Outness, Stigma, and Primary Health Care Utilization among Rural LGBT Populations

Patient care practices for LGBTQ+ individuals in clinical genetics: A scoping review

Individuals who are LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, and/or have a sexual orientations and/or gender identity beyond cisheteronormative conceptions) face systemic barriers to healthcare, leading to significant health inequities. To address these challenges, genetic providers must better understand and inclusively address LGBTQ+ patient needs. This scoping review aims to map the current landscape of genetic care practices and their inclusivity toward LGBTQ+ individuals. We conducted a systematic search of databases, including Ovid MEDLINE, PsycINFO, and Web of Science, identifying 65 relevant articles focused on LGBTQ+ patient experiences and care practices within genetic healthcare services. Our thematic analysis of the articles highlights three major themes: exclusionary clinical environments and tools, provider biases and educational needs, and patient-reported barriers in accessing genetic services. Many articles underscored the importance of inclusive language and criticized the conflation of sex, sex chromosomes, and gender. A significant focus was on cancer care for transgender and gender-diverse individuals, revealing a need for more data on the effects of gender-affirming care on cancer risk assessment. Moreover, genetic counselors often report insufficient training in LGBTQ+ health needs, contributing to biases and knowledge gaps. Despite increased awareness among providers of the need for inclusive care, LGBTQ+ patients encounter substantial barriers, including medical distrust and limited family health history, which may deter them from disclosing their identities due to the risk of discrimination. This review calls for standardized data collection practices regarding sex-related variables, gender modality, and sexual orientation, alongside specialized training programs for providers. By emphasizing critical areas for research, policy changes, and education, we aim to promote equitable, patient-centered genetic services for LGBTQ+ communities.

Emergency Healthcare Utilization and Unmet Care Needs in Chemsex Users: A Cross-Sectional Survey among Sexual Minority Men

Chemsex entails potential risks that may lead to medical emergencies. This cross-sectional study analyzed data from an anonymous, self-administered online survey on substance use among 1,203 sexual minority men (SMM) who engage in chemsex in Spain. The study aimed to determine the proportion of chemsex users that have sought emergency care following a session, identify their reasons for consultation, examine associated sociodemographic factors, and assess the proportion who felt they should have sought emergency care but did not. Frequencies of emergency consultations following chemsex sessions and episodes where participants felt they should have sought care but did not were calculated. Associations between seeking emergency care and sociodemographic and substance use factors were analyzed using Poisson regressions. Reasons for consultation were categorized based on responses to an open-ended question. 15.4% (95%CI:12.9-17.8) of chemsex users sought emergency care to request HIV post-exposure prophylaxis (PEP), and 4.0% (95%CI: 2.9-5.1) for other reasons. However, 21.8% (95%CI:19.3-24.2) did not seek care despite feeling they should have. The most common reasons for consultation were overdose symptoms, STI symptoms, and trauma. Living in smaller towns was associated with 2.4 times lower likelihood of visiting emergency services (95% CI:1.2-5.0). Injection substance use and mephedrone use were associated with 2.7 (95%CI:1.2-5.9) and 2.3 (95%CI:1.0-5.2) times higher likelihood of seeking care, respectively. Emergency visits for reasons other than requesting PEP were infrequent among chemsex users; however, a notable percentage felt they should have sought care but did not. Risk reduction strategies should prioritize addressing injection use and mephedrone consumption.

Sexual Violence and Revictimization in Rural LGBTQ+ Communities

Previous research has shown there is a high prevalence of sexual violence (SV) and revictimization among the LGBTQ+ community. Little is known about the prevalence of SV and revictimization among rural LGBTQ+ individuals. This study investigates patterns of revictimization and the prevalence of SV among sexual and gender minority individuals. Less resources, services, and more social isolation in rural areas may exacerbate SV. The Illinois Cohort Study is a longitudinal cohort made up of LGBTQ+ individuals with recruitment from June to September 2022. Individuals that have met the screening criteria were delivered a series of surveys for completion, after obtaining consent and given an incentive for their participation. Survey questions on intimate partner violence, sexual assault, and revictimization were collected and described using descriptive statistics. Rural areas were defined as having a population less than 50,000. A total of N = 74 participants responded to the third survey. There were 46% of participants who identified as non-cisgender, and roughly 48% of participants identified as bisexual, pansexual, or other. There were 58% of participants who experienced some form of SV. Factors significantly associated with SV included age, gender, and total Adverse Childhood Experience score (p < .001, .0278, and .002, respectively). There were 70% of participants who reported experiencing SV more than once. Those who reported being sexually victimized more than once reported the abuse lasting an average of 11 years. There were 46% of participants who felt unsafe or trapped in their current relationship. Lesbian (31%) or bisexual (31%) participants were significantly more likely to report feeling afraid in their relationship (p = .041). This study showed that in rural areas, SV is prevalent among LGBTQ+ individuals. Data can be used to produce interventions and resources to reduce the prevalence of SV and revictimization among rural LGBTQ+ individuals.

Investigating mental health disparities in rural sexual and gender minority adults: protocol for the rural exploration and approaches to LGBTQ + Mental Health (REALM) prospective cohort study

BACKGROUND

Sexual and gender minority (SGM) persons experience substantial mental health disparities throughout the life course, including increased vulnerability to depression and suicide. Few existing studies, however, have explored how pervasive experiences of SGM-related stigma, discrimination, and trauma (i.e., minority stress) contribute to adverse mental health outcomes among diverse sub-populations of SGM adults living in rural areas of the United States. This paper describes the protocol for a prospective cohort study, "Rural Exploration and Approaches for LGBTQ + Mental Health (REALM)," that will explore minority stress in relation to mental health conditions and suicidal behaviors among rural SGM adults.

METHODS

Online processes will be used to recruit and enroll a diverse sample of up to 2,500 SGM adults aged 18 + living in rural counties and small metropolitan areas in the United States to complete an online baseline survey. This will include: up to 1,000 cisgender sexual minority persons (up to n = 500 each cisgender women and cisgender men); and up to 1,500 gender minority persons (up to n = 500 persons who were assigned male at birth and identify as a woman, female, and/or transfeminine; up to n = 500 persons who were assigned female at birth and identify as a man, male, and/or transmasculine; and up to n = 500 persons who identify as some other gender, including non-binary, gender non-conforming, and/or agender regardless of sex assigned at birth). All enrolled participants will subsequently be followed over a 12-month period, with repeated surveys at three-month intervals. Included survey measures will focus on sociodemographic information, mental health, substance use, suicidal behaviors, minority stressors, psychological processes, and other related risk and protective factors.

DISCUSSION

This study presents a critical opportunity to better understand how minority stress contributes to adverse mental health outcomes among populations that remain underrepresented in research and programs in 2024. Results will be used to create more targeted, acceptable, and impactful intervention content and strategies that mitigate stigma, promote mental health, and prevent suicidal behaviors among rural SGM adults.

Characterization of People Living with HIV Who Inject Drugs in Mexico City: Importance for Transmission and Detection

People who inject drugs (PWID) face a heightened risk of acquiring/transmitting HIV, enhanced by stigma and limited health care access. In Mexico, studies on PWID have focused on the north of the country. This study aimed to delineate characteristics of PWID living with HIV in Mexico City, identify profiles based on the substance injected, and evaluate variables associated with forming transmission clusters. A cross-sectional study was conducted with data from 2019 to 2023. Participants completed a questionnaire on sociodemographic, clinical, and behavioral variables. Bivariate and multi-variate logistic regression analyses were made. Among PWID, 96.3% were male (n = 437), of which 90.1% were men who have sex with men, 1.5% were cisgender females (n = 7), and 2.2% were transgender females (n = 10). PWID were more likely to use drugs during sex (adjusted odds ratio [aOR] = 3.3, 95% confidence interval [CI]: 1.7-6.4, p < 0.001), have more sexually transmitted diseases (aOR = 1.7, 95% CI: 1.1-2.9, p = 0.035), and have less condom use (aOR = 0.5, 95% CI: 0.3-0.8, p = 0.002). The most frequently injected substance was crystal meth, and those who injected it were more likely to have syphilis (aOR = 2.9, 95% CI: 1.2-7.1, p = 0.021), use Grindr (aOR = 3.6, 95% CI: 1.5-8.9, p < 0.001), and engage in high-risk practices (aOR = 6.9, 95% CI: 2.1-22.7, p < 0.001) in the last 3 months. Those under 25 years (p = 0.002), recently infected (p < 0.001), and who practiced insertive anal sex (p < 0.001) were more likely to be part of a cluster. These findings, and the increasing use of crystal meth, underscore the critical need to implement targeted risk-reduction strategies for PWID living with HIV and to design interventions responsive to specific profiles associated with different substances, taking into account not only their risk practices but also protective behaviors such as HIV testing.

Marginalized Identities, Healthcare Discrimination, and Parental Stress about COVID-19

Objective

This paper assesses stress disparities among marginalized parents in 2020-21 during the COVID-19 pandemic through the mechanism of healthcare discrimination.

Background

The pandemic upended the lives of American families and had particularly stark mental health consequences for women, racial and ethnic minority (REM), and sexual and gender minority (SGM) parents. Scholars have been called to understand these unequal experiences via marginalizing mechanisms rather than using race, gender, and sexual identities as proxies for racism, sexism, and cis-heterosexism.

Method

Structural equation modeling was used to test associations between marginalized identities and parental stress about COVID among partnered parents using healthcare discrimination, a marginalizing mechanism, as a mediator. The data come from The National Couples' Health and Time Study, a population-representative study of couples in the U.S.

Results

Findings indicate that compared to non-marginalized parents, Black parents, women, transgender and non-binary parents, and gay, lesbian, and bisexual parents experienced higher levels of parental stress about COVID through heightened healthcare discrimination. When accounting for healthcare discrimination, only one marginalized identity-that of women-was directly associated with parental stress about COVID along with the indirect relationship through healthcare discrimination.

Conclusion

These findings highlight healthcare discrimination as a process that puts marginalized parents at risk for heightened stress. Parental stress has the potential to accumulate across the life course and crossover to children and communities.

Relationships between structural stigma, societal stigma, and minority stress among gender minority people

Structural stigma towards gender minority (GM; people whose current gender does not align with sex assigned at birth) people is an important contributor to minority stress (i.e., stress experienced due to one's marginalized GM identity), although existing variables are unclear in their inclusion of social norms, or societal stigma, as a key component of the construct. We examined potential variables representing structural stigma, including variables that are inclusive of societal stigma, to identify those that most strongly relate to minority stress outcomes. We tested variables identified in the literature as measures of structural stigma inclusive of societal stigma (LGBT + Business Climate Index, state voting behaviors, and Google Trends search data), the most commonly used structural stigma variable (State Policy Environment Tally), and proxy variables (region, population density) for comparison. The relationships between structural stigma and minority stress model outcomes were tested in a sample of GM participants from The Population Research in Identity and Disparities for Equality (PRIDE) Study (N = 2,094) 2019 Annual Questionnaire using a structural equation model (SEM). Lower structural stigma (i.e., higher LGBT Business Climate Index) was associated with lower experienced stigma (β= -0.260, p < .01) and lower anticipated stigma (β= -0.433, p < .001). Greater conservative voting behavior was associated with less experienced stigma (β= -0.103, p < .01). Living in a more densely populated county was also associated with lower anticipated stigma (β=-0.108, p < .001) and greater identity outness (β = 0.053, p < .05). Two of the identified structural stigma variables that were inclusive of societal stigma (i.e., LGBT + Business Climate Index, conservative voting behaviors) and one proxy variable (population density) were associated with minority stress outcomes. However, the most commonly used variable for structural stigma (State Policy Environment Tally) was not associated with any outcomes. The State LGBT + Business Climate Index showed the most promise for use as a structural stigma variable in future research. The application of this variable should be investigated further to explore its association with health outcomes and to inform efforts to reduce health equity barriers experienced by GM people through addressing structural stigma in a manner inclusive of societal stigma.

Racism, homophobia, and the sexual health of young Black men who have sex with men in the United States: A systematic review

Black gay, bisexual, and other men who have sex with men (BMSM) experience the highest rates of HIV acquisition annually out of any population in the United States, and young BMSM (YBMSM) are heavily impacted by this inequity as they enter adulthood. Despite a high annual HIV incidence, extant literature has found BMSM to engage in fewer sexual risk behaviors than White and Hispanic/Latino men who have sex with men, resulting in a gap between risk behaviors and the inequity of HIV infection. Structural factors, such as racism and homophobia, are thus being examined in order to understand this disconnect between behavior and HIV incidence. The purpose of this systematic review was to examine the discrimination experiences of YBMSM due to racism and homophobia in the United States and to evaluate the effect of these experiences on their sexual health. Four databases (MEDLINE, CINAHL Complete, APA PsycINFO, and Sociology Source Ultimate) were searched to examine the available qualitative, quantitative, and mixed method studies relevant to the research question. Out of 17 included studies, the majority were qualitative in design and were conducted in urban settings. Racism and homophobia affected YBMSM's sense of belonging, sexual identity, and sexual partnership choices. Often, masculinity would interact with these two constructs to impact how YBMSM engaged in sexual behavior, such as condomless sex, as well as their likelihood to seek sexual health care. Future research is needed to fully understand the relationships between discrimination and sexual health to develop effective structurally responsive interventions that will help decrease the inequities experienced by YBMSM.

Unmet Healthcare Needs and Medical Cannabis Use Among Sexual and Gender Minoritized Adults in a High-Stigma Environment

Sexual and gender minoritized (SGM) individuals in high-stigma areas may use cannabis to cope with unmet healthcare needs and elevated stress. Adults in Oklahoma (Mage = 43.9[SD = 16.8], 54.5% female, 71.4% non-Hispanic White) completed a cross-sectional survey (August-September 2022). Logistic regression examined the association of SGM identity (SGM or non-SGM) with past-year unmet healthcare need (yes/no). Logistic and linear regressions also examined main and interactive effects of SGM identity and unmet healthcare needs on past-month medical cannabis use and number of relaxation/tension-reduction reasons for cannabis use endorsed. Analyses were unadjusted and adjusted for sociodemographic and healthcare characteristics. In adjusted analyses, SGM (vs. non-SGM) adults were more likely to report unmet healthcare needs (aOR = 2.24, 95% CI[1.47, 3.42], p < .001) and past-month medical cannabis use (aOR = 2.15 [1.07, 4.34], p = .033). In unadjusted analyses, SGM (versus non-SGM) adults and those with unmet healthcare needs (versus without) endorsed more relaxation/tension reduction reasons for cannabis use in separate main effects (ps < .029), and adults with unmet healthcare needs (vs. without) were more likely to report past-month medical cannabis use (OR = 2.31 [1.86, 2.88]). SGM identity X unmet healthcare need interactions did not emerge (ps > .05). SGM individuals in high-stigma environments may use cannabis to compensate for insufficient healthcare.

Applying the Concept of Epistemic Injustice as a Philosophical Window to Examine Discrimination Experiences of LGBTQIA+ Migrants With Nurses

Both stigma and discrimination, defined as a lack of knowledge of and a sense of discomfort in providing care to lesbian, gay, bisexual, transgender, queer, intersex, and + (LGBTQIA+) migrants, was found to manifest in a sample of LGBTQIA+ migrants who received nursing care in a recent study. The study concluded that nurses continue to have a limited understanding of the experiences of LGBTQIA+ migrants in the Canadian context, and that LGBTQIA+ migrants continue to have troubling 'care' experiences with nurses. Miranda Fricker has developed the concept of epistemic injustice drawing on feminist philosophy and social epistemology. Epistemic injustice refers to unfair treatment of a person by judging them as 'not a knower' in a communicative situation. For example, in a few circumstances when LGBTQIA+ migrants were admitted to psychiatric units due to suicide ideations as a direct result of identifying as a LGBTQIA+ migrants, the medical and nursing team responded with 'They are in Canada now. It is safe here!' and 'So, you are [LGBTQIA + ]! What's the big deal?' These unjust statements reflect an epistemic situation in which the hearer is negating what was heard, that is, that the speaker's intersecting identities of LGBTQIA+ and new immigrant has directly led to suicide ideation. The concept of epistemic injustice helps to frame this situation as one where the care provider is not doing justice to the needs of LGBTQIA+ migrants. This article draws on the narrative of an LGBTQIA+ migrant who is not recognised as a credible source of knowledge about their own lives and needs in the context of Canadian nursing care. Epistemic injustice helps to understand how stigma and discrimination is produced in this community by the very nursing profession who ostensibly want to help them.

Cisgender Sexual Minority Women's Interest in Telemental Health Services: A Latent Class Analysis

Introduction: Telemental health is increasingly recognized for its potential to overcome barriers like cost and stigma, particularly for marginalized groups. Sexual minority women in particular may benefit from increased access to telemental health services, due to the unique health disparities faced by this population. However, very little research thus far has assessed the telemental health preferences of this group. Methods: The present study surveyed 1,092 cisgender sexual minority women regarding their demographic information, mental health, and telemental health preferences, using the Prolific.co research platform. Latent class analysis was conducted to identify subgroups within the sample based on their responses to the survey. Results: Results revealed diverse attitudes toward telemental health, with some that prefer in-person sessions, whereas others show a strong interest in virtual options. Latent class analysis identified five groups, termed the Neutral, Ambivalent, Inclined, Inclined Related to Travel, and Averse groups. There were statistically significant differences between groups on measures of rurality, socioeconomic status, previous therapy experience, and symptoms of depression and anxiety. Overall, sexual minority women demonstrated interest in telemental health, especially individuals with mobility challenges and those living in rural areas. Conclusion: This study underscores the importance of tailoring mental health services to diverse needs and suggests that telemental health could be a valuable tool in addressing health disparities among sexual minority women. Importantly, these data were conducted prior to the COVID-19 pandemic. Further research could examine how sexual minority women's attitudes toward telemental health have shifted since the COVID-19 pandemic and how telemental health services could be tailored for marginalized subgroups.

Substance Use and Discrimination in a Sample of U.S.-Based Latinx Sexual Minority Men and Their Main Partners

OBJECTIVE

Substance use, including drug and alcohol misuse, is associated with myriad health conditions, including a higher risk for HIV infection. Although preliminary evidence suggests that higher levels of relationship functioning can buffer against the deleterious health consequences of discrimination on mental health broadly, such protective associations have been understudied with respect to alcohol and drug use. The topic is particularly understudied among Latino sexual minority men even though they are at greater risk for problematic substance use behaviors and are likely to experience multiple forms of discrimination (e.g., racism, homophobia).

METHOD

To address this gap in the literature, we sampled 95 predominantly Latino sexual minority male couples to assess their drinking and drug use behaviors, relationship functioning, and experiences of discrimination. We used Actor-Partner Interdependence models to test our hypotheses.

RESULTS

We found that having a partner who experienced discrimination and higher partner reports of relationship functioning buffered against the negative relationship between own experiences of discrimination and drug use, but not problematic drinking.

CONCLUSIONS

Our results suggest that higher relationship functioning serves as a buffer between the negative ramifications of discrimination on drug use, but not problematic drinking. We explicate implications for policy and practice to facilitate well-being among coupled Latino sexual minority men.

Social and Systemic Barriers to Transition-Related Surgical Procedures for Transgender Americans

Purpose: Transgender and gender-diverse (TGD) individuals in the United States face disproportionate barriers to health care access. This study compared characteristics of individuals who have and have not undergone gender-affirming surgery with the goal of identifying social and systemic barriers to transition-related surgery. Methods: Data were extracted from the 2015 United States Transgender Survey, a cross-sectional nonprobability sample of nearly 28,000 TGD adults. The primary outcome was having undergone gender-affirming surgery. Multivariable logistic regression models were constructed to determine correlates of receipt of gender-affirming surgery. A subgroup analysis was performed to explore differences by insurance types regarding coverage of surgical procedures and presence of in-network providers. Results: In total, 6009 (21.7%) participants underwent transition-related procedures. Increased odds of undergoing surgery were associated with older age, living in congruent gender, higher education attainment, and greater income. Decreased odds were linked with male sex assignment at birth, first recognizing TGD status at older ages, living in states without trans-protective health laws, no close transgender-knowledgeable health care provider, nonbinary status, and identifying as sexual minority. Residing in states without trans-protective health laws correlated with increased surgery denials over the previous 12-month period. Compared to White TGD individuals, TGD individuals who were Black, Latinx, or Another Race were significantly more likely to encounter health equity-related barriers to surgery. Conclusions: Gender-affirming surgery access is differentially distributed across demographic and modifiable equity-related factors amenable to interventions. Efforts are needed to address the number and geographic distribution of transgender health-competent providers, improve TGD legal protections, and increase access to health insurance for minority TGD individuals, who are disproportionately under/uninsured.

Hepatitis A vaccination in a racially and sexually diverse population of gay, bisexual, and other men who have sex with men: Findings from the QVax study

BACKGROUND

Previous studies found vaccination uptake of vaccine-preventable diseases (VPD) to be associated with race/ethnicity and medical mistrust among key populations, however, few studies examine Hepatitis A vaccination uptake.

METHODS

This cross-sectional study used online survey data collected from NJ and NY residents identifying as lesbian, gay, bisexual, transgender, queer (LGBTQ+) from October 2021 through November 2022.

RESULTS

This study used a subsample of 222 gay, bisexual, and other cisgender men, 66.7% White, with mean age 41.22 years (SD = 15.23), and 60% fully vaccinated for Hepatitis A. Overall, average group-based medical mistrust scores did not differ among non-vaccinated participants compared to fully or partially vaccinated participants. However, higher group-based medical mistrust scores were associated with non-White identifying participants, and were highest among Hispanic/Latinx (2.68, sd = 0.43) and Black non-Hispanic (2.58, sd = 0.50) participants (p < .001). Vaccination patterns did not differ among fear or vaccine confidence-based items.

CONCLUSIONS

Our results contribute to the limited knowledge of differences in Hepatitis A vaccination uptake among men who have sex with men, and support the need for targeted intervention programs that acknowledge the diverse population of LGBTQ + identifying individuals and their associated health behaviors.

Non-binary patients in ART: new challenges and considerations

OBJECTIVES

To discuss the increasing visibility of non-binary individuals and inclusive policies and practices in assisted reproductive technologies (ART).

METHODS

Comparison between traditional ART approach designed for binary genders and propose approach in non-binary individuals.

RESULTS

Traditional ART services, designed for binary genders, must adapt to address the unique fertility needs of non-binary patients. This includes using gender-neutral language, providing comprehensive fertility assessments, and offering hormone therapy and fertility preservation options. Children of non-binary parents benefit from open communication about gender diversity, enhancing psychological well-being. Positive societal attitudes and inclusive environments in schools are crucial for preventing discrimination and promoting mental health. A systemic approach is required to make ART inclusive. This involves training staff, adjusting facilities, updating documentation, and advocating for supportive legislation. Addressing the reproductive needs of non-binary individuals ensures equitable access to care and supports their family-building goals.

CONCLUSIONS

Ensuring the well-being of children in non-binary families requires psychological support, inclusive healthcare, legal recognition, social support, and comprehensive education.

Transgender, Gender-Diverse, and Nonbinary Experiences in Physical Therapy: A Descriptive Qualitative Study

OBJECTIVE

The objective was to explore experiences with and identify barriers and facilitators of utilizing physical therapy for people who identify as transgender, gender diverse, and nonbinary (TGNB).

METHODS

A qualitative descriptive design was employed using semistructured interviews conducted in New Zealand. Eligible participants were individuals who were 12 years old or older, who self-identified as TGNB, and who had accessed physical therapy at a community-based clinic that also provides a gender-affirming service. Participants were recruited via email invitation to the clinic database. Interview data were analyzed using reflexive thematic analysis. Demographics are reported descriptively.

RESULTS

Seventeen individuals (15-64 years old and identifying as 11 different genders) participated. All participants reported physical therapy experiences relating to 1 or more of the following 4 themes: challenging cisnormativity at policy, environmental, clinic, and therapist levels; safety and trust throughout the clinical experience, including clinic credibility for being a safe provider, clinic displays of TGNB inclusivity, implementation of safe clinic processes, and respectful therapist interactions; inclusive experiences in a clinic that provided affordable care and took active steps to understand and affirm TGNB identities and with physical therapists who had a high level of knowledge of TGNB-specific health issues and took a biopsychosocial approach to care; and sensitivity to body discomfort or dysphoria triggers. Barriers to and facilitators of care were identified at policy, environmental, clinic, and therapist levels.

CONCLUSION

People who identify as TGNB face challenges to accessing safe and culturally sensitive physical therapy. However, there are achievable areas for improvement at policy, environmental, clinic, and physical therapist levels to gain trust and engagement in care for the TGNB community.

IMPACT

This study provides a detailed exploration of TGNB physical therapy experiences and identifies specific areas of improvement for TGNB physical therapy care to provide clinicians and physical therapy clinics insights into the provision of safe and culturally sensitive physical therapy.

LGBTQIA+ Cultural Competence in Physical Therapist Education and Practice: A Qualitative Study From the Patients' Perspective

OBJECTIVE

The purpose of this study was to explore the experiences of cultural competence and humility among patients of the lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) community in physical therapy. Researchers sought to understand the perspectives of adults over 18 years old who have received physical therapy and identify as a member of the LGBTQIA+ community.

METHODS

A phenomenological qualitative approach was utilized for this study. Patients were recruited through social media and LGBTQIA+ advocacy organizations across the United States. Twenty-five patients agreed to participate in the study. Focus groups and individual interviews were conducted using a semi-structured interview guide informed by Campinha-Bacote domains of cultural competence (cultural awareness, skill, knowledge, encounter, and desire) to collect individual experiences, discussions, thoughts, perceptions, and opinions.

RESULTS

Three central themes and subthemes emerged from the data and were categorized according to cultural acceptance (societal impact, implicit and explicit bias), power dynamics between the in-group and out-group (out-group hyperawareness of their otherness), and participant solutions (policy, training, education).

CONCLUSION

An LGBTQIA+ patient's experience is influenced by the provider cultural acceptance, and the resulting power dynamics that impact LGBTQIA+ patients' comfort, trust, and perceptions of care. Enhanced patient experiences were found more prevalent with providers that possessed elevated levels of education or experience with this community, supporting Campinha-Bacote assumption that there is a direct relationship between level of competence in care and effective and culturally responsive service.

IMPACT

Awareness of the underlying issues presented in these themes will assist in the development of effective solutions to improve LGBTQIA+ cultural competence among physical therapists and physical therapist assistants on a systemic level.

Compulsive Sexual Behavior Disorder and Problematic Pornography Use in Cisgender Sexual Minority Individuals: The Associations with Minority Stress, Social Support, and Sexualized Drug Use

Compulsive Sexual Behavior Disorder (CSBD), recently recognized in the ICD-11 as an independent disorder, has been shown to be more prevalent in sexual minorities. However, we still lack studies investigating which factors contribute to CSBD and related behaviors in this group. In our cross-sectional study, we investigated the relationships between characteristics potentially contributing to CSBD and problematic pornography use (PPU) in sexual minority individuals: sexual minority stress (internalized sexual stigma, discrimination experiences, and openness about one's sexual orientation), perceived social support, and sexualized drug use (also more prevalent in sexual minorities). We adjusted for gender, age, sexual orientation, and the frequency of sexual behaviors. Cisgender sexual minority participants (n = 198, 72.7% men, 27.3% women; Mage = 27.13, SD = 7.78) completed an online survey. We conducted a two-step linear regression. In the first step, we introduced sociodemographic variables and the frequency of sexual activities. In the second step, we placed the predictors of main interest: perceived social support, minority stress measures, and the frequency of sexualized drug use. Our results showed that social support was negatively related to CSBD, while experiences of discrimination due to sexual orientation and engagement in sexualized drug use were associated with higher CSBD symptom severity. Internalized sexual stigma related to greater PPU severity. The discussed relationships were weak to moderate in strength. Implications of current results for therapy and diagnosis of CSBD in sexual minorities are discussed. The role of minority stressors and other factors specific to sexual minorities requires further exploration to design well-suited therapeutic interventions.

'A void in our community': exploring the complexities of delivering and implementing primary care services for transgender individuals in Northern Ontario

AIM

To understand how the implementation of primary care services for transgender individuals is undertaken and delivered by practitioners in Northern Ontario.

BACKGROUND

Northern Ontario, Canada, has a shortage of primary care health practitioners, and of these, there are a limited number providing transgender primary care. Transgender people in Northern Ontario must also negotiate a lack of allied and specialty services related to transgender health and travel over long distances to access those services that do exist.

METHODS

A convergent mixed methods design was guided by normalization process theory (NPT) to explore transgender primary care delivery and implementation by nurses, nurse practitioners, physicians, social workers, and psychotherapists. A survey measuring implementation processes was elaborated through qualitative interviews with participants. Analysis of key themes emerging using the NPT framework informed understanding of primary care successes, barriers, and gaps in Northern Ontario.

FINDINGS

Key themes included the need for more education on transgender primary care practice, increased need for training and awareness on transgender resources, identification of unique gaps and barriers to access in Northern Ontario transgender care, and the benefits of embedding and normalizing transgender care in clinical practice to practitioners and transgender patients. These findings are key to understanding and improving access and eliminating healthcare barriers for transgender people in Northern Ontario.

Social influence on drug use and sexual behaviors among rural LGBTQ+ individuals

Background: Traveling to meet sexual partners and substance use are associated with increased risk of infectious disease. It is important to understand what factors may increase substances use or increased infection transmission risk (IITR) sexual behaviors among rural LGBTQ+ individuals.Objective: This study investigates substance use and sexual behaviors associated with increased infection transmission risk among rural LGBTQ+ individuals, and how these are associated with relationship type (friends or romantic partners) and travel distance.Methods: Participants (18 years+, identify as LGBTQ+, and provided a $25 gift card) were recruited from Illinois (25 counties), in 2021. Data included demographics, sexual and drug use behaviors, and assessed how these behaviors varied by relationship type and distance traveled (e.g. when meeting friends out-of-state).Results: The 398 participants were 79.1% White and 12.3% Black. By orientation, 29% heterosexual, 36% gay/lesbian, and 35% bisexual/other. By identity, 43% cisgender male, 51% cisgender female, and 6% genderqueer/other. Alcohol use while visiting out-of-state friends was more frequent among transgender (vs cisgender men; OR = 9.686, 95% confidence interval = 2.123-44.19), and individuals traveling > 1/month (all p < .050). Infection-related sexual behaviors while visiting out-of-state romantic partners was more frequent among prescription medication misuse (all p < .050) and traveling > 1/week (vs < 1/month; OR = 3.399, 95% CI = 1.037-11.144).Conclusion: This study of rural LGBTQ+ identified that alcohol use was associated with travel to visit out-of-state romantic partners, and prescription medication misuse increased infection-related sexual behavior during out-of-state travel. Health professionals can develop substance use and increased infection transmission risk sexual behavior interventions on gender minority groups in rural areas and target those who are traveling.

Assessing the Conceptualizations of Coping and Resilience in LGBTQ2S+ People with Cancer: Working towards Greater Awareness in Cancer Care

People with cancer may suffer negative psychosocial outcomes due to the challenges of cancer. LGBTQ2S+ people routinely experience negative psychosocial outcomes in health care settings, but have showcased resilience in the face of discrimination; however, this has never been studied in a cancer context. Thus, this study aims to assess coping and resilience in LGBTQ2S+-identifying people diagnosed with cancer using a strengths-based approach. A qualitative exploratory design was used. Ten self-identified LGBTQ2S+ people who have completed their cancer treatment were recruited. Participants completed clinical, health, and demographic questionnaires and, subsequently, semi-structured qualitative interviews. Conceptualizations of coping and resilience in the semi-structured interviews were analyzed using interpretative phenomenological analysis (IPA). Participants were members of various gender identities and sexual orientations. In addition to identifying needed LGBTQ2S+-specific resources, four narratives emerged: support networks, regaining control in life, conflicting identities, and traditional coping methods. Most participants' cancer journeys were characterized by a 'Second Coming-Out' phenomenon, where LGBTQ2S+ people with cancer use coping strategies, similar to those used when coming out, to produce resilience throughout their cancer journey. This work provides exploratory insight into LGBTQ2S+ people with cancer, but more research is required with a larger sample.

Understanding the Experiences of Latinx LGBTQ Texans at the Beginning of the COVID-19 Pandemic

Marginalized communities have been disproportionately affected by COVID-19, including both racial/ethnic minority and sexual minority populations. To date, there has been little research examining the impact of the COVID-19 pandemic at the intersections of marginalized identities. Furthermore, available national data on COVID-19 outcomes may obscure our understanding of region-specific outcomes, particularly in the U.S. South. Using an intersectional approach, we explore differences in worries over COVID-19, preventative behaviors, and COVID-19 outcomes in the early months of the pandemic in a diverse sample of LGBTQ people (N = 1076) living in Texas. Our findings indicated that LGBTQ Latinx people in Texas reported more COVID-19 related worries and adverse outcomes than non-Latinx LGBTQ people. These findings are in line with previous research that found that the increased risk to Latinx and LGBTQ populations in public health crises is often overlooked and can be attributed to many factors such as socioeconomic status, occupational propensity, disparities in physical health, and barriers to healthcare access. Furthermore, our findings suggest the necessity of utilizing an intersectional approach when examining the disproportionate burden marginalized communities face in public health crises.

Travel Burden and Timely Linkage to Care Among People Newly Diagnosed with HIV Infection in South Carolina from 2005 to 2020

This retrospective study explored the association between travel burden and timely linkage to care (LTC) among people with HIV (PWH) in South Carolina. HIV care data were derived from statewide all-payer electronic health records, and timely LTC was defined as having at least one viral load or CD4 count record within 90 days after HIV diagnosis before the year 2015 and 30 days after 2015. Travel burden was measured by average driving time (in minutes) to any healthcare facility visited within six months before and one month after the initial HIV diagnosis. Multivariable logistic regression models with the least absolute shrinkage and selection operator were employed. From 2005 to 2020, 81.2% (3,547 out of 4,366) of PWH had timely LTC. Persons who had longer driving time (adjusted Odds Ratio (aOR): 0.37, 95% CI: 0.14-0.99), were male versus female (aOR: 0.73, 95% CI: 0.58-0.91), had more comorbidities (aOR: 0.73, 95% CI: 0.57-0.94), and lived in counties with a higher percentage of unemployed labor force (aOR: 0.21, 95% CI: 0.06-0.71) were less likely to have timely LTC. However, compared to those aged between 18 and 24 years old, those aged between 45 and 59 (aOR:1.47, 95% CI: 1.14-1.90) or older than 60 (aOR:1.71, 95% CI: 1.14-2.56) were more likely to have timely LTC. Concentrated and sustained interventions targeting underserved communities and the associated travel burden among newly diagnosed PWH who are younger, male, and have more comorbidities are needed to improve LTC and reduce health disparities.

An examination of nurse practitioner students' perceptions of knowledge, confidence, and experiences related to caring for lesbian, gay, bisexual, transgender, and queer or questioning patients: A national perspective

BACKGROUND

Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) individuals are significantly less likely to have a primary health care provider, be uninsured, and postpone medical care. A health care provider's lack of knowledge in LGBTQ+ health needs, low confidence in discussing sexuality, and bias can result in LGBTQ+ patients choosing to delay or avoid seeking care. These are missed opportunities for health care providers to recognize their unique needs, provide education and preventive screenings and care, and manage chronic conditions.

PURPOSE

The aim of this study was to examine nurse practitioner students' perceptions of knowledge, confidence, and experiences related to caring for LGBTQ+ patients.

METHODOLOGY

Using a descriptive, cross-sectional survey research design, a 29-item online survey was distributed through email to nurse practitioner students (n = 419) across the United States.

RESULTS

Overall, nurse practitioners (NP) students demonstrated infrequent questioning related to gender preferences, sexual terms, and clarification of relationships. Results showed that 77.9% of NP students within two terms of graduation had not received any LGBTQ+-specific training. Almost 75% of the NP students reported not routinely asking about sexuality, and 82% reported infrequently or never asking gender identity. Furthermore, 93.1% of respondents reported providers infrequently or never ask about preferred gender or pronouns, and 86% reported providers infrequently inquire about sexual identity in primary care visits.

CONCLUSIONS

Study findings demonstrate the uniqueness of managing care for LGBTQ+ patients and importance for more detailed LGBTQ+ health training in curricula in NP programs.

IMPLICATIONS

Closing the gap in health care for LGBTQ+ patients is paramount in addressing global health disparities and population care.

Stigma, Mental Health, and Health care Use Among Rural Sexual and Gender Minority Individuals

Sexual and gender minorities (SGM) frequently experience depression and health care-related stigma. Health care satisfaction is important for seeking care, but little is known about SGM health care satisfaction, and especially as it relates to depression among rural SGM. From May 25 to July 2, 2021, we surveyed rural Illinois (IL) individuals aged ≥18 years on the topics of demographics, depression, health care satisfaction, past health care experiences, internalized stigma, and victimization. Among the 398 respondents, the gender identity distribution included cisgender males and females (171 and 203, respectively) and transgender males and females (8 and 7, respectively), while sexual orientation included heterosexuals (114), gay/lesbians (143), and other orientations (141). Analyses were conducted with respect to both identity and orientation (and their interaction). In univariate analysis, transgender individuals were more likely than cisgender to screen positive for depression and less likely to report feeling accepted by their medical provider. Compared to heterosexual respondents, gay/lesbians and other orientations were more likely to screen positive for depression. In logistic regression, factors associated with increased risk of depression included nonheterosexual orientation and past poor health care experiences. In linear regression, factors most commonly associated with the seven satisfaction subscales include: sexual orientation, past poor experiences, and employment. There were significant differences in depression across both sexual orientation and gender identity, and in health care satisfaction by sexual orientation. Rural SGMs are more vulnerable to depression and less likely to report satisfactory care. As health care engagement is critical for screening and care adherence, engaging rural SGM in a routine and satisfactory fashion is needed.

Rural and urban differences in disparities in substance use and substance use disorders affecting sexual minority populations

BACKGROUND

Sexual minority populations are at elevated risk for substance use (SU) and substance use disorders (SUD) compared to heterosexual populations. These disparities are theorized to be amplified for rural sexual minority populations due to their increased exposure to minority stress and reduced access to sexual minority communities. However, there is a lack of research examining differences in SU disparities affecting sexual minority populations by urbanicity, and little research has examined differences in SUD treatment utilization by sexual minority status or urbanicity.

METHODS

We utilized data from 2015 to 2019 National Survey on Drug Use and Health to examine disparities in SU, SUD, SUD treatment utilization, and unmet SUD treatment need between sexual minority and heterosexual populations and test whether such disparities vary by urbanicity.

RESULTS

Results indicate that disparities in SU and SUD affecting sexual minority populations generalize across urbanicities. A subset of disparities differed by urbanicity, and the direction of these differences varied, with some disparities being stronger in urban than rural populations and vice versa. Despite elevated treatment utilization among some sexual minority groups, disparities in unmet SUD treatment need were prevalent across urbanicities and sexual identity groups.

CONCLUSIONS

Study findings highlight the ubiquity of disparities in SU, SUD, and unmet SUD treatment need affecting rural and urban sexual minority populations, while also demonstrating nuanced differences in disparities by urbanicity. The persistence of disparities in unmet SUD treatment need emphasizes the need for future research to identify factors contributing to this disparity and for policies that alleviate these disparities.

Adverse Childhood Experiences and Health Outcomes Among Sexual and Gender Minorities: A Systematic Review

Current research indicates a strong association between adverse childhood experiences (ACEs) and adverse health outcomes. Participants in frequently cited ACE research are predominantly heterosexual and cis gendered; the extent to which ACEs affect health outcomes among sexual and gender minorities (SGMs) is unclear. This systematic review examined the frequency of, and relationship between, ACEs and negative health outcomes among SGM. CINAHL, MEDLINE, PsycARTICLES, PsycINFO, Scopus, and PubMed databases were searched with no date restriction. After eliminating duplicates, titles and abstracts were reviewed resulting in 22 articles to be critiqued using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies. A total of 22 studies met final inclusion criteria. The frequency of reporting at least one ACE among SGMs ranged from 51.4 to 91.6%, while the frequency of reporting four or more ACEs ranged from 18.1 to 60.7%. SGMs reported a higher frequency of ACEs than non-SGM. ACEs were associated with poorer mental and physical health outcomes, as well as increased risky behavior among SGMs. SGMs report a high frequency of ACEs, but current studies did not include data regarding ongoing stigma and adversities that may further contribute to their negative health outcomes. Further research is needed to fully understand the impact of adversities experienced due to the sexual and/or gender orientation of this minority group.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-023-00576-4.

Palliative Care Professionals' Perceptions of Communication With Sexual and Gender Minority Patients

PURPOSE

For sexual and gender minority (SGM) individuals who identify as lesbian, gay, bisexual, transgender, queer, or any other sexual orientation or gender identity (LGBTQ+), the quality of palliative care can depend upon how clinicians view and communicate with this historically minoritized group. Prior literature has demonstrated that SGM patients access care at lower rates, and palliative care clinicians have suggested that SGM patients are more likely to experience discrimination than heterosexual patients. This study examined palliative care clinicians' perspectives and experiences regarding patient communication, care settings, the built environment, and inclusive care for SGM older adults with serious illness.

METHODS

The health disparities research framework informed a descriptive qualitative analysis of interview data with palliative care professionals (N = 20) across diverse healthcare settings within Colorado regarding their experiences and beliefs about communication and the care of SGM patients.

RESULTS

Three main themes emerged: (1) Limited sexual orientation and gender identity (SOGI) data collection; (2) Organizational and environmental inclusivity, and the "neutral" space viewed as safe; (3) Missing training platforms regarding SGM patients and a lack of opportunity to identify and discuss SGM patient needs.

CONCLUSION

Study findings illuminated the following barriers to providing SGM-inclusive care: perspectives around (1) limitations and preferences regarding collection of SOGI data, (2) organizational and environmental inclusivity, and (3) education and training regarding cultural humility and communication with SGM patients. Findings indicate the need for multidimensional research to better understand and address SGM health disparities and promote equitable care.

Challenging Norms: The Impact of Transgender and Gender-Diverse Realities on Work and School Participation

IMPORTANCE

Disruption in school and the workplace are health concerns for transgender people.

OBJECTIVE

To evaluate transgender individuals' thoughts and comfort with how others perceive their gender identity (social affirmation) and its association with outness in the workplace and mistreatment at work or school.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Survey respondents older than age 18 yr from the Study of Transition, Outcomes & Gender cohort (N = 696; n = 350 assigned male at birth, n = 346 assigned female at birth [AFAB]).

OUTCOMES AND MEASURES

Ever "out" to employer and treated unfairly at work or school or fired from job. Predictors were high social affirmation and comfort with how others perceive own gender identity. Descriptive statistics and logistic regression were used for analyses.

RESULTS

Individuals reporting high social affirmation were less likely to experience mistreatment at work or school than those with low social affirmation (odds ratio [OR] = 0.57, 95% confidence interval [CI] [0.38, 0.86]). Individuals AFAB who felt comfortable with how others perceived their gender identity were less likely to be out to their employers than individuals AFAB who did not (OR = 0.45; 95% CI [0.20, 0.97]).

CONCLUSIONS AND RELEVANCE

Individuals with high social affirmation were less likely to experience work or school mistreatment, and feeling comfortable with how others perceive their gender identity did not signify the need to be out. Plain-Language Summary: Occupational therapy practitioners can play a pivotal role when working with transgender individuals by assisting in creating new routines for self-presentation at work or school, navigating social environments, and providing guidance in self-advocacy skills. Individuals assigned male at birth may be in greater need because they report lower levels of social affirmation and acceptance at school and work than individuals assigned female at birth.

When Stigma, Disclosure, and Access to Care Collide: An Ethical Reflection of mpox Vaccination Outreach

Experiences of stigma in health care encounters among LGBTQ+ populations (lesbian, gay, bisexual, transgender, and queer and questioning) have long been a barrier to care. Marginalization and historically grounded fears of stigmatization have contributed to a reluctance to disclose sexual behavior and/or gender identity to health care providers. We reflect on how student nurses grappled with the ethics of patient disclosure while providing mobile outreach in Chicago for mpox (formerly monkeypox) from fall 2022 to spring 2023. Student nurses addressed how requiring disclosure of sexual behavior or sexual orientation may serve as a barrier to accessing preventive care, such as mpox vaccination. Accounts of stigma and criminalization experienced by LGBTQ+ people provide insight on challenges historically associated with disclosure in health care.

Disparities in Cardiovascular Disease-Related Outcomes Among Cancer Survivors in the United States: A Systematic Review of the Literature

BACKGROUND

Cancer and cardiovascular disease (CVD) are major causes of morbidity and mortality in the United States (US). Cancer survivors have increased risks for CVD and CVD-related mortality due to multiple factors including cancer treatment-related cardiotoxicity. Disparities are rooted in differential exposure to risk factors and social determinants of health (SDOH), including systemic racism. This review aimed to assess SDOH's role in disparities, document CVD-related disparities among US cancer survivors, and identify literature gaps for future research.

METHODS

Following the Peer Review of Electronic Search Strategies (PRESS) guidelines, MEDLINE, PsycINFO, and Scopus were searched on March 15, 2021, with an update conducted on September 26, 2023. Articles screening was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, a pre-defined Population, Exposure, Comparison, Outcomes, and Settings (PECOS) framework, and the Rayyan platform. A modified version of the Newcastle-Ottawa Scale was used to assess the risk of bias, and RAW Graphs for alluvial charts. This review is registered with PROSPERO under ID #CRD42021236460.

RESULTS

Out of 7,719 retrieved articles, 24 were included, and discussed diverse SDOH that contribute to CVD-related disparities among cancer survivors. The 24 included studies had a large combined total sample size (n=7,704,645; median=19,707). While various disparities have been investigated, including rural-urban, sex, socioeconomic status, and age, a notable observation is that non-Hispanic Black cancer survivors experience disproportionately adverse CVD outcomes when compared to non-Hispanic White survivors. This underscores historical racism and discrimination against non-Hispanic Black individuals as fundamental drivers of CVD-related disparities.

CONCLUSIONS

Stakeholders should work to eliminate the root causes of disparities. Clinicians should increase screening for risk factors that exacerbate CVD-related disparities among cancer survivors. Researchers should prioritise the investigation of systemic factors driving disparities in cancer and CVD and develop innovative interventions to mitigate risk in cancer survivors.

Intersectional stigma and the non-communicable disease syndemic in the context of HIV: protocol for a multisite, observational study in the USA

INTRODUCTION

The increasing burden of non-communicable diseases, such as hypertension, diabetes and dyslipidaemia, presents key challenges to achieving optimal HIV care outcomes among ageing people living with HIV. These diseases are often comorbid and are exacerbated by psychosocial and structural inequities. This interaction among multiple health conditions and social factors is referred to as a syndemic. In the USA, there are substantial disparities by social position (ie, racial, ethnic and socioeconomic status) in the prevalence and/or control of non-communicable diseases and HIV. Intersecting stigmas, such as racism, classism and homophobia, may drive these health disparities by contributing to healthcare avoidance and by contributing to a psychosocial syndemic (stress, depression, violence victimisation and substance use), reducing success along the HIV and non-communicable disease continua of care. Our hypothesis is that marginalised populations experience disparities in non-communicable disease incidence, prevalence and control, mediated by intersectional stigma and the psychosocial syndemic.

METHODS AND ANALYSIS

Collecting data over a 4 year period, we will recruit sexual minority men (planned n=1800) enrolled in the MACS/WIHS Combined Cohort Study, a long-standing mixed-serostatus observational cohort in the USA, to investigate the following specific aims: (1) assess relationships between social position, intersectional stigma and the psychosocial syndemic among middle-aged and ageing sexual minority men, (2) assess relationships between social position and non-communicable disease incidence and prevalence and (3) assess relationships between social position and HIV and non-communicable disease continua of care outcomes, mediated by intersectional stigma and the psychosocial syndemic. Analyses will be conducted using generalised structural equation models using a cross-lagged panel model design.

ETHICS AND DISSEMINATION

This protocol is approved as a single-IRB study (Advarra Institutional Review Board: Protocol 00068335). We will disseminate results via peer-reviewed academic journals, scientific conferences, a dedicated website, site community advisory boards and forums hosted at participating sites.

Evaluating variations in the barriers to colorectal cancer screening associated with telehealth use in rural U.S. Pacific Northwest

PURPOSE

The incidence and mortality rates of colorectal cancer (CRC) remain consistently high in rural populations. Telehealth can improve screening uptake by overcoming individual and environmental disadvantages in rural communities. The present study aimed to characterize varying barriers to CRC screening between rural individuals with and without experience in using telehealth.

METHOD

The cross-sectional study surveyed 250 adults aged 45-75 residing in rural U.S. states of Alaska, Idaho, Oregon, and Washington from June to September 2022. The associations between CRC screening and four sets of individual and environmental factors specific to rural populations (i.e., demographic characteristics, accessibility, patient-provider factors, and psychological factors) were assessed among respondents with and without past telehealth adoption.

RESULT

Respondents with past telehealth use were more likely to screen if they were married, had a better health status, had experienced discrimination in health care, and had perceived susceptibility, screening efficacy, and cancer fear, but less likely to screen when they worried about privacy or had feelings of embarrassment, pain, and discomfort. Among respondents without past telehealth use, the odds of CRC screening decreased with busy schedules, travel burden, discrimination in health care, and lower perceived needs.

CONCLUSION

Rural individuals with and without previous telehealth experience face different barriers to CRC screening. The finding suggests the potential efficacy of telehealth in mitigating critical barriers to CRC screening associated with social, health care, and built environments of rural communities.

Βarriers and Gaps to Medical Care for Transgender Individuals: A TRANSCARE Scoping Review with a Focus on Greece

Trans people face substantial barriers to care worldwide. In Greece, limited evidence regarding trans health and actions to improve accessibility in healthcare services is available. This study aims to identify barriers to care for transgender populations in order to discuss the potential gaps in healthcare providers' training in this direction. A scoping review was conducted in PubMed. Study eligibility criteria included: (a) reporting on at least one barrier to care for trans individuals or at least one educational need for healthcare providers; (b) free full text availability; and (c) publishing from 2015 and afterwards. Discrepancies in study inclusion were discussed between the research team until consensus was reached. Out of 560 identified references, 69 were included in this study, with only three reporting empirical research from Greece. Several individual-, interpersonal-, and institutional-level barriers to healthcare for trans individuals were identified. These included discriminatory treatment by healthcare providers, a lack of knowledgeable providers trained on trans-specific healthcare issues, lack of trusted and safe healthcare environments, health coverage-related issues, and healthcare systems that do not take into account particular transgender health issues during care provision. Improving access to care for transgender people is a multidimensional issue that should be addressed at the societal, healthcare, and research levels. Actions for future professional education initiatives should focus on respecting transgender identity, protecting confidentiality, creating trusted provider-patient relationships, and providing sufficient competency on trans-specific healthcare issues.

Sexual Orientation and Racial Bias in Relation to Medical Specialty

Physician explicit and implicit biases involving race and sexual orientation (SO) affect patient and provider experiences in healthcare settings. An anonymous survey was disseminated nationally to graduating medical students, residents, and practicing physicians to evaluate SO and racial biases across medical specialties. SO explicit and implicit bias were measured with the Attitudes toward Lesbians and Gay Men Scale, short form (ATLG-S) and Gay-Straight Implicit Association Test (IAT). Racial explicit and implicit bias were measured with the Quick Discrimination Index (QDI) and the Black-White IAT. Medical specialty was associated with racial explicit bias and specialty prestige with Black-White IAT score. Medical specialty and specialty prestige were not associated with SO bias. Female sex, sexual and gender minority (SGM) identity, and decreased religiosity were associated with reduced SO and racial bias. Provider race was associated with racial implicit and explicit bias.

Exploring Aromanticism Through an Online Qualitative Investigation With the Aromantic Community: "Freeing, Alienating, and Utterly Fantastic"

Objective

To explore what aromanticism is, common misconceptions about this identity, and the experiences people have connecting with an aromantic identity.

Methods

An online, international open-ended survey with a convenience sample of aromantic individuals (N = 1642) analyzed with thematic analysis.

Results

To identify as aromantic involves a spectrum of experiences with romance commonly tied to experiencing stigma. Connecting with an aromantic identity allows for a greater understanding of the self and a connection to a community.

Conclusions

Future research is needed to explore the experiences and perspectives of this community to gather better understanding of their needs and how to prevent/limit stigmatizing experiences.

[Daily use of HIV pre-exposure prophylaxis among gay, bisexual and other men who have sex with men in Spain: Prevalence and associated factors]

OBJECTIVE

We aim to estimate the prevalence of daily HIV pre-exposure prophylaxis (PrEP) use 6 months after public funding approval in Spain and identify associated factors in a national sample of gay, bisexual and other men who have sex with men (GBMSM).

MATERIAL AND METHODS

We analysed 4692 HIV-undiagnosed GBMSM men recruited via an online questionnaire distributed nationally via gay contact apps and websites between May and July 2020. We estimated the proportion of participants using daily PrEP and identified associated factors using Poisson regression with robust variance.

RESULTS

Daily PrEP use was reported by 2.8% (95% CI 2.3-3.3) of all participants. Daily PrEP use was independently associated with being recruited into community programmes, being older than 30 years, living in a large city, living with men, having condomless anal intercourse with more than 10 sexual partners, using drugs for sex, especially chemsex drugs, and being diagnosed with a sexually transmitted infection.

CONCLUSION

Six months after PrEP was approved in Spain, the prevalence of daily use is low in a national sample of GBMSM men. There is a need to promote access, demand and interest in PrEP, especially among young GBMSM men, those living in small and medium-sized cities, and those who hide their relationships with other men.

Examining County-Level Associations between Federally Qualified Health Centers and Sexually Transmitted Infections: A Political Ecology of Health Framework

Federally Qualified Health Centers (FQHCs) are the largest providers of healthcare for sexually transmitted infections (STIs) in medically underserved communities in the United States (US). Through the Affordable Care Act (ACA), FQHCs have grown in number, but the impact of this growth on STIs is poorly understood. This ecological study seeks to quantify the association between FQHCs and STI prevalence in all US counties. Variables were described utilizing medians and interquartile ranges, and distributions were compared using Kruskal-Wallis tests. Median rates of chlamydia in counties with high, low, and no FQHCs were 370.3, 422.6, and 242.1 cases per 100,000 population, respectively. Gonorrhea rates were 101.9, 119.7, and 49.9 cases per 100,000 population, respectively. Multivariable linear regression models, adjusted for structural and place-based characteristics (i.e., Medicaid expansion, social vulnerability, metropolitan status, and region), were used to examine county-level associations between FQHCs and STIs. Compared to counties with no FQHCs, counties with a high number of FQHCs had chlamydia rates that were an average of 68.6 per 100,000 population higher (β = 68.6, 95% CI: 45.0, 92.3) and gonorrhea rates that were an average of 25.2 per 100,000 population higher (β = 25.2, 95% CI: 13.2, 37.2). When controlled for salient factors associated with STI risks, greater FQHC availability was associated with greater diagnosis and treatment of STIs. These findings provide empirical support for the utility of a political ecology of health framework and the critical role of FQHCs in confronting the STI epidemic in the US.

Collectives for Care: Perspectives of Providers and Community Members in Transgender Health Care in a Southern U.S. City

Affirming and accessible health care may improve health outcomes for trans individuals in the U.S. We explored strategies to improve affirming care for trans individuals from the perspectives of providers and transgender and non-binary community members. Forty members of a collective group of gender-affirming providers (GAP) in the southern U.S. were recruited to participate in a brief online survey. A graphical LASSO undirected network analysis approach visualized associations across outcomes and explanatory variables. Multinomial ordered (or logistic, for binary outcomes) models explored associations between a common set of explanatory variables and outcomes. Strong partial correlations (network) and statistically significant explanatory variables (ordinal and logistic models) were identified. Additionally, we conducted three focus groups (FGs) audio-recorded over Zoom with 11 community members. Four study team members analyzed the transcripts using content analyses. Survey results indicated that higher frequency of attendance at monthly provider meetings, additional training, and provision of training and consultation were associated with greater perceived competence among GAP members. To improve services, FG participants suggested treating patients as experts, increasing diversity and representation among providers, and expanding the GAP group. These results highlight the critical need to design and implement community-identified interventions to improve gender-affirming services and enhance provider training.

LGBTQ Utilization of a Statewide Tobacco Quitline: Engagement and Quitting Behavior, 2010-2022

INTRODUCTION

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals use tobacco at disproportionately high rates but are as likely as straight tobacco users to want to quit and to use quitlines. Little is known about the demographics and geographic distribution of LGBTQ quitline participants, their engagement with services, or their long-term outcomes.

AIMS AND METHODS

Californians (N = 333 429) who enrolled in a statewide quitline 2010-2022 were asked about their sexual and gender minority (SGM) status and other baseline characteristics. All were offered telephone counseling. A subset (n = 19 431) was followed up at seven months. Data were analyzed in 2023 by SGM status (LGBTQ vs. straight) and county type (rural vs. urban).

RESULTS

Overall, 7.0% of participants were LGBTQ, including 7.4% and 5.4% of urban and rural participants, respectively. LGBTQ participants were younger than straight participants but had similar cigarette consumption. Fewer LGBTQ participants reported a physical health condition (42.1% vs. 48.4%) but more reported a behavioral health condition (71.1% vs. 54.5%; both p's < .001). Among both LGBTQ and straight participants, nearly 9 in 10 chose counseling and both groups completed nearly three sessions on average. The groups had equivalent 30-day abstinence rates (24.5% vs. 23.2%; p = .263). Similar patterns were seen in urban and rural subgroups.

CONCLUSIONS

LGBTQ tobacco users engaged with and appeared to benefit from a statewide quitline even though it was not LGBTQ community-based. A quitline with staff trained in LGBTQ cultural competence can help address the high prevalence of tobacco use in the LGBTQ community and reach members wherever they live.

IMPLICATIONS

This study describes how participants of a statewide tobacco quitline broke down by sexual orientation and gender. It compares participants both by SGM status and by type of county to provide a more complete picture of quitline participation both in urban areas where LGBTQ community-based cessation programs may exist and in rural areas where they generally do not. To our knowledge, it is the first study to compare LGBTQ and straight participants on their use of quitline services and quitting aids, satisfaction with services received, and rates of attempting quitting and achieving prolonged abstinence from smoking.

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.

Behaviors associated with HIV transmission risk among rural sexual and gender minority and majority residents

Multiple rural states and communities experience elevated rates of human immunodeficiency virus (HIV), often associated with diminished healthcare access and increased drug use. Though a substantial proportion of rural populations are sexual and gender minorities (SGM), little is known of this group regarding substance use, healthcare utilization, and HIV transmission behaviors. During May-July 2021, we surveyed 398 individuals across 22 rural Illinois counties. Participants included cisgender heterosexual males (CHm) and females (CHf) (n = 110); cisgender non-heterosexual males and females (C-MSM and C-WSW; n = 264); and transgender individuals (TG; n = 24). C-MSM participants were more likely to report daily-to-weekly alcohol and illicit drug use prescription medication misuse (versus CHf; aOR = 5.64 [2.37-13.41], 4.42 [1.56-12.53], and 29.13 [3.80-223.20], respectively), and C-MSM participants more frequently reported traveling to meet with romantic/sex partners. Further, more C-MSM and TG than C-WSW reported healthcare avoidance and denial due to their orientation/identity (p < 0.001 and p = 0.011, respectively); 47.6% of C-MSM and 58.3% of TG had not informed their provider about their orientation/identity; and only 8.6% of C-MSM reported ever receiving a pre-exposure prophylaxis (PrEP) recommendation. More work is needed to explore the substance use and sexual behaviors of rural SGM, as well as their healthcare interactions, to better target health and PrEP engagement campaigns.

Concept Analysis: LGBT+ Inclusive Health Care

Clients who identify as lesbian, gay, bisexual, transgender, queer/questioning (LGBT+) may experience barriers in health care access and services. LGBT+ clients want a welcoming, inclusive, and affirming encounter with nurses and other health care providers. This concept analysis used a modified Walker and Avant method to clarify the concept of LGBT+ inclusive health care. Antecedents, attributes, and consequences of LGBT+ inclusive health care were identified from the literature. The results of this concept analysis of LGBT+ inclusive health care can inform future research, policy, education, and practice to address the health care needs of this population.

Adolescent Perspectives on the Use of Telemedicine for Confidential Health Care: An Exploratory Mixed-Methods Study

PURPOSE

Telemedicine can improve access to adolescent health care, but adolescents may experience barriers to accessing this care confidentially. Gender-diverse youth (GDY) may especially benefit from telemedicine through increased access to geographically limited adolescent medicine subspecialty care but may have unique confidentiality needs. In an exploratory analysis, we examined adolescents' perceived acceptability, preferences, and self-efficacy related to using telemedicine for confidential care.

METHODS

We surveyed 12- to 17-year-olds following a telemedicine visit with an adolescent medicine subspecialist. Open-ended questions assessing acceptability of telemedicine for confidential care and opportunities to enhance confidentiality were qualitatively analyzed. Likert-type questions assessing preference for future use of telemedicine for confidential care and self-efficacy to complete components of telemedicine visits confidentially were summarized and compared across cisgender versus GDY.

RESULTS

Participants (n = 88) included 57 GDY and 28 cisgender females. Factors affecting the acceptability of telemedicine for confidential care related to patient location, telehealth technology, adolescent-clinician relationships, and quality or experience of care. Perceived opportunities to protect confidentiality included using headphones, secure messaging, and prompting from clinicians. Most participants (53/88) were likely or very likely to use telemedicine for future confidential care, but self-efficacy for completing components of telemedicine visits confidentially varied by component.

DISCUSSION

Adolescents in our sample were interested in using telemedicine for confidential care, but cisgender and GDY recognized threats to confidentiality that may reduce acceptability of telemedicine for these services. Clinicians and health systems should carefully consider youth's preferences and unique confidentiality needs to ensure equitable access, uptake, and outcomes of telemedicine.

LGBTQI+ representation in pre-licensure nursing textbooks: A qualitative descriptive analysis

BACKGROUND

To improve health equity, nursing curricula should include content specific to the needs of marginalized and underserved communities, such as lesbian, gay, bisexual, transgender, queer, and intersex groups (LGBTQI+). Harmful and absent academic discussions of LGBTQI+ patients lead to provider discomfort and inadequacy in treating this patient population. Nursing schools are well-positioned to increase comfort with LGBTQI+ content as part of pre-licensure curricula. This article presents a systematic evaluation of LGBTQI+ content in nursing pre-licensure textbooks and the nature and quality of the representations.

METHODS

A qualitative descriptive analysis of LGBTQI+ content from 14 nursing-specific textbooks required by a pre-licensure degree program at the Johns Hopkins School of Nursing was conducted by a student-led team with faculty oversight. A priori and iterative search terms were used to identify and extract text segments that referenced LGBTQI+ content in each textbook. An iterative codebook was developed, codes were applied, and analysis of the information and context in which the terms were presented was performed.

RESULTS

The research team observed gaps and notable patterns in distribution of LGBTQI+ terms and health content areas across the textbooks reviewed. The majority of LGBTQI+ search terms were identified in the following health content areas: social determinants of health, sexual/reproductive health, pediatric sexual & gender diversity, intersectionality, and infectious disease. Based on qualitative descriptive analyses, the data were organized into the following categories: a) Language; b) Medicalization; c) Vague, Incomplete, or Lacking Specificity; and d) Comprehensive Approach.

CONCLUSION

Findings highlight the need for increased academic exposure for pre-licensure nursing students regarding the care of LGBTQI+ patients. Thoughtful inclusion of LGBTQI+ content may better foster the delivery of evidence-based care for this patient population. These findings underscore the need for improved nursing curricula to support nurses in delivering affirming care for LGBTQI+ populations.

Review of current 2SLGBTQIA+ inequities in the Canadian health care system

Gender identity and sexual orientation are determinants of health that can contribute to health inequities. In the 2SLGBTQIA+ community, belonging to a sexual and/or gender minority group leads to a higher risk of negative health outcomes such as depression, anxiety, and cancer, as well as maladaptive behaviors leading to poorer health outcomes such as substance abuse and risky sexual behavior. Empirical evidence suggests that inequities in terms of accessibility to health care, quality of care, inclusivity, and satisfaction of care, are pervasive and entrenched in the health care system. A better understanding of the current Canadian health care context for individuals of the 2SLGBTQIA+ community is imperative to inform public policy and develop sensitive public health interventions to make meaningful headway in reducing inequity. Our search strategy was Canadian-centric and aimed at highlighting the current state of 2SLGBTQIA+ health inequities in Canada. Discrimination, patient care and access to care, education and training of health care professionals, and crucial changes at the systemic and infrastructure levels have been identified as main themes in the literature. Furthermore, we describe health care-related disparities in the 2SLGBTQIA+ community, and present available resources and guidelines that can guide healthcare providers in narrowing the gap in inequities. Herein, the lack of training for both clinical and non-clinical staff has been identified as the most critical issue influencing health care systems. Researchers, educators, and practitioners should invest in health care professional training and future research should evaluate the effectiveness of interventions on staff attitudinal changes toward the 2SLGBTQIA+ community and the impact on patient outcomes.

Clinical, psychosocial, and sociodemographic factors of sexual and gender minority groups with cancer: A systematic review

PURPOSE

Psychosocial health varies depending on demographic and clinical factors and the social context in which individuals grow and live. Sexual and gender minority (SGM) populations experience health disparities due to systemic factors that privilege cisgender and heterosexual identities. We reviewed the literature on the psychosocial, sociodemographic, and clinical factors in SGM groups with cancer and described the associations among these factors.

METHODS

We conducted a systematic review according to Fink's methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in the PubMed, PsycInfo, Cumulative Index of Nursing and Allied Health Literature, and LGBTQ+ Life databases. Quantitative articles published in English or Spanish were included. Grey literature and studies with participants in hospice care were excluded. The quality of the publications was assessed with the Joanna Briggs Institute criticalappraisal tools.

RESULTS

The review included 25 publications. In SGM groups, systemic cancer treatment was associated with worse psychosocial outcomes; and older age, employment, and higher income were associated with better psychosocial outcomes.

CONCLUSIONS

SGM groups with cancer are different from their heterosexual cisgender peers in sociodemographic, psychosocial, and clinical factors. Clinical and sociodemographic factors are associated with psychosocial outcomes among SGM individuals with cancer.

High Interest in Long-acting Injectable Pre-exposure Prophylaxis (LAI-PrEP) for HIV Prevention Among Men Who Have Sex With Men (MSM): Result From A Nationwide Survey in Malaysia

The recent approval of long-acting injectable cabotegravir (CAB-LA) as PrEP for HIV prevention could be an attractive alternative for MSM, particularly among those who face barriers to adherence using the oral pill. This study reports on the awareness of long-acting injectable PrEP (LAI-PrEP) and factors associated with interest in LAI-PrEP use among a nationwide sample of MSM in Malaysia. An online cross-sectional survey was conducted between August and September 2021 to explore perspectives on PrEP modalities among Malaysian MSM (N = 870). Convenience sampling was used to recruit participants using ads on two platforms hornet and facebook. While only 9.1% of the study participants were aware of LAI-PrEP, the majority had heard of oral PrEP (80.9%). After giving a description of it, a large majority (86.6%) expressed interest in using it if made accessible. Those who had a prior history of HIV testing (aOR = 1.9; 95% CI = 1.2-3.2) were more likely to use LAI-PrEP. Interestingly, despite the concerns related to potential high cost (aOR = 3.4; 95% CI = 2.1-5.5) and long-term side effects (aOR = 1.9; 95% CI = 1.2-3.1), the majority of the participants were interested in using LAI-PrEP. Those who were afraid of (or disliked) syringes were less interested in using it (aOR = 0.2; 95% CI; 0.1-0.4). In the recent context that LAI-PrEP was shown to be safe and effective at preventing HIV, our results indicate its potential relevance as an additional PrEP option that could accelerate the uptake and scale-up of PrEP. However, it is crucial to conduct future research urgently to improve the understanding of strategies that could enhance the accessibility, acceptability, and affordability of LAI-PrEP for MSM in low- and middle-income countries, including Malaysia.

Cisheteronormativity and its influence on the psychosocial experience of LGBTQ+ people with cancer: A qualitative systematic review

OBJECTIVE

Cisheteronormativity refers to the relationship of heterosexual and cisgender privilege stemming from patriarchy. Although studies have shown that cisheteronormativity can impact health outcomes for lesbian, gay, bisexual, transgender, queer and other sexual, gender diverse, and gender nonconforming (LGBTQ+) people, the specific impact on cancer care has not been described. We synthesized the qualitative evidence on how cisheteronormativity impacts the psychosocial experience of LGBTQ+ people with cancer.

METHODS

We conducted a historic search in the CINAHL, LGBT+ Health, PsycInfo, and PubMed databases. Qualitative studies that described the psychosocial experience of LGBTQ+ people with cancer were included. After appraising the quality of the publications, 11 articles were included. Then, we conducted inductive nominal coding, taxonomic analysis, and thematic synthesis.

RESULTS

Two main themes emerged, (1) Cisheteronormativity as a social determinant of health, and (2) Cancer, sexual orientation, and gender: Associations and introjections. The themes comprise four categories and 13 subcategories that describe the impact of cisheteronormativity on the cancer experience of LGBTQ+ people.

CONCLUSION

Cisheteronormativity within the healthcare system impacts the psychosocial experience of LGBTQ+ people with cancer. Understanding how these gender biases, norms, and social expectations impact the cancer experience is necessary to transform social norms and promote health equity.

Working Through Stigma: A Constructivist Grounded Theory of Delivering Health Services to Diverse 2SLGBTQ Populations

Previous research inadequately explores processes and factors influencing the delivery of health services to sexual and gender minorities in ways that equitably attend to the infinite diversity held by these groups. This study employed Intersectionality and Critical Theories to inform Constructivist Grounded Theory methods and methodology; social categories of identity were strategically adopted to explore domains of power operating across multiple forms of oppression, think through subjective realities, and generate a nuanced rendering of power relations influencing health service delivery to diverse 2SLGBTQ populations in a Canadian province. Semi-structured interviews were conducted and the co-constructed theory of Working Through Stigma, with three interrelated concepts, depending on context, resolving histories, and surviving the situation, was generated. The theory depicts the concerns of participants and what they do about power relations influencing health service delivery and broader social contexts. While the negative impacts of stigma were widely and diversely experienced by patients and providers, ways of working within power relations emerged that would be impossible if stigma was not present, highlighting opportunities to positively impact those from stigmatized groups. As such, Working Through Stigma is a theory that flouts the tradition of stigma research; it offers theoretical knowledge that can be used to work within power relations upholding stigma in ways that increase access to quality health services for those whose historical underservicing can be attributed to stigma. In doing so, the stigma script is flipped and strategies for working against practices and behaviours that uphold cultural supremacies may be realized.