Faculty Bibliography

PURPOSE/OBJECTIVE:To design a replicable simulation curriculum collaboratively with the transgender and gender diverse community to improve clinician knowledge and comfort with providing reproductive care to this population. METHODS:This is a prospective, single arm pre-post analysis of obstetrics and gynecology residents at a single academic institution after completion of a novel simulation curriculum. The primary outcome was the change in resident comfort and knowledge in providing transgender and gender diverse patient care. A thematic analysis of learner and standardized patient free text responses was analyzed for insights on perceived learner experiences. RESULTS:This curriculum was created with iterative feedback from the transgender community and involved only transgender and gender diverse-identified standardized patients. Thirty residents participated, with 22 responding to both the pre-and post-curriculum surveys, and 11 responding to a 6-month post-curriculum survey. There were significant improvements in learner comfort and knowledge after participation that were found to persist at 6 months. Qualitative analysis demonstrated that this was a positive and powerful learning experience for both residents and standardized patients. CONCLUSIONS:This simulation curriculum may be an effective and impactful tool to increase trainee comfort and knowledge of transgender and gender diverse patient care, which is important given the lack of physician training in the care for these individuals. By building the foundation with resident learners, the ultimate goal is to enhance the pool of clinicians confident and capable of caring for transgender and gender diverse patients, to increase access to care, and to improve health outcomes in this vulnerable population.

BACKGROUND:A growing number of adolescents are coming out as transgender and gender expansive (TGE). These teenagers have been shown to have significantly worse health outcomes than their cisgender peers. Hypotheses to explain this discrepancy are based on increased stress levels surrounding the societal acceptance of gender identity. In this context, elevated allostatic load (AL), which describes the wear and tear sustained by the body in response to repeated exposure to stress, has been associated with adverse long-term health outcomes. OBJECTIVE:This protocol aims to measure AL among TGE adolescents compared with their cisgender peers and assess how AL varies depending on psychological stress and perceived societal acceptance. METHODS:This is an observational proof-of-concept pilot study in which AL will be measured by assaying an array of inflammatory cytokines and cortisol in urine, saliva, and hair samples of TGE youth, and these parameters will be compared with those of age-matched control participants. A questionnaire will assess 4 aspects of psychosocial well-being: presence and management of depression and anxiety, gender identity support by family members, gender minority stress, and degree of perceived safety in the surrounding community. Samples and surveys will be collected at 3 visits (baseline, 6 months, and 12 months). This study will incorporate TGE coinvestigators to inform all aspects of design, data collection, and analysis and ensure that practices are carried out in a respectful and sensitive manner. RESULTS:As of May 2021, the start of data collection for this project has continued to be postponed as a result of the COVID-19 pandemic, which has both impacted the functioning of the clinic and funding requests. We hope to begin participant recruitment and interviews with coinvestigators soon. CONCLUSIONS:We hypothesize that AL will be primarily influenced by psychological well-being and perceived support and that it will be similar in TGE adolescents and in age-matched cisgender control participants when acceptance and perceived support are high. The results of this study have the potential to increase our understanding of the health challenges faced by TGE individuals during adolescence as well as to show that low levels of acceptance may have detrimental health outcomes secondary to elevated ALs; this may lead to the development of a biomarker profile to assess allostatic stress in TGE patients that can be used to guide management. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)/UNASSIGNED:PRR1-10.2196/24100.

As more young people feel safe to outwardly identify as transgender or gender expansive (TGE), meaning that their gender identity does not align with the sex they were assigned at birth, an increasing number of youth who identify as TGE seek gender-affirming medical care (GAMC). GAMC raises a number of ethical questions, such as the capacity of a minor to assent or consent, the role of parents or legal guardians in decisions about treatment, and implications for equitable access to care when differing parental or custodial viewpoints are present. These questions are further complicated by the difficulties in explaining the limits of long-term research in GAMC, with regard to the preservation of fertility, for example. We present two de-identified composite case studies to highlight dilemmas that may arise and offer recommendations to better support patient- and family-centered decision making for GAMC. These include employing a multidisciplinary shared decision-making approach, disentangling informed consent and assent from chronological age, developing a consistent approach to the assessment of decisional capacity, and developing age-appropriate informational materials.

The number of gender diverse and transgender youth presenting for treatment are increasing. This is a vulnerable population with unique medical needs; it is essential that all pediatricians attain an adequate level of knowledge and comfort caring for these youth so that their health outcomes may be improved. There are several organizations which provide clinical practice guidelines for the treatment of transgender youth including the WPATH and the Endocrine Society and they recommend that certain eligibility criteria should be met prior to initiation of gender affirming hormones. Medical intervention for transgender youth can be broken down into stages based on pubertal development: pre-pubertal, pubertal and post-pubertal. Pre-pubertally no medical intervention is recommended. Once puberty has commenced, youth are eligible for puberty blockers; and post-pubertally, youth are eligible for feminizing and masculinizing hormone regimens. Treatment with gonadotropin releasing hormone agonists are used to block puberty. Their function is many-fold: to pause puberty so that the youth may explore their gender identity, to delay the development of (irreversible) secondary sex characteristics, and to obviate the need for future gender affirmation surgeries. Masculinizing hormone regimens consists of testosterone and feminizing hormone regimens consist of both estradiol as well as spironolactone. In short term studies gender affirming hormone treatment with both estradiol and testosterone has been found to be safe and improve mental health and quality of life outcomes; additional long term studies are needed to further elucidate the implications of gender affirming hormones on physical and mental health in transgender patients. There are a variety of surgeries that transgender individuals may desire in order to affirm their gender identity; it is important for providers to understand that desire for medical interventions is variable among persons and that a discussion about individual desires for surgical options is recommended.

Transgender and gender-nonconforming (TGNC) youth who suffer from gender dysphoria are at a substantially elevated risk of numerous adverse physical and psychosocial outcomes compared with their cisgender peers. Innovative treatment options used to support and affirm an individual's preferred gender identity can help resolve gender dysphoria and avoid many negative sequelae of nontreatment. Yet, despite advances in these relatively novel treatment options, which appear to be highly effective in addressing gender dysphoria and mitigating associated adverse outcomes, ethical challenges abound in ensuring that young patients receive appropriate, safe, affordable treatment and that access to this treatment is fair and equitable. Ethical considerations in gender-affirming care for TGNC youth span concerns about meeting the obligations to maximize treatment benefit to patients (beneficence), minimizing harm (nonmaleficence), supporting autonomy for pediatric patients during a time of rapid development, and addressing justice, including equitable access to care for TGNC youth. Moreover, although available data describing the use of gender-affirming treatment options are encouraging, and the risks of not treating TGNC youth with gender dysphoria are evident, little is known about the long-term effects of both hormonal and surgical interventions in this population. To support ethical decision-making about treatment options, we encourage the development of a comprehensive registry in the United States to track long-term patient outcomes. In the meantime, providers who work with TGNC youth and their families should endeavor to offer ethically sound, patient-centered, gender-affirming care based on the best currently available evidence.

PURPOSE:Routine human immunodeficiency virus (HIV) screening reduces HIV progression and transmission. Our aims were to determine prevalence and factors associated with prior HIV screening among a cohort of youth living with HIV. METHODS:Retrospective chart review of youth living with HIV aged 14-26 at an HIV clinic comparing characteristics between those with and without HIV screening within the year prior to diagnosis RESULTS: Subjects (n = 301) were male (85%), African-American (87%), and men who have sex with men (84%). Subjects seen 1 year prior to diagnosis (n = 58) contributed 179 visits for missed opportunities with 59% having a documented sexual history in the electronic health record and 48% tested for HIV. Subjects with symptoms suggesting acute HIV infection (51%) were more likely to be tested (p = .04). In the adjusted model, documentation of sexual history and demographic factors was not associated with prior testing. CONCLUSION:We identified high rates of missed opportunities for HIV testing and sexual history documentation in the year prior to diagnosis, underscoring the need for routine HIV screening in adolescents.

Lesbian, gay, bisexual, transgender (LGBT), and questioning youth represent a diverse population who are affected by many sexual health inequities, including increased risk for human immunodeficiency virus (HIV) and sexually transmitted infections (STIs). To provide comprehensive sexual health care for LGBT youth, providers should set the stage with a nonjudgmental, respectful tone. Providers should be competent in recognizing symptoms of STIs and HIV and aware of the most up-to-date screening guidelines for LGBT youth. Sexual health visits should also focus on prevention, including safer sex practices, HIV pre-exposure and post-exposure prophylaxis, family planning, and immunization for hepatitis and human papillomavirus.

Many adolescents are at high risk for HIV infection, and those who are infected or at-risk commonly present to the ED, often as their only or frequent source of care. It is important to consider routine screening and to have a high index of suspicion for AHI in this setting. If a diagnosis of HIV infection is made, immediate linkage to care with a specialist in adolescent and young adult HIV infection should be prioritized. For the known HIV-infected patient, management must consider unique possibilities of OIs, IRIS, and medication side effects. For any patient on ART, drug-drug interactions must be noted as part of any treatment plan. If a young person presents with a recent sexual or needlestick exposure of concern, every effort to prescribe and ensure follow-up for PEP should be made. It is essential for physicians to understand and comply with local regulations regarding HIV testing and adolescents' rights for associated confidential care. Finally, physicians who see adolescents in acute care settings have a tremendous opportunity to make a difference in ensuring improved health outcomes for youth living with HIV and to prevent new infections.