Comparing the Healthcare Utilization and Engagement in a Sample of Transgender and Cisgender Bisexual+ Persons

Cancer screening attendance rates in transgender and gender-diverse patients: a systematic review and meta-analysis

OBJECTIVES

To examine disparities in attendance rates at cancer screening services between transgender and gender-diverse (TGD) people in comparison with their cisgender (CG) counterparts, and to determine whether these differences were based on the anatomical organ screened.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE (via Ovid), CINAHL Complete (via EBSCO) and Cochrane Library from inception to 30 September 2023.

METHODS

Studies for inclusion were case-control or cross-sectional studies with quantitative data that investigated TGD adults attending any cancer screening service. Exclusion criteria were studies with participants who were ineligible for cancer screening or without samples from TGD individuals, qualitative data and a cancer diagnosis from symptomatic presentation or incidental findings. A modified Newcastle-Ottawa Scale was used to assess risk of bias, during which seven reports were found incompatible with the inclusion criteria and excluded. Results were synthesised through random-effects meta-analysis and narrative synthesis.

RESULTS

We identified 25 eligible records, of which 18 were included in the analysis. These were cross-sectional studies, including retrospective chart reviews and survey analyses, and encompassed over 14.8 million participants. The main outcomes measured were up-to-date (UTD) and lifetime (LT) attendance. Meta-analysis found differences for UTD cervical (OR 0.37, 95% CI 0.23 to 0.60, p<0.0001) and mammography (OR 0.41, 95% CI 0.20 to 0.87, p=0.02) but not for prostate or colorectal screening. There were no meaningful differences seen in LT attendance based on quantitative synthesis. Narrative synthesis of the seven remaining articles mostly supported the meta-analysis. Reduced rates of screening engagement in TGD participants were found for UTD cervical and mammography screening, alongside LT mammography screening.

CONCLUSIONS

Compared with their CG counterparts, TGD individuals had lower rates of using cervical and mammography screening at the recommended frequencies but displayed similar prevalences of LT attendance. The greatest disparity was seen in UTD cervical screening. Limitations of this review included high risk of bias within studies, high heterogeneity and a lack of resources for further statistical testing. Bridging gaps in healthcare to improve cancer screening experiences and outcomes will require consolidated efforts including working with the TGD community.

PROSPERO REGISTRATION NUMBER

CRD42022368911.

Gender-Affirming Hormone Therapy and Cervical Cancer Screening Rates in Transgender Men and Nonbinary People: A Cross-Sectional Study from a Boston Community Health Center

Purpose: Clinical monitoring for patients receiving gender-affirming hormone therapy (GAHT) has the potential to facilitate their receipt of preventive health services. We aimed to determine whether GAHT is associated with increased utilization of cervical cancer screening among transgender men (TM) and nonbinary persons assigned female at birth (NB-AFAB). Methods: We conducted a cross-sectional observational study of a single community health center in Boston. Persons of all gender identities eligible for cervical cancer screening during 2008-2019 were assessed. The outcome of interest was receipt of cervical cancer screening based on U.S. Preventive Services Task Force recommendations. We compared the proportion of persons who received cervical cancer screening by prescription of GAHT. Results: We identified 13,267 eligible persons. This cohort included 10,547 (79.5%) cisgender women, 1547 (11.7%) TM, and 1173 (8.8%) NB-AFAB persons. Among all persons eligible for cervical cancer screening, TM and NB-AFAB persons were less likely to receive screening than cisgender women (56.2% and 56.1% vs. 60.5% respectively; odds ratio [OR] = 0.84; 95% confidence interval [CI] = 0.75-0.93; OR = 0.84; 95% CI = 0.74-0.94, respectively). Among TM, those prescribed testosterone were more likely to receive cervical cancer screening than those not prescribed testosterone (57.9% vs. 48.2%, OR = 1.47; 95% CI = 1.14-1.92). Among NB-AFAB adults, those prescribed testosterone were more likely to receive cervical cancer screening than those not prescribed testosterone (61.9% vs. 51.5%, OR = 1.53; 95% CI = 1.21-1.93). Conclusions: The benefits of engagement in care to access GAHT may extend beyond the hormonal intervention to preventive health services.

HIV Services Uptake Among People Living with HIV in Jiangsu Province, China: A Cross-Sectional Study

Healthcare disparities are common among people living with HIV (PLWH) in China and likely impact access to HIV services. This study aimed to assess the current status of access to HIV services among PLWH and explore the correlates of service uptake using baseline data from a prospective cohort study among PLWH in Jiangsu Province. Guided by Andersen's behavioral model, univariable and multivariable logistic regressions were conducted to identify factors associated with access to HIV services. Out of 8989 eligible PLWH included in this study, 46.4% perceived difficulty in seeing a healthcare professional for HIV treatment services in 2021-2022. PLWH aged 18-34 years (adjusted odds ratio [AOR] = 1.69, 95% CI 1.32-2.15), 35-39 years (AOR = 1.33, 95% CI 1.08-1.65), identified as a bisexual/other (AOR = 1.14, 95% CI 1.01-1.29), had a college and above education (AOR = 1.32, 95% CI 1.07-1.63), and perceived moderate (AOR = 1.70, 95% CI 1.51-1.91) and severe (AOR = 2.20, 95% CI 1.94-2.49) levels of HIV stigma were more likely to perceive difficulty in seeing healthcare professionals for HIV treatment in 2021-2022. Living in northern Jiangsu was also associated with increased odds of perceiving difficulty in seeing healthcare professionals for HIV treatment (AOR = 1.12, 95% CI 1.00-1.26). These findings underscore the need for innovative solutions to eliminate the practical barriers to HIV services utilization among PLWH who are bisexual, well-educated, and effective HIV-related stigma reduction interventions.

A Transgender Health Information Resource: Participatory Design Study

BACKGROUND

Despite the abundance of health information on the internet for people who identify as transgender and gender diverse (TGD), much of the content used is found on social media channels, requiring individuals to vet the information for relevance and quality.

OBJECTIVE

We developed a prototype transgender health information resource (TGHIR) delivered via a mobile app to provide credible health and wellness information for people who are TGD.

METHODS

We partnered with the TGD community and used a participatory design approach that included focus groups and co-design sessions to identify users' needs and priorities. We used the Agile software development methodology to build the prototype. A medical librarian and physicians with expertise in transgender health curated a set of 97 information resources that constituted the foundational content of the prototype. To evaluate the prototype TGHIR app, we assessed the app with test users, using a single item from the System Usability Scale to assess feature usability, cognitive walk-throughs, and the user version of the Mobile Application Rating Scale to evaluate the app's objective and subjective quality.

RESULTS

A total of 13 people who identified as TGD or TGD allies rated their satisfaction with 9 of 10 (90%) app features as good to excellent, and 1 (10%) of the features-the ability to filter to narrow TGHIR resources-was rated as okay. The overall quality score on the user version of the Mobile Application Rating Scale was 4.25 out of 5 after 4 weeks of use, indicating a good-quality mobile app. The information subscore received the highest rating, at 4.75 out of 5.

CONCLUSIONS

Community partnership and participatory design were effective in the development of the TGHIR app, resulting in an information resource app with satisfactory features and overall high-quality ratings. Test users felt that the TGHIR app would be helpful for people who are TGD and their care partners.

Canadian Guideline on the Management of a Positive Human Papillomavirus Test and Guidance for Specific Populations

The purpose of this paper is to provide evidence-based guidance on the management of a positive human papilloma virus (HPV) test and to provide guidance around screening and HPV testing for specific patient populations. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC), and the Canadian Partnership Against Cancer. The literature informing these guidelines was obtained through a systematic review of relevant literature by a multi-step search process led by an information specialist. The literature was reviewed up to July 2021 with manual searches of relevant national guidelines and more recent publications. The quality of the evidence and strength of recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include primary care providers, gynecologists, colposcopists, screening programs, and healthcare facilities. The implementation of the recommendations will ensure an optimum implementation of HPV testing with a focus on the management of positive results. Recommendations for appropriate care for underserved and marginalized groups are made.

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.

Social Support, Identity Affirmation, and Psychological Well-Being: A Developmental and Intersectional Comparison between Italian Cisgender and Non-Binary People with Bisexual Orientation

Incorporating the perspectives of positive psychology, intersectionality, and life course into minority stress theory, this study aimed to examine the relationships between social support, identity affirmation, and psychological well-being among 483 Italian individuals with bisexual orientation, accounting for differences in gender identity (cisgender vs. non-binary) and age groups (young, early, and middle adult). A mediation model was tested in which identity affirmation served as a presumed mediator between social support and psychological well-being. We also examined whether gender identity and age group moderated the hypothesized associations. Multivariate ANOVA and multigroup mediation analyses were conducted. Results showed that (a) cisgender individuals had higher social support and psychological well-being than non-binary individuals, but not identity affirmation, which was higher in the latter group, (b) psychological well-being, but not social support and identity affirmation, differed between groups, with the youngest cohort reporting worse health than their elders, (c) identity affirmation mediated the relationship between social support and psychological well-being, (d) mediation was significant only in binary individuals (compared to cisgender), whereas no age differences were found. Overall, this study highlights the need to consider bisexual individuals as a nonhomogeneous population living multiple life experiences, especially when minority identities intersect.

Differences in Health Care Access, Utilization, and Experiences Among LGBTQ+ Subgroups in the Southern United States

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) individuals experience health inequities and barriers to accessing appropriate, affirming care. Little is known about differing health care experiences within the LGBTQ+ population, particularly among individuals living in underserved areas. This study explored health care experiences and utilization among LGBTQ+ subgroups: lesbian and gay cisgender individuals (n = 258), bisexual+ cisgender individuals (n = 71), and transgender and gender-diverse individuals (n = 80). Participants were recruited from a geographic region in South Carolina and Georgia and completed an online survey regarding negative health care experiences, barriers to care, and utilization of different health care venues and services. Results revealed significant differences between LGBTQ+ subgroups, with transgender and gender-diverse participants reporting more discriminatory experiences and greater barriers to care. Bisexual+ cisgender individuals also experienced some disparities compared with lesbian and gay cisgender individuals. Most participants endorsed a need for more competent providers. Findings and recommendations are considered within the context of the Southeastern United States for addressing access and utilization disparities among LGBTQ+ communities.

Health Insurance Prevalence Among Gender Minority People: A Systematic Review and Meta-Analysis

Purpose

Gender minority (GM) (people whose gender does not align with the sex assigned at birth) people have historically been insured at lower rates than the general population. The purpose of this review is to (1) assess the prevalence of health insurance among GM adults in the United States, (2) examine prevalence by gender, and (3) examine trends in prevalence before and after implementation of the Affordable Care Act.

Methods

Published articles from PubMed, EMBASE, and Web of Science databases before April 26th, 2019, were included. This review is registered on PROSPERO (CRD42019133627). Analysis was guided by a random-effects model to obtain a meta-prevalence estimate for all GM people and stratified by gender subgroup. Heterogeneity was assessed using a Q-test and I 2 measure.

Results

Of 55 included articles, a random pooled estimate showed that 75% GM people were insured (95% confidence interval [CI]: 0.71-0.79; p<0.001). Subgroup analysis by gender determined 70% of transgender women (95% CI: 0.64-0.76; p<0.001; I 2=97.16%) and 80% of transgender men (95% CI: 0.77-0.83; p=0.01; I 2=54.51%) were insured. Too few studies provided health insurance prevalence data for gender-expansive participants (GM people who do not identify as solely man or woman) to conduct analysis.

Conclusion

The pooled prevalence of health insurance among GM people found in this review is considerably lower than the general population. Standardized collection of gender across research and health care will improve identification of vulnerable individuals who experience this barrier to preventative and acute care services.

Evaluating the Quality and Reliability of Gender-affirming Surgery Videos on YouTube and TikTok

Background:

Social media platforms have changed the way medical information is disseminated. Transgender patients may utilize social media to learn about gender-affirming surgery (GAS). Although videos on social media are readily accessible, their content is not verified or peer-reviewed. Therefore, this study aimed to evaluate the quality and reliability of YouTube and TikTok videos related to GAS.

Methods:

YouTube and TikTok were queried for gender-affirming top surgery, metoidioplasty, phalloplasty, breast augmentation, and vaginoplasty. Quality of video content was analyzed by the DISCERN scale. Quality scores were compared among the type of GAS, account user, and content category.

Results:

There were 275 YouTube videos and 55 TikTok videos. Most videos focused on masculinizing top surgery (P < 0.001). Overall, videos on masculinizing GAS had higher quality and reliability than videos on feminizing GAS (P < 0.001). Chest surgery videos were of higher quality than those on genital surgery (P ≤ 0.001). Videos on masculinizing top surgery had the highest quality, whereas vaginoplasty had the lowest quality and reliability (P < 0.001). Videos produced by health care professionals and academic institutions had the greatest quality and reliability, respectively (P < 0.0001), whereas videos produced by patients were the least reliable (P < 0.0001).

Conclusions:

Videos on GAS ranged from poor to good quality and reliability. Health care professionals, especially plastic surgeons, should create high-quality videos on social media to educate transgender patients. There should also be greater efforts in disseminating existing high-quality videos on social media. Resources posted on social media platforms can reach a wide audience through accessible means.

The Cisnormative Blindspot Explained: Healthcare Experiences of Trans Men and Non-Binary Persons and the accessibility to inclusive sexual & reproductive Healthcare, an integrative review

Trans men and non-binary persons assigned female at birth (AFAB) often encounter resistance and reluctance pertaining to their healthcare needs. As a result of patriarchal-based decision-making and cis-heteronormative ideologies, the trans and gender diverse (TGD) population is routinely left out of representation in research, education, and healthcare. The aim of this integrative literature review is to describe the experiences of trans men and non-binary persons AFAB in healthcare interactions and their sexual and reproductive healthcare needs. A total of 32 articles were analyzed, synthesized, and reconceptualized through joint inductive and deductive analysis with a transfeminist and intersectional lens. From these papers, two broader concepts emerged with five sub-concepts that portrayed underlying barriers to care (primed with fear, onus of self-advocacy, and call for competence) and internalized ideologies (pregnancy incompatibility and presumptive care). A multidisciplinary approach is essential to employ in implementation efforts involving improved standards of care and in achieving desired family planning. As this is not as linear as addressing a knowledge gap, but one of deeper set intrinsic ideologies, instruction on the necessary impact of continued education and peer learning within the context of in-group dynamics can help the efficiency of designated change agents within the healthcare systems themselves.

To Go or Not to Go: Factors That Influence Health Care Use Among Trans Adults in a Non-Representative U.S. Sample

Trans people tend to utilize health care at rates lower than cisgender people, which commonly results in short-term and long-term unfavorable health outcomes. Theoretically informed by Andersen's behavioral model of health services use and Lerner and Robles' adapted behavioral model of health services use for transgender people, the current study examined how individual characteristics of trans people along with the external environment and health care service environment they must navigate impact their health care utilization. Binary logistic regression was used to analyze data from the 2015 United States Trans Survey (N = 27,715), the largest trans sample to date. Perception of health care provider (HCP) knowledge, health insurance status, and health care costs each produced the strongest effect on visiting a doctor or HCP in the past year. The results showed that having a provider that had some level of knowledge about trans people was potentially most critical to increase utilization. Discussion points include increasing trans-focused curriculum in health professional schools, utilizing trans standardized patients in health professional schools, and holding insurance companies accountable to provide trans affirming care.

On the Basis of Gender: A Medical-Legal Review of Barriers to Healthcare for Transgender and Gender-Expansive Patients

Transgender individuals will seek medical intervention for transition-related services as well as medical treatment for general health needs similar to cisgender individuals. However, people in the transgender community face unique barriers to treatment such as the lack of knowledge among health-care professionals, insurance coverage, and legal protections. This paper reviews barriers, major legal cases, and federal policy related to the health needs for transgender and gender expansive individuals. The authors call for a social work response at the macro and micro level. Advocacy for health care access for transgender individuals is a social justice issue social workers are uniquely positioned to work toward. At the micro level, social workers must help educate and advocate for their clients to bring transgender-sensitive practices to the health care system.

Bridging Barriers to Cervical Cancer Screening in Transgender Men: A Scoping Review

Estimates of high-risk human papillomavirus (HPV) infection and susceptibility to HPV-related cancer in transgender men (TM) are comparable to prevalence rates found in cisgender women. Regular and thorough screening for cervical cancer is equally as crucial for TM as for cisgender women; however, despite continued risk for cervical cancer in TM and associated recommendations for screening, studies indicate disparities in rates of cervical cancer screening (CCS) in TM compared to cisgender women. The current scoping review explores TM’s knowledge and experiences of CCS and barriers to screening uptake in this population. A range of barriers were identified including the need for health-care services to provide care for TM within the context of a nonbinary approach to gender identity and health. Findings synthesized from relevant research studies (n = 15; published 2008–2019) are presented, and recommendations are drawn from these findings to inform primary health-care providers’ clinical practice and care of TM.

Self-Reported Health Concerns and Healthcare Experiences among Diverse Bisexual Men: An Exploratory Qualitative Study

Bisexual individuals have disproportionately higher rates of physical and mental health concerns compared to both heterosexual and gay/lesbian individuals. Few studies have examined diverse bisexual-identified men's perceived health concerns for themselves and other bisexual men or their experiences in healthcare settings. This qualitative study explored health and healthcare experiences among cisgender and transgender bisexual men, most of whom were also men of color. Data were collected through semi-structured interviews. Participants included 31 self-identified bisexual men from the Chicago area. Participants were asked questions surrounding bisexual men's health and healthcare experiences in general and their personal experiences, drawing connections between intersecting bisexual and racial/ethnic identities. Interview transcripts were analyzed using thematic analysis. Participants reported sexual health and mental health as the top health concerns for bisexual men. Participants viewed their bisexual identity as a motivator for seeking healthcare services and adopting safer sex practices. Mental health challenges faced by respondents were connected to bisexual stereotypes and fear of disclosing bisexual and transgender identities. Furthermore, perceptions of masculinity amongst bisexual men of color were particularly salient in connecting to their mental health experiences. The intersection of participants' transgender and bisexual identities impacted their healthcare experiences in general healthcare settings, with many participants reporting a lack of cultural competence and provider knowledge concerning their identities. LGBTQ Federally Qualified Health Centers, however, were described as providing compassionate care. Our findings suggest the need for more interventions that account for bisexual men's intersecting identities. Furthermore, increased provider training is necessary for providing affirmative care to bisexual men.

Psychosocial Needs of Bisexual People: Findings from a Mixed-Methods Research Study

More attention has recently been paid to the unique experiences and health needs of LGBTQ + people. To date, there has been a limited focus on the distinct psychosocial needs of bisexuals. A larger mixed-methods study explored the wider needs of a LGBTQ + cohort. The aim of this paper is to report the specific experiences of bisexuals and highlight their distinct psychosocial issues and concerns. The online survey instrument contained Likert-scale and qualitative questions and was completed by a total sample of LGBT people (n = 125), of which 19 participants self-identified as bisexual. The qualitative responses of the bisexuals were extracted and analyzed separately to identify emergent themes that were: accessing responsive services, culturally competent services, supports and interventions, and knowledge, skills and confidence. The study findings inform and enhance the understanding of the issues that impact upon the health and well-being of bisexuals, thereby contributing to promoting the wider social inclusion and human rights agenda by guiding mental health service developments, policy initiatives, education provision and future research.

Barriers and facilitators to cervical cancer screening among transgender men and non-binary people with a cervix: A systematic narrative review

Cervical cancer mortality in the United Kingdom (UK) has decreased over the last decade, largely due to uptake of cervical cancer screening. However, only those with a female gender marker on their health records are invited, creating a significant barrier to gender minorities accessing screening. We undertook a systematic review to synthesise published literature on cervical cancer screening among eligible gender minorities, aiming to identify barriers and facilitators that might inform changes in UK policy and clinical practice. We conducted a broad search across Medline, Embase, PsycInfo and Global Health databases to 3rd January 2020 and included any original, peer-reviewed research, published in the English language that reported on cervical cancer screening among gender minorities assigned female at birth (AFAB). Twenty-seven studies were critically appraised and included in the final synthesis, which identified significant disparities in cervical cancer screening uptake between gender minorities AFAB and cis women. It revealed a lack of knowledge surrounding the relationship between gender minority status and cervical cancer risk among both service users and providers and highlighted significant barriers to access for gender minorities AFAB. Cervical cancer screening was not universally associated with dysphoria among gender minorities AFAB and we recommend that providers explore patients' preferences around screening, while avoiding assumptions. Providers should be proficient in examination techniques that maximise patient autonomy and minimise gender dysphoria or pain. Self-swabs for high-risk HPV may provide a more acceptable, evidence-based, alternative to Pap smears but there remains a need for further UK-specific research, to inform changes in policy.

Deficiencies in Scientific Evidence for Medical Management of Gender Dysphoria

Individuals who experience a gender identity that is discordant with biological sex are increasingly presenting to physicians for assistance in alleviating associated psychological distress. In contrast to prior efforts to identify and primarily address underlying psychiatric contributors to gender dysphoria, interventions that include uncritical social affirmation, use of gonadotropin-releasing hormone agonists to suppress normally timed puberty, and administration of cross-sex steroid hormones to induce desired secondary sex characteristics are now advocated by an emerging cohort of transgender medicine specialists. For patients with persistent gender dysphoria, surgery is offered to alter the appearance of breasts and genital organs. Efforts to address ethical concerns regarding this contentious treatment paradigm are dependent upon reliable evidence on immediate and long-term risks and benefits. Although strong recommendations have been made for invasive and potentially irreversible interventions, high-quality scientific data on the effects of this approach are generally lacking. Limitations of the existing transgender literature include general lack of randomized prospective trial design, small sample size, recruitment bias, short study duration, high subject dropout rates, and reliance on "expert" opinion. Existing data reveal significant intervention-associated morbidity and raise serious concern that the primary goal of suicide prevention is not achieved. In addition to substantial moral questions, adherence to established principles of evidence-based medicine necessitates a high degree of caution in accepting gender-affirming medical interventions as a preferred treatment approach. Continued consideration and rigorous investigation of alternate approaches to alleviating suffering in people with gender dysphoria are warranted.

SUMMARY

This paper provides an overview of what is currently known about people who experience a gender identity that differs from their biological sex and the associated desire to engage the medical profession in alleviating associated discomfort and distress. The scientific evidence used to support current recommendations for affirming one's preferred gender, halting normally timed puberty, administering cross-sex hormones, and surgically altering primary and secondary sexual traits are summarized and critically evaluated. Serious deficits in understanding the cause of this condition, the reasons for the marked increase in people presenting for medical care, together with immediate and long-term risks relative to benefit of medical intervention are exposed.