Faculty Bibliography

The purpose of this review is to create a set of provisional criteria for Institutional Review Boards (IRBs) to refer to when assessing the ethical orientation of transgender health research proposals. We began by searching for literature on this topic using databases and the reference lists of key articles, resulting in a preliminary set of criteria. We then collaborated to develop the following nine guidelines: (1) Whenever possible, research should be grounded, from inception to dissemination, in a meaningful collaboration with community stakeholders; (2) language and framing of transgender health research should be non-stigmatizing; (3) research should be disseminated back to the community; (4) the diversity of the transgender and gender diverse (TGGD) community should be accurately reflected and sensitively reflected; (5) informed consent must be meaningful, without coercion or undue influence; (6) the protection of participant confidentiality should be paramount; (7) alternative consent procedures should be considered for TGGD minors; (8) research should align with current professional standards that refute conversion, reorientation, or reparative therapy; and (9) IRBs should guard against the temptation to avoid, limit, or delay research on this subject.

Transgender medicine presents a particular challenge for the development of evidence-based guidelines, due to limitations in the available body of evidence as well as the exclusion of gender identity data from most public health surveillance activities. The guidelines that have been published are often based on expert opinion, small studies, and data gathered outside the US. The existence of guidelines, however, helps legitimate the need for gender-affirming medical and surgical interventions. Research conducted on transgender populations should be grounded in gender-affirming methodologies and focus on key areas such as health outcomes after gender-affirming interventions.

Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested "best practices" for how to integrate clinical care and research for the field of HIV prevention. Holistic and culturally responsive HIV prevention interventions must be grounded in the lived realities the trans community faces to reduce disparities in HIV infection. HIV prevention interventions will be most effective if they use a structural approach and integrate primary concerns of transgender people (eg, gender-affirmative care and management of gender transition) alongside delivery of HIV-related services (eg, biobehavioral prevention, HIV testing, linkage to care, and treatment).

BACKGROUND: Terminology related to sexuality and gender is constantly evolving, and multiple factors are at play when individuals answer questions on surveys. METHODS: We examined patterns of responding to the National Health Interview Survey (NHIS) sexual identity questions in a multisite health intervention study for lesbian and bisexual women aged 40 to 84 years. RESULTS: Of 376 participants, 80% (n = 301) chose "lesbian or gay," 13% (n = 49) selected "bisexual," 7% (n = 25) indicated "something else," and 1 participant chose "don't know the answer." In response to the follow-up question for women who said "something else" or "don't know," most (n = 17) indicated that they were "not straight, but identify with another label." One participant chose "transgender, transsexual, or gender variant," five chose "You do not use labels to identify yourself," and three chose "you mean something else." Lesbian, bisexual, and "something else" groups were compared across demographic and health-related measures. Women who reported their sexual identity as "something else" were younger, more likely to have a disability, more likely to be in a relationship with a male partner, and had lower mental health quality of life than women who reported their sexual identity as lesbian or bisexual. CONCLUSIONS: Respondents who answer "something else" pose challenges to analysis and interpretation of data, but should not be discarded from samples. Instead, they may represent a subset of the community that views sexuality and gender as fluid and dynamic concepts, not to be defined by a single label. Further study of the various subsets of "something else" is warranted, along with reconsideration of the NHIS question options.

PURPOSE: Provider curricula to reduce potential weight bias or stigma in treating lesbian and bisexual (LB) women who are overweight or obese were pilot-tested in two unique settings. Trainings used LB cultural competency and motivational interviewing techniques to improve provider-patient interactions. METHODS: Two training formats were used: Clinic Format and Academic Format. Clinic Format training was pilot tested at Lyon-Martin Health Services, a Program of HealthRight360, a community health center serving women, lesbians, and transgender people in San Francisco and in two community settings. Academic Format training was pilot tested by the Mautner Project of Whitman-Walker Health with physicians, medical residents, and students at Georgetown, George Washington, Howard, and Vanderbilt Universities. Both programs measured provider knowledge and attitude change. RESULTS: Both programs saw significant percentage point gains in knowledge about LB women's avoidance of health care based on body size. Participants in the Academic Format program saw the greatest gain in knowledge about understanding health care avoidance (30 percentage point increase), whereas Clinic Format program participants gained most in understanding how to appropriately discuss weight loss with patients (23 percentage point increase). CONCLUSIONS: Both programs increased provider knowledge about the barriers to health care facing LB women who are overweight and obese, reducing the potential for future negative interactions. However, the two programs differed in how they conceptualized the relationship between weight and health, likely contributing to differences in knowledge gain among participants at each site. Future studies should test differences between the two formats across site type or staff baseline knowledge differences.