Primary Care Providers' Attitudes, Practices, and Knowledge in Treating LGBTQ Communities

The Effect of Education on Homophobia and Attitudes Toward Gay Men and Lesbian Women among Medical Faculty Students: A Turkish Sample

Problem: Gay men (GMs) and lesbian women (LWs) can be exposed to misunderstanding, pressure, condemnation, obstructed access to public services, social isolation, and discrimination in many countries. They may also encounter various difficulties in accessing health services. Being GM and LW is generally unacceptable in Turkey, and both are perceived as abnormal. Medical students may require education on the subject of sexual orientation to improve their knowledge of and attitudes toward LGBT individuals, to help them remain neutral and avoid prejudice in providing health services for such individuals, and to ensure that such care is unbiased. Intervention: This one-group pretest-post-test design study was performed with third-year students at the Ondokuz Mayıs University Medical Faculty (Samsun-Turkey) on 01-31 September, 2021. Three hundred twenty-five students took part. We evaluated students' attitudes toward homophobia and being GM and LW following a two-week multidisciplinary education program. The program included such topics as "Marginalization," "Interaction between cultures," "Sexual orientation," "Faith-based marginalization," "Sub-cultures," "Health protection," "Gender," and "Marginalized groups." For objective acquisition, we organized small group work, experience-sharing sessions (such as different orientation groups, different ethnic groups, and different behavioral templates), presentations, and panel activities. Context: Some circles in Türkiye regard LGBT individuals as representing an attack on national and spiritual values, and they are used as part of the political discourse. Studies are being performed in some medial faculties in Türkiye concerning the inclusion of subjects related to LGBT individuals in the educational curriculum. However, these studies have not yet assumed the form of a curriculum design including content, method, and testing. It is important for subjects concerning LGBT individuals to be considered more extensively in medical education in Türkiye, and for awareness of the rights of these individuals in the community and of combating discrimination to be improved. Outcome: We observed a significant decrease in students' homophobia after education. Significant decreases were observed in agreement with statements to the effect that being a GM or LW is a disease, that it can be treated, that people can be identified as GMs and LWs based on their behavior, and that they pose a major threat to society. Lessons Learned: It is unclear whether education aimed at all marginalized groups will produce different results to those of programs aimed specifically at GMs and LWs, but we think that applying programs directed toward discrimination and prejudice together will yield more effective results.

Disparities in Mortality by Sexual Orientation in a Large, Prospective Cohort of Female Nurses

Importance

Extensive evidence documents health disparities for lesbian, gay, and bisexual (LGB) women, including worse physical, mental, and behavioral health than heterosexual women. These factors have been linked to premature mortality, yet few studies have investigated premature mortality disparities among LGB women and whether they differ by lesbian or bisexual identity.

Objective

To examine differences in mortality by sexual orientation.

Design, Setting, and Participants

This prospective cohort study examined differences in time to mortality across sexual orientation, adjusting for birth cohort. Participants were female nurses born between 1945 and 1964, initially recruited in the US in 1989 for the Nurses' Health Study II, and followed up through April 2022.

Exposures

Sexual orientation (lesbian, bisexual, or heterosexual) assessed in 1995.

Main Outcome and Measure

Time to all-cause mortality from assessment of exposure analyzed using accelerated failure time models.

Results

Among 116 149 eligible participants, 90 833 (78%) had valid sexual orientation data. Of these 90 833 participants, 89 821 (98.9%) identified as heterosexual, 694 (0.8%) identified as lesbian, and 318 (0.4%) identified as bisexual. Of the 4227 deaths reported, the majority were among heterosexual participants (n = 4146; cumulative mortality of 4.6%), followed by lesbian participants (n = 49; cumulative mortality of 7.0%) and bisexual participants (n = 32; cumulative mortality of 10.1%). Compared with heterosexual participants, LGB participants had earlier mortality (adjusted acceleration factor, 0.74 [95% CI, 0.64-0.84]). These differences were greatest among bisexual participants (adjusted acceleration factor, 0.63 [95% CI, 0.51-0.78]) followed by lesbian participants (adjusted acceleration factor, 0.80 [95% CI, 0.68-0.95]).

Conclusions and Relevance

In an otherwise largely homogeneous sample of female nurses, participants identifying as lesbian or bisexual had markedly earlier mortality during the study period compared with heterosexual women. These differences in mortality timing highlight the urgency of addressing modifiable risks and upstream social forces that propagate and perpetuate disparities.

Unpacking the Paradox: Understanding the Gap Between Perceived and Actual Competence in LGBTQ+ Health Care

BACKGROUND

Awareness about existing health disparities affecting sexual minorities remains insufficient, and nursing professionals often lack self-awareness about their biases and assumptions concerning lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ) individuals.

PURPOSE

To explore how exposure to the LGBTQ community, during both classroom and clinical experiences, relates to nursing students' confidence in providing culturally congruent care to this group.

METHODS

This nonexperimental correlational study occurred at a Midwest 4-year public university, involving final-semester baccalaureate nursing students who completed demographic and educational preparation surveys regarding their confidence in providing health care to the LGBTQ population.

RESULTS

Results indicate that participants with no direct care experience were more confident in their communication skills and culturally congruent patient care for sexual minorities compared to those exposed to sexual minorities in clinical settings.

CONCLUSIONS

Nursing students' perceptions and experiences in delivering culturally congruent health care to sexual minorities provide an interesting perspective for examining the Dunning-Kruger effect.

Lack of Informed and Affirming Healthcare for Sexual Minority Men: A Call for Patient-Centered Care

BACKGROUND

Sexual minority men (SMM) face severe health inequities alongside negative experiences that drive avoidance of medical care. Understanding how SMM experience healthcare is paramount to improving this population's health. Patient-centered care, which emphasizes mutual respect and collaboration between patients and providers, may alleviate the disparaging effects of the homophobia that SMM face in healthcare settings.

OBJECTIVE

To explore how SMM perceive their experiences with healthcare providers and how care can most effectively meet their needs.

DESIGN

Semi-structured qualitative interviews focused on healthcare experiences, pre-exposure prophylaxis (PrEP), and HIV-related beliefs were conducted between July and November 2018.

PARTICIPANTS

The study included a sample of 43 young adult SMM (ages 25-27), representing diverse socioeconomic, racial, and ethnic backgrounds, in New York City.

APPROACH

Researchers utilized a multiphase, systematic coding method to identify salient themes in the interview transcripts.

KEY RESULTS

Analyses revealed three main themes: (1) SMM perceived that their clinicians often lack adequate skills and knowledge required to provide care that considers participants' identities and behaviors; (2) SMM desired patient-centered care as a way to regain agency and actively participate in making decisions about their health; and (3) SMM felt that patient-centered care was more common with providers who were LGBTQ-affirming, including many who felt that this was especially true for LGBTQ-identified providers.

CONCLUSIONS

SMM expressed a clear and strong desire for patient-centered approaches to care, often informed by experiences with healthcare providers who were unable to adequately meet their needs. However, widespread adoption of patient-centered care will require improving education and training for clinicians, with a focus on LGBTQ-specific clinical care and cultural humility. Through centering patients' preferences and experiences in the construction of care, patient-centered care can reduce health inequities among SMM and empower healthcare utilization in a population burdened by historic and ongoing stigmatization.

Whose Role is It Anyway? Sexual Racism and Sexual Positioning Among Young Sexual Minority Black Men

Racialized Sexual Discrimination (RSD), also referred to as "sexual racism," is widely reported among young sexual minority Black men (YSMBM). Though RSD is driven in part by sexual scripts and racial stereotypes, little is known about YSMBM's experiences with RSD with respect to their sexual positioning roles. Using data from a cross-sectional web-survey of YSMBM (N = 726), a multivariate Kruskal Wallis test was conducted comparing YSMBM who identified as mostly bottom, versatile, or mostly top, on the degree to which they were affected by four RSD experiences, as well as the frequency with which they encountered these experiences. Men identifying as mostly bottom reported significantly stronger negative reactions to same-race rejection and encountering sexual role assumptions than men identifying as mostly top. Men identifying as versatile encountered same-race rejection significantly more frequently than men identifying as mostly top. Men identifying as mostly bottom encountered White superiority significantly more frequently than men identifying as mostly top. RSD may impact YSMBM differentially based on sexual position. These findings may have implications for culturally competent clinical practice, as well as analytic implications (e.g., estimating more complex statistical models) for sexual racism research, which remains an important yet underexamined field in the health sciences.

Explorative Questionnaire Study About Education with Regard to the Health of Sexual Minorities at an Austrian Medical University

Physicians can play a critical role in helping lesbian, gay, and bisexual-identified (LGB) individuals face minority stress. The current questionnaire study among 305 medical students (62.6% women/37.4% men; Mage = 23.4, SD = 3.2) assessed whether medical students learn about LGB-specific concepts at an Austrian medical university. Students reported that their education contained little content about LGB-specific concepts. The majority of students did not hold negative attitudes toward homosexuality and they would like a larger range of courses concerning LGB-specific topics. The barrier most strongly associated with the intention to ask future patients about their sexual orientation was the belief that sexual orientation was irrelevant for clinical practice. Future education programs on LGB-specific topics may not need to focus on reducing negative attitudes toward sexual minorities, but should contain more facts on LGB individuals' specific healthcare needs and explain to students why a patient's sexual orientation is important to healthcare.

Urologists and Lesbian, Gay, Bisexual, Transgender, or Queer Patients: A Survey-based Study of the Practice Patterns, Attitudes, and Knowledge Base of Urologists Toward Their Lesbian, Gay, Bisexual, Transgender, or Queer Patients

OBJECTIVE

To assess urologists' attitudes toward treating lesbian, gay, bisexual, transgender, or queer (LGBT) patients and counseling practices during diagnosis and treatment of prostate cancer.

METHODS

A 35-question survey was sent to program directors of U.S. urology residency programs.

RESULTS

154 responses met the inclusion criteria. Respondents were primarily male, heterosexual, in academia, representing a range of ages and geography. 54.2% of respondents don't assume patients are heterosexual. While 88% of providers feel comfortable discussing sexual health with LGBTQ patients, 42.9% disagree that knowing sexual orientation is necessary to providing optimal care. 57.8% of respondents don't provide intake forms to indicate sexual orientation and 60.4% don't inquire about sexual orientation during history-taking. A majority (32.7%) reported 1-5 hours of LGBTQ health training. 74.3% believe more training is needed. 74.5% agreed to being listed as an LGBTQ-Friendly Provider currently, 65.8% felt they needed additional training. 63.6% agreed the prostate is a source of sexual pleasure. 55.9% believed it important to assess sexual satisfaction in patients who engage in receptive anal intercourse after prostate cancer treatment. Responses were mixed regarding the timing of resuming receptive anal intercourse after treatment and whether patients are counseled to refrain from anal stimulation before PSA testing. Answers to knowledge questions regarding anal cancer and communication were primarily correct; answers to questions regarding anejaculation and differences in health concerns were mixed.

CONCLUSION

Ongoing education is necessary on specific differences between heterosexual and lesbian, gay, bisexual, transgender, or queer (LGBTQ) patient concerns and how to apply this knowledge in order to address the needs of a rapidly aging LGBTQ population.

LGBTQ + cultural competency training for health professionals: a systematic review

BACKGROUND

Health disparities experienced by LGBTQ + individuals have been partially attributed to health professionals' lack of cultural competence to work with them. Cultural competence, the intricate integration of knowledge, skills, attitudes, and behaviors that improve cross-cultural communication and interpersonal relationships, has been used as a training framework to enhance interactions between LGBTQ + patients and health professionals. Despite multiple published LGBTQ + cultural competency trainings, there has been no quantitative appraisal and synthesis of them. This systematic review assessed articles evaluating the design and effectiveness of these trainings and examined the magnitude of their effect on cultural competence outcomes.

METHODS

Included studies quantitatively examined the effectiveness of LGBTQ + cultural competency trainings for health professionals across all disciplines in various healthcare settings. 2,069 citations were retrieved from five electronic databases with 44 articles meeting inclusion criteria. The risk of bias in the included studies was assessed by two authors utilizing the Joanna Briggs Institute critical appraisal checklists. Data extracted included study design, country/region, sample characteristic, training setting, theoretical framework, training topic, modality, duration, trainer, training target, measurement instrument, effect size and key findings. This review followed the PRISMA statement and checklist to ensure proper reporting.

RESULTS

75% of the studies were published between 2017 and 2023. Four study designs were used: randomized controlled trial (n = 1), quasi-experimental pretest-posttest without control (n = 39), posttest only with control (n = 1) and posttest only without control (n = 3). Training modalities were multiple modalities with (n = 9) and without simulation (n = 25); single modality with simulation (n = 1); and with didactic lectures (n = 9). Trainings averaged 3.2 h. Ten studies employed LGBTQ + trainers. The training sessions resulted in statistically significant improvements in the following cultural competence constructs: (1) knowledge of LGBTQ + culture and health (n = 28, effect size range = 0.28 - 1.49), (2) skills to work with LGBTQ + clients (n = 8, effect size range = 0.12 - 1.12), (3) attitudes toward LGBTQ + individuals (n = 14, effect size range = 0.19 - 1.03), and (4) behaviors toward LGBTQ + affirming practices (n = 7, effect size range = 0.51 - 1.11).

CONCLUSIONS

The findings of this review highlight the potential of LGBTQ + cultural competency training to enhance cultural competence constructs, including (1) knowledge of LGBTQ + culture and health, (2) skills to work with LGBTQ + clients, (3) attitudes toward LGBTQ + individuals, and (4) behaviors toward LGBTQ + affirming practices, through an interdisciplinary and multi-modal approach. Despite the promising results of LGBTQ + cultural competency training in improving health professionals' cultural competence, there are limitations in study designs, sample sizes, theoretical framing, and the absence of longitudinal assessments and patient-reported outcomes, which call for more rigorous research. Moreover, the increasing number of state and federal policies that restrict LGBTQ + health services highlight the urgency of equipping health professionals with culturally responsive training. Organizations and health systems must prioritize organizational-level changes that support LGBTQ + inclusive practices to provide access to safe and affirming healthcare services for LGBTQ + individuals.

Exploring a case for education about sexual and gender minorities in postgraduate emergency medicine training: forming recommendations for change

Social medicine and health advocacy curricula are known to be uncommon in postgraduate medical education. As justice movements work to unveil the systemic barriers experienced by sexual and gender minority (SGM) populations, it is imperative that the emergency medicine (EM) community progress in its efforts to provide equitable, accessible, and competent care for these vulnerable groups. Given the paucity of literature on this subject in the context of EM in Canada, this commentary borrows evidence from other specialties across North America. Trainees across specialties and of all stages are caring for an increasing number of SGM patients. Lack of education at all levels of training is identified as a significant barrier to adequately caring for these populations, thereby precipitating significant health disparities. Cultural competency is often mistakenly attributed to a willingness to treat rather than the provision of quality care. However, positive attitudes do not necessarily correlate with trainee knowledge. Barriers to creating and implementing culturally competent curricula are plentiful, yet facilitating policies and resources are rare. While international bodies continuously publish position statements and calls to action, concrete change is seldom made. The scarcity of SGM curricula can be attributed to the universal absence of formal acknowledgment of SGM health as a required competency by accreditation boards and professional membership associations. This commentary synthesizes hand-picked literature in an attempt to inform healthcare professionals on their journey toward developing culturally competent postgraduate medical education. By thematically organizing evidence into a stepwise approach, the goal of this article is to borrow ideas across medical and surgical specialties to inform the creation of recommendations and make a case for an SGM curriculum for EM programs in Canada.

Evaluation of the Three National Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexual and Gender Minority (LGBTQ+)-Competent Provider Directories in the United States

Provider directories may serve as a bridge solution until lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) education becomes a requisite within standard medical education. The three national LGBTQ+-competent provider directories in the United States were evaluated. Two directories served the LGBTQ+ community while one served the gender minority community. All enumerated thousands of providers. One allowed provider-specific feedback. All provided searchable criteria (e.g., provider name, location, specialty, population identity, service type, payment types, gender identity, and languages spoken). By implementing these key features, existing and future directories could better provide equitable healthcare access for the LGBTQ+ population.

Health Center Leadership Perspectives Regarding Barriers to and Facilitators of Providing Culturally Responsive Care for Sexual and Gender Minority Patients

Purpose: This study identified barriers and facilitators associated with providing culturally responsive care for sexual and gender minority (SGM) patients at federally qualified health centers (FQHCs) in the United States, from the perspective of clinical leadership. Methods: Between July and December 2018, 23 semistructured, in-depth qualitative interviews were held with clinical leaders representing six FQHCs residing in rural and urban settings. Stakeholders included Chief Executive Officer, Executive Director, Chief Medical Officer, Medical Director, Clinic Site Director, and Nurse Manager positions. Interview transcripts were analyzed using inductive thematic analysis. Results: Barriers included personnel factors related to lack of training and fear, competing priorities, and environments that focused on treating all patients similarly. Facilitators included established partnerships with external organizations, staff with prior SGM training and knowledge, and active initiatives in clinic settings targeting SGM care. Conclusions: Clinical leadership expressed strong support for evolving their FQHCs into organizations that provide culturally responsive care for their SGM patients. FQHC staff across all levels of clinical care would benefit from regularly occurring training sessions on culturally responsive care for SGM patients. To ensure sustainability, improve staff buy-in, and mitigate the impact of staff turnover, improving culturally competent care for SGM patients should be a shared goal and responsibility for leadership, medical providers, and administrative staff. CTN Registration: NCT03554785.

Practice, attitudes and views of right to access of sexual and reproductive health services by LGBTQI among primary health care nurses in Tshwane

BACKGROUND

Sexual and reproductive healthcare services (SRHS) are crucial investments for improving individual well-being and granting an opportunity to exercise sexual and reproductive rights. Primary health care (PHC) nurses are described as gatekeepers, preventing many individuals, including the members of the lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) community, from accessing much-needed healthcare services.

AIM

The study aimed at exploring the experiences and perceptions of PHC nurses during the provision of SRHS for members of the LGBTQI community.

SETTING

The study was conducted among eight clinics around Tshwane in South Africa.

METHODS

Twenty-seven professional nurses were selected purposively, using an exploratory design approach. A semistructured interview guide and in-depth face-to-face interviews were used to gather data. Data were analysed using thematic content analysis (TCA).

RESULTS

Four themes emerged: understanding of SRHS, attitudes of PHC nurses, frequency of rendering services based on utilisation of SHR and views of nurses on the right to access SRHS.

CONCLUSION

A heteronormative approach was mostly indicated when rendering SHRS to the members of the LGBTQI community. Members of the LGBTQI community do not use the SRHS as often as heterosexual patients; lack of training, skills and knowledge were identified as barriers to rendering much-needed SRHS for members of the LGBTQI community.Contribution: The findings of this study assisted in demonstrating the PHC nurses' perceptions, experiences, skills and knowledge of LGBTQI SRHS, thus improving the members of the LGBTQI community's accessibility and utilisation of SRHS.

"Ditch the white coats": What LGBTQ+ patients prefer in their primary care provider

BACKGROUND

Health disparities in lesbian, gay, bisexual, transgender, queer and other sexual and gender minority (LGBTQ+) individuals are well documented, and there is a dearth of primary care providers (PCPs) with the knowledge, skills, and attitudes to sensitively care for this diverse population.

PURPOSE

The purpose of this research study was to ask LGBTQ+ patients what qualities they prefer in their PCP. The findings will be used to better prepare nurse practitioners (NPs) to care for this diverse community and inform the training of future NPs to provide patient-centered care to LGBTQ+ individuals.

METHODOLOGY

In this qualitative descriptive study, four focus groups were conducted remotely between December 2020 and January 2021 with self-identified LGBTQ+ patients of an LGBTQ+ health center in the northeast. Thematic analysis of the data elicited codes, categories, and themes. Strategies were implemented to promote trustworthiness of the results.

RESULTS

Twenty-eight participants shared the qualities they value in their PCP. Analysis revealed four themes: "Ditch the white coats"; "Meet me where I am"; "The relationship is key"; and "Be knowledgeable about and comfortable with LGBTQ+ people and their health care needs."

CONCLUSIONS

The focus groups elucidated important information on caring for the LGTBQ+ communities and insights into what NPs must do to provide patient-centered care to this diverse population.

IMPLICATIONS

These findings can improve practice through a better understanding of LGBTQ+ patients' perspectives. Additionally, this study demonstrates the feasibility of directly asking our patients what they want in their health care provider.

Primary Healthcare Nurse’s Barriers and Facilitators to Providing Sexual and Reproductive Healthcare Services of LGBTQI Individuals: A Qualitative Study

In most cases, we only hear Lesbians, Gays, Bisexuals, Transgender, Queer, and Intersex (LGBTQI) patients complaining about nurses being the reason for not accessing and utilizing healthcare services; for example, studies reports on the different attitudes of healthcare providers including nurses against LGBTQI patients. However, factors influencing the behavior of South African Primary Healthcare (PHC) Nurses toward LGBTQI patients are rarely reported. The study aimed to explore how PHC nurses experienced and perceived sexual and reproductive health services for LGBTQI individuals in Tshwane, Gauteng Province, South Africa. The study followed qualitative research using an exploratory design approach. The sample included 27 PHC nurses from Tshwane, Gauteng Province, South Africa. In-depth face-to-face interviews were coded and analyzed using Thematic Content Analysis (TCA) which included five interrelated steps. The results revealed three main themes: barriers to the provision of LGBTQI-related SRHS, facilitators for the provision of SRHS to LGBTQI individuals, and strategies to improve LGBTQI individuals’ SRHS accessibility and availability. Common barriers were related to the institutions, PHC nurses, the general public, and LGBTQI patients themselves. Regardless of the challenges faced by PHC nurses, there were some enabling factors that pushed them to continue rendering SHRS to LGBTQI patients who came to their clinics. Almost all PHC nurses suggested the importance of awareness, transparency, collaboration, and the need for training related to LGBTQI healthcare issues.

Classroom Instruction: Medical Students' Attitudes Toward LGBTQI+ Patients

The Association of American Medical Colleges declared it essential that medical students receive instruction on the health needs of lesbian, gay, bisexual, transgender, questioning, and intersex (LGBTQI⁺) individuals. The integration of LGBTQI⁺ health and instruction in medical curricula, however, is scant. A pre-post confidential survey study was completed by first-year medical students (N = 103; 85% response rate) in the context of classroom instruction. The California State University Northbridge instrument assessed students' perspectives on LGBTQI⁺ Patient-Care, Comfort with LGBTQI⁺ Patient Interactions, Gender and Sexuality, Civil Rights, and LGBTQI⁺ Education. Post-instruction, students reported a significant increase in understanding of bisexuality (p = .02), being transgender (p = .006), and LGBTQI⁺ couples' adoption rights (p = .003). The findings support the incorporation of LGBTQI⁺ instruction into medical curricula and suggest that educators may consider consulting pre-intervention data before teaching LGBTQI⁺ health content, which would allow material to be tailored toward learner-specific needs.

“We Treat Everyone Equally”: Hospice Care Team Members’ Language Use Regarding Sexual and Gender Minority Patients and Caregivers

Purpose

The way Hospice Care Team (HCT) members talk about patients and caregivers reflects personal attitudes and experiences, training, and broader social and cultural discourse. This secondary analysis examined the framing language professional hospice care providers used when discussing end-of-life care for LGBTQ+ patients and caregivers.

Methods

Discourse analysis and frame theory informed a secondary, qualitative analysis of focus group data collected with hospice providers (N = 48) in 3 U.S. states regarding their knowledge, experience, and opinions about end-of-life care for LGBTQ+ patients and caregivers.

Results

The following four (often overlapping) frames were identified (1) A normalizing frame which dismissed differences between LGBTQ+ patients/caregivers and non-LGBTQ+ individuals in general, and especially at end-of-life (2) A homogenizing frame which cast being LGBTQ+ as an intrinsic, universal characteristic and did not differentiate between different groups, specifically conflating orientation and gender identity (3) A pathologizing frame in which providers related being LGBTQ+ to disease conditions or illegal behaviors (4) An individualizing frame which focused on between-group differences, acknowledged variation, and emphasized the importance of historical context for personalized care.

Conclusion

Examination of discursive frames used by providers enhances understanding of how social and cultural influences, along with training and experience, shape how HCT members approach working with LGBTQ+ patients and families, and illuminates areas where additional education and training are needed. Our findings support the need for ongoing efforts to improve HCT members’ knowledge and skill regarding the needs of LGBTQ+ patients and families within the context of hospice and end-of-life care.

An Assessment of LGBTQ+ Cultural Competency and Attitudes of US Otolaryngologists

Otolaryngologists can play a significant role in the care of lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) patients through gender-affirming care and routine care in everyday practice. To avoid stigmatizing LGBTQ+ patients, otolaryngologists should maintain high levels of LGBTQ+ cultural competency; however, US otolaryngology programs offer limited amounts of LGBTQ+ topics in didactic curricula, and the LGBTQ+ cultural competency of otolaryngologists remains unknown. A cross-sectional survey of demographics, attitude questions, and the 7-point Likert LGBT-Development of Clinical Skills Scale was distributed to otolaryngologists across the United States. Otolaryngologists (n = 176) had moderately high Overall LGBTQ+ cultural competency (mean, 5.82; range, 3.83-7.00), moderately high Basic Knowledge (mean, 5.43; range, 1.53-7.00), moderately high Clinical Preparedness (mean, 5.34; range, 2.00-7.00), and high Attitudinal Awareness (mean, 6.51; range, 2.42-7.00). Attending otolaryngologists had significantly lower LGBTQ+ Basic Knowledge than residents and fellows (P = .002). Further education at all levels of practice, including attendings, is necessary to improve LGBTQ+ cultural competency among otolaryngologists.

"Let's Be a Person to Person and Have a Genuine Conversation": Comparing Perspectives on PrEP and Sexual Health Communication Between Black Sexual Minority Men and Healthcare Providers

Patient-provider communication is a key factor affecting HIV pre-exposure prophylaxis (PrEP) awareness and access among Black sexual minority men (SMM). Optimizing patient-provider communication requires a deeper understanding of communication dynamics. In this study, we investigated the perspectives of both HIV-negative/status-unknown Black SMM and practicing community healthcare providers regarding patient-provider communication about PrEP and sexual health. We conducted eleven semi-structured qualitative focus groups (six with Black SMM; five with providers) in the Northeastern USA and thematically analyzed transcripts. A total of 36 Black SMM and 27 providers participated in the focus groups. Our analysis revealed points of alignment and divergence in the two groups' perspectives related to patient-provider communication. Points of alignment included: (1) the importance ascribed to maximizing patients' comfort and (2) belief in patients' right to non-discriminatory healthcare. Points of divergence included: (1) Black SMM's preference for sexual privacy versus providers' preference that patients share sexual information, (2) Black SMM's perception that providers have an ethical responsibility to initiate conversations about PrEP with patients versus providers' perception of such conversations as being optional, and (3) Black SMM's preference for personalized sexual health conversations versus providers' preference for standardized conversations. Findings underscore a need for providers to offer more patient-centered sexual healthcare to Black SMM, which should entail routinely presenting all prevention options available-including PrEP-and inviting open dialogue about sex, while also respecting patients' preferences for privacy about their sexuality. This approach could increase PrEP access and improve equity in the US healthcare system.

Sexual minorities are at elevated risk of cardiovascular disease from a younger age than heterosexuals

Cardiovascular disease is the leading cause of death worldwide. In this study, we assessed factors related to cardiovascular disease risk and outcomes among sexual minorities (SM). Data from multiple waves of the PATH study were used in this analysis. Multivariable regression models were used to assess the association between sexual identity and: tobacco or e-cigarette use, adverse cardiovascular events, and age at first diagnosis of adverse cardiovascular disease events. In our sample (N = 23,205), 1,660 (7.15%) participants identified as SM. SM men, relative to heterosexual men, are more likely to be diagnosed with high blood pressure (aRR = 1.27; 95% CI 1.10, 1.47), high cholesterol (aRR = 1.32; 95% CI: 1.12, 1.55), congestive heart failure (aRR = 2.29; 95% CI 1.13, 4.65), stroke (aRR = 2.39; 95% CI: 1.14, 5.04), heart attack (aRR = 2.40; 95% CI 1.42, 4.04), and other heart conditions (aRR = 1.52; 95% CI: 1.06, 2.18). Although no simple differences were observed among SM women compared to heterosexual women, SM women were more likely to be diagnosed at a younger age for high blood pressure (aRR = -0.69; 95% CI - 1.08, - 0.29), high cholesterol (aRR = -0.77; 95% CI - 1.15, - 0.38), stroke (aRR =  - 1.04; 95% CI - 1.94, - 0.13), and heart attack (aRR =  - 1.26; 95% CI - 2.42, - 0.10). SM men were only diagnosed at a younger age for stroke (aRR =  - 1.18; 95% CI - 2.06, - 0.30). Compared to heterosexuals, sexual minorities are at higher risk for cardiovascular disease, more likely to develop cardiovascular disease at an earlier age, and more likely to use tobacco products. Future research should focus on decreasing cardiovascular risk among sexual minorities including reducing tobacco use and stress. Screening recommendations for sexual minority populations should also be reviewed in light of a growing body of literature suggesting elevated risk from a young age.

Development, Implementation, and Effectiveness of a Self-sustaining, Web-Based LGBTQ+ National Platform: A Framework for Centralizing Local Health Care Resources and Culturally Competent Providers

Background

The lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) population has long faced substantial marginalization, discrimination, and health care disparities compared to the cisgender, heterosexual population. As the etiology of such disparities is multifaceted, finding concrete solutions for LGBTQ+ health care equity is challenging. However, the internet may offer the space to initiate an effective model.

Objective

In an effort to make LGBTQ+ public resources and culturally competent providers transparent, modernize medical education, and promote cultural competency, OutCare Health—a nonprofit 501(c)(3) multidisciplinary, multicenter web-based platform—was created.

Methods

The organization employs a cyclic, multidimensional framework to conduct needs assessments, identify resources and providers, promote these efforts on the website, and educate the next generation of providers. LGBTQ+ public health services are identified via the internet, email, and word of mouth and added to the Public Resource Database; culturally competent providers are recruited to the OutList directory via listservs, medical institutions, local organizations, and word of mouth; and mentors are invited to the Mentorship Program by emailing OutList providers. These efforts are replicated across nearly 30 states in the United States.

Results

The organization has identified over 500 public health organizations across all states, recognized more than 2000 OutList providers across all states and 50 specialties, distributed hundreds of thousands of educational materials, received over 10,000 monthly website visits (with 83% unique viewership), and formed nearly 30 state-specific teams. The total number of OutList providers and monthly website views has doubled every 12-18 months. The majority of OutList providers are trained in primary, first point-of-care specialties such as family medicine, infectious disease, internal medicine, mental health, obstetrics and gynecology, and pediatrics.

Conclusions

A web-based LGBTQ+ platform is a feasible, effective model to identify public health resources, culturally competent providers, and mentors as well as provide cultural competency educational materials and education across the country. Such a platform also has the opportunity to reach self-perpetuating sustainability. The cyclic, multidisciplinary, multidimensional, multicenter framework presented here appears to be pivotal in achieving such growth and stability. Other organizations and medical institutions should heavily consider using this framework to reach their own communities with high-quality, culturally competent care for the LGBTQ+ population.

Combating LGBTQ+ health disparities by instituting a family medicine curriculum

Research shows that a growing number of people in the United States are identifying as LGBTQ+. Therefore, it is more important than ever that clinicians are trained to be knowledgeable, inclusive, and culturally aware. Unfortunately, there is a lack of LGBTQ+ health education requirements in graduate medical education. As a result, fewer clinicians are prepared to care for this growing population. The shortage of knowledgeable clinicians contributes to LGBTQ+ health disparities and barriers to care. One strategy to combat these deficiencies in health care is for Family Medicine residency programs to create and carry out an LGBTQ+ health curriculum. This article will review LGBTQ+ health topics, identify efforts that Family Medicine residency programs can make, and summarize curriculum developments made by the St. Vincent's Family Medicine Residency Program.

Intersectional Effects of Sexual Orientation Concealment, Internalized Homophobia, and Gender Expression on Sexual Identity and HIV Risk Among Sexual Minority Men of Color: A Path Analysis

ABSTRACT

In the United States, 13 million people identify as sexual and gender minorities. The purposes of this article were to (a) examine the associations among sexual orientation concealment and internalized homophobia with HIV knowledge, health literacy, and transactional sex through sexual identity; and (b) assess whether gender expression moderates those relationships in sexual minority men of color. A multigroup mediation path model examined the association between sexual orientation concealment and internalized homophobia on HIV knowledge, health literacy, and transactional sex through sexual identity by gender expression. Results suggest that, among those with a masculine gender expression, as sexual concealment increased, health literacy decreased. The association between sexual orientation concealment and transactional sex varied by participant's gender expression as did the association between internalized homophobia and HIV knowledge. Multiple intersecting identities, when faced with anticipated discrimination and homophobia, can negatively affect health outcomes and increase HIV risk in sexual minority men of color.

Clinician's Experience and Self-Perceived Knowledge and Attitudes toward LGBTQ + Health Topics

Phenomenon: Research on clinicians' knowledge and attitudes toward lesbian, gay, bisexual, transgender, queer/questioning, and other sexual and gender minorities (LGBTQ+) health topics has relied mostly on small early-career samples. The influence of clinical experience on knowledge and attitudes has not been examined. The study purpose was to examine physicians' and advanced practice providers' (a) self-perceived knowledge and attitudes about LGBTQ + health topics, (b) the relationship between clinical experience and self-perceived knowledge and attitudes, and (c) preferences for LGBTQ + medical education.Approach: An online anonymous survey was emailed to 3667 physicians and advanced practice providers at a large southeastern multisite healthcare institution. Logistic regression determined associations between clinical experience, knowledge, and attitudes.Findings: There were 880 (24.0%) respondents. Most were physicians (70%). Thirty-eight percent had more than 15 years of experience. Fifty-four percent preferred online education. Few reported sophisticated knowledge of six LGBTQ + health topics (6%-10%). The majority felt that these were either important or very important for all physicians. After accounting for demographics, experience was not associated with knowledge or attitudes.Insights: Knowledge gaps yet positive attitudes suggest that additional training on LGBTQ + patients is warranted and likely to be well received. The lack of influence of experience on knowledge and attitudes may suggest that training is applicable to clinicians of all experience levels. Future research should determine if knowledge and attitudes toward LGBTQ + health topics influence culturally competent healthcare practices.

A Comparative Case Study Analysis of Cultural Competence Training at 15 U.S. Medical Schools

PURPOSE

Twenty years have passed since the Liaison Committee on Medical Education (LCME) mandated cultural competence training at U.S. medical schools. There remain multiple challenges to implementation of this training, including curricular constraints, varying interpretations of cultural competence, and evidence supporting the efficacy of such training. This study explored how medical schools have worked to implement cultural competence training.

METHOD

Fifteen regionally diverse public and private U.S. medical schools participated in the study. In 2012-2014, the authors conducted 125 interviews with 52 administrators, 51 faculty or staff members, and 22 third- and fourth-year medical students, along with 29 focus groups with an additional 196 medical students. Interviews were recorded, transcribed, and imported into NVivo 10 software for qualitative data analysis. Queries captured topics related to students' preparedness to work with diverse patients, engagement with sociocultural issues, and general perception of preclinical and clinical curricula.

RESULTS

Three thematic areas emerged regarding cultural competence training: formal curriculum, conditions of teaching, and institutional commitment. At the formal curricular level, schools offered a range of courses collectively emphasizing communication skills, patient-centered care, and community-based projects. Conditions of teaching emphasized integration of cultural competence into the preclinical years and reflection on the delivery of content. At the institutional level, commitment to institutional diversity, development of programs, and degree of prioritization of cultural competence varied.

CONCLUSIONS

There is variation in how medical schools approach cultural competence. Among the 15 participating schools, longitudinal and experiential learning emerged as important, highlighting the needs beyond mere integration of cultural competence content into the formal curriculum. To determine efficacy of cultural competence programming, it is critical to conduct systematic assessment to identify and address gaps. While LCME standards have transformed aspects of medical education, further research is needed to clarify evidence-based, effective approaches to this training.

Misinformation, Gendered Perceptions, and Low Healthcare Provider Communication Around HPV and the HPV Vaccine Among Young Sexual Minority Men in New York City: The P18 Cohort Study

Human papillomavirus (HPV) is the most common sexually transmitted infection among adults in the United States, and can cause several types of cancer. This is of particular concern for sexual minority men, as their increased risk of HIV acquisition increases risk for HPV and HPV-associated cancers, particularly when coupled with low rates of HPV vaccination. As part of a larger study of the syndemic of HIV, substance use, and mental health among young sexual minority men in New York City, we sought to explore what sexual minority men know about HPV and the HPV vaccine, along with their experiences have been communicating about the virus and vaccine. We interviewed 38 young sexual minority men with diverse sociodemographic characteristics and identified three main themes: low knowledge about HPV infection and vaccination, highly gendered misconceptions about HPV only affecting women, and lack of communication from healthcare providers about HPV. The prevalence of incorrect HPV knowledge, coupled with inadequate education and vaccination in healthcare settings, indicates a missed opportunity for HPV prevention in a high-risk and high-need population.

Assessing the LGBT cultural competency of dementia care providers

INTRODUCTION

Although dementia risk factors are elevated in lesbian, gay, bisexual, and transgender (LGBT) older adults and are perpetuated by a lack of cultural competency, no known studies have quantified LGBT cultural competency among dementia care providers.

METHODS

Dementia care providers (N = 105) across the United States completed a survey consisting of the 7-point Likert LGBT-Development of Clinical Skills Scale.

RESULTS

Dementia care providers reported very high affirming attitudes (M = 6.67, standard deviation [SD] = 0.71), moderate knowledge (M = 5.32, SD = 1.25), and moderate clinical preparedness (M = 4.93, SD = 1.23). Compared to previously published data, they reported significantly lower knowledge than medical students. There were no differences compared to psychiatry residents.

DISCUSSION

The current state of dementia care providers' LGBT cultural competency has significant, yet modifiable, gaps. Better education, including more LGBT patient exposure, is necessary to improve the care being provided to members of the LGBT community impacted by dementia illness.

Include-integrate-involve: Deciphering oral healthcare providers' professional demeanor towards sexual and gender minority cohorts in a metropolitan city of western India

Objectives

The Sexual and Gender Minorities (SGM) have been subject to disparities in healthcare. This study gauges and compares the demeanor of oral health task force in privately-funded and government-funded dental schools of India towards SGM cohorts.

Study design

A descriptive, cross-sectional, point prevalent study was conducted following standard statements of the STROBE guidelines and using the Medical Condition Regard Scale (MCRS). It was conducted among the clinical oral health taskforce hailing from private-funded and government-funded institutes.

Methods

One-way ANOVA test computed differences in mean MCRS scores among the undergraduates, postgraduates and faculty. Independent t-test compared responses of participants from private institutions and government institutions using SPSS version 17 statistical software.

Results

All the respondents were mostly but not completely satisfied to work with SGM patients (MCRS score ​= ​4.55 ​± ​1.114) indicative of some underlying hesitance. Though everyone had a positive regard, undergraduates and those from private institutions felt more compassionate and showed greater willingness to put in extra efforts to help them feel at ease (P-value <0.05). This is interpretive of more receptiveness towards specialized training and policy reforms of these individuals.

Conclusion

The significant differences between institutes and designations highlight disparities in knowledge and training resulting in the underlying hesitation. Health education urgently needs a targeted and focused SGM-related training program to deconstruct these disparities and provide equitable oral and general health for all individuals irrespective of their sexual orientation.

Hospice interdisciplinary team providers' attitudes toward sexual and gender minority patients and caregivers

OBJECTIVE

Hospice interdisciplinary team (IDT) providers' attitudes toward sexual and gender minority (SGM) patients and family caregivers impacts quality of care and end-of-life outcomes. This study assessed hospice IDT provider attitudes toward SGM patients and caregivers and identified demographic predictors.

METHODS

Hospice IDT providers (N = 122) completed an adapted 11-item scale measuring attitudes toward SGM hospice patients and caregivers. Descriptive statistics, confirmatory factor analysis, and regression models were conducted.

RESULTS

The hospice-adapted Attitudes Toward LGBT Patients Scale (ATLPS) demonstrated acceptable Cronbach's alpha (0.707). Total scores ranged from 32 to 55 (M = 47.04, SD = 5.64) showing that attitudes were generally positive. Being religious (B=-3.169, p = 0.008) was associated with more negative attitudes, while higher education (B = 1.951, p = 0.002) and time employed in hospice agency (B = 0.600, p = 0.028) were associated with more positive attitudes.

CONCLUSION

This is among the first studies to assess SGM-specific hospice IDT attitudes. Participants had relatively positive attitudes, influenced by religious beliefs, clinical experience, and education. CFA results suggest the need for better instruments to measure this complex construct.

PRACTICE IMPLICATIONS

Education incorporating evidence of disparities, life-course perspectives, and end-of-life experiences of diverse cohorts of SGM patients and families may build on hospice IDT members' experience and training by influencing attitudes, reducing bias and improving competency.

Educating health and social care practitioners on the experiences and needs of older LGBT+ adults: Findings from a systematic review

AIM(S)

To report review findings into interventions used to educate the health and social care workforce on the experiences and needs of LGBT+ older adults.

BACKGROUND

Research demonstrates that inequalities in outcomes on health and social well-being for LGBT+ older adults are perpetuated by the cumulative disadvantages from discrimination and social exclusion throughout the life course and a lack of culturally competent workforce.

METHODS

A systematic search of peer-reviewed papers published before February 2020 was conducted in electronic databases. The search resulted in a screening of 2,509 papers with nine matching the inclusion criteria, which were rated using the MERSQI quality measure.

RESULTS

Studies demonstrated some positive outcomes of interventions, especially an increase in knowledge, but less so in skills and attitudes.

DISCUSSION

More robust designs such as randomized controlled trials, the use of standardized measures and a focus more on the longitudinal impact of educational interventions could improve the quality of study designs.

CONCLUSION(S)

Diversification of intervention content and patient and public involvement in the design, delivery and evaluation of educational interventions could improve efforts and have a more sustained impact on LGBT+ ageing inequalities.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers have important roles in supporting staff education and ensuring LGBT+ inclusive practice.

Methods and strategies for effectively surveying the LGBTQ+ population

The Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) population is at a substantially elevated risk for myriad health complications, due in large part to structural and social inequities. As such, the LGBTQ population is an important demographic to survey regarding their health. As with many populations facing inequality, the LGBTQ population is often hard to sample. In light of this challenge, several approaches may be required in order to effectively surveying this population. Specifically, advances in sampling methodologies, leveraging community partnerships, and culturally aware question design appear to increase the likelihood of a successful LGBTQ-focused health survey. The Southern LGBTQ Health Study is examined as a case study in effectively conducting a large, multi-state LBTQ health survey. They used a simple snowball sampling strategy where their online health survey was distributed through a wide network of community organizations across several states. They also employed members of the LGBTQ community as "Survey Ambassadors" to help recruit their peers to participate in the study. This case study demonstrated several successful methods. Their combined sampling methodology resulted in almost 6000 respondents. Their question for sexual orientation ("Check all that apply") resulted in rich, easy to interpret data and was well received by the participants. However, this case study also provided valuable learning opportunities. Had they used a more formalized approach to their sampling, they would have had greater generalizability to their target population. Also, the use of an open-ended question regarding gender identity generated data that was not conducive to formal analysis without significant resources dedicated to cleaning the data.