Endocrinology Fellows' Perception of Their Confidence and Skill Level in Providing Transgender Healthcare

Objective: Both educational content and hours devoted to transgender health training of endocrinology fellows are suboptimal. The objective of this study was to assess the perspectives of endocrinology fellows on their training in transgender health.Methods: We evaluated the state of comfort and knowledge of transgender healthcare among endocrinology fellows attending Endocrine University. Surveys were administered to fellows before and after their participation in a case-based session on transgender health.Results: The majority of fellows felt that training in transgender health is important (95.9%, 189/197); however, only 58.9% reported inclusion of dedicated transgender content in their training programs. Fellows who had received transgender healthcare education, and those who had seen more transgender patients in their training, were more likely to be confident in treating patients with hormone therapy (P<.001 and P<.0001, respectively). Following the case-based session, 62.4 % of fellows reported that they would change their practice, 72.8% felt that their comfort level with transgender care had improved, and 91% felt that transgender content such as that provided in the educational session should be mandatory in endocrinology training programs. Methods most desired by fellows to improve their education included lectures from visiting professors (70.3%), participation in elective rotations (62.1%), online training modules (57.9%), and attendance at meetings with transgender topics (57.4%).Conclusion: Transgender health education of U.S. endocrinology fellows is suboptimal. Participation in a case-based session significantly increased the comfort level of endocrinology fellows in key areas of transgender health.Abbreviation: ACGME = Accreditation Council for Graduate Medical Education     

Inhospitable Healthcare Spaces: Why Diversity Training on LGBTQIA Issues Is Not Enough

In an effort to address healthcare disparities in lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, many hospitals and clinics institute diversity training meant to increase providers’ awareness of and sensitivity to this patient population. Despite these efforts, many healthcare spaces remain inhospitable to LGBTQ patients and their loved ones. Even in the absence of overt forms of discrimination, LGBTQ patients report feeling anxious, unwelcome, ashamed, and distrustful in healthcare encounters. We argue that these negative experiences are produced by a variety of subtle, ostensibly insignificant features of healthcare spaces and interpersonal interactions called microaggressions. Healthcare spaces and providers often convey heteronormative microaggressions, which communicate to LGBTQ—and, we suggest, intersex and asexual (IA)—people that their identities, experiences, and relationships are abnormal, pathological, unexpected, unwelcome, or shameful. We identify heteronormative microaggressions common to healthcare settings and specify how they negatively impact LGBTQIA patients. We argue that standard diversity training cannot sufficiently address heteronormative microaggressions. Despite these challenges, healthcare institutions and providers must take responsibility for heteronormative microaggressions and take steps to reduce their frequency and mitigate their effects on LGBTQIA care. We conclude by offering strategies for problem-solving at the level of medical education, institutional culture and policy, and individual awareness.     

Evidence-Based Curricular Content Improves Student Knowledge and Changes Attitudes towards Transgender Medicine

Objective: Previous studies have demonstrated that the addition of transgender medicine content to a medical school curriculum increased students' comfort and willingness to treat transgender patients. We aimed to demonstrate that (1) evidence-based curricular content would improve knowledge of and change attitudes towards transgender medicine, and (2) students would consider cross-sex hormone therapy a legitimate treatment option for transgender patients.Methods: Curricular content with a focus on the biologic evidence for the durability of gender identity was added to the first-year medical program at Boston University School of Medicine. Immediately before and after exposure to the content, students were presented with an assessment of their knowledge of the etiology of gender identity.Results: Immediately following exposure to the content, a significant number of students changed their answer regarding the etiology of gender identity so that the number of correct responses increased from 63% (n = 56) to 93% (n = 121) (P<.001). For transgender treatment, the number of correct responses increased from 20% (n = 56) before exposure to the content to 50% (n = 121) following exposure (P<.001).Conclusion: The addition of transgender medicine content to a medical school curriculum with a focus on the biologic evidence for a durable gender identity is an effective means of educating students about the etiology of gender identity and the appropriateness of cross-sex hormone therapy as a treatment for transgender patients.     

A Simple Curriculum Content Change Increased Medical Student Comfort with Transgender Medicine

ObjectiveA barrier to safe therapy for transgender patients is lack of access to care. Because transgender medicine is rarely taught in medical curricula, few physicians are comfortable with the treatment of transgender conditions. Our objective was to demonstrate that a simple content change in a medical school curriculum would increase students' willingness to care for transgender patients.MethodsCurriculum content was added to the endocrinology unit of the Boston University second-year pathophysiology course regarding rigidity of gender identity, treatment regimens, and monitoring requirements. All medical students received an online, anonymous questionnaire 1 month prior to and 1 month after receiving the transgender teaching. The questionnaire asked about predicted comfort using hormones to treat transgender individuals. Shifts in the views of the second-year students were compared with views of students not exposed to the curriculum change.ResultsPrior to the unit, 38% of students self-reported anticipated discomfort with caring for transgender patients. In addition, 5% of students reported that the treatment was not a part of conventional medicine. Students in the second-year class were no different than other students. Subsequent to the teaching unit, the second-year students reported a 67% drop in discomfort with providing transgender care (P<.001), and no second-year students reported the opinion that treatment was not a part of conventional medicine.ConclusionA simple change in the content of the second-year medical school curriculum significantly increased students' self-reported willingness to care for transgender patients.(Endocr Pract. 2013;19:633-637)     

A Simple Intervention Raised Resident-Physician Willingness to Assist Transgender Patients Seeking Hormone Therapy

Objective: Lack of physician knowledge about transgender medicine is a barrier to care. An intervention with medical students changed attitudes about providing transgender medical care, but it is unknown whether at the level of postgraduate education an intervention could have a similar effect. We conducted such an intervention with resident-physicians.Methods: An intervention on transgender medicine covering the durability of gender identity and hormonal treatment regimens was added to the curriculum for residents. An anonymous survey assessed the residents' knowledge and willingness to assist with hormonal therapy before and after the lecture.Results: The percent of residents who agreed that they felt sufficiently knowledgeable to assist with hormonal therapy for a female-to-male patient increased significantly, from 5% before to 76% following the lecture (χ², 24.7; degrees of freedom, 1; P<.001). The percent of residents who reported that they felt sufficiently knowledgeable to assist with hormonal therapy for a male-to-female patient increased significantly, from 5% before to 71% following the lecture (χ², 24.0; degrees of freedom, 1; P<.001). The intervention increased resident knowledge about hormonal therapy for hypogonadal men (χ², 11.4; degrees of freedom, 1; P<.001) and women (χ², 9.4; degrees of freedom, 1; P = .002). The intervention made more residents agree that gender identity has a biologic basis that remains constant (P<.001) and that hormonal and surgical therapies should be offered (P = .047).Conclusion: The lecture significantly increased residents' knowledge and willingness to assist with hormonal therapy for transgender patients.Abbreviation: PGY = postgraduate year     

Testosterone Levels Achieved by Medically Treated Transgender Women in a United States Endocrinology Clinic Cohort

Objective: Most transgender women depend on medical treatment alone to lower testosterone levels in order to align physical appearance with gender identity. The medical regimen in the United States typically includes spironolactone and estrogens. The purpose of this cross-sectional study was to assess the testosterone suppression achieved among transgender women treated with spironolactone and estrogens.Methods: Testosterone and estradiol levels were extracted from the electronic medical records of 98 anonymized transgender women treated with oral spironolactone and oral estrogen therapy at the Endocrinology Clinic at Boston Medical Center.Results: Patients starting therapy required about 9 months to reach a steady-state testosterone, with significant heterogeneity of levels achieved among patients. Patients with normal body mass index (BMI) had higher testosterone levels, whereas patients with obese BMI had lower testosterone levels throughout treatment. Stratification of patients by age or spironolactone dosage revealed no significant difference in testosterone levels achieved. At steady state, patients in the highest suppressing quartile were able to achieve testosterone levels of 27 ng/dL, with a standard deviation of 21 ng/dL. Measured serum estradiol levels did not change over time and did not correlate with dosage of estradiol administered.Conclusion: Among a cohort of transgender women treated with spironolactone and estrogen, the highest suppressing quartile could reliably achieve testosterone levels in the female range at virtually all times. The second highest suppressing quartile could not achieve female levels but remained below the male range virtually all of the time. One quartile was unable to achieve any significant suppression.Abbreviations:BMC = Boston Medical CenterBMI = body mass indexCPY = cyproterone acetateLC-MS/MS = liquid chromatography–tandem mass spectrometryQ = quartile     

Children and Adolescents with Gender Dysphoria in Israel: Increasing Referral and Fertility Preservation Rates

Objective: To describe patient characteristics at presentation, management, and fertility preservation rates among a cohort of Israeli children and adolescents with gender dysphoria (GD).Methods: We performed a retrospective chart review of 106 consecutive children and adolescents with GD (<18 years) referred to and followed at the multidisciplinary Israeli Pediatric Gender Dysphoria Clinic from March 2013 through December 2018.Results: Of the 106 patients, 10 were prepubertal (9 prepubertal transgender females), and 96 were pubertal (38 pubertal transgender females). The GD population increased 11-fold since the establishment of our clinic in 2013. The subject's median age at referral was 15.5 years (range, 4.6 to 18 years). At the time of referral, 91 (95%) of the pubertal group had completed sexual maturation in their assigned gender at birth. Thirteen (13.5%) patients had attempted suicide, and 11 (11.5%) reported having had suicidal thoughts. Fourteen (45%) pubertal transgender females and 3 (6.5%) pubertal transgender males completed fertility preservation. Gonadotropin-releasing hormone analog treatment was prescribed in 77 (80%) patients at a mean age of 15.9 ± 1.6 years. Gender-affirming hormones were prescribed in 61 (64%) patients at a mean age of 16.5 ± 1.3 years. No severe side effects were recorded. Two (2%) of the pubertal group expressed regret about medical treatment.Conclusion: Children and adolescents with GD are presenting for medical attention at increasing rates. Israeli adolescents with GD have high fertility preservation rates, perhaps attributable to cultural perspectives. Taking advantage of the option to preserve fertility can be achieved when proper counseling is both available and promoted by medical personnel.Abbreviations: GAH = gender-affirming hormone; GD = gender dysphoria; GnRHa = gonadotropin-releasing hormone analog; MHP = mental health professional     

Prolactin Levels Do Not Rise Among Transgender Women Treated With Estradiol and Spironolactone

Objective: Existing transgender treatment guidelines suggest that there is a need to monitor prolactin levels in patients receiving transfeminine hormone treatment. Also, recent studies suggest that use of cyproterone acetate as an adjunctive anti-androgen during transgender hormone treatment may elevate serum prolactin. We sought to determine whether the reported relationship between transfeminine estradiol treatment and hyperprolactinemia would be evident when the regimen used spironolactone as the adjunctive anti-androgen.Methods: Estradiol levels, testosterone levels, prolactin levels, body mass index (BMI), and prescribed spironolactone dosage were extracted from the electronic medical records of 98 de-identified transgender women treated with estrogen therapy at the Endocrinology Clinic at Boston Medical Center (BMC). Up to 6 years of data were available for some patients.Results: We found no statistically significant relationship between prolactin and any of the other measures. No estrogen dose-associated elevations in prolactin were found. None of the patients were diagnosed with prolactinoma.Conclusion: Our data suggest that there may be no significant rise in prolactin when transgender women are treated with estrogen along with spironolactone as the adjunct anti-androgen. It may be unnecessary to monitor prolactin in patients on this treatment combination.Abbreviations: BMI = body mass index; BMC = Boston Medical Center; HT = hormone therapy     

Estrogen Levels Do Not Rise With Testosterone Treatment For Transgender Men

Objective: Existing transgender treatment guidelines suggest that for transmasculine treatment, there is a possible need for estrogen-lowering strategies adjunct to testosterone therapy. Further, guidelines advocate consideration of prophylactic female reproductive tissue surgeries for transgender men to avoid the possibility of estrogen-related health risks. Despite the paucity of objective data, some transgender men seek conversion inhibitors. We sought to determine estradiol levels in transgender men treated with testosterone therapy and the change in those levels with treatment, if any.Methods: Estradiol levels were extracted from the electronic medical records of 34 anonymized transgender men treated with testosterone therapy at the Endocrinology Clinic at Boston Medical Center. Data were sufficient to observe 6 years of follow-up.Results: With increased testosterone levels in trans-gender men, a significant decrease in estradiol levels was noted. There was a significant negative correlation between testosterone levels and body mass index, which may serve to explain part of the mechanism for the fall in estradiol levels. Even though the fall in estradiol levels was significant statistically, the actual levels remained within the normal male range, even with 6 years of follow-up.Conclusion: These data suggest that when exogenous testosterone is used to achieve normal serum male testosterone levels for transgender men, it is converted to normal male levels of estradiol, with some decline in those estradiol levels that might be attributable to a fall in fat mass. There appears to be no role for aromatase conversion inhibitors or other estrogen-reducing strategies in trans-gender men.Abbreviation: BMI = body mass index     

Face-ism and Objectification in Mainstream and LGBT Magazines

In visual media, men are often shown with more facial prominence than women, a manifestation of sexism that has been labeled face-ism. The present research extended the study of facial prominence and gender representation in media to include magazines aimed at lesbian, gay, bisexual, and transgender (LGBT) audiences for the first time, and also examined whether overall gender differences in facial prominence can still be found in mainstream magazines. Face-ism emerged in Newsweek, but not in Time, The Advocate, or Out. Although there were no overall differences in facial prominence between mainstream and LGBT magazines, there were differences in the facial prominence of men and women among the four magazines included in the present study. These results suggest that face-ism is still a problem, but that it may be restricted to certain magazines. Furthermore, future research may benefit from considering individual magazine titles rather than broader categories of magazines, given that the present study found few similarities between different magazines in the same media category—indeed, Out and Time were more similar to each other than they were to the other magazine in their respective categories.     

WPA guidance on mental health and mental health care in migrants

The purpose of this guidance is to review currently available evidence on mental health problems in migrants and to present advice to clinicians and policy makers on how to provide migrants with appropriate and accessible mental health services. The three phases of the process of migration and the relevant implications for mental health are outlined, as well as the specific problems of groups such as women, children and adolescents, the elderly, refugees and asylum seekers, and lesbian, gay, bisexual and transgender individuals. The concepts of cultural bereavement, cultural identity and cultural congruity are discussed. The epidemiology of mental disorders in migrants is described. A series of recommendations to policy makers, service providers and clinicians aimed to improve mental health care in migrants are provided, covering the special needs of migrants concerning pharmacotherapies and psychotherapies.     

High Body Mass Index is A Significant Barrier to Gender-Confirmation Surgery for Transgender and Gender-Nonbinary Individuals

Objective: Transgender and gender-nonbinary individuals (TGNB) are disproportionately impacted by obesity. In addition to the associated health impact, obesity represents a significant barrier to accessing gender-confirmation surgery (GCS). The purpose of this study was to determine the prevalence of obesity among TGNB surgical candidates at an urban academic medical center and evaluate the efficacy of self-monitored weight management.Methods: The study was conducted at the Center for Transgender Medicine and Surgery at Mount Sinai in New York City. Data abstraction from a quality improvement database was completed for patients with a documented body mass index (BMI) and a GCS consult from October 2015 through February 2019. A total of 1,457 TGNB patients with a documented BMI and a GCS consult in the historical period of review were included in analysis. Data were abstracted to determine the prevalence of obesity among GCS candidates and evaluate the current default pre-operative self-monitored weight management protocol.Results: Of 1,457 TGNB patients, 382 (26%) were obese (BMI ≥30 kg/m²) at initial surgical consult. In addition, 369 (27%) were obese at a subsequent follow-up, suggesting no statistically significant change in the rate of obesity among evaluated TGNB despite self-monitored weight management (P = .5272).Conclusion: Obesity is a significant barrier to gender affirming surgery for transgender individuals. Self-monitored weight management is an unsuccessful strategy for improvement even among individuals who would be predicted to be motivated.Abbreviations: BMI = body mass index; CTMS = Center for Transgender Medicine and Surgery (at Mount Sinai); GCS = gender confirmation surgery; TGNB = transgender and gender-nonbinary     

Outness,Stigma, and Primary Health Care Utilization among Rural LGBT Populations

Background

Prior studies have noted significant health disadvantages experienced by LGBT (lesbian, gay, bisexual, and transgender) populations in the US. While several studies have identified that fears or experiences of stigma and disclosure of sexual orientation and/or gender identity to health care providers are significant barriers to health care utilization for LGBT people, these studies have concentrated almost exclusively on urban samples. Little is known about the impact of stigma specifically for rural LGBT populations, who may have less access to quality, LGBT-sensitive care than LGBT people in urban centers.

Methodology

LBGT individuals residing in rural areas of the United States were recruited online to participate in a survey examining the relationship between stigma, disclosure and “outness,” and utilization of primary care services. Data were collected and analyzed regarding LGBT individuals’ demographics, health care access, health risk factors, health status, outness to social contacts and primary care provider, and anticipated, internalized, and enacted stigmas.

Results

Higher scores on stigma scales were associated with lower utilization of health services for the transgender & non-binary group, while higher levels of disclosure of sexual orientation were associated with greater utilization of health services for cisgender men.

Conclusions

The results demonstrate the role of stigma in shaping access to primary health care among rural LGBT people and point to the need for interventions focused towards decreasing stigma in health care settings or increasing patients’ disclosure of orientation or gender identity to providers. Such interventions have the potential to increase utilization of primary and preventive health care services by LGBT people in rural areas.     

Queer in America: Citizenship for Sexual Minority Youth

Sexual minority youth face many challenges in their daily lives. This article considers the barriers that hinder their opportunities for citizenship development in 3 key developmental domains: family, faith, and education. Theoretical perspectives on sexuality and citizenship provide a lens through which to view examples of settings in which sexual minority youth have created new spaces within which to explore their identities, develop community, and create social change. These settings include online communities for lesbian, gay, bisexual, transgender, and questioning youth, and high school Gay-Straight Alliances.     

Transgender Care by Endocrinologists in the United States

Objective: Little is known about the attitudes and practice patterns of transgender care by endocrinologists. The objective of this study was to assess the knowledge, practice patterns, access, and competency among a representative sample of endocrinologists in the mid-Atlantic region of the United States.Methods: An anonymous 19-item paper survey was administered to 80 conference attendees that included 61 adult endocrinologists, 13 endocrinology fellows, 2 pediatric endocrinologists, and 4 nurse practitioners/physician assistants.Results: The participation rate was estimated to be ~80%. Sixty-three percent of endocrinology providers were willing to provide transgender care, but the majority of providers had no current transgender patients under their care. Half of providers had read the Endocrine Society's clinical practice guidelines, with a rate of 70% among those under age 40. Nonetheless, only 20% were “very” comfortable in discussing gender identity and/or sexual orientation, and 41% described themselves as “somewhat” or “very” competent to provider transgender care.Conclusion: Endocrinologists and other providers have received more education and training on transgender care within the past decade. Nevertheless, many participants have had little opportunity to care for transgender patients, and they rate their competency to do so as low. Research is needed on how to increase comfort levels regarding gender identity among those who provider care to transgender patients.     

Frequency of Discrimination,Harassment, and Violence in Lesbian,Gay Men,and Bisexual in Italy

Background

This cross-sectional study assessed the frequency of discrimination, harassment, and violence and the associated factors among a random sample of 1000 lesbian, gay men, and bisexual women and men recruited from randomly selected public venues in Italy.

Methods

A face-to-face interview sought information about: socio-demographics, frequency of discrimination, verbal harassment, and physical and sexual violence because of their sexual orientation, and their fear of suffering each types of victimization.

Results

In the whole sample, 28.3% and 11.9% self-reported at least one episode of victimization because of the sexual orientation in their lifetime and in the last year. Those unmarried, compared to the others, and with a college degree or higher, compared to less educated respondents, were more likely to have experienced an episode of victimization in their lifetime. Lesbians, compared to bisexual, had almost twice the odds of experiencing an episode of victimization. The most commonly reported experiences across the lifetime were verbal harassment, discrimination, and physical or sexual violence. Among those who had experienced one episode of victimization in their lifetime, 42.1% self-reported one episode in the last year. Perceived fear of suffering violence because of their sexual orientation, measured on a 10-point Likert scale with a higher score indicative of greater fear, ranges from 5.7 for verbal harassment to 6.4 for discrimination. Participants were more likely to have fear of suffering victimization because of their sexual orientation if they were female (compared to male), lesbian and gay men (compared to bisexual women and men), unmarried (compared to the others), and if they have already suffered an episode of victimization (compared to those who have not suffered an episode).

Conclusions

The study provides important insights into the violence experiences of lesbian, gay men, and bisexual women and men and the results may serve for improving policy initiatives to reduce such episodes.     

Disparities in Adverse Childhood Experiences among Sexual Minority and Heterosexual Adults: Results from a Multi-State Probability-Based Sample

Background

Adverse childhood experiences (e.g., physical, sexual and emotional abuse, neglect, exposure to domestic violence, parental discord, familial mental illness, incarceration and substance abuse) constitute a major public health problem in the United States. The Adverse Childhood Experiences (ACE) scale is a standardized measure that captures multiple developmental risk factors beyond sexual, physical and emotional abuse. Lesbian, gay, and bisexual (i.e., sexual minority) individuals may experience disproportionately higher prevalence of adverse childhood experiences.

Purpose

To examine, using the ACE scale, prevalence of childhood physical, emotional, and sexual abuse and childhood household dysfunction among sexual minority and heterosexual adults.

Methods

Analyses were conducted using a probability-based sample of data pooled from three U.S. states’ Behavioral Risk Factor Surveillance System (BRFSS) surveys (Maine, Washington, Wisconsin) that administered the ACE scale and collected information on sexual identity (n = 22,071).

Results

Compared with heterosexual respondents, gay/lesbian and bisexual individuals experienced increased odds of six of eight and seven of eight adverse childhood experiences, respectively. Sexual minority persons had higher rates of adverse childhood experiences (IRR = 1.66 gay/lesbian; 1.58 bisexual) compared to their heterosexual peers.

Conclusions

Sexual minority individuals have increased exposure to multiple developmental risk factors beyond physical, sexual and emotional abuse. We recommend the use of the Adverse Childhood Experiences scale in future research examining health disparities among this minority population.     

Differential Endocrine and Metabolic Effects of Testosterone Suppressive Agents in Transgender Women

Objective: Suppression of testosterone secretion and/or action in transgender women using cyproterone acetate (CPA), spironolactone, or gonadotropin-releasing hormone analogues (GA) is achieved through various mechanisms. Our objective was to characterize possible differential effects of these compounds on metabolic and endocrine variables.Methods: We conducted a historic cohort study of transgender patients treated in a tertiary referral center. A longitudinal analysis of treatment naïve patients and a cross-sectional analysis of the whole cohort at the last visit was carried out.Results: Among 126 transgender women (75 treatment-naïve), CPA was the predominant androgen suppressive therapy (70%), followed by spironolactone (17.6%), and GA (10.2%). Among those who were treatment-naïve, the increase in serum prolactin levels over baseline was greater at 3 months following CPA initiation (mean change 397 ± 335 mIU/L) than following spironolactone (20.1 ± 87 mIU/L) or GA initiation (64.6 ± 268 mIU/L; P = .0002). Prolactin levels remained higher in the CPA-treated group throughout follow-up, irrespective of estradiol levels, which were similar between the groups. A worse metabolic profile was associated with treatment with CPA than with spironolactone or GA. In the CPA compared to the spironolactone and GA groups, high-density lipoprotein-cholesterol levels were lower (47.1 ± 10.4, 54.4 ± 12.2, and 60.3 ± 13, respectively; P = .0076), while body mass index levels (24.3 ± 5, 21.7 ± 2.3, and 20.7 ± 3.1 kg/m²; P = .03), and systolic (117 ± 12.1, 109 ± 12.2, and 105 ± 13.3 mm Hg; P = .01) and diastolic (74 ± 9, 65.6 ± 5.5, and 65.4 ± 11 mm Hg; P = .0008) blood pressure levels were higher at the last visit.Conclusion: Treatment of transgender women with CPA was associated with hyperprolactinemia and a worse cardiovascular risk profile than treatment with spironolactone or GA.Abbreviations: BMI = body mass index; CPA = cyproterone acetate; E2 = estradiol; FSH = follicle-stimulating hormone; GA = gonadotropin-releasing hormone analogues; LH = luteinizing hormone     

High School Gay–Straight Alliances (GSAs) and Young Adult Well-Being: An Examination of GSA Presence,Participation, and Perceived Effectiveness

Gay–Straight Alliances (GSAs) are student-led, school-based clubs that aim to provide a safe environment in the school context for lesbian, gay, bisexual, and transgender (LGBT) students, as well as their straight allies. The present study examines the potential for GSAs to support positive youth development and to reduce associations among LGBT-specific school victimization and negative young adult well-being. The sample includes 245 LGBT young adults, ages 21–25, who retrospectively reported on the presence of a GSA in their high school, their participation in their school's GSA, and their perceptions of whether or not their GSA was effective in improving school safety. Findings revealed that the presence of a GSA, participation in a GSA, and perceived GSA effectiveness in promoting school safety were differentially associated with young adult well-being and, in some cases, buffered the negative association between LGBT-specific school victimization and well-being. Implications for future research and schools are discussed.     

Current Knowledge and Practices of Heath Care Professionals on Opioid-Induced Adrenal Insufficiency

Objective: Opioid-induced adrenal insufficiency (OIAI) is reported in up to 29% of chronic opioid users through suppression of the hypothalamus-pituitary-adrenal axis. Unrecognized adrenal insufficiency leads to increased morbidity and potentially death; thus, healthcare provider (HCP) awareness of OIAI is crucial. The aim of the present study was to assess the knowledge and current practices of HCPs regarding OIAI and to identify factors associated with decreased awareness.Methods: We carried out a cross-sectional, anonymous survey of HCPs in internal medicine specialties that prescribe or care for patients taking chronic opioids.Results: Of 91 (30%) participants who completed the survey, 51 (56%) were men and 52 (57%) were in training. Most responders were general internal medicine providers (n = 33, 36%), followed by endocrinologists (n = 13, 14%) and various other specialties (n = 45, 49%). While 61 (67%) of respondents prescribed opioids, only 17 (19%) were comfortable in their knowledge of opioid side effects. Among nonendocrine providers, 53 (68%) identified adrenal insufficiency as a known opioid-induced endocrinopathy. Compared to other providers, endocrinologists were more likely to recognize opioid-related endocrinopathies (69% versus 24%, P = .01) and to identify the correct symptoms for OIAI (38% versus 9%, P <.001). One in four nonendocrine providers reported discomfort in managing glucocorticoid replacement therapy. The majority (60%) of providers indicated that online resources and continuing medical education lectures would improve knowledge of OIAI.Conclusion: Our study identified several deficiencies in HCP knowledge of opioid-induced endocrine effects, especially in nonendocrine providers. As many symptoms of OIAI overlap with those of underlying conditions, OIAI could be potentially missed, highlighting the need to further educate providers about opioid-induced endocrinopathies.Abbreviations: ACTH = adrenocorticotropic hormone; AI = adrenal insufficiency; CME = continuing medical education; HCP = healthcare professional; OIAI = opioid-induced adrenal insufficiency