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Assessing and Addressing the Risk of Venous Thromboembolism Across the Spectrum of Gender Affirming Care: A Review

Arrington-Sanders, Renata; Connell, Nathan T; Coon, Devin; Dowshen, Nadia; Goldman, Anna L; Goldstein, Zil; Grimstad, Frances; Javier, Noelle Marie; Kim, Ellie; Murphy, Martina; Poteat, Tonia; Radix, Asa; Schwartz, Aviva; St Amand, Colt; Streed, Carl G; Tangpricha, Vin; Toribio, Mabel; Goldstein, Robert H
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.
PMCID:10081942
PMID: 36539066
ISSN: 1530-891x
CID: 5506072

Cancer patient and provider responses to companion scales assessing experiences with LGBTQI-affirming healthcare

Pratt-Chapman, Mandi L; Wang, Yan; Quinn, Gwendolyn P; Shirima, Sylvia; Adler, Sarah; Brazinskaite, Ruta; Kamen, Charles; Radix, Asa; Warren, Barbara; Eckstrand, Kristen; Lopez, Ana Maria
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.
PMCID:10103145
PMID: 37064143
ISSN: 2234-943x
CID: 5465962

Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series [Case Report]

Thornhill, John P; Palich, Romain; Ghosn, Jade; Walmsley, Sharon; Moschese, Davide; Cortes, Claudia P; Galliez, Rafael Mello; Garlin, Amy B; Nozza, Silvia; Mitja, Oriol; Radix, Asa E; Blanco, Jose Luis; Crabtree-Ramirez, Brenda; Thompson, Melanie; Wiese, Lothar; Schulbin, Hubert; Levcovich, Ariela; Falcone, Marco; Lucchini, Anna; Sendagorta, Elena; Treutiger, Carl-Johan; Byrne, Ruth; Coyne, Katherine; Meyerowitz, Eric A; Grahn, Anna M; Hansen, Ann-Brit Eg; Pourcher, Valerie; DellaPiazza, Michelle; Lee, Rachel; Stoeckle, Marcel; Hazra, Aniruddha; Apea, Vanessa; Rubenstein, Emma; Jones, Joyce; Wilkin, Aimee; Ganesan, Anuradha; Henao-Martínez, Andrés F; Chow, Eric J; Titanji, Boghuma K; Zucker, Jason E; Ogoina, Dimie; Orkin, Chloe M
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.
PMID: 36403584
ISSN: 1474-547x
CID: 5382762

Predictors of Past-Year Health Care Utilization Among Young Men Who Have Sex with Men Using Andersen's Behavioral Model of Health Service Use

Diaz, José E; Sandh, Simon; Schnall, Rebecca; Garofalo, Robert; Kuhns, Lisa M; Pearson, Cynthia R; Bruce, Josh; Batey, D Scott; Radix, Asa; Belkind, Uri; Hidalgo, Marco A; Hirshfield, Sabina
PMID: 35867076
ISSN: 2325-8306
CID: 5289732

A Cautionary Tale: The Doomed Gender Identity Clinic at Johns Hopkins Hospital [Comment]

Keuroghlian, Alex S; Radix, Asa E
PMID: 36191312
ISSN: 1539-3704
CID: 5351402

Transgender Individuals and Digital Health

Radix, Asa E; Bond, Keosha; Carneiro, Pedro B; Restar, Arjee
PURPOSE OF REVIEW/OBJECTIVE:The goal of this review is to assess the use of digital technologies to promote the health and well-being of transgender and gender diverse (TGD) people. RECENT FINDINGS/RESULTS:TGD individuals experience numerous health disparities, including low uptake of HIV prevention strategies, such as pre-exposure prophylaxis, increased HIV incidence, and suboptimal HIV-related outcomes. These health disparities are the result of widespread intersectional stigma on the basis of gender identity, gender expression, socioeconomic class, race, and ethnicity, which negatively impact access to general medical and transgender-specific health care. TGD individuals often delay or avoid essential medical services due to fear of discrimination. Clinicians frequently lack training, competence, and skills in transgender medicine, further exacerbating the health disparities faced by TGD people. Digital technologies have been used to improve research and clinical care for TGD populations through various modalities; telemedicine, telehealth and mHealth. Digital health technologies, including HIT-enabled clinical decision support, telehealth, telemedicine, and mHealth, offer innovative ways to improve health care access, improve quality of care, and reduce health disparities for TGD populations, including and beyond HIV outcomes, through enhanced care delivery, clinician education, and enhancing social support networks.
PMCID:9493149
PMID: 36136217
ISSN: 1548-3576
CID: 5335572

Examining the Geospatial Distribution of Health and Support Services for Transgender, Gender Nonbinary, and Other Gender Diverse People in New York City

Callander, Denton; Kim, Byoungjun; Domingo, Micah; Tabb, Loni Philip; Radix, Asa; Timmins, Liadh; Baradaran, Amir; Clark, Michael B; Duncan, Dustin T
A geospatial analysis of services that support transgender and gender diverse ("trans") people in New York City (NYC) was conducted to investigate associations with neighborhood-level sociodemographic characteristics. In June 2019, there were 5.3 services for every 100,000 of the general NYC population; controlling for other covariates, they were more commonly located in neighborhoods with larger populations of non-Hispanic Black (rate ratio [RR]=1.02, 95% confidence interval [CI]: 1.00-1.04), Hispanic/Latino (RR=1.03, 95% CI: 1.00-1.06), and gay/lesbian people (RR=1.53, 95% CI: 1.03-2.34). These findings suggest that the distribution of trans-focused services in NYC is proximal to communities that are most in need, but research should examine proximity to trans people specifically and distribution in nonurban areas.
PMCID:9398481
PMID: 36033214
ISSN: 2688-4887
CID: 5337512

Patient reported outcomes in genital gender-affirming surgery: the time is now [Letter]

Agochukwu-Mmonu, Nnenaya; Radix, Asa; Zhao, Lee; Makarov, Danil; Bluebond-Langner, Rachel; Fendrick, A Mark; Castle, Elijah; Berry, Carolyn
Transgender and non-binary (TGNB) individuals often experience gender dysphoria. TGNB individuals with gender dysphoria may undergo genital gender-affirming surgery including vaginoplasty, phalloplasty, or metoidioplasty so that their genitourinary anatomy is congruent with their experienced gender. Given decreasing social stigma and increasing coverage from private and public payers, there has been a rapid increase in genital gender-affirming surgery in the past few years. As the incidence of genital gender-affirming surgery increases, a concurrent increase in the development and utilization of patient reported outcome measurement tools is critical. To date, there is no systematic way to assess and measure patients' perspectives on their surgeries nor is there a validated measure to capture patient reported outcomes for TGNB individuals undergoing genital gender-affirming surgery. Without a systematic way to assess and measure patients' perspectives on their care, there may be fragmentation of care. This fragmentation may result in challenges to ensure patients' goals are at the forefront of shared- decision making. As we aim to increase access to surgical care for TGNB individuals, it is important to ensure this care is patient-centered and high-quality. The development of patient-reported outcomes for patients undergoing genital gender-affirming surgery is the first step in ensuring high quality patient-centered care. Herein, we discuss the critical need for development of validated patient reported outcome measures for transgender and non-binary patients undergoing genital reconstruction. We also propose a model of patient-engaged patient reported outcome measure development.
PMCID:9038968
PMID: 35467181
ISSN: 2509-8020
CID: 5217282

Limited Evidence for Use of a Black Race Modifier in eGFR Calculations: A Systematic Review

Marzinke, Mark A; Greene, Dina N; Bossuyt, Patrick M; Chambliss, Allison B; Cirrincione, Lauren R; McCudden, Christopher R; Melanson, Stacy E F; Noguez, Jaime H; Patel, Khushbu; Radix, Asa E; Takwoingi, Yemisi; Winston-McPherson, Gabrielle; Young, Bessie A; Hoenig, Melanie P
BACKGROUND:Commonly used estimated glomerular filtration rate (eGFR) equations include a Black race modifier (BRM) that was incorporated during equation derivation. Race is a social construct, and a poorly characterized variable that is applied inconsistently in clinical settings. The BRM results in higher eGFR for any creatinine concentration, implying fundamental differences in creatinine production or excretion in Black individuals compared to other populations. Equations without inclusion of the BRM have the potential to detect kidney disease earlier in patients at the greatest risk of chronic kidney disease (CKD), but also has the potential to over-diagnose CKD or impact downstream clinical interventions. The purpose of this study was to use an evidence- based approach to systematically evaluate the literature relevant to the performance of the eGFR equations with and without the BRM and to examine the clinical impact of the use or removal. CONTENT/BACKGROUND:PubMed and Embase databases were searched for studies comparing measured GFR to eGFR in racially diverse adult populations using the Modification of Diet in Renal Disease or the 2009-Chronic Kidney Disease Epidemiology Collaboration-creatinine equations based on standardized creatinine measurements. Additionally, we searched for studies comparing clinical use of eGFR calculated with and without the BRM. 8,632 unique publications were identified; an additional 3 studies were added post-hoc. In total, 96 studies were subjected to further analysis and 44 studies were used to make a final assessment. SUMMARY/CONCLUSIONS:There is limited published evidence to support the use of a BRM in eGFR equations.
PMID: 34927677
ISSN: 1530-8561
CID: 5092682

Determining the Benefits of Gender-Affirming Surgery-A Call for Action

Agochukwu-Mmonu, Nnenaya; Radix, Asa; Fendrick, A Mark
PMID: 34851378
ISSN: 2168-6262
CID: 5065712