Faculty Bibliography

There is growing evidence that people who are transgender and gender diverse (TGD) are impacted by disparities across a variety of cardiovascular risk factors compared with their peers who are cisgender. Prior literature has characterized disparities in cardiovascular morbidity and mortality as a result of a higher prevalence of health risk behaviors. Mounting research has revealed that cardiovascular risk factors at the individual level likely do not fully account for increased risk in cardiovascular health disparities among people who are TGD. Excess cardiovascular morbidity and mortality is hypothesized to be driven in part by psychosocial stressors across the lifespan at multiple levels, including structural violence (eg, discrimination, affordable housing, access to health care). This American Heart Association scientific statement reviews the existing literature on the cardiovascular health of people who are TGD. When applicable, the effects of gender-affirming hormone use on individual cardiovascular risk factors are also reviewed. Informed by a conceptual model building on minority stress theory, this statement identifies research gaps and provides suggestions for improving cardiovascular research and clinical care for people who are TGD, including the role of resilience-promoting factors. Advancing the cardiovascular health of people who are TGD requires a multifaceted approach that integrates best practices into research, health promotion, and cardiovascular care for this understudied population.

Gay, bisexual and other men who have sex with men (MSM) and transgender individuals face the highest burden of human immunodeficiency virus (HIV) infection. HIV pre-exposure prophylaxis (PrEP) is an effective evidence-based biomedical intervention to reduce acquisition of HIV infection but uptake has been suboptimal in lesbian, gay, bisexual, and transgender (LGBT) populations. Primary care providers play an integral role in addressing HIV disparities by educating patients and facilitating access to PrEP. After PrEP initiation, primary care providers should assess for and manage adverse effects, provide appropriate laboratory monitoring, support adherence, and assist patients with access to low-cost or free PrEP options if needed.

OBJECTIVE:The aim of this study was to determine whether homophobic victimization was associated with alcohol consumption and riding with an intoxicated driver or driving a car while under the influence of alcohol or drugs among adolescent men who have sex with men (MSM). METHODS:Cross-sectional analysis used baseline data from a national HIV prevention trial (NCT03167606) for adolescent MSM aged 13-18 years (N = 747). Multivariable logistic regression models assessed associations between homophobic victimization (independent variable) and alcohol-related outcomes (dependent variables), controlling for age, parents' education level, sexual orientation, health literacy, race, and ethnicity. RESULTS:Most participants (87%) reported at least one form of homophobic victimization in their lifetime, with verbal insults being the most frequently reported (82%). In the bivariate analysis, alcohol consumption and riding with an intoxicated driver or driving a car while under the influence were associated with many forms of victimization. Exposure to at least one form of victimization was associated with increased odds of alcohol consumption (OR: 2.31; 95% CI: 1.38-3.87) and riding with an intoxicated driver or driving a car while under the influence (OR: 2.25; 95% CI: 1.26-4.00), after controlling for covariates. CONCLUSION:Increased risk of alcohol consumption and risky alcohol-related behaviors were found among adolescent MSM who experienced homophobic victimization. Interventions should address homophobic victimization and its impact on adolescent MSM, as well as disentangling motivations for underage drinking, riding with an intoxicated driver or driving a car while under the influence.

OBJECTIVE:The widespread and frequent use of mobile technology among adolescents, including sexual minority adolescents, presents an opportunity for the development of mobile health (mHealth) technology to combat the continuing HIV epidemic among young men who have sex with men (YMSM). We analyzed perceptions of the quality and impact of an HIV prevention mobile app on sexual risk reduction among YMSM. METHODS:Participants were recruited from a larger randomized controlled trial of the MyPEEPS Mobile app among YMSM aged 13-18 years. Data were collected via semi-structured interviews to assess quality and user satisfaction with MyPEEPS Mobile app using analysis informed by the Information Systems Success framework. Interview data were transcribed verbatim and analyzed using six themes: information quality, net benefit, user satisfaction, product quality, service quality, and health care barriers. RESULTS:Interviews were conducted with 40 YMSM (45% Hispanic; 80% non-White; 88% non-rural resident; 28% aged 17 years). Participants' responses indicated that information quality was high, reporting that the app information was concise, easy to understand, useful, and relevant to their life. The net benefits were stated as improvements in their decision-making skills, health behaviors, communication skills with partner(s), and increased knowledge of HIV risk. There was general user satisfaction and enjoyment when using the app, although most of the participants did not intend to reuse the app unless new activities were added. Participants expressed that the product quality of the app was good due to its personalization, representation of the LGBTQIA + community, and user-friendly interface. Although no major technical issues were reported, participants suggested that adaption to a native app, rather than a web app, would improve service quality through faster loading speed. Participants also identified some health care barriers that were minimized by app use. CONCLUSIONS:The MyPEEPS Mobile app is a well received, functional, and entertaining mHealth HIV prevention tool that may improve HIV prevention skills and reduce HIV risk among YMSM.

INTRODUCTION/BACKGROUND:Preexposure prophylaxis (PrEP) is effective in preventing HIV among adherent users. However, PrEP uptake among transgender women is low, and current prescribing guidelines from the Centers for Disease Control and Prevention (CDC) are not specific to transgender women. Self-perceived risk of HIV among those who are PrEP-indicated is not well understood. METHODS:This cross-sectional analysis included 1293 transgender women screened at baseline from March 2018 to May 2020 for a multisite, prospective cohort study. We compared the prevalence of PrEP indication using current CDC prescribing criteria versus transgender women-specific criteria developed by study investigators with community input. We identified factors associated with study-specific PrEP indication and factors associated with self-perceived low to no HIV risk among those who were PrEP-indicated. We also calculated descriptive statistics to depict the PrEP care continuum. RESULTS:PrEP indication prevalence using transgender women-specific criteria was 47% (611), 155 more than who were identified using the CDC criteria. Eighty-three percent were aware of PrEP, among whom 38% had ever used PrEP. Among PrEP ever users, 63% were using PrEP at the time of the study. There were 66% of current PrEP users who reported 100% adherence within the previous 7 days. Among those who were PrEP-indicated, 13% were using and adherent to PrEP at the time of the study. More than half (55%) of PrEP-indicated participants had low or no self-perceived HIV risk. CONCLUSIONS:These findings suggest that further guidance is needed for health care providers in prescribing PrEP to transgender women. Greater uptake and adherence are also needed for optimal effectiveness.

Electronic consultations (eConsults) have demonstrated benefits in many areas of clinical care including educational value for primary care clinicians (PCCs). It has been shown that few PCCs have knowledge and confidence to manage transgender and gender non-binary (TGNB) patients. In this report, we explored the impact of eConsults submitted to a TGNB specialist panel on PCC experience and on their education on TGNB-related topics. We conducted a retrospective review of de-identified data from the RubiconMD electronic consultation platform used by PCCs in 36 U.S. states for eConsults submitted to the TGNB specialty. We found that 90% of eConsults were from federally qualified health centers, other community clinics, and rural areas. Primary care clinicians reported outcomes as "educational" for 50% and "improved care plan" for 88% of eConsults. These results suggest that eConsults play an important role in educating PCCs on TGNB care and may also lead to improved PCC and patient experiences.

Background/UNASSIGNED:A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons' experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients. Methods/UNASSIGNED:This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review. Results/UNASSIGNED:The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2-0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons' experience with patient regret and request for reversal was consistent with the existing literature. Conclusions/UNASSIGNED:In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Primary care providers often express a desire to be more involved with their patients as they transition to hospice care. Given that these providers have a central role in the care of their patients, they have the potential to significantly improve the experiences of lesbian, gay, bisexual, transgender, and queer patients who face serious illnesses. This article discusses the barriers to quality hospice and palliative care experienced by many sexual and gender minorities, as well as specific ways in which primary care physicians can promote equitable end-of-life care.