Faculty Bibliography

OBJECTIVE:Accumulating evidence demonstrates that gender affirming hormone therapy (GAHT) improves mental health outcomes in transgender persons. Data specific to the risks associated with GAHT for transgender persons continue to emerge, allowing for improvements in understanding, predicting, and mitigating adverse outcomes while informing discussion about desired effects. Of particular concern is the risk of venous thromboembolism (VTE) in the context of both longitudinal GAHT and the perioperative setting. Combining what is known about the risk of VTE in cisgender individuals on hormone therapy (HT) with the evidence for transgender persons receiving HT allows for an informed approach to assess underlying risk and improve care in the transgender community. OBSERVATIONS/METHODS:Hormone formulation, dosing, route, and duration of therapy can impact thromboembolic risk, with transdermal estrogen formulations having the lowest risk. There are no existing risk scores for VTE that consider HT as a possible risk factor. Risk assessment for recurrent VTE and bleeding tendencies using current scores may be helpful when assessing individual risk. Gender affirming surgeries present unique perioperative concerns, and certain procedures include a high likelihood that patients will be on exogenous estrogens at the time of surgery, potentially increasing thromboembolic risk. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Withholding GAHT due to potential adverse events may cause negative impacts for individual patients. Providers should be knowledgeable about the management of HT in transgender individuals of all ages, as well as in the perioperative setting, to avoid periods in which transgender individuals are off GAHT. Treatment decisions for both anticoagulation and HT should be individualized and tailored to patients' overall goals and desired outcomes, given that the physical and mental health benefits of gender affirming care may outweigh the risk of VTE.

BACKGROUND/UNASSIGNED:Sexual and gender minority (SGM) persons are at a higher risk for some cancers and may have poorer health outcomes as a result of ongoing minority stress, social stigma, and cisnormative, heteronormative healthcare environments. This study compared patient and provider experiences of affirming environmental and behavioral cues and also examined provider-reported knowledge, attitudes, behaviors, and clinical preparedness in caring for SGM patients among a convenience sample. METHODS/UNASSIGNED:-tests compared continuous variables. Other results were reported using descriptive frequencies. RESULTS/UNASSIGNED:Both patient and provider samples were predominantly female sex assigned at birth, cisgender, and heterosexual. Providers were more likely than patients to report affirming cues in clinic, as well as the ability for patients to easily document their name in use and pronouns. Providers were more likely to report asking about patient values and preferences of care versus patients' recollection of being asked. Patients were more likely to report understanding why they were asked about both sex assigned at birth and gender identity compared to providers' perceptions that patients would understand being asked about both. Patients were also more likely to report comfort with providers asking about sex assigned at birth and gender identity compared to providers' perceptions of patient comfort. SGM providers had greater knowledge of SGM patient social determinants of health and cancer risks; felt more prepared to care for gay patients; were more likely to endorse the importance of knowing patient sexual orientation and gender identity; and were more likely to indicate a responsibility to learn about SGM patient needs and champion positive system changes for SGM patients compared to heterosexual/cisgender peers. Overall, providers wished for more SGM-specific training. CONCLUSION/UNASSIGNED:Differences between patient and provider reports of affirming environments as well as differences between SGM and heterosexual/cisgender provider care support the need for expanded professional training specific to SGM cancer care.

Gender incongruence describes a condition in which an individual's gender identity does not align with their sex assigned at birth, based on anatomic characteristics. Individuals with gender incongruence may request surgical interventions, and gender-affirmation surgery plays an important role for these individuals. The basis of care derives from principles elucidated in The Standards of Care; international guidelines that help inform clinical decision-making. Historically, mental healthcare professionals (MHPs) and surgeons have worked collaboratively to select "appropriate" surgical candidates. However, as our understanding of gender identity evolves, so does the relationship between the MHP and the surgeon. The role of the MHP has shifted from a requirement to verify an individual's identity to that of supporting and participating in a shared decision-making process between the individual and their healthcare team. This article discusses the evolution of the relationship between the MHP and surgeon as well as providing insight into the history of this relationship.

To alleviate health disparities experienced by sexual and gender minority (SGM) patients, cancer care professionals need further education on the needs of SGM cancer patients and their loved ones and caregivers. The Together-Equitable-Accessible-Meaningful (TEAM) Training to Improve Cancer Care for SGM Patients (TEAM SGM) was developed and piloted to address this need. This study reports healthcare professional learner outcomes from the TEAM SGM pilot intervention. The TEAM SGM Training pilot consisted of 2.5 h of content from the original online self-paced TEAM Training plus 12 1-h Zoom sessions on specialized topics in addition to readings and activities. Participants (n = 28), representing seven cancer service organizations from six states in the USA, were recruited through newsletter listservs and social media. All participants (n = 28) completed the pre-test and twenty-two participants completed the post-test. Using five factors confirmed in a separate Confirmatory Factor Analysis, paired t-tests of TEAM SGM participant pre- and post-test data were conducted. Statistically significant improvements were found in four of five factors: Environmental Cues (t(21) = 2.56, p = .018), Knowledge (t(21) = 2.15, p = .043), Clinical Preparedness (t(7) = 3.89, p = .006), Clinical Behaviors (t(21) = 2.48, p = .022). The Attitudes factor was not significantly improved from pre-intervention to post-intervention likely due to strong affirming attitudes toward SGM patients at baseline. TEAM SGM is a feasible, effective training to build capacity in SGM-affirming care for cancer care providers.

PURPOSE/UNASSIGNED:Earlier literature has reported on the utility of diagnostic codes and demographic information for identifying transgender patients. We aim to assess which method identifies the most transgender patients utilizing readily available tools from within the electronic health record (EHR). METHODS/UNASSIGNED:(ICD-10) diagnostic codes and demographic data specific to transgender patients from January 2011 to April 2019. RESULTS/UNASSIGNED:Demographic data and ICD-10 codes yielded 1494 individual EHRs with transgender-specific data domains. ICD-10 diagnostic codes alone identified 942 (63.05%) unique EHRs. Demographics alone identified 218 (14.59%) unique EHRs. A total of 334 (22.36%) unique EHRs had both ICD-10 and demographic identifiers. Of those identified by transgender-specific demographic data (552), 294 (53.26%) were trans masculine, 215 (38.95%) were trans feminine, and 43 (7.79%) were nonbinary. Of the 552 demographic-identified transgender patients, 141 (25.86%) were identified by a two-part gender identity demographic question. CONCLUSIONS/UNASSIGNED:ICD-10 diagnostic codes, not demographic data, identified the most transgender patient records, but neither diagnostic codes alone nor demographic data captured the full population. Only 26.36% of the charts identified as transgender patients had both ICD-10 codes and demographic data. We recommend that when identifying transgender populations through EHR domains, a combination of diagnostic codes and demographic data be used. Furthermore, research is needed to optimize disclosure and collection of demographic information for gender minority populations.

BACKGROUND/UNASSIGNED:This article is by a group of trans and nonbinary researchers and experts in the field of trans health who have conducted an analysis of trans health research needs. AIMS/UNASSIGNED:To highlight topics that need further research and to outline key considerations for those conducting research in our field. METHODS/UNASSIGNED:The first author conducted semi-structured interviews with all coauthors, and these were used to create a first draft of this manuscript. This draft was circulated to all authors, with edits made until consensus was reached among the authors. RESULTS/UNASSIGNED:More comprehensive long-term research that centers trans people's experiences is needed on the risks and benefits of gender affirming hormones and surgeries. The trans health research field also needs to have a broader focus beyond medical transition or gender affirmation, including general health and routine healthcare; trans people's lives without, before, and after medical gender affirmation; and sexuality, fertility, and reproductive healthcare needs. More research is also needed on social determinants of health, including ways to make healthcare settings and other environments safer and more supportive; social and legal gender recognition; the needs of trans people who are most marginalized; and the ways in which healing happens within trans communities. The second part of this article highlights key considerations for researchers, the foremost being acknowledging trans community expertise and centering trans community members' input into research design and interpretation of findings, in advisory and/or researcher roles. Ethical considerations include maximizing benefits and minimizing harms (beneficence) and transparency and accountability to trans communities. Finally, we note the importance of conferences, grant funding, working with students, and multidisciplinary teams. DISCUSSION/UNASSIGNED:This article outlines topics and issues needing further consideration to make the field of trans health research more responsive to the needs of trans people. This work is limited by our authorship group being mostly White, all being Anglophone, and residing in the Global North.

BACKGROUND:Between May and November, 2022, global outbreaks of human monkeypox virus infection have been reported in more than 78 000 people worldwide, predominantly in men who have sex with men. We describe the epidemiological and clinical characteristics of monkeypox virus infection in cisgender (cis) and transgender (trans) women and non-binary individuals assigned female sex at birth to improve identification and understanding of risk factors. METHODS:International collaborators in geographical locations with high numbers of diagnoses of monkeypox virus infection were approached and invited to contribute data on women and non-binary individuals with confirmed monkeypox virus infection. Contributing centres completed deidentified structured case-report spreadsheets, adapted and developed by participating clinicians, to include variables of interest relevant to women and non-binary individuals assigned female at birth. We describe the epidemiology and clinical course observed in the reported infections. FINDINGS:Collaborators reported data for a total of 136 individuals with monkeypox virus infection who presented between May 11 and Oct 4, 2022, across 15 countries. Overall median age was 34 years (IQR 28-40; range 19-84). The cohort comprised 62 trans women, 69 cis women, and five non-binary individuals (who were, because of small numbers, grouped with cis women to form a category of people assigned female at birth for the purpose of comparison). 121 (89%) of 136 individuals reported sex with men. 37 (27%) of all individuals were living with HIV, with a higher proportion among trans women (31 [50%] of 62) than among cis women and non-binary individuals (six [8%] of 74). Sexual transmission was suspected in 55 (89%) trans women (with the remainder having an unknown route of transmission) and 45 (61%) cis women and non-binary individuals; non-sexual routes of transmission (including household and occupational exposures) were reported only in cis women and non-binary individuals. 25 (34%) of 74 cis women and non-binary individuals submitted to the case series were initially misdiagnosed. Overall, among individuals with available data, rash was described in 124 (93%) of 134 individuals and described as anogenital in 95 (74%) of 129 and as vesiculopustular in 105 (87%) of 121. Median number of lesions was ten (IQR 5-24; range 1-200). Mucosal lesions involving the vagina, anus, or oropharynx or eye occurred in 65 (55%) of 119 individuals with available data. Vaginal and anal sex were associated with lesions at those sites. Monkeypox virus DNA was detected by PCR from vaginal swab samples in all 14 samples tested. 17 (13%) individuals were hospitalised, predominantly for bacterial superinfection of lesions and pain management. 33 (24%) individuals were treated with tecovirimat and six (4%) received post-exposure vaccinations. No deaths were reported. INTERPRETATION:The clinical features of monkeypox in women and non-binary individuals were similar to those described in men, including the presence of anal and genital lesions with prominent mucosal involvement. Anatomically, anogenital lesions were reflective of sexual practices: vulvovaginal lesions predominated in cis women and non-binary individuals and anorectal features predominated in trans women. The prevalence of HIV co-infection in the cohort was high. FUNDING:None.