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Tuesday, July 26, 2022

Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments

Key Points

Question What are the health care experiences of adults undergoing medical and/or surgical detransition?

Findings In this qualitative study, 28 adults with heterogenous gender identities were interviewed about their experiences of detransition, including their health care encounters when discontinuing or reversing gender-affirming medical and/or surgical care. A majority of respondents reported no decisional regrets regarding prior gender-affirming interventions; however, participants frequently discussed health care avoidance, clinician stigma, and experiencing clinicians who lacked detransition-related clinical knowledge.

Meaning These findings suggest that clinicians may be insufficiently knowledgeable to meet the needs of this population, and further research and clinical guidance are required to better support people who detransition after pursuing gender-affirming health care.

Abstract

Importance Medical education, research, and clinical guidelines are available to support the initiation of gender-affirming care for transgender and nonbinary people. By contrast, little is known about the clinical experiences of those who discontinue or seek to reverse gender-affirming medical or surgical interventions due to a change in gender identity, often referred to as detransition.

Objective To examine the physical and mental health experiences of people who initiated medical or surgical detransition to inform clinical practice.

Design, Setting, and Participants Using constructivist grounded theory as a qualitative approach, data were collected in the form of in-depth interviews. Data were analyzed using an inductive 2-stage coding process to categorize and interpret detransition-related health care experiences to inform clinical practice. Between October 2021 and January 2022, individuals living in Canada who were aged 18 years and older with experience of stopping, shifting, or reversing a gender transition were invited to partake in semistructured virtual interviews. Study advertisements were circulated over social media, to clinicians, and within participants’ social networks. A purposive sample of 28 participants who discontinued, shifted, or reversed a gender transition were interviewed.

Main Outcomes and Measures In-depth, narrative descriptions of the physical and mental health experiences of people who discontinued or sought to reverse prior gender-affirming medical and/or surgical interventions.

Results Among the 28 participants, 18 (64%) were assigned female at birth and 10 (36%) were assigned male at birth; 2 (7%) identified as Jewish and White, 5 (18%) identified as having mixed race and ethnicity (which included Arab, Black, Indigenous, Latinx, and South Asian), and 21 (75%) identified as White. Participants initially sought gender-affirmation at a wide range of ages (15 [56%] were between ages 18 and 24 years). Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Participants reported divergent perspectives about their past gender-affirming medical or surgical treatments. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Medical detransition was often experienced as physically and psychologically challenging, yet health care avoidance was common. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs.

Conclusions and Relevance This study’s results suggest that further research and clinical guidance is required to address the unmet needs of this population who discontinue or seek to reverse prior gender-affirming interventions.

READ ON: Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments | Health Disparities | JAMA Network Open | JAMA Network

Prevalence of Mental Health Problems in Transgender Children Aged 9 to 10 Years in the US, 2018

Introduction

Research into the mental health of transgender and gender diverse (henceforth, transgender) young people points to concerning levels of depression, anxiety, and other mental health issues.¹^-5 Much of this research has focused on transgender young people attending specialist gender clinics¹^,3^-5 or recruited via community-based convenience sampling.² Although such studies have made important contributions to understanding the mental health of transgender young people, they have critical limitations and potential biases. Clinical samples may misestimate the prevalence and severity of mental health problems, while convenience samples may experience selection bias. Both cases lead to challenges in generalizing findings to the general population. To address these shortcomings, research using representative community samples of transgender young people is required.

Methods

This cohort study compared mental health outcomes between transgender and cisgender children aged 9 to 10 years who completed baseline assessment in the Adolescent Brain Cognitive Development study, which recruited more than 11 000 children across the US using multistage probability sampling with the aim of obtaining a representative sample of the US population. The Adolescent Brain Cognitive Development study was approved by the institutional review board at the University of California, San Diego. Parents provided informed consent and children additionally gave their assent. Using the parent-reported Child Behavior Checklist, we assessed standardized T scores for 6 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)–oriented subscales (depressive/anxiety/somatic/attention-deficit/hyperactivity disorder/oppositional defiant/conduct problems) and suicidality. Data were analyzed using Stata statistical software version 17 (StataCorp). We calculated the odds ratio using multilevel logistic regression. We did not set any arbitrary cut off defining a priori level of significance based on best practice. We have used odds ratios to report the effect size and confidence interval to report the variability of the estimate in the general population. Data were analyzed in March 2022. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Additional methods are outlined in the eMethods in the Supplement.

Results

This analysis included 7169 children and compared transgender (58 participants) and cisgender (7111 participants) children who understood and answered the question “Are you transgender?” The 4692 participants who reported not understanding this question were excluded along with 17 who did not record a response. The mean (SD) age of participants was 10.03 (0.62) years. Transgender children represented 0.8% (weighted) of respondents and for all 6 subscales recorded higher mean T scores, although these were all in the reference range and the standardized mean difference in each case was small (Table). We also determined the proportion of cisgender and transgender children who scored in the borderline or clinical range (T ≥65) for each subscale (Table). The odds ratio of transgender children being in this range was increased for all 6 subscales (range, 1.57 [95% CI, 0.50-4.91] to 3.13 [95% CI, 1.46-6.71]) as well as for suicidality (odds ratio, 5.79 [95% CI, 2.08-16.16]), although the results for attention-deficit/hyperactivity disorder and oppositional defiant problems were not statistically significant (Table).

Discussion

Previous research using clinical samples of transgender children aged 5 to 11 years⁴ reported lower rates of depression and anxiety than we observed in this cohort study. Apart from methodological differences in assessing mental health, a possible reason for this disparity is that transgender children attending specialist gender clinics are likely to have support from their families (a key protective factor for the mental health of transgender young people); in comparison, many transgender children in the general population lack parental support for their gender.

Previous studies using clinical and convenience samples of transgender adolescents had higher rates of depression and anxiety compared with our sample.¹^-3,5 This is consistent with earlier clinic-based observations that transgender children have lower rates of anxiety and depression compared with transgender adolescents,⁴ which may be explained by observations from the general population that depression and anxiety more frequently develop during adolescence.⁶

The small number of transgender participants is a limitation of our study, as is the exclusion of many children who did not understand the question on gender identity. Nevertheless, this is, to our knowledge, the first study to report rates of DSM-5–related problems using a representative population sample of transgender children. Our findings suggest that by 9 to 10 years of age transgender children already show increased susceptibility to mental health problems compared with their cisgender peers, which has important public health implications. Whether this is due to stigma, minority stress, discrimination, or gender dysphoria is unclear, but providing appropriate mental health supports to this vulnerable group is paramount.

Article Information

Accepted for Publication: June 6, 2022.

Published: July 22, 2022. doi:10.1001/jamanetworkopen.2022.23389

Corresponding Author: Kenneth C Pang, PhD, Murdoch Children’s Research Institute, 50 Flemington Rd, Parkville, VIC 3052, Australia (ken.pang@mcri.edu.au).

Author Contributions: Dr Pang and Mr Russell had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Coghill, Pang.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Russell, Pang.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Russell, Hoq, Pang.

Obtained funding: Pang.

Administrative, technical, or material support: Pang.

Supervision: Coghill, Pang.

Conflict of Interest Disclosures: Mr Russell reported being a member of the Australian Professional Association for Trans Health. Dr Coghill reported receiving personal fees from Servier, Takeda, Novartis, Oxford University Press, Cambridge University Press, and Medice outside the submitted work. Dr Pang reported being a member of the World Professional Association for Transgender Health, a member of the Australian Professional Association for Trans Health, and a member of the editorial board of the journal Transgender Health. No other disclosures were reported.

Funding/Support: Mr Russell is supported through an Australian Government Research Training Program Scholarship. No other funding relates to the study. Dr Pang is supported by funding from the Hugh Williamson Foundation, the Royal Children’s Hospital Foundation and the National Health and Medical Research Council.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References

Connolly MD, Zervos MJ, Barone CJ II, Johnson CC, Joseph CL. The mental health of transgender youth: advances in understanding. J Adolesc Health. 2016;59(5):489-495. doi:10.1016/j.jadohealth.2016.06.012 PubMed Google Scholar Crossref

Strauss P, Cook A, Winter S, Watson V, Wright-Toussaint D, Lin A., Trans-pathways: the mental health experiences and care pathways of trans young people-summary of results. Telethon Kids Institute. 2017. Accessed August 20, 2021. https://www.telethonkids.org.au/projects/past/trans-pathways/

Olson J, Schrager SM, Belzer M, Simons LK, Clark LF. Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria. J Adolesc Health. 2015;57(4):374-380. doi:10.1016/j.jadohealth.2015.04.027 PubMed Google Scholar Crossref

Holt V, Skagerberg E, Dunsford M. Young people with features of gender dysphoria: demographics and associated difficulties. Clin Child Psychol Psychiatry. 2016;21(1):108-118. doi:10.1177/1359104514558431 PubMed Google Scholar Crossref

Khatchadourian K, Amed S, Metzger DL. Clinical management of youth with gender dysphoria in Vancouver. J Pediatr. 2014;164(4):906-911. doi:10.1016/j.jpeds.2013.10.068 PubMed Google Scholar Crossref

Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602. doi:10.1001/archpsyc.62.6.593
Article PubMed Google Scholar Crossref

Staffing Patterns in US Nursing Homes During COVID-19 Outbreaks

Key Points

Question What is the association between severe COVID-19 outbreaks and US nursing home staffing patterns?

Findings In this cohort study of 2967 nursing homes in 2020, owing to increased absences and departures, there were statistically significant declines in staffing levels during a severe COVID-19 outbreak that remained statistically significantly reduced 16 weeks after the outbreak’s start. Facilities temporarily increased hiring, contract staff, and overtime to bolster staffing during outbreaks, but these measures did not fully replace lost staff, particularly certified nursing assistants.

Meaning Considerable staffing challenges suggest a potential need for policy action to ensure adequate staffing levels during nursing home outbreaks to protect resident health.

Abstract

Importance Staff absences and departures at nursing homes may put residents at risk and present operational challenges.

Objective To quantify changes in nursing home facility staffing during and after a severe COVID-19 outbreak.

Design, Setting, and Participants In this cohort study, daily staffing payroll data were used to construct weekly measures of facility staffing, absences, departures, and use of overtime and contract staff among US nursing homes experiencing a severe COVID-19 outbreak that started between June 14, 2020, and January 1, 2021. Facility outbreaks were identified using COVID-19 case data. An event-study design with facility and week fixed effects was used to investigate the association of severe outbreaks with staffing measures.

Exposures Weeks since the beginning of a severe COVID-19 outbreak (4 weeks prior to 16 weeks after).

Main Outcomes and Measures Total weekly staffing hours, staff counts, staff absences, departures, new hires, overtime and contract staff hours measured for all nursing staff and separately by staff type (registered nurses, licensed practical nurses, certified nursing assistants), facility self-reported staff shortages, and resident deaths.

Results Of the included 2967 nursing homes experiencing severe COVID-19 outbreaks, severe outbreaks were associated with a statistically significant drop in nursing staffing levels owing to elevated absences and departures. Four weeks after an outbreak’s start, around when average new cases peaked, staffing hours were 2.6% (95% CI, 2.1%-3.2%) of the mean below preoutbreak levels, despite facilities taking substantial measures to bolster staffing through increased hiring and the use of contract staff and overtime. Because these measures were mostly temporary, staffing declined further in later weeks; 16 weeks after an outbreak’s start, staffing hours were 5.5% (95% CI, 4.5%-6.5%) of the mean below preoutbreak levels. Staffing declines were greatest among certified nursing assistants, primarily owing to smaller increases in new hires of this staff type compared with licensed practical nurses and registered nurses.

Conclusions and Relevance In this cohort study of nursing homes experiencing severe COVID-19 outbreaks, facilities experienced considerable staffing challenges during and after outbreaks. These results suggest the need for policy action to ensure facilities’ abilities to maintain adequate staffing levels during and after infectious disease outbreaks.

READ / DOWNLOAD: JAMA Health Forum – Health Policy, Health Care Reform, Health Affairs | JAMA Health Forum | JAMA Network

How the intestine replaces and repairs itself

Peer-Reviewed Publication

ROCKEFELLER UNIVERSITY

Small intestine — IMAGE: A SIDE VIEW OF THE SMALL INTESTINE WITH LYMPHATIC CAPILLARIES IN YELLOW AND INTESTINAL STEM CELLS IN PINK. view more
CREDIT: ROBIN CHEMERS NEUSTEIN LABORATORY OF MAMMALIAN CELL BIOLOGY AND DEVELOPMENT AT THE ROCKEFELLER UNIVERSITY

To act as a robust barrier against pathogens while also absorbing needed nutrients, the lining of the intestines must regenerate on a daily basis to remain equal to the task. The intestine’s resident stem cells are responsible for meeting this need for constant repair and replenishment, but each stem cell faces decisions that depend on the overall conditions of the intestine and the needs of the moment. Bad decisions and poor coordination could result in intestinal diseases or cancer.

A new study suggests that stem cells are able to integrate cues from their surroundings and coordinate their behavior across the tissue through networks of vasculature in their close vicinity.

Rockefeller scientists found that lymphatic capillaries—fine vessels that transport immune cells and drain fluids from tissues—represent a signaling hub that communicates with stem cells to regulate their activity. With molecular guidance from the lymphatics, the stem cells produce daughter cells to repopulate the intestinal lining or self-renew to restock the stem cell reserve.

The findings, published in the journal Cell Stem Cell, provide new insights about primary intestinal components whose disrupted communication may contribute to intestinal disorders, such as inflammatory bowel disease. “The key to treating these diseases will be to figure out who talks to whom in this ecosystem and how we can reset the communication networks,” says Rachel Niec, a clinical scholar in the laboratory of Elaine Fuchs.

Communications in the crypt

The intestinal stem cells reside in so-called crypts, found at the base of densely packed indentations in the intestinal lining. The stem cells may renew and stay in the crypt, or differentiate into specialized cells, which then migrate out of the crypt to replenish the gut lining. “To understand how stem cells balance self-renewal with differentiation, we needed a more complete picture of crypt niches,” says Marina Schernthanner, a graduate student in the Fuchs lab.

To zoom in on the crypt, the team used a suite of techniques, including single-cell and spatial transcriptomics, which allowed them to identify cell types at specific locations and study their signaling molecules. The results showed that lymphatic capillaries, which form an intimate connection with the stem cells in the crypt, produce a number of proteins known to be important for stem cell functioning.

One previously underappreciated protein, REELIN, emerged as a top candidate for mediating communications between lymphatics and stem cells. By manipulating the amount of REELIN in lab-grown intestinal organoid cultures in some experiments and genetically suppressing it in mice in others, the researchers found that REELIN directly governs the regenerative behavior of intestinal stem cells.

The involvement of the lymphatic system in stem cell functioning is a relatively new concept. A previous study by the Fuchs team revealed that lymphatics are also closely involved with stem cells of the skin and play a key role in hair regeneration. There, however, it is the hair follicle stem cells that signal to lymphatic capillaries. By controlling their interactions with lymphatics, the stem cells synchronize hair regeneration across the tissue. “This suggests that lymphatics may be a conserved feature of stem cell niches, but their relationship to stem cells are likely tailored around the needs of each tissue,” Niec says.

JOURNAL

Cell Stem Cell

DOI

10.1016/j.stem.2022.05.007

HKUST researchers developed nanoporous zinc electrodes that make primary alkaline zinc batteries rechargeable

Peer-Reviewed Publication

HONG KONG UNIVERSITY OF SCIENCE AND TECHNOLOGY

(From left) Prof. Chen Qing and his research group members Dr. Li Liangyu (postdoctoral fellow) and Xiao Diwen (PhD student) at the lab of HKUST Energy Institute. On the lab bench is a set-up for fabricating the nanoporous zinc metal electrode. — IMAGE: (FROM LEFT) PROF. CHEN QING AND HIS RESEARCH GROUP MEMBERS DR. LI LIANGYU (POSTDOCTORAL FELLOW) AND XIAO DIWEN (PHD STUDENT) AT THE LAB OF HKUST ENERGY INSTITUTE. ON THE LAB BENCH IS A SET-UP FOR FABRICATING THE NANOPOROUS ZINC METAL ELECTRODE. view more
CREDIT: HKUST

A research team at The Hong Kong University of Science and Technology (HKUST) has developed a new electrode design that is set to enable the rechargeability of alkaline zinc batteries, one of the most common types of non-rechargeable batteries used in our daily lives, shedding light on a wider application of rechargeable batteries.

Batteries are ever important in the age of smart cities and global digitalization. Yet, a majority of batteries in the market are not rechargeable, or called primary batteries. They are disposed after a single use, an unsustainable practice that poses a serious threat to the environment.

Compared with other types of primary batteries, alkaline zinc batteries are cheap, safe, and energy-dense. They are used in many household items such as flashlights and remote controllers. Given the advantages, there is never a lack of effort from researchers worldwide trying to make alkaline zinc batteries rechargeable.

Yet, such effort has been falling short because the battery reaction of zinc is hardly reversible. When the battery is discharged, zinc particles in the zinc electrode are covered with a thick and non-uniform layer of insulating zinc oxide, losing the metal surface and electric conductivity, both necessary for the electrode to be recharged.

To tackle the issue, a research team led by Prof. CHEN Qing from the Department of Mechanical & Aerospace Engineering and Department of Chemistry at HKUST developed a nanoporous zinc metal electrode that is capable of stabilizing the electrochemical transition between zinc and zinc oxide, successfully turning an alkaline zinc-air coin cell, a type of primary battery usually found in hearing aids, into a rechargeable battery stable for over 80 hours. The team shaped zinc into curvy filaments hundreds of nanometers wide, nested in a freestanding solid with numerous, similarly narrow pores. When the battery is discharged, a thin layer of zinc oxide nucleates on the zinc filaments, preserving the metallic network and enabling the zinc electrode to return to its initial structure.

The team also tested out the nanoporous zinc electrode in alkaline nickel-zinc batteries, a kind of uncommon secondary zinc battery which normally offer 50-80 times of discharging and charging under a condition competitive against the state-of-the-art lithium-ion batteries. The result demonstrated a multi-fold increase to over 200 times.

“The needs for batteries are diverse and difficult to be met by a single technology. Zinc batteries are finding their niche. We just need to make sure that the microstructure of the zinc electrodes can withstand hundreds, and hopefully thousands, of times of discharging and charging when getting the most energy out of the batteries,” said Prof. Chen. “Our work achieves so by understanding and then designing how atoms organize themselves at the liquid-solid interface that is manifested by the nanoporous structure, which has been applied to address a range of technological challenges,” he explained.

Prof. Chen added that while a few hundred times of discharging and charging may not seem many, alkaline zinc batteries have an edge in safety and low cost, which are ideal for industrial applications such as golf carts and forklifts. They also suit emerging applications, for example, the backup power of data centers, which do not demand many times of discharging and charging but require the battery to be extremely safe.

Prof. Chen’s group has been working with industrial partners since the beginning of the research in 2018 and will continue engaging them for the commercialization of the promising technologies.

The team’s research work was recently published in Nature Communications.

Led by Prof. Chen, the team included postdoctoral fellow Dr. LI Liangyu, former research assistant Anson TSANG Yung-Chak, PhD student XIAO Diwen, former postdoctoral fellow Dr. ZHU Guoyin, as well as Prof. ZHI Chunyi from the City University of Hong Kong.

CAPTION

A 3D model of the nanoporous structure in the zinc electrode, magnified by 10,000 times for the visualization.

CREDIT

HKUS

JOURNAL

Nature Communications

DOI

10.1038/s41467-022-30616-w

ARTICLE TITLE

Phase-transition tailored nanoporous zinc metal electrodes for rechargeable alkaline zinc-nickel oxide hydroxide and zinc-air batteries