Tag Archive for: barriers

Ovarian Cancer Prevention: Within Reach but Unevenly Accessible

Authors: Emily Thorlakson, BSN RN (Vancouver Coastal Health) Alexandra Lukey, PhD(c), MSN, RN (University of British Columbia, Department of Obstetrics and Gynecology)  | Editors: Romina Garcia de leon, Janielle Richards (Blog Co-Coordinators)

Published: October 4, 2024

The current state of ovarian cancer

Ovarian cancer is ranked number five in the leading causes of cancer deaths among females. Screening is a key pillar in cancer prevention, but unfortunately, there are no effective screening options for ovarian cancer. This leads to the majority of cases being diagnosed at late stages which reduces the chance of surviving ovarian cancer. Interestingly, science has shown over the last twenty years that most ovarian cancers start on the fallopian tubes and later spread to the ovaries instead of starting on the ovaries as researchers initially thought. This recent understanding has led to a new primary prevention opportunity called “opportunistic salpingectomy.”

 Can Ovarian Cancer Be Prevented?

Opportunistic salpingectomy involves removing both fallopian tubes while leaving the ovaries intact; this procedure is typically completed during another scheduled surgery. Salpingectomy has gained traction as the latest research has proven that removing the fallopian tubes significantly decreases the risk of getting the most common and deadly type of ovarian cancer, called high-grade serous ovarian cancer. The most promising evidence of this comes from a population-based cohort study of people who received opportunistic salpingectomy for cancer prevention. This study found that individuals who had this particular surgery had no cases of serous ovarian cancer and significantly fewer than expected cases of other types of ovarian cancer. Also, researchers looked at the rates of different types of cancers that we would not expect salpingectomy to impact, and the study found that rates of other cancers, such as breast and colorectal cancers, were within the expected range. Therefore, these results increased the confidence that it was salpingectomy and not other confounding factors causing the lower ovarian cancer rates.

 Is Salpingectomy Accessible to Everyone?

As salpingectomy becomes a more common procedure, we must ensure that everyone has equal access to it. Studies have already shown that geographical location, race, ethnicity, and rurality influence whether or not patients are offered opportunistic salpingectomy. For example, people who live in rural locations have less opportunity to be offered an opportunistic salpingectomy. Lack of equity is evident in research, as a study discovered that Black females were nearly half as likely to receive opportunistic salpingectomy in contrast to tubal ligation when sterilization was being done at the same time as a caesarian section. So, while they received permanent contraception, they did not receive the full preventative benefit of salpingectomy. Barriers to salpingectomy are compounded further by healthcare provider bias, lack of insurance coverage, low awareness or lack of healthcare resources.

Equity regarding salpingectomy is further complicated by the history of injustices and reproductive violence, such as forced and coerced sterilization of immigrants, Black, Latina, and Indigenous people; people with disabilities; and people with chronic medical conditions. For opportunistic salpingectomy to be available and equitably accessible to everyone, we must face the root of the problem by getting researchers, clinicians, and policymakers to address historical injustices while maintaining patient autonomy.

 How Can We Make Opportunistic Salpingectomy More Accessible?
  • Understand Barriers in Rural Areas: Identify and address challenges in rural and remote areas to patients who want opportunistic salpingectomy.
  • Partner with Indigenous Communities: Collaborate with Indigenous leaders to have culturally safe discussions about ovarian cancer prevention.
  • Knowledge Mobilization: Provide education and bias training for healthcare providers to ensure they offer this option fairly to all patients.

Unveiling the Gap: Understanding Heart Disease in Women

Authors: Najah Adreak, MD, MSc in Surgery, University of British Columbia | Editors:  Romina Garcia de leon and Shayda Swann

Published: February 16th, 2024

Have you heard that heart disease is a man’s disease? In fact, heart disease is the leading cause of death for women worldwide. Since 2015, Canada and other nations have reported an increase in female deaths from heart disease, highlighting the urgent need for comprehensive understanding and targeted interventions. In Canada, every 20 minutes, one woman dies from a heart attack,  every 7 minutes one woman is diagnosed with heart disease, and women are 7x more likely to die of cardiovascular disease than breast cancer. Heart and vascular disease stand as the leading causes of hospitalization and premature death among women in Canada, affecting one in three women globally. Despite these alarming figures, women remain understudied, underdiagnosed, and under-treated, with healthcare providers often unaware of their unique risk factors and atypical presentation of heart and vascular disease. 

How Heart Disease Differs in Women: Unveiling the Discrepancies

The distinct nature of heart disease in women compared to men emphasizes the need for specialized attention. Factors such as different symptoms, risk factors, and causes necessitate unique diagnostic and treatment approaches.

Heart attacks in women often go unrecognized. The Hollywood-style chest pain:” Chest-clutching, crushing pain’’ may not be the predominant symptom, with women more likely to present with 3+ symptoms, including jaw, neck, arm, or back pain, excessive sweating, shortness of breath, stomach discomfort, and more. Downplaying symptoms and attributing them to non-heart-related issues can lead to misdiagnosis or underdiagnosis. Proactively seeking medical help is important to ensure proper diagnosis and treatment. 

Did you know that the early signs of heart attack are missed in 78% of women, especially if they are young or come with less common symptoms? Women and their doctors can be slow to identify the signs and symptoms of a heart event. According to a study published in The New England Journal of Medicine in 2000, women are 7 times more likely to be sent back home from the ER while having a heart attack, when compared to men. 

It is imperative to also acknowledge the often overlooked burden placed on women due to caregiver responsibilities and the strain arising from juggling work and household duties. Women — particularly younger women — may have their signs attributed to anxiety, heartburn, or other “female” issues and are less likely to get immediate treatment.

 

Causes of Heart Disease in Women: Beyond the Basics

Heart disease can manifest differently in women and men, presenting with various types. 

Women, in particular, are more susceptible to distinct conditions, such as a tear in the large blood vessels of the heart (spontaneous coronary artery dissection, SCAD), tightening of the large heart blood vessels that restrict blood flow (coronary vasospasm), small vessel disease (microvascular dysfunction), weakened heart due to a stressful event (Takotsubo cardiomyopathy), and weakened heart during or after pregnancy (peripartum cardiomyopathy). The prevalence of SCAD, for instance, is notably higher in women, making up to 35% of heart attacks in women under 50. Notably, smoking, diabetes, high blood pressure, and a family history of heart disease serve as notable warning signs specifically for women. For instance, women living with diabetes are 3x more likely to die from heart disease compared to men. 

Several unique risk factors contribute to an elevated risk of heart disease in women, including specific pregnancy complications such as premature birth, diabetes or hypertension during pregnancy, and preeclampsia. Additionally, early menopause, polycystic ovary syndrome, and systemic inflammatory and autoimmune disorders like rheumatoid arthritis and lupus can increase the risk. Indigenous women in Canada and those from particular racial and ethnic groups such as South Asian, Chinese, black and Afro-Caribbean descent experience higher rates of heart disease and poorer outcomes compared to Caucasian Canadians. They are also at a higher risk of cardiovascular disease. 

 

Empowering Women: Mitigating Heart Disease Risks

Despite the concerning statistics, more than 80% of risk factors for heart and vascular diseases can be prevented through proactive measures:

  • Be Active and Keep Moving: Regular physical activity is crucial for maintaining heart health. Check this guideline for more 
  • Eat a Variety of Nutritious Foods
  • Manage Stress
  • Live Free from Commercial Tobacco and Vaping
  • Limit Alcohol and Substance Misuse
  • Get Regular Health Checkups

Wear Red Canada: A Collective Effort for Women’s Heart Health

In 2018, the Canadian Women’s Heart Health Alliance was established to transform clinical practice and enhance collaborative action on women’s cardiovascular health in Canada. The annual Wear Red Canada awareness campaign, set on February 13, aims to improve heart health for women of all ages.

Participation in Wear Red Canada is open to all, with activities ranging from wearing red to sharing key messages on social media using hashtags #HerHeartMatters and #WearRedCanada. Participating in virtual movement challenge events, attending webinars, and engaging with the Wear Red Canada community on Facebook are impactful ways to support women’s heart health.

Understanding the nuances of heart disease in women is essential for effective prevention and treatment strategies. By acknowledging the differences and taking proactive steps, we can work together to reduce the prevalence of heart and vascular diseases in women.

 

Beyond Boundaries: Patient and Community Engagement Reshaping Research Training

Authors: Juliette Wilson-Sanchez, MSc Student, Queen’s Cancer Research Institute, Department of Biomedical and Molecular Sciences, Queen’s University and Farzaneh Afzali, PhD Candidate, Department of Biomedical and Molecular Sciences, Queen’s University | Editors: Romina Garcia de leon, Shayda Swann (Blog Coordinators) 

As graduate students, we’re often asked how we stay motivated to continue our work after all the long nights and endless failed experiments. For us, the answer was simple – the community of patients we have met throughout our training continuously pushes us to work harder. The opportunity to see beyond the bench and hear the stories of patients affected by what we are studying provides a more in-depth perspective of our research and its impact. Over the past few years, our involvement in the local patient community, organizing events such as the Walk of Hope, has informed us of the ways in which we can support our patient community, improve the communication of our work, and tailor aspects of our research questions. These conclusions are the result of close interactions with patients within our local community. These interactions have completely shifted the way we reflect on our work – but are these interactions beneficial to the patients?

A sense of community is beneficial for cancer patients in many ways. Patients who participate in support groups have been shown to have better quality of life and improved mental health. While these support groups remain an important source of community for patients, it is important that researchers work to provide a similar sense of support to patients. Initiatives such as the Queen’s Cancer Research Institute’s Patient Engagement Network (QCRI-PEN), work towards establishing meaningful connections and bidirectional exchange of ideas between researchers and patients in the local community. 

Patient engagement in initiatives such as the QCRI-PEN aims to follow Health Quality Ontario’s guiding principles of patient engagement. Patients are invited to share their ideas, concerns, and desires in a trusted circle. This patient-centric approach cultivates a sense of ownership and empowerment in the patient community, making them active players in their healing journey. Participating in patient partnerships in research can highlight pressing needs in the patient community that supporters may not be aware of. For example, patient partners associated with Ovarian Cancer Canada participate and provide guidance on clinical and basic research funded by Ovarian Cancer Canada. Over the years, this has ensured that patients from across the country have felt included and heard by the research community. Studies, such as the Every Woman Study, are examples of the outcome of mutually beneficial partnerships between researchers and patients as their successful recruitment was mainly conducted using their own collaborative networks and social media. Through the relationships fostered by patient engagement, studies are able to reach a diverse group of patients and reach an understanding of what issues are more pertinent to that specific community. This information is essential for the improving quality of life for cancer patients; however, many cancer patients do not participate in patient-oriented research. One study demonstrated only 5% of cancer patients were actively engaged in research and only 26% expressed interest in doing so. Low participation may be a result of a lack of trust or a sense of partnership between researchers and patients, further emphasizing the importance of reinforcing community engagement in research.

Bridging the trust gap between patients and researchers requires mutual endeavor that benefits both parties. Trust in science and the researchers conducting the studies remains one of the barriers to patient participation in research. Reinforcing a trusting relationship through the creation of a supportive community is key to improving research and subsequently patient experience. One of the main elements we have observed as a key component of a supportive community is effective and reciprocal communication. Unfortunately, one of the fundamental reasons we have observed that keeps patients away from the scientific community is complicated science terminology. This barrier not only keeps patients and caretakers away from participating in research but also hinders the process of making informed decisions and unleashes more opportunities for misinformation to spread. Trainees have been shown to benefit from science communication courses that prepare them for this important aim alongside support from health advocates and communicators who can translate complicated scientific terminology to lay terms and also help bridge this gap. As ovarian cancer research trainees, we have learned how to communicate our research using accessible language to our community through the Walk of Hope and QCRI-PEN events that established connections with patients and provided us with feedback from our community. 

As research trainees, we are committed to nurturing these bonds with our patient partners. The ongoing mutual support and shared insights from a more informed and involved community empower us to serve patients more effectively. We would love to be an inspiration for fellow trainees and researchers, encouraging them to foster these meaningful connections with their communities. These moments of connection are something we hold dear, forever grateful for the enrichment they bring to our scientific journey.  

 

How Oppression in Iran Impacts Women’s Health

 

Authors: Shayda Swann, MD/PhD Candidate, University of British Columbia & Bahareh Azadi, Graduate Student, University of British Columbia

Editor: Negin (Events & Communications Specialist), Romina Garcia de leon (Blog Coordinator).

Publication date: Oct 7th, 2022

In light of the recent death of Mahsa Amini, a 22-year-old Iranian woman, while detained by Iran’s “morality police”, we sought to explore and expose the impacts of oppression in Iran on women’s health. While we could consider this issue from many vantages, we focus here on how systemic oppression impacts women’s reproductive and mental health. 

Before delving into the topic, we felt it critical to declare our positionality. Shayda is an Iranian-White MD/PhD student whose research involves women’s sexual and reproductive health. Shayda has never lived in Iran but feels a deep attachment to the country where her family originated and escaped religious persecution as members of the Baha’i Faith. 

Bahareh is an Iranian graduate student and health researcher who lived in Iran until the age of 14 before immigrating with her family to Canada in pursuit of a better future. Since immigrating, Bahareh has frequently visited Iran as a young woman where she has had several encounters with the “morality police” and has experienced first-hand the consequences of the oppressive norms of the regime. 

Impact on women’s sexual and reproductive health

Sexual and reproductive health refers to upholding rights and freedoms concerning body autonomy, reproductive choice, prevention of sexually transmitted infections, menstrual hygiene, and various other aspects of women’s lives.

A 2015 report by Amnesty International points to numerous ways in which oppression in Iran limits women’s sexual/reproductive health. Before 2012, Iran’s Family and Population Planning program met several successes, including reducing the fertility rate from 6.5 to 1.6 births per woman between 1976-2012. This program was cut in 2012, accompanied by statements from high-ranking officials that contraception should only be used with consent from the husband, thus limiting women’s autonomy. These changes, unsurprisingly, were accompanied by an increase in sexually transmitted infections among women, with a 550% increase in the prevalence of HIV from 2007 to 2015. 

In 2021, women’s reproductive choices were further restricted by the “rejuvenation of the population and support of family” bill, which severely limits women’s access to contraception. The bill further mandates the creation of materials that denounce contraception and abortion, while encouraging women to have more children. Policies such as this violate women’s body autonomy and reproductive rights, put them at higher risk for unsafe pregnancy and sexually transmitted infections, and limit their educational and occupational opportunities; therefore, these policies compound the socio-structural barriers faced by Iranian women.

Menstrual education is another important aspect of women’s reproductive health. A 2018 review found “weak knowledge” about reproductive physiology and menstrual health among Iranian girls, attributing this to sociocultural and political barriers that limit reproductive health education. Importantly, one study found that only 26% of adolescent girls report receiving adequate information about puberty.

Another study emphasized how shame and anxiety shape young women’s experience of menstruation in Iran. Shockingly, a study investigating knowledge about menstrual health among girls found that less than half (41.2%) of participants considered menstruation to be a normal physiological process, and only 1.6% had “good knowledge” about menstrual hygiene. These studies underscore a concerning lack of education and understanding of menstruation, which is likely perpetuated by culturally-rooted shame and lack of political will to incorporate this into public education, thus depriving young girls of the necessary information about their bodies.

Women’s reproductive health is further threatened by the country’s marriage laws. The legal age of marriage for girls in Iran is thirteen-years-old, or younger if allowed by the court, compared to age fifteen for boys. Child marriage is not only legal in Iran, but is tacitly encouraged through government loans, with rates of child marriage rising drastically since the introduction of these loans. In the first half of 2021, more than 16,000 Iranian girls between the ages of ten and fourteen were married. This unquestionably leads to younger pregnancy ages – which increases the risk for complications, fetal illness, and maternal mortality – along with violence and reduced educational/employment opportunities. We concur with statements by the United Nations that child marriage is a human rights violation and “can lead to a lifetime of suffering”. These are but a few examples of how oppressive and discriminatory policies threaten the health of Iranian women and girls.

Impact on women’s mental health

Mental health is defined as emotional, psychological, and social well-being. State of mind affects many aspects of life, including how people think, feel, act, deal with adversity, relate to others, and make decisions. Women living in countries affected by war and political instability have a higher risk of developing mental health disorders than men. 

A 2014 study reported that more than 25% (as high as 36% in the capital, Tehran) of Iranian women suffer from mental disorders. Iranian women are particularly vulnerable to experiencing mental health disorders due to social and cultural factors, including being of lower overall social standing, having inferior rights, and being subject to strict laws that dictate their everyday lives. They are treated as ‘second-class’ citizens and live in a patriarchal society with male-dominated attitudes and discriminatory laws that impose restrictions on their rights and personal liberties, such as laws that require women to cover their body with loose-fitting clothing and cover their hair with hijab from the age of nine-years-old. 

This law is enforced by the “morality police” and authorities have long detained, fined, and jailed thousands of women for “improper hijab.” Those who resist detention are brutally beaten. Iranian women are left to constantly assess their performance against gender norms and strict laws; being subject to this constant scrutiny renders them unable to attend to more important issues that affect their lives (Figure 1). 

 

Figure 1: Persepolis by Marjane Satrapi.

Another factor that greatly contributes to the vulnerability of Iranian women to mental health disorders is related to discriminatory labor laws and regulations that limit the financial freedom of women and their participation in the job market. 

The link between financial standing and mental health comes as no surprise. Financial instability is a major cause of stress and contributes to mental health challenges. Women who experience financial instability are at a higher risk for developing mental health disorders, such as anxiety and depression. According to a report released by the Statistical Center of Iran in 2015, although women make up over 50% of university graduates, their participation in the job market is as low as 17%. 

This is a direct consequence of domestic laws that limit women’s access to employment, in addition to placing restrictions on the types of professions that women can participate in. Further, Iranian law grants men the authority to prevent their wives from obtaining employment, and some employers go as far as to require consent from a woman’s husband. Thus, it is not surprising that the chronic exposure of Iranian women to societal pressures and their continued struggle for basic rights places them at higher risk for developing mental health disorders. 

Conclusion

Here, we chose to highlight only two of the many ways that women’s health is jeopardized by oppressive social and political circumstances in Iran. As Iranian women in health research, we felt compelled to highlight these issues, with the hopes of drawing greater awareness to these inequitable and unjust circumstances. We stand in solidarity with the women of Iran as they fight for freedom.

 

Using the Power of Sex Differences in Research: What a difference 10 years Did Not Make

Authors: Rebecca Rechlin, BSc Behavioural Neuroscience; Tallinn Splinter, BSc Biology, University of British Columbia | Editors: Negin Nia, Romina Garcia de leon  (Blog Coordinators).

Published: August 26th, 2022.

Females have been overlooked in health research for decades, and despite 10 years of advancements and improvements in knowledge, this has still not changed significantly.  Historically, there has been a long-standing bias of using males predominantly in scientific research instead of females, and as male and female health differ, this has led to health disparities for both males and females. Biological differences between females and males exist in diseases, such as in disease progression, symptomatology, and drug efficacy in many neurological and physiological diseases.

The study of these sex differences is essential for the understanding and advancement of disease treatment and precision medicine. For example women have double the risk for adverse drug reactions compared to men, which may in part be due to incorrect dosing (for instance despite both men and women being recommended the same dose for acetaminophen, an active ingredient in Tylenol, women break down the drug 60% slower than men). The biomedical and clinical research community is beginning to make corrections for these inequalities by issuing mandates for including females in clinical trials (such as by the NIH in 1993), and frameworks from funding agencies to address sex and gender in upcoming research (CIHR: Sex and Gender based Analysis (SGBA)) in 2010, and NIH: Sex As a Biological Variable (SABV) in 2016), however, there is still a long way to go to reach equality. Despite these mandates and increased approving attitudes towards these policies, the literature shows very little improvement in the analysis or examination of any potential sex differences.

Our study aimed to investigate whether and how possible sex differences were being investigated in neuroscience and psychiatry research. We looked at over 3,000 neuroscience and psychiatry studies in 2009 and in 2019 to see whether researchers were including both sexes in their studies. We found that only 53% of these studies actually included both males and females, and only 16.5% of these used an equal number of males and females throughout their study. Of the papers that used both sexes only 6% actually analyzed sex as a discovery variable. We found that the majority (60%) of the papers that used both sexes did not do any analysis by sex. This is concerning, as this means that we will lose out on important scientific discoveries if researchers are failing to embrace the power of studying potential sex differences. 

 

Figure 1: An infographic depicting the change in percentages of total papers sampled reporting studies in 2009 and 2019 that used both sexes, a single sex, omitted sex, papers reporting studies that used an optimal design or analyses for the discovery of possible sex differences irrespective of discipline. Reprinted with permission from Rechlin et al. 2022

It is important to note that biology sex and gender are two different things, and neither one is binary. Sex refers to the biological and physiological attributes of females and males, whereas gender is a psychosocial construct that includes one’s gender identity, and the norms and expectations set out by society. In our analysis we focused on studies using males and females (or sex) in rodents, humans and in research using cell lines, but the study of gender differences is also important to study and examine in regards to disease and treatments.

However studying sex differences, while important is not the only path towards equitable findings and discoveries in both men and women’s health research. With that in mind we found that although 27% of all studies in 2019 were conducted in males, only 3% were in females only! That means there were 9x more studies in males than in females! This greater focus on male health likely contributes to the health disparity and contributes to the historical male bias in assuming females and males are the same. Single sex studies are still essential for the discovery of sex-specific diseases/conditions such as prostate cancer in males and cervical conditions in females. Females specific factors, such as pregnancy and menopause, contribute to health outcomes and disease risk. For example, depression has a higher prevalence in women than men, and the risk of depression is largely increased during perimenopause and during the postpartum period.

So what can we do to improve these disparities? For starters, researchers need to actually analyze their data by using sex as a factor (or discovery variable). This essentially means including sex as one of the independent variables of the study (and not just controlling for it), allowing for the discovery of potential sex differences. It is also important for researchers to use a balanced and consistent study design, meaning they need to use both males and females consistently and in relatively equal numbers throughout their study. And even if they don’t find any sex differences, then the paper should make that statement with supporting statistics and a table to show the means and variation of the dependent variables by sex. This information of no sex differences is just as important as the discovery of them.

For funding agencies, one solution is to have funding dedicated specifically for SABV and SGBA proposals and not as a supplement to regular funding. More training modules from funders or scholarly organizations with an SABV focus may help, however, enticing researchers to explore the influence of sex and gender in their data may be a more fruitful approach. If journals, especially those with higher visibility, adopt calls for papers using sex and gender-based analyses this may serve as a catalyst to ensure more researchers consider possible sex differences and further promote the notion that this research is important to publish. Since we published our paper – Nature journals have committed to ensuring sex and gender are considered in their study design, by requiring authors to state how and why sex/gender was considered, or to state why it was not. If implemented as intended, this is a good first step to increase the amount of studies considering sex and gender in their analysis, and may be a great leap towards fixing these health disparities. 

 

Barriers in Transgender Research

Author: Keila Turino Miranda, BSc Honours in Pharmacology, University of Alberta, Twitter: @keila_turino | Editors: Alex Lukey and Arrthy Thayaparan (Blog Coordinators) 

Published: October 29th, 2020

The transgender community is a growing and underserved population estimated to reach over one million in the USA alone. In comparison to their cis-counterparts, where sex (biological attributes) and gender (socially constructed roles, behaviours, expressions and identities) align, transgender individuals experience gender dysphoria. Gender dysphoria is defined as a persistent feeling that an individual’s biological sex does not match their gender identity. As a result, transgender individuals experience severe distress, which significantly impairs their ability to function in society. This condition occurs on a spectrum, where transgender individuals are at the extreme end. This clinical diagnosis results in gender-affirming hormone therapy initiation, where feminization or masculinization goals are initiated. For transgender women, gender-affirming hormone therapy consists of the use of exogenous synthetic estrogens often in conjunction with anti-androgens to promote feminization (breast growth, decreased facial and body hair, genital atrophy, etc.) and minimize the effects of endogenous androgens like testosterone (deepening of the voice, differential distribution of body fat and muscle).

Protocols for Transgender Care

Estrogen gender-affirming hormone therapy formulation, dose, administration route, and co-administration with anti-androgens vary on individual goals for transitioning. Higher doses may be used for a more pronounced transitioning, while lower doses may be used if the individual is predisposed to other health complications. Additionally, the administration route may vary based on personal preference or recommendation by the health care practitioner. An example of this is seen in the preference for non-oral (transdermal patch, intravenous injection, etc.) estrogen gender-affirming hormone therapy over oral routes. This preference is a direct result of experimental data in cis-women showing that oral estrogen therapy, whether for contraceptive or postmenopausal use, is associated with an increased cardiovascular risk compared to non-oral estrogen. As a result, transgender women over the age of 45 or with a predisposition to cardiovascular disease are prescribed non-oral forms of estrogen to minimize risk. However, no current research suggests that this finding is also consistent or applicable to transgender women. Therefore, protocols for the care of transgender women have been modelled after research done in cis-women populations. However, this can become problematic as these two populations differ by biological attributes, societal pressures and other factors. Whether or not this is appropriate can only be determined through further research into gender-affirming hormone therapy routes of administration.

Current Research in the Transgender Field

Transgender women face healthcare disparities and have higher rates of substance use disorders, depression, anxiety and suicidality. Moreover, transgender women receiving gender-affirming hormone therapy are disproportionally affected by cardiovascular disease. Despite the growing number of the transgender population and the increased prevalence of gender-affirming hormone therapy use, research outside of HIV prevalence is limited. A newly published study on HIV prevention reported the positive impact greater social support in discussing HIV-related issues has on HIV prevention knowledge. These results point to the growing body of thought regarding minority stress. Stigmatized minority groups, such as the transgender population, show chronically elevated levels of stress. In addition to the limited research seen in transgender health, there is a lack of acknowledgement of minority stress and its implications on disease progression.

Barriers in Transgender Research 

As an up-and-coming field, transgender research is limited by its heterogeneity in terminology and study quality. Researchers in this field must often consider the variability and advancement of the use of transgender terminology in active avoidance of transphobia. For example, outdated terms such as she-male, cross-sex and trans-sexual are often seen in previous literature, and Alberta Health Services contraindicates its use. Additionally, systematic reviewers in the field must consider these terms to capture relevant transgender research adequately. 

As previously discussed, there is great variability in gender-affirming hormone therapy dose, formulation and administration route. As a result, there is significant heterogeneity in available studies, which is a barrier for appropriate quantification of their effects on transgender health and disease progression. Route of gender-affirming hormone therapy administration is postulated as partly responsible for this as the pharmacokinetics (drug absorption, distribution, metabolism and excretion) and pharmacodynamics (drug action and mechanism) vary. Pharmacokinetics is an important consideration as oral and non-oral therapies are subjected to differential levels of metabolism, total systemic dose, excretion rates, and other variables, which affect their drug actions and mechanism (pharmacodynamics). These are vital considerations as drug interactions affect disease progression, and in long term cases, morbidity and mortality. 

In addition to experimental group variability, there are also inappropriate control groups, thus serving as an additional barrier. The psychological benefits provided by gender-affirming hormone therapy renders the use of placebo groups unethical. Researchers are limited to recruiting transgender individuals who have not initiated gender-affirming hormone therapy in search of an appropriate control. Although it would be unlikely to recruit these individuals and abstain from therapy initiation throughout the study, this would provide an appropriate control group as these individuals would share the same gender-identity. Additionally, researchers may opt to use cis-men as a sex (biological attributes) control. With this, studies looking to compare morbidity and mortality of diseases would be better equipped to assess transgender health as it pertains to gender-affirming hormone therapy use.

Cross-sectional studies aiming to obtain estimates of disease incidence and prevalence are limited by the inadequate collection of gender identity information in clinics and national surveys. This further prevents accurate and up-to-date epidemiological analysis of transgender health and serves as a further barrier for researchers and clinicians looking to address this population’s health adversities.

Future Directions 

Listed research barriers should be addressed through appropriate stratification of gender-affirming hormone therapy by dose, formation, administration route, and use of anti-androgens. Additionally, the implementation of appropriate control groups, cis-men and/or transgender women without therapy, is essential for adequate quantification of disease progression, morbidity and mortality. These modifications, accompanied by large cohort studies with sufficient follow-up, will allow for the advancement of clinical understandings and protocols.  Lastly, practicing clinicians caring for transgender patients should appreciate gender-affirming hormone therapy’s psychological benefits when considering the potential risks associated.

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