1. Write a paragraph describing the extent to which an socioecological framework incorporating issues related to social determinants has been applied to your area of research. Are there opportunities for improving our understanding of or approach to disparities in your area with a greater emphasis on a socioecological framework?
My area of research focuses on bone health in transgender youth receiving gender-affirming medical therapies. This very narrow scope of study has thus far only been described in two papers evaluating European/Dutch-speaking cohorts, where there are no discussions of socioeconomic status or other social determinants of health (race/ethnicity, insurance status, etc). My presumption is that the Dutch-speaking populations were likely homogeneous and that basic insurance was required (by law, must be provided to the pediatric population) in The Netherlands and Belgium. Mental health outcomes of transgender youth certainly include literature regarding social stigma and minority stress, but there are no data relating to skeletal health outcomes in American transgender youth, much less the particular age group of transgender youth I am interested in studying. Epidemiologic studies through population-based surveys have specifically investigated socioeconomic inequities, including measures of household income, race/ethniticity, employment status, housing status, insurance status, weight, relationship status, mental health, and smoking/alcohol status (Conron et al., Am J of Public Health 2012). Unfortunately, skeletal health was not one of the health measures that was studied. In 2016, The Lancet published a 3-part series dedicated to transgender health disparities. That being said, there are countless opportunities to study skeletal health in transgender youth receiving gender-affirming medical therapies in the context of a socioecological framework, since access to safe outdoor spaces may determine weight-bearing exercise, while access to healthy and affordable food options may determine dietary calcium and vitamin D intake, all of which are important determinants of bone health.
2. In the WHO reading, A conceptual framework for action on the structural determinants of health, the authors describe structural stratifiers (e.g. income, education, etc) and intermediary determinants such as material and psychosocial circumstances. Pick 3 of these factors (at least one structural and one intermediary). Explain why you chose the factors (might use Braveman article to provide justification) and describe how each could be an important determinant of a health outcome of your choosing. The association could be reported in published research or it could be your hypothesized relationship. Consider whether how these factors might function over the lifecourse and/or intergenerationally.
Income: Because attainment of gender-affirming medical therapy requires a financial payout, particularly for families whose insurance policies do not cover such therapies, income can influence which patients will receive adequate treatment at the optimal time. For instance, those with enough income (despite insurance rejection) would be able to pay out of pocket for puberty suppression medications, whereas those with lower incomes may not be able to afford such costs. Since gender dysphoria typically magnifies with pubertal changes of the non-affirmed gender, this would cause an imbalance in mental health outcomes between the groups, as early gender affirmation with social support and treatment revealed less mental health disparities between the groups (Olson et.al., Pediatrics 2016). Increased depression or body dysphoria may then lead to disordered eating, which has been associated with decreased bone mineral density.
Education: Empirically, higher education seems to correlate with improved understanding of gender identity and gender dysphoria in gender non-conforming youth. Additionally, we have experienced quite varied training and acceptance of our gender dysphoric youth in the Northern California school systems, such that those with more support may ultimately serve their students better than those who try to navigate the system on their own. The difference in stress and potential for disparities in mental health outcomes make education an important factor to consider, especially in bone health. Those patients who experiences less support in school (or who experience more bullying), may end up doing less weight-bearing exercise, thus again affecting bone mineral density.
Race/ethnicity: Minority populations are often more critical of gender non-conforming individuals, as evidenced by violence particularly against black transgender women. Not only would this affect mental health and self-esteem, but also life expectancy disparities may be seen amongst different racial or ethnic groups. Because transgender youth are already marginalized in society, the addition of minority status likely amplifies experienced discrimination. I would expect these minority transgender youth to have worse health status and outcomes (such as BMI) as presented in the CSDH conceptual framework chapter and Brakeman article.