Jack L. Turban

Sox2 in the differentiation of cochlear progenitor cells.

HMG domain transcription factor, Sox2, is a critical gene for the development of cochlear hair cells, the receptor cells for hearing, but this has been ascribed to expansion of the progenitors that become hair cells. Here, we show that Sox2 activated Atoh1, a transcription factor important for hair cell differentiation, through an interaction with the 3′ enhancer of Atoh1. Binding to consensus sequences in the Atoh1 enhancer was dependent on the level of Sox2, and the extent of enhancer binding correlated to the extent of activation. Atoh1 activation by Sox2 was required for embryonic hair cell development: deletion of Sox2 in an inducible mutant, even after progenitor cells were fully established, halted development of hair cells, and silencing also inhibited postnatal differentiation of hair cells induced by inhibition of γ-secretase. Sox2 is thus required in the cochlea to both expand the progenitor cells and initiate their differentiation to hair cells.

Transgender Youth: The Building Evidence Base for Early Social Transition

ransgender youth are individuals who experience an incongruence between their gender assigned at birth T and their experienced gender identity. Such patients are increasingly coming to the attention of mental health providers, because they are subject to significant rates of depression, anxiety, and suicidality. In the past few decades, the medical community has made large strides to support these youth. After a comprehensive evaluation, clinicians can now, in conjunction with psychosocial support, offer a range of hormonal interventions to patients that help their bodies match their identities. Transgender adolescents who receive puberty blockers and cross-sex hormones, as outlined in the World Professional Association of Transgender Health Standards of Care and the 2009 Endocrine Society guidelines, have been shown to have less internalizing psychopathology after treatment. Despite clear protocols for the endocrine treatment of transgender adolescents who have reached puberty, the approach to treating prepubertal children has remained controversial. The most recent American Academy of Child and Adolescent Psychiatry Practice Parameter on Gay, Lesbian, or Bisexual Orientation, Gender Nonconformity, and Gender Discordance in Children and Adolescents published in 2012 highlighted that the evidence base for treating prepubertal transgender children at that time was nearly nonexistent, leaving practitioners with little more than their own clinical judgment. However, clinical judgment in this area varies significantly. Judgments fall primarily into 3 approaches. The first approach suggests that psychotherapeutic techniques should be instituted to help transgender children identify with their gender assigned at birth. This approach rests on the assumption that gender identity in prepubertal youth may be malleable and that psychotherapeutic interventions may promote identification with one’s gender assigned at birth, preventing the need for future medical intervention. The second approach recommends exploring gender identity with the patient, with no interventions to lessen cross-gender identification. However, this approach simultaneously advises against “social transition,” citing potential high rates of desistence in crossgender identification from childhood to adolescence, and anecdotal evidence that some transgender youth who ultimately transition back to living as their birth genders suffer distress, mostly owing to fear of peer judgment. The third approach recommends an open exploration of the child’s gender identity with no goal in sight (transgender or not) and supports social transition for those children who express a desire. This approach rests on the belief that

Psychiatric disorders, suicidal ideation, and sexually transmitted infections among post-deployment veterans who utilize digital social media for sexual partner seeking

INTRODUCTION Digital social media platforms represent outlets through which individuals may find partners for sexual encounters. Using a sample of US post-deployment military veterans, the current study evaluated the prevalence of digital sex seeking as well as clinical correlates of psychopathology, suicidal ideation, and sexually transmitted infections (STIs). METHODS Using data from a baseline telephone interview and follow-up internet-based survey, we examined the prevalence of sexual partnering via digital social media platforms in a national sample of 283 US combat veterans. RESULTS Among veterans, 35.5% of men and 8.5% of women reported having used digital social media to meet someone for sex. Individuals who reported having used digital social media to find sexual partners (DSMSP+) as compared to those who did not (DSMSP-) were more likely to be young, male, and in the Marine Corps. After adjusting for sociodemographic variables, DSMSP+ status was associated with post-traumatic stress disorder (OR=2.26, p=0.01), insomnia (OR=1.99, p=0.02), depression (OR=1.95, p=0.03), hypersexuality (OR=6.16, p<0.001), suicidal ideation (OR=3.24, p=0.04), and treatment for an STI (OR=1.98, p=0.04). CONCLUSION Among US post-deployment military veterans, DSMSP+ behaviors were prevalent, particularly among men. The association between DSMSP+ behaviors and PTSD, insomnia, depression, hypersexuality, suicidal ideation, and STIs suggest that veterans who engage in DSMSP+ behaviors should be particularly thoroughly screened and evaluated for these psychiatric concerns and counseled on the benefits of safe sexual practices.

Knowledge and attitudes toward transgender health

Hormonal interventions for transgender adolescents have become increasingly common; however, there is a paucity of research on medical student knowledge of, and attitudes toward, these interventions following didactic instruction. Furthermore, no studies have examined whether students can be aware of the literature on the mental health benefits of these treatments yet continue to find them unethical.

Potentially Reversible Social Deficits Among Transgender Youth

Recently, there has been increased attention to a putative relationship between Autism Spectrum Disorder (ASD) and gender dysphoria, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnosis for those whose gender assigned at birth does not match their gender identity. Studies have shown an over-representation of ASD symptoms among transgender youth. These studies, however, have used scales that are non-specific for ASD. These ASD symptoms may represent social deficits that are secondary to social stress and deprivation, as transgender youth suffer high rates of peer and family rejection. These social deficits may not represent true ASD and may be reversible as patients are affirmed in their gender identities and social stress is reduced.

Understanding Pediatric Patients Who Discontinue Gender-Affirming Hormonal Interventions

It is estimated that as many as 1% of American adolescents have a gender identity that is not congruent with their sex assigned at birth.1 Guidelines developed in the Netherlands and then adopted throughout the world allow clinicians to prevent physical changes of puberty with the use of gonadotropin-releasing hormone analogs (GnRHa) when the first signs of puberty have manifested, a point at which the patient’s dysphoria surrounding gender often intensifies. This may be followed with exogenous testosterone or estrogen therapy at ages as young as 14 years, but more typically at approximately 16 years of age, to more closely align the adolescent’s body with their inner sense of their gender.2,3 Despite widespread use of these treatments, there is to our knowledge currently only 1 published longitudinal study that follows up transgender adolescents into adulthood.4 In that study of 55 adolescents, psychiatric symptoms improved over the period of the protocol, and none of the adolescents changed their minds or chose to discontinue the gender affirmation process. In our clinical experience, nearly all adolescents who initiate treatment with a GnRHa maintain a transgender identity and continue hormone treatment in adulthood. Occasionally, some adolescents discontinue hormones. Here we present one of those cases, along with a discussion of how clinicians can better understand and support these youths.