gender conforming (a very feminine female student or very masculine male student) to 7 being most GNC (a very masculine female student or a very feminine male student). The study sample was ethnically diverse with 16% of students identifying as white non-Hispanic, 19% identifying as black non-Hispanic, and 55% identifying as Hispanic of any race.

In the study population, approximately one in five students reported either moderate (students who described themselves as equally feminine and masculine) or high (female students who described themselves as very/mostly/somewhat masculine or male students who described themselves as very/mostly/somewhat feminine) levels of GNC. Among female students, moderate GNC was significantly associated with feeling sad and hopeless, seriously considering attempting suicide, and making a suicide plan. However, in female students substance use was not associated with GNC. Among male students, suicidal thoughts, plans, and attempts all demonstrated a linear increase with GNC, with the greatest prevalence occurring in male students expressing high levels of GNC. Prevalence of substance use, specifically nonmedical use of prescription drugs, cocaine use, methamphetamine use, heroin use, and intravenous drug also was associated with high GNC in male students. Study authors hypothesize that these differences occur because GNC male youth experience more overt harassment, compared with GNC female youth, but further study is needed.

Our understanding of the diversity of gender expressions present in youth populations continues to evolve. Findings from this study add to a growing body of evidence demonstrating a relatively high prevalence of GNC in youth populations, and potential health disparities these youth may face. This study underscores the need for continued study in this area. Family support and acceptance have been demonstrated to be strong protective factors for transgender-, lesbian-, and gay-identified youth. Studies identifying protective factors for GNC youth are needed.⁴

As health care providers, we need to continue to ask patients and families about gender identity and be aware of gender expression. When youth present as GNC, we should recognize that they may be at increased risk and, in addition to assessing overall mental health and risk for substance use, also assess for degree of social/familial support and potential stressors.4 We also should continue to advocate for support systems within schools sensitive to the needs of GNC students, as these may be a potential avenue to improve overall mental health for students. It is important to continue to expand our understanding of the diverse gender identities and expressions of the youth we serve. This hopefully will allow us to identify not only potential risk factors and health disparities, but also protective factors that can help better inform the development of effective interventions so all youth can reach their full potential.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. Email her at [email protected].

References

1. “WPATH (World Professional Association of Transgender Health) Board Responds to Federal Effort to Redefine Gender,” press release, Oct. 23, 2018.

2. “LGBTQ+ Definitions” at Trans Student Educational Resources.3. J Sex Res. 2013;50(3-4):299-317.

4. JAMA Pediatr. 2018 Nov 1;172(11):1010-1.

5. Psychol Sex Orientat Gend Divers. 2016 Dec;3(4):489-98.

6. J Adolesc Health. 2016; 58(2)(supple):S1-2.

7. JAMA Pediatr. 2018 Nov;172(11):1020-8.

ORLANDO – Many pediatricians have little support or guidance in how to address the unique issues that arise during care of transgender and gender-diverse children and adolescents, Colleen A. Kraft, MD, president of the American Academy of Pediatrics, said in an interview.

The AAP’s policy on caring and supporting these patients is evidence-based, and includes recommendations on providing appropriate health care services for transgender individuals, as well as respect and understanding for families. In the interview, Dr. Kraft, discussed the role pediatricians have in providing a safe and supportive environment for transgender and gender-diverse individuals and their families.

“[These children] need to be listened to, they need to be respected for who they are, and they need access to the appropriate health services,” Dr. Kraft said.

The AAP’s policy statement on ensuring care and support for transgender children and adolescents is available here.

Dr. Kraft reported no relevant conflicts of interest.

ORLANDO – Many pediatricians have little support or guidance in how to address the unique issues that arise during care of transgender and gender-diverse children and adolescents, Colleen A. Kraft, MD, president of the American Academy of Pediatrics, said in an interview.

The AAP’s policy on caring and supporting these patients is evidence-based, and includes recommendations on providing appropriate health care services for transgender individuals, as well as respect and understanding for families. In the interview, Dr. Kraft, discussed the role pediatricians have in providing a safe and supportive environment for transgender and gender-diverse individuals and their families.

“[These children] need to be listened to, they need to be respected for who they are, and they need access to the appropriate health services,” Dr. Kraft said.

The AAP’s policy statement on ensuring care and support for transgender children and adolescents is available here.

Dr. Kraft reported no relevant conflicts of interest.

ORLANDO – Many pediatricians have little support or guidance in how to address the unique issues that arise during care of transgender and gender-diverse children and adolescents, Colleen A. Kraft, MD, president of the American Academy of Pediatrics, said in an interview.

The AAP’s policy on caring and supporting these patients is evidence-based, and includes recommendations on providing appropriate health care services for transgender individuals, as well as respect and understanding for families. In the interview, Dr. Kraft, discussed the role pediatricians have in providing a safe and supportive environment for transgender and gender-diverse individuals and their families.

“[These children] need to be listened to, they need to be respected for who they are, and they need access to the appropriate health services,” Dr. Kraft said.

The AAP’s policy statement on ensuring care and support for transgender children and adolescents is available here.

Dr. Kraft reported no relevant conflicts of interest.

Physicians have a duty to uphold to all kinds of people we serve, and transgender people are just that: people.

According to the U.S. Transgender Survey of 2015, one-third of transgender individuals have experienced a negative reaction from a health care provider in the past year. About 40% have attempted suicide in their lifetime, nearly nine times the rate of the U.S. general population. HIV positivity in the transgender community is nearly five times the rate of the U.S. general population.

In many states across the United States, including Pennsylvania, there are no comprehensive nondiscrimination laws that protect members of the LGBTQ community from being denied housing or from being fired because of their sexual orientation or gender identity and expression. Members of the transgender community have experienced brutal, unfair judgment and have been denied fair opportunities.

There have been numerous cases where transgender individuals have been treated unfairly by private businesses and public institutions. These instances include people being physically assaulted, verbally harassed, or denied their basic rights.

The denial of these fundamental rights calls for change, and the responsibility of this shift toward equality falls upon a faction of some of the most important people in our society: American physicians.

As a practicing physician in adolescent medicine, I have watched numerous transgender adolescents deal with the difficult transition process. These patients are at an already vulnerable time of their lives and often need support from those who are in the best position to provide it.

Esteemed medical organizations such as the American Medical Association have iterated their beliefs about the importance of equality in medical treatment several times, mentioning that their support for equal care is blind of gender, sexual orientation, and gender identity.

The AMA has developed numerous policies that support LGBTQ individuals. General policies developed include those on the Continued Support of Human Rights and Freedom, the Nondiscrimination Policy, and Civil Rights Restoration. Several additional physician- and patient-centered policies have also been developed to reinforce the AMA’s support.

As a doctor who can recognize the importance of this initiative, I think it is of utmost importance that physicians support, spearhead, and lead this movement – not as part of a political agenda, but for the purpose of providing aid to a community that has not been receiving the clinical or social acknowledgment it deserves.

Often, transgender patients look to their health care providers for counsel, support, and education when confused about government legislation, insurance policies, and benefits. Yet, many physicians find themselves to be either unaware of the answers or unable to help with current resources at hand when approached about this issue. That is the case despite the wide number of resources and articles that are available to educate physicians to support their patients.

In cases like these, it is imperative that transgender patients, as any other patient would, receive the guidance and support they need. It is a respected obligation to our valued profession that we are continuously learning – exploring, discovering, and seeing the future of treatment for the benefit of those we serve, especially for the growing needs of our transgender patients.

The dynamics of equal treatment for the transgender community require significant action of health care professionals, and it is the will and power of American physicians that will propel this movement toward victory. As a transgender Pennsylvanian and American, I am proud to serve my community, my state, and my nation as the secretary of health for the Commonwealth of Pennsylvania.

In addition to serving as Pennsylvania’s secretary of health, Dr. Levine is professor of pediatrics and psychiatry at Penn State University, Hershey.

Physicians have a duty to uphold to all kinds of people we serve, and transgender people are just that: people.

According to the U.S. Transgender Survey of 2015, one-third of transgender individuals have experienced a negative reaction from a health care provider in the past year. About 40% have attempted suicide in their lifetime, nearly nine times the rate of the U.S. general population. HIV positivity in the transgender community is nearly five times the rate of the U.S. general population.

In many states across the United States, including Pennsylvania, there are no comprehensive nondiscrimination laws that protect members of the LGBTQ community from being denied housing or from being fired because of their sexual orientation or gender identity and expression. Members of the transgender community have experienced brutal, unfair judgment and have been denied fair opportunities.

There have been numerous cases where transgender individuals have been treated unfairly by private businesses and public institutions. These instances include people being physically assaulted, verbally harassed, or denied their basic rights.

The denial of these fundamental rights calls for change, and the responsibility of this shift toward equality falls upon a faction of some of the most important people in our society: American physicians.

As a practicing physician in adolescent medicine, I have watched numerous transgender adolescents deal with the difficult transition process. These patients are at an already vulnerable time of their lives and often need support from those who are in the best position to provide it.

Esteemed medical organizations such as the American Medical Association have iterated their beliefs about the importance of equality in medical treatment several times, mentioning that their support for equal care is blind of gender, sexual orientation, and gender identity.

The AMA has developed numerous policies that support LGBTQ individuals. General policies developed include those on the Continued Support of Human Rights and Freedom, the Nondiscrimination Policy, and Civil Rights Restoration. Several additional physician- and patient-centered policies have also been developed to reinforce the AMA’s support.

As a doctor who can recognize the importance of this initiative, I think it is of utmost importance that physicians support, spearhead, and lead this movement – not as part of a political agenda, but for the purpose of providing aid to a community that has not been receiving the clinical or social acknowledgment it deserves.

Often, transgender patients look to their health care providers for counsel, support, and education when confused about government legislation, insurance policies, and benefits. Yet, many physicians find themselves to be either unaware of the answers or unable to help with current resources at hand when approached about this issue. That is the case despite the wide number of resources and articles that are available to educate physicians to support their patients.

In cases like these, it is imperative that transgender patients, as any other patient would, receive the guidance and support they need. It is a respected obligation to our valued profession that we are continuously learning – exploring, discovering, and seeing the future of treatment for the benefit of those we serve, especially for the growing needs of our transgender patients.

The dynamics of equal treatment for the transgender community require significant action of health care professionals, and it is the will and power of American physicians that will propel this movement toward victory. As a transgender Pennsylvanian and American, I am proud to serve my community, my state, and my nation as the secretary of health for the Commonwealth of Pennsylvania.

In addition to serving as Pennsylvania’s secretary of health, Dr. Levine is professor of pediatrics and psychiatry at Penn State University, Hershey.

Physicians have a duty to uphold to all kinds of people we serve, and transgender people are just that: people.

According to the U.S. Transgender Survey of 2015, one-third of transgender individuals have experienced a negative reaction from a health care provider in the past year. About 40% have attempted suicide in their lifetime, nearly nine times the rate of the U.S. general population. HIV positivity in the transgender community is nearly five times the rate of the U.S. general population.

In many states across the United States, including Pennsylvania, there are no comprehensive nondiscrimination laws that protect members of the LGBTQ community from being denied housing or from being fired because of their sexual orientation or gender identity and expression. Members of the transgender community have experienced brutal, unfair judgment and have been denied fair opportunities.

There have been numerous cases where transgender individuals have been treated unfairly by private businesses and public institutions. These instances include people being physically assaulted, verbally harassed, or denied their basic rights.

The denial of these fundamental rights calls for change, and the responsibility of this shift toward equality falls upon a faction of some of the most important people in our society: American physicians.

As a practicing physician in adolescent medicine, I have watched numerous transgender adolescents deal with the difficult transition process. These patients are at an already vulnerable time of their lives and often need support from those who are in the best position to provide it.

Esteemed medical organizations such as the American Medical Association have iterated their beliefs about the importance of equality in medical treatment several times, mentioning that their support for equal care is blind of gender, sexual orientation, and gender identity.

The AMA has developed numerous policies that support LGBTQ individuals. General policies developed include those on the Continued Support of Human Rights and Freedom, the Nondiscrimination Policy, and Civil Rights Restoration. Several additional physician- and patient-centered policies have also been developed to reinforce the AMA’s support.

As a doctor who can recognize the importance of this initiative, I think it is of utmost importance that physicians support, spearhead, and lead this movement – not as part of a political agenda, but for the purpose of providing aid to a community that has not been receiving the clinical or social acknowledgment it deserves.

Often, transgender patients look to their health care providers for counsel, support, and education when confused about government legislation, insurance policies, and benefits. Yet, many physicians find themselves to be either unaware of the answers or unable to help with current resources at hand when approached about this issue. That is the case despite the wide number of resources and articles that are available to educate physicians to support their patients.

In cases like these, it is imperative that transgender patients, as any other patient would, receive the guidance and support they need. It is a respected obligation to our valued profession that we are continuously learning – exploring, discovering, and seeing the future of treatment for the benefit of those we serve, especially for the growing needs of our transgender patients.

The dynamics of equal treatment for the transgender community require significant action of health care professionals, and it is the will and power of American physicians that will propel this movement toward victory. As a transgender Pennsylvanian and American, I am proud to serve my community, my state, and my nation as the secretary of health for the Commonwealth of Pennsylvania.

In addition to serving as Pennsylvania’s secretary of health, Dr. Levine is professor of pediatrics and psychiatry at Penn State University, Hershey.

WASHINGTON – Respondents to the 2015 United States Transgender Survey (USTS) reported living with HIV at nearly five times the rate in the U.S. population. Reported HIV rates were even higher among transgender women, especially transgender women of color, according to Sandy James, JD, PhD, the lead author of the USTS and its former research director (2014-2017).

© 2018 National Center for Transgender Equality

In addition, the survey results detailed high rates of physical and mental health issues, difficulties accessing health care, and negative experiences when receiving medical care.

“There [had been] a dearth of data available about trans people,” said Dr. James, and hard data are required to make any meaningful changes to health care systems, but “now we have numbers.”

The nationwide USTS was the largest survey ever to document the experiences of transgender adults in the United States, comprising 27,715 respondents from all 50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, and U.S. military bases overseas.

The USTS provided a comprehensive examination of a wide range of life outcomes, including those related to health, employment, income, and education. This survey of transgender adults (18 years of age and older) was anonymous, was available in both English and Spanish, and was conducted in the summer of 2015 by the National Center for Transgender Equality.

The document details the stresses and dangers that transgender people face in their daily lives, including attempted suicide rates higher than the norm (40% having attempted suicide in their lifetime, nearly nine times the 4.6% rate in the U.S. population). Nearly 1 in 10 respondents were physically attacked in the past year because of being transgender, and nearly half (47%) of respondents reported having been sexually assaulted during their lifetime.

Respondents reported living with HIV (1.4%) at nearly five times the rate in the U.S. population (0.3%), with HIV rates higher among transgender women (3.4%), especially transgender women of color. Nearly one in five black transgender women were living with HIV, and Native American Indian and Latina women also reported higher rates of infection: 4.6% and 4.4%, respectively.

A total of 25% of respondents experienced a problem in the past year with their insurance related to being transgender, such as being denied coverage for care related to gender transition or being denied coverage for routine care because they were transgender.

In terms of the health care environment, 33% of those who saw a health care provider in the past year reported having at least one negative experience related to being transgender, with higher rates for people of color and people with disabilities. This included being refused treatment, being verbally harassed or physically or sexually assaulted, or having to teach the provider about transgender people to get appropriate care, according to the survey.

In addition, 23% of respondents reported that they did not see a doctor when they needed to in the past year because of fear of being mistreated as a transgender person, and 33% did not see a doctor when needed because they could not afford care.

“I urge you to go and find the survey and look at all of the results, it is really important,” Dr. James stated. He stressed the fact that the breakout reports, including the report on black respondents, the Latino/a response report (in both English and Spanish), and the other minority and individual state reports, can all provide a more detailed view of what is going on in the transgender community than anything previously available.

Dr. James reported having no disclosures.
 

[email protected]

SOURCE: James S. Sexually Transmitted Diseases 2018. 45 [Supplement 2] Session 5D. S289.

WASHINGTON – Respondents to the 2015 United States Transgender Survey (USTS) reported living with HIV at nearly five times the rate in the U.S. population. Reported HIV rates were even higher among transgender women, especially transgender women of color, according to Sandy James, JD, PhD, the lead author of the USTS and its former research director (2014-2017).

© 2018 National Center for Transgender Equality

In addition, the survey results detailed high rates of physical and mental health issues, difficulties accessing health care, and negative experiences when receiving medical care.

“There [had been] a dearth of data available about trans people,” said Dr. James, and hard data are required to make any meaningful changes to health care systems, but “now we have numbers.”

The nationwide USTS was the largest survey ever to document the experiences of transgender adults in the United States, comprising 27,715 respondents from all 50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, and U.S. military bases overseas.

The USTS provided a comprehensive examination of a wide range of life outcomes, including those related to health, employment, income, and education. This survey of transgender adults (18 years of age and older) was anonymous, was available in both English and Spanish, and was conducted in the summer of 2015 by the National Center for Transgender Equality.

The document details the stresses and dangers that transgender people face in their daily lives, including attempted suicide rates higher than the norm (40% having attempted suicide in their lifetime, nearly nine times the 4.6% rate in the U.S. population). Nearly 1 in 10 respondents were physically attacked in the past year because of being transgender, and nearly half (47%) of respondents reported having been sexually assaulted during their lifetime.

Respondents reported living with HIV (1.4%) at nearly five times the rate in the U.S. population (0.3%), with HIV rates higher among transgender women (3.4%), especially transgender women of color. Nearly one in five black transgender women were living with HIV, and Native American Indian and Latina women also reported higher rates of infection: 4.6% and 4.4%, respectively.

A total of 25% of respondents experienced a problem in the past year with their insurance related to being transgender, such as being denied coverage for care related to gender transition or being denied coverage for routine care because they were transgender.

In terms of the health care environment, 33% of those who saw a health care provider in the past year reported having at least one negative experience related to being transgender, with higher rates for people of color and people with disabilities. This included being refused treatment, being verbally harassed or physically or sexually assaulted, or having to teach the provider about transgender people to get appropriate care, according to the survey.

In addition, 23% of respondents reported that they did not see a doctor when they needed to in the past year because of fear of being mistreated as a transgender person, and 33% did not see a doctor when needed because they could not afford care.

“I urge you to go and find the survey and look at all of the results, it is really important,” Dr. James stated. He stressed the fact that the breakout reports, including the report on black respondents, the Latino/a response report (in both English and Spanish), and the other minority and individual state reports, can all provide a more detailed view of what is going on in the transgender community than anything previously available.

Dr. James reported having no disclosures.
 

[email protected]

SOURCE: James S. Sexually Transmitted Diseases 2018. 45 [Supplement 2] Session 5D. S289.

WASHINGTON – Respondents to the 2015 United States Transgender Survey (USTS) reported living with HIV at nearly five times the rate in the U.S. population. Reported HIV rates were even higher among transgender women, especially transgender women of color, according to Sandy James, JD, PhD, the lead author of the USTS and its former research director (2014-2017).

© 2018 National Center for Transgender Equality

In addition, the survey results detailed high rates of physical and mental health issues, difficulties accessing health care, and negative experiences when receiving medical care.

“There [had been] a dearth of data available about trans people,” said Dr. James, and hard data are required to make any meaningful changes to health care systems, but “now we have numbers.”

The nationwide USTS was the largest survey ever to document the experiences of transgender adults in the United States, comprising 27,715 respondents from all 50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, and U.S. military bases overseas.

The USTS provided a comprehensive examination of a wide range of life outcomes, including those related to health, employment, income, and education. This survey of transgender adults (18 years of age and older) was anonymous, was available in both English and Spanish, and was conducted in the summer of 2015 by the National Center for Transgender Equality.

The document details the stresses and dangers that transgender people face in their daily lives, including attempted suicide rates higher than the norm (40% having attempted suicide in their lifetime, nearly nine times the 4.6% rate in the U.S. population). Nearly 1 in 10 respondents were physically attacked in the past year because of being transgender, and nearly half (47%) of respondents reported having been sexually assaulted during their lifetime.

Respondents reported living with HIV (1.4%) at nearly five times the rate in the U.S. population (0.3%), with HIV rates higher among transgender women (3.4%), especially transgender women of color. Nearly one in five black transgender women were living with HIV, and Native American Indian and Latina women also reported higher rates of infection: 4.6% and 4.4%, respectively.

A total of 25% of respondents experienced a problem in the past year with their insurance related to being transgender, such as being denied coverage for care related to gender transition or being denied coverage for routine care because they were transgender.

In terms of the health care environment, 33% of those who saw a health care provider in the past year reported having at least one negative experience related to being transgender, with higher rates for people of color and people with disabilities. This included being refused treatment, being verbally harassed or physically or sexually assaulted, or having to teach the provider about transgender people to get appropriate care, according to the survey.

In addition, 23% of respondents reported that they did not see a doctor when they needed to in the past year because of fear of being mistreated as a transgender person, and 33% did not see a doctor when needed because they could not afford care.

“I urge you to go and find the survey and look at all of the results, it is really important,” Dr. James stated. He stressed the fact that the breakout reports, including the report on black respondents, the Latino/a response report (in both English and Spanish), and the other minority and individual state reports, can all provide a more detailed view of what is going on in the transgender community than anything previously available.

Dr. James reported having no disclosures.
 

[email protected]

SOURCE: James S. Sexually Transmitted Diseases 2018. 45 [Supplement 2] Session 5D. S289.

Researchers have highlighted the need for contraception counseling for transgender men, after a study found around half of transgender men had not been asked by their health care providers about their fertility desires.

Writing in Contraception, researchers reported the results of an anonymous, online survey of 197 female-to-male transgender men, 86% of whom were taking masculinizing hormones.

Overall, 17% of respondents had experienced a pregnancy, with 60 pregnancies reported in total. While participants who had never taken hormones had a nearly 200% higher incidence of pregnancy, compared with those who had taken testosterone, one pregnancy occurred while the subject was taking testosterone, and five of seven reported abortions were in participants who had used testosterone prior to conception.

A total of 30 participants (16.4%) believed testosterone was a contraceptive method, and 10 said that a health care provider had advised them to use testosterone for contraception. However, nearly half of all participants did report using condoms for contraception, making it the most common method. IUDs were the second most common method of contraception currently used.

Nearly one-third of participants said they had used some type of contraceptive pill at some point, 17 said they had tried more than one type of pill, and 36 had used combination pills. However, of those who had used combination pills, nearly half stopped using them because of side effects or because of concern about extra feminine hormones.

The authors noted that most study participants expressed a desire to become a parent. Around one-quarter wanted to bear a child while the majority said they would consider adoption.

One-quarter of respondents had fears about not achieving a desired pregnancy, and for some, those fears began after initiating hormone treatments. Just over half the respondents said their health care provider had not asked about their fertility desires.

“Transgender men have unintended pregnancy as well as future fertility desires, and yet, there is a paucity of reproductive health care best practices research for this unique population,” wrote Alexis Light, MD, MPH, of MedStar Washington Hospital Center, and her coauthors. “This survey confirms earlier studies: Transgender men do become pregnant, both intentionally and unintentionally, and some transgender men engage in behaviors that can lead to unintended pregnancy.”

The study authors called for doctors to be more equipped and prepared to counsel transgender men on contraception and discuss other reproductive health concerns.

The study was supported by MedStar Washington Hospital Center. No conflicts of interest were declared.

SOURCE: Light A et al. Contraception. 2018 Jun 23. doi: 10.1016/j.contraception.2018.06.006.

Researchers have highlighted the need for contraception counseling for transgender men, after a study found around half of transgender men had not been asked by their health care providers about their fertility desires.

Writing in Contraception, researchers reported the results of an anonymous, online survey of 197 female-to-male transgender men, 86% of whom were taking masculinizing hormones.

Overall, 17% of respondents had experienced a pregnancy, with 60 pregnancies reported in total. While participants who had never taken hormones had a nearly 200% higher incidence of pregnancy, compared with those who had taken testosterone, one pregnancy occurred while the subject was taking testosterone, and five of seven reported abortions were in participants who had used testosterone prior to conception.

A total of 30 participants (16.4%) believed testosterone was a contraceptive method, and 10 said that a health care provider had advised them to use testosterone for contraception. However, nearly half of all participants did report using condoms for contraception, making it the most common method. IUDs were the second most common method of contraception currently used.

Nearly one-third of participants said they had used some type of contraceptive pill at some point, 17 said they had tried more than one type of pill, and 36 had used combination pills. However, of those who had used combination pills, nearly half stopped using them because of side effects or because of concern about extra feminine hormones.

The authors noted that most study participants expressed a desire to become a parent. Around one-quarter wanted to bear a child while the majority said they would consider adoption.

One-quarter of respondents had fears about not achieving a desired pregnancy, and for some, those fears began after initiating hormone treatments. Just over half the respondents said their health care provider had not asked about their fertility desires.

“Transgender men have unintended pregnancy as well as future fertility desires, and yet, there is a paucity of reproductive health care best practices research for this unique population,” wrote Alexis Light, MD, MPH, of MedStar Washington Hospital Center, and her coauthors. “This survey confirms earlier studies: Transgender men do become pregnant, both intentionally and unintentionally, and some transgender men engage in behaviors that can lead to unintended pregnancy.”

The study authors called for doctors to be more equipped and prepared to counsel transgender men on contraception and discuss other reproductive health concerns.

The study was supported by MedStar Washington Hospital Center. No conflicts of interest were declared.

SOURCE: Light A et al. Contraception. 2018 Jun 23. doi: 10.1016/j.contraception.2018.06.006.

Researchers have highlighted the need for contraception counseling for transgender men, after a study found around half of transgender men had not been asked by their health care providers about their fertility desires.

Writing in Contraception, researchers reported the results of an anonymous, online survey of 197 female-to-male transgender men, 86% of whom were taking masculinizing hormones.

Overall, 17% of respondents had experienced a pregnancy, with 60 pregnancies reported in total. While participants who had never taken hormones had a nearly 200% higher incidence of pregnancy, compared with those who had taken testosterone, one pregnancy occurred while the subject was taking testosterone, and five of seven reported abortions were in participants who had used testosterone prior to conception.

A total of 30 participants (16.4%) believed testosterone was a contraceptive method, and 10 said that a health care provider had advised them to use testosterone for contraception. However, nearly half of all participants did report using condoms for contraception, making it the most common method. IUDs were the second most common method of contraception currently used.

Nearly one-third of participants said they had used some type of contraceptive pill at some point, 17 said they had tried more than one type of pill, and 36 had used combination pills. However, of those who had used combination pills, nearly half stopped using them because of side effects or because of concern about extra feminine hormones.

The authors noted that most study participants expressed a desire to become a parent. Around one-quarter wanted to bear a child while the majority said they would consider adoption.

One-quarter of respondents had fears about not achieving a desired pregnancy, and for some, those fears began after initiating hormone treatments. Just over half the respondents said their health care provider had not asked about their fertility desires.

“Transgender men have unintended pregnancy as well as future fertility desires, and yet, there is a paucity of reproductive health care best practices research for this unique population,” wrote Alexis Light, MD, MPH, of MedStar Washington Hospital Center, and her coauthors. “This survey confirms earlier studies: Transgender men do become pregnant, both intentionally and unintentionally, and some transgender men engage in behaviors that can lead to unintended pregnancy.”

The study authors called for doctors to be more equipped and prepared to counsel transgender men on contraception and discuss other reproductive health concerns.

The study was supported by MedStar Washington Hospital Center. No conflicts of interest were declared.

SOURCE: Light A et al. Contraception. 2018 Jun 23. doi: 10.1016/j.contraception.2018.06.006.