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Social media use is ubiquitous among lesbian, gay, bisexual, and transgender or nonbinary (LGBT) adolescents. The time spent on LGBT sites and involvement in social justice-oriented web-based civic activities can increase exposure to heterosexist and transphobic posts, resulting in increases in depression, anxiety, and substance use. Collaborative social justice civic engagement may also increase LGBT adolescents' social support on the web, which may buffer the mental health and substance use risks associated with web-based discrimination. Drawing on the minority stress and stress-buffering hypotheses, this study aimed to test time spent on LGBT sites, involvement in web-based social justice activities, the mediating effect of web-based discrimination, and the moderating effect of web-based social support on mental health and substance use. An anonymous web-based survey conducted from October 20 to November 18, 2022, analyzed data from 571 respondents (mean age 16.4, SD 1.1 years): 125 cisgender lesbian girls, 186 cisgender gay boys, 111 cisgender bisexual adolescents, and 149 transgender or nonbinary adolescents. Measures included demographics, web-based LGBT identity disclosure, hours per week spent on LGBT social media sites, engagement in web-based social justice activities (Online Civic Engagement Behavior Construct), exposure to web-based discrimination (Online Victimization Scale), web-based social support (adapted from scales examining web-based interactions), depressive and anxiety symptoms, and substance use (the Patient Health Questionnaire modified for Adolescents; Generalized Anxiety Disorder 7-item; and Car, Relax, Alone, Forget, Friends, Trouble Screening Test). The time spent on LGBT social media sites was unrelated to web-based discrimination after civic engagement was accounted for (90% CI -0.007 to 0.004). Web-based social justice civic engagement was positively associated with social support (β=.4, 90% CI 0.2-0.4), exposure to discrimination (β=.6, 90% CI 0.5-0.7), and higher substance use risk (β=.2, 90% CI 0.2-0.6). Consistent with minority stress theory, exposure to web-based discrimination fully mediated the positive association between LGBT justice civic engagement and depressive (β=.3, 90% CI 0.2-0.4) and anxiety symptoms (β=.3, 90% CI 0.2-0.4). Web-based social support did not moderate the association between exposure to discrimination with depressive (90% CI -0.07 to 0.1) and anxiety symptoms (90% CI -0.06 to 0.1) and substance use (90% CI -0.04 to 0.01). This study highlights the importance of examining LGBT youth's specific web-based activities and the need for future research to focus on the intersectional experiences of LGBT adolescents from racial and ethnic minoritized groups through culturally sensitive questions. This study also calls for social media platforms to implement policies that mitigate the effects of algorithms that expose youth to heterosexist and transphobic messaging, such as adopting machine learning algorithms that can efficiently recognize and remove harmful content.

Background Using correct pronouns is an impactful way to establish affirming environments for transgender and nonbinary (TGNB) patients. However, physicians often report struggling with this. Objective This study set out to conduct an initial root cause analysis of factors contributing to medical students and physicians failing to use TGNB patients’ correct pronouns. Methods A 10-item Qualtrics survey was sent to medical students, residents, and physicians practicing in Central Ohio. Participants were asked to describe perceived challenges or barriers colleagues have regarding correctly using TGNB patients’ correct pronouns. A directed content analysis of participant responses was performed utilizing a fishbone diagram root cause analysis tool as a basis for conceptualizing and categorizing barriers. All coding was completed by independent reviewers utilizing a consensus reconciliation methodology. Results Of 928 survey respondents, 763 met the study inclusion criteria, of which 453 provided analyzable responses. Of these 453, attendings with five or more years of practice (32.5%) and medical students (27.4%) made up the two largest demographic categories. 1.7% of respondents identified as transgender, nonbinary, and/or genderqueer, and 64% identified as heterosexual/straight. Five core barrier categories were identified: documentation, patient care, environment, knowledge, and individuals. Sub-categories were also identified, including lack of documentation, discomfort, medical culture, lack of standardization, prejudice, and assumptions. Conclusion The study identifies important barriers to medical professionals correctly using TGNB patients’ pronouns. The root cause analysis conducted as part of this study demonstrates the necessity of multi-pronged, system-level interventions to support ensuring TGNB patients are addressed using the correct pronouns.

Abstract Background Inflammatory bowel disease (IBD) is a global healthcare problem that affects around 3 million people in the United States. Although the impact of gender-affirming hormone therapy (GAHT) on IBD severity has been studied in cisgender patients, there is currently no literature on the impact of exogenous hormone therapy (HT) in transgender and nonbinary (TGNB) individuals. Methods We conducted a retrospective chart review of TGNB adults diagnosed with IBD and treated with HT for gender dysphoria at Johns Hopkins Hospital (2015-2022). We aimed to determine whether the use of GAHT was associated with subsequent increase in IBD severity. We compared the incidence of flares before vs after GAHT. Results Twenty-two patients were analyzed. More than half (59%) of them were assigned female at birth, identified as transmen, and underwent masculinizing HT. Their median (interquartile range) age was 30 (25-36) years. More patients had Crohn’s disease compared with ulcerative colitis (13 [59.1%] vs 9 [40.9%], P = .23) with a median IBD duration of 6.2 (1.8-12.3) years. Nine (41%) patients were on biologics. Of 15 patients on HT, 8 (36.3%) experienced at least one flare. Most of them were treated with steroids (66.7%), and 6 (40%) required hospital or emergency room admission. The proportion of patients who flared after GAHT was similar to that before GAHT: 9 (60%) vs 8 (53.3%), P = 1.0. Conclusions GAHT was not associated with increased incidence of flares. Larger prospective randomized studies are needed to confirm our findings and understand the interaction between GAHT and IBD in TGNB individuals. Lay Summary This retrospective study conducted at Johns Hopkins Hospital (2015-2022) examined the impact of hormone therapy (HT) on inflammatory bowel disease (IBD) activity in transgender and nonbinary individuals. Analyzing 22 patients, we found no significant increase in IBD flares post-HT initiation.

Objectives Transgender, nonbinary, and gender expansive (TGE) persons experience pregnancies and have abortions, yet abortion care remains rooted in a gender binary, often centering the needs, experiences, and challenges of cisgender women. Despite guidance supporting gender-affirming sexual and reproductive healthcare (SRH), barriers for TGE people seeking abortions persist. We conducted an exploratory case study with key informants to understand their perception of TGE abortion seekers' needs with specific considerations for those in restrictive abortion settings. Methods Qualitative interviews focused on gender-affirming care and abortion provision were conducted with U.S.-based key informant clinicians (n = 4) who could provide powerful insights into gaps and experiences faced by TGE individuals. Participants were eligible if they currently or previously provided abortions and had experience practicing gender-affirming care. Interviews focused on informants’ perceptions of TGE patients’ needs when seeking abortions. Results Findings highlight the unique barriers TGE patients face when seeking abortions, including lack of provider knowledge, in-clinic stigmatization, and gender marginalization. It is notable that key informants who practiced in abortion-protective political environments have greater access to resources to implement gender-affirming care than those in restrictive contexts. Results are summarized in a clinical recommendations document which provides an accessible starting point for clinicians to begin building gender-inclusive abortion spaces. Conclusions It is necessary to further understand barriers facing TGE abortion seekers and integrate recommendations and emerging evidence into abortion practice. This study contributes to a growing knowledge base which emphasizes the need for inclusive abortion spaces and highlights key considerations for improving access and quality for TGE abortions seekers.

Background While research has emphasized the importance of parental support for LGBTQIA + youth wellbeing, there remains limited understanding of parental experiences with nonbinary children, particularly those prepubescent. This study aimed to explore how parents of nonbinary children ages 5–8 learn to support their child’s identity, examining initial reactions, emotional processes, supportive behaviors, societal responses, and associated challenges and rewards. Methods A qualitative study was conducted using Reflexive Thematic Analysis (RTA) within a framework of ontological relativism and epistemological constructivism. Nine parents of nonbinary children aged 5–8 from the Northeastern United States participated in semi-structured interviews lasting 60–80 min. Questions explored various aspects of parenting nonbinary children, including the child’s gender identity, parental feelings, experiences sharing the child’s identity, and challenges and rewards of raising a gender-diverse child. The research team, comprising individuals who identify as trans, genderqueer, and nonbinary, employed collaborative coding and thematic development. Results Four main themes were constructed: (1) Parents hear and support their child’s nonbinary identity , this theme highlights immediate acceptance and efforts parents make to affirm their child’s gender; (2) Parents learn about ways cisnormative society harms their child , here, parents recognize the societal pressures and barriers their children face; (3) Parents take significant and proactive steps to affirm their child , this theme documents the actions parents take to support their child in environments that invalidate their identity; and (4) Gender is just one aspect of who my child is , this theme reflects on parental insights of gender as just one part of their child’s overall personhood. Conclusions This study provides insights into the experiences of parents supporting young nonbinary children, emphasizing the importance of affirming expressed identity, the parent-child relationship, and proactive support in navigating cisnormative societal structures. Findings highlight the transformative experience of parenting nonbinary children, with parents often challenging their own preconceptions of gender and coming to more nuanced understandings. These results can inform supportive interventions and policies for nonbinary children and their families, and we hope to contribute to a growing body of research that shifts narratives towards joy, resilience, and community in trans and nonbinary experiences.

Abstract Background Transgender and nonbinary (TGNB) individuals comprise 0.5% to 0.6% of the U.S. population and face significant healthcare disparities, yet little is known about inflammatory bowel disease (IBD) in this group. We aimed to characterize IBD prevalence, comorbidities, healthcare utilization, and the impact of hormone replacement therapy (HRT) in TGNB individuals. Methods Using TriNetX, we analyzed (1) IBD prevalence among TGNB adults, (2) comparisons of IBD patients who are and who are not TGNB, and (3) comparisons of TGNB IBD patients with and without HRT. Outcomes included demographics, comorbidities, laboratory markers, healthcare encounters, IBD treatment, and cardiovascular and thrombotic events. Results Of 111 227 TGNB patients, prevalence of Crohn’s disease and ulcerative colitis was 0.508% and 0.448%, respectively, increasing with age. TGNB patients were younger (32.5 years of age vs 46.9 years of age; P < .001), exhibited higher rates of gastrointestinal and psychiatric comorbidities, and had more outpatient, emergency, and hospital visits, yet they underwent fewer endoscopies (25.7% vs 30.7% risk; P = .011) and were less likely to receive targeted IBD therapy than cisgender patients. Patients with HRT had more outpatient encounters (66.7% vs 58.2%; P = .010) and were more likely to use therapies like mesalamine (12.4% vs 7.6%; P = .021) than those without HRT. There were no significant differences in laboratory markers or thrombotic or cardiovascular events in these analyses. Conclusions TGNB IBD patients experience greater gastrointestinal and psychiatric comorbidities and receive fewer interventions overall despite greater healthcare contact. HRT was not associated with worsening disease or complications. These findings highlight critical disparities and the need for further research in this population. Lay Summary Transgender and nonbinary individuals with inflammatory bowel disease experience greater comorbidities and healthcare utilization without evidence that hormone therapy worsens disease outcomes, though they receive fewer diagnostic and treatment interventions, highlighting disparities and the need for more inclusive, equitable care.

Transgender and nonbinary (TNB) individuals face disparities in nearly every aspect of health. One factor associated with poor health outcomes in other marginalized populations is health literacy, yet no identified studies examine health literacy in TNB samples. Moreover, most health literacy frameworks focus primarily on the capacities of individual patients to understand and use healthcare information, with little attention given to provider literacy and environmental factors. In partnership with a statewide LGBTQ advocacy organization, we recruited 46 transgender and nonbinary individuals to participate in seven focus groups conducted in urban, suburban, and rural locations throughout Colorado. TNB participants consistently engaged in efforts to increase their own health literacy and that of their medical providers yet faced multiple barriers to improve care. Difficulty identifying and physically reaching care, insurance and out-of-pocket expenses, negative experiences with healthcare providers and staff, provider incompetence, discriminatory and oppressive practices, and exclusionary forms and processes emerged as barriers to enacted health literacy among participants. Conversely, facilitators of enacted healthcare literacy included positive experiences with healthcare providers and staff, and inclusive forms and processes.

Prepubertal transgender, nonbinary, and gender-diverse (TGD) children (ie, those asserting gender identity, expressing gender-role behavior outside of culturally defined norms for their sex registered at birth, or both) are presenting in greater numbers to pediatric gender clinics across the United States and abroad. A large subset of TGD children experiences gender dysphoria, that is, distress that arises from the incongruence between gender identity and sex registered at birth. A lack of consensus exists regarding care for prepubertal TGD children due, in part, to a dearth of empirical research on longitudinal developmental trajectories of gender identity, role behavior, and gender dysphoria (when present). The objective of this National Institutes of Health-funded study is to provide evidence to inform clinical care for prepubertal TGD children by establishing a US longitudinal cohort (N=248) of prepubertal TGD children and their caregivers that is followed prospectively at 6-month intervals across 18 months. At each timepoint, clinical and behavioral data are collected via web-based visit from child and caregiver reporters. Latent class analysis, among other methods, is used to identify subgroups and longitudinally characterize the gender identity and gender-role behavior of TGD children. These models will define longitudinal patterns of gender identity stability and characterize the relationship between TGD classes and mental and behavioral health outcomes, including the moderating role of social gender transition (when present), on these associations. Baseline data collection (N=248) is complete, and the identification of TGD subgroups based on gender identity and expression using latent class analysis is anticipated in 2024. The completion of all 4 waves of data collection is anticipated in July 2024, coinciding with the start of a no-cost study extension period. We anticipate longitudinal analyses to be completed by winter 2024. Through a longitudinal observational design, this research involving prepubertal TGD children and their caregivers aims to provide empirical knowledge on gender development in a US sample of TGD children, their mental health symptomology and functioning over time, and how family initiated social gender transition may predict or alleviate mental health symptoms or diagnoses. The research findings have promise for clinicians and families aiming to ensure the best developmental outcome for these children as they develop into adolescents. DERR1-10.2196/55558.

Health care education about transgender/gender-diverse (TGD) individuals is often lacking regarding the complex care of these patients. This educational research initiative aimed to assess the pedagogical impact of digital first-person narratives/storytelling (DST) on health care faculty to illuminate the particular health care needs of TGD patients. In a continuing education offering, empathy, self-knowledge, self-reflection, and bias-reduction were promoted while evaluating attitudes and beliefs of clinical faculty using a valid pre- and post- tool. Qualitative statements from volunteer faculty provided more context to their ratings and to note comfort level when thinking about teaching about the care of gender-diverse patients as well as interest in using DST with future students. This study lacked a significant change in measured attitudes and beliefs from volunteer faculty participants, but a strong articulation of greater comfort level and satisfaction with using DST as a tool and a commitment to teaching about the care of TGD patients and families. •Health care providers desire knowledge about gender dysphoria and care for transgender and gender-diverse people (TGD).•TGD patients face discrimination and bias that affects their health access and health outcomes.•First-person digital narratives can be a pedagogical approach to teach clinicians about the specific care needs of TGD people and to improve knowledge and attitudes/empathy.•Nurse practitioner, midwifery, and physician faculty interested in teaching about this care found this approach very engaging and an overall positive and effective learning experience.

Introduction Gender identity change efforts (GICE) aim to change one’s gender identity to be congruent with sex assigned at birth. Practicing conversion efforts with minors is outlawed for licensed professionals in many U.S. jurisdictions, yet it remains legal in many other jurisdictions and for religious counselors. Literature remains scant but points to a harmful role GICE may play in the lives of transgender and nonbinary (TNB) persons. We examine how GICE is associated with mental and physical wellbeing and proximal minority stressors among TNB persons. Methods Using the U.S. TransPop online survey data (2016–2018) collected from 271 TNB adults, we conducted multivariate regression models examining the association between GICE exposure and psychological distress (Kessler-6), past 30-day physical and mental health, healthcare-related stigma anticipation, and proximal stressors (i.e., negative future expectation, nondisclosure of gender identity, and internalized transphobia). Covariates included race, age, gender identity, education level, census poverty level, and sexual orientation. Results The average participant was 39 years old and identified as a transgender woman (44%) and white (69%). TNB participants with GICE exposure, on average, reported 4 points (0–23) higher psychological distress levels and 8.1 additional days with poor mental health over the past 30 days. Significantly higher healthcare stigma fears and negative expectation were also observed among GICE-exposed participants. Conclusions Findings indicate poorer mental wellbeing among GICE-exposed TNB persons who also report more healthcare-related stigma fears and negative future expectation. Policy Implications Considering the relationship between GICE exposure and poor mental wellbeing, our findings give further credence to efforts aimed at outlawing GICE.