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Background: The process of level of care (LOC) determination has been traditionally fraught with unreliability and lack of objectivity. There is a similar need for reliable objective LOC determination tools for youth in the juvenile justice systems, which have high prevalence of psychiatric disorders and unmet mental health needs and are disproportionately from minority backgrounds. The CASII has already demonstrated significant interrater reliability and validity in studies with mental health and child welfare populations. Method: In 2004 and 2005, the Tennessee CPORT team reviewed 206 youth in the juvenile justice system ages 13 and older, 92.8% male, with 37.4% Caucasian, 55.8% African American. Instruments used included the CASII, CAFAS, CBCL, YSR, TRF, and the CPORT Child and Family Indicators. Results: There was a significant correlation between all of the CASII subscales and the CAFAS Total Scores (Pearson coefficients 0.210 to 0.618). The CASII Total Score and the CASII LOC were both highly correlated to CBCL, the YSR, and the TRF total scores and sub-scales. Significant correlations between the CASII LOC were found in 10 of the 13 CPORT Child and Family Indicators, while actual LOC placement was significantly correlated with only 4 of the 13 dimensions. The actual LOC placement was significantly different than recommended CASII LOC (p < 0.0000), with the majority of recommended LOCs being lower. Conclusions: This LOC tool is demonstrating high levels of reliability and validity in different systems of care settings, including juvenile justice, child welfare, and mental health contexts. Use of the CASII could result in significant savings in resources that could be used to provide services for adolescent offenders, and in reduction in unnecessary restrictiveness of placements.

This article explores how inservice teachers articulate and challenge notions of effective teaching as part of an environment of high-stakes teacher evaluation (HSTE) in Tennessee. Drawing on data from public forum speeches at school board meetings, policy documents, and interviews, we used thematic discourse analysis to investigate how teacher effectiveness is discursively constructed by teachers. Findings demonstrate how participants drew upon competing definitions of effective teaching to build a discursive case for potential areas for improvement regarding the observation of teaching as part of HSTE policies. Because measures of teacher performance are an issue of much debate in the United States, teachers’ descriptions of the relationships between teaching evaluations, observations, professional development, and student learning are critical to understanding how to develop effective procedures for observation and evaluation. Implications for developing evaluation informed by teachers’ experiences are discussed.

Purpose of review Transgender individuals experience unique health disparities but are the subject of little focused health research. This manuscript reviews current literature on transgender medical and mental health outcomes and proposes research priorities to address knowledge gaps. Recent findings Published research in transgender healthcare consists primarily of case reports, retrospective and crosssectional studies, involving largely European settings. Challenges to US-based transgender health research include a diverse population where no single center has sufficient patient base to conduct clinical research with statistical rigor. Treatment regimens are heterogeneous and warrant study for best practices. Current research suggests increased mortality and depression in transgender individuals not receiving optimal care, and possibly a modest increase in cardiovascular risk related to hormone therapy. Current evidence does not support concerns for hormone-related malignancy risk. Summary The priorities for transgender medical outcomes research should be to determine health disparities and comorbid health conditions over the life span, along with the effects of mental health, medical, and surgical interventions on morbidity and mortality. Specific outcomes of interest based on frequency in the literature, potential severity of outcome, and patient-centered interest, include affective disorders, cardiovascular disease, malignancies, fertility, and time dose-related responses of specific interventions.

Purpose of review This article describes methodological challenges, gaps, and opportunities in US transgender health research. Recent findings Lack of large prospective observational studies and intervention trials, limited data on risks and benefits of sex affirmation (e.g., hormones and surgical interventions), and inconsistent use of definitions across studies hinder evidence-based care for transgender people. Systematic high-quality observational and interventiontesting studies may be carried out using several approaches, including general population-based, health systems-based, clinic-based, venue-based, and hybrid designs. Each of these approaches has its strength and limitations; however, harmonization of research efforts is needed. Ongoing development of evidencebased clinical recommendations will benefit from a series of observational and intervention studies aimed at identification, recruitment, and follow-up of transgender people of different ages, from different racial, ethnic, and socioeconomic backgrounds and with diverse gender identities. Summary Transgender health research faces challenges that include standardization of lexicon, agreed upon population definitions, study design, sampling, measurement, outcome ascertainment, and sample size. Application of existing and new methods is needed to fill existing gaps, increase the scientific rigor and reach of transgender health research, and inform evidence-based prevention and care for this underserved population.

Purpose: There are no large controlled studies of health disparities in transgender (TG) or gender dysphoric patients. The Veterans Health Administration (VHA) is the largest healthcare system in the United States and was an early adopter of electronic health records. We sought to determine whether medical and/or mental health disparities exist in VHA for clinically diagnosed TG veterans compared to matched veterans without a clinical diagnosis consistent with TG status. Methods: Using four ICD-9-CM codes consistent with TG identification, a cohort of 5135 TG veterans treated in VHA between 1996 and 2013 was identified. Veterans without one of these diagnoses were matched 1:3 in a case-control design to determine if medical and/or mental health disparities exist in the TG veteran population. Results: In 2013, the prevalence of TG veterans with a qualifying clinical diagnosis was 58/100,000 patients. Statistically significant disparities were present in the TG cohort for all 10 mental health conditions examined, including depression, suicidality, serious mental illnesses, and post-traumatic stress disorder. TG Veterans were more likely to have been homeless, to have reported sexual trauma while on active duty, and to have been incarcerated. Significant disparities in the prevalence of medical diagnoses for TG veterans were also detected for 16/17 diagnoses examined, with HIV disease representing the largest disparity between groups. Conclusion: This is the first study to examine a large cohort of clinically diagnosed TG patients for psychiatric and medical health outcome disparities using longitudinal, retrospective medical chart data with a matched control group. TG veterans were found to have global disparities in psychiatric and medical diagnoses compared to matched non-TG veterans. These findings have significant implications for policy, healthcare screening, and service delivery in VHA and potentially other healthcare systems.

Purpose: Transgender (TG) persons are overrepresented in prison settings and in the U.S. veteran population. Health disparities studies of large populations of transgender people involved with the criminal justice system have not been published to date. Methods: We studied a large cohort of TG veterans who received care in Veterans Health Administration (VHA) facilities during 2007-2013 (n = 4,793) and a 3:1 matched control group of veterans without known TG identification (n = 13,625). Three hundred twenty six (n = 138 TG, 188 non-TG) had received VHA services in programs designed to address the needs of justice involved (JI) veterans. We linked patients in each of the three groups to their medical and administrative data. Results: TG veterans were more likely to be justice involved than controls (2.88% vs. 1.38%; P < .0001). Compared to non-TG JI veterans, TG JI veterans were more likely to have a history of homelessness (80% vs. 67%; P < .05) and to have reported sexual trauma while serving in the military (23% vs. 12%; P < .01). Significant health disparities were noted for TG JI veterans for depression, hypertension, obesity, posttraumatic stress disorder, serious mental illness, and suicidal ideation/attempts. Conclusion: These data suggest that TG veterans experience a number of health risks compared to non-TG veterans, including an increased likelihood of justice involvement. TG veterans involved with the criminal justice system are a particularly vulnerable group and services designed to address the health care needs of this population, both while incarcerated and when in the community, should take these findings into account in the development of health screenings and treatment plans.

All known cases of breast cancer in patients with a diagnosis consistent with transgender identification were identified in the Veterans Health Administration (1996-2013). Ten cases were confirmed: seven birth sex females and three birth sex males. Of the three birth sex males, two identified as gender dysphoric male-to-female and one identified as transgender with transvestic fetishism. The birth sex males all presented with late-stage disease that proved fatal, whereas most of the birth sex female transgender veterans presented with earlier stage disease that could be treated. These cases support the importance of screening for breast cancer using standard guidelines in birth sex males and females. Family history of breast cancer should be obtained from transgender people as part of routine care. This report expands the known cases of breast cancer in transgender persons from 5 to 12 (female-to-male) and from 10 to 13 (male-to-female).