Changing language, changes lives: Learning the lexicon of LGBTQ+ health equity

Patient voices and student insights into LGBTQ+ healthcare: a call for equitable healthcare through medical education

PURPOSE

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender diverse (LGBTQ+) individuals have health needs specific to their identities. However, they face discrimination and cis-heteronormativity in most patient-provider interactions, which often translate into poor healthcare. Evidence suggests doctors are inadequately trained to care for LGBTQ+ patients. Medical students are well-placed as the future workforce to establish affirming behaviours. This study garners LGBTQ+ patients' healthcare experiences, where limited qualitative evidence exists, and explores whether students have insight into these experiences.

METHOD

Thirty LGBTQ+ patients and twenty students, evenly divided between Singapore and the United Kingdom (UK), two legally and culturally different countries, consented to semi-structured interviews in 2022 to evaluate their LGBTQ+ healthcare perceptions. Thematic analysis was conducted using a collaborative, iterative process involving five investigators, with frequent auditing of data interpretation.

RESULTS

Most patients described implicit biases with a lack of support and professionalism from doctors, hindering health outcomes. Patients experienced misgendering and a lack of recognition of sexual and gender diversity; students appreciated the need to acknowledge patient identity. Although perceptions surrounding certain themes were similar between patients and students in both countries, patients' voices on the complexity and dissatisfaction of gender-diverse care contrasted with students' lack of insight on these themes. Singapore patients were more concerned with sociolegal acceptance affecting health needs, whilst UK patients noted more nuanced barriers to healthcare. Although many students were unsure about specific health needs and perceived a lack of training, they expressed willingness to create an equitable healthcare environment.

CONCLUSIONS

LGBTQ+ patients provided powerful narratives on discrimination surrounding their healthcare needs. To address these, medical students must be encouraged by healthcare educators to develop identity-affirming behaviours as future change-makers and challenge cis-heteronormative views. Alongside vital institutional changes tailored to each country, patients' and students' collective action would create meaningful educational opportunities to reach culture change.

Mapping the scientific literature on obstetric and perinatal health among sexual and gender minoritized (SGM) childbearing people and their infants: a scoping review

BACKGROUND

Evidence suggests sexual and gender minoritized (SGM) childbearing individuals and their infants experience more adverse obstetric and perinatal outcomes compared to their cisgender, heterosexual counterparts. This study aimed to comprehensively map obstetric and perinatal physical health literature among SGM populations and their infants and identify knowledge gaps.

METHODS

PubMed, Embase, CINAHL, and Web of Science Core Collection were systematically searched to identify published studies reporting obstetric and perinatal outcomes in SGM individuals or their infants. Study characteristics, sample characteristics, and outcome findings were systematically extracted and analyzed.

RESULTS

Our search yielded 8,740 records; 55 studies (1981-2023) were included. Sexual orientation was measured by self-identification (72%), behavior (55%), and attraction (9%). Only one study captured all three dimensions. Inconsistent measures of sexual orientation and gender identity (SOGI) were common, and 68% conflated sex and gender. Most (85%) focused on sexual minorities, while 31% addressed gender minorities. Demographic measures employed varied widely and were inconsistent; 35% lacked race/ethnicity data, and 44% lacked socioeconomic data. Most studies (78%) examined outcomes among SGM individuals, primarily focusing on morbidity and pregnancy outcomes. Pregnancy termination was most frequently studied, while pregnancy and childbirth complications (e.g., gestational hypertension, postpartum hemorrhage) were rarely examined. Evidence of disparities were mixed. Infant outcomes were investigated in 60% of the studies, focusing on preterm birth and low birthweight. Disparities were noted among different sexual orientation and racial/ethnic groups. Qualitative insights highlighted how stigma and discriminatory care settings can lead to adverse pregnancy and birth outcomes.

CONCLUSIONS

Frequent conflation of sex and gender and a lack of standardized SOGI measures hinder the comparison and synthesis of existing evidence. Nuanced sociodemographic data should be collected to understand the implications of intersecting identities. Findings on perinatal health disparities were mixed, highlighting the need for standardized SOGI measures and comprehensive sociodemographic data. The impact of stigma and discriminatory care on adverse outcomes underscores the need for inclusive healthcare environments. Future research should address these gaps; research on SGM perinatal outcomes remains urgently lacking.

TRIAL REGISTRATION

The review protocol was developed a priori in February 2023, registered on Open Science Framework ( https://doi.org/10.17605/OSF.IO/5DQV4 ) and published in BMJ Open ( https://bmjopen.bmj.com/content/13/11/e075443 ).

Undergraduate Nursing Faculty Knowledge, Beliefs, and Experiences with Teaching LGBTQ+ Content: A Scoping Review

BACKGROUND

Nursing education research about inclusion of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) health content in undergraduate nursing curricula primarily focuses on student learning outcomes. There is less research evidence about the experiences of nursing faculty with teaching LGBTQ+ health topics.

PURPOSE

The purpose of this scoping review was to identify current evidence about pre-licensure, undergraduate nursing faculty knowledge, beliefs, and experiences with teaching LGBTQ+ content.

METHODS

Six EBSCO databases were searched for manuscripts published between 2012 and 2023. Peer-reviewed articles, published in English, describing studies of pre-licensure, undergraduate nursing faculty knowledge, beliefs, and experiences with teaching LGBTQ+ health content were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews was used to guide inclusion of studies for review.

RESULTS

The literature search yielded 612 results, of which 58 were selected for full text screening. Twelve total studies were retained for this scoping review.

CONCLUSIONS

Faculty knowledge related to LGBTQ+ health is framed by a "deficit narrative," emphasizing physical and mental health risks and negative outcomes. Faculty beliefs are often measured with instruments that reflect cisnormativity or heteronormativity. There is an ongoing need to research the experiences of inclusion of LGBTQ+ content by pre-licensure, undergraduate nursing faculty.

Nursing care of transgender persons: A systematic mapping study

AIM

To identify, organize, and report findings of published literature related to the delivery of nursing care for transgender people.

BACKGROUND

Transgender people describe negative interactions with healthcare providers, which have led to delayed care and suboptimal health outcomes. Nurses report being unprepared to care for transgender patients despite published standards for delivery of gender-affirming care. Previous studies indicate focused transgender nursing care education improves positive healthcare experiences and reducing disparities for transgender people.

DESIGN

A systematic mapping strategy was employed to perform this mapping study.

METHODS

Using the search terms transgender, transgendered, gender-nonconforming, nonbinary, gender identity, nursing care, nurse attitudes, health care delivery/disparities, patient-centered care, and gender-affirming care a literature search was completed within CINAHL Complete, MEDLINE Complete, and Psychology and Behavioral Sciences Collection. Of 1250 articles identified, duplicates were removed before the titles, abstracts, and full text were screened for relevance.

RESULTS

A final sample of thirteen studies focusing on transgender patient care, practicing nurses' experiences, and nurse education was analyzed. The findings confirmed a dearth of primary research related to nursing care of transgender people.

CONCLUSIONS

Little research has been conducted in the last five years regarding nursing care provided to transgender people and nurse education regarding aspects of transgender and gender-affirming care. Despite increased research, innovative interventions remain imperative to address the gap in nursing education regarding gender-affirming health care.

Stigma, social and structural vulnerability, and mental health among transgender women: A partial least square path modeling analysis

INTRODUCTION

Existing literature suggests that transgender women (TW) may be at high risk for adverse mental health due to stress attributed to combined experiences of stigma and complex social and structural vulnerabilities. Little research has examined how these co-occurring experiences relate to mental health. We aimed to test a theoretically driven conceptual model of relationships between stigma, social and structural vulnerabilities, and mental health to inform future intervention tailoring.

DESIGN/METHODS

Partial least square path modeling followed by response-based unit segmentation was used to identify homogenous clusters in a diverse community sample of United States (US)-based TW (N = 1418; 46.2% White non-Hispanic). This approach examined associations between latent constructs of stigma (polyvictimization and discrimination), social and structural vulnerabilities (housing and food insecurity, unemployment, sex work, social support, and substance use), and mental health (post-traumatic stress and psychological distress).

RESULTS

The final conceptual model defined the structural relationship between the variables of interest within stigma, vulnerability, and mental health. Six clusters were identified within this structural framework which suggests that racism, ethnicism, and geography may be related to mental health inequities among TW.

CONCLUSION

Our findings around the impact of racism, ethnicism, and geography reflect the existing literature, which unfortunately shows us that little change has occurred in the last decade for TW of color in the Southern US; however, the strength of our evidence (related to sampling structure and sample size) and type of analyses (accounting for co-occurring predictors of health, i.e., stigma and complex vulnerabilities, reflecting that of real-world patients) is a novel and necessary addition to the literature. Findings suggest that health interventions designed to offset the negative effects of stigma must include anti-racist approaches with components to reduce or eliminate barriers to resources that contribute to social and structural vulnerabilities among TW. Herein we provide detailed recommendations to guide primary, secondary, and tertiary prevention efforts.

CLINICAL RELEVANCE

This study demonstrated the importance of considering stigma and complex social and structural vulnerabilities during clinical care and design of mental health interventions for transgender women who are experiencing post-traumatic stress disorder and psychological distress. Specifically, interventions should take an anti-racist approach and would benefit from incorporating social support-building activities.

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.

Knowledge, behaviours, and training related to 2SLGBTQIA+ health education amongst entry-level physiotherapy students in Canada: results of a nationwide, cross-sectional survey

BACKGROUND

Individuals who identify as 2SLGBTQIA+ report worse health outcomes than heterosexual/cisgender counterparts, in part due to poor experiences with healthcare professionals. This may stem from inadequate 2SLGBTQIA+ health and inclusiveness training in health professional student education. The purpose of the study was to evaluate knowledge, behaviours, and training related to 2SLGBTQIA+ health education and inclusiveness for entry-level physiotherapy students in Canada.

METHODS

We conducted a nationwide, cross-sectional survey with physiotherapy students from accredited Canadian physiotherapy programs. We administered the survey through Qualtrics and recruited students through targeted recruitment emails and social media posts on Twitter and Instagram between August and December 2021. Survey responses are reported as frequencies (percentage). We also completed multivariable logistic regressions to evaluate associations among question responses related to working with 2SLGBTQIA+ individuals (i.e., communication, feeling prepared and assessment competency). Covariates included training hours (< 10/10 + hours) and 2SLGBTQIA+ identity (yes/no).

RESULTS

A total of 150 students responded to the survey, with 35 (23%) identifying as 2SLGBTQIA+ . Many students felt confident in communicating effectively with clients who identify as 2SLGBTQIA+ (69%). However, only half (47%) felt comfortable assessing clients who identify as 2SLGBTQIA+ . Routine practice of inclusive behaviours such as using pronouns, considering identities are fluid and a patient's gender identity and/or sexual orientation may shift from one visit to the next, and considering trauma-informed care practices were reported from less than half of the students (< 45%). Around 29% of students reported no 2SLGBTQIA+ training in their physiotherapy program, while 47% reported 0-10 hours, and 24% reported 10 + hours of training. Students with 10 + hours of training had 92% higher odds of feeling competent in assessing 2SLGBTQIA+ clients, compared to those with < 10 hours of training.

CONCLUSIONS

Entry-level physiotherapy students in Canada show a lack of understanding and awareness for 2SLGBTQIA+ health and inclusive behaviours which can meaningfully impact patient experience. Students report feeling incompetent when working with 2SLGBTQIA+ patients, which may be associated with lack of 2SLGBTQIA+ training in their programs. Greater efforts and attention towards increasing 2SLGBTQIA+ health education and inclusivity in Canadian entry-level physiotherapy programs is critically needed.

Stressors in health care and their association to symptoms experienced by gender diverse people

OBJECTIVES

Many individuals whose gender does not align with the sex they were assigned at birth (gender diverse [GD] people) report stressful health care encounters. We examined the relationship of these stressors to symptoms of emotional distress and impaired physical functioning among GD people.

STUDY DESIGN

This study was conducted using a cross-sectional design with data from the 2015 United States Transgender Survey.

METHODS

Composite metrics of health care stressors and physical impairments were developed, and the Kessler Psychological Distress Scale (K-6) provided a measure of emotional distress. Linear and logistic regression were used to analyze the aims.

RESULTS

A total of 22,705 participants from diverse gender identity subgroups were included. Participants who experienced at least one stressor in health care during the past 12 months had more symptoms of emotional distress (β = 0.14, P < .001) and 85% greater odds of having a physical impairment (odds ratio = 1.85, P < .001). Transgender men exposed to stressors were more likely than transgender women to experience emotional distress and have a physical impairment, with other gender identity subgroups reporting less distress. Black participants exposed to stressful encounters reported more symptoms of emotional distress than White participants.

CONCLUSIONS

The results suggest that stressful encounters in health care are associated with symptoms of emotional distress and greater odds of physical impairment for GD people, with transgender men and Black individuals being at greatest risk of emotional distress. The findings indicate the need for assessment of factors that contribute to discriminatory or biased health care for GD people, education of health care workers, and support for GD people to reduce their risk of stressor-related symptoms.

Participation, barriers, and facilitators of cancer screening among LGBTQ+ populations: A review of the literature

The LGBTQ+ community is at higher risk of certain cancers but is less likely to participate in screening programs or engage with preventive healthcare. Despite this, the barriers and facilitators to cancer screening are not well understood in this population. We conducted a literature review of research related to LGBTQ+ participation in cancer screening, as well as barriers and facilitators to participation. Following abstract and full-text screening, 50 studies were included in the final synthesis. Compared to their heterosexual counterparts, lesbian and bisexual women were less likely to participate in cervical cancer screening and mammography, but gay and bisexual men were more likely to participate in anal and colorectal cancer screening. Transgender individuals had lower rates of screening than cisgender individuals for all cancer types. Barriers to participation were found at the individual-, provider-, and administrator-level, and good communication with a healthcare provider was the strongest facilitator. These results provide reasonable first steps toward improving participation rates for LGBTQ+ populations in cancer screening. Patient-centered approaches should draw on core guiding principles to inform the provision of care, including anticipating LGBTQ+ patients, improving knowledge about care for these patients, and confronting individually-held biases that may affect care, in order to improve care experiences and participation rates in preventive services.

Providing gender affirming and inclusive care to transgender men experiencing pregnancy

OBJECTIVES AND DESIGN

Information about providing professional and appropriate perinatal care to transgender men in the perinatal setting is scarce, and healthcare providers often have insufficient knowledge or skills to provide this care. In response, a quality improvement educational program for nursing staff was developed and implemented, with the goal of evaluating the impact of this intervention on nurses' knowledge, skills, and attitudes when caring for pregnant transgender men.

SETTING AND PARTICIPANTS

The training was offered to nursing staff of a 24-bed inpatient perinatal unit at a large, private academic medical center in a major East Coast city during the unit's quarterly staff meeting in March 2020.

INTERVENTION

The training covered the provision of affirming and inclusive perinatal care for transgender men. The content of the training was based on recommendations in the literature and reviewed by content experts.

MEASUREMENTS

Pre-test (N = 55) and post-test (N = 23) online self-administered surveys assessed nursing staff's knowledge of, comfort, and interest in providing gender affirming care for transgender men. Mann-Whitney U and Fischer's exact tests were used to determine significant changes in knowledge and attitudes over time.

FINDINGS

Findings suggest the training improved nursing staff's self-reported knowledge and skills in providing gender affirming care to pregnant transgender men over time, with participants demonstrating improved knowledge about communication around pronouns, gender identity, reproductive systems, and obstetric history. Awareness of resources for both professional development and to refer transgender patients also improved. However, persistent deficits in other knowledge, skills, and attitudes remained, suggesting that nurses would likely benefit from further support and training in transgender-specific health issues.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Findings support the utility of unit-based training in improving affirming and inclusive care in the perinatal setting. This highlights opportunities for supporting nurses' professional practice of caring for transgender patients experiencing pregnancy and may be adapted for use in other specialty units.