Patient Acceptance of Sexual Orientation and Gender Identity Questions on Intake Forms in Outpatient Clinics: A Pragmatic Randomized Multisite Trial

Affirming Care for LGBTQ+ Patients

The lesbian, gay, bisexual, transgender, and queer(LGBTQ +) community is a marginalized minority group who continues to face and experience significant discrimination, prejudice, stigma, oppression, and abuse in various societal domains including health care. The older adult LGBTQ + community is an especially vulnerable group as they have unique minority stressors attributed to intersectional identities of age, ableism, ethnicity, and employment, among other factors. It is critical for health care providers to recognize and mitigate disproportionate care by engaging in strategies that promote inclusion and affirmation of their sexual orientation and gender identity. The biopsychosocial, cultural, and spiritual framework is a useful tool to care for this community in a holistic and compassionate way.

A Holistic Framework for the Evaluation of Kidney Function in a Gender-Diverse Landscape

The most commonly used equations to estimate glomerular filtration rate incorporate a binary male-female sex coefficient, which has important implications for the care of transgender, gender-diverse, and nonbinary (TGD) people. Whether "sex assigned at birth" or a binary "gender identity" is most appropriate for the computation of estimated glomerular filtration rate (eGFR) is unknown. Furthermore, the use of gender-affirming hormone therapy (GAHT) for the development of physical changes to align TGD people with their affirmed gender is increasingly common, and may result in changes in serum creatinine and cystatin C, the biomarkers commonly used to estimate glomerular filtration rate. The paucity of current literature evaluating chronic kidney disease (CKD) prevalence and outcomes in TGD individuals on GAHT makes it difficult to assess any effects of GAHT on kidney function. Whether alterations in serum creatinine reflect changes in glomerular filtration rate or simply changes in muscle mass is unknown. Therefore, we propose a holistic framework to evaluate kidney function in TGD people. The framework focuses on kidney disease prevalence, risk factors, sex hormones, eGFR, other kidney function assessment tools, and the mitigation of health inequities in TGD people.

Limitations and Future Directions in Sex, Sexuality, and Gender Diverse Research in Neurology

Sex, sexuality, and gender diversity is understudied and underserved in neurology. Neurology research inclusive of LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual) people is limited. Existing research struggles with a paucity of neurology studies collecting sex, sexuality, and gender diverse (SSGD) data, conflation of sex and gender, lack of precision in measures, neglect of younger and older populations, nebulous benefit to community, and absent intersectionality. Future directions in SSGD neurology research include precise and community-based measurements, respect for LGBTQIA+ colleagues, and the application of minority stress models. All patients stand to benefit from research that elucidates how SSGD variables influence neurological health. ANN NEUROL 2024;95:421-431.

The Society of General Internal Medicine's Recommendations to Improve LGBTQ + Health

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ +) individuals experience bias in healthcare with 1 in 6 LGBTQ + adults avoiding healthcare due to anticipated discrimination and overall report poorer health status compared to heterosexual and cisgendered peers. The Society of General Internal Medicine (SGIM) is a leading organization representing academic physicians and recognizes that significant physical and mental health inequities exist among LGBTQ + communities. As such, SGIM sees its role in improving LGBTQ + patient health through structural change, starting at the national policy level all the way to encouraging change in individual provider bias and personal actions. SGIM endorses a series of recommendations for policy priorities, research and data collection standards, and institutional policy changes as well as community engagement and individual practices to reduce bias and improve the well-being and health of LGBTQ + patients.

Adults' willingness to report sexual orientation and gender identity when registering for a digital health application: A cross-sectional quantitative study

The collection of patient sexual orientation and gender identity information is crucial in identifying and addressing disparities in healthcare access, quality, and outcomes for sexual and gender minority individuals. While some studies have explored patients' willingness to disclose this information in specific settings, little is known about response rates in digital health applications. In light of the growing use of digital health, including virtual care, we sought to determine whether adults would respond to optional sexual orientation and gender identity fields during registration for a digital health application offered through their employer-provided benefits. We analyzed response rates for sexual orientation and gender identity by age, race and ethnicity, and region among individuals over age 17 between September 9th and December 31, 2022. Our study, which included over 41,000 commercially-insured adults from all 50 states, found that nearly 80% were willing to report their sexual orientation and gender identity. However, we observed higher nonresponse rates among older adults and individuals living in central and southern regions, with no consistent pattern by race and ethnicity. Our findings indicate that digital health applications could be a valuable resource for collecting this data from a diverse group of adults. Nevertheless, digital health companies must ensure that they use the data responsibly, identifying quality improvement initiatives and contributing to research that can inform health policies for sexual and gender minority individuals.

Patient Attitudes on Collection of Sexual Orientation and Gender Identity Data in a Women's Health Clinic with an Embedded Transgender Medicine Program

Purpose: We examined patient attitudes about the collection of sexual orientation and gender identity (SOGI) data in a mixed sample of sexual and gender minority (SGM) and cisgender heterosexual people. Methods: SOGI questions and an evaluation questionnaire were administered to a convenience sample of patients presenting at an academic women's health clinic with an embedded transgender medicine program. Clinic census is ∼10,000 patients, which includes some 1000 cisgender males and 800 transgender patients. Bivariate and multivariate analyses were performed. Our methods expand on prior study in this area through implementing an analysis which divides the sample into three groups; cisgender heterosexual, cisgender sexual minority, and transgender respondents, and includes an intersectional approach to the analysis by income and age range, race/ethnicity, and presence of a non-English language spoken at home. Results: Some 231 respondents participated out of 291 approached, including 149 cisgender heterosexual respondents, 26 cisgender sexual minority respondents, and 56 transgender people of any sexuality. Scores were high regarding ease and accuracy of the SOGI questionnaire, and willingness to answer SOGI questions. Among those identifying as cisgender/heterosexual, non-White respondents had an odds ratio of 5.48 of being offended by sexual behavior questions compared with White respondents. Respondents overwhelmingly preferred to complete questionnaires through confidential electronic or pen-and-paper means. Conclusion: Patients were overwhelmingly willing to complete SOGI data questionnaires in a clinic setting, and preferred to do so using confidential means rather than by live interview by staff or providers.

Survey of Clinical Providers and Allied Health Staff at a National Cancer Institute-Designated Comprehensive Cancer Center: Cultural Awareness in the Care of LGBTQ2S + Patients with Cancer

To identify potential gaps in attitudes, knowledge, and practices towards LGBTQ2S + patients with a cancer diagnosis, a survey of clinical providers (CP) and allied health staff (AHS) was conducted to identify areas of improvement and guide development for future education and training. A previously published, validated survey was adapted at the direction of a LGBTQ2S + Patient and Family Advisory Council, and modified to include AHS. The survey was disseminated to all faculty and staff, and was adapted to the participants' self-identified level of patient interaction/care responsibilities. Subsections consisted of questions related to demographics, knowledge, attitudes, and practice behaviors towards participating in the care of LGBTQ2S + patients. Results were quantified using stratified analysis and an attitude summary measure. Of the 311 respondents, 179 self-identified as CPs and 132 as AHS. There was high agreement in comfort treating or assisting LGBTQ2S + patients by CP and AHS respondents, respectively. CPs possessed significantly higher knowledge regarding LGBTQ2S + health when compared to AHS; however, there remained high percentages of "neutral" and "do not know or prefer not to answer" responses regardless of clinical role. There was high agreement regarding the importance of knowing a patient's gender identity (GI) and pronouns (CP vs. AHS; 76.9% vs. 73.5% and 89.4% vs. 84.1%, respectively), whereas patient's sexual orientation and sex assigned at birth (CP vs. AHS; 51.1% vs. 53.5% and 58.6% vs. 62.9%, respectively) were viewed as less important. There was high interest in receiving education regarding the unique needs of LGBTQ2S + patients regardless of clinical role. Stratified analyses of CPs revealed early-career physicians (< 1-5 years from graduation) expressed higher interest in additional education and involvement with LGBTQ2S + -focused trainings when compared to mid- and late-career providers. This is the first study, to our knowledge, assessing the attitudes, knowledge, and practices of CPs and AHS regarding the care of LGBTQ2S + patients with cancer. Overall, there was high comfort treating/assisting LGBTQ2S + patients among CP and AHS respondents, respectively; yet, both groups possessed significant gaps in LGBTQ2S + -focused knowledge.

Validation of an administrative algorithm for transgender and gender diverse persons against self-report data in electronic health records

OBJECTIVE

To adapt and validate an algorithm to ascertain transgender and gender diverse (TGD) patients within electronic health record (EHR) data.

METHODS

Using a previously unvalidated algorithm of identifying TGD persons within administrative claims data in a multistep, hierarchical process, we validated this algorithm in an EHR data set with self-reported gender identity.

RESULTS

Within an EHR data set of 52 746 adults with self-reported gender identity (gold standard) a previously unvalidated algorithm to identify TGD persons via TGD-related diagnosis and procedure codes, and gender-affirming hormone therapy prescription data had a sensitivity of 87.3% (95% confidence interval [CI] 86.4-88.2), specificity of 98.7% (95% CI 98.6-98.8), positive predictive value (PPV) of 88.7% (95% CI 87.9-89.4), and negative predictive value (NPV) of 98.5% (95% CI 98.4-98.6). The area under the curve (AUC) was 0.930 (95% CI 0.925-0.935). Steps to further categorize patients as presumably TGD men versus women based on prescription data performed well: sensitivity of 97.6%, specificity of 92.7%, PPV of 93.2%, and NPV of 97.4%. The AUC was 0.95 (95% CI 0.94-0.96).

CONCLUSIONS

In the absence of self-reported gender identity data, an algorithm to identify TGD patients in administrative data using TGD-related diagnosis and procedure codes, and gender-affirming hormone prescriptions performs well.

Patient Perceptions of Sexual Orientation and Gender Identity Data Collection in an Outpatient Radiation Oncology Setting

PURPOSE

Sexual and gender minority patients with cancer experience significant health disparities requiring tailored care. Collecting sexual orientation and gender identity (SOGI) data in the electronic medical record (EMR) could allow care to be tailored and is in line with radiation oncology's mission to better serve diverse patients. This article describes a systematic method for collecting SOGI data for all patients starting radiation treatment in a department of radiation oncology (DRO).

METHODS AND MATERIALS

During a 3-month experimental period, DRO staff administered a demographic questionnaire and attitude survey to new adult patients. SOGI demographic data, entered into the EMR by nursing staff, were extracted and analyzed for all patients from the experimental period and from the 3 months prior (control period). Descriptive and categorical data completion rates were compared between the experimental and control periods using independent-samples t tests and Pearson χ2 tests.

RESULTS

A total of 788 patients were included in this analysis: 368 in the control period and 420 in the experimental period. Of the 420 patients enrolled in the experimental period, 267 (63.6%) were offered a survey, of whom 211 (79.0%) completed the survey. There were higher rates of sexual orientation responses entered into the EMR for the experimental group compared with the control group (56.9% vs 27.1%; P <.001), with the highest response rates for patients who completed a survey (82.9%). Ten patients (2.9%) identified as gay or lesbian and 100% identified as cisgender. The majority of patients were not upset by the form, with only 11 patients (5.2%) stating that any specific question caused them distress.

CONCLUSIONS

Collecting SOGI data via a demographic form is feasible in an outpatient DRO. This approach was well received by the majority of patients and could lead to provision of higher-quality, tailored care.

"No one size fits all" A Multi-Method Survey of Oncology Allied Health Professionals Experiences with Lesbian, Gay, Bisexual, Transgender/Queer Questioning Adolescent, and Young Adult Patients with Cancer and Reproductive and Sexual Health"

Objectives: To assess training needs for providers who care for adolescent and young adult (AYA) lesbian, gay, bisexual, transgender/queer questioning (LGBTQ) cancer patients, we conducted a mixed-method survey. During their cancer care experience, AYA cancer patients experience physical, psychosocial, and reproductive health challenges. In addition to these challenges, AYA LGBTQ individuals are a diverse and medically underserved population who experience unique challenges and disparities in medical care. Methods: Health care providers (n = 351) who participated in our reproductive health in cancer training program completed a survey with 28 quantitative items and 4 open-ended items assessing knowledge, confidence discussing reproductive health, and confidence in knowledge specific to reproductive needs and general health needs among AYA LGBTQ patients. Results: Confidence discussing and confidence in knowledge of reproductive and general health needs are lower regarding transgender and nonbinary patients. Nearly half of providers (45%) demonstrated low knowledge, while 38% and 17% demonstrated moderate and high knowledge, respectively. Open comments indicated providers desired more training around the needs of Trans and nonbinary patients, and creating welcoming environments. Conclusions: The majority of our participants demonstrate low or moderate knowledge regarding factors that can influence AYA LGBTQ patient care, suggesting that this is a key area for improvement. Furthermore, improving provider knowledge may subsequently improve confidence in general and reproductive needs of LGBTQ patients, resulting in improved patient-centered care. Improving provider knowledge and confidence may then ultimately help reduce disparities in cancer care among this patient population.

Equity for Sexual and Gender Diverse Persons in Medicine and Dermatology

Dermatologists can play a key role in improving health equity for sexual and gender diverse (SGD) patients through cultivating awareness of how their patients' sexual and gender identity may affect their skin health, developing SGD-inclusive curricula and safe spaces in medical training, promoting workforce diversity, practicing with intersectionality in mind, and engaging in advocacy for their patients, whether it be through daily practice, legislative and public policy initiatives, or research.

Imaging Care for Transgender and Gender Diverse Patients: Best Practices and Recommendations

Transgender and gender diverse (TGD) people experience health disparities, and many avoid necessary medical care because of fears of discrimination or mistreatment. Disparate care is further compounded by limited understanding of gender-affirming hormone therapy (GAHT) and gender-affirming surgery among the medical community. Specific to radiology, TGD patients report more negative imaging experiences than negative general health encounters, highlighting the need for guidance and best practices for inclusive imaging care. A patient's imaging journey provides numerous opportunities for improvement. Inclusive practice in a radiology department starts with ordering and scheduling the examination, facilitated by staff education on appropriate use of a patient's chosen name, gender identity, and pronouns. Contemporary electronic health record systems have the capacity for recording detailed sexual orientation and gender identity data, but staff must be trained to solicit and use this information. A welcoming environment can help TGD patients to feel safe during the imaging experience and may include institutional nondiscrimination policies, gender-neutral signage, and all-gender single-user dressing rooms and bathrooms. Image acquisition should be performed using trauma-informed and patient-centered care. Finally, radiologists should be aware of reporting considerations for TGD patients, such as avoiding the use of gender in reports when it is not medically relevant and using precise, respectful language for findings related to GAHT and gender-affirming surgical procedures. As a field, radiology has a range of opportunities for improving care delivery for TGD patients, and the authors summarize recommended best practices. See the invited commentary by Stowell in this issue. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Instituting Sexual Orientation and Gender Identity Training and Documentation to Increase Inclusivity at a Pediatric Health System

In this mixed-methods quality improvement project, we implemented and evaluated sexual orientation and gender identity (SOGI) form rollout in the electronic medical record. Families in our gender diversity program completed a baseline survey in 2017 (55/328 responded) and follow-up in 2020 (180/721 responded) to evaluate the frequency of affirmed name and pronoun use in the hospital. Survey feedback informed system-wide inclusivity efforts and training. SOGI was implemented in 2020 after 1,662 providers completed an online training and 11,090 team members completed gender and sexual orientation inclusivity training. We recommend similar trainings for health systems utilizing SOGI.

Health Communication and Sexual Orientation, Gender Identity, and Expression

The purpose of this article is to provide guidance on completing a thorough, competent, and culturally appropriate health history with details specific to the care of lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons and communities.

Effects of Including Gender Pronoun Questions in Surveys

This research examines whether the mere presence of asking about gender pronouns (e.g., she/her, he/him, they/them, and ze/zir) in a survey enhances participants’ attitudes and satisfaction of answering the questions. A large sample (N = 1,511) of heterosexual, cisgender, and LGBTQIA+ participants across the United States (US) were surveyed an online “personality test” (as a deception), with the real purpose of examining whether asking a pronoun question enhanced their perceptions of the survey. Three demographic groups were included: (i) heterosexual–cisgender (n = 503), (ii) gay–cisgender (n = 509), and (iii) genderqueer (trans, non-conforming, other, n = 499). Half of each group were randomly given either a survey that included a gender pronoun question (test) or not (control), and then all rated their perceptions of the survey questions. For participants who identified as heterosexual or gay, no major differences were found between survey conditions. However, participants who identified as genderqueer experienced significant increases of satisfaction, comfort level, and perceived relevance of the questions when given a survey that asked their gender pronouns versus the survey that did not. These findings have implications for any surveys that ask about personal demographics, and suggest that any form of written communication should include clarity about gender pronouns.

Ensuring equitable, inclusive and meaningful gender identity- and sexual orientation-related data collection in the healthcare sector: insights from a critical, pragmatic systematic review of the literature

In several countries, no gender identity- and sexual orientation-related data is routinely collected, if not for specific health or administrative/social purposes. Implementing and ensuring equitable and inclusive socio-demographic data collection is of paramount importance, given that the LGBTI community suffers from a disproportionate burden in terms of both communicable and non-communicable diseases. To the best of the authors' knowledge, there exists no systematic review addressing the methods that can be implemented in capturing gender identity- and sexual orientation-related data in the healthcare sector. A systematic literature review was conducted for filling in this gap of knowledge. Twenty-three articles were retained and analysed: two focussed on self-reported data, two on structured/semi-structured data, seven on text-mining, natural language processing, and other emerging artificial intelligence-based techniques, two on challenges in capturing sexual and gender-diverse populations, eight on the willingness to disclose gender identity and sexual orientation, and, finally, two on integrating structured and unstructured data. Our systematic literature review found that, despite the importance of collecting gender identity- and sexual orientation-related data and its increasing societal acceptance from the LGBTI community, several issues have to be addressed yet. Transgender, non-binary identities, and also intersex individuals remain often invisible and marginalized. In the last decades, there has been an increasing adoption of structured data. However, exploiting unstructured data seems to overperform in identifying LGBTI members, especially integrating structured and unstructured data. Self-declared/self-perceived/self-disclosed definitions, while being respectful of one's perception, may not completely be aligned with sexual behaviours and activities. Incorporating different levels of information (biological, socio-demographic, behavioural, and clinical) would enable overcoming this pitfall. A shift from a rigid/static nomenclature towards a more nuanced, dynamic, 'fuzzy' concept of a 'computable phenotype' has been proposed in the literature to capture the complexity of sexual identities and trajectories. On the other hand, excessive fragmentation has to be avoided considering that: (i) a full list of options including all gender identities and sexual orientations will never be available; (ii) these options should be easily understood by the general population, and (iii) these options should be consistent in such a way that can be compared among various studies and surveys. Only in this way, data collection can be clinically meaningful: that is to say, to impact clinical outcomes at the individual and population level, and to promote further research in the field.

“I Think There's Only Two Fields for That”: Hospital Registrar Attitudes and Practices for Collecting Patient Gender Identity Data

Purpose

This study aimed to understand the experiences of hospital registrars in collecting gender identity data.

Methods

A qualitative study that thematically analyzed key informant interviews with 37 registrars regarding their attitudes and practices in collecting gender identity data.

Results

Collection of gender identity is influenced by (1) system-level barriers, (2) discrepancies in source of truth for documentation, and (3) registrars' underlying attitudes and behaviors.

Conclusions

Findings demonstrate that person- and system-level barriers can interfere with the accurate and respectful collection of gender identity data, which is critical for tracking and addressing lesbian, gay, bisexual, transgender, and queer health disparities.

The Erasure of Intersex, Transgender, Nonbinary, and Agender Experiences Through Misuse of Sex and Gender in Health Research

Conflation of the terms and concepts of "sex" and "gender" continues to perpetuate the invisibility of sex and gender minorities and obscure information about the ways in which biological sex and gender affect health. The misuse of sex and gender terms and the sex and gender binaries can yield inaccurate results but also, more importantly, contributes to the erasure of intersex, transgender, nonbinary, and agender health experiences. In this article, we discuss ways in which public health researchers can use sex and gender terms correctly and center the health experiences of intersex, transgender, nonbinary, and agender individuals. This includes promoting sensitivity in approaching sex and gender minority communities, improving survey questions, and collaborating with GSM communities to improve research quality and participant experiences. Improving our standards for the quality of sex and gender term usage and centering sex and gender minorities in public health research are imperative to addressing the health inequalities faced by sex and gender minorities.

In her own words: understanding the health needs of older lesbians

This project illuminates the unique struggles and barriers lesbians face. A community advisory board (CAB) was developed and 31 in-depth interviews were conducted with lesbians aged 56-84 in the Rocky Mountain region. Interviews were audio recorded, transcribed, and coded using critical discourse analysis. Themes included: a culture of identity-hiding; lack of recognition and discrimination in health care; channeling passion, fear, and anger into action; concerns about aging; and identified health needs and opportunities. There is a need for innovative and equitable services that understand the barriers and struggles that older lesbian adults face so they can receive high-quality care.

LGBTQ-Affirmative Behavioral Health Services in Primary Care

Behavioral health concerns related to sexual and gender minority stress impair functioning and limit quality of life. With greater interest in implementing LGBTQ-affirmative health care practices, primary care providers likely will see larger numbers of LGBTQ individuals presenting with behavioral health concerns. Behavioral health and medical providers may not feel prepared to address the biological, psychological, social, and cultural minority stress factors that have an impact on LGBTQ patients. LGBTQ-affirmative behavioral health providers in primary care can offer a unique service by conducting tailored evaluations and individualized interventions targeting multifactorial influences that cause and perpetuate psychological distress in LGBTQ patients.

Screening for Gender Identity in Adolescent Well Visits: Is It Feasible and Acceptable?

PURPOSE

This study aimed to pilot systematic gender identity screening during adolescent well checks and examine perceptions of feasibility and acceptability of screening from adolescents, parents/guardians, and clinicians.

METHODS

Adolescents aged 12-18 years with a well visit between July 1, 2018, and June 30, 2019 (n = 134,114; 817 pilot and 133,297 usual care) in Kaiser Permanente Northern California (KPNC) pediatric primary care clinics. "What is your gender?" was added to the previsit questionnaire in pilot clinics; all other KPNC clinics provided usual care. Additional anonymous surveys were administered to adolescents and parents/guardians in the pilot clinics and to all KPNC pediatric clinicians. Multivariable logistic regression examined associations between clinics and patients reporting as transgender and gender diverse (TGD). Descriptive statistics summarized patient, parent/guardian, and clinician perceptions of gender identity screening.

RESULTS

Adjusting for age and race/ethnicity, adolescents had higher odds of reporting as TGD in pilot clinics than in usual care (odds ratio = 6.91, 95% confidence interval = 3.76-12.74). Two thirds of adolescents, 75.5% of parents/guardians, and 92.5% of clinicians felt it was important to screen for gender identity in primary care. Less than 2% of adolescents found the question confusing, offensive, or uncomfortable, and 2.8% of parents/guardians felt it was offensive. In addition, 36.4% of clinicians and 3.6% of parents/guardians were concerned it would affect visit workflow/time.

CONCLUSIONS

Most adolescents, parents/guardians, and pediatric clinicians viewed systematic gender identity screening as both feasible and acceptable. Standardized gender identity screening during adolescent well checks could facilitate and increase identification of TGD adolescents and the delivery of gender-affirming care for adolescents and families in need.

Implementation of Collection of Patients' Disability Status by Centralized Scheduling

BACKGROUND

Collection of disability status in electronic health records (EHRs) is critical to addressing the significant health care disparities experienced by patients with disabilities. Despite this, little evidence exists to inform implementation.

METHODS

This pilot trial evaluated the implementation of collection of patients' disability status during primary care new patient registration by centralized call center staff. The study took place over six weeks at an academic hospital system in Colorado. Staff received a 30-minute training on how to ask and document disability status in the EHR. Completion rate of collection, fidelity, and concordance were assessed through chart reviews and recordings of patient registration calls. Focus groups with staff and phone interviews with patients assessed the experience of including disability screeners in patient registration.

RESULTS

A total of 3,673 new patients were registered at one of the 53 primary care clinics during the study period. Completion of disability status in the EHR increased from 10% at baseline to > 50% by the last week of the trial, which was then maintained for eight weeks. Challenges were identified in the recorded calls with fidelity of if and how the questions were asked. No patient complaints were reported, and patients reported no concerns regarding collection of disability status during interviews.

CONCLUSION

Documenting disability status during patient registration was effective and was not concerning to patients. To make initial steps to providing equitable care, efforts should be made to implement this type of screening universally across the clinical encounter.

"It'd Be Great to Have the Options There": A Mixed-Methods Study of Gender Identity Questions on Clinic Forms in a Primary Care Setting

PURPOSE

Transgender youth experience significant barriers to health care. Asking patients about gender identity on clinic intake forms is recommended to improve care in adult populations. Little is known about how to implement these recommendations in adolescent populations. This study aimed to evaluate the addition of gender-related questions in an adolescent primary care setting and to determine if adding these questions to clinic forms could improve documentation of gender identity in the electronic health record (EHR).

METHODS

We conducted cognitive interviews with 21 adolescents (n = 11 transgender, n = 10 cisgender) to examine gender-related questions (name, pronoun, gender identity, assigned sex at birth). These questions were added to a clinic intake form. We conducted a retrospective chart review of patients who came to the clinic for a physical examination visit three months before (n = 615) and after (n = 827) the form change and used chi-square tests to examine the differences in EHR documentation of gender identity.

RESULTS

In interviews, the new questions were acceptable and interpretable to adolescents of diverse gender identities. Participants described the questions as beneficial to all patients and perceived them as an indicator of a welcoming clinic environment. The retrospective chart review found that provider documentation of gender identity in the EHR significantly increased after the form change from 51.3% to 66.3% (p < .0001).

CONCLUSIONS

This intervention was acceptable to adolescents and associated with a significant increase in EHR documentation. Future studies should investigate how the form change may have facilitated discussion about gender and health and implications for provider training and support.

Sexual minority bariatric patients: preliminary examination of eating behaviors, anxiety, and depression

BACKGROUND

Disparities in obesity care and bariatric surgery persist among patients of diverse identities. However, little is known about sexual minority (SM) bariatric patients.

OBJECTIVES

This study sought to describe, in a preliminary fashion, sexual orientation variables of outness, self-esteem, and perceived discrimination among a sample of SM patients pursuing bariatric surgery. The study also sought to compare SM and heterosexual bariatric candidates on measures of eating behaviors, anxiety, and depression.

SETTING

Academic medical center in the United States.

METHODS

Data were collected as part of a standard psychological evaluation for surgical clearance between May 1, 2018 and December 31, 2019. Data included demographic characteristics, sexual orientation variables, eating behaviors, anxiety, and depression. Descriptive statistics were included to present findings among SM patients. One-way analyses of covariance were conducted to assess differences between SM and heterosexual patients.

RESULTS

A total of 633 patients were evaluated (38 SM and 595 heterosexual). SM patients had high outness scores with high self-esteem and minimal perceived discrimination. SM patients endorsed lower cognitive restraint, higher disinhibition, and increased hunger compared with heterosexual patients (P < .05). SM patients also reported significantly more symptoms of anxiety and depression compared with heterosexual patients (P < .05).

CONCLUSIONS

Findings provide preliminary evidence toward the importance of assessing for sexual orientation among bariatric patients. Future research is warranted to assess the unique role of sexual orientation, as well as explore causal links between sexual orientation, eating behaviors, and mental health among bariatric patients pre- and post surgery.

Self-Reported Screening for Rectal Sexually Transmitted Infections Among Men Who Have Sex With Men

BACKGROUND

Rectal gonorrhea and chlamydia are common and predict human immunodeficiency virus (HIV) acquisition among men who have sex with men (MSM); however, screening for rectal sexually transmitted infections (STIs) is not routine.

METHODS

In 2017, we recruited sexually active MSM in the Portland, Oregon metropolitan area through venue-based sampling. Our outcome of interest was self-reported rectal STI screening in the prior 12 months among those who had a health care visit in the same time period. Stratified by HIV status and preexposure prophylaxis (PrEP) use, we assessed the prevalence and predictors of screening.

RESULTS

Of 403 participants, 162 (40.2%) reported rectal STI screening. Sixty (25.7%) of 233 HIV-negative men who did not report PrEP use in the prior 12 months; 61 (69.3%) of the 88 HIV-negative men who reported PrEP use in the prior 12 months; and, 41 (59.4%) of 69 men living with HIV-reported screening, respectively. Among HIV-negative men who did not report PrEP use in the prior 12 months, having a health care provider who offered HIV testing (adjusted prevalence ratio [aPR], 2.21; 95% confidence interval [CI], 1.38-3.52) and condomless anal sex with casual partners in the prior 12 months (aPR, 1.63; 95% CI, 1.01-2.65) were independently associated with rectal STI screening. The HIV-negative men on PrEP who had a syphilis diagnosis in the prior 12 months were more likely to be screened than those without syphilis (aPR, 1.33; 95% CI, 1.11-1.59). Men living with HIV who reported having a provider who always or often initiates conversations about sex were more likely to report screening compared with men who did not have such a provider (aPR, 1.46; 95% CI, 1.06-2.03).

CONCLUSIONS

Rectal STI screening is not universal in a venue-based sample of sexually active MSM. Implementing innovative, acceptable, and accessible screening practices, enhancing health literacy around STI screening and improving provider comfort with talking about sex are paramount to increasing rectal STI screening.

Planning and implementing sexual orientation and gender identity data collection in electronic health records

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people experience significant health disparities across the life course and require health care that addresses their unique needs. Collecting information on the sexual orientation and gender identity (SO/GI) of patients and entering SO/GI data in electronic health records has been recommended by the Institute of Medicine, the Joint Commission, and the Health Resources and Services Administration as fundamental to improving access to and quality of care for LGBTQ people. Most healthcare organizations, however, have yet to implement a system to collect SO/GI data due to multiple barriers. This report addresses those concerns by presenting recommendations for planning and implementing high-quality SO/GI data collection in primary care and other health care practices based on current evidence and best practices developed by a federally qualified health center and leader in LGBTQ health care.