Health Care Inequities of Sexual and Gender Minority Patients

"It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals

BACKGROUND

There is a critical need to identify specific causes of and tailored solutions to diagnostic error in sexual and gender minority (SGM) populations.

PURPOSE

To identify challenges to diagnosis in SGM adults, understand the impacts of patient-reported diagnostic errors on patients' lives and elicit solutions.

METHODS

Qualitative study using in-depth semistructured interviews. Participants were recruited using convenience and snowball sampling. Recruitment efforts targeted 22 SGM-focused organisations, academic centres and clinics across the USA. Participants were encouraged to share study details with personal contacts. Interviews were analysed using codebook thematic analysis.

RESULTS

Interviewees (n=20) ranged from 20 to 60 years of age with diverse mental and physical health symptoms. All participants identified as sexual minorities, gender minorities or both. Thematic analysis revealed challenges to diagnosis. Provider-level challenges included pathologisation of SGM identity; dismissal of symptoms due to anti-SGM bias; communication failures due to providers being distracted by SGM identity and enforcement of cis-heteronormative assumptions. Patient-level challenges included internalised shame and stigma. Intersectional challenges included biases around factors like race and age. Patient-reported diagnostic error led to worsening relationships with providers, worsened mental and physical health and increased self-advocacy and community-activism. Solutions to reduce diagnostic disparities included SGM-specific medical education and provider training, using inclusive language, asking questions, avoiding assumptions, encouraging diagnostic coproduction, upholding high care standards and ethics, involving SGM individuals in healthcare improvement and increasing research on SGM health.

CONCLUSIONS

Anti-SGM bias, queerphobia, lack of provider training and heteronormative attitudes hinder diagnostic decision-making and communication. As a result, SGM patients report significant harms. Solutions to mitigate diagnostic disparities require an intersectional approach that considers patients' gender identity, sexual orientation, race, age, economic status and system-level changes.

Examining the pedagogical practices that support cultural proficiency development in graduate health science students

BACKGROUND

Health disparities are often a function of systemic discrimination and healthcare providers' biases. In recognition of this, health science programs have begun to offer training to foster cultural proficiency (CP) in future professionals. However, there is not yet consensus about the best ways to integrate CP into didactic and clinical education, and little is known about the role of clinical rotations in fostering CP.

METHODS

Here, a mixed-methods approach was used to survey students (n = 131) from a private all-graduate level osteopathic health sciences university to gain insight into the training approaches students encountered related to CP and how these may vary as a function of academic progression. The research survey included instruments designed to quantify students' implicit associations, beliefs, and experiences related to the CP training they encountered through the use of validated instruments, including Implicit Association Tests and the Ethnocultural Empathy Inventory, and custom-designed questions.

RESULTS

The data revealed that most students (73%) had received CP training during graduate school which primarily occurred via discussions, lectures, and readings; however, the duration and students' perception of the training varied substantially (e.g., training range = 1-100 hours). In addition, while students largely indicated that they valued CP and sought to provide empathetic care to their patients, they also expressed personal understandings of CP that often fell short of advocacy and addressing personal and societal biases. The results further suggested that clinical rotations may help students attenuate implicit biases but did not appear to be synergistic with pre-clinical courses in fostering other CP knowledge, skills, and attitudes.

CONCLUSIONS

These findings highlight the need to utilize evidence-based pedagogical practices to design intentional, integrated, and holistic CP training throughout health science programs that employ an intersectional lens and empowers learners to serve as advocates for their patients and address systemic challenges.

Reimagining sexual and reproductive healthcare for LGBTQ communities

Qualitative interviews were conducted with nine individuals identifying as LGBTQ to identify recommendations for improving sexual and reproductive healthcare at a local clinic on the California Central Coast. Interviewees were recruited at local Pride events. Grounded theory methodology revealed several themes related to participants' desires for a LGBTQ-affirmative sexual and reproductive healthcare setting. Themes identified included: Beyond Enacted Inclusivity (avoiding a performative demonstration of LGBTQ-affirming care); Anti-Institutional Care (a political and visual challenge to what the healthcare setting should look like), a One-Stop-Shop (encompassing several types of care under one roof); Constrained Visibility (where LGBTQ identities are reflected but not exposed); and Community and Social Wellness (to be in community with other LGBTQ-serving organisations and one another in mutual support and celebration). Research implications and clinical recommendations are described at the local and system levels.

Promoting Sexual and Gender Minority Health Clinical Skills Training for All Medical Students

Despite societal, legal, and cultural improvements in their well-being, sexual and gender minority (SGM) people in the United States still face substantial physical and mental health disparities that are exacerbated by physician stigma and lack of training. Although there have been efforts at medical schools nationwide to address these disparities and interweave SGM health education into existing preclerkship courses, opportunities to practice related clinical skills during the clerkship years remain largely elective. Furthermore, national survey data from 2020 indicate that SGM Americans continue to delay or avoid medical care because of physician discrimination. By providing predominantly opt-in opportunities for hands-on SGM health clinical training, educators risk perpetuating existing structural inequities and widening health disparities. In this article, the authors advocate for required SGM health clinical training for all undergraduate medical students, regardless of intended specialty. They highlight 3 types of elective SGM health clinical training models currently in use at medical schools across the country, including student-run clinics, advanced electives, and longitudinal scholarly concentrations. Using these examples, the authors then outline ways that educators can interweave required SGM health clinical training into undergraduate medical education, including with the recruitment and retention of SGM faculty, staff, and students; required SGM standardized patient experiences; the integration of SGM clinical opportunities throughout the core clerkships; and partnerships with SGM health centers. Using these methods, medical schools can mobilize passionate students, faculty, and leaders to both counter the bigotry and hate faced by SGM populations and develop innovative strategies to improve SGM patient health outcomes and expand opportunities for SGM health scholarship.

Physician Perceptions on Cancer Screening for LGBTQ+ Patients

The LGBTQ+ community experiences cancer disparities due to increased risk factors and lower screening rates, attributable to health literacy gaps and systemic barriers. We sought to understand the experiences, perceptions, and knowledge base of healthcare providers regarding cancer screening for LGBTQ+ patients. A 20-item IRB-approved survey was distributed to physicians through professional organizations. The survey assessed experiences and education regarding the LGBTQ+ community and perceptions of patient concerns with different cancer screenings on a 5-point Likert scale. Complete responses were collected from 355 providers. Only 100 (28%) reported past LGBTQ+-related training and were more likely to be female (p = 0.020), have under ten years of practice (p = 0.014), or practice family/internal medicine (p < 0.001). Most (85%) recognized that LGBTQ+ subpopulations experience nuanced health issues, but only 46% confidently understood them, and 71% agreed their clinics would benefit from training. Family/internal medicine practitioners affirmed the clinical relevance of patients' sexual orientation (94%; 62% for medical/radiation oncology). Prior training affected belief in the importance of sexual orientation (p < 0.001), confidence in understanding LGBTQ+ health concerns (p < 0.001), and willingness to be listed as "LGBTQ+-friendly" (p = 0.005). Our study suggests that despite a paucity of formal training, most providers acknowledge that LGBTQ+ patients have unique health needs. Respondents had a lack of consensus regarding cancer screenings for lesbian and transgender patients, indicating the need for clearer screening standards for LGBTQ+ subpopulations and educational programs for providers.

Impacts of psychological wellbeing with HIV/AIDS and cancer among sexual and gender minorities: A systematic review and meta-analysis

Background

The agony and economic strain of cancer and HIV/AIDS therapies severely impact patients' psychological wellbeing. Meanwhile, sexual minorities experience discrimination and mental illness. LGBT individuals with cancer and HIV/AIDS play two roles. It is important to understand and examine this groups mental wellbeing.

Objective

The purpose of this study is to synthesize current studies on the impact of HIV/AIDS and cancer on LGBT patients' psychological wellbeing.

Methods

This research uses a systematic literature review at first and later stage a meta-analysis was run on the same review. In this study, data from Google academic and Web of Science has been used to filter literature. PRISMA 2020 Flow Diagram seeks research on LGBT cancer and HIV/AIDS patients. The above sites yielded 370 related papers, some of which were removed due to age or inaccuracy. Finally, meta-analyses was done on 27 HIV/AIDS and 33 cancer patients's analyse.

Results

The research included 9,898 LGBT cancer sufferers with AIDS and 14,465 cancer sufferers with HIV/AIDS. Using meta-analysis, we discovered the gap in psychological wellbeing scores between HIV/AIDS LGBT and non-LGBT groups ranged from -10.86 to 15.63. The overall score disparity between the HIV/AIDS LGBT and non-LGBT groups was 1.270 (95% CI = 0.990-1.560, Z = 86.58, P < 0.1). The disparity in psychological wellbeing scores between cancer LGBT group and general group varies from -8.77 to 20.94 in the 34 papers examined in this study. Overall, the psychological wellbeing score disparity between the cancer LGBT subset and the general group was 12.48 (95% CI was 10.05-14.92, Test Z-value was 268.40, P-value was <0.1).

Conclusion

Inflammation and fibrosis in HIV/AIDS and cancer sufferers adversely affect their psychological wellbeing.

Gender identity and transition: relationships with sleep disorders in US youth

STUDY OBJECTIVES

Transgender or gender-nonconforming (TGNC) identity is associated with higher burden of sleep disorders relative to cisgender identity. However, the role of gender-affirming therapy (GAT) in sleep disorders is poorly understood. This study examined relationships between TGNC identity, transition, and sleep disorders among TGNC and cisgender youth.

METHODS

This retrospective cross-sectional study utilized a large US-based administrative claims database (deidentified Optum Clinformatics Data Mart Database) to identify youth aged 12-25 years who obtained a diagnosis of TGNC identity and those who pursued GAT. Descriptive statistics estimated distributions of demographic and health characteristics by gender identity. Unadjusted and age-adjusted logistic regression models were used to examine associations between TGNC identity, GAT, and sleep disorders.

RESULTS

This study included 1,216,044 youth, of which 2,603 (0.2%) were identified as TGNC. Among the 1,387 TGNC who pursued GAT, 868 and 519 were identified as transmasculine and transfeminine, respectively. Adjusted analysis showed increased odds of insomnia (odds ratio = 5.4, 95% confidence interval 4.7, 6.2), sleep apnea (odds ratio = 3.0, 95% confidence interval 2.3, 4.0), and other sleep disorders (odds ratio = 3.1, 95% confidence interval 2.5, 3.9) in TGNC relative to cisgender youth. Decreased odds of any sleep disorder were observed in the TGNC youth on GAT (odds ratio = 0.5, 95% confidence interval 0.4, 0.7) relative to those not on GAT.

CONCLUSIONS

This study demonstrated a high burden of sleep disorders in TGNC youth in comparison to cisgender. However, GAT may confer a protective effect on sleep disorders among TGNC youth. Longitudinal assessments of sleep disorders prior to and post-GAT are needed to uncover their temporal relationships.

CITATION

Gavidia R, Whitney DG, Hershner S, Selkie EM, Tauman R, Dunietz GL. Gender identity and transition: relationships with sleep disorders in US youth. J Clin Sleep Med. 2022;18(11):2553-2559.

Progression of Gender Dysphoria in Children and Adolescents: A Longitudinal Study

BACKGROUND AND OBJECTIVES

The progression of gender-expansive behavior to gender dysphoria and to gender-affirming hormonal treatment (GAHT) in children and adolescents is poorly understood.

METHODS

A cohort of 958 gender-diverse (GD) children and adolescents who did not have a gender dysphoria-related diagnosis (GDRD) or GAHT at index were identified. Rates of first GDRD and first GAHT prescription were compared across demographic groups.

RESULTS

Overall, 29% of participants received a GDRD and 25% were prescribed GAHT during the average follow-up of 3.5 years (maximum 9 years). Compared with youth assigned male sex at birth, those assigned female sex at birth were more likely to receive a diagnosis and initiate GAHT with hazard ratio (95% confidence interval) estimates of 1.3 (1.0-1.7), and 2.5 (1.8-3.3), respectively. A progression to diagnosis was more common among those aged ≥15 years at initial presentation compared with those aged 10 to 14 years and those aged 3 to 9 years (37% vs 28% vs 16%, respectively). By using the youngest group as a reference, the adjusted hazard ratios (95% confidence interval) for a GDRD were 2.0 (1.3-3.0) for age 10 to 14 years and 2.7 (1.8-3.9) for age ≥15 years. Racial and ethnic minorities were less likely to receive a diagnosis or be prescribed GAHT.

CONCLUSIONS

This study characterized the progression of GD behavior in children and adolescents. Less than one-third of GD youth receive an eventual GDRD, and approximately one-quarter receive GAHT. Female sex at birth, older age of initial GD presentation to medical care, and non-Hispanic white race and ethnicity increased the likelihood of receiving diagnosis and treatment.