LGBTQ+ health education for medical students in the United States: a narrative literature review

INTRODUCTION

People who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, and other sexual/gender minorities (LGBTQ+) may experience discrimination when seeking healthcare. Medical students should be trained in inclusive and affirming care for LGBTQ+ patients. This narrative literature review explores the landscape of interventions and evaluations related to LGBTQ+ health content taught in medical schools in the USA and suggests strategies for further curriculum development.

METHODS

PubMed, ERIC, and Education Research Complete databases were systematically searched for peer-reviewed articles on LGBTQ+ health in medical student education in the USA published between 1 January 2011-6 February 2023. Articles were screened for eligibility and data was abstracted from all eligible articles. Data abstraction included the type of intervention or evaluation, sample population and size, and key outcomes.

RESULTS

One hundred thirty-four articles met inclusion criteria and were reviewed. This includes 6 (4.5%) that evaluate existing curriculum, 77 (57.5%) study the impact of curriculum components and interventions, 36 (26.9%) evaluate student knowledge and learning experiences, and 15 (11.2%) describe the development of broad learning objectives and curriculum. Eight studies identified student knowledge gaps related to gender identity and affirming care and these topics were covered in 34 curriculum interventions.

CONCLUSION

Medical student education is important to address health disparities faced by the LGBTQ+ community, and has been an increasingly studied topic in the USA. A variety of curriculum interventions at single institutions show promise in enhancing student knowledge and training in LGBTQ+ health. Despite this, multiple studies indicate that students report inadequate education on certain topics with limitations in their knowledge and preparedness to care for LGBTQ+ patients, particularly transgender and gender diverse patients. Additional integration of LGBTQ+ curriculum content in areas of perceived deficits could help better prepare future physicians to care for LGBTQ+ patients and populations.

Intergenerational Storytelling as a Developmental Resource in LGBTQ+ Communities

LGBTQ+ people continue to be threatened by systemic censorship and erasure in public spaces and discourses, making community-based resources for positive development crucial. In this study, we examined one such developmental resource-LGBTQ+ intergenerational storytelling about cultural-historical events. LGBTQ+ adults (N = 495) ranging in age from 17 to 80 years (M = 39.22, SD = 19.89) responded to an online survey about LGBTQ+ intergenerational storytelling and relationships. Results showed that although LGBTQ+ intergenerational storytelling was reported to occur infrequently, sharing stories across generations was considered important, and LGBTQ+ people desired even greater intergenerational connection. Intergenerational narratives reported by participants were primarily about cultural-historical events involving adversity and oppression (e.g. AIDS crisis), policy and legislation (e.g. marriage equality), and protest, resistance, and activism (e.g. Stonewall uprising). Stories were mostly told by older friends in private or social settings for the purpose of passing on LGBTQ+ history. Lessons learned through storytelling were diverse but tended to focus on appreciation and affirmation. Valuing intergenerational storytelling was associated with positive psychosocial identity. This study suggests that intergenerational storytelling may be an important developmental resource for LGBTQ+ people and other marginalized communities.

LGBTQ+ faculty, queering health sciences classrooms: student perspectives

Lesbian, gay, bisexual, transgender, and queer plus (LGBTQ+) students in undergraduate science, technology, engineering, and math (STEM) majors are more likely to drop out than their cisgender, heterosexual peers despite having equivalent grades and research exposure. It has been demonstrated that a sense of belonging, a very strong predictor of student retention, is low in LGBTQ+-identified STEM undergraduates. It has further been posited that faculty openness and authenticity can enhance a sense of belonging for LGBTQ+ students through the creation of an inclusive classroom culture. The authors of this article, three LGBTQ+-identified faculty in the health sciences department at Boston University, surveyed students enrolled in their courses to elicit student thoughts, feelings, and behaviors regarding the effect of faculty 1) sharing their identity openly in the classroom, and 2) actively working to create open, inclusive dialogue and space in their classrooms. Of 86 student participants across multiple classes, the large majority of students, both LGBTQ+-identified and non-LGBTQ+-identified, described feeling safe, included, and welcomed in the classroom. They described engaging more in peer-to-peer education and felt that instructor authenticity created a safe and inclusive classroom. A minority of LGBTQ+-identified students and non-LGBTQ+-identified students reported feeling unsure of voicing their opinions, for the former related to insecurity about being LGBTQ+ and the latter feeling a liberal bias existed in the classroom. Altogether, these results suggest a positive effect on student sense of belonging when faculty authenticity and intentionality create inclusive classroom environments in the health sciences.NEW & NOTEWORTHY Openness and authenticity of lesbian, gay, bisexual, transgender, and queer plus (LGBTQ+)-identified faculty in the health sciences positively affect students by helping them feel seen, welcomed, and included for both students who identify as LGBTQ+ and those who do not. Moreover, faculty openness fostered student action by encouraging them to have peer-to-peer discussions about inclusive language and engage more openly in classroom discussions. Creating academic job security for LGBTQ+-identified faculty to be open can enhance classroom culture, student engagement, and learning.

Psychosocial and Financial Issues Affecting LGBTQ+ Older Adults

Isolation, financial insecurity, incomplete advance care planning, and lack of safe/affordable/inclusive long-term care are challenges magnified in gender and sexual minorities. LGBTQIA+ older adults are disproportionately more likely to live alone and experience financial poverty and social isolation. LGBTQIA+ adults suffering from cognitive impairment are an especially defenseless population due to their lack of social connection and potential lack of financial resources and advance care planning.

Evaluating the Impact of an Adolescent Sexuality Education Workshop on Medical Student Communication in an Objective Structured Clinical Examination

PURPOSE

Gaps still exist in medical education about the sexual health needs of sexual diverse populations, and little is known about how translatable current learning modules are to patient encounters. Efforts at an academic medical institution have been made to address this need, including a two-hour adolescent sexuality workshop during the Core Clerkship in Pediatrics. This workshop's efficacy was evaluated in an objective structured clinical examination (OSCE) given to rising fourth-year medical students, where the standardized patient case focused on an adolescent cisgender male with dysuria and in a new, same-sex relationship.

METHODS

Performance of students who completed the workshop prior to the OSCE (n = 48) were compared to those of students who did not participate in the workshop prior to the OSCE (n = 17). The encounters were recorded and transcribed, and the deidentified transcripts were scored on a rubric focusing on five domains: sexual identity disclosure, behavioral assessment, psychosocial history, counseling and anticipatory guidance, and relationship building.

RESULTS

Student's t-test comparison of the scores found significantly higher scores for the psychosocial history domain (p = .04), particularly concerning disclosure of a new boyfriend and recent sexual activity (p = .008), for students who had the workshop before the OSCE.

DISCUSSION

Students who took the adolescent sexuality workshop performed better in gathering psychosocial information in an OSCE encounter a sexual minority adolescent. These results affirm prior work that active learning on sexual diverse health in medical school curricula may prepare students for effective engagement with adolescents exploring their sexuality.

Federal and State Policy Issues Affecting Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults

Anti-lesbian, gay, bisexual, transgender, and queer (LGBTQ) + discrimination is widespread, harming the health of LGBTQ + people and constituting a barrier to care. This contributes to higher rates of poverty among LGBTQ + people, especially among people of color, and lower insurance coverage rates. The Affordable Care Act's expansion of insurance access has reduced uninsurance rates among LGBT people and people living with human immunodeficienc virus (HIV). Systemic improvements in culturally responsive health care have occurred over the past decade, including increased collection and use of sexual orientation and gender identity data to improve quality of care. As older LGBTQ + people enter elder service systems, reforms are needed to ensure equitable access.

Postacute Care and Long-term Care for LGBTQ+ Older Adults

LGBTQ + older adults have a high likelihood of accessing nursing home care. This is due to several factors: limitations performing activities of daily living and instrumental activities of daily living, restricted support networks, social isolation, delay seeking assistance, limited economic resources, and dementia. Nursing home residents fear going in the closet, which can have adverse health effects. Cultivating an inclusive nursing home culture, including administration, staff, and residents, can help older LGBTQ + adults adjust and thrive in long-term care.

Home-Based Care for Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, or another diverse gender identity Older Adults

The home-based medicine ecosystem is rapidly expanding. With this expansion, it is increasingly important to understand the unique needs of homebound older adults. There is likely significant intersectionality across the lesbian, gay, bisexual, transgender, queer or questioning, or another diverse gender identity (LGBTQ+) older adult population and the homebound population. This article begins to outline some strategies and approaches to entering the home of LGBTQ+ older adults in inclusive and trauma-informed ways and encourages home-based care teams, organizations, and health systems to utilize existing resources created by the LGBTQ+ aging community to provide universal skills training for the workforce.

"I wouldn't have felt so alone": The sexual health education experiences of transgender and gender diverse youth living in the southeastern United States

BACKGROUND

Transgender and gender diverse youth experience multiple disproportionate adverse sexual health outcomes. Sexual health education teaches knowledge, attitudes, and skills for promoting sexual health, including reducing risk for sexually transmitted infection, HIV acquisition, and unintended pregnancy. Provision of sexual health education may be protective, but research remains scarce.

METHODS

We conducted a multi-stage thematic analysis of 33 in-depth interviews among transgender and gender diverse youth (ages 15-24) living in the southeastern United States on their sexual health education experiences.

RESULTS

Our study participants described school-based sexual health education as unhelpful due to a lack of relevant information, inadequately prepared teachers, and a perceived negative tone toward sexuality. They reported relying on online sources of sexual health information, finding relevant content and community despite some limitations. Participants desired content and pedagogy that expands beyond binary and white-centric presentations of sexuality and gender and sought resources that provide relevant, accurate, and judgment-free information while holding positive framing around sexuality and gender.

CONCLUSION

There is much work needed to improve the breadth, quality, and relevance of school-based sexual health education. Sexual health education can improve by strengthening critical media literacy skills of youth; raising staff cultural competency on gender, race, and sexual identity through training and supports; using culturally relevant and inclusive curricula; and partnering with community-based organizations. Transgender and gender diverse youth would benefit from sexual health education from multiple sources which is queer-friendly, affirms their existence, and provides information on gender, race, and sexuality in positive and expansive ways.

Suicide-Related Media Reporting With a Focus on Sexual and Gender Minority Identities

Background: Little is known about the quality of media reports on suicide and prevention targeting persons with sexual or gender minority identities (LGBTQ+). Aims: To assess the quality of suicide-related media reporting of LGBTQ+ people and its consistency with media guidelines. Method: We conducted a content analysis of 5,652 media items in two US states (Washington and Oregon) published within 1 year. Results: There were only few differences in the reporting about suicide in LGBTQ+ as compared to non-LGBTQ+ reports. LGBTQ+ media items more often portrayed suicide as monocausal [Oregon: OR = 1.75, 95% CI (1.03-2.98), p = .038; Washington: OR = 3.00, 95% CI (1.81-4.97), p < .001] and linked them to adverse life experiences [OR = 2.16, 95% CI (1.38-3.38), p < .001; OR = 2.09, 95% CI (1.30-3.38), p = .002] than non-LGBTQ+ items. They also more often featured mental health experts [OR = 1.79, 95% CI (1.04-3.10), p = .034; OR = 2.12, 95% CI (1.23-3.67), p = .006] and contacts to support services [OR = 2.22, 95% CI (1.41-3.48), p < .001; OR = 2.70, 95% CI (1.64-4.45), p < .001]. Limitations: Aspects possibly influencing the portrayal of LGBTQ+ suicide and prevention beyond the characteristics listed were not investigated. Conclusion: Suicide-related media reporting related to LGBTQ+ issues features potentially beneficial aspects but tends to overlook multifactorial causes of suicide. Diverse factors contributing to LGBTQ+ suicide and prevention warrant greater attention.

Clinical outcomes for sexual and gender minority adolescents in a dialectical behaviour therapy programme

BACKGROUND

Sexuality and gender minoritised (SGM) adolescents are at increased risk of self-injury and suicide, and experience barriers to accessing mental health support. Dialectical behaviour therapy (DBT) is an effective treatment for self-injury and emotion dysregulation in adolescent populations, but few studies have published outcomes of DBT for SGM young people.

AIMS

This study aimed to investigate treatment outcomes and completion for SGM adolescents and their cisgender and heterosexual peers, in the National & Specialist CAMHS, DBT service (UK).

METHOD

Treatment completion, and opting out before and during treatment were examined for sexual and gender identity groups, as well as changes by the end of treatment in emotion dysregulation, self-injury, in-patient bed-days, emergency department attendances, and borderline personality disorder, depression and anxiety symptoms.

RESULTS

SGM adolescents were over-represented in this service, even after considering their increased risk for self-injury. No statistically significant differences were found for treatment completion between the sexual orientation and gender identity groups, although there were patterns indicating possible lower treatment uptake and completion that warrant further investigation. Clinical outcomes for treatment-completers showed improvement by the end of DBT for each group, with few exceptions.

DISCUSSION

These results are from relatively small subsamples, and it was not possible to separate by sex assigned at birth. Findings should be treated tentatively and as early indications of effect sizes to inform future studies. This study suggests that DBT could be a useful treatment for SGM adolescents in a highly specialist treatment setting.

"What Works" to Support LGBTQ+ Young People's Mental Health: An Intersectional Youth Rights Approach

Despite overwhelming international evidence of elevated rates of poor mental health in LGBTQ+ youth compared to their cis-heterosexual peers, we know relatively little about effective mental health services for this population group. This study aims to produce the first early intervention model of "what works" to support LGBTQ+ youth with emerging mental health problems. Utilizing a mixed method case study, we collected data across 12 UK mental health service case study sites that involved: (a) interviews with young people, parents, and mental health practitioners (n = 93); (b) documentary analysis; (c) nonparticipant observation. The data analysis strategy was theoretical using the "explanation-building" analytical technique. Our analysis suggests an intersectional youth rights approach with 13 principles that must be enacted to provide good mental health services as advocated by the United Nations Convention on the Rights of the Child and World Health Organization. This approach should address the multiple forms of marginalization and stigmatization that LGBTQ+ youth may experience, enable informed independent decision-making, and uphold the right to freedom of safe self-expression. A rights-based approach to mental health services for LGBTQ+ young people is not prominent. This needs to change if we are to tackle this mental health inequality and improve the mental well-being of LGBTQ+ youth worldwide.

Are HIV Prevention Services Reaching all LGBTQ+ Youth? An Intersectional Analysis in a National Sample

Although research has examined disparities in HIV prevention behaviors, intersectional research is needed to understand who may be underserved. This study examines disparities in consistent condom use, HIV testing, and PrEP awareness and use across assigned sex, gender identity, sexual orientation, and racial/ethnic identity in a large sample of sexually active LGBTQ+ youth (mean age = 16.5) who completed the 2022 LGBTQ National Teen Survey. Four social identities were included as indicators in Chi-Square Automated Interaction Detection models to uncover disparate rates of HIV preventive behaviors. Generally, HIV testing and PrEP services were higher among gay/lesbian and queer youth assigned male, and lower among those assigned female. Certain LGBTQ+ youth may be systematically missed by these services, (e.g., those assigned female; those assigned male who also identify as bisexual, pansexual, asexual, questioning, or straight (and trans/gender diverse)). Providers should strive to serve populations who are not being reached by HIV prevention services.

LGBTQ+ Inclusivity Training and Education: A Toolkit for Skilled Nursing Facilities

OBJECTIVES

The objective of this study was to develop the LGBTQ+ Inclusivity Training and Education (LITE) toolkit and to examine the usability and acceptability of the LITE toolkit to health care workers and staff who work within skilled nursing facilities (SNFs).

DESIGN

A community-engaged approach using human-centered design to develop the LITE toolkit. To test the usability and acceptability of the LITE toolkit, we provided a posttest survey to users after a 9-week period.

SETTING AND PARTICIPANTS

The LITE toolkit was distributed to 25 SNFs throughout a 7-county area in North Carolina.

METHODS

Development processes included an LGBTQ+ community advisory board, development of resource topics and a list of best practices, and development of a website. The LITE toolkit comprised a website of LGBTQ+ resources, poster of 6 Best Practices to LGBTQ+ Care, rainbow lapel pins, and writing pens with the LITE logo. Online surveys were distributed to SNF administrators to share with health care workers and staff to collect data on the usability and acceptability of the LITE toolkit. Descriptive statistics were used for data analysis.

RESULTS

Fifteen participants completed the survey. Answering all survey questions was not a requirement. Seventy-nine percent (n = 14) of SNF health care workers indicated that the LITE toolkit was "easy to understand" and that they were satisfied with the contents. Fifty-three percent (n = 15) responded that the LITE toolkit would improve the way they care for patients. Sixty-six percent (n = 15) of health care workers and staff strongly agreed the LITE toolkit was applicable to their job role.

CONCLUSIONS AND IMPLICATIONS

Providing useful and acceptable LGBTQ+-focused training and education for members of the SNF community addresses the need for health care worker and staff training to foster equitable care and inclusive environments for the LGBTQ+ older adult community. Additional work focused on understanding the facilitators and barriers to using the LITE toolkit in the SNF setting is needed.

Outlining Individual and Contextual Factors Related to LGBTQ+ Bullying: A Systematic Review of Two Decades of Research

Scientific interest in lesbian, gay, bisexual, transgender, queer and any other sexual orientation, gender identity and/or expression (LGBTQ+) bullying in educational settings has grown exponentially in recent years. However, the varied ways of measuring its occurrence and associated factors have made it difficult to achieve a holistic understanding of this problem. Therefore, this systematic review aimed to provide an updated overview of individual and contextual factors related to LGBTQ+ bullying over the past two decades, based on the measurement approach to this phenomenon. Studies published from 2000 to 2020 were analyzed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses strategy. Inclusion and exclusion criteria were applied in a staggered process, and 111 articles met all the criteria. Studies focusing on LGBTQ+ bullying victimization or aggression were eligible for inclusion. Our analysis revealed LGBTQ+ bullying is usually examined by measures of general aggressions (47.8%) from the victims' perspective (87.3%). The best-represented factors across studies were individual characteristics (63.1%; n = 70), especially participants' sexual orientation and gender identity and expression (68.5%). Boys/males, from a binary gender perspective, and sexual and gender minority youth in general, were more at risk of being targeted for LGBTQ+ bullying. Although contextual factors were far less well-represented, the results revealed that gay-straight alliances, anti-homophobia policies, and social support act as protective factors. This review highlights the need to analyze LGBTQ+ bullying considering the full spectrum of sexual and gender diversity, to examine in more detail its contextual risk/protective factors, and to design public policies and psychoeducational programs in order to address the low effectiveness of generic interventions. Implications for future research and practice are discussed.

A Needs Assessment Approach for Adolescent and Young Adult Sexual and Gender Diverse Cancer Survivors

Sexual and gender diverse (SGD) adolescent and young adult (AYA) cancer survivors are an increasing and vulnerable group with unique needs that often remain unmet in the healthcare system. This paper describes the conceptualization and development of a community-based organization dedicated to serving SGD AYAs, in addition to reporting on the results of a community-led needs assessment. A total of 56 SGD AYA community members completed the online survey. Most participants were between the ages of 26 to 33, identified as white, cisgender, bisexual women, and had hematologic malignancies. Identified unmet needs of SGD AYAs included the following: sexual health and family planning; gender affirmation; financial stability; and emotional support. Areas within the community organization were identified as gaps, areas of expansion, and assets. Results highlight the role of community and academic partnerships in improving cancer care delivery for SGD AYA cancer survivors.

Student-Led Webinar to Support LGBTQ+ Students Applying to Medical School During the COVID-19 Pandemic

Lesbian, gay, bisexual, transgender, queer, intersex, asexual, non-binary, two-spirit, and other (LGBTQ+) students are a diverse group with unique and frequently overlooked needs in medical training. The present study was designed to understand the concerns of LGBTQ+ applicants to medical school and examine the effectiveness of a webinar in alleviating concerns. Sixty participants joined webinars discussing the medical school application process with particular attention to concerns pertinent to the LGBTQ+ population. Pre and post surveys were administered to examine webinar effectiveness and participant concerns. Results were analyzed using quantitative and qualitative methods. Pre-medical students reported that the webinar format was helpful for their application process. Specifically, pre- and post-test analyses revealed that the webinar increased both students' preparedness as well as their confidence in disclosing their LGBTQ+ identity or being "out" when applying to medical school. Student-led, online webinars increase LGBTQ+ students' confidence and help address SGM students' concerns about applying to medical school.

Changing attitudes about LGBTQ+ older adults: the Gen Silent Survey Project

OBJECTIVES

Lesbian, gay, bisexual, transgender, queer, and more (LGBTQ+) older adults may experience challenges accessing services due to stigma. Aging service providers seeking to create an inclusive culture need training tools. This study examined if a film (Gen Silent) could increase provider's knowledge of and empathy for LGBTQ+ older adults.

METHODS

A pretest - posttest survey was administered at film screenings in New Hampshire to assess knowledge and attitudes of participants (N = 108). Data were analyzed descriptively, Wilcoxon signed-rank test was used to compare matched samples, and linear and logistic regression models compared group differences.

RESULTS

Scores on eight of the nine measures improved after watching Gen Silent. Most participants (83%) indicated their thoughts and views had changed after watching the film. Statistically significant between group differences are discussed.

CONCLUSIONS

The documentary Gen Silent was found to be an adequate, introductory training tool about LGBTQ+ aging.

Neurosurgical Training

OBJECTIVE

The aim of this study is to gauge the current social climate in neurosurgical residency training and attitudes regarding sexual orientation and gender identity.

METHODS

We conducted a cross-sectional study through a 35-question questionnaire distributed to roughly 1700 residents at all U.S. neurosurgical residency programs.

RESULTS

A total of 107 responses were obtained. Seventeen residents (16%) identified as being an LGBTQ+ individual. The majority (76%) of LGBTQ+ residents were concerned about how their sexual orientation would be perceived while applying to programs, and 47% endorsed purposefully concealing sexual orientation at work for fear of rejection or reprisal. More than half (56%) of those surveyed have witnessed homophobic/transphobic remarks by patients. While at work, 29% of LGBTQ+ individuals stated they are uncomfortable being open with their sexual orientation, and 3 LGBTQ+ individuals admitted being the target of direct homophobic/transphobic comments.

CONCLUSIONS

This is the first study to our knowledge that has been conducted assessing the presence, perception, and treatment of LGBTQ+ trainees in neurosurgical residency. Our study outlines the challenges LGBTQ+ individuals face when applying to neurosurgical programs, which involves the perception of their sexual orientation, their witnessed instances of homophobic and transphobic comments by coworkers and patients, and their hesitation with discussing their social lives compared with their non-LGBTQ+ peers at work for fear of judgment or reprisal. Ongoing research is needed to address these issues to obtain workplace respect and fairness in this population and thus create an accepting atmosphere and achieve social justice in neurosurgery training.

Letters from Queer Elders: Transmitting Intergenerational Wisdom in LGBTQ+ Communities

Intergenerational relationships have been established as a critical locus of psychosocial development, meeting needs of identity development for youth, generativity for elders, and connection and belonging for both. However, intergenerational relationships are both rare in the LGBTQ+ community and sorely needed as a buffer to the discrimination and harm that those within the community experience from systemic and structural oppression. Focusing on sexual identity, and employing a letter writing paradigm, we investigated the content of wisdom that LGB elders have to share with youth. In a descriptive, exploratory, mixed-methods, and pre-registered study, 94 adults ranging in age 50 to 79 years (M = 55.98; SD = 6.30) wrote letters to a fictional youth, Sam, as well as completed surveys of psychosocial development and well-being. Letters were content coded for themes, as well as for emotional tone and subjective perspective. The most common themes of wisdom shared included knowing and celebrating oneself, negotiating an oppressive society, and finding one's community. Those who wrote more emotionally positive letters scored higher on measures of wisdom and generativity, and lower on embitterment. Results are discussed in terms of the importance of cultivating opportunities for wisdom-sharing within LGBTQ+ communities to promote flourishing across the lifespan.

Experiences of stress and social safety among sexual and gender minority youth by disability status

BACKGROUND

Though separate bodies of research have shown sexual and gender minority (SGM) youth, and youth with disabilities, separately, face distinct social and health disparities, little is known about youth who both identify as SGM and have disabilities.

OBJECTIVE

The current study examined differences in wellbeing among SGM youth by disability category (i.e., physical, developmental, psychiatric) across victimization, bullying, dating violence, school safety, and experienced stress.

METHODS

Using self-reported data from 9418 SGM youth aged 13-17 in the United States, multivariate linear regressions were conducted to examine how stress and social safety experiences varied across disability status.

RESULTS

Compared to SGM youth without a disability, SGM youth across all disability categories (physical, developmental, psychiatric) had greater odds of LGBT- and disability-based victimization, greater average stress, as well as lower levels of school safety. SGM youth with any disability, physical disability, or psychiatric disability also had greater odds of dating violence compared to SGM youth without a disability.

CONCLUSION

SGM youth with disabilities may be in particular need of targeted programs that address both disability and sexual/gender identities, and may benefit from increased supports across developmental contexts (e.g., against bullying in school). Stakeholders should consider how such support can be improved, tailored, and implemented, for SGM youth and the diversity of disabilities they have.

Loud, Proud, and All Around Hilarious: Queer Humor in Contemporary Graphic Novels as a Method of Interpersonal Affirmation and Awareness

Despite the prevalent humor in political, performative, and personal means of expression throughout American LGBTQ+ history, there is not yet an academic analysis on the overlap between queer theory and humor theory. In this article, I explore the ways in which LGBTQ+ writers use humorous techniques to highlight aspects of queerness to establish a theory of queer humor. I rely on three contemporary graphic narratives as a platform for humorous expression and for challenging social expectations, specifically in regards to LGBTQ+ identities and experiences. Through these close readings, I find queer humor exposes cultural policings of gender performativity by promoting queer experiences over normative assumptions and building solidarity with the reader regardless of their identity. These methods encourage acknowledgments and accommodations of queer existence within a heterosexist society.

Past experiences and preferences for LGBTQ + sex education among LGBTQ + college students

Background: Lesbian, gay, bisexual, transgender, queer, and others (LGBTQ+) students experience more negative sexual health outcomes than their cisgender, heterosexual peers and do not have access to relevant sex education. This denial necessitates comprehensive sex education in college for LGBTQ + students. Objective: Given the rise of online learning and that LGBTQ + students are already drawn to online spaces, this research seeks to determine preferences in virtual LGBTQ + sexuality education content and delivery LGBTQ + college students. Methods: We conducted a survey with US college students who identified as LGBTQ+ (N = 91) to identify past experiences with sex education, desires for future sex education, and preferences for online learning. Results: Past sex education, resources used, consequences, preferences for LGBTQ + sexuality and online education are discussed. Conclusions: Overall, we find high comfort with online learning, heteronormative and cisnormative past sex education courses created negative physical and mental health outcomes, and desires for tailored sex education.

LGBTQ+ new and expectant parents' experiences of perinatal services during the UK's first COVID-19 lockdown

BACKGROUND

COVID-19 created specific challenges for new and expectant parents and perinatal services. Services changed rapidly in the United Kingdom (UK), including the withdrawal of home birth services, birth center closures, and restrictions on the number of birth partners allowed in the birth room. The purpose of this study was to examine how these changes affected the experiences of LGBTQ+ parents in the UK.

METHODS

An online survey was conducted in April 2020 to provide real-time data capture of new and expectant families' experiences. It was open to those in the third trimester, or to those who had given birth since the beginning of the first UK lockdown period, and their partners. The survey asked open-ended questions about perinatal experiences. Demographic data were also collected, including sexual orientation and gender. Responses were collected from 1754 participants, including 76 who self-identified as LGBTQ+.

RESULTS

Thematic analysis identified that LGBTQ+ new and expectant parents faced similar issues to cisgendered, heterosexual expectant parents, though additional concerns were also noted relating to support and recognition. Heterocentric policies negatively affect lesbian families. Non-birthing co-mothers feared invalidation as parents. Sexual minority pregnant women were more likely than heterosexual pregnant women to consider additional birth supporters and to consider freebirthing.

DISCUSSION

Service changes introduced in the pandemic were cisheteronormative, creating additional challenges for LGBTQ+ new and expectant parents and compounding existing inequalities. When planning, changing, or evaluating perinatal services, specific consideration is needed to include birthing parents who are not mothers and mothers who did not give birth. If appropriate care is not available, consequences may include impaired perinatal wellbeing and restricted birth choices. Including sexual orientation and gender in data collection enables different perspectives to be considered.

Emotion Regulation Difficulties Moderate the Association Between Typical Drinking and Sexual Assault Victimization Among Sexual and Gender Minority University Students

Sexual and gender minority (SGM) students report higher alcohol consumption, emotion regulation difficulties, and sexual assault victimization severity than cisgender, heterosexual individuals. A sample of 754 undergraduate students completed an online survey assessing alcohol use, emotion regulation, and sexual victimization. Regression analyses indicated that, among SGM students with higher emotion regulation difficulties, typical weekly drinking was positively associated with sexual assault victimization severity, but among cisgender, heterosexual students and SGM students with lower emotion regulation difficulties, there was no association between drinking and victimization severity. Thus, SGM students benefit from interventions targeting alcohol use and emotion regulation difficulties.

A Request for Gender-Affirming Treatment in End-of-Life Care: A Case Study From an Inpatient VA Hospice Program

Hospice care involves focusing on our patients' goals of care and good symptom management. This coincides with a focus on their comfort, dignity, and respect. Working with lesbian, gay, bisexual, transgender, queer and/or questioning (LGBTQ+) patients on a hospice service can be challenging for medical staff. Many of these potential challenges relate to lack of training of medical professionals. These patients often receive discriminatory care compared to those who do not identify as LGBTQ+. This case study describes an assigned-male-at-birth Veteran admitted to a Veterans Affairs Community Living Center (CLC) hospice service who, after admission, informed staff of the strong desire to go forward with gender reassignment. Despite a prognosis of 6 months, working with the Veteran to help achieve these goals, supporting the medical plans for providing gender-transition information, and focusing on addressing the Veteran with appropriate pronouns were critical to our medical team's support for our Veteran at this difficult time.

Pediatric Residents' Preparedness, Attitudes, and Knowledge in LGBTQ+ Health Care

INTRODUCTION

The objective of this study was to evaluate pediatric residents' lesbian, gay, bisexual, transgender, queer, and all sexual and gender diverse (LGBTQ+) care.

METHOD

In June 2022, U.S. pediatric residents completed an anonymous online survey including the Lesbian, Gay, Bisexual, and Transgender-Development of Clinical Skills Scale (LGBT-DOCSS).

RESULTS

Pediatric residents (n = 78) reported low-to-moderate annual amounts of LGBT curricular hours (3.32 ± 3.17) and LGBT patients (13.84 ± 15.11) as well as low-to-moderate clinical preparedness and knowledge and high positive attitudes. They were significantly less likely to report receiving adequate training and supervision, having experience, and feeling competent in transgender care compared with lesbian, gay, and bisexual care. In general, pediatric residents who reported more LGBT education and LGBT patients also reported higher LGBT-DOCSS scores.

DISCUSSION

Pediatric residents in this study had substantial shortcomings in LGBTQ+ care. Pediatric programs must increase LGBTQ+ education and LGBTQ+ patient exposure.

Interpersonal protective factors for LGBTQ+ youth at multiple intersecting social identities and positions

Interpersonal supports are protective against multiple negative health outcomes for youth such as emotional distress and substance use. However, finding interpersonal support may be difficult for youth exposed to intersecting racism, heterosexism, and cisgenderism, who may feel they are "outsiders within" their multiple communities. This study explores disparities in interpersonal supports for youth at different sociodemographic intersections. The 2019 Minnesota Student Survey includes data from 80,456 high school students, including measures of four interpersonal supports: feeling cared about by parents, other adult relatives, friends, and community adults. Exhaustive Chi-square Automatic Interaction Detection analysis was used to examine all interactions among four social identities/positions (racialized/ethnic identity, sexual identity, gender identity, sex assigned at birth) to identify groups who report different rates of caring from each source (Bonferroni adjusted p<.05). In the overall sample, 69.24% perceived the highest level of caring ("very much") from parents, 50.09% from other adult relatives, 39.94% from friends, and 15.03% from community adults. Models identified considerable differences in each source of support. For example, more than 72% of straight, cisgender youth reported their parents cared about them very much, but youth who identified as LGBQ and TGD or gender-questioning were much less likely to report high parent caring (less than 36%) across multiple racialized/ethnic identities and regardless of sex assigned at birth. Findings highlight the importance of better understanding the ways interpersonal support might differ across groups, and underscore a need for intersectionality-tailored interventions to develop protective interpersonal supports for LGBTQ+ youth, rather than one-size-fits-all approaches.

Unveiling the shadows: Exploring the reality of commercial sexual exploitation among LGBTQ+ youth in out-of-home care

BACKGROUND

LGBTQ+ youth frequently encounter familial rejection based on their sexuality and gender identity and are at greater risk of being maltreated by their family, often prompting them to leave or run away from their parents' home. Such youth may find themselves living independently and, once they leave home, tend to be vulnerable to all kinds of abuse and sexual victimization, sometimes leading to different types of commercial sexual exploitation.

OBJECTIVE

This study aimed to comprehensively explore the subjective perspectives and understandings of commercial sexual exploitation among LGBTQ+ youth in out-of-home care in Israel.

METHODS

The study employed a critical constructivist grounded theory approach. Thirty-one in-depth semi-structured interviews were conducted with LGBTQ+ youth aged 16 to 32 (average 21.6), who aged out of one or more of the out-of-home care services for LGBTQ+ youth in Israel.

RESULTS

Our analysis indicates four main constructions of commercial sexual exploitation that depict the experiences of the participants: (1) survival sex; (2) gray prostitution; (3) sugar daddy; and (4) sex work.

CONCLUSIONS

Our findings highlight the diverse manifestations of commercial sexual exploitation among LGBTQ+ youth, shedding light on its pervasive nature and significant scale. Several of these manifestations are characterized by ambivalence and are placed in the gray areas of commercial sexual exploitation, making it challenging to identify.

3-month prevalence of unwanted sexual contact victimization in a national sample of college students: differences by race, gender identity, and sexual identity

IMPORTANCE

Most unwanted sexual contact victimization (USCV) research utilizes predominantly white, cisgender, heterosexual college student samples. Estimates of USCV prevalence and demographic variation can determine the need for dedicated funding and culturally relevant campus services for students in high-risk groups.

OBJECTIVE

To estimate the national prevalence and demographic variation in self-reported USCV within the first three months of college.

DESIGN

Data are from the Sexual Assault Prevention for Undergrads (SAPU) (2020-2021) dataset. SAPU is an online intervention program administered to students on more than 600 college campuses in the United States (N = 250,359). Group differences were assessed by race/ethnicity, gender identity, and sexual identity, and then stratified by gender to assess within-gender group differences.

SETTING

The SAPU dataset includes public and private institutions and 2-year and 4-year colleges with varying sizes of enrollment.

PARTICIPANTS

The sample is demographically diverse, and consists of newly matriculated U.S. college students, most of whom complete the SAPU program within the first three months of enrollment.

MAIN OUTCOMES AND MEASURES

The primary outcome measure is self-reported USCV within the first three months of college enrollment, analyzed for subgroup differences. We hypothesized that USCV would be higher among students from racial/ethnic, gender, and sexual minority populations.

RESULTS

Nearly 8% of transgender men reported USCV, followed by 7.4% of transgender women, 7.4% of genderqueer/gender non-conforming students, 4.5% of women, and 1.5% of men. Several subgroups reported exceedingly high rates of USCV, including Black students who identified as transgender women (35.7%) and American Indian/Alaska Native/Native Hawaiian/Pacific Islander students who identified as trans men (55.6%) or genderqueer/gender non-conforming (41.7%).

CONCLUSIONS AND RELEVANCE

Universal and targeted (selective and indicated) intervention programs are needed to lessen USCV, particularly among gender minority students who also identify as Black, Indigenous, other person of color, or as a sexual minority.

Risk and protective factors for suicidality among lesbian, gay, bisexual, transgender, and queer (LGBTQ+) young people, from countries with a high global acceptance index (GAI), within the context of the socio-ecological model: A scoping review

INTRODUCTION

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) young people experience higher prevalence rates of suicidality than their heterosexual and/or cisgender peers. However, there is limited research that can inform suicide prevention efforts. Our aim was to synthesize quantitative, qualitative, and mixed methods research on risk and protective factors among LGBTQ+ young people, from countries with a high Global Acceptance Index.

METHODS

A scoping review guided by Arksey and O'Malley's five-stage framework, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews protocol. Five databases and grey literature were searched for relevant studies. Identified factors were clustered by thematic type, according to the socio-ecological model to identify empirical trends and knowledge gaps. The mixed methods appraisal tool was used for quality assessment of studies.

RESULTS

Sixty-six studies met our inclusion criteria. Overall, 59 unique risk factors and 37 unique protective factors were identified. Key risk factors include past suicidality, adverse childhood experiences, internalized queerphobia, minority stress, interpersonal violence, bullying, familial conflict, and anti-LGBTQ+ policies/legislation. Key protective factors include self-affirming strategies, adult/peer support, at-school safety, access to inclusive healthcare, family connectedness, positive coming out experiences, gender-affirming services and LGBTQ+ inclusive policies and legislation.

CONCLUSIONS

Overall, our findings affirm that multiple risk and protective factors, at all levels of the socio-ecological model, interact in complex, unique and diverse ways upon suicidality among LGBTQ+ young people. Implications for suicide prevention are discussed. Further empirical studies are required, particularly at the communities, policies, and societal levels of the socio-ecological model, and these studies should include a focus on protective factors and significant within-group differences.

An Examination of Pregaming Behavior and Motives among Sexual and Gender Minority College Students

Introduction: Pregaming is a popular but high-risk drinking behavior common among college students. Although sexual and gender minority (SGM) college students are a vulnerable population with regards to hazardous alcohol use and alcohol consequences, there is currently limited research investigating the pregaming behavior of this group. The present study aimed to (1) examine mean level differences in pregaming behaviors and motives between SGM and non-SGM college students and (2) explore how SGM status was associated with pregaming behaviors and if SGM status moderated the association between motives and pregaming behaviors. Methods: The sample consisted of 485 college student drinkers in the US, with 19% (n = 93) identifying as SGM. All participants completed measures of past 30-day pregaming frequency and quantity (yielding a total pregaming drinks outcome) and drinking consequences experienced on pregaming days. Results: SGM participants consumed significantly fewer pregaming drinks than non-SGM participants, but did not significantly differ on alcohol-related consequences or drinking motives. The pregaming motive of intimate pursuit moderated the association between SGM status and total pregaming drinks, such that non-SGM participants with high intimate pursuit motives drank the heaviest. Conclusions: Our findings suggest that SGM students consume significantly fewer pregaming drinks than their non-SGM counterparts. However, they may be at a similar risk of experiencing pregaming consequences as non-SGM students. SGM students were less susceptible to the effect of intimate pursuit motives on pregaming drink consumption. This study offers support for past research regarding the effects of certain pregaming motives on pregaming drink consumption and consequences.

Navigating the landscape: Roles, perspectives, and experiences of psychologists supporting gender diverse children and young people in school settings

Purpose

This review aimed to explore and synthesize the perspectives and experiences of school-based psychological professionals providing support to gender diverse CYP across the world, to foreground the voices of those with relevant experience and support future practice.

Methods

A systematic review of five databases (PsychINFO, CINAHL, ERIC, SCOPUS and PROQUEST dissertations and theses) was performed between September and November 2022. Articles were included if they contained qualitative, primary research data representing the voice of at least one school-based psychological professional with experience working with gender diverse children and young people. Articles were excluded if they did not contain primary research data, were quantitative, related to non-school based psychologists or focussed on participant views in the absence of direct experience working with gender diverse pupils. Articles were thematically summarized and organized into a data extraction table.

Results

Eighteen studies were identified for review, including 11 studies based in the USA, five in the UK, one in Australia and one in Cyprus. The voices of school-based professionals, including school counselors, school psychologists, trainee and qualified educational psychologists, were represented. The themes created highlighted the importance of the environment in which psychologists were working, the reliance on their own views and values to guide their work in the absence of clear guidance, the role psychologists saw they had to advocate for gender diverse CYP, as well as barriers and systems they were fighting against.

Conclusion

The review highlighted the need for psychologists to advocate for gender diverse children and young people, in an often non-inclusive environment where there was a need to work systemically with schools. Future research is needed to explore young people's experiences of the support that they are receiving and would like to receive.

Responses to Sexual and Gender Identity Measures in Population-Level Data by Birth Cohort: A Research Note

The measurement of sexual and gender identity in the United States has been evolving to generate more precise demographic estimates of the population and a better understanding of health and well-being. Younger cohorts of sexual- and gender-diverse adults are endorsing identities outside of the lesbian, gay, bisexual, and transgender (LGBT) labels. Current population-level surveys often include a category such as "something else" without providing further details, and doing so inadequately captures these diverse identities. In this research note, our analysis of the most recent federal data source to incorporate sexual and gender identity measures-the Household Pulse Survey-reveals that younger birth cohorts are more likely to select "something else" for their sexual identity and "none of these" for their gender identity. The observed sexual and gender identity response patterns across birth cohorts underscore the importance of developing and applying new strategies to directly measure sexual- and gender-diverse adults who identify with identities outside of those explicitly captured on surveys. The integration of sexual and gender identity measures in population-level surveys carries broader implications for civil rights and for addressing health inequities and therefore must be responsive to cohort differences in identification.

Disrespectful and inadequate palliative care to transgender persons

OBJECTIVES

The purpose of this study was to describe disrespectful, inadequate, and abusive care to seriously ill patients who identify as transgender and their partners.

METHODS

A cross-sectional mixed methods study was conducted. The sample included 865 nurses, physicians, social workers, and chaplains. Respondents were asked whether they had observed disrespectful, inadequate, or abusive care due to the patient being transgender and to describe such care.

RESULTS

Of the 21.3% of participants who reported observing discriminatory care to a transgender patient, 85.3% had observed disrespectful care, 35.9% inadequate care, and 10.3% abusive care. Disrespectful care included insensitivity; rudeness, ridicule, and gossip by staff; not acknowledging or accepting the patient's gender identity or expression; privacy violations; misgendering; and using the incorrect name. Inadequate care included denying, delaying, or rushing care; ignorance of appropriate medical and other care; and marginalizing or ignoring the spouse/partner.

SIGNIFICANCE OF RESULTS

These findings illustrate discrimination faced by seriously ill transgender patients and their spouse/partners. Providers who are disrespectful may also deliver inadequate care to transgender patients, which may result in mistrust of providers and the health-care system. Inadequate care due to a patient's or spouse's/partner's gender identity is particularly serious. Dismissing spouses/partners as decision-makers or conferring with biological family members against the patient's wishes may result in unwanted care and constitute a Health Insurance Portability and Accountability Act of 1996 (HIPAA) violation. Institutional policies and practices should be assessed to determine the degree to which they are affirming to both patients and staff, and revised if needed. Federal and state civil rights legislation protecting the LGBTQ+ community are needed, particularly given the rampant transphobic legislation and the majority of states lacking civil rights laws protecting LGBTQ+ people. Training healthcare professionals and staff to become competent and comfortable treating transgender patients is critical to providing optimal care for these seriously ill patients and their spouse/partner.

Implementation of LGBTQ+ affirming care policies in the Veterans Health Administration: preliminary findings on barriers and facilitators in the southern United States

Background

In the United States Department of Veterans Affairs (VA), veterans who are lesbian, gay, bisexual, transgender, queer, and similar gender and sexual minoritized people (LGBTQ+) experience health disparities compared to cisgender, heterosexual veterans. VA's LGBTQ+ Health Program created two healthcare policies on providing LGBTQ+ affirming care (healthcare that is inclusive, validating, and understanding of the LGBTQ+ population). The current project examines providers' barriers and facilitators to providing LGBTQ+ affirming care and LGBTQ+ veterans' barriers and facilitators to receiving LGBTQ+ affirming care.

Methods

Data collection and analysis were informed by the Consolidated Framework for Implementation Research, which was adapted to include three health equity domains. Data collection involved telephone interviews conducted with 11 VA providers and 12 LGBTQ+ veterans at one rural and one urban VA medical center, and one rural VA community clinic. Qualitative data were rapidly analyzed using template analysis, a data reduction technique.

Results

Providers described limited education, limited time, lack of experience with the population, and a lack of awareness of resources as barriers. Providers discussed comfort with consulting trusted peers, interest in learning more about providing LGBTQ+ affirming care, and openness and acceptance of the LGBTQ+ community as facilitators. LGBTQ+ veterans described a lack of provider awareness of their needs, concerns related to safety and discrimination, and structural discrimination as barriers. LGBTQ+ veterans described positive relationships with providers, knowledge of their own healthcare needs, and ability to advocate for their healthcare needs as facilitators. Although VA's LGBTQ+ affirming care policies are in place, providers and veterans noted a lack of awareness regarding specific healthcare processes.

Conclusion

Allowing more time and capacity for education and engaging LGBTQ+ veterans in determining how to improve their healthcare may be the path forward to increase adherence to LGBTQ+ affirming care policies. Engaging patients, especially those from marginalized backgrounds, in strategies focused on the uptake of policy may be a path to improve policy implementation. It is possible that creating truly collaborative structures in which patients, staff, providers, leadership, and policymakers can work together towards policy implementation may be a useful strategy. In turn, improved policy implementation would result in increased physical and mental health for LGBTQ+ veterans.

Problems in management of medication overuse headache in transgender and gender non-conforming populations

Primary headache disorders, such as migraine, account for a significant portion of disability rates worldwide, yet patients still struggle to receive the adequate medical and emotional support necessary to improve health outcomes. Insufficient pain management through either impractical pharmaceutical treatments or absent emotional support networks can worsen physical and mental health outcomes since comorbidities commonly associated with headache include hypertension, diabetes, depression, and anxiety. A lack of awareness on headache pathology and its observable severity can lead to pain-related prejudice that destroys beneficial aspects of patient self-advocacy and self-efficacy, thus potentially discouraging the use of healthcare services in favor of maladaptive coping skills. Acute treatments for primary headache disorders include non-steroidal anti-inflammatory drugs (i.e., aspirin, ibuprofen), triptans (i.e., sumatriptan), and opioids; however, continuous use of these pain-relieving agents can generate a secondary headache known as medication overuse headache (MOH). Recent work highlighting the overlap of morphological and functional brain changes in MOH and substance use disorder (SUD) suggests that insufficient pain management encourages analgesic misuse. The LGBTQ+ community-specifically transgender and gender non-conforming persons-struggles with high rates of mental illness and substance abuse. Since gender-affirming sex hormone therapy influences migraine progression, transgender and gender non-conforming (trans*) patients on hormone therapy have a higher risk for worsening migraine symptoms. However, trans* patients are less likely to have access to appropriate pain management techniques, thus preventing positive health outcomes for this vulnerable population.

Prevalence, severity and risk factors of psychiatric disorders amongst sexual and gender diverse young people during the COVID-19 pandemic: A systematic review

Before the COVID-19 pandemic, the prevalence and severity of psychiatric disorders among sexual and gender diverse (SGD) young people was greater than in their heterosexual/cisgender peers. We systematically reviewed literature examining the prevalence, severity, and risk factors for psychiatric disorders among SGD young people aged 25 and under during the pandemic. Four databases (MEDLINE, PsycInfo, Scopus and Web of Science) were searched. Eligibility criteria were studies assessing prevalence rates, mean symptomology scores and risk factors of psychiatric disorders using contemporaneous screening measures or diagnosis. Thirteen studies of mixed quality were identified. Most studies indicated SGD young people were at high risk of experiencing several psychiatric disorders including depressive and generalised anxiety disorder compared to the general population. This group also experienced more severe symptomology of various psychiatric disorders compared to their heterosexual/cisgender peers. Risk factors included those specific to the pandemic along with factors that led to greater risk before the pandemic. This systematic review has indicated evidence of heightened risk of psychiatric disorders among SGD young people during the COVID-19 pandemic. It is important for clinicians to acknowledge the needs of SGD young people, working with them to co-develop more inclusive care as they deal with the pandemic's fallout.

Body Image Among Sexual and Gender Minorities: An Intersectional Analysis

Body image is consequential for overall well-being and has a complex relation to gender. Sexual and gender minority (SGM) individuals develop body image amid intersecting systems of oppression, such as sexism, cisnormativity, heteronormativity, and gender binary pressures. This study used an intersectionality framework to examine how various aspects of gender identification (cis/trans, binary/nonbinary, woman/man identification) related to body image differences among SGM individuals. We also assessed whether identification with conventionally masculine and feminine personality traits predicted body image. We used one-way and two-way ANOVAs and linear regressions to analyze two indicators of body image (body appreciation and drive for muscularity) in a sample of 643 SGM individuals (148 sexual minority (SM) cis women, 171 trans women, 121 SM cis men, 43 trans men, 160 nonbinary individuals). Results implicated cisnormativity as an influential and hierarchical force for body image, although woman/man and binary/nonbinary identification also played roles in group differences. With a few exceptions, masculine but not feminine trait identification significantly predicted body appreciation and drive for muscularity, indicating a complicated association with overall body image. These findings underscore the value of an intersectional lens for analyzing how broad social forces may manifest in individual-level body image for SGM individuals.

Use of Machine Learning Tools in Evidence Synthesis of Tobacco Use Among Sexual and Gender Diverse Populations: Algorithm Development and Validation

BACKGROUND

From 2016 to 2021, the volume of peer-reviewed publications related to tobacco has experienced a significant increase. This presents a considerable challenge in efficiently summarizing, synthesizing, and disseminating research findings, especially when it comes to addressing specific target populations, such as the LGBTQ+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, Two Spirit, and other persons who identify as part of this community) populations.

OBJECTIVE

In order to expedite evidence synthesis and research gap discoveries, this pilot study has the following three aims: (1) to compile a specialized semantic database for tobacco policy research to extract information from journal article abstracts, (2) to develop natural language processing (NLP) algorithms that comprehend the literature on nicotine and tobacco product use among sexual and gender diverse populations, and (3) to compare the discoveries of the NLP algorithms with an ongoing systematic review of tobacco policy research among LGBTQ+ populations.

METHODS

We built a tobacco research domain-specific semantic database using data from 2993 paper abstracts from 4 leading tobacco-specific journals, with enrichment from other publicly available sources. We then trained an NLP model to extract named entities after learning patterns and relationships between words and their context in text, which further enriched the semantic database. Using this iterative process, we extracted and assessed studies relevant to LGBTQ+ tobacco control issues, further comparing our findings with an ongoing systematic review that also focuses on evidence synthesis for this demographic group.

RESULTS

In total, 33 studies were identified as relevant to sexual and gender diverse individuals' nicotine and tobacco product use. Consistent with the ongoing systematic review, the NLP results showed that there is a scarcity of studies assessing policy impact on this demographic using causal inference methods. In addition, the literature is dominated by US data. We found that the product drawing the most attention in the body of existing research is cigarettes or cigarette smoking and that the number of studies of various age groups is almost evenly distributed between youth or young adults and adults, consistent with the research needs identified by the US health agencies.

CONCLUSIONS

Our pilot study serves as a compelling demonstration of the capabilities of NLP tools in expediting the processes of evidence synthesis and the identification of research gaps. While future research is needed to statistically test the NLP tool's performance, there is potential for NLP tools to fundamentally transform the approach to evidence synthesis.

The Current State of Health Inequities in COPD

An understanding of the health inequities that surround the treatment and prevention of COPD is required to address the barriers that hinder improvement of care for underserved populations. This scoping review was conducted to identify the existing evidence of social factors that affect the health, health-care access, and health-care quality of patients with COPD within the United States, and to identify gaps in knowledge to help direct future research. We followed the guidelines from the Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and Meta Analyses Extension for Scoping Reviews. In July 2022, a literature search by using Ovid (Embase) and MEDLINE (PubMed) databases was conducted to identify articles on COPD, published between 2016 and 2021, written in English, and that investigated at least one health inequity as defined by the National Institutes of Health. All studies were screened for inclusion criteria and were extracted in a masked, duplicate manner. Each health inequity was investigated, extracted, and summarized. Thirty articles were screened in full text, and 19 were found to meet inclusion criteria. Common social factors investigated in the COPD literature included race/ethnicity, income, and education. Since the implementation of the National Institutes of Health's sex and gender minority category in 2016, only one study within our sample examined LGBTQ+ (lesbian, gay, bisexual, transgender, queer [or sometimes questioning], and others) patients with COPD. The least commonly investigated social factors that affect patients with COPD were rural/under-resourced (geography), sex and gender, and LGBTQ+ affiliation. In addition, occupational status was not investigated by any included studies in our sample. Our scoping review underlines the lack of research with regard to inequities that affect patients with COPD. We propose researching hormone replacement therapy's impact on lung function in transgender and nonbinary patients with COPD. Implementation science studies are suggested to enhance intervention for COPD medication adherence among racial/ethnic minority groups, given the intersectionalities of social factors that disproportionately affect this population. We, also recommend developing telemedicine pulmonary rehabilitation technology for rurally located patients with COPD.

The sexual and gender minority (LGBTQ+) medical trainee: the journey through medical education

In this literature overview, we share with the reader challenges faced by LGBTQ + individuals pursuing medical education, from undergraduate to postgraduate training. The LGBTQ + acronym has evolved to encompass the diverse spectrum of sexual orientation and gender identities. Recently, the term "Sexual and Gender Minority" (SGM) has emerged as an umbrella term to provide consistency in research advancing SGM health. The unique obstacles LGBTQ + trainees encounter are highlighted throughout this article, including external factors influencing career decisions, a lack of LGBTQ + healthcare curricula, discriminatory social interactions, limited mentorship opportunities, and a higher mental health burden. These challenges have the capacity to affect educational experiences, personal well-being, and professional growth. Additionally, we examine the impact of inclusive institutional climates on LGBTQ + trainees' selection of medical schools and residency programs, as they may prioritize inclusiveness and diversity when making their choice. In postgraduate training, LGBTQ + trainees continue to face challenges, exemplified by disparities in placement rates and discriminatory experiences based on sexual orientation and gender identity. We describe the gap in current research and its long-term impact of these challenges on career paths. Hostile environments persist in certain specialties, and the lack of LGBTQ + mentorship and support can hinder academic pursuits. We shed light on the unique and pervasive challenges faced by LGBTQ + trainees throughout their medical education journey, while emphasizing the need for inclusive policies, support systems, and research to address these challenges. With increasing research and studies, we hope to create a medical workforce and community that better represents the diverse communities it serves.

Transgender and gender diverse individuals' perspectives on discussions of fetal sex chromosomes in obstetrics care

In the past decade, prenatal cell-free DNA screening (cfDNA) has become ubiquitous as a screening tool for fetal aneuploidy and sex chromosomes. Healthcare provider (HCP) discussions and public perceptions of sex and gender uniquely impact transgender and gender diverse (TGD) individuals, and existing cfDNA guidelines lack recommendations regarding how to discuss sex and gender prenatally. The aim of this exploratory qualitative study was to examine TGD individuals' opinions regarding fetal sex chromosome disclosure sessions. Twelve semi-structured virtual interviews were conducted with TGD individuals regarding their perspectives on the discussion of fetal sex chromosomes by HCPs within the prenatal setting. Interviews were coded and analyzed using a reflexive thematic approach, generating four major themes: (1) Current practices in prenatal care exclude gender diverse people; (2) HCPs' responsibility to de-gender discussions of sex chromosomes in prenatal care; (3) HCPs' responsibility to acknowledge gender diversity; and (4) HCPs' influence on societal perceptions of sex and gender. More guidance is needed from professional societies regarding best practices for HCP discussions of sex chromosomes, sex, and gender. Participants recommended HCPs educate patients about sex chromosomes and their relevance to health while avoiding the conflation of sex and gender terms. Additionally, there is an acute need for trans-inclusive prenatal healthcare. Ultimately, HCPs' and organizations are in a prime position to deconstruct rigid gender binaries and promote societal inclusion of TGD people.

Sex and gender correlates of sexually polymorphic cognition

BACKGROUND

Sexually polymorphic cognition (SPC) results from the interaction between biological (birth-assigned sex (BAS), sex hormones) and socio-cultural (gender identity, gender roles, sexual orientation) factors. The literature remains quite mixed regarding the magnitude of the effects of these variables. This project used a battery of classic cognitive tests designed to assess the influence of sex hormones on cognitive performance. At the same time, we aimed to assess the inter-related and respective effects that BAS, sex hormones, and gender-related factors have on SPC.

METHODS

We recruited 222 adults who completed eight cognitive tasks that assessed a variety of cognitive domains during a 150-min session. Subgroups were separated based on gender identity and sexual orientation and recruited as follows: cisgender heterosexual men (n = 46), cisgender non-heterosexual men (n = 36), cisgender heterosexual women (n = 36), cisgender non-heterosexual women (n = 38), gender diverse (n = 66). Saliva samples were collected before, during, and after the test to assess testosterone, estradiol, progesterone, cortisol, and dehydroepiandrosterone. Psychosocial variables were derived from self-report questionnaires.

RESULTS

Cognitive performance reflects sex and gender differences that are partially consistent with the literature. Interestingly, biological factors seem to better explain differences in male-typed cognitive tasks (i.e., spatial), while psychosocial factors seem to better explain differences in female-typed cognitive tasks (i.e., verbal).

CONCLUSION

Our results establish a better comprehension of SPC over and above the effects of BAS as a binary variable. We highlight the importance of treating sex as a biological factor and gender as a socio-cultural factor together since they collectively influence SPC.

Minority Stress, Self-Awareness, and Coping Strategies during the COVID-19 Pandemic among Italian Transgender Young Adults

BACKGROUND

The security measures implemented in response to the COVID-19 emergency have caused complex consequences. The aim of the present study is to examine the repercussions of the pandemic on individuals belonging to gender identity minority groups, who have experienced heightened levels of stress in comparison to the general population.

METHODS

Online interviews with 12 transgender participants who resided in Italy during the pandemic were conducted and subsequently analyzed following the thematic analysis methodology.

RESULTS

The majority of the participants reported an increase in stress levels primarily attributed to the lack of acceptance and support within their familial environments, obstacles encountered in accessing specialized healthcare services, and a lack of support from the broader LGBTQ+ community. Despite these challenges, several participants developed effective coping strategies and a subset of them also benefited from multiple resilience factors, including familial support and assistance from mental health professionals.

CONCLUSIONS

The outcomes of the present study indicate that the COVID-19 pandemic, while fostering certain protective factors within this population, has also given rise to new and critical mental health concerns. These findings hold significant implications for professionals working with transgender populations, highlighting the necessity of addressing these emerging mental health issues.

"Expectation is Always that the Practitioner Might Not Be Okay with Queerness": Experiences of LGBTQ+ With the Healthcare System in Saskatchewan, Canada

This project aimed to explore the experiences of perceived mistrust and stigma by the LGBTQ+ members while accessing healthcare services in Saskatchewan, Canada. In partnership with local organization, a community-based participatory research (CBPR) approach was employed and, semi structured descriptive interviews were conducted. Sixteen participants ranging from age 20-60 were recruited and interviewed. Inductive coding method with thematic data analysis was performed, and descriptive comprehensive results were produced. The LGBTQ+ community reported negative experiences within the context of four emerging themes: (a) perceived stigma and discrimination in healthcare settings, (b) practitioners' LGBTQ+-specific healthcare knowledge, (c) the need for LGBTQ+-specific cultural sensitivity and inclusion, and (d) a call for changes in healthcare policy. Each theme and its corresponding experiences serve as a baseline of information to demonstrate the need for improved access to safe healthcare and increased sustainable health for the LGBTQ+ community members. This calls for training and education, establishing cultural sensitivity, and mandating policy changes could improve the experiences of the LGBTQ+ community members.

Emerging Evidence: A Systematic Literature Review of Disordered Eating Among Transgender and Nonbinary Youth

PURPOSE

This systematic literature review explores the evidence base related to the diagnosis and clinical management of eating disorders among transgender and gender nonbinary (TGNB) youth. Through an exploration of the literature, this review highlights key considerations for providers working with this population, including the complex relationship between body image and gender, the assessment of subthreshold eating disorder symptoms, the impact of gender-affirming care on eating disorder treatment outcomes, and available evidence-based metrics, with attention to factors impacting treatment, including family support, psychiatric comorbidities, and community safety.

METHODS

We conducted a search of the databases PubMed and Ovid MEDLINE for articles pertaining to eating disorders and TGNB youth, with forward citation chaining conducted via Google Scholar to provide a review of recent publications. Twenty-six articles published from 2017 to 2022 met the criteria for full-text review.

RESULTS

The selected articles primarily explored data from the United States and varied widely in methodology, including a systematic literature review (n = 1), narrative literature reviews (n = 3), case series (n = 4), case studies (n = 2), cross-sectional population surveys (n = 7), cross-sectional patient surveys (n = 3), other cross-sectional studies (n = 3), retrospective chart reviews (n = 2), and a retrospective longitudinal cohort study (n = 1). Most commonly, researchers sampled patients within the setting of gender clinics. Researchers used a range of validated measures in clinical settings, with the Eating Disorder Examination Questionnaire most frequently reported. The literature highlights several considerations unique to transgender populations, including the complex relationship between gender dysphoria, body dissatisfaction, disordered eating behavior, and gender-affirming care.

DISCUSSION

In clinical settings with TGNB youth, providers may consider implementing validated screening measures to assess for eating disorders. Future research should emphasize a nuanced understanding of the heterogeneity among TGNB patient populations and the impact of gender identity on treatment of eating disorders.

Health Disparities Among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: A Structural Competency Approach

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) older adults experience significant health disparities. Examining these disparities has become an international research priority, but gaps remain. In this review article, we summarize major contributions of and ongoing gaps in health disparities research among LGBTQ+ older adults, while focusing on four major content areas: (a) social determinants of health disparities, (b) mental, cognitive, and physical health disparities, (c) reproductive and sexual health disparities, and (d) seeking LGBTQ+-affirming and age-friendly care. Using a structural competency approach, we develop a four-part agenda for this research area that enhances our understanding of how macro-level systems, institutions, and structures drive health disparities among aging LGBTQ+ communities. We also outline future research on structural competency in LGBTQ+ older adult health, while providing recommendations for researchers and clinicians. These recommendations illuminate potential best practices for bettering the health and quality of life of LGBTQ+ older populations.

Transgender college students' mental health: Comparing transgender students to their cisgender peers

Objective: Although researchers in higher education have focused more attention on transgender individuals, gaps remain, particularly related to aspects of health and wellness. Participants: Participants were a nationally representative sample of college students. Methods:Anova and follow up post hoc tests were utilized to examine measures of transgender college students' mental health in comparison to their cisgender peers who identify as heterosexual, lesbian, gay, and bisexual. Results: Findings indicate that transgender students were more likely to report physically harming themselves or attempt suicide, but responded similarly to peers on other measures. Conclusions: Individuals who work with transgender college students can benefit from this reserach by understanding how to support and avoid marginalizing these students.