Purpose: This study aimed to evaluate histological alterations and androgen receptor (AR) expression within breast tissue associated with masculinizing gender-affirming hormone therapy (GAHT) exposure of different duration in transgender men. Methods: A retrospective review of breast histopathological specimens obtained from 81 transgender men following gender-affirming mastectomy between 2017 and 2023 was conducted. Histological features and AR expression were compared between individuals with and without prior GAHT exposure, as well as between short-term (<24 months) and long-term (≥24 months) exposure. Results: Breast tissue exposed to masculinizing GAHT showed significantly increased stromal fibrosis ( p = 0.009), and reduced prevalence of usual ductal hyperplasia ( p = 0.001) and fibrocystic changes ( p = 0.041). No significant differences in atypia or malignant lesions were observed between groups. AR expression was significantly higher in GAHT-exposed tissue ( p < 0.0001), particularly among individuals receiving therapy for ≥24 months ( p = 0.019), and was associated with a greater proportion of strong AR staining intensity ( p = 0.024). Fibrosis levels did not differ according to GAHT duration ( p = 0.838). Conclusions: Masculinizing GAHT was associated with increased AR expression, particularly with prolonged exposure. Transgender men receiving GAHT in this study did not exhibit premalignant or malignant breast changes. These findings warrant further investigation in larger prospective cohorts with a follow-up period and utilization of molecular and genetic analysis to clarify the effects of masculinizing GAHT on breast carcinogenesis.
Purpose: We examined the frequency of family rejection among transgender women sex workers with HIV in the Dominican Republic and assessed the relationship between family rejection and mental health and drug use. Methods: In this exploratory study, we analyzed cross-sectional survey data collected in 2019 as part of a mixed-methods study with transgender women sex workers with HIV (N = 100). Family rejection due to being transgender was assessed with a single-item measure of frequency of rejection with three response categories: never, sometimes, and many times. We conducted multivariate logistic regressions to examine the association between frequency of family rejection and depressive and anxiety symptoms, and recent drug use. Results: Among participants, 31% reported never being rejected by family, 36% rejected sometimes, and 33% rejected many times. Individuals who reported being rejected many times by family were significantly more likely to report depressive symptoms (adjusted odds ratio [aOR]: 3.12, 95% confidence interval [CI]: 1.10-8.81) and drug use (aOR: 3.45, 95% CI: 1.17-10.17) compared with those who reported never being rejected by family. Having experienced rejection many times was not associated with anxiety symptoms. There were no significant differences between those who reported never being rejected by family and those who reported being sometimes rejected. Conclusion: Family rejection was associated with depression and drug use among transgender women sex workers with HIV. These findings suggest that interventions focused on reducing family rejection of transgender family members could be critical for improving mental health and substance use outcomes among transgender women sex workers with HIV.
Purpose: This study was designed to explore associations between body image satisfaction and aspects of gender congruence that relate to eating attitudes and behaviors among transgender young adults. Methods: Participants' demographic data, body mass index, and ability to access gender-affirming hormones, along with the validated Body Image Scale (BIS), Family Gender Environment (FGE), and Transgender Congruence Scale (TCS) were analyzed from 82 transgender participants -24 transgender male, 27 transgender female, and 31 nonbinary individuals aged 18-26, surveyed in 2024. The primary outcome was disordered eating attitudes and behaviors as measured by the Eating Disorders Examination Questionnaire (EDE-Q) total score. Results: Forty-four percent of respondents indicated a history of eating disorders. Lower TCS total scores (OR = 0.53, p = 0.04) and higher scores on FGE exclusion and abuse subscale (OR = 2.03, p = 0.03) were associated with increased odds of reporting an eating disorder history. EDE-Q scores were associated with TCS total score (beta = -0.51; p = 0.02); the FGE scales on exclusion and abuse (beta = 0.72; p = 0.002), changing gender expression (beta = 0.62; p = 0.004), and viewing gender as a moral wrong (beta = 0.60; p = 0.002); the BIS secondary subscale (beta = 1.10; p < 0.001), and BMI (beta = 0.04; p = 0.03). Conclusions: Disordered eating attitudes and behaviors were found to be highly prevalent among a sample of the transgender population. These behaviors were heavily influenced by body image, gender congruence, negative family support, and other aspects of gender identity and affirmation.
Purpose: Facial feminization surgery (FFS) encompasses procedures aimed at modifying facial features to align with a more feminine aesthetic. While qualitative assessments of outcomes are common, quantitative evaluations remain limited. This study quantified changes in forehead, chin, and gonial angle morphology following FFS using computed tomography (CT) segmentation. Methods: Patients who underwent FFS in an academic medical center from 2020 to 2024 with pre- and postoperative CT scans were included. CT segmentations of the forehead, chin, and gonial angles were performed using Mimics software. Volume and surface area were assessed. Additional measurements included frontonasal and bossing angles for the forehead, sagittal and vertical projection for the chin, and the intergonial-interzygomatic distance ratio for the gonial angles. Paired t-tests compared pre- and postoperative measurements. Results: Eighty patients were included. Forehead volume decreased by 14.44%, surface area by 6.31%, frontonasal angle by 6.78%, and bossing angle by 25.71% (all p < 0.05). Chin volume decreased by 3.77% (p = 0.003), while surface area decreased by 2.04% (p = 0.06). Sagittal chin projection increased by 8.92% (p < 0.001), but vertical projection did not change significantly. Gonial angle volume decreased by 10.30%, surface area by 5.41%, and intergonial-interzygomatic distance ratio decreased from 0.77 to 0.76 (all p < 0.0001). Conclusion:CT segmentation provides a quantitative assessment of craniofacial changes following FFS. Significant changes in forehead, chin, and gonial angle parameters were observed. These findings provide a comprehensive quantitative description of skeletal changes following FFS and define postoperative morphometric patterns across key facial regions.
Purpose: This study aimed to assess whether transmasculine and nonbinary adolescents can make decisions about and benefit from mastectomy in a manner comparable to transmasculine and nonbinary adults. Methods: This cross-sectional matched (matched for surgery year and technique) control study was conducted between October 2023 and June 2024. It compared 16-17-year-old transmasculine and nonbinary adolescents with 18-20-year-old young adults on several aspects. Decisional conflict was assessed preoperatively, while decisional regret and treatment satisfaction were assessed postoperatively. Social support, gender appearance, chest/nipple satisfaction, mental health, and quality of life were assessed pre- and postoperatively. Results: Preoperatively, 20 adolescents and 25 young adults participated. Postoperatively, 37 adolescents and 35 young adults participated. The mean follow-up period was 2.6 (standard deviation, 0.60) years after mastectomy. No significant differences existed between age groups in any assessed aspect, either pre- or postoperatively, except that adolescents reported more social support than young adults postoperatively. Both age groups experienced low decisional conflict preoperatively, and low decisional regret and high treatment satisfaction postoperatively. Comparing preoperative (preop) and postoperative (postop) adolescents and young adults, both postop age groups reported greater gender appearance satisfaction, mental health, and quality of life compared to their preop age groups with large to medium effect sizes. Age of mastectomy was not associated with any of the postop outcomes in multivariate analyses. Conclusions: These findings support offering mastectomy to trans masculine and nonbinary adolescents from age 16 when clinically appropriate and carefully counseled.
Purpose: Drug-drug interaction (DDI) concerns between estrogen-based gender-affirming hormone therapy (E-GAHT) and antiretroviral therapy (ART) remain poorly characterized. We assessed serum estradiol concentrations in transgender women with HIV on E-GAHT and bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC) compared with transgender women without HIV on E-GAHT.Methods: This parallel-group study (2023/24) included transgender women with and without HIV taking E-GAHT (>= 2 mg/day oral 17-beta estradiol plus anti-androgen therapy) for >= 3 months. Transgender women with HIV were on suppressive ART for >= 6 months and taking or switched to BIC/TAF/FTC. Estradiol concentrations were collected at month 2 pre-dose and then 1, 2, 3, 4, 6, 8, and 24 h post-dose. Medians of estradiol maximum concentration (Cmax), time to Cmax (Tmax), and area under the curve (AUC) were compared between groups using Wilcoxon rank-sum test. The proportions of estradiol 4 h concentration (C4h) within the target range (200-735 pmol/L) were compared using Fisher's exact test.Results: Among 25 participants (10 on BIC/TAF/FTC and 15 controls), the median oral 17-beta estradiol dose was 4 mg/day (range 2-8 mg). Median estradiol Cmax and Tmax were 357.5 pmol/L and 1.5 h for BIC/TAF/FTC users and 262 pmol/L and 4 h for controls (p = 0.12 and p = 0.13, respectively). AUCs were similar between groups (p = 0.24). Of the transgender women with HIV 80% had estradiol C4h within the target range, compared with 53% of transgender women without HIV (p = 0.23).Conclusions: Estradiol concentrations were comparable between groups indicating a low likelihood of a relevant DDI, but this conclusion is limited by the small sample size.
Purpose: The goal of this study was to examine relationship and substance use correlates of condomless anal sex (CAS), a behavior associated with HIV and sexually transmitted infections (STIs), among a sample of transgender men in the United States. Methods: Secondary analyses were conducted on data from an online survey collected from November 2017 to March 2020. Recruitment occurred through social media and geosocial dating applications. The odds of CAS with casual male partners were predicted from socio-demographics, substance use, sexual behavior, pre-exposure prophylaxis (PrEP) use, relationship status, sexual agreements, and main partner identity. Results: A total of 2,231 transgender men completed the survey. Of these, 1,312 (58.8%) were single, and 919 (41.2%) were in a relationship (5.6% with a monogamous sexual agreement and 35.5% with a nonmonogamous sexual agreement). Among those in a relationship, 25.8% of those not on PrEP and 36.8% of those with a main male partner had CAS with a casual male partner. Logistic regression analyses indicated that heavy drinking (odds ratio [OR] = 1.31, p = 0.009), illicit drug use (OR = 1.98, p < 0.001), and identifying as gay (OR = 1.39, p = 0.004) were significantly associated with the odds of CAS with casual male partners. The odds of CAS with casual male partners did not differ across relationship status and sexual agreement groups (single, partnered-monogamous; partnered-nonmonogamous). Conclusions: These findings support the potential risk for HIV or STI transmission among transgender men, especially for those who are binge drinking and using illicit drugs.
Purpose: The decision to undergo feminizing genital gender-affirming surgery (gGAS) and which option to choose is complex. We aimed to develop a design-validated interactive decision aid (DA) for individuals contemplating feminizing gGAS.Methods: A series of focus groups (February 2019 to July 2022) with health care professionals (HCPs) and target population representatives was organized to inform DA development. Development consisted of four phases: (i) Defining the scope of the DA framework and content, (ii) Collecting DA content and prototyping, (iii) Validation of the DA content and framework, (iv) Usability testing and finalization of the GenderAid.Results: In total, 32 transgender women, 2 nonbinary individuals, and 15 HCPs participated in six focus groups. Three DA components were developed: (i) Information, (ii) Comparator, and (iii) Choice Compass. The DA focuses on four treatment options: no surgery (yet), orchiectomy, vulvoplasty, and vaginoplasty. The Information covers topics such as preparation for surgery, information on surgical options, aftercare, dilating and fertility. The Comparator presents arguments for and against each option, quoted directly from participants in the first person singular. The Choice Compass includes value clarification exercises (making trade-offs between treatment arguments). The DA renders a personalized summary that can guide discussions with HCPs. The concept version of the GenderAid was well received in the focus group organized to test its usability.Conclusions: The GenderAid was developed in collaboration with HCPs and community members. Early evaluation suggests that it is a promising tool to support individuals in making decisions about feminizing gGAS.
Purpose: This study aimed to compare social determinants of health, gender affirmation, sexual health resource access, and health characteristics among transgender women living with and without human immunodeficiency virus (HIV) in the Atlanta cohort of the Leading Innovation for Transgender Women's Health and Empowerment study.Methods: Participants were recruited and enrolled between March 2018 and August 2020. The baseline study visit included a socio-behavioral survey, HIV testing, and sexually transmitted infection testing. Descriptive statistics were calculated, and age- and race-adjusted logistic regression models were fit, assessing associations between participant characteristics, including social determinants of health, gender affirmation, sexual health resource access, health, and biomarker-confirmed HIV status (dependent variable).Results: Of 131 participants, 37.4% (N = 49) were living with HIV and 62.6% (N = 82) were living without HIV. Several measures of health care access and sexual health support, including having had at least one individual interaction with an outreach worker or counselor (adjusted odds ratio [aOR] 2.5, 95% confidence interval [CI]: 1.1-5.9), were positively associated with living with HIV. Adverse mental health-related experiences, including suicidal ideation (aOR: 0.3, 95% CI 0.1-0.6) and history of physical violence (aOR 0.3, 95% CI 0.1-0.7), were inversely associated with living with HIV.Conclusions: Transgender women in Atlanta with gender affirmation, health care access, and fewer adverse mental health-related experiences were more likely to be living with HIV than without HIV. Further studies are needed to explore how organizational resources allocated for people living with HIV may explain these findings and the potential implications of expanding resources to transgender women living without HIV.
Purpose: This study aimed to analyze disparities in healthcare services for Chinese transgender men across multiple dimensions: age, education level, economic status, and region.Methods: This cross-sectional study examined healthcare disparities among Chinese transgender men between November 2022 and May 2023. A structured questionnaire assessed four domains: demographics (age, education, income, and region); healthcare access; hormone therapy status and barriers; and medication practices. Participants were recruited through medical institutions and WeChat platforms, with snowball sampling used to augment recruitment. Data were analyzed using R software. Analyses employed descriptive statistics to characterize the sample and chi-square tests to evaluate group differences, with statistical significance set at p < 0.05.Results: The study revealed patterns in healthcare access and hormone therapy utilization among Chinese transgender men. Transgender men with higher education levels predominantly obtained transgender-related information through digital peer networks. Transgender men with income reported heightened concerns about medication safety, whereas those without income emphasized affordability challenges. Furthermore, transgender men in central and western China demonstrated a greater reliance on online pharmacy purchases and expressed heightened concerns regarding medication efficacy.Conclusions: Healthcare access, hormone therapy choices, and medication procurement practices among Chinese transgender men require substantial improvement. This is particularly urgent for minors, individuals without a university education, those without a stable income, and residents of central and western regions.
Purpose: This study queried if young transgender and gender-diverse (TGD) individuals designated male at birth (DMAB) could accurately self-assess testicular volume (TV) for pubertal monitoring.Methods: This was a cross-sectional study of self-identified TGD young people DMAB (age 9-18 years) who required assessment of pubertal status between May 2021 and October 2022. TV measurements with Prader orchidometers were used, followed by a satisfaction survey using questions with ordinal responses. Analytics with weighted kappa coefficients and percent agreement compared clinician exams and self-exams for TV (and corresponding Tanner stage). Descriptive statistics were used for survey items and patient demographics.Results: There was a 20% perfect agreement between self-exam and clinician exam among the 30 participants sampled (mean age = 13.7 years, mean left TV = 12.8 mL [Tanner 4], mean right TV = 12.4 mL [Tanner 4]). When measurements disagreed, 47% were off by one orchidometer bead, with 60% overestimating by one bead. There was moderately high inter-rater reliability between self-exam and clinician exam for TV (kappaw = 0.57, 95% confidence interval [CI]: 0.48-0.65) and for Tanner stage (kappaw = 0.59, 95% CI: 0.49-0.69). When surveyed, 43% of participants preferred self-exam and 53% reported positive experience in the study.Conclusions: Most participants measured TV within one bead size or Tanner stage of the clinician, with 20% perfect agreement and moderately high inter-rater reliability. Participants reported acceptability of self-exam. Participants tended to overestimate testicular size, and measurements were inaccurate for prepubertal TV sizes. Therefore, self-exams should not be used to differentiate between prepuberty and puberty.
Purpose: This study examined the perspectives of transgender and gender diverse (TGD) people on fertility preservation and future biological family building at the initiation of gender-affirming hormone therapy (GAHT), aiming to enhance counseling practices and support informed decision-making.Method: This international multicenter questionnaire study was conducted as part of the European Network for the Investigation of Gender Incongruence across four outpatient clinics in four countries. Participants completed a fertility questionnaire at the initiation of GAHT from January 2017 to June 2023.Results: Of 661 participants, 58% were assigned female at birth (AFAB) and 42% assigned male at birth (AMAB). Most received information on GAHT's effects on fertility (78%), with 36% expressing a (future) desire for parenthood, biologically or otherwise. Cryopreservation rates for people AFAB were 7% and 24% for people AMAB. The most common reason for not freezing gametes was not finding it necessary, in both people AFAB and AMAB.Conclusions: Our study shows that many TGD individuals desire to parent children. However, they do not always consider a biological relation a necessity. This partly explains the low uptake of fertility preservation.
Purpose:Gender affirmation (GA) has been associated with improved healthcare engagement and health outcomes. Given the lack of a valid tool to measure GA in healthcare settings (GAHS) among transgender women living with HIV (TWLH) in India, we tested the validity and reliability of a 4-item GAHS scale. Methods:We used baseline, 3-month, and 6-month data from a longitudinal observational cohort study among 140 TWLH. We conducted exploratory factor analysis (EFA) using baseline data to determine the underlying factor structure measuring GA, and confirmatory factor analysis (CFA) using 3-month data. We assessed group ('transgender woman' vs indigenous transfeminine identities) and longitudinal measurement invariance across three time points. Convergent validity was assessed by correlating GA scores with medical GA and social factors, discriminant validity by their correlation with baseline HIV-related stigma, and predictive validity by their correlation with mental health and antiretroviral treatment (ART) outcomes. Results:EFA indicated a single-factor structure. CFA confirmed a 4-item single-factor model with good fit (χ2=7.66 (2), p=0.02), high reliability (α=0.83), and measurement invariance. Convergent validity was supported by significant correlations between GA and social support, resilience resources, and physician trust. Discriminant validity was supported as GA scores were not correlated with internalized HIV-stigma. Higher baseline GA scores significantly predicted better 3-month ART adherence and lower anxiety, demonstrating predictive validity. Conclusion:The GAHS scale demonstrated strong psychometric properties, exhibiting good validity and reliability, making it suitable for screening or monitoring GA in healthcare settings and for research purposes. Future studies should evaluate this scale among diverse populations of transgender people.
Purpose: This study assessed the prevalence and correlates of depressive symptoms among travestis and transgender women in Rio de Janeiro, Brazil.Methods: We conducted a cross-sectional analysis of the Transcendendo cohort (2015-2023) using baseline data from travestis and transgender women aged >= 18. Depressive symptoms were evaluated using the 10-item Center for Epidemiological Studies Depression Scale score >= 10. Sociodemographics, HIV status, at-risk substance use, violence victimization, and sexual partnership characteristics were analyzed as correlates in a modified Poisson regression model with a log link and robust variance to obtain adjusted prevalence ratios (aPRs) and 95% confidence intervals (95% CIs).Results: A total of 885 participants were included, with a median age of 29 years (interquartile range = 24-38), 73.3% identified as Black/Parda, and 65.9% had more than 8 years of education. A high percentage (89.4%) screened positive for depressive symptoms. In the multivariable analysis, depressive symptoms were significantly associated with sexualized drug use in the past 6 months (aPR = 1.08; 95% CI = 1.01-1.16; p = 0.032), lifetime sexual assault (aPR = 1.05; 95% CI = 1.00-1.10; p = 0.029), and recent tobacco use (aPR = 1.05; 95% CI = 1.00-1.10; p = 0.040). Having a stable partner was associated with a lower prevalence of depressive symptoms (aPR = 0.90; 95% CI = 0.84-0.96; p = 0.002).Conclusions: This study found a high prevalence of depressive symptoms among travestis and transgender women, with correlates including sexualized drug use, sexual assault, and tobacco use. These findings highlight the need to expand mental health services, address trauma, and implement harm reduction approaches for substance use in this population.
Purpose:The rate is on the rise of transgender women choosing to have a gender-affirming vaginoplasty in the United States of America, and little is documented on postoperative recommendations to decrease complications and maximize function. This review aimed to identify the indications to incorporate pelvic floor physical therapy into the process for transgender women completing a gender-affirming vaginoplasty. Methods:Articles were gathered from CINAHL, SPORTDiscus, PubMed, and MEDLINE with keywords including "transgender," "transsexual," "gender affirmation surgery," "sex reassignment," "pelvic floor," "physical therapy," "male-to-female," and "complications." A total of 13 sources were found to be relevant to this study and included in the review. Results:Results from this literature review found that transgender women frequently have complications of urinary incontinence, prolonged pelvic pain, and neovaginal stenosis after completing vaginoplasty surgery. A case study and two retrospective studies demonstrated positive outcomes from physical therapy related to pelvic pain, dilation protocol, and urinary and bowel function. Conclusions:Minimal research shows positive outcomes following pelvic floor physical therapy program for transgender women following gender-affirming vaginoplasty. However, no true conclusions can be drawn due to lack of research comparing pelvic floor physical therapy following gender-affirming vaginoplasty with a control.
This study assessed trends and disparities in chest masculinization with and without nipple–areolar complex (NAC) reconstruction across insurance type, socioeconomic strata, geography, and time. Transgender and gender-diverse patients who underwent chest masculinization between 2016 and 2020 were identified using the Massachusetts All-Payer Claims Database. Demographics, comorbidities, and socioeconomic factors were compared between patients with and without NAC reconstruction. Among 912 patients, 638 (70.0%) underwent chest masculinization with NAC reconstruction, and 274 (30.0%) underwent chest masculinization without reconstruction. Patients undergoing NAC reconstruction were more likely to live in higher-income ZIP codes and Greater Boston. The relative proportion of chest masculinization with NAC reconstruction increased from 60.5% in 2016 to 81.0% in 2019, but declined in 2020. Publicly insured patients had lower insurer payments for NAC. This study found rising rates of chest masculinization with documented coding for NAC reconstruction, as well as socioeconomic and geographic disparities in access.
Purpose: HIV viral suppression rates are often lower among transgender and gender diverse (TGD) people compared to cisgender individuals. We sought to determine if insurance-based care coordination mitigated disparities in viral suppression for TGD individuals.Methods: We examined two tiers of care coordination (standard or health homes) from a Medicaid HIV Special Needs Plan between 2016 and 2018, which identified TGD or cisgender clients. Durable viral suppression (DVS) was defined as having at least two successive suppressed viral loads (<= 200 cc/mL) >= 90 days apart. Logistic regression estimated whether DVS was associated with gender identity, care coordination, and their interaction, adjusting for demographics and the social deprivation index.Results: There were 5893 enrollees, with a median age of 45 (range: 18-64); most were non-Hispanic (NH) Black (n = 3023, 51.3%), and few were TGD (n = 485, 8.2%) or used health homes (n = 1086, 18.4%). Being TGD was not associated with DVS; therefore, no interaction was examined. Health home enrolment (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.02, 1.39) and older age (OR: 1.01, 95% CI: 1.01-1.02) were associated with higher odds of DVS. Being NH Black (OR: 0.53, 95% CI: 0.41-0.68), Hispanic White (OR: 0.71, 95% CI: 0.54-0.93), or Hispanic Black (OR: 0.66, 95% CI: 0.49-0.90) compared with NH White and greater social deprivation (OR: 0.99, 95% CI: 0.98-0.99) were associated with lower odds of DVS.Conclusions: Structural factors were more strongly associated with DVS than gender identity. However, future research is needed to understand the remaining disparities.
Purpose: This study aimed to determine the prevalence of and factors associated with physical and sexual violence among Hijra and transgender persons in India.Methods: This cross-sectional analysis utilized data from 4964 Hijra and transgender persons across 11 Indian states from the Integrated Biological and Behavioral Surveillance Survey 2014-2015. Data were collected using cluster sampling for fixed locations and time-location sampling for mobile Hijra and transgender persons. Bivariate analysis utilizing binary logistic regression was performed to identify factors linked to each type of violence. We used stepwise logistic regression with a backward elimination approach to identify independent factors associated with physical and sexual violence. We calculated crude odds ratios and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) to assess associations between variables. All statistical analyses were carried out using STATA version 16.1.Results: The prevalence of physical and sexual violence among Hijra and transgender persons was 27.2% and 22.3%, respectively. Substance use Hijra and transgender persons who were engaged in high-risk work had higher odds of experiencing physical violence compared with those involved in traditional occupations (aOR 2.00; 95% CI 1.34-2.94, p = 0.001). Hijra and transgender persons who were divorced/widowed/others had higher odds of having experienced sexual violence compared with those who were currently married (aOR 1.78; 95% CI 1.23-2.58, p = 0.002).Conclusion: Factors associated with increased risk of physical and sexual violence against Hijra and transgender persons in India included substance use, involvement in high-risk work, inconsistent condom use, and certain relationship dynamics.
Purpose: Examining emergency department (ED) care experiences of transgender and gender expansive (T/GE) persons is critical to recognizing gaps in care, mitigating harm, and implementing gender-affirming, trauma-informed care processes. This study analyzed ED care experiences of T/GE patients and identified opportunities for improvement. Methods: Using modified grounded theory methods, qualitative interviews were conducted at two large, urban academic medical centers. Purposive sampling of adult ED patients reporting T/GE identities was employed from August 10, 2022, to February 3, 2023. Sociodemographic data were collected, and private semi-structured interviews were conducted. Qualitative outcomes included ED avoidance, past negative care experiences, perceptions of ED care, recommendations for improvement, and future likelihood of accessing ED care when needed. Thematic analysis was performed, and the Minority Stress Theory provided the framework for interpretation. Results: Of 33 patients enrolled, 20 completed interviews. Participants were 75% young adults (18-35 years), 75% White, 45% college-educated, and 60% and 30% engaged in gender-affirming hormonal and surgical treatment, respectively. Five themes emerged: ED experiences modulate levels of self-efficacy; negative experiences are frequent and contribute to avoidance; lack of clinician comfort or competence is harmful; ED care exacerbates challenges related to intersectionality, while intersectionality/plural identities can complicate ED care; and standardized institutional policies and practices are needed. Conclusion: Gender-affirming care in the ED is possible and requires intentional effort. By understanding these themes through the lens of Minority Stress Theory, we emphasize the importance of structural interventions to improve health care delivery for T/GE individuals in ED settings.
