Juno Obedin-Maliver, MD, MPH, MAS, FACOG, is an Assistant Professor in the Department of Obstetrics and Gynecology at Stanford University School of Medicine.
Dr. Juno Obedin-Maliver is a board-certified obstetrician/gynecologist who provides excellent clinical care and strives to advance scientific knowledge through her research.
She practices full-spectrum gynecology including outpatient, in-patient, operative, and emergency care services. This specifically includes collaborative management of cervical dysplasia and abnormal pap smears, abnormal uterine bleeding, contraception and family planning, pelvic pain, abnormal discharge, sexually transmitted infection testing and treatment, and more. She specializes in the gynecological and reproductive health care needs of sexual and gender minority people which include but are not limited to lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ+) people. This interest and experience drives her research interests towards promoting the health and well-being and equity of LGBTQ people.
Dr. Obedin-Maliver, is the Co-Director of The PRIDE Study (pridestudy.org), a multi-site online prospective longitudinal cohort of sexual and gender minority individuals based at Stanford. She also serves on the medical advisory board of the University of California San Francisco Center of Excellence for Transgender Health and is helping to author the next version of the World Professional Association for Transgender Health (WPATH) Standards of Care. Dr. Obedin-Maliver has also been active in health policy including involvement in helping to legally redefine consideration of sexually intimate partner status and to remove the Medicare Non-Coverage Determination ruling on gender -affirming surgeries.
For more information about her research and career please see: pridestudy.org and http://med.stanford.edu/obedin-maliver.html
- Obstetrics and Gynecology
- LGBTQ+ Health
- Reproductive Health of Transgender People
- Family Planning
Honors & Awards
1st Place Expert Choice: Improving Wait Times and Care Integration for Transgender Patients, San Francisco Veterans Affairs (SFVA) Systems Improvement Fair (2018)
GET(Gene, Environments, Traits)y Diversity Award, GET Award Committee (2016)
Outstanding Resident Award, University of California, San Francisco - Nurse-Midwifery Student Award for Resident Physicians (2014)
Chancellor’s Award for Gay, Lesbian Bisexual and/or Transgender (GLBT) Leadership, University of California, San Francisco (2012)
Outstanding Resident Award in Medical Student Teaching - Obstetrics and Gynecology., University of California, San Francisco (2011)
Julius R. Krevans Award for Service as an Intern, San Francisco General Hospital (2011)
eQuality Scholarship for service to the LGBTQ community, The Kaiser Permanente Foundation (2010)
Scholarship for Lesbian, Gay, Bisexual, and Transgender (LGBT) Activism and Leadership, Markowski-Leach Memorial Fund (2008)
Cardinal Free Clinic - Student Member Service Award, Stanford University School of Medicine (2008)
Full Tuition Merit Scholarship, School of Public Health - Master's Program, University of California at Berkeley (2007)
Ingenuity Award for Community Service, Hampshire College (2004)
Reproductive Rights Activist Service Corps Internship Grant, Civil Liberties and Public Policy Program (2002)
Scholarship for Achievement in the Sciences, Canon-Jensen Memorial Fund (2001)
Scholarship for Academic Achievement in the Sciences, Monterey Bay Women In Science Fund (2001)
Residency: UCSF Obstetrics and Gynecology (2014) CA
Medical Education: Stanford University School of Medicine (2010) CA
Fellowship, San Francisco Veterans Affairs Medical Center & University of California, San Francisco, Women's Health and Clinical Research (2016)
MAS, University of California, San Francisco, Clinical Research (2016)
Board Certification: American Board of Obstetrics and Gynecology, Obstetrics and Gynecology (2015)
MPH, University of California, Berkeley, Masters in Public Health (2008)
Diversity and Identity
Project RESIST: Increasing Resistance to Tobacco Marketing Among Young Adult Sexual Minority Women Using Inoculation Message Approaches
Project RESIST is an R01 study funded by NCI focused on determining the effects of using culturally tailored inoculation approaches to increase resilience to tobacco marketing influences among young adult sexual minority women ages 18-30 and incorporates critical stakeholder inputs that support later adoption and implementation. The study team is utilizing formative research to design and pre-test anti-smoking messages and two national longitudinal online survey experiments.
Stanford is currently not accepting patients for this trial. For more information, please contact Mitchell Lunn, MD, MAS, FACP, FASN, 650-725-7783.
Migraine, Migraine Disability, Trauma, and Discrimination in Sexual and Gender Minority Individuals.
OBJECTIVE: This study sought to describe migrainous headache frequency and severity and to examine the relationship between trauma, discrimination, and migraine-associated disability in a sample of sexual and/or gender minority (SGM) adults.METHODS: We performed a cross-sectional study of SGM people in The Population Research in Identity and Disparities for Equality (PRIDE) Study from August-October 2018. The primary exposure was any trauma or discrimination, regardless of attribution. The primary outcome was moderate-severe migraine disability, as defined by a Migraine Disability Assessment (MIDAS) Questionnaire score ≥11. We performed descriptive analysis comparing respondents with any migrainous headache to those without. Multivariable logistic regression examined the association between trauma/discrimination and migraine disability, controlling first for sociodemographic and clinical factors and then for psychiatric comorbidities.RESULTS: Of the 3,325 total respondents, 1,126 (33.9%) screened positive for migrainous headache by ID-Migraine criteria. Most people with migraine self-reported moderate (n=768, 68.2%) or severe (n=253, 22.5%) intensity. The median MIDAS score was 11 (interquartile range [IQR] 5-25). Most respondents with migraine (n=1055, 93.7%) reported a history of trauma or discrimination. In unadjusted analysis, exposure to both trauma and discrimination was associated with higher odds of moderate-severe disability (OR 1.76, 95% CI 1.34-2.32). After adjustment for self-reported psychiatric comorbidities of anxiety, depression, and post-traumatic stress disorder, this association lost statistical significance.CONCLUSION: Migrainous headache is common among our sample of SGM adults, and prior experiences with trauma and discrimination is associated with increased migraine disability. Our findings suggest that psychiatric comorbidities play a significant role in this relationship, identifying a potentially modifiable risk factor for disability in SGM people with migraine.
View details for DOI 10.1212/WNL.0000000000200941
View details for PubMedID 35817570
Psychometric evaluation of the muscle dysmorphic disorder inventory (MDDI) among gender-expansive people.
Journal of eating disorders
2022; 10 (1): 95
Muscle dysmorphia is generally classified as a specific form of body dysmorphic disorder characterized by a pathological drive for muscularity and the preoccupation that one is too small or not sufficiently muscular. The majority of research on the condition has been conducted in cisgender men with a paucity of literature on gender minority people, a population that is at risk for muscle dysmorphia. One of the most widely used measures of muscle dysmorphia symptoms, the Muscle Dysmorphic Disorder Inventory (MDDI), has not been psychometrically validated for use in gender minority samples, the aim of the present study.We evaluated the psychometric properties of the MDDI in a sample of 1031 gender-expansive individuals (gender minority people whose gender identity differs from that assumed for their sex assigned at birth and is not exclusively binary man or woman) aged 18-74 who were part of The PRIDE Study, a large-scale, U.S., longitudinal cohort study.Using a two-step, split-sample exploratory and confirmatory factor analytic approach, we found support for the original three-factor structure of the measure. The subscales showed adequate internal consistency, and convergent validity was supported based on significant associations of the MDDI subscale scores with theoretically related scores on a widely used measure of disordered eating.These findings provided novel support for adequate psychometric properties of the MDDI in a sample of gender-expansive individuals, facilitating the use of this measure in future research on muscle dysmorphia in this understudied and at-risk population.
View details for DOI 10.1186/s40337-022-00618-6
View details for PubMedID 35794647
Psychometric validation of the Muscle Dysmorphic Disorder Inventory (MDDI) among U.S. transgender men.
2022; 42: 43-49
Muscle dysmorphia (MD) is characterized by a pervasive belief or fear of insufficient muscularity and an elevated drive for muscularity, representing the pathological and extreme pursuit of muscularity. Psychometric properties of one of the most widely used measures of MD symptoms-the Muscle Dysmorphic Disorder Inventory (MDDI)-have yet to be evaluated in transgender men despite emerging evidence suggesting differential risk for MD symptoms in this population. In this study, we assessed the psychometric properties of the MDDI in a sample of 330 transgender men ages 18-67 years who participated in a large-scale national longitudinal cohort study of sexual and gender minority adults in the U.S. Using a two-step, split-sample approach, an initial exploratory factor analysis supported a three-factor structure and a subsequent confirmatory factor analysis of a re-specified three-factor model demonstrated good overall fit (χ2/df = 1.84, CFI =0.94, TLI =0.92, RMSEA =0.07 [90% CI =0.05,.09], SRMR =0.08). Moreover, results supported the internal consistency and convergent validity of the MDDI subscales in transgender men. Findings inform the use of the MDDI among transgender men and provide a foundation to support further work on the MDDI and MD symptoms among gender minority populations.
View details for DOI 10.1016/j.bodyim.2022.05.001
View details for PubMedID 35653965
COVID-19 News and Its Association with the Mental Health of Sexual and Gender Minority Adults: A Cross-Sectional Study.
JMIR public health and surveillance
BACKGROUND: Sexual and gender minority (SGM; people whose sexual orientation is not heterosexual and/or whose gender identity varies from what is traditionally associated with the sex assigned to them at birth) people experience high rates of trauma and significant disparities in anxiety and post-traumatic stress disorder (PTSD). Exposure to traumatic stressors, such as news related to COVID-19, may be associated with symptoms of anxiety and PTSD.OBJECTIVE: to evaluate the relationship of COVID-19 news exposure with anxiety and PTSD symptoms in a sample of SGM adults in the United States (US).METHODS: Data were collected between March 23 and August 2, 2020 from The PRIDE Study, a national, longitudinal, cohort study of SGM people. Regression analyses were used to analyze the relationship between self-reported news exposure and (1) symptoms of anxiety using the General Anxiety Disorder (GAD) 7-item Scale and (2) symptoms of COVID-related PTSD using the Impact of Events Scale-Revised (IES-R).RESULTS: Our sample included a total of 3,079 SGM participants. Each unit increase in COVID-19-related news exposure was associated with greater anxiety symptoms (OR=1.77,95% CI [1.63, 1.93], P<.001) and 1.93 greater odds of PTSD (95% CI [1.74, 2.14], P<.001).CONCLUSIONS: Our study found that COVID-19 news exposure was positively associated with greater symptoms of anxiety and PTSD among SGM people. This supports previous literature in other populations where greater news exposure was associated with poorer mental health. Further research is needed to determine the direction of this relationship and to evaluate for differences among SGM subgroups with multiple marginalized identities.CLINICALTRIAL:
View details for DOI 10.2196/34710
View details for PubMedID 35486805
DESIGNING FOR ADOPTION AND ADAPTATION OF EVIDENCE-BASED ANTI-TOBACCO MESSAGING BY ORGANIZATIONS SERVING LGBTQ plus COMMUNITIES
OXFORD UNIV PRESS INC. 2022: S491
View details for Web of Science ID 000788118601400
Sexual and/or Gender Minority Parental Structures among California Births, 2016-2020.
American journal of obstetrics & gynecology MFM
BACKGROUND: Sexual and/or gender minority (SGM) people account for roughly 7.1% of the U.S. population, and an estimated one-third are parents. Little is known about SGM people who become pregnant, despite this population having documented health care disparities that may impact pregnancy.OBJECTIVES: Our objective was to describe parental structures among birth parents and the pre-pregnancy characteristics of parents giving birth in likely sexual and/or gender minority (SGM) parental structures from California birth certificates.STUDY DESIGN: We conducted a population-based study using birth certificate data from all live births in California from 2016 through 2020 (n = 2,257,974). The state amended its birth certificate in 2016 to enable the recording of more diverse parental roles. Now, parents on birth certificates are classified as "parent giving birth" and "parent not giving birth" and people in either role can identify as "mother," "father," or "parent." We examined all potential combinations of parenting roles and grouped parental structures of "mother-mother" and all structures designating a "father" as the "parent giving birth" into likely SGM groups. We assessed the distribution of pre-pregnancy characteristics across parental structure groups ("mother-father," "SGM," "mother only," "unclassified," and "missing both parental roles").RESULTS: SGM parents accounted for 6,802 (0.3%) of live births in California over the 5-year study period. The most common SGM parental structures were "mother-mother" (n=4,310; 63% of the group) and "father-father" (n=1,486; 22% of the group). Compared with "parents giving birth" in the "mother-father" structure (n=2,055,038; 91%), a higher proportion of "parents giving birth" in the "SGM" group were 35 years or older, white, college-educated, and had commercial health insurance. In addition, a higher proportion had a high pre-pregnancy body mass index. Although likely underreported overall, the proportion who used assisted reproductive technology was much higher among those in the "SGM" group (1.4%) than in the "mother-father" group (0.05%). Cigarette smoking in the three months prior to pregnancy was similar in both groups.CONCLUSION: Changes to the California birth certificate have revealed a multiplicity of parental structures. Our findings suggest that SGM parents differ from other parental structures and from the general SGM population and warrant further research.
View details for DOI 10.1016/j.ajogmf.2022.100653
View details for PubMedID 35462057
Human Papillomavirus Vaccination Over Time in Heterosexual and Sexual Minority Adults in the United States.
2022; 6 (1): 307-312
We proposed to identify the factors that determine the trends in human papillomavirus (HPV) vaccination initiation and completion among heterosexual and sexual minority adults.Using National Health and Nutrition Examination Survey database from 2007 to 2016, we performed chi-squared tests and multivariate logistic regression analysis.Heterosexual females initiated vaccination at 23.5% compared with sexual minority females at 34.6% (p<0.001). Although heterosexual males also had a lower vaccination initiation than sexual minority males (7.7% vs. 15.5%; p=0.12), their completion rate appeared higher (38% vs. 17%; p=0.14).Interventions are needed to enhance support for completion rates of HPV vaccine among sexual minority individuals.
View details for DOI 10.1089/heq.2021.0058
View details for PubMedID 35557550
View details for PubMedCentralID PMC9081066
Gender- and Sexual Orientation- Based Inequities: Promoting Inclusion, Visibility, and Data Accuracy in Oncology.
American Society of Clinical Oncology educational book. American Society of Clinical Oncology. Annual Meeting
2022; 42: 1-17
Sexual and gender minority (SGM) people, including agender, asexual, bisexual, gay, gender diverse, genderqueer, genderfluid, intersex, lesbian, nonbinary, pansexual, queer, and transgender people, comprise approximately 10% or more of the U.S. population. Thus, most oncologists see SGM patients whether they know it or not. SGM people experience stigma and structural discrimination that lead to cancer disparities. Because of the lack of systematic and comprehensive data collection, data regarding SGM cancer incidence, outcomes, and treatment responses are limited. Collection of data regarding sexual orientation, gender identity, transgender identity and/or experience, anatomy, and serum hormone concentrations in oncology settings would drastically increase collective knowledge about the impact of stigma and biologic markers on cancer outcomes. Increasing the safety of oncology settings for SGM people will require individual, institutional, and systems changes that will likely improve oncologic care for all patients.
View details for DOI 10.1200/EDBK_350175
View details for PubMedID 35658501
Appearance and performance-enhancing drugs and supplements, eating disorders, and muscle dysmorphia among gender minority people.
The International journal of eating disorders
OBJECTIVE: Appearance and performance-enhancing drugs and supplements (APEDS) can be used to enhance muscle growth, athletic performance, and physical appearance. The aim of this study was to examine the lifetime use of APEDS and associations with eating disorder and muscle dysmorphia symptoms among gender minority people.METHOD: Participants were 1653 gender minority individuals (1120 gender-expansive [defined as a broad range of gender identities that are generally situated outside of the woman-man gender binary, e.g., genderqueer, nonbinary] people, 352 transgender men, and 181 transgender women) recruited from The Population Research in Identity and Disparities for Equality Study in 2018. Regression analyses stratified by gender identity examined associations of any APEDS use with eating disorder and muscle dysmorphia symptom scores.RESULTS: Lifetime APEDS use was common across groups (30.7% of gender-expansive people, 45.2% of transgender men, and 14.9% of transgender women). Protein supplements and creatine supplements were the most commonly used APEDS. Among gender-expansive people and transgender men, lifetime use of any APEDS was significantly associated with higher eating disorder scores, dietary restraint, binge eating, compelled/driven exercise, and muscle dysmorphia symptoms. Any APEDS use was additionally associated with laxative use among gender-expansive people. Among transgender women, use of any APEDS was not significantly associated with eating disorder or muscle dysmorphia symptoms.DISCUSSION: APEDS use is common and associated with eating disorder and muscle dysmorphia symptoms in gender-expansive people and transgender men, thus highlighting the importance of assessing for these behaviors and symptoms among these populations, particularly in clinical settings.PUBLIC SIGNIFICANCE: This study aimed to examine APEDS use among gender minority people. We found that 30.7% of gender-expansive (e.g., nonbinary) people, 45.2% of transgender men, and 14.9% of transgender women reported lifetime APEDS use, which was associated with eating disorder and muscle dysmorphia symptoms in transgender men and gender-expansive people. Clinicians should assess for these behaviors in gender minority populations.
View details for DOI 10.1002/eat.23708
View details for PubMedID 35352378
Comparison of depressive symptoms and inflammation between sexual minorities and heterosexuals using NHANES study of 8538 participants.
2022; 12 (1): 3792
The present study aims to compare the rate of depressive symptoms and inflammation levels between sexual minorities and heterosexuals. Data were obtained from the National Health and Nutrition Examination Survey from 2005 to 2010. Depressive-related symptoms were measured using the Patient Health Questionnaire-9 scoring system. C-reactive protein was analyzed with the Behring Nephelometer. Of 8538 participants, 95.8% self-reported as heterosexual and 4.2% as sexual minority. Depressive symptoms were reported in 7.1% of heterosexuals compared to 15.8% in sexual minorities (P=0.001). In heterosexuals, C-reactive protein was higher in those with depressive symptoms compared to those without (P<0.001). In sexual minorities, similar results were found, however, it was statisticallyinsignificant. The intersection group of black sexual minority females reported the highest rate of depressive symptoms at 33.4%. We found that depressive symptoms were higher in sexual minorities compared to heterosexuals. Furthermore, systemic inflammation was highest in the intersection group of black sexual minority females.
View details for DOI 10.1038/s41598-022-07702-6
View details for PubMedID 35260636
Sexual and/or gender minority disparities in obstetric and birth outcomes.
American journal of obstetrics and gynecology
Many sexual and/or gender minority individuals build families through pregnancy and childbirth, but it is unknown whether they experience different clinical outcomes than non-sexual and/or gender minority individuals.To evaluate obstetric and birth outcomes among likely sexual and/or gender minority patients in comparison with likely non-sexual and/or gender minority patients.We performed a population-based cohort study of live birth hospitalizations during 2016-2019 linked to birth certificates in California. California changed its birth certificate in 2016 to include gender-neutral fields "parent giving birth" and "parent not giving birth," with options for each role to specify "mother," "father," or "parent." We classified birthing patients in mother-mother partnerships and those who identified as a father in any partnership as likely sexual and/or gender minority, and classified birthing patients in mother-father partnerships as likely not sexual and/or gender minority. We used multivariable modified Poisson regression models to estimate risk ratios for associations between likely sexual and/or gender minority parental structures and outcomes. Models were adjusted for sociodemographic factors, comorbidities, and multifetal gestation selected by causal diagrams. We replicated analyses after excluding multifetal gestations.In the final birthing patient sample, 1,483,119 were mothers with father partners, 2,572 were mothers with mother partners, and 498 were fathers with any partner. Compared with birthing patients in mother-father partnerships, birthing patients in mother-mother partnerships experienced significantly higher rates of multifetal gestation (aRR 3.9, 95% CI 3.4-4.4), labor induction (aRR 1.2, 95% CI 1.1-1.3), postpartum hemorrhage (aRR 1.4, 95% CI 1.3-1.6), severe morbidity (aRR 1.4, 95% CI 1.2-1.8), and non-transfusion severe morbidity (aRR 1.4, 95% CI 1.1-1.9). Severe morbidity was identified following the Centers for Disease Control and Prevention "severe maternal morbidity" index. Gestational diabetes mellitus, hypertensive disorders of pregnancy, cesarean birth, preterm birth (<37 weeks' gestation), low birthweight (<2,500 g), and low Apgar score (<7 at 5 minutes) did not significantly differ in multivariable analyses. No outcomes significantly differed between father birthing patients in any partnership and birthing patients in mother-father partnerships in either crude or multivariable analyses, although the risk of multifetal gestation was non-significantly higher (aRR 1.5, 95% CI 0.9-2.7). Adjusted risk ratios for outcomes were similar after restriction to singleton gestations.Birthing mothers with mother partners experienced disparities in several obstetric and birth outcomes, independent of sociodemographic factors, comorbidities, and multifetal gestation. Birthing fathers in any partnership were not at significantly elevated risk of any adverse obstetric or birth outcome considered in this study.
View details for DOI 10.1016/j.ajog.2022.02.041
View details for PubMedID 35358492
Perinatal considerations for care of transgender and nonbinary people: a narrative review.
Current opinion in obstetrics & gynecology
PURPOSE OF REVIEW: The visibility of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities, specifically the transgender and nonbinary (TGNB) communities, continues to grow. However, there is little description, much less guidance toward optimizing, the pregnancy-related care of TGNB people. The overarching goal of this paper is to provide guidance that aids in reimagining obstetrics to include people of all genders.RECENT FINDINGS: This article will review current literature and provide recommendations specific to the hospital birthing environment to help address the lack of knowledge regarding pregnancy-related care of TGNB individuals. This care is further divided into three main times: (1) preconception, antepartum care, and triage, (2) intrapartum, and (3) postpartum. We also discuss considerations for the general medical care of TGNB individuals.SUMMARY: Understanding facilitators and barriers to gender affirming pregnancy-related care of TGNB individuals are first steps toward providing a respectful, affirming, and evidence-based environment for all patients, especially TGNB individuals. Here we provide context, discussion, and resources for providers and TGNB patients navigating pregnancy-related care. Lastly, this review challenges researchers and clinicians with future directions for the care of TGNB individuals in this continually expanding field.
View details for DOI 10.1097/GCO.0000000000000771
View details for PubMedID 35102108
- Reproductive health in transgender and gender diverse individuals: A narrative review to guide clinical care and international guidelines INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022
Risk Factors for Dual Burden of Severe Maternal Morbidity and Preterm Birth by Insurance Type in California.
Maternal and child health journal
OBJECTIVES: Among childbearing women, insurance coverage determines degree of access to preventive and emergency care for maternal and infant health. Maternal-infant dyads with dual burden of severe maternal morbidity and preterm birth experience high physical and psychological morbidity, and the risk of dual burden varies by insurance type. We examined whether sociodemographic and perinatal risk factors of dual burden differed by insurance type.METHODS: We estimated relative risks of dual burden by maternal sociodemographic and perinatal characteristics in the 2007-2012 California birth cohort dataset stratified by insurance type and compared effects across insurance types using Wald Z-statistics.RESULTS: Dual burden ranged from 0.36% of privately insured births to 0.41% of uninsured births. Obstetric comorbidities, multiple gestation, parity, and birth mode conferred the largest risks across all insurance types, but effect magnitude differed. The adjusted relative risk of dual burden associated with preeclampsia superimposed on preexisting hypertension ranged from 9.1 (95% CI 7.6-10.9) for privately insured to 15.9 (95% CI 9.1-27.6) among uninsured. The adjusted relative risk of dual burden associated with cesarean birth ranged from 3.1 (95% CI 2.7-3.5) for women with Medi-Cal to 5.4 (95% CI 3.5-8.2) for women with other insurance among primiparas, and 7.0 (95% CI 6.0-8.3) to 19.4 (95% CI 10.3-36.3), respectively, among multiparas.CONCLUSIONS: Risk factors of dual burden differed by insurance type across sociodemographic and perinatal factors, suggesting that care quality may differ by insurance type. Attention to peripartum care access and care quality provided by insurance type is needed to improve maternal and neonatal health.
View details for DOI 10.1007/s10995-021-03313-1
View details for PubMedID 35041142
Appearance and performance-enhancing drugs and supplements (APEDS): Lifetime use and associations with eating disorder and muscle dysmorphia symptoms among cisgender sexual minority people.
2022; 44: 101595
Appearance and performance-enhancing drugs and supplements (APEDS) are used to enhance muscle growth, athletic performance, and physical appearance. The aim of this study was to examine the lifetime use of APEDS and associations with eating disorder and muscle dysmorphia symptoms among cisgender sexual minority people.Participants were cisgender sexual minority people (1090 gay men, 100 bisexual plus men, 564 lesbian women, and 507 bisexual plus women) recruited from The PRIDE Study in 2018 who reported lifetime APEDS use and completed the Eating Disorder Examination-Questionnaire (EDE-Q) and the Muscle Dysmorphic Disorder Inventory (MDDI). Regression analyses stratified by gender and sexual orientation examined associations of any APEDS use with EDE-Q and MDDI scores.Lifetime APEDS use was common across the four groups of cisgender sexual minority people (44% of gay men, 42% of bisexual plus men, 29% of lesbian women, and 30% of bisexual plus women). Protein supplements and creatine supplements were the most commonly used APEDS. Any APEDS use was associated with higher EDE-Q scores on one or more subscales in all sexual minority groups. Further, any APEDS use was associated with higher MDDI Total Scores in all groups; any APEDS use was associated with all MDDI subscale scores in cisgender gay men only.APEDS use is common and associated with eating disorder and muscle dysmorphia symptoms in sexual minority men and women, thus highlighting the importance of assessing for these behaviors and symptoms among these populations in clinical settings.
View details for DOI 10.1016/j.eatbeh.2022.101595
View details for PubMedID 35066385
Obstetric and birth outcomes among sexual and/or gender minority patients, California, 2016-2019
MOSBY-ELSEVIER. 2022: S69-S70
View details for Web of Science ID 000737459400074
Representation of Sexual and Gender Minority People in Patient Nondiscrimination Policies of Cancer Centers in the United States.
Journal of the National Comprehensive Cancer Network : JNCCN
Sexual and gender minority (SGM) people are an underserved population who face high rates of discrimination in healthcare, including receipt of cancer treatment. Several national organizations have identified the importance of patient nondiscrimination policies that explicitly recognize SGM people in creating safe healthcare environments.We performed a web-based analysis of NCI-designated Cancer Centers to evaluate the landscape of patient nondiscrimination policies in major cancer centers with regard to representation of SGM people.We found that 82% of cancer centers had a patient nondiscrimination policy on their website. The most commonly mentioned SGM-related term was "sex" (n=48; 89%), followed by "sexual orientation" (n=37; 69%) and "gender identity" (n=36; 67%). None of the policies included "sex assigned at birth" or "LGBTQ/SGM identity." Of the policies reviewed, 65% included protections for both sexual orientation and gender identity. Cancer centers with academic affiliations were significantly more likely to have policies that included both of these protections compared with nonacademic institutions (100% vs 79%; P=.005).Our study shows that patient nondiscrimination policies across NCI-designated Cancer Centers are not always accessible to patients and their families online and do not consistently represent SGM people in their content. Because the SGM population is both at higher risk for cancer and for discrimination in the healthcare setting, it is crucial to create inclusive, safe, and equitable cancer care environments for this group. Administrators and clinicians should view the patient nondiscrimination policy as an opportunity to offer expansive protections to SGM people that extend beyond those offered in federal and state laws. Additionally, the patient nondiscrimination policy should be visible and accessible to patients seeking cancer care as a signal of safety and inclusion.
View details for DOI 10.6004/jnccn.2021.7078
View details for PubMedID 35168202
Associations among romantic and sexual partner history and muscle dysmorphia symptoms, disordered eating, and appearance- and performance-enhancing drugs and supplement use among cisgender gay men.
2022; 41: 67-73
This study examined relationship status (e.g., single versus not single) and number of sexual partners in relation to muscularity- and disordered eating-related attitudes and behaviors among 1090 cisgender gay men enrolled in The PRIDE Study in 2018. Participants completed measures assessing muscle dysmorphia (MD) symptoms, disordered eating attitudes and behaviors, and appearance- and performance-enhancing drug or supplement (APEDS) use. In linear regression models adjusting for theoretically relevant covariates, neither relationship status nor number of past-month sexual partners was associated with disordered eating attitudes. In terms of MD symptoms, single (versus not single) relationship status was associated with greater appearance intolerance, and a greater number of sexual partners was associated with greater drive for size and functional impairment. In adjusted logistic regression models, a greater number of past-month sexual partners was associated with use of anabolic-androgenic steroids, synthetic performance-enhancing substances, protein supplements, and creatine supplements, as well as greater likelihood of engaging in compelled/driven exercise. Across all associations, effect sizes were generally small. Overall, results support that inquiring about sexual partners may have utility in evaluating risk for muscularity-oriented attitudes and behaviors among cisgender gay men. Future work will need to replicate these findings, particularly in more diverse samples.
View details for DOI 10.1016/j.bodyim.2022.02.004
View details for PubMedID 35228105
Healthcare Mistreatment, State‐Level Policy Protections, and Healthcare Avoidance Among Gender Minority People
Sexuality Research and Social Policy
View details for DOI 10.1007/s13178-022-00748-1
Do Ask, Tell, and Show: Contextual Factors Affecting Sexual Orientation and Gender Identity Disclosure for Sexual and Gender Minority People.
Purpose: Sexual and gender minority (SGM) people-including members of lesbian, gay, bisexual, transgender, and queer communities-remain underrepresented in health research due to poor collection of sexual orientation and gender identity (SOGI) data. We sought to understand the contextual factors affecting how SGM research participants interact with SOGI questions to enhance participant experience and increase the accuracy and sensitivity of research findings. Methods: We recruited SGM adults for in-person semi-structured focus groups or online cognitive interviews from 2016 to 2018. During focus groups and cognitive interviews, we asked participants to respond to SOGI question sets. We employed template analysis to describe the contextual factors that affected SGM participants' responses to SOGI questions. Results: We had a total of 74 participants, including 55 participants organized into nine focus groups and 19 participants in cognitive interviews. Most self-identified as a sexual minority person (88%), and 51% identified as a gender minority person. Two main themes were: (1) the need to know the relevance (of why SOGI questions are asked) and (2) the importance of environmental and contextual cues (communicating physical safety and freedom from discrimination that influenced SOGI disclosure). Conclusions: Contextualizing the relevance of SOGI data sought could help improve the accuracy and sensitivity of data collection efforts. Environmental cues that communicate acceptance and safety for SGM individuals in research settings may support disclosure. Researchers should consider these contextual factors when designing future studies to improve research experiences for SGM individuals and increase the likelihood of future participation.
View details for DOI 10.1089/lgbt.2021.0159
View details for PubMedID 35073205
Birth registration policies in the United States and their relevance to sexual and/or gender minority families: Identifying existing strengths and areas of improvement.
Social science & medicine (1982)
1800; 293: 114633
Birth certificates are some of the most critical identity documents available to current residents of the United States, yet sexual and gender minority (SGM) parents frequently face barriers in obtaining accurate documents for their children. It is essential for SGM parents to have accurate birth certificates for their children at the time of birth registration so that they do not experience undue burden in raising their children and establishing their status as legal parents. In this analysis, we focused on the birth registration process in the US as they apply to SGM family-building and the assignation of parentage on birth certificates at the time of a child's birth. We utilized keyword-based search criteria to identify, collect, and tabulate official state policies related to birth registration. Birth registration policies rely on gendered, heteronormative assumptions about the sex and gender of a child's parents in all but three states when identifying the birthing person and in all but eight states when identifying the non-birthing person. We found additional barriers for SGM parents who give birth outside of a marriage or legal union. These barriers leave SGM parents particularly vulnerable to inaccuracies on their children's identity documents and incomplete recognition of their parental roles and rights. Existing birth registration policies also do little to ensure the inclusion of diverse family structures in administrative data collection. There are many ways to modify existing birth registration policies and enhance the inclusion of SGM parents within governmental administrative structures. We conclude with suggestions to improve upon existing birth registration systems by de-linking parental sex and gender from birthing role, parental role, and contribution to the pregnancy.
View details for DOI 10.1016/j.socscimed.2021.114633
View details for PubMedID 34933243
Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: Results from a national, quantitative survey.
International journal of transgender health
2021; 22 (1-2): 30-41
Background: Transgender, nonbinary, and gender-expansive (TGE) people experience pregnancy. Quantitative data about pregnancy intentions and outcomes of TGE people are needed to identify patterns in pregnancy intentions and outcomes and to inform clinicians how best to provide gender-affirming and competent pregnancy care. Aims: We sought to collect data on pregnancy intentions and outcomes among TGE people assigned female or intersex at birth in the United States. Methods: Collaboratively with a study-specific community advisory team, we designed a customizable, online survey to measure sexual and reproductive health experiences among TGE people. Eligible participants included survey respondents who identified as a man or within the umbrella of transgender, nonbinary, or gender-expansive identities; were 18 years or older; able to complete an electronic survey in English; lived in the United States; and were assigned female or intersex at birth. Participants were recruited through The PRIDE Study - a national, online, longitudinal cohort study of sexual and gender minority people - and externally via online social media postings, TGE community e-mail distribution lists, in-person TGE community events, and academic and community conferences. We conducted descriptive analyses of pregnancy-related outcomes and report frequencies overall and by racial and ethnic identity, pregnancy intention, or testosterone use. Results: Out of 1,694 eligible TGE respondents who provided reproductive history data, 210 (12%) had been pregnant. Of these, 115 (55%) had one prior pregnancy, 47 (22%) had two prior pregnancies, and 48 (23%) had three or more prior pregnancies. Of the 433 pregnancies, 169 (39%) resulted in live birth, 142 (33%) miscarried, 92 (21%) ended in abortion, two (0.5%) ended in stillbirth, two (0.5%) had an ectopic pregnancy, and seven (2%) were still pregnant; nineteen pregnancies (4%) had an unknown outcome. Among live births, 39 (23%) were delivered via cesarean section. Across all pregnancies, 233 (54%) were unintended. Fifteen pregnancies occurred after initiation of testosterone, and four pregnancies occurred while taking testosterone. Among all participants, 186 (11%) wanted a future pregnancy, and 275 (16%) were unsure; 182 (11%) felt "at risk" for an unintended pregnancy. Discussion: TGE people in the United States plan for pregnancy, experience pregnancy (intended and unintended) and all pregnancy outcomes, and are engaged in family building. Sexual and reproductive health clinicians and counselors should avoid assumptions about pregnancy capacity or intentions based on a patient's presumed or stated gender or engagement with gender-affirming hormone therapy.
View details for DOI 10.1080/26895269.2020.1841058
View details for PubMedID 34796363
View details for PubMedCentralID PMC8040680
Sexual Wellness in Cisgender Lesbian, Gay, and Bisexual People.
The Urologic clinics of North America
2021; 48 (4): 461-472
Cisgender sexual minority persons have sexual wellness needs that go well beyond disease prevention. Despite historical asymmetries in research and clinical attention to sexual wellness in cisgender lesbian, gay, and bisexual persons, a growing body of evidence exists on how to optimally care for these populations. Additional research and development is warranted.
View details for DOI 10.1016/j.ucl.2021.06.005
View details for PubMedID 34602168
From 'Shark-Week' to 'Mangina': An Analysis of Words Used by People of Marginalized Sexual Orientations and/or Gender Identities to Replace Common Sexual and Reproductive Health Terms.
2021; 5 (1): 707-717
Purpose: To explore sexual and reproductive health (SRH)-related word-use among sexual and gender minority (SGM) individuals in the United States. Methods: In 2019, we fielded an online quantitative survey on the SRH experiences of SGM adults. Eligible participants included transgender, nonbinary, and gender-expansive (TGE) people assigned female or intersex at birth, and cisgender sexual minority women (CSMW) in the United States. The survey asked participants to indicate if they used each of nine SRH terms, and if not, to provide the word(s) they used. We analyzed patterns in replacement words provided by respondents and tested for differences by gender category with tests of proportions. Results: Among 1704 TGE and 1370 CSMW respondents, 613 (36%) TGE respondents and 92 (7%) CSMW respondents replaced at least 1 SRH term (p-for-difference <0.001). Many (23%) replacement words/phrases were entirely unique. For six out of the nine terms, TGE respondents indicated that use of the provided term would depend on the context, the term did not apply to them, or they did not have a replacement word/phrase that worked for them. Conclusions: SRH terms commonly used in clinical and research settings cause discomfort and dysphoria among some SGM individuals. To address inequities in access to and quality of SRH care among SGM individuals, and to overcome long standing fear of mistreatment in clinical settings, more intentional word-use and elicitation from providers and researchers could increase the quality and affirming nature of clinical and research experiences for SGM people.
View details for DOI 10.1089/heq.2021.0022
View details for PubMedID 34909540
View details for PubMedCentralID PMC8665782
- Sexual Orientation Diversity and Specialty Choice Among Graduating Allopathic Medical Students in the United States. JAMA network open 2021; 4 (9): e2126983
- From 'Shark-Week' to 'Mangina': An Analysis of Words Used by People of Marginalized Sexual Orientations and/or Gender Identities to Replace Common Sexual and Reproductive Health Terms HEALTH EQUITY 2021; 5 (1): 707-717
- You miss 100% of the shots you don't take: time to push boundaries in fertility care of transgender people. Fertility and sterility 2021
Endometrial findings among transgender and gender nonbinary people using testosterone at the time of gender-affirming hysterectomy.
Fertility and sterility
OBJECTIVE: To describe clinical characteristics and associated endometrial findings of transgender and gender nonbinary people using gender-affirming testosterone.DESIGN: Retrospective case series.SETTING: Academic medical center and public safety net hospital.PATIENT(S): Eighty-one patients using gender-affirming testosterone therapy undergoing hysterectomy for the indication of gender affirmation from 2000 to2018.INTERVENTION(S): None.MAIN OUTCOME MEASURE(S): Preoperative clinical characteristics and endometrium surgical pathology diagnoses.RESULT(S): Median age was 31 years (interquartile range [IQR] 27-40), and median body mass index 27 kg/m2 (IQR 24-30). Six patients (7%) were parous and 60 (74%) had amenorrhea. Thirty-three patients (40%) had proliferative and 40 (50%) atrophic endometrium. Endometrial polyps were found in nine patients (11%) of the sample. Endometrial findings were similar in the subgroup of 60 patients with preoperative amenorrhea. There were no cases of endometrial hyperplasia or malignancy. In bivariate analysis, those with proliferative endometrium were found to be, on average, 5.6 years younger than those with atrophic endometrium. There were no clinical factors associated with having proliferative versus atrophic endometrium in multivariable models.CONCLUSION(S): People using gender-affirming testosterone may have either proliferative or atrophic endometrium, including people who present with amenorrhea. Further study is needed to develop evidence-based guidelines for appropriate screening for endometrial hyperplasia or cancer in this population.
View details for DOI 10.1016/j.fertnstert.2020.11.008
View details for PubMedID 33583596
Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States.
BMJ sexual & reproductive health
Transgender, nonbinary and gender-expansive (TGE) people face barriers to abortion care and may consider abortion without clinical supervision.In 2019, we recruited participants for an online survey about sexual and reproductive health. Eligible participants were TGE people assigned female or intersex at birth, 18 years and older, from across the United States, and recruited through The PRIDE Study or via online and in-person postings.Of 1694 TGE participants, 76 people (36% of those ever pregnant) reported considering trying to end a pregnancy on their own without clinical supervision, and a subset of these (n=40; 19% of those ever pregnant) reported attempting to do so. Methods fell into four broad categories: herbs (n=15, 38%), physical trauma (n=10, 25%), vitamin C (n=8, 20%) and substance use (n=7, 18%). Reasons given for abortion without clinical supervision ranged from perceived efficiency and desire for privacy, to structural issues including a lack of health insurance coverage, legal restrictions, denials of or mistreatment within clinical care, and cost.These data highlight a high proportion of sampled TGE people who have attempted abortion without clinical supervision. This could reflect formidable barriers to facility-based abortion care as well as a strong desire for privacy and autonomy in the abortion process. Efforts are needed to connect TGE people with information on safe and effective methods of self-managed abortion and to dismantle barriers to clinical abortion care so that TGE people may freely choose a safe, effective abortion in either setting.
View details for DOI 10.1136/bmjsrh-2020-200966
View details for PubMedID 33674348
Online health information seeking, health literacy, and human papillomavirus vaccination among transgender and gender-diverse people.
Journal of the American Medical Informatics Association : JAMIA
The purpose of this study is to describe online health information seeking among a sample of transgender and gender diverse (TGD) people compared with cisgender sexual minority people to explore associations with human papillomavirus (HPV) vaccination, and whether general health literacy and eHealth literacy moderate this relationship.We performed a cross-sectional online survey of TGD and cisgender sexual minority participants from The PRIDE Study, a longitudinal, U.S.-based, national health study of sexual and gender minority people. We employed multivariable logistic regression to model the association of online health information seeking and HPV vaccination.The online survey yielded 3258 responses. Compared with cisgender sexual minority participants, TGD had increased odds of reporting HPV vaccination (aOR, 1.5; 95% CI, 1.1-2.2) but decreased odds when they had looked for information about vaccines online (aOR, 0.7; 95% CI, 0.5-0.9). TGD participants had over twice the odds of reporting HPV vaccination if they visited a social networking site like Facebook (aOR, 2.4; 95% CI, 1.1-5.6). No moderating effects from general or eHealth literacy were observed.Decreased reporting of HPV vaccination among TGD people after searching for vaccine information online suggests vaccine hesitancy, which may potentially be related to the quality of online content. Increased reporting of vaccination after using social media may be related to peer validation.Future studies should investigate potential deterrents to HPV vaccination in online health information to enhance its effectiveness and further explore which aspects of social media might increase vaccine uptake among TGD people.
View details for DOI 10.1093/jamia/ocab150
View details for PubMedID 34383916
Community norms of the Muscle Dysmorphic Disorder Inventory (MDDI) among cisgender sexual minority men and women.
2021; 21 (1): 297
Representing the pathological extreme pursuit of muscularity, muscle dysmorphia (MD) is characterized by a pervasive belief or fear around insufficient muscularity and an elevated drive for muscularity. Despite evidence of elevated body image-related concerns among sexual minority populations, little is known about the degree of muscle dysmorphia (MD) symptoms among sexual minorities, particularly based on Muscle Dysmorphic Disorder Inventory (MDDI) scores. The objective of this study was to examine the nature and severity of MD symptoms in cisgender sexual minority men and women and provide community norms of the MDDI for these populations.Data from participants in The PRIDE Study, an existing study of health outcomes in sexual and gender minority people from the United States, were examined. Participants included cisgender gay men (N = 1090), cisgender bisexual plus (bisexual, pansexual, and/or polysexual) men (N = 100), cisgender lesbian women (N = 563), and cisgender bisexual plus women (N = 507). We calculated means, standard deviations (SD), and percentiles for the MDDI total and subscale scores for cisgender sexual minority men and women. We compared MDDI scores by sexual orientation using linear regression models, both unadjusted and adjusted for sociodemographics.Overall, the sample was 85.2% White, 3.0% Asian or Pacific Islander, 2.0% Black, 0.5% Native American, 3.9% multiracial, and 6.6% Hispanic/Latino/a. The mean age was 38.6 (SD = 14.3) and 69.4% had a college degree or higher. Means (SD) for the MDDI total score were 27.4 (7.7) for cisgender gay men, 26.4 (6.4) for cisgender bisexual plus men, 24.3 (6.1) for cisgender lesbian women, and 24.6 (5.5) for cisgender bisexual plus women. There were no significant differences in MDDI scores between cisgender gay and bisexual plus men, or between cisgender lesbian women and bisexual plus women in unadjusted or adjusted models.These normative data provide insights into the experience of MD symptoms among cisgender sexual minority men and women and can aid researchers and clinicians in the evaluation of MD symptoms and interpretation of MDDI scores in sexual minority populations.
View details for DOI 10.1186/s12888-021-03302-2
View details for PubMedID 34103034
- Understanding co-occurring depression symptoms and alcohol use symptoms among cisgender sexual minority women JOURNAL OF GAY & LESBIAN SOCIAL SERVICES 2021; 33 (4): 427-450
Minority Stress, Structural Stigma, and Physical Health Among Sexual and Gender Minority Individuals: Examining the Relative Strength of the Relationships.
Annals of behavioral medicine : a publication of the Society of Behavioral Medicine
Sexual and gender minority (SGM; i.e., non-heterosexual and transgender or gender-expansive, respectively) people experience physical health disparities attributed to greater exposure to minority stress (experiences of discrimination or victimization, anticipation of discrimination or victimization, concealment of SGM status, and internalization of stigma) and structural stigma.To examine which components of minority stress and structural stigma have the strongest relationships with physical health among SGM people.Participants (5,299 SGM people, 1,902 gender minority individuals) were from The Population Research in Identity and Disparities for Equality (PRIDE) Study. Dominance analyses estimated effect sizes showing how important each component of minority stress and structural stigma was to physical health outcomes.Among cisgender sexual minority women, transmasculine individuals, American Indian or Alaskan Native SGM individuals, Asian SGM individuals, and White SGM individuals a safe current environment for SGM people had the strongest relationship with physical health. For gender-expansive individuals and Black, African American, or African SGM individuals, the safety of the environment for SGM people in which they were raised had the strongest relationship with physical health. Among transfeminine individuals, victimization experiences had the strongest relationship with physical health. Among Hispanic, Latino, or Spanish individuals, accepting current environments had the strongest relationship with physical health. Among cisgender sexual minority men prejudice/discrimination experiences had the strongest relationship with physical health.Safe community environments had the strongest relationships with physical health among most groups of SGM people. Increasing safety and buffering the effects of unsafe communities are important for SGM health.
View details for DOI 10.1093/abm/kaab051
View details for PubMedID 34228052
Community norms of the Muscle Dysmorphic Disorder Inventory (MDDI) among gender minority populations.
Journal of eating disorders
2021; 9 (1): 87
Representing the pathological extreme pursuit of muscularity, muscle dysmorphia (MD) is characterized by a pervasive belief or fear around insufficient muscularity and an elevated drive for muscularity. Despite evidence of heightened body image-related concerns among gender minority populations, little is known about the degree of MD symptoms among gender minorities, particularly based on Muscle Dysmorphic Disorder Inventory (MDDI) scores. The objective of this study was to assess community norms of the MDDI in gender-expansive people, transgender men, and transgender women.Data from participants in The PRIDE Study, an existing study of health outcomes in sexual and gender minority people, were examined. We calculated means, standard deviations, and percentiles for the MDDI total and subscale scores among gender-expansive people (i.e., those who identify outside of the binary system of man or woman; n = 1023), transgender men (n = 326), and transgender women (n = 177). The Kruskal-Wallis test was used to assess group differences and post hoc Dunn's tests were used to examine pairwise differences.Transgender men reported the highest mean MDDI total score (30.5 ± 7.5), followed by gender-expansive people (27.2 ± 6.7), then transgender women (24.6 ± 5.7). The differences in total MDDI score were driven largely by the Drive for Size subscale and, to a lesser extent, the Functional Impairment subscale. There were no significant differences in the Appearance Intolerance subscale among the three groups.Transgender men reported higher Drive for Size, Functional Impairment, and Total MDDI scores compared to gender-expansive people and transgender women. These norms provide insights into the experience of MD symptoms among gender minorities and can aid researchers and clinicians in the interpretation of MDDI scores among gender minority populations.
View details for DOI 10.1186/s40337-021-00442-4
View details for PubMedID 34261536
Psychometric evaluation of the Muscle Dysmorphic Disorder Inventory (MDDI) among cisgender gay men and cisgender lesbian women.
2021; 38: 241–50
Despite increasing empirical interest in muscle dysmorphia (MD), a dearth of research has assessed this construct in sexual minority populations. In particular, the psychometric properties of one of the most widely used measures of MD symptoms-the Muscle Dysmorphic Disorder Inventory (MDDI)-have not been evaluated in sexual minority populations despite emerging evidence suggesting differential risk for MD symptoms across sexual orientation groups. In this study, we assessed the psychometric properties of the MDDI in a sample of 715 cisgender gay men and 404 cisgender lesbian women ages 18-50 years who participated in a large-scale national longitudinal cohort study of sexual and gender minority adults. The factor structure of the MDDI was examined in each sample using a two-step, split-sample exploratory and confirmatory factor analytic approach. Exploratory factor analysis supported a three-factor structure in both samples, which were confirmed by confirmatory factor analysis. Moreover, results supported the internal consistency reliability and convergent validity of the MDDI subscales in both samples. Cumulatively, these findings suggest that the MDDI is an appropriate measure of MD symptoms among cisgender gay men and cisgender lesbian women.
View details for DOI 10.1016/j.bodyim.2021.04.008
View details for PubMedID 33962223
- Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: Results from a national, quantitative survey INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2020
- Prepregnancy Counseling for People of All Genders: Enhancing Safe and Accessible Family Building for Transgender, Gender Diverse, and Non-binary Individuals CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020
Stakeholder Perceptions and Experiences Regarding Access to Contraception and Abortion for Transgender, Non-Binary, and Gender-Expansive Individuals Assigned Female at Birth in the U.S.
Archives of sexual behavior
Sexual and reproductive health (SRH) care often excludes the needs and experiences of transgender, non-binary, and gender-expansive (TGE) individuals. This study aimed to collect diverse stakeholder perspectives on barriers and facilitators to contraception and abortion for TGE individuals assigned female at birth (AFAB), assess knowledge and attitudes about unintended pregnancy prevention in these populations, and identify recommendations for improving SRH services for people of all genders. Between October 2017 and January 2018, we conducted 27 in-depth interviews with SRH stakeholders, including five TGE individuals who had obtained contraception or abortion care, and 22 clinicians, researchers, and advocates experienced in transgender healthcare. We iteratively developed a codebook and conducted thematic analysis to capture the spectrum of perspectives across interviews. Stakeholders reported a range of barriers to contraception and abortion access for TGE people AFAB, including inability to afford services, lack of gender-affirming clinicians, difficulty obtaining insurance coverage, and misconceptions about fertility and unplanned pregnancy risk. Deterrents to care-seeking included gendered healthcare environments, misgendering, and discrimination. Stakeholders described provider knowledge gaps and a perceived lack of medical education relevant to the SRH needs of TGE people. Recommendations included using gender-inclusive language and gender-affirming patient education materials and improving provider training on gender-affirming SRH care. Stakeholders identified substantial barriers to high-quality contraception and abortion care for TGE AFAB people in the U.S. They recommended specific interventions at the provider and institutional levels to improve experiences with care for TGE people and ensure broader access to gender-affirming SRH services.
View details for DOI 10.1007/s10508-020-01707-w
View details for PubMedID 32385584
Contraceptive counseling for transgender and gender diverse people who were female sex assigned at birth.
Everyone of reproductive potential, no matter sex or gender, may have contraceptive needs. However, with no professional society guidelines and scant data on contraceptive use for transgender and gender-diverse (TGD) populations, clinicians' abilities to counsel patients on use, safety, side effects, and efficacy is severely limited. We know very little about how estrogen- and progestin-containing contraceptive methods interact with gender-affirming testosterone therapy. Consequently, providers must extrapolate from data on use of hormonal contraceptive methods in presumed cisgender women and rely on clinical expertise. Based on available literature and expert opinion, there are important considerations for each method that can help guide contraceptive counseling with TGD patients. Specific considerations include differential experience of side-effects in TGD patients, barriers to access, and potential misconceptions regarding menstruation and reproductive capacity. When counseling a TGD person about their contraception options, providers should engage in shared decision-making, acknowledging the spectrum of identities and experiences within these communities. In order to support gender-affirming patient-centered care, providers should also create a space that is welcoming, use language that promotes inclusivity, and perform physical exams that consider the potential physical and emotional discomforts specific to these patients. Given the lack of population-specific data and guidelines, we encourage providers to integrate what is known about contraceptive use in cisgender women with the unique needs of TGD persons to apply a shared decision-making contraceptive counseling approach with members of these communities.
View details for DOI 10.1016/j.contraception.2020.04.001
View details for PubMedID 32304766
The Imperative for Transgender and Gender Nonbinary Inclusion: Beyond Women's Health.
Obstetrics and gynecology
We aim to make evident that solely referencing cisgender women in the context of sexual and reproductive health-particularly pregnancy planning and care-excludes a diverse group of transgender and gender nonbinary people who have sexual and reproductive health needs and experiences that can be similar to but also unique from those of cisgender women. We call on clinicians and researchers to ensure that all points of sexual and reproductive health access, research, sources of information, and care delivery comprehensively include and are accessible to people of all genders. We describe barriers to sexual and reproductive health care and research participation unique to people of marginalized gender identities, provide examples of harm resulting from these barriers, and offer concrete suggestions for creating inclusive, accurate, and respectful care and research environments-which will lead to higher quality health care and science for people of all genders.
View details for DOI 10.1097/AOG.0000000000003816
View details for PubMedID 32282602
Providing Patient-Centered Perinatal Care for Transgender Men and Gender-Diverse Individuals: A Collaborative Multidisciplinary Team Approach In Reply
OBSTETRICS AND GYNECOLOGY
2020; 135 (2): 484–85
View details for Web of Science ID 000524416100046
Characterization of substance use among underrepresented sexual and gender minority participants in The Population Research in Identity and Disparities for Equality (PRIDE) Study.
Background: Profiles of substance use among less commonly described subgroups of sexual and gender minority (SGM) people (e.g., queer, genderqueer) remain largely unknown. Objective(s): To identify substance use differences among less commonly described SGM identity-based subgroups. Methods: The PRIDE Study is a national, online, longitudinal cohort study of self-identified SGM adults living in the U.S. Between 2015-2017, an iPhone application was used to administer three cross-sectional health questionnaires to participants, one of which included questions about binge alcohol, marijuana, and other drug use (substance use). This study was a secondary data analysis of participant responses to substance use survey items. Logistic regression and generalized linear modeling assessed relationships between sexual orientation or gender and use of or reported problems with substances within the past year. Results: Among the 1790 participants included in this study, 51.0% reported binge alcohol use, 39.8% reported marijuana use, and 19.7% reported other drug use (65.9% endorsed use of one or more of these) within the past year. Over 30% indicated substance use had been a problem in their life. Asexual individuals had lower odds of reporting past year binge alcohol and marijuana use (aOR: 0.27, 95% CI: 0.12-0.61; aOR: 0.38, 95% CI: 0.15-0.96, respectively), and queer participants had higher odds of reporting past year marijuana use (aOR: 2.52, 95% CI: 1.58-4.03) compared to lesbian participants. Gender nonbinary participants had lower odds of reporting past year binge alcohol use (aOR: 0.48, 95% CI: 0.32-0.71) and transmasculine participants had higher odds of reporting past year marijuana use (aOR: 2.18, 95% CI: 1.10-4.31) compared to cisgender women. Conclusions: Substance use heterogeneity exists between SGM groups. Comprehensive assessment of sexual orientation and gender may improve understanding of substance use and increase equity within support and treatment services for SGM populations.HighlightsWe examined substance use among less represented sexual and gender minority groups.Alcohol and other drug use were examined by both sexual orientation and gender identity.Analyses included identities such as queer, pansexual, genderqueer and nonbinary.Alcohol use differed across asexual, genderqueer and gender nonbinary groups.Marijuana use differed across queer, asexual and transmasculine groups.
View details for DOI 10.1080/08897077.2019.1702610
View details for PubMedID 32032500
Screening gender minority people for harmful alcohol use.
2020; 15 (4): e0231022
This study identifies how to screen for harmful alcohol use among gender minority (e.g., transgender and gender-expansive) people using brief screening methods and identifies which screening methods perform best among gender-expansive, transfeminine, and transmasculine subgroups, as screening recommendations are not currently available. Using 2018 Annual Questionnaire data from The PRIDE Study, area under the curve (AUC) values were compared to identify which screening methods ("4 or more" or "5 or more" drinks on one occasion in the past year, or one or more items from the Alcohol Use Disorders Identification Test [AUDIT]) best predicted (i) harmful alcohol use and (ii) one or more past year alcohol dependence symptoms or consequences. Among 1892 participants, "5 or more" drinks on one occasion (AUC ranges: 0.82-0.86) performed better than "4 or more" drinks (AUC ranges: 0.78-0.81) in predicting harmful drinking. The screening methods "4 or more" drinks, "5 or more" drinks, and the consumption items of the AUDIT (AUDIT-C) using a cutoff score of 3 all maximized sensitivity and specificity to predict alcohol dependence symptoms or consequences in gender minority people overall (AUC: 0.77-0.78). Screening for "5 or more" drinks on one occasion within the past year performed as well as or better than other screening methods to detect both harmful drinking and alcohol dependence-related symptoms or consequences. This single-item screening method can identify if more extensive alcohol use assessment is warranted with gender minority people.
View details for DOI 10.1371/journal.pone.0231022
View details for PubMedID 32255781
Meeting the Patient Care, Education, and Research Missions: Academic Medical Centers Must Comprehensively Address Sexual and Gender Minority Health.
Academic medicine : journal of the Association of American Medical Colleges
While sociopolitical advances have improved the rights of sexual and gender minorities (i.e., lesbian, gay, bisexual, transgender, queer [LGBTQ+] persons), they continue to face a health system that discriminates against them and does not provide competent, comprehensive care. Despite calls for advancing research, there remains limited sexual and gender minority health research funding, mentorship, and institutional support. Academic medical centers are best suited to systematically tackle disparities and improve care for all sexual and gender minority people through their tripartite missions of patient care, education, and research. In this article, the authors outline discrimination experienced by LGBTQ+ persons and highlight the unique disparities they experience across access and outcomes. The authors posit that by systematically improving clinical care of, incorporating education and training about, and research with LGBTQ+ people into their core missions, academic medical centers can dramatically change the health care landscape. Academic medical centers can eliminate health disparities, expand necessary research endeavors about sexual and gender minorities, and prepare the health care workforce to address the unique needs of these overlooked populations.
View details for DOI 10.1097/ACM.0000000000003703
View details for PubMedID 32852319
Community norms for the Eating Disorder Examination Questionnaire (EDE-Q) among transgender men and women.
2020; 37: 101381
Transgender men and women may be at risk for eating disorders, but prior community norms of the Eating Disorders Examination Questionnaire (EDE-Q) are based on presumed cisgender men and woman and have not intentionally included transgender people. The objective of this study was to develop community norms for eating disorder attitudes and disordered eating behaviors in transgender men and women using the EDE-Q. Participants were 312 transgender men and 172 transgender women participants in The PRIDE Study, an existing cohort study of sexual and gender minority people. We present mean scores, standard deviations, and percentile ranks for the Global score and four subscale scores of the EDE-Q in transgender men and women. Transgender men and women reported any occurrence (≥1/week) of dietary restraint (25.0% and 27.9%), objective binge episodes (11.2% and 12.8%), excessive exercise (8.0% and 8.1%), self-induced vomiting (1.6% and 1.7%), and laxative misuse (.3% and .6%), respectively. Compared to a prior study of presumed cisgender men 18-26 years (Lavender, De Young, & Anderson, 2010), our age-matched subsample of transgender men reported lower rates of objective binge episodes and excessive exercise. Compared to a prior study of presumed cisgender women 18-42 years (Mond, Hay, Rodgers, & Owen, 2006), we found that an age-matched sample of transgender women reported higher rates of dietary restraint but lower rates of excessive exercise. These norms should aid clinicians in applying and researchers in investigating and interpreting the EDE-Q scores of transgender men and women.
View details for DOI 10.1016/j.eatbeh.2020.101381
View details for PubMedID 32416588
Development of an affirming and customizable electronic survey of sexual and reproductive health experiences for transgender and gender nonbinary people.
2020; 15 (5): e0232154
To address pervasive measurement biases in sexual and reproductive health (SRH) research, our interdisciplinary team created an affirming, customizable electronic survey to measure experiences with contraceptive use, pregnancy, and abortion for transgender and gender nonbinary people assigned female or intersex at birth and cisgender sexual minority women. Between May 2018 and April 2019, we developed a questionnaire with 328 items across 10 domains including gender identity; language used for sexual and reproductive anatomy and events; gender affirmation process history; sexual orientation and sexual activity; contraceptive use and preferences; pregnancy history and desires; abortion history and preferences; priorities for sexual and reproductive health care; family building experiences; and sociodemographic characteristics. Recognizing that the words people use for their sexual and reproductive anatomy can vary, we programmed the survey to allow participants to input the words they use to describe their bodies, and then used those customized words to replace traditional medical terms throughout the survey. This process-oriented paper aims to describe the rationale for and collaborative development of an affirming, customizable survey of the SRH needs and experiences of sexual and gender minorities, and to present summary demographic characteristics of 3,110 people who completed the survey. We also present data on usage of customizable words, and offer the full text of the survey, as well as code for programming the survey and cleaning the data, for others to use directly or as guidelines for how to measure SRH outcomes with greater sensitivity to gender diversity and a range of sexual orientations.
View details for DOI 10.1371/journal.pone.0232154
View details for PubMedID 32365110
What Sexual and Gender Minority People Want Researchers to Know About Sexual Orientation and Gender Identity Questions: A Qualitative Study.
Archives of sexual behavior
Sexual and gender minority (SGM) people-including members of the lesbian, gay, bisexual, transgender, and queer communities-are understudied and underrepresented in research. Current sexual orientation and gender identity (SOGI) questions do not sufficiently engage SGM people, and there is a critical gap in understanding how SOGI questions reduce inclusion and accurate empirical representation. We conducted a qualitative study to answer the question, "For SGM people, what are the major limitations with current SOGI questions?" Focus groups probed reactions to SOGI questions adapted from prior national surveys and clinical best practice guidelines. Questions were refined and presented in semi-structured cognitive interviews. Template analysis using a priori themes guided analysis. There were 74 participants: 55 in nine focus groups and 19 in cognitive interviews. Participants were diverse: 51.3% identified as gender minorities, 87.8% as sexual minorities, 8.1% as Hispanic/Latinx, 13.5% as Black or African-American, and 43.2% as Non-white. Two major themes emerged: (1) SOGI questions did not allow for identity fluidity and complexity, reducing inclusion and representation, and (2) SOGI question stems and answer choices were often not clear as to which SOGI dimension was being assessed. To our knowledge, this represents the largest body of qualitative data studying SGM perspectives when responding to SOGI questions. We present recommendations for future development and use of SOGI measures. Attention to these topics may improve meaningful participation of SGM people in research and implementation of such research within and for SGM communities.
View details for DOI 10.1007/s10508-020-01810-y
View details for PubMedID 32875381
- Depression and Anxiety Changes Among Sexual and Gender Minority People Coinciding with Onset of COVID-19 Pandemic. Journal of general internal medicine 2020
Community norms for the Eating Disorder Examination Questionnaire (EDE-Q) among gender-expansive populations.
Journal of eating disorders
2020; 8 (1): 74
Gender-expansive individuals (i.e., those who identify outside of the binary system of man or woman) are a marginalized group that faces discrimination and have a high burden of mental health problems, but there is a paucity of research on eating disorders in this population. This study aimed to describe the community norms for the Eating Disorder Examination Questionnaire (EDE-Q) in gender-expansive populations.The participants were 988 gender-expansive individuals (defined as neither exclusively cisgender nor binary transgender) from The PRIDE study, an existing longitudinal cohort study of health outcomes in sexual and gender minority people.We present the mean scores, standard deviations, and percentile ranks for the Global score and four subscale scores of the EDE-Q in this group as a whole and stratified by sex assigned at birth. Gender-expansive individuals reported any occurrence (≥1/28 days) of dietary restraint (23.0%), objective binge episodes (12.9%), excessive exercise (7.4%), self-induced vomiting (1.4%), or laxative misuse (1.2%). We found no statistically significant differences by sex assigned at birth. Compared to a prior study of transgender men and women, there were no significant differences in eating attitudes or disordered eating behaviors noted between gender-expansive individuals and transgender men. Transgender women reported higher Restraint and Shape Concern subscale scores compared to gender-expansive individuals. Compared to a prior study of presumed cisgender men 18-26 years, our age-matched gender-expansive sample had higher Eating, Weight, and Shape Concern subscales and Global Score, but reported a lower frequency of objective binge episodes and excessive exercise. Compared to a prior study of presumed cisgender women 18-25 years, our age-matched gender-expansive sample had a higher Shape Concern subscale score, a lower Restraint subscale score, and lower frequencies of self-induced vomiting, laxative misuse, and excessive exercise.Gender-expansive individuals reported lower Restraint and Shape Concern scores than transgender women; higher Eating, Weight, and Shape Concern scores than presumed cisgender men; and lower Restraint but higher Shape Concern scores than presumed cisgender women. These norms can help clinicians in treating this population and interpreting the EDE-Q scores of their gender-expansive patients.
View details for DOI 10.1186/s40337-020-00352-x
View details for PubMedID 33292636
Abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States.
American journal of obstetrics and gynecology
Transgender, nonbinary, and gender-expansive (TGE) people who were assigned female or intersex at birth experience pregnancy and have abortions. No data have been published on individual abortion experiences or preferences of this understudied population.To fill existing evidence gaps on the abortion experiences and preferences of TGE people in the United States to inform policies and practices to improve access to and quality of abortion care for this population.In 2019, we recruited TGE people assigned female or intersex at birth and aged 18 years and older from across the United States to participate in an online survey about sexual and reproductive health recruited through The PRIDE Study and online postings. We descriptively analyzed closed- and open-ended survey responses related to pregnancy history, abortion experiences, preferences for abortion method, recommendations to improve abortion care for TGE people, and respondent sociodemographic characteristics.The majority of the 1,694 respondents were less than 30 years of age. Respondents represented multiple gender identities and sexual orientations and resided across all four United States Census Regions. Overall, 210 (12%) respondents had ever been pregnant; these 210 reported 421 total pregnancies, of which 92 (22%) ended in abortion. For respondents' most recent abortion, 41 (61%) were surgical, 23 (34%) were medication, and 3 (4.5%) used another method (primarily herbal). Most recent abortions took place at or before nine weeks gestation (n=41, 61%). If they were to need an abortion today, respondents preferred medication abortion to surgical abortion three to one (n=703 versus n=217), but 514 (30%) respondents did not know which method they would prefer. Reasons for medication abortion preference among the 703 respondents included a belief that it is the least invasive method (n=553, 79%) and the most private method (n=388, 55%). To improve accessibility and quality of abortion care for TGE patients, respondents most frequently recommended that abortion clinics adopt gender-neutral or gender-affirming intake forms, that providers utilize gender-neutral language, and that greater privacy be incorporated into the clinic.These data contribute significantly to the evidence base on individual experiences of and preferences for abortion care for TGE people. Findings can be used to adapt abortion care to better include and affirm the experiences of this underserved population.
View details for DOI 10.1016/j.ajog.2020.09.035
View details for PubMedID 32986990
Community norms for the eating disorder examination questionnaire (EDE-Q) among cisgender bisexual plus women and men.
Eating and weight disorders : EWD
Cisgender bisexual plus (including bisexual, pansexual, and polysexual) women and men experience unique health concerns including eating disorders. The purpose of this study was to develop community norms for eating disorder attitudes and disordered eating behaviors in cisgender bisexual plus women and men using the Eating Disorders Examination Questionnaire (EDE-Q).Participants were cisgender bisexual plus women (n = 462) and men (n = 93) participants in The PRIDE Study, an existing study of sexual and gender minority people.Mean and standard deviation of EDE-Q scores among cisgender bisexual plus women and men, respectively, were: Global (1.75 ± 1.26, 1.56 ± 1.18), Restraint (1.34 ± 1.44, 1.42 ± 1.53), Eating Concern (0.96 ± 1.13, 0.63 ± 0.96), Weight Concern 2.27 ± 1.55, 1.89 ± 1.46), and Shape Concern 42 ± 1.62, 2.30 ± 1.57). Among cisgender bisexual plus women and men, respectively, 27.5% and 22.6% scored in the clinically significant range on the Global score. Bisexual plus women and men reported any occurrence (≥ 1/28 days) of dietary restraint (19.3%, 23.7%), objective binge episodes (11.1%, 10.8%), excessive exercise (4.5%, 5.4%), self-induced vomiting (1.7%, 0.0%), and laxative misuse (0.4%, 1.1%), respectively. A lower percentage of age-matched cisgender bisexual plus women (18-25 years) reported any occurrence of objective binge episodes, self-induced vomiting, laxative misuse, and excessive exercise than previously published in young women. Age-matched cisgender bisexual plus men (18-26 years) reported higher weight concern subscale scores than previously published in young men.These norms should aid clinicians in applying and interpreting the EDE-Q scores of cisgender bisexual plus women and men.Level V: cross-sectional descriptive study.
View details for DOI 10.1007/s40519-020-01070-8
View details for PubMedID 33270173
Eating disorder attitudes and disordered eating behaviors as measured by the Eating Disorder Examination Questionnaire (EDE-Q) among cisgender lesbian women.
2020; 34: 215–20
The Eating Disorder Examination Questionnaire (EDE-Q) is a measure of eating disorder attitudes and disordered eating behaviors. Prior descriptive studies of the EDE-Q for women either did not assess or omitted reporting sexual orientation. This study's objective was to assess eating disorder attitudes and disordered eating behaviors as measured by the EDE-Q among cisgender lesbian women. We present mean scores and standard deviations for the EDE-Q among 563 self-identified cisgender lesbian women ages 18-77 who were recruited from The PRIDE Study in 2018. Among cisgender lesbian women, 3.4 % scored in the clinically significant range on the Restraint, 1.6 % on the Eating Concern, 9.1 % on the Weight Concern, 13.9 % on the Shape Concern, and 3.9 % on the Global Score scales of the EDE-Q. We found that 13.5 % of participants reported any occurrence (≥1/28 days) of dietary restriction, 8.7 % for objective binge episodes, 5.3 % for excessive exercise, .4% for self-induced vomiting, and .4% for laxative misuse. Participants reported a current (1.8 %) or lifetime (7.1 %) diagnosis of an eating disorder by a clinician. These EDE-Q descriptive data capture eating disorder attitudes and disordered eating behaviors among cisgender lesbian women and may aid clinicians and researchers in interpreting the EDE-Q in this specific population.
View details for DOI 10.1016/j.bodyim.2020.06.005
View details for PubMedID 32652490
- Response to Letter. Obstetrics and gynecology 2020; 135 (2): 484–85
- Supporting sexual and gender minority health: Research priorities from mental health professionals JOURNAL OF GAY & LESBIAN MENTAL HEALTH 2019
Providing Patient-Centered Perinatal Care for Transgender Men and Gender-Diverse Individuals: A Collaborative Multidisciplinary Team Approach.
Obstetrics and gynecology
2019; 134 (5): 959-963
Little is documented about the experiences of pregnancy for transgender and gender-diverse individuals. There is scant clinical guidance for providing prepregnancy, prenatal, intrapartum, and postpartum care to transgender and gender-diverse people who desire pregnancy.Our team provided perinatal care to a 20-year-old transgender man, which prompted collaborative advocacy for health care systems change to create gender-affirming patient experiences in the perinatal health care setting.Systems-level and interpersonal-level interventions were adopted to create gender-affirming and inclusive care in and around pregnancy. Basic practices to mitigate stigma and promote gender-affirming care include staff trainings and query and use of appropriate name and pronouns in patient interactions and medical documentation. Various factors are important to consider regarding testosterone therapy for transgender individuals desiring pregnancy.
View details for DOI 10.1097/AOG.0000000000003506
View details for PubMedID 31599839
View details for PubMedCentralID PMC6814572
Community norms for the Eating Disorder Examination Questionnaire among cisgender gay men.
European eating disorders review : the journal of the Eating Disorders Association
Prior norms of the Eating Disorders Examination Questionnaire (EDE-Q) among men have not considered sexual orientation. This study's objective was to assess EDE-Q community norms among cisgender gay men.Participants were 978 self-identified cisgender gay men from The PRIDE Study recruited in 2018.We present mean scores and standard deviations for the EDE-Q among cisgender gay men ages 18-82. Among cisgender gay men, 4.0% scored in the clinically significant range on the global score, 5.7% on the restraint, 2.1% on the eating concern, 10.5% on the weight concern, and 21.4% on the shape concern subscales of the EDE-Q. The global score as well as weight and shape concerns in a young adult subsample (18-26 years) from The PRIDE Study were higher than previously reported norms in young men (Lavender, 2010). Participants reported any occurrence (≥1/28 days) of dietary restraint (19.8%), objective binge episodes (10.9%), excessive exercise (10.1%), laxative misuse (1.1%), and self-induced vomiting (0.6%). Binge eating, excessive exercise, and self-induced vomiting in The PRIDE Study subsample were lower than previously reported in young men.We provide EDE-Q norms among cisgender gay men, which should aid clinicians and researchers to interpret the EDE-Q scores of cisgender gay men.
View details for DOI 10.1002/erv.2708
View details for PubMedID 31793119
- Opening the Ob/Gyn Door to Sexual and Gender Minority Patients Contemporary Ob/Gyn. Volume 64, No 01. 2019 11–15
The "All of Us" Research Program.
The New England journal of medicine
2019; 381 (7): 668–76
Knowledge gained from observational cohort studies has dramatically advanced the prevention and treatment of diseases. Many of these cohorts, however, are small, lack diversity, or do not provide comprehensive phenotype data. The All of Us Research Program plans to enroll a diverse group of at least 1 million persons in the United States in order to accelerate biomedical research and improve health. The program aims to make the research results accessible to participants, and it is developing new approaches to generate, access, and make data broadly available to approved researchers. All of Us opened for enrollment in May 2018 and currently enrolls participants 18 years of age or older from a network of more than 340 recruitment sites. Elements of the program protocol include health questionnaires, electronic health records (EHRs), physical measurements, the use of digital health technology, and the collection and analysis of biospecimens. As of July 2019, more than 175,000 participants had contributed biospecimens. More than 80% of these participants are from groups that have been historically underrepresented in biomedical research. EHR data on more than 112,000 participants from 34 sites have been collected. The All of Us data repository should permit researchers to take into account individual differences in lifestyle, socioeconomic factors, environment, and biologic characteristics in order to advance precision diagnosis, prevention, and treatment.
View details for DOI 10.1056/NEJMsr1809937
View details for PubMedID 31412182
More Similarities Than Differences? An Exploratory Analysis Comparing the Sexual Complaints, Sexual Experiences, and Genitourinary Health of Older Sexual Minority and Sexual Majority Adults.
The Journal of Sexual Medicine
2019; 16 (3): 347-350
View details for DOI 10.1016/j.jsxm.2019.01.308
A digital health research platform for community engagement, recruitment, and retention of sexual and gender minority adults in a national longitudinal cohort study--The PRIDE Study.
Journal of the American Medical Informatics Association : JAMIA
Sexual and gender minority (SGM) people are underrepresented in research. We sought to create a digital research platform to engage, recruit, and retain SGM people in a national, longitudinal, dynamic, cohort study (The PRIDE Study) of SGM health.We partnered with design and development firms and engaged SGM community members to build a secure, cloud-based, containerized, microservices-based, feature-rich, research platform. We created PRIDEnet, a national network of individuals and organizations that actively engaged SGM communities in all stages of health research. The PRIDE Study participants were recruited via in-person outreach, communications to PRIDEnet constituents, social media advertising, and word-of-mouth. Participants completed surveys to report demographic as well as physical, mental, and social health data.We built a secure digital research platform with engaging functionality that engaged SGM people and recruited and retained 13 731 diverse individuals in 2 years. A sizeable sample of 3813 gender minority people (32.8% of cohort) were recruited despite representing only approximately 0.6% of the population. Participants engaged with the platform and completed comprehensive annual surveys- including questions about sensitive and stigmatizing topics- to create a data resource and join a cohort for ongoing SGM health research.With an appealing digital platform, recruitment and engagement in online-only longitudinal cohort studies are possible. Participant engagement with meaningful, bidirectional relationships creates stakeholders and enables study cocreation. Research about effective tactics to engage, recruit, and maintain active participation from all communities is needed.This digital research platform successfully recruited and engaged diverse SGM participants in The PRIDE Study. A similar approach may be successful in partnership with other underrepresented and vulnerable populations.
View details for DOI 10.1093/jamia/ocz082
View details for PubMedID 31162545
Resilience Against Depression Disparities (RADD): a protocol for a randomised comparative effectiveness trial for depression among predominantly low-income, racial/ethnic, sexual and gender minorities.
2019; 9 (10): e031099
Depression is the leading cause of adult disability and common among sexual and gender minority (SGM) adults. The current study builds on findings showing the effectiveness of depression quality improvement (QI) and delivery of cognitive behavioural therapy (CBT) skills provided by community health workers in reducing depression. Depression QI approaches across healthcare and social/community services in safety-net settings have shown improvements in mental wellness, mental health quality of life and depression over 12 months. Further, a randomised study showed improved depression among low-income racial/ethnic minorities enrolled in a CBT-informed resiliency class (Building Resilience and Increasing Community Hope (B-RICH)). The current protocol describes a comparativeness effectiveness study to evaluate whether predominantly low-income, SGM racial/ethnic minority adults randomised to a CBT-informed resiliency class have improvements in depressive symptoms over and above community-engaged QI resources and training only.The study approached three clusters of four to five programs serving predominantly SGM and racial/ethnic minority communities in the USA: two clusters in Los Angeles, California, and one in New Orleans, Louisiana. Clusters are comprised of one primary care, one mental health and two to three community agencies (eg, faith-based, social services/support, advocacy). All programs received depression QI training. The current study employed a community-partnered participatory research model to adapt the CBT-informed resiliency class, B-RICH+, to SGM communities. Study participants were screened and recruited in person from participating programs, and will complete baseline, 6- and 12-month survey follow-ups. Participants were depressed adults (8-item Patient Health Questionnaire ≥10; ≥18 years of age) who provided contact information. Enrolled participants were individually randomised to B-RICH+ or depression QI alone. Primary outcomes are depressive symptoms; secondary outcomes are mental health quality of life, mental wellness and physical health quality of life. Data collection for this study is ongoing.The current study was approved by the UCLA Institutional Review Board. Study findings will be disseminated through scientific publications and community conferences.https://clinicaltrials.gov/ct2/show/NCT02986126.
View details for DOI 10.1136/bmjopen-2019-031099
View details for PubMedID 31641001
Using mobile technology to engage sexual and gender minorities in clinical research.
2019; 14 (5): e0216282
Historical and current stigmatizing and discriminatory experiences drive sexual and gender minority (SGM) people away from health care and clinical research. Being medically underserved, they face numerous disparities that make them vulnerable to poor health outcomes. Effective methods to engage and recruit SGM people into clinical research studies are needed.To promote health equity and understand SGM health needs, we sought to design an online, national, longitudinal cohort study entitled The PRIDE (Population Research in Identity and Disparities for Equality) Study that enabled SGM people to safely participate, provide demographic and health data, and generate SGM health-related research ideas.We developed an iPhone mobile application ("app") to engage and recruit SGM people to The PRIDE Study-Phase 1. Participants completed demographic and health surveys and joined in asynchronous discussions about SGM health-related topics important to them for future study.The PRIDE Study-Phase 1 consented 18,099 participants. Of them, 16,394 provided data. More than 98% identified as a sexual minority, and more than 15% identified as a gender minority. The sample was diverse in terms of sexual orientation, gender identity, age, race, ethnicity, geographic location, education, and individual income. Participants completed 24,022 surveys, provided 3,544 health topics important to them, and cast 60,522 votes indicating their opinion of a particular health topic.We developed an iPhone app that recruited SGM adults and collected demographic and health data for a new national online cohort study. Digital engagement features empowered participants to become committed stakeholders in the research development process. We believe this is the first time that a mobile app has been used to specifically engage and recruit large numbers of an underrepresented population for clinical research. Similar approaches may be successful, convenient, and cost-effective at engaging and recruiting other vulnerable populations into clinical research studies.
View details for DOI 10.1371/journal.pone.0216282
View details for PubMedID 31048870
Urinary Incontinence in a National Cohort of Older Women: Implications for Caregiving and Care Dependence
JOURNAL OF WOMENS HEALTH
2018; 27 (9): 1097–1103
Urinary incontinence (UI) can interfere with older women's ability to perform activities of daily living (ADLs), but little is known about factors that predispose incontinent women to become functionally dependent or compromise their ability to serve as caregivers to others.UI, caregiving, and care-receiving behaviors were assessed by questionnaire in a national sample of community-dwelling older women. Multivariable models evaluated associations between incontinence and care dependence, assessed factors associated with care dependence among incontinent women, and compared health among female caregivers with and without incontinence.Of the 1703 women, 27% reported weekly or more incontinence and 13% monthly incontinence. Women with weekly or more incontinence were more likely than women without incontinence to report receiving care for ADLs (AOR = 2.39, CI = 1.61-3.56) or instrumental ADLs (AOR = 1.94, CI = 1.42-2.63). Compared to 46% of women without incontinence, 60% of women with monthly or weekly incontinence reported unmet care needs (p = 0.0002). Factors associated with care dependence included more frequent incontinence, older age, marital status, and fair/poor health (p < 0.05 for all). Overall, 15% of women served as a caregiver for another adult, which did not differ by incontinence status (p = 0.84), but female caregivers with incontinence reported worse health than those without incontinence (p = 0.0004).In this national cohort, older women with incontinence were more likely to be functionally dependent and have unmet care needs than those without incontinence, after adjustment for other factors. At least one in ten incontinent women served as caregivers, despite having worse health than female caregivers without incontinence.
View details for DOI 10.1089/jwh.2017.6891
View details for Web of Science ID 000435559200001
View details for PubMedID 29902123
View details for PubMedCentralID PMC6148721
The new era of precision population health: insights for the All of Us Research Program and beyond.
Journal of translational medicine
2018; 16 (1): 211
Although precision medicine has made advances in individualized patient treatments, there needs to be continued attention on tailored population health and prevention strategies (often termed "precision population health"). As we continue to link datasets and use "big data" approaches in medicine, inclusion of diverse populations and a focus on disparities reduction are key components within a precision population health framework. Specific recommendations from the All of Us Research Program and the Precision Public Health Summit provide examples for moving this field forward.
View details for DOI 10.1186/s12967-018-1585-5
View details for PubMedID 30053823
View details for PubMedCentralID PMC6062956
From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers
BMC PREGNANCY AND CHILDBIRTH
2017; 17: 332
Some transgender men retain their uterus, get pregnant, and give birth. However, societal attitudes about gender have erected barriers to openly being pregnant and giving birth as a transgender man. Little research exists regarding transgender men's reproductive needs. Anecdotal observations suggest that social change and increasing empowerment of transgender men may result in increasing frequency and openness about pregnancy and birth. Specific needs around conception, pregnancy, and newborn care may arise from transphobia, exogenous testosterone exposure, or from having had (or desiring) gender-affirming surgery. We undertook a qualitative study to understand the needs of transgender men who had given birth.We interviewed 10 transgender men who had been recruited for a recently published online cross-sectional survey of individuals (n = 41). Subjects had given birth while identifying as male. Interviews were recorded, transcribed, and systematically coded. Analysis used a priori and emergent codes to identify central themes and develop a framework for understanding participant experiences.Participants reported diverse experiences and values on issues including prioritization and sequencing of transition versus reproduction, empowerment in healthcare, desire for external affirmation of their gender and/or pregnancy, access to social supports, and degree of outness as male, transgender, or pregnant. We identified structural barriers that disempowered participants and describe healthcare components that felt safe and empowering. We describe how patients' strategies, and providers' behaviors, affected empowerment. Anticipatory guidance from providers was central in promoting security and empowerment for these individuals as patients.Recognizing diverse experiences has implications in supporting future patients through promoting patient-centered care and increasing the experiential legibility. Institutional erasure creates barriers to transgender men getting routine perinatal care. Identifying this erasure helps shape recommendations for how providers and clinics can provide appropriate care. Specific information regarding reproduction can be helpful to patients. We provide recommendations for providers' anticipatory guidance during the pre-transition, pre-conception, prenatal, and postpartum periods. Ways to support and bring visibility to the experience of transgender men are identified. Improving clinical visibility and affirming gender will likely enhance patient experience and may support patient-centered perinatal healthcare services.
View details for DOI 10.1186/s12884-017-1491-5
View details for Web of Science ID 000415331900002
View details for PubMedID 29143629
View details for PubMedCentralID PMC5688401
- Gynecologic Care for Transgender Adults CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017; 6 (2): 140–48
Feasibility of Vaginal Hysterectomy for Female-to-Male Transgender Men.
Obstetrics and gynecology
2017; 129 (3): 457-463
To describe the hysterectomy data among a cohort of transgender men and nontransgender (ie, cisgender) women with a particular goal to evaluate the feasibility of vaginal hysterectomy among transgender men.This cohort study includes all hysterectomies performed for benign indications on transgender men and cisgender women at a single academic county hospital from 2000 to 2012. Hysterectomy cases and patient gender were identified by billing records and confirmed by review of medical records. Primary study outcome was the hysterectomy route among transgender men compared with cisgender women. We also examined risk factors and operative outcomes. Student two-sided t tests, χ analysis, and descriptive statistics are presented; sensitivity analyses using regression techniques were performed.Hysterectomies for benign gynecologic procedures were performed in 883 people: 33 on transgender men and 850 on cisgender women. Transgender men were younger, had fewer pregnancies and deliveries, and smaller uteri. The leading indication for hysterectomy differed significantly: pain (85%) was most common among transgender men (compared with 22% in cisgender women; P<.001), whereas leiomyomas (64%) was most common for cisgender women (compared with 21% in transgender men; P<.001). Vaginal hysterectomies were performed in 24% transgender men and 42% of cisgender women. Estimated blood loss was less among transgender men (P=.002), but when uterine size and route of hysterectomy were considered, the difference between gender groups was no longer significant. There was no difference in patients experiencing complications between the groups.Transgender men and cisgender women have different preoperative characteristics and surgical indications. Vaginal hysterectomies have been successfully completed among transgender men. Because vaginal hysterectomy is a viable procedure for this population, it should be considered in surgical planning for transgender men.
View details for DOI 10.1097/AOG.0000000000001866
View details for PubMedID 28178042
Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco
2017; 95 (2): 186–89
Although many transgender men may be able to conceive, their reproductive health needs are understudied.We retrospectively reviewed charts of transgender men presenting to a clinic for sex workers to describe the proportion at risk for pregnancy, pregnancy intentions, and contraceptive use.Of 26 transgender men identified, half were at risk for pregnancy. Most desired to avoid pregnancy but used only condoms or no contraception. Two individuals desired pregnancy, were taking testosterone (a teratogen), and not using contraception.Further research is needed to explore how to best provide family planning services including preconception and contraception care to transgender men.
View details for DOI 10.1016/j.contraception.2016.09.005
View details for Web of Science ID 000392895300011
View details for PubMedID 27621044
- Transgender men and pregnancy OBSTETRIC MEDICINE 2016; 9 (1): 4–8
Lesbian, Gay, Bisexual, and Transgender Patient Care: Medical Students' Preparedness and Comfort.
Teaching and learning in medicine
2015; 27 (3): 254-263
Phenomenon: Lesbian, gay, bisexual, and transgender (LGBT) individuals face significant barriers in accessing appropriate and comprehensive medical care. Medical students' level of preparedness and comfort caring for LGBT patients is unknown.An online questionnaire (2009-2010) was distributed to students (n = 9,522) at 176 allopathic and osteopathic medical schools in Canada and the United States, followed by focus groups (2010) with students (n = 35) at five medical schools. The objective of this study was to characterize LGBT-related medical curricula, to determine medical students' assessments of their institutions' LGBT-related curricular content, and to evaluate their comfort and preparedness in caring for LGBT patients.Of 9,522 survey respondents, 4,262 from 170 schools were included in the final analysis. Most medical students (2,866/4,262; 67.3%) evaluated their LGBT-related curriculum as "fair" or worse. Students most often felt prepared addressing human immunodeficiency virus (HIV; 3,254/4,147; 78.5%) and non-HIV sexually transmitted infections (2,851/4,136; 68.9%). They felt least prepared discussing sex reassignment surgery (1,061/4,070; 26.1%) and gender transitioning (1,141/4,068; 28.0%). Medical education helped 62.6% (2,669/4,262) of students feel "more prepared" and 46.3% (1,972/4,262) of students feel "more comfortable" to care for LGBT patients. Four focus group sessions with 29 students were transcribed and analyzed. Qualitative analysis suggested students have significant concerns in addressing certain aspects of LGBT health, specifically with transgender patients. Insights: Medical students thought LGBT-specific curricula could be improved, consistent with the findings from a survey of deans of medical education. They felt comfortable, but not fully prepared, to care for LGBT patients. Increasing curricular coverage of LGBT-related topics is indicated with emphasis on exposing students to LGBT patients in clinical settings.
View details for DOI 10.1080/10401334.2015.1044656
View details for PubMedID 26158327
Sexual and Gender Minority Identity Disclosure During Undergraduate Medical Education: "In the Closet" in Medical School
2015; 90 (5): 634-644
To assess identity disclosure among sexual and gender minority (SGM) students pursuing undergraduate medical training in the United States and Canada.From 2009 to 2010, a survey was made available to all medical students enrolled in the 176 MD- and DO-granting medical schools in the United States and Canada. Respondents were asked about their sexual and gender identity, whether they were "out" (i.e., had publicly disclosed their identity), and, if they were not, their reasons for concealing their identity. The authors used a mixed-methods approach and analyzed quantitative and qualitative survey data.Of 5,812 completed responses (of 101,473 eligible respondents; response rate 5.7%), 920 (15.8%) students from 152 (of 176; 86.4%) institutions identified as SGMs. Of the 912 sexual minorities, 269 (29.5%) concealed their sexual identity in medical school. Factors associated with sexual identity concealment included sexual minority identity other than lesbian or gay, male gender, East Asian race, and medical school enrollment in the South or Central regions of North America. The most common reasons for concealing one's sexual identity were "nobody's business" (165/269; 61.3%), fear of discrimination in medical school (117/269; 43.5%), and social or cultural norms (110/269; 40.9%). Of the 35 gender minorities, 21 (60.0%) concealed their gender identity, citing fear of discrimination in medical school (9/21; 42.9%) and lack of support (9/21; 42.9%).SGM students continue to conceal their identity during undergraduate medical training. Medical institutions should adopt targeted policies and programs to better support these individuals.
View details for DOI 10.1097/ACM.0000000000000657
View details for Web of Science ID 000353879700027
View details for PubMedID 25692563
- Time for OBGYNs to Care for People of All Genders JOURNAL OF WOMENS HEALTH 2015; 24 (2): 109–11
Transgender men who experienced pregnancy after female-to-male gender transitioning.
Obstetrics and gynecology
2014; 124 (6): 1120-7
To conduct a cross-sectional study of transgender men who had been pregnant and delivered after transitioning from female-to-male gender to help guide practice and further investigation.We administered a web-based survey from March to December 2013 to inquire about demographics, hormone use, fertility, pregnancy experience, and birth outcomes. Participants were not required to have been on hormone therapy to be eligible. We used a mixed-methods approach to evaluate the quantitative and qualitative data.Forty-one self-described transgender men completed the survey. Before pregnancy, 61% (n=25) had used testosterone. Mean age at conception was 28 years with a standard deviation of 6.8 years. Eighty-eight percent of oocytes (n=36) came from participants' own ovaries. Half of the participants received prenatal care from a physician and 78% delivered in a hospital. Qualitative themes included low levels of health care provider awareness and knowledge about the unique needs of pregnant transgender men as well as a desire for resources to support transgender men through their pregnancy.Transgender men are achieving pregnancy after having socially, medically, or both transitioned. Themes from this study can be used to develop transgender-appropriate services and interventions that may improve the health and health care experiences of transgender men.
View details for DOI 10.1097/AOG.0000000000000540
View details for PubMedID 25415163
- Lesbian, Gay, Bisexual, and Transgender Health and Medical Education Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2011; 306 (21): 2326–27
Lesbian, Gay, Bisexual, and Transgender-Related Content in Undergraduate Medical Education
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2011; 306 (9): 971-977
Lesbian, gay, bisexual, and transgender (LGBT) individuals experience health and health care disparities and have specific health care needs. Medical education organizations have called for LGBT-sensitive training, but how and to what extent schools educate students to deliver comprehensive LGBT patient care is unknown.To characterize LGBT-related medical curricula and associated curricular development practices and to determine deans' assessments of their institutions' LGBT-related curricular content.Deans of medical education (or equivalent) at 176 allopathic or osteopathic medical schools in Canada and the United States were surveyed to complete a 13-question, Web-based questionnaire between May 2009 and March 2010.Reported hours of LGBT-related curricular content.Of 176 schools, 150 (85.2%) responded, and 132 (75.0%) fully completed the questionnaire. The median reported time dedicated to teaching LGBT-related content in the entire curriculum was 5 hours (interquartile range [IQR], 3-8 hours). Of the 132 respondents, 9 (6.8%; 95% CI, 2.5%-11.1%) reported 0 hours taught during preclinical years and 44 (33.3%; 95% CI, 25.3%-41.4%) reported 0 hours during clinical years. Median US allopathic clinical hours were significantly different from US osteopathic clinical hours (2 hours [IQR, 0-4 hours] vs 0 hours [IQR, 0-2 hours]; P = .008). Although 128 of the schools (97.0%; 95% CI, 94.0%-99.9%) taught students to ask patients if they "have sex with men, women, or both" when obtaining a sexual history, the reported teaching frequency of 16 LGBT-specific topic areas in the required curriculum was lower: at least 8 topics at 83 schools (62.9%; 95% CI, 54.6%-71.1%) and all topics at 11 schools (8.3%; 95% CI, 3.6%-13.0%). The institutions' LGBT content was rated as "fair" at 58 schools (43.9%; 95% CI, 35.5%-52.4%). Suggested successful strategies to increase content included curricular material focusing on LGBT-related health and health disparities at 77 schools (58.3%, 95% CI, 49.9%-66.7%) and faculty willing and able to teach LGBT-related curricular content at 67 schools (50.8%, 95% CI, 42.2%-59.3%).The median reported time dedicated to LGBT-related topics in 2009-2010 was small across US and Canadian medical schools, but the quantity, content covered, and perceived quality of instruction varied substantially.
View details for Web of Science ID 000294542600015
View details for PubMedID 21900137