Family Planning for Sexual Minority Women

Does the approach used to measure sexual identity affect estimates of health disparities differently by race? A randomized experiment from the National Survey of Family Growth

The inclusion of "something else" as a response option for survey questions about sexual identity has been shown to significantly moderate estimated differences between sexual identity subgroups in the distributions of various health outcomes in national health surveys, specifically for substance use/misuse and reproductive health. This moderation effect may be larger depending on the respondent's race, possibly due to the intersectionality of multiple minority identities and compounding minority stressors. To test this hypothesis, we conducted secondary analyses of data from five consecutive years of the National Survey of Family Growth (2015-2019) [n = 18,903 (8510 males, 10,393 females)] in the United States, where respondents were randomly assigned to receive either a four-category version of the sexual identity question that included "something else" as a response option along with lesbian/gay, bisexual, and heterosexual, or a three-category version that omitted "something else." We focused on model-based estimates of distributions of health outcomes across subgroups defined by both race and sexual identity and tested the race moderation hypothesis using three-way interactions involving sexual identity, question type received (four-category vs. three-category), and race (Black, White, and other). Based on this randomized experiment, we found evidence of significant differences between the four-category and three-category question versions of sexual identity, in terms of the associations between sexual identity and several health outcomes, along with moderation of these differences by the respondent's race. For some outcomes, such as wanting a child or another child, the magnitudes of the estimated sexual identity differences among racial minority individuals, specifically between bisexual and heterosexual women, were sensitive to the measurement of sexual identity. These results further suggest a need for improved sexual minority measurement, especially among racial minorities. These differences were also mostly found among women, suggesting further intersectionality of groups exposed to specific stressors.

Gynecologic Care for Sexual and Gender Minority Patients

Sexual and gender minority (SGM) people, including lesbian, gay, bisexual, transgender, and queer individuals, are a diverse population with a wide spectrum of gynecologic needs. Institutionalized cisheteronormativity, stigmatization, lack of provider training, and fear of discrimination contribute to health disparities in this patient population. In this article, we review key topics in the gynecologic care of SGM patients and provide strategies to enable gynecologists to provide SGM people with equitable and inclusive full spectrum reproductive health care.

Asexual or not sure: Findings from a probability sample of undergraduate students

OBJECTIVE

Present study aims to: 1) examine demographic correlates of LGB, asexual, or not sure participants 2) describe the prevalence of diverse sexual behaviors, 3) assess the prevalence of event-level sexual behaviors and 4) examine predictors of sexual pleasure.

PARTICIPANTS

761 non-heterosexual undergraduates at a large, public U.S. university.

METHODS

Randomly sampled undergraduate students completed a confidential, cross-sectional online survey.

RESULTS

Of 761 non-heterosexual respondents; 567 identified as LGB, 47 asexual, and 147 not sure. Asexual students, those not sure were less likely to report having engaged in solo and partnered sexual activities and report sexual activities being less pleasurable at most recent sexual event, compared with LGB students. This difference (relative to LGB) became nonsignificant when accounting for reported sexual activities.

CONCLUSIONS

Our findings inform how college students define and experience their sexual identities and assist college health professionals in training on sexuality and prevention of risk factors.

Design Thinking for Health Disparities and Interdisciplinary Knowledge Translation: An LGBTQ+ Youth Health Literacy Project

This article discusses the use of codesign, design thinking (DT), and design jams in collaboration with interdisciplinary scholars, service providers, and community-based stakeholders as an approach to social work intervention development-specifically, to tackle health inequities and timely knowledge translation (KT). An application of these methods to the problem of sexual health disparities and lack of access to inclusive sexual health education in school-based settings for LGBTQ+ youth is discussed. LGBTQ+ Youth HeLP (Health Literacy Project) is a holistic online sexual health resource providing evidence-based information to LGBTQ+ youth in an accessible and age-appropriate format. This article considers potential opportunities and obstacles for utilizing DT to develop responsive solutions to health inequities and health-related KT learned from the project. Codesign offers effective options for generating collaborations that may increase cross-stakeholder perspective taking in group settings and produce high-quality outputs with increased likelihood of uptake.

Contraceptive Care Disparities Among Sexual Orientation Identity and Racial/Ethnic Subgroups of U.S. Women: A National Probability Sample Study

Background: Sexual minority women may use contraception for various reasons but face notable barriers to contraceptive care, including stigma and discrimination. However, studies examining sexual orientation disparities in contraceptive care have largely relied on nonprobability samples of predominately White women and may thus not be generalizable to U.S. women overall or Black and Latina women in particular. Materials and Methods: Using data from the 2006 to 2017 National Survey of Family Growth, a large national probability sample of U.S. women 15-44 years of age (N = 25,473), we used multivariable logistic regression to estimate adjusted odds ratios for receiving a contraceptive method or prescription and contraceptive counseling from a health care provider in the past year among sexual orientation identity and racial/ethnic subgroups of heterosexual, bisexual, and lesbian White, Black, and Latina women relative to White heterosexual women. Results: Among women overall, 33.9% had received contraception and 18.3% had obtained contraceptive counseling. Black (odds ratio [OR] = 0.73, 95% confidence interval [CI]: 0.65-0.82) and Latina (OR = 0.73, 95% CI: 0.64-0.82) heterosexual women, White (OR = 0.80, 95% CI: 0.65-0.99) and Black (OR = 0.43, 95% CI: 0.32-0.58) bisexual women, and White (OR = 0.23, 95% CI: 0.13-0.43), Black (OR = 0.19, 95% CI: 0.09-0.40), and Latina (OR = 0.08, 95% CI: 0.03-0.22) lesbian women had significantly lower adjusted odds of receiving contraception compared with White heterosexual women. White (OR = 0.36, 95% CI: 0.15-0.85), Black (OR = 0.42, 95% CI: 0.18-0.98), and Latina (OR = 0.22, 95% CI: 0.09-0.53) lesbian women also had significantly lower adjusted odds of obtaining contraceptive counseling relative to White heterosexual women. Conclusions: Policies, programs, and practices that facilitate access to person-centered contraceptive care among marginalized sexual orientation identity and racial/ethnic subgroups of U.S. women are needed to promote reproductive health equity.

Reproductive Considerations for the LGBTQ+ Community

When working with LGBTQ+ patients who want to build families, primary care providers play a key role in increasing access to reproductive health care. There is growing demand for assisted reproductive services among LGBTQ+ individuals who do not already have their own children or do not wish to adopt. Fertility-preservation options are available for transgender patients; however, many of these treatments are inaccessible to patients because of lack of insurance coverage and high cost. Legal options for LGBTQ+ patients' reproduction vary by state. Knowledge of the laws and regulations in your own state of practice is necessary to manage expectations.

Pregnancy (im)possibilities: identifying factors that influence sexual minority women's pregnancy desires

Sexual minority women (SMW) face both increased risk for unintended pregnancy and barriers to achieving wanted pregnancy, but little research investigates SMW's pregnancy desires. To fill this gap, we conducted five focus groups and 11 in-depth interviews with 20-30-year-old SMW in three US cities. Findings highlight that the heteronormative pregnancy planning paradigm lacks salience for SMW. While some SMW clearly wish to avoid pregnancy, many others are unsure, and factors influencing this uncertainty include relationship context, anticipating logistical barriers, and discord between queer identity and pregnancy.

How Doctors' Beliefs Influence Gynecological Health Care for Women Who Have Sex with Other Women

Background: Women who occasionally or regularly have sex with other women (WSW) are rarely identified in primary care. Although we know about their specific health needs, health care professionals still find it difficult to ask questions about sexual orientation (SO) and behaviors, and sometimes, patients may find them difficult to answer. The presumption of heterosexuality still remains a widespread attitude in health care. This study took place in a primary care setting, and aimed to identify differences in gynecological health care and clinical practice for women, according to what their presumed SO and behaviors were. Methods: We conducted a cross-sectional observational, descriptive, and comparative study from October 2018 to February 2019. Three hundred thirty-eight general practitioners (GPs) from Rhône-Alpes area (France) received an anonymous questionnaire with clinical case vignettes. The main outcome was the percentage of GPs who perform a different gynecological follow-up for WSW and non-WSW. Results: In total, 165 questionnaires were analyzed. Ninety percent of respondents performed a different gynecological follow-up for WSW, compared with other women. They less often addressed topics such as contraception needs, use of barrier protections, and screening of sexually transmitted infections. Ninety-two percent of respondents were aware that they have WSW among their patients, but 2/3 of them never or rarely asked about SO. Conclusion: Most GPs know that they manage WSW but may misidentify these patients and their real care needs. Therefore, WSW receive a different and poorer follow-up than non-WSW. Clinical guidelines would be useful to improve and standardize quality and experience of health care for WSW.

Sexual Minority Women and Contraceptive Use: Complex Pathways Between Sexual Orientation and Health Outcomes

Compared with their heterosexual peers, sexual minority women (SMW; e.g., queer, bisexual, lesbian, pansexual) have an elevated risk for unintended pregnancy.A team of social science and clinical researchers qualitatively documented the multilevel pathways leading to this disparity, particularly the contexts of contraceptive use. From August 2017 to April 2018, we conducted focus groups and interviews with young adult cisgender SMW in 3 cities: Chicago, Illinois; Madison, Wisconsin; and Salt Lake City, Utah.Most participants reported experience with both penile-vaginal intercourse and contraception. However, they faced several queer-specific barriers to preventing unwanted pregnancy, including a comparative lack of self-concept as contraceptive users, fear of stigma from both queer and health care communities, use of less-effective methods because of infrequent penile-vaginal intercourse and a sense that longer-acting methods were "overkill," and previous experiences of discrimination such as homophobia and gender-based violence. However, participants also reported ways that contraception could align with queer identity, including both taking advantage of noncontraceptive benefits and framing contraception as sex- and queer-positive. These facilitators can inform future efforts to help SMW better meet their pregnancy prevention needs.

Disparities in accessing infertility care in the United States: results from the National Health and Nutrition Examination Survey, 2013-16

OBJECTIVE

To investigate infertility rates and access to infertility care among women in the United States.

DESIGN

Retrospective cross-sectional.

SETTING

Not applicable.

PATIENT(S)

Women between 20 and 44 years-old who participated in the National Health and Nutrition Examination Survey between 2013 and 2016 and answered questions RHQ074 ("have you ever attempted to become pregnant over a period of at least a year without becoming pregnant?") and RHQ076 ("have you ever been to a doctor or other medical provider because you were unable to become pregnant?").

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Rates of infertility and accessing infertility care.

RESULT(S)

Women reported infertility at a rate of 12.5% (95% confidence interval, 10.8-14.4). Higher infertility rates were noted with increasing age and body mass index. There were no differences in infertility rates by race/ethnicity, education, income, U.S. citizenship, insurance, or primary location of health care. However, women with less than a high school diploma accessed infertility care less than women with a college degree (5.0% vs. 11.6%). Women with incomes less than $25,000 sought infertility care less than those with incomes above $100,000 (5.4% vs. 11.6%). Non-U.S. citizens accessed infertility care less than U.S. citizens (6.9% vs. 9.4%), and uninsured women reported fewer visits for infertility than insured women (5.9% vs. 9.9%). Women who used the emergency department as their primary medical location reported accessing infertility care less than those who relied on a hospital outpatient unit (1.4% vs. 14.9%).

CONCLUSION(S)

These nationally representative findings highlight the need to address disparities in access to infertility care.

Sexual Minority Women's Experiences With Sexual Identity Disclosure in Contraceptive Care

OBJECTIVE

To describe a group of young sexual minority women's experiences with and preferences for sexual identity disclosure in the context of contraceptive care.

METHODS

In Chicago, Illinois, Salt Lake City, Utah, and Madison, Wisconsin, investigators conducted five focus groups (n=22) and 11 interviews with women aged 20-30 years who identified as something other than heterosexual. Focus groups explored social norms regarding contraceptive care; interviews documented individual experiences with contraceptive care. Using a qualitative descriptive approach and combined deductive and inductive content analysis, investigators coded transcripts for themes related to disclosing sexual orientation to contraceptive providers.

RESULTS

Participants described the process of sexual identity disclosure in contraceptive care in three stages: 1) listening for whether, when, and how health care providers asked about sexual orientation, 2) deciding whether or not to disclose sexual identity to providers, and 3) evaluating responses from providers after disclosure. Participants wanted providers to: avoid assumptions and ask about both sexual identity and sexual behaviors, signal their openness and competence around the health of sexual minority women during contraceptive encounters, and focus discussions on the individual patient's priorities and needs for contraceptive care.

CONCLUSION

Decisions made by sexual minority women about sexual identity disclosure in contraceptive contexts are influenced by previous and current interactions with health care providers. Contraceptive providers should ask all patients about sexual identity and sexual behavior, avoid assumptions about use of and need for contraception, and acknowledge the prevalence of marginalization, discrimination, and stigma experienced by sexual minority women and their communities in health care contexts.

Understanding the Reproductive Experience and Pregnancy Outcomes of Lesbian Women Undergoing Donor Intrauterine Insemination

PURPOSE

The study purpose was to evaluate the reproductive experience, specifically cycle characteristics and treatment outcomes, of lesbian women. In addition, we aimed to determine whether there are differences in pregnancy outcomes when comparing lesbian women undergoing ovulation induction (OI) versus natural cycles with donor intrauterine insemination (IUI), as well as lesbian and heterosexual women undergoing the same assisted reproductive technology treatment.

METHODS

This was a retrospective cohort study including women who underwent an IUI with cryopreserved sperm between 2006 and 2018. The primary outcome of interest was clinical pregnancy (CP) rate.

RESULTS

A total of 216 lesbian women (451 natural cycles and 441 OI cycles) and 584 heterosexual women (1177 natural cycles and 1238 OI cycles) were included in the study. Thirty percent of lesbian women had a hysterosalpingogram as part of their initial workup. Approximately 40% of lesbian women who underwent OI/IUI had previously undergone at least one natural cycle/IUI. There was no significant difference in CP rate when comparing lesbian women and heterosexual women undergoing natural or OI/IUI, or when comparing lesbian women who underwent natural versus OI/IUI cycles. However, there was a significantly higher multiple gestation rate among lesbian women undergoing OI compared with those undergoing natural cycles (11.8% vs. 0%, p = 0.01).

CONCLUSION

This large study showed that while pregnancy outcomes were similar between groups, the multiple gestation rate was higher in lesbian women undergoing OI compared with lesbian women undergoing natural cycles.