Proportion of patients who disclose their sexual orientation to healthcare providers and its relationship to patient outcomes: A meta-analysis and review

Discrimination in the medical setting among LGBTQ+ adults and associations with cancer screening

PURPOSE

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender diverse (LGBTQ+) individuals experience disparities in cancer screening. We examined whether experience of LGBTQ+ -related discrimination in medical settings was associated with cancer screening disparities.

METHODS

Participants were recruited via social media for a cross-sectional survey study. Those who self-reported as LGBTQ+ , being 40+ years of age, and residing in the US were eligible. Participants reported their clinical and demographic characteristics, cancer screening history, and experiences of discrimination in a medical setting. We examined the odds (OR) of ever undergoing cancer screening by experienced discrimination, stratified by sex assigned at birth.

RESULTS

Participants (n = 310) were on average 54.4 ± 9.0 years old and primarily White (92.9%). Most identified as lesbian (38.1%) or gay (40.0%) while 17.1% were transgender or gender diverse. Nearly half (45.5%) reported experiencing LGBTQ+ -related discrimination in the medical setting. Participants assigned female at birth with discriminatory experiences had significantly lower odds of ever undergoing colonoscopy/sigmoidoscopy compared to those without discriminatory experiences (OR: 0.37; 95% Confidence Interval (CI) 0.15-0.90). No significant differences in colonoscopy/sigmoidoscopy uptake were observed in those assigned male at birth by discriminatory experiences (OR: 2.02; 95% CI 0.59-6.91). Pap tests, mammogram, and stool colorectal cancer screening did not differ by discriminatory experience.

CONCLUSION

Discrimination in medical settings was commonly reported by LGBTQ+ individuals in this study. When treating LGBTQ+ patients, clinicians should ask about prior experiences and continue to promote cancer screening. Future studies should examine discrimination as a key driver of LGBTQ+ disparities in cancer screening.

Trends in Sexual Orientation and Gender Identity Data Collection

OBJECTIVE

The aim of this study was to determine response patterns to sexual orientation and gender identity (SOGI) questions in the Behavioral Risk Factor Surveillance System (BRFSS) over time and to assess nonresponse and indeterminate responses by demographic characteristics.

METHODS

This is a secondary data analysis of the SOGI module of the BRFSS. We used data from 46 states and Guam that implemented SOGI questions between 2014 and 2022. We used weighted analyses that accounted for the sampling design, determined SOGI response patterns by year, and assessed nonresponse and indeterminate responses by demographic characteristics.

RESULTS

Over time, increasing numbers self-reported as sexual and gender minority respondents, while heterosexual identity declined. Sexual orientation nonresponse and indeterminate responses increased with time, while respondents' reports of not knowing gender identity declined. Hispanic, older, respondents, those with lower education, and those who completed the questionnaire in Spanish had higher SOGI nonresponse and indeterminate responses.

CONCLUSIONS

The low amount of SOGI nonresponse and indeterminate responses in the BRFSS can be instructive for the implementation of SOGI questions in medical settings. SOGI data collection in all settings requires improving procedures for the groups that have been shown to have elevated nonresponse and indeterminate response.

Internalized Sexual Stigma, Sexual Orientation Disclosure, and Patient Experience Among Gay Men and Lesbian Women in Taiwan: A Cross-Sectional Survey

Purpose: Previous research has found that stigma, discrimination, and depression are associated with the sexual minority population's medical experiences. However, there is still a lack of relevant research results in Taiwan. This study investigated the health-seeking experiences and influencing factors of gay men and lesbian women in Taiwan. Methods: We recruited gay men and lesbian women through lesbian, gay, bisexual, and transgender (LGBT)-friendly websites and associations between November 2019 and June 2020. Surveys included the demographics, medical visiting experiences, Measure of Internalized Stigma, Patient Health Questionnaire-9, and Daily Heterosexist Experiences Questionnaire. Results: There were 270 participants, including 188 gay men and 82 lesbian women. Most respondents refused to disclose their sexual orientation to health care providers; some feared seeking medical care and preferred seeking LGBT-friendly health care services. Compared with lesbian women, gay men had higher levels of internalized sexual stigma, victimization, concealing sexual orientation, and experiences of medical staff denying services. Discrimination, depressive severity, and internalized sexual stigma affected the medical visit experience. Conclusion: In Taiwan, the health care experiences of gay men and lesbian women are affected by discrimination, internalized sexual stigma, and severe depression, while facing challenges of fear of seeking medical care or reluctance to disclose their sexual orientation.

Lack of Informed and Affirming Healthcare for Sexual Minority Men: A Call for Patient-Centered Care

BACKGROUND

Sexual minority men (SMM) face severe health inequities alongside negative experiences that drive avoidance of medical care. Understanding how SMM experience healthcare is paramount to improving this population's health. Patient-centered care, which emphasizes mutual respect and collaboration between patients and providers, may alleviate the disparaging effects of the homophobia that SMM face in healthcare settings.

OBJECTIVE

To explore how SMM perceive their experiences with healthcare providers and how care can most effectively meet their needs.

DESIGN

Semi-structured qualitative interviews focused on healthcare experiences, pre-exposure prophylaxis (PrEP), and HIV-related beliefs were conducted between July and November 2018.

PARTICIPANTS

The study included a sample of 43 young adult SMM (ages 25-27), representing diverse socioeconomic, racial, and ethnic backgrounds, in New York City.

APPROACH

Researchers utilized a multiphase, systematic coding method to identify salient themes in the interview transcripts.

KEY RESULTS

Analyses revealed three main themes: (1) SMM perceived that their clinicians often lack adequate skills and knowledge required to provide care that considers participants' identities and behaviors; (2) SMM desired patient-centered care as a way to regain agency and actively participate in making decisions about their health; and (3) SMM felt that patient-centered care was more common with providers who were LGBTQ-affirming, including many who felt that this was especially true for LGBTQ-identified providers.

CONCLUSIONS

SMM expressed a clear and strong desire for patient-centered approaches to care, often informed by experiences with healthcare providers who were unable to adequately meet their needs. However, widespread adoption of patient-centered care will require improving education and training for clinicians, with a focus on LGBTQ-specific clinical care and cultural humility. Through centering patients' preferences and experiences in the construction of care, patient-centered care can reduce health inequities among SMM and empower healthcare utilization in a population burdened by historic and ongoing stigmatization.

Baby Boomer Gay Men's Experiences with Primary Healthcare

This research explored baby boomer gay men's experiences with primary healthcare and their perspectives of future long-term care. Baby boomer gay men's perspectives about primary healthcare remain understudied in the United States. A descriptive qualitative study was conducted with 30 baby boomer men in the Southwest USA. We used semi-structured interviews to assess participants' initiation and maintenance of primary healthcare, disclosure of sexual orientation to providers, and perspectives about future healthcare needs, including long-term care. Data were analyzed with a latent thematic analysis. We found baby boomer gay men anticipate discrimination because of their sexual orientation whenever they establish healthcare with new providers. Participants identified circumstantial comfort in the new healthcare setting as a key motivator to disclose their sexual orientation. Thus, baby boomer gay men specifically sought gay or gay-friendly healthcare providers to ease the burden of managing disclosure and to permit free discussion of their sexual orientation and healthcare needs. Participants faced recurring anticipation of rejection and discrimination from healthcare providers, which extends to their perceptions of current healthcare encounters and future long-term care placement. Healthcare providers would benefit from understanding the practice implications of this dynamic. Future research on primary healthcare inclusivity is needed.

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.

Communication between healthcare providers and communicatively-vulnerable patients with associated health outcomes: A scoping review of knowledge syntheses

OBJECTIVE

Summarize literature on provider-patient communication linked to health outcomes in communicatively-vulnerable patient populations.

METHODS

Scoping review of reviews: systematically searched six databases.

INCLUSION CRITERIA

systematic searches and syntheses of literature; one or more providers and communicatively-vulnerable patients; synchronous in-person communication; intermediate or health outcome linked to communication.

RESULTS

The search yielded 14,615 citations; 47 reviews - with wide range of providers, communication vulnerabilities, communication practices, and health outcomes - met inclusion criteria. Methodology included qualitative, quantitative, and mixed approaches. Quality ranged from very low to high. Six categories of communication practices linked to health outcomes were identified: 1) motivation-based; 2) accommodation of language, culture, gender, sexual identity, and other concordance with the patient; 3) cultural adaptations of interventions; 4) use of interpreters; 5) other provider-patient communication practices; 6) patient communication practices.

CONCLUSION

Communication practices were studied in a wide range of providers, with common themes regarding best practices. A unique finding is the role of the patient's communication practices. The specificity of communication practices studied is heterogeneous, with many reviews providing insufficient details.

PRACTICE IMPLICATIONS

Motivation-based practices and culturally- and linguistically-appropriate care have impacts on patient outcomes across a range of settings with different professions and communicatively-vulnerable groups.

Sexual orientation and gender identity inequities in cervical cancer screening by race and ethnicity

BACKGROUND

In the United States, inequities in preventive health behaviors such as cervical cancer screening have been documented. Sexual orientation, gender identity, and race/ethnicity all individually contribute to such disparities. However, little work has investigated their joint impact on screening behavior.

METHODS

Using sampling weighted data from the 2016 and 2018 Behavioral Risk Factor Surveillance System, we assessed differences in two metrics via chi-square statistics: 1) lifetime uptake, and 2) up-to-date cervical cancer screening by sexual orientation and gender identity, within and across racial/ethnic classifications.

RESULTS

Within all races, individuals who identify as members of sexual and gender minority (SGM) communities reported higher rates of never being screened (except for Black transgender men) than straight or cisgender individuals (p < 0.0001). [*START* Across all races, the Asian/Pacific Islander transgender population (32.4%; weighted n (w.n.) = 1,313) had the lowest proportion of lifetime screening, followed by the Asian/Pacific Islander gay/lesbian (53.0%, w.n. = 21,771), Hispanic transgender (58.7%; w.n. = 24,780), Asian/Pacific Islander bisexual (61.8%, w.n. = 54,524), and Hispanic gay/lesbian (69.6%, w.n. = 125,781) populations. *END*] Straight or cisgender Non-Hispanic White (w.n. = 40,664,476) individuals had the highest proportion of lifetime screening (97.7% and 97.5%, respectively). However, among individuals who had been screened at least once in their lifetime, identifying as SGM was not associated with a decreased proportion of up-to-date screening within or between races.

CONCLUSIONS

Due to small sample sizes, especially among Asian/Pacific Islander and Hispanic populations, confidence intervals were wide. Heterogeneity in screening participation by SGM status within and across racial/ethnic groups were observed.

IMPACT

These screening disparities reveal the need to disaggregate data to account for intersecting identities and for studies with larger sample sizes to increase estimate reliability.

Healthcare experiences among Black and White sexual and gender minority cancer survivors: a qualitative study

PURPOSE

The purpose of this study was to explore healthcare experiences of Black and White sexual and gender minority (SGM) cancer survivors across the cancer care continuum.

METHODS

This was a qualitative analysis of two focus groups and eight individual interviews completed as part of a larger initiative using a community-engaged research approach to reduce cancer disparities in marginalized communities. There was a total of 16 participants in the study (9 were White, 7 were Black) and data were collected between 2019 and 2020.

RESULTS

Three main themes emerged from the thematic analysis: strategically coming out, provider preferences, and health system challenges. Participants noted that they often came out through their support system, decided to come out based on the relevance of their SGM identity that they perceived, and expressed a desire for privacy. Lack of an accessible and competent PCP was tied to delayed cancer diagnosis and many participants voiced a preference for consistency when they found a provider they liked.

CONCLUSIONS

Providers across specialties can address barriers for SGM patients by not making assumptions about patient sexual orientation or gender identity. Institutions should systematically collect sexual orientation and gender identity information. Primary care providers should be aware that due to resistance to switching from trusted providers, they may need to take greater initiative to facilitate cancer screenings for their patients when appropriate or take special care when making referrals to ensure they are using SGM-affirming providers.

IMPLICATIONS FOR CANCER SURVIVORS

SGM cancer survivors often benefit from a cultivating relationship with a trusted PCP or other provider.

Integrating LGBTQIA + Community Member Perspectives into Medical Education

ProblemLGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minorities) people have unique health care needs related to their sexual orientation, gender identity and expression, and sex development. However, medical education has historically excluded LGBTQIA + health-related content in formal curricula. It is common for medical students to interact with diverse patient populations through clinical rotations; however, access to and knowledge about LGBTQIA + patients is inconsistently prioritized in medical schools. This is especially true for LGBTQIA + patients with intersecting historically marginalized identities, such as people of color and people with disabilities. Learning from and listening to medically underserved community members can help both medical students and educators better understand the unique health needs of these communities, and address implicit biases to improve health care and outcomes for their patients. Intervention: To address the lack of LGBTQIA + health-related content in medical education and improve access to and knowledge about LGBTQIA + patients, LGBTQIA + community members' perspectives and lived experiences were integrated into undergraduate medical education via four primary methods: Community Advisory Groups, community panel events, standardized patients, and community member interviews. Context: LGBTQIA + community members' perspectives and lived experiences were integrated into medical education at Harvard Medical School (HMS) as part of the HMS Sexual and Gender Minority Health Equity Initiative. Impact: LGBTQIA + community members' perspectives and lived experiences were successfully integrated into multiple aspects of medical education at HMS. During this process, we navigated challenges in the following areas that can inform similar efforts at other institutions: representation of diverse identities and experiences, meeting and scheduling logistics, structural barriers in institutional processes, and implementation of community member recommendations. Lessons Learned: Based on our experiences, we offer recommendations for integrating LGBTQIA + community members' perspectives into medical education. Engaging community members and integrating their perspectives into medical education will better enable medical educators at all institutions to teach students about the health care needs of LGBTQIA + communities, and better prepare medical students to provide affirming and effective care to their future patients, particularly those who are LGBTQIA+.

Do Ask, Do Tell: Understanding Disclosure of Sexuality and Implications Among MSM Active Duty Service Members

INTRODUCTION

Men who have sex with men (MSM) account for over half of new diagnoses of human immunodeficiency virus (HIV) every year in the United States, with over one-third of this population being unaware of their HIV status. The U.S. Military requires biannual HIV testing for all service members. Although this may be an appropriate recommendation for the military at large, current health protection agencies suggest more frequent testing for those at increased risk of HIV transmission, such as those in the MSM community. However, more frequent testing for those at higher risk relies heavily on the preliminary step of patient disclosure of sexual practices to health care providers.

MATERIALS AND METHODS

An exploratory cross-sectional study was conducted in order to gain a better understanding of the relationship between sexual health variables and the disclosure of sexual identity to health care providers by MSM service members. A convenience sample of MSM currently serving in the U.S. military services (N = 354) was used to collect demographic data, sexual health and history, and opinions concerning medical treatment and HIV. Analyses of the data were conducted using univariate analysis and multivariate regression.

RESULTS

Men of color were more likely to report a higher degree of sexual identification transparency with their health care providers, which deviates from the civilian population. Pre-exposure prophylaxis (PrEP) uptake was increased among individuals who were more transparent with their health care providers.

CONCLUSIONS

Findings from this study indicate that feeling more comfortable sharing one's sexual identification with a health care provider results in increased engagement with HIV prevention measures. Potential implications for the Military Health System are the advancement of preventive sexual health screening procedures and the development and revision of policies that promote positive outcomes for gender and sexual minorities.

Reinforcing or Disrupting Gender Affirmation: The Impact of Cancer on Transgender Embodiment and Identity

There is a pressing need for greater understanding and focus on cancer survivorship and informal cancer caring of trans people (binary and non-binary), across tumor types, to inform culturally safe trans inclusive cancer information and care. This qualitative study, part of the mixed methods Out with Cancer project, examined experiences of trans embodiment and identity after cancer diagnosis and treatment. We drew on open-ended survey responses from 63 trans cancer survivors and 23 trans cancer carers, as well as interviews and a photo-elicitation activity with a subset of 22 participants (15 cancer survivors, 7 cancer carers). Reflexive thematic analysis identified three themes: Cancer enhances trans embodiment, through experiences of gender euphoria following cancer treatment, and acceleration of decisions about gender affirmation; cancer erases or inhibits gender affirmation; trans embodiment is invisible or pathologized in cancer care. These findings demonstrate that trans embodiment and identity, as well as the process of gender affirmation, may be disrupted by cancer or informal cancer caring. Conversely, cancer and cancer treatment can positively impact the embodied identity and lives of trans people, despite the anxiety and strain of negotiating medical procedures. However, if healthcare professionals operate within a cis-heteronormative framework and do not understand the meaning of embodied change following cancer treatment for trans individuals, these positive benefits may not be realized.

Survey of Lesbian, Gay, Bisexual, Transgender, and Queer Parents' Experiences Accessing Health Care for their Children With Developmental Disabilities

INTRODUCTION

This study explored the impact of health care (HC) bias and discrimination on lesbian, gay, bisexual, transgender, and queer (LGBTQ) parents and their children with developmental disabilities.

METHOD

We conducted a national online survey of LGBTQ parents of children with developmental disabilities using social media and professional networks. Descriptive statistics were compiled. Open-ended responses were coded using inductive and deductive approaches.

RESULTS

Thirty-seven parents completed the survey. Most participants identified as highly educated, White, lesbian or queer, cisgender women and reported positive experiences. Some reported bias and discrimination, including heterosexist forms, LGBTQ disclosure challenges, and, because of their LGBTQ identity, feeling mistreated by their children's providers or being refused needed HC for their child.

DISCUSSION

This study advances knowledge around LGBTQ parents' experiences of bias and discrimination while accessing children's HC. Findings highlight the need for additional research, policy change, and workforce development to improve HC for LGBTQ families.

Stigma and Barriers in Health Care Among a Sample of Transgender and Gender-Diverse Active Duty Service Members

BACKGROUND

Transgender and/or gender-diverse (TGD) persons are vulnerable to stigma and health care inequities; however, data are particularly limited among TGD active duty military service members despite ongoing changes to service policies. TGD-related stressors may impede access to and utilization of health care due to fear of potential discrimination and distress, thereby adversely impacting military readiness.

METHODS

We examined stigma and barriers in health care and associations with physical and mental health in an online sample of 177 active duty service members who self-identified as TGD. To assess associations between stigma and barriers in health care with mental and physical health, linear regressions were conducted adjusting for age, gender identity, race, and rank.

RESULTS

Over half (65%) of the participants reported at least 1 instance of stigma and/or barrier in health care. Stigma and barriers to health care were significantly associated with greater self-reported depressive symptoms (β=0.20, P =0.03), anxiety (β=0.21, P =0.03), stress (β=0.30, P =0.001), and poorer overall mental health (β=-0.23, P =0.007), after adjusting for covariates. Nearly one-quarter of participants had not disclosed their gender identity to their primary care clinician.

CONCLUSIONS

Findings suggested that stigma and barriers to affirming health care were prevalent among active duty service members identifying as TGD, specifically, difficulty accessing gender-affirming care and negative assumptions from clinicians. These experiences may adversely affect mental health and impede the quality of health care received by a population already vulnerable to health inequities. Given recent changes to military policy, efforts may be warranted to improve access to timely, affirming care and clinician training.

A secondary mixed methods analysis examining midwives' responses regarding patient sexual orientation and gender identity (SOGI) disclosure

OBJECTIVE

Recent research suggests that midwives generally have positive attitudes towards sexual and gender minority (SGM) clients; however, little research has examined whether and how these attitudes translate into specific clinical practices. In this study, we performed a secondary mixed methods analysis to examine midwives' beliefs and practices regarding the importance of asking and knowing their patients' sexual orientation and gender identity (SOGI).

METHODS

A confidential, anonymous paper survey was mailed to all midwifery practice groups (n = 131) in Ontario, Canada. Participants were midwives who were members of the Association of Ontario Midwives who responded to the survey (n = 267). Sequential explanatory mixed methods analysis was employed: quantitative SOGI questions were analyzed first, followed by qualitative open response comments to explain and contextualize the quantitative findings.

FINDINGS

Midwives' responses indicated that it was not important to know or ask about clients' SOGI because (1) it is not necessary to be able to provide the best care to everyone, and (2) the onus is on the client to disclose SOGI. Midwives indicated that they would like more training and knowledge to be able to confidently care for SGM.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Midwives' hesitancy to ask or know SOGI demonstrates that positive attitudes do not necessarily translate into current best practices for obtaining SOGI data in the context of SGM care provision. Midwifery education and training programs should address this gap.

Supporting Reproductive Care for Patients Requiring Solid Organ Transplant

After a solid organ transplant, individuals have the capability to maintain a successful pregnancy. However, many posttransplant pregnancies are unintended, thereby posing risks to health. There is a critical need to strengthen patient education regarding safe approaches to conception, general reproductive health, and childbearing capabilities. The complex needs of patients after transplant, including management of graft health and medication regimens, may distract from the usual reproductive care offered to other individuals of childbearing potential. Thorough education about immunosuppressant medications, contraceptive methods, and expected waiting periods before conceiving are essential. Nurses can work with each individual and direct the interprofessional health care team to provide effective, safe, comprehensive, and inclusive reproductive care to patients posttransplant.

"We're Moving in the Right Direction. Still a Long Way to Go": Experiences and Perceptions of the Climate for LGBTQ+ Employees at a Pediatric Hospital

A positive LGBTQ+ (lesbian, gay, bisexual, transgender/nonbinary, queer) workplace climate is critical for healthcare employee satisfaction, productivity, and patient care. The current study assessed LGBTQ+ workplace climate among 791 employees from a large urban pediatric hospital. Several workplace climate domains were assessed in an online survey: employee attitudes, training, experiences related to working with LGBTQ+ colleagues, patients and families, and LGBTQ+-specific experiences. For most domains, half or more of respondents perceived an affirming LGBTQ+ climate. LGBTQ+ employees perceived a less affirming climate than cisgender heterosexual employees. LGBTQ+ employees, especially transgender/nonbinary employees, experienced numerous discriminatory situations. Over 90% of participants felt competent and qualified to work with LGB patients/families; 80% felt competent and qualified to work with TNB patients/families. Themes from open-ended survery responses reflected three LGBTQ+ climate components: systemic, interpersonal, and "grassroots" (affinity group) initiatives. Findings inform strategies to improve LGBTQ+ employee experiences and competency caring for LGBTQ+ patients and families.

My Life, My Story and Identity Disclosure Among Transgender and Gender Diverse Veterans: A Program Evaluation

Transgender and gender diverse individuals face minority stressors during and after military service, increasing risk for poor health outcomes. Identity disclosure may mitigate these consequences through improving access to healthcare. Yet, stigma may impede Veterans' self-disclosure, and providers may not inquire about identities, hindering necessary screenings and treatments. In this program evaluation, we examined a narrative medicine approach, "My Life, My Story," to discern whether storytelling invites identity disclosure. This program may facilitate improved person-centered care by increasing clinicians' awareness of Veterans' identities.

Sexual Orientation and Gender Identity Data Reporting Among U.S. Health Centers

INTRODUCTION

Sexual orientation and gender identity data collection is necessary to address health inequities. This study examines sexual orientation and gender identity data reporting among community health centers.

METHODS

Using the 2016-2019 Uniform Data System for 1,381 community health centers, trends in reporting of sexual orientation and gender identity data were examined. Multivariable logistic regression was used to assess associations between community health center characteristics and whether sexual orientation and gender identity data were available for ≥75% of a community health center's patients in 2019. Data were analyzed in 2021.

RESULTS

In 2016-2019, the percentage of community health centers with sexual orientation and gender identity data for ≥75% of patients increased from 14.9% to 53.0%. In 2019, community health centers were more likely to have this data for ≥75% of patients if they were in nonmetro counties (OR=1.48, 95% CI=1.04, 2.10 versus metro), were in the South (OR=2.27, 95% CI=1.57, 3.31) or West (OR=1.91, 95% CI=1.27, 2.88 versus the Northeast), and had more patients aged between 18 and 39 years (OR=1.04, 95% CI=1.02, 1.07), between 40 and 64 years (OR=1.04, 95% CI=1.02, 1.06 vs <18 years), or veterans (OR=1.10, 95% CI=1.01, 1.20). This was less likely among community health centers serving 10,000-20,000 patients (OR=0.70, 95% CI=0.52, 0.95) and >20,000 patients (OR=0.44, 95% CI=0.32, 0.61 vs <10,000) and community health centers with more patients of American Indian/Alaskan Native (OR=0.98, 95% CI=0.97, 0.99) or unknown race (OR=0.92, 95% CI=0.86, 0.97 versus White).

CONCLUSIONS

Collection of sexual orientation and gender identity data by community health centers has increased substantially since 2016, although gaps remain.

LGBTQI Inclusive Cancer Care: A Discourse Analytic Study of Health Care Professional, Patient and Carer Perspectives

Background

Awareness of the specific needs of LGBTQI cancer patients has led to calls for inclusivity, cultural competence, cultural safety and cultural humility in cancer care. Examination of oncology healthcare professionals' (HCP) perspectives is central to identifying barriers and facilitators to inclusive LGBTQI cancer care.

Study Aim

This study examined oncology HCPs perspectives in relation to LGBTQI cancer care, and the implications of HCP perspectives and practices for LGBTQI patients and their caregivers.

Method

357 oncology HCPs in nursing (40%), medical (24%), allied health (19%) and leadership (11%) positions took part in a survey; 48 HCPs completed an interview. 430 LGBTQI patients, representing a range of tumor types, sexual and gender identities, age and intersex status, and 132 carers completed a survey, and 104 LGBTQI patients and 31 carers undertook an interview. Data were analysed using thematic discourse analysis.

Results

Three HCP subject positions - ways of thinking and behaving in relation to the self and LGBTQI patients - were identified:'Inclusive and reflective' practitioners characterized LGBTQI patients as potentially vulnerable and offered inclusive care, drawing on an affirmative construction of LGBTQI health. This resulted in LGBTQI patients and their carers feeling safe and respected, willing to disclose sexual orientation and gender identity (SOGI) status, and satisfied with cancer care. 'Egalitarian practitioners' drew on discourses of ethical responsibility, positioning themselves as treating all patients the same, not seeing the relevance of SOGI information. This was associated with absence of LGBTQI-specific information, patient and carer anxiety about disclosure of SOGI, feelings of invisibility, and dissatisfaction with healthcare. 'Anti-inclusive' practitioners' expressed open hostility and prejudice towards LGBTQI patients, reflecting a cultural discourse of homophobia and transphobia. This was associated with patient and carer distress, feelings of negative judgement, and exclusion of same-gender partners.

Conclusion

Derogatory views and descriptions of LGBTQI patients, and cis-normative practices need to be challenged, to ensure that HCPs offer inclusive and affirmative care. Building HCP's communicative competence to work with LGBTQI patients needs to become an essential part of basic training and ongoing professional development. Visible indicators of LGBTQI inclusivity are essential, alongside targeted resources and information for LGBTQI people.

Do Ask, Tell, and Show: Contextual Factors Affecting Sexual Orientation and Gender Identity Disclosure for Sexual and Gender Minority People

Purpose:

Sexual and gender minority (SGM) people—including members of lesbian, gay, bisexual, transgender, and queer communities—remain underrepresented in health research due to poor collection of sexual orientation and gender identity (SOGI) data. We sought to understand the contextual factors affecting how SGM research participants interact with SOGI questions to enhance participant experience and increase the accuracy and sensitivity of research findings.

Methods:

We recruited SGM adults for in-person semi-structured focus groups or online cognitive interviews from 2016 to 2018. During focus groups and cognitive interviews, we asked participants to respond to SOGI question sets. We employed template analysis to describe the contextual factors that affected SGM participants' responses to SOGI questions.

Results:

We had a total of 74 participants, including 55 participants organized into nine focus groups and 19 participants in cognitive interviews. Most self-identified as a sexual minority person (88%), and 51% identified as a gender minority person. Two main themes were: (1) the need to know the relevance (of why SOGI questions are asked) and (2) the importance of environmental and contextual cues (communicating physical safety and freedom from discrimination that influenced SOGI disclosure).

Conclusions:

Contextualizing the relevance of SOGI data sought could help improve the accuracy and sensitivity of data collection efforts. Environmental cues that communicate acceptance and safety for SGM individuals in research settings may support disclosure. Researchers should consider these contextual factors when designing future studies to improve research experiences for SGM individuals and increase the likelihood of future participation.

"You Could Tell I Said the Wrong Things": Constructions of Sexual Identity Among Older Gay Men in Healthcare Settings

Older gay men commonly conceal their sexual identity in healthcare settings due to past experiences and expectations of encountering stigma and discrimination in these contexts. Although insights on how older gay men construct their sexual identity in healthcare may help contextualize this phenomenon, this question remains under-explored. Accordingly, we present the findings of a secondary grounded theory analysis of individual interview data, which we originally collected to examine the healthcare experiences of 27 gay men ages 50 and over, to explore constructions of sexual identity among the group. Our findings broadly reveal that older gay men's varying exposure to intersecting systems of oppression, together with their perceptions of different healthcare settings, may be critical in shaping their constructions of sexual identity in these contexts. Our research supports the need for healthcare policies and practices that address stigma and discrimination as salient barriers to sexual identity disclosure among older gay men.

The role of disclosure & perceptions about providers in health discussions among gay and bisexual young men

OBJECTIVES

Gay and bisexual men may feel discomfort discussing sensitive topics such as sexual behaviors and substance use with their health providers, which may prevent them from receiving important health information. This study investigates whether patients' perceptions of their provider's sexual orientation predicts patient-provider discussions of sexual and general health topics, and whether this relationship is moderated by patients' disclosure of sexual orientation to providers.

METHODS

Data were collected online from a sample of 576 gay and bisexual men living in the USA, aged 18-26. Adjusted risk ratios were estimated by using modified Poisson regression with robust error variance.

RESULTS

Participants who believed their providers were gay or bisexual were more likely to have discussed sexual health topics, but not general health topics; simple slopes analyses revealed that this effect was stronger among those who had not disclosed to their providers. Disclosure was also consistently associated with increased likelihood of discussing almost all topics.

CONCLUSIONS

Findings highlight differences in communication based on disclosure and perceived sexual orientation of provider, suggesting the need to further explore how these differences influence young gay and bisexual men's health.

PRACTICE IMPLICATIONS

Dyads may be more likely to discuss sexual health topics when patients believe their providers are sexual minorities themselves. In addition, patient-provider dyads may be likelier to discuss various health topics when providers are aware of patients' sexual minority statuses.

Veterans' Reported Comfort in Disclosing Sexual Orientation and Gender Identity

BACKGROUND

The Veterans Health Administration (VHA) does not routinely collect and document sexual orientation and gender identity (SOGI) data despite research on health disparities among sexual and gender minority (SGM) veterans. Due to the legacy of previous Department of Defense policies that prohibited disclosure of sexual or gender minority identities among active-duty personnel, minority veterans may be reluctant to respond to SOGI questions on confidential VHA surveys and in discussions with their VHA providers. Veterans may generally find SOGI questions uncomfortable and may not appreciate their relevance to health care.

OBJECTIVE

The purpose of this research was to examine veterans' comfort in reporting identity characteristics on confidential VHA surveys and in discussion with their VHA providers and whether comfort differed by sociodemographic characteristics.

RESEARCH DESIGN

The project involves the secondary analysis of quantitative data from a quality improvement survey project.

SUBJECTS

A total of 806 veterans were surveyed.

RESULTS

Overall, 7.15% endorsed sexual or gender minority identity which is a higher rate than the 4.5% noted in the general US population. Cisgender and heterosexual veterans were more comfortable reporting identity characteristics both on VHA confidential surveys and in discussion with VHA providers compared with SGM veterans.

CONCLUSIONS

These data suggest that the majority of veterans feel comfortable reporting their identities both on surveys and in the context of health care. Understanding these perceptions can assist VHA programs in implementing SOGI data collection and disclosure in clinical care, creating a welcoming environment of care for SGM veterans that does not make veterans from other backgrounds feel uncomfortable.

Human papillomavirus (HPV) vaccine uptake among a community-recruited sample of gay, bisexual, and other men who have sex with men in the three largest cities in Canada from 2017 to 2019

INTRODUCTION

In 2015/2016, Canada's largest provinces implemented publicly-funded human papillomavirus (HPV) vaccination programs for gay, bisexual, and other men who have sex with men (GBM) ≤ 26 years old. We sought to describe HPV vaccine uptake among GBM and determine barriers and facilitators to vaccine initiation with a focus on healthcare access and utilization.

METHODS

Engage is a cohort study among GBM aged 16 + years in three Canadian cities recruited from 2017 to 2019 via respondent driven sampling (RDS). Men completed a comprehensive questionnaire at baseline. By publicly-funded vaccine eligibility (≤26 years old = eligible for vaccination, ≥27 years old = ineligible), we described HPV vaccine uptake (initiation = 1 + dose, completion = 3 doses) and explored factors associated with vaccine initiation using Poisson regression. All analyses were weighted with the RDS-II Volz-Heckathorn estimator.

RESULTS

Across the three cities, 26-35% and 14-21% of men ≤ 26 years and 7-26% and 2-9% of men ≥ 27 years initiated and completed HPV vaccination, respectively. Vaccine initiation was significantly associated with STI/HIV testing or visiting a HIV care specialist in the past six months (≤26: prevalence ratio[PR] = 2.15, 95% confidence interval[CI] 1.06-4.36; ≥27: PR = 2.73, 95%CI 1.14-6.51) and past hepatitis A or B vaccination (≤26: PR = 2.88, 95%CI 1.64-5.05; ≥27: PR = 2.03, 95%CI 1.07-3.86). Among men ≥ 27 years old, vaccine initiation was also positively associated with accessing PrEP, living in Vancouver or Toronto, but negatively associated with identifying as Latin American and increasing age. Vaccine initiation was twice as likely among men ≥ 27 years with private insurance versus no insurance.

CONCLUSIONS

Sixty-five to 74% of men eligible for publicly-funded vaccine across the three cities remained unvaccinated against HPV by 2019. High vaccine cost may partly explain even lower uptake among men ≥ 27 years old. Men seeking sexual health care were more likely to initiate vaccination; bundling vaccination with these services may help improve HPV vaccine uptake.

Disclosure of Same-Sex Sexual Practices to Family and Healthcare Providers by Men Who Have Sex with Men and Transgender Women in Nigeria

Disclosure of same-sex sexual practices by men who have sex with men (MSM) and transgender women (TGW) may facilitate appropriate healthcare engagement, including risk assessment for HIV and other sexually transmitted infections (STIs), and negotiation of condom use with partners. However, disclosure may also generate stigma. In these cross-sectional analyses, MSM and TGW were categorized based on self-report of disclosure to family members and healthcare providers (HCP) at enrollment into the TRUST/RV368 study of comprehensive HIV and STI care programs in Abuja and Lagos, Nigeria. Multivariable Poisson regression models with robust error variance were used to estimate relative risk of disclosure with 95% confidence intervals. Pearson's chi-squared test was used to compare condom use and stigma indicators by disclosure status. Of 2557 participants who answered baseline questions about disclosure, 384 (15.0%) had ever disclosed to a family member and 733 (28.7%) to HCP, including 192 (7.5%) who disclosed to both. Higher education, prevalent HIV infections, and residence in Lagos were each associated with increased likelihood of disclosure to family and HCP. Older participants were more likely to disclose to HCP but not family. Participants who made a disclosure to family or HCP were more likely to report condom use during anal sex as well as perceived and experienced stigma that included healthcare avoidance, blackmail, assault, and sexual violence as compared to participants who had not disclosed. Improved disclosure practices within safe spaces may enhance engagement of MSM and TGW in healthcare and HIV prevention services.

Identity cues influence sexual minorities' anticipated treatment and disclosure intentions in healthcare settings: Exploring a multiple pathway model

The present work experimentally examines how identity cues that signal minority inclusion contribute to sexual minorities' (SM) healthcare visit expectations. We find that minority representation cues reduced SM's (N = 188) expectations of a healthcare provider's bias and increased perceived provider cultural competency which was, in turn, associated with lower anticipated identity-based devaluation and greater sexual orientation disclosure comfort. Providers' diversity-valuing statements had mixed effects highlighting the importance of more concrete indicators of inclusion in this context. This work suggests that a lack of identity safety cues in healthcare settings may contribute to disparate health outcomes for sexual minority populations.

Variation in Sexual Orientation Documentation in a National Electronic Health Record System

Purpose: The purpose of this study was to determine variation in sexual minority (SM) sexual orientation documentation within the electronic medical records of the Veterans Health Administration (VHA). Methods: Documentation of SM sexual orientation was retrospectively extracted from clinical notes and administrative data in the VHA from October 1, 1999 to July 1, 2019. The rate of documentation overall and by calendar year was calculated, and differences across patient, provider, and clinic characteristics were evaluated. Results: Approximately 1.4% of all VHA Veterans (n = 115,911) had at least one documentation of SM sexual orientation, including 79,455 men and 36,456 women. The rate of documentation increased from 81.01/100,000 in 2000 to 568.84/100,000 in 2018. The majority of documentations (58.7%) occurred in mental health settings by non-MD mental health/social work counselors, whereas only 9.6% occurred in primary care settings. Although 99% of these Veterans had a primary care visit, only 19% had SM status recorded in that setting. Conclusion: Documentation patterns of SM sexual orientation varied considerably in the VHA with notable gaps in primary care. Diverse approaches to culturally competent training for primary care clinicians and patient-facing collection strategies could facilitate documentation of sexual orientation.

A survey of Canadian radiation therapists' perspectives on caring for LGBTQ2SPIA+ cancer patients

PURPOSE

The lesbian, gay, bisexual, trans, queer, two-spirit, pansexual, intersex, asexual, plus (LGBTQ2SPIA+) population faces unique cancer health risks and barriers to competent healthcare. This study aimed to identify current knowledge, attitudes, and practice behaviours amongst radiation therapists regarding the LGBTQ2SPIA+ community to ultimately improve care given to this population.

METHODS

A 22-item online survey was sent out to Canadian radiation therapy department managers and forwarded to radiation therapists. The survey collected demographics and addressed knowledge, attitudes, and practice behaviours regarding the LGBTQ2SPIA+ population. Results were analyzed using descriptive statistics, inferential statistics and thematic analysis.

RESULTS

214 radiation therapists completed the survey. Over 70% were unfamiliar with all terms associated with "LGBTQ2SPIA+". 91.6% believed that being conscious of the LGBTQ2SPIA+ community is important to their role as a therapist; however, 34.5% reported "rarely" or "never" adapting practice behaviours when caring for this community. Only 17.3% felt they had received adequate information to comfortably care for the LGBTQ2SPIA+ population, with 86.9% interested in receiving more education on specific patient needs. The open-ended questions revealed four themes: uncertainty regarding knowledge of the LGBTQ2SPIA+ community; willingness and/or desire to improve practice behaviours; therapists are already aware of some unique needs of the LGBTQ2SPIA+ community; and some therapists believe that all patients should be treated equally. National generalizability is limited due to insufficient data collected from all geographical regions.

CONCLUSION

Overall, this study was unable to provide national generalizability, however the results suggest that amongst the respondents there are knowledge gaps and inconsistencies in practice when caring for LGBTQ2SPIA+ cancer patients. Given the limited literature available, and the results from this study, more education and research is warranted to bridge knowledge gaps and aid in providing inclusive patient care.

A Meta-Analysis of Blood Pressure Disparities Among Sexual Minority Men

Purpose: The aim was to review and summarize reports on three measures of elevated blood pressure (BP) among sexual minority men (encompassing men who have sex with men [MSM] and both men and women [MSMW]), using men who have sex with women (MSW) as the reference population. Methods: Crude prevalence rates were calculated, and a meta-analysis was conducted to summarize the likelihood of elevated BP history, antihypertensive medication use, and elevated BP above a cutoff value, as well as the mean differences (MDs) in systolic BP (SBP) and diastolic BP (DBP) measurements. We used random effects to generate estimates with their respective 95% confidence intervals (CIs); alpha was set at 0.05. Results: Studies (n = 20) were published between 2007 and 2018, mostly in the United States. The likelihood of elevated BP history was not statistically significantly higher among sexual minority men, except when the measurement of sexual orientation was multidimensional (odds ratio [OR] 1.41, 95% CI 1.12-1.78). The likelihood of antihypertensive medication use was only statistically significantly higher for men who self-identified as MSMW (OR 1.44, 95% CI 1.11-1.85). When elevated BP was determined through a set cutoff, MSM were less likely (OR 0.34, 95% CI 0.16-0.70), whereas MSMW were more likely (OR 2.25, 95% CI 1.54-3.28) to have elevated BP. Although there were no statistically significant findings in the MD for SBP, the MD for DBP among sexual minority men was significantly higher (MD 1.46, 95% CI 1.38-1.55 mmHg) than among the MSW comparison group. Conclusions: Sexual minority men classified using a multidimensional approach to sexual orientation had a significantly higher likelihood of elevated BP history. Using BP cutoffs yielded opposite effects in MSM and MSMW. Although SBP was not different compared to MSW, DBP-a marker of hypertension at earlier ages-was elevated among sexual minority men.

Addressing Diversity in PTSD Treatment: Clinical Considerations and Guidance for the Treatment of PTSD in LGBTQ Populations

Purpose of review

Trauma exposure is widespread but is especially common among lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals. LGBTQ individuals also experience higher rates of discrimination, victimization, and minority stress which can complicate posttraumatic stress disorder (PTSD) treatment but also represent independent intervention targets. In this review, we highlight existing evidence-based practices, current limitations, and provide recommendations for care in the absence of established guidelines for treatment PTSD among LGBTQ patients.

Recent findings

Trauma-focused therapies (e.g., CPT, PE) and medications (e.g., SSRIs, SNRIs) have shown benefit for people with PTSD. However, evaluations of these interventions have failed to examine the role of LGBTQ identities in recovery from trauma, and existing PTSD treatments do not account for ongoing threat to safety or the pervasive minority stress experienced by LGBTQ patients. In addition, many LGBTQ patients report negative experiences with healthcare, necessitating increased education and cultural awareness on the part of clinicians to provide patient-centered care and, potentially, corrective mental health treatment experiences.

Summary

Providers should routinely assess trauma exposure, PTSD, and minority stress among LGBTQ patients. We provide assessment and screening recommendations, outline current evidence-based treatments, and suggest strategies for integrating existing treatments to treat PTSD among LGBTQ patients.

Lesbian, Gay, Bisexual, and Transgender Veterans' Experiences of Discrimination in Health Care and Their Relation to Health Outcomes: A Pilot Study Examining the Moderating Role of Provider Communication

Purpose: Lesbian, gay, bisexual, and transgender (LGBT) veterans report discrimination in health care, which may be associated with negative health outcomes/behaviors and has implications for LGBT identity disclosure to providers. Quality provider communication may serve to offset some of the deleterious effects of discrimination; however, no research to date has examined provider communication with respect to health among LGBT patients.

Methods: Participants were 47 LGBT veterans who completed measures related to past health care experiences, experiences of discrimination in health care, perceptions of provider communication, and measures of anxiety, depression, post-traumatic stress disorder symptoms, and alcohol/tobacco use.

Results: The majority of LGBT veterans reported experiencing LGBT-based discrimination in health care, which was associated with higher rates of tobacco use and less comfort in disclosing their LGBT identity to providers. We also found evidence of moderation, such that high-quality provider communication appeared to buffer these associations.

Conclusion: LGBT veterans face unique challenges with respect to receiving appropriate health care. The high frequencies of reported discrimination in health care is problematic and warrants further research and intervention. These results highlight the important role of provider communication, and the potential for quality communication to buffer against certain effects, particularly with respect to tobacco use and LGBT identity disclosure, which is an important protective factor.

Fostering sexual and gender minority status disclosure in patients

Members of the sexual and gender minority (SGM) community face complex barriers to accessing quality healthcare. NPs have a responsibility to create welcoming care settings where patients can share a trusting provider-patient relationship to disclose their SGM status, an event shown to improve patient outcomes.

Does Concealing a Sexual Minority Identity Prevent Exposure to Prejudice?

Concealing a stigmatized identity is considered self-protective in that it presumably decreases exposure to bias during intergroup interactions relative to disclosing the identity. We conducted two studies exploring sexual minorities’ expectations about the self-protective properties of concealment and the reality concerning whether concealment prevents exposure to bias. In Study 1, half of sexual minorities who imagined interacting with a straight peer chose to conceal their identity, and this was predicted by the belief that concealment carries protective benefits. Study 2 randomly assigned sexual minorities to reveal or conceal their sexual orientations in actual interactions with straight peers. Neither sexual minority partners nor independent sexual minority coders perceived less bias among straight partners who interacted with sexual minorities concealing versus disclosing their identities. This was confirmed with Bayesian inferences demonstrating more evidence for the null model than the alternative. We discuss the potential benefits and costs of disclosure.