Healthcare Mistreatment and Avoidance in Trans Masculine Adults: The Mediating Role of Rejection Sensitivity

Two Gender Medicine: Provider-Side Barriers to Caring for Transgender and Gender Diverse Patients

Experienced and anticipated discrimination during health care visits result in lower health care utilization rates, which contribute to persistent health disparities between transgender and gender diverse (TGD) individuals and the general population. Most strategies for improving health care delivery to TGD patients place the responsibility on providers, overlooking the role of medical systems and institutions in creating the environments where negative health care experiences occur. Relying on the inhabited institutionalism framework, this study explores system- and institutional-level barriers to the provision of quality care to TGD patients identified by health care providers and administrators, including relevant contextual details of, and interactions between, these barriers. Based on interview data from health care providers and administrators from a variety of practices across Texas, we identified two overarching themes and six subthemes. We demonstrate how our interviewees' responses reveal an institutional logic of "two-gender medicine," which creates barriers to health care provision in both formal medical education and training and throughout the managed care model of practice. We also illustrate how health care workers find ways to resist this logic in the course of their practice. Addressing these barriers to delivering competent and compassionate care to TGD patients that providers encounter could make long overdue strides toward addressing health disparities.

Latin Transgender and Gender-Diverse Individuals' Perceptions of Well-Being During the COVID-19 Pandemic

Latin transgender and gender-diverse (LTGGD) individuals experienced the public health measures mandated during the COVID-19 pandemic in unique ways. Intersecting ethnic and gender-identifying frameworks contributes to differing access, support, and well-being observations. The aim of this study was to examine emerging adult LTGGD individuals' perceptions of their health and well-being experiences during the COVID-19 pandemic in South Florida. Interviews were conducted with nine self-identifying LTGGD individuals. Using a thematic analysis, a total of three major themes were identified as shaping the participants' experiences and perceptions of health during COVID-19, including (a) healthcare interactions, (b) challenges, and (c) opportunities. Some of the participants were mixed in their perceptions of their well-being during the COVID-19 pandemic; negative concerns included the inability to access general and transgender/gender-diverse specific health services. However, others note that they were happy that the pandemic allowed them to avoid contexts where they regularly experienced microaggressions due to their identities. Additionally, various participants were able to use this time of isolation to identify providers with greater knowledge about LTGGD health needs. These findings highlight the importance of providing culturally competent and humility-centered skills to healthcare providers and others supporting the LTGGD population's well-being.

Sexual and Gender Identity-Associated Disparities in University Students' Experiences with Inappropriate, Disrespectful, and Coercive Health Care

Purpose: Inappropriate, disrespectful, or coercive health care (IDCH) is associated with patient age and sexual orientation and gender identity (SOGI) and can impact healthcare engagement and outcomes. Emerging adulthood is a critical period for establishing trust in health care, yet little is known about university students' IDCH experiences. This study assessed the IDCH prevalence and identified IDCH-SOGI associations in a university student sample. Methods: Using data from the cross-sectional IDC Survey (2021), we quantified the lifetime prevalence of 18 IDCH items in a sample of 3403 university students. Chi-squared and Kruskal-Wallis tests were used to assess bivariate associations between IDCH items and SOGI. We modeled associations between demographic characteristics and two types of provider-sexual misconduct using logistic regression. Results: Statistically significant associations between SOGI and 17 of the analyzed IDCH items were identified. Self-reported IDCH experiences were more prevalent among minoritized SOGI students than heterosexual cisgender students, including receiving inappropriate/harmful treatment and dismissive or biased provider communication. Gender minority and sexual minority cisgender male and female students had significantly higher odds of ever being touched inappropriately during an exam, compared with heterosexual cisgender males (adjusted odds ratios [95% confidence interval]: 3.07 [1.59-5.93], 2.34 [1.24-4.41], and 1.85 [1.16-2.90], respectively). SOGI was not significantly associated with experiencing a provider's sexual advances. Conclusion: University students with historically minoritized SOGIs may be particularly vulnerable to IDCH experiences; research is needed to understand differential experiences within minoritized sexual and gender subpopulations. Patient and provider education about healthcare norms and trauma-centered care could potentially reduce IDCH and its harms.

Breast Cancer Screening Referral Patterns and Compliance in Transgender Male Patients

Purpose

Screening guidelines for breast cancer (BC) in transgender male (TM) patients are not well defined. This study describes referral patterns and compliance with referral for BC screening among TM patients receiving care at a tertiary care center.

Methods

This was a retrospective cohort study of TM patients, 40-74 years of age, presenting for care between 2017 and 2020. The electronic medical record was queried for medical history and cancer screening data. Compliance with referral and screening was defined as occurring within 2 years of when screening would be expected.

Results

Of the 266 patients identified, 45 met inclusion criteria. One (2.2%) had a history of BC, 0 (0%) had hereditary BC risk, and 11 (24.4%) had a family history of BC. Of the patients, 18 (40%) were referred for BC screening, of whom 13 (72.2%) were compliant with screening. Ten (55.6%) were referred by a primary care provider, 2 (11.1%) were referred by a transgender medicine specialist, and 6 (33.3%) were referred by both. Of the cohort, 27 (60%) had undergone masculinizing mastectomy. Six (22.2%) of these patients were referred for screening, of whom 0 (0%) had pre-screening clinical findings indicating need for screening. Of the 18 (40%) patients who had not undergone masculinizing mastectomy, 12 (66.7%) were referred for BC screening.

Conclusions

There was heterogeneity in referral patterns for BC screening between TM patients who had undergone masculinizing mastectomy and those who had not. BC screening guidelines should be established for TM patients who have undergone masculinizing mastectomy.

Previous mental health care and help-seeking experiences: Perspectives from sexual and gender minority survivors of near-fatal suicide attempts

Sexual and gender minority (SGM) populations face heightened risk of suicide compared to their heterosexual and cisgender counterparts, and a previous suicide attempt is among the strongest predictors of suicide mortality. Despite this increased risk, limited research has explored mental health help-seeking behavior and previous mental health care experiences of SGM individuals among the highest risk for suicide-individuals with a recent, near-fatal suicide attempt. This study presents thematic analysis results of interviews with 22 SGM individuals who reported at least one near-fatal suicide attempt in the past 18 months. Identified themes were (a) factors that affect help-seeking for SGM individuals with a recent, near-fatal suicide attempt, including previous mental health care experiences, support systems, and structural barriers and facilitators; (b) hospitalization is not a one-size fits all solution; and (c) recommendations for improving care for this population. Findings demonstrate that anti-SGM stigma may magnify existing barriers to mental health care across all socioecological levels. Notably, participants cited a fear of loss of autonomy from inpatient hospitalization and previous discriminatory experiences when seeking mental health care as hampering help-seeking. Given increased risk for suicide mortality, this patient population is a necessary stakeholder in suicide prevention and intervention development and policy discussions affecting mental health care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Understanding the delivery of substance use treatment services to transgender and gender-diverse people: Findings from a mixed-methods study of healthcare professionals

BACKGROUND

Transgender and gender diverse (TGD) people who use drugs report barriers to accessing substance use treatment, including provider mistreatment. Little research has explored the multilevel factors that shape the capacity of substance use treatment professionals to provide gender-affirmative care (i.e., care that respects and affirms one's gender) to TGD people.

METHODS

From October 2021 to March 2022, substance use treatment and harm reduction professionals in Rhode Island were surveyed (N = 101) and qualitatively interviewed (N = 19) about the provision of substance use treatment-related services to TGD people. Quantitative data were analyzed descriptively; differences were examined using Fisher exact tests (p < 0.05). Qualitative interviews were coded and analyzed using thematic analysis.

RESULTS

Participants reported limited exposure to TGD people and lacked training on TGD health, which resulted in limited cultural and clinical competency and low self-efficacy in their ability to care for TGD people. Participants also highlighted structural factors (e.g., non-inclusive intake forms, limited availability of gender-inclusive ancillary community services) that restricted their ability to provide effective and affirming care to TGD people. Some participants also reported a "gender blind" ethos at their institutions- described by some as ignoring the potential impact of TGD peoples' unique experiences on their substance use and ability to benefit from treatment. While some perceived gender blindness as problematic, others believed this approach enabled substance use treatment professionals to consider all the identities and needs that patients/clients may have. Despite differences in treatment approaches, most participants agreed that their workplaces could benefit from efforts to create a safe and affirming space for people who use drugs, particularly TGD patients/clients.

CONCLUSION

Results underscore how structural, interpersonal, and individual factors contributed to barriers in the provision of gender-affirmative substance use-related care for TGD people. Findings can inform efforts to increase the capacity of providers to deliver gender-affirmative substance use-related services, which is essential to supporting the recovery goals of TGD people.

HIV pre-exposure prophylaxis programme preferences among sexually active HIV-negative transgender and gender diverse adults in the United States: a conjoint analysis

INTRODUCTION

Current implementation efforts have failed to achieve equitable HIV pre-exposure prophylaxis (PrEP) provision for transgender and gender-diverse (trans) populations. We conducted a choice-based conjoint analysis to measure preferences for key attributes of hypothetical PrEP delivery programmes among a diverse online sample predominantly comprised of transmasculine and nonbinary individuals in the United States.

METHODS

Between April 2022 and June 2022, a national online survey with an embedded conjoint analysis experiment was conducted among 304 trans individuals aged ≥18 years in the United States to assess five PrEP programme attributes: out-of-pocket cost; dispensing venue; frequency of visits for PrEP-related care; travel time to PrEP provider; and ability to bundle PrEP-related care with gender-affirming hormone therapy services. Participants responded to five questions, each of which presented two PrEP programme scenarios and one opt-out option per question and selected their preferred programme in each question. We used hierarchical Bayes estimation and multinomial logistic regression to measure part-worth utility scores for the total sample and by respondents' PrEP status.

RESULTS

The median age was 24 years (range 18-56); 75% were assigned female sex at birth; 54% identified as transmasculine; 32% as nonbinary; 14% as transfeminine. Out-of-pocket cost had the highest attribute importance score (44.3%), followed by the ability to bundle with gender-affirming hormone therapy services (18.7%). Minimal cost-sharing ($0 out-of-pocket cost) most positively influenced the attribute importance of cost (average conjoint part-worth utility coefficient of 2.5 [95% CI 2.4-2.6]). PrEP-experienced respondents preferred PrEP delivery in primary care settings (relative utility score 4.7); however, PrEP-naïve respondents preferred pharmacies (relative utility score 5.1).

CONCLUSIONS

Participants preferred programmes that offered PrEP services without cost-sharing and bundled with gender-affirming hormone therapy services. Bolstering federal regulations to cover PrEP services and prioritizing programmes to expand low-barrier PrEP provision are critical to achieving equitable PrEP provision. Community-engaged implementation research conducted by and in close collaboration with trans community stakeholders and researchers are needed to streamline the design of patient-centred PrEP programmes and develop implementation strategies that are salient to the diverse sexual health needs of trans patients.

Demographic factors associated with healthcare avoidance and delay in the transgender population: Findings from a systematic review

Purpose

Healthcare avoidance and delay (HAD) in the transgender population has been well documented, and research has explored a range of associated factors that help to identify those most at risk of HAD. This review addresses a gap in the research by synthesizing research exploring associations between HAD and demographic factors.

Methods

A systematic search of literature published at any time up to December 2021 was conducted, using five databases (EBSCO, EMBASE, PubMed, Scopus, and Web of Science) and manually searching reference lists of included studies. After exclusion of duplicates, 608 unique records were subjected to double screening. Papers reporting statistical analyses of HAD in association with any sociodemographic variables were included in this review. Papers consisted of nineteen cross-sectional studies. Narrative synthesis was used to address findings.

Results

Nineteen studies met inclusion criteria, exploring HAD in association with a wide range of demographic factors, including sex and gender, social transition factors, age, race and ethnicity, socioeconomic factors, veteran status, education, sexuality, relationship status, citizenship, place of residence, and state demographics. Findings identified intra-community demographic risk factors, with consistent evidence for increased HAD among transmasculine, and younger, participants. Lower income and higher educational attainment were also associated with increased HAD, while remaining areas had weak or little evidence for association with HAD.

Conclusion

This review expands knowledge in this area by highlighting demographic factors associated with increased HAD in research literature, and exploring how these may be further investigated to address substantial gaps in the body of research.

Does discrimination prevent transgender and gender diverse people from seeking healthcare?: A nationwide cohort study in South Korea

Introduction

Using Asia's first nationwide cohort dataset, this study aimed to assess the prevalence of anti-transgender discrimination and healthcare avoidance and delay (HAD) and examine their associations among transgender and gender diverse (TGD) adults in South Korea.

Methods

We analyzed a two-wave (2020-2021) longitudinal dataset of 190 Korean TGD adults. Anti-transgender discrimination were classified accordingly: experienced at (1) neither wave, (2) baseline (2020) only, (3) follow-up (2021) only, and (4) both waves. We also asked about HAD in the past 12 months at follow-up for both transition-related and non-transition-related healthcare services. Multivariate modified Poisson regression was used to examine the associations between anti-transgender discrimination and HAD.

Results

Of 190 participants, 102 (53.7%) experienced anti-transgender discrimination at both waves, and 130 (68.4%) reported HAD at follow-up. Compared to those without any experiences of anti-transgender discrimination, those who experienced it in both waves had a 1.78-times (95% CI: 1.21-2.63) higher prevalence of non-transition-related HAD, but not among those who experienced it in either wave. In contrast, anti-transgender discrimination was not associated with transition-related HAD.

Conclusion

In order to enhance healthcare access for transgender and gender diverse (TGD) individuals, it is necessary to implement interventions, such as anti-discrimination laws, that protect them from discrimination.

Perspective on equitable translational studies and clinical support for an unbiased inclusion of the LGBTQIA2S+community

Research regarding the mental health of the Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, 2 Spirit (LGBTQIA2S+) community has been historically biased by individual and structural homophobia, biphobia, and transphobia, resulting in research that does not represent the best quality science. Furthermore, much of this research does not serve the best interests or priorities of LGBTQIA2S + communities, despite significant mental health disparities and great need for quality mental health research and treatments in these populations. Here, we will highlight how bias has resulted in missed opportunities for advancing understanding of mental health within LGBTQIA2S + communities. We cite up-to-date research on mental health disparities facing the LGBTQIA2S + community and targeted treatment strategies, as well as guidance from health care professionals. Importantly, research is discussed from both preclinical and clinical perspectives, providing common language and research priorities from a translational perspective. Given the rising tide of anti-transgender sentiment among certain political factions, we further emphasize and discuss the impact of historical and present day ciscentrism and structural transphobia in transgender mental health research, from both clinical and translational perspectives, with suggestions for future directions to improve the quality of this field. Finally, we address current best practices for treatment of mental health issues in this community. This approach provides an opportunity to dispel myths regarding the LGBTQIA2S + community as well as inform the scientific community of best practices to work with this community in an equitable manner. Thus, our approach ties preclinical and clinical research within the LGBTQIA2S + community.

Transgender and gender diverse adults' reflections on alcohol counseling and recommendations for providers

Transgender and gender diverse (TGD) populations experience health disparities due to societal stigma that increases TGD individuals' sources of stress and decreases access to health protective resources. Research has linked experiences of stigma to risky alcohol use, yet there remains a dearth of culturally sensitive alcohol use interventions that meet the needs of TGD people. The present study was conducted to inform modifications to the content and delivery of an existing brief, telehealth, motivational intervention to decrease at-risk alcohol use among TGD adults. Individual semi-structured in-depth qualitative interviews were conducted with TGD adults who reported recent alcohol use (n = 18) to explore factors that facilitate positive interactions with health care providers and identify relevant information for alcohol use disorder treatment. Participants were recruited from an LGBTQ +-focused health center in Los Angeles, California. Two major themes and recommendations emerged: (a) A multicultural orientation of humility is important to develop productive therapeutic relationships with TGD clients when delivering motivational interviewing; (b) Due to insufficient appropriate data on alcohol use and health in TGD populations, feedback used in motivational alcohol counseling needs to be modified to better serve TGD clients. These findings show that counselors' philosophy and behavior, as well as session content, need to be considered when working with TGD populations within the context of alcohol counseling. These findings also have implications for intervention development, clinical treatment, and future research. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Victimization Within and Beyond the Prison Walls: A Latent Profile Analysis of Transgender and Gender Diverse Adults

Background: Transgender and gender diverse (TGD) people are disproportionately incarcerated in the United States relative to the general population. A dearth of quantitative research has explored victimization as a risk factor for incarceration as well as the victimization experiences of formerly incarcerated TGD populations. Methods: In 2019, 574 TGD adults completed an online survey assessing sociodemographics, victimization across settings, and incarceration history. Latent class analysis was used to identify two sets of latent subgroups based on respondent's victimization experiences: 1) lifetime victimization (low; moderate; and high) and 2) classes of victimization while incarcerated (low; moderate; and high). Bivariate and multivariable logistic regression analyses examined sociodemographic, mental health, and lifetime victimization experiences associated with lifetime incarceration (Outcome 1). Among those with incarceration histories, bivariate hierarchical logistic regression analyses also explored the association between gender identity, race/ethnicity, HIV status, visual gender non-conformity, and class of victimization during incarceration (Outcome 2) . Results: Participants' mean age was 31.4 (SD = 11.2), 43.4% had a non-binary gender identity, 81.5% were White, non-Hispanic, 2.1% were living with HIV, and 13.2% had been incarcerated. In the multivariable model for Outcome 1, high levels of victimization, age, being a racial/ethnic minority, being a trans woman, living with HIV, and past-12-month polysubstance use were all associated with increased odds of lifetime incarceration (p-values < 0.05). In the bivariate hierarchical logistic regression analyses for Outcome 2, living with HIV and having a visually gender non-conforming expression were significantly associated with elevated odds of experiencing high levels of victimization while incarcerated (p-values < 0.05). Conclusion: Findings document the relationships between victimization and incarceration among TGD people as well as identify the subpopulations at greater risk for incarceration and experiencing victimization while incarcerated. Efforts are needed to prevent victimization across the life course, including while incarcerated and support TGD individuals in coping with the negative sequelae of victimization and incarceration experiences.

Centering the Needs of Transgender, Nonbinary, and Gender-Diverse Populations in Neuroendocrine Models of Gender-Affirming Hormone Therapy

Most studies attempting to address the health care needs of the millions of transgender, nonbinary, and/or gender-diverse (TNG) individuals rely on human subjects, overlooking the benefits of translational research in animal models. Researchers have identified many ways in which gonadal steroid hormones regulate neuronal gene expression, connectivity, activity, and function across the brain to control behavior. However, these discoveries primarily benefit cisgender populations. Research into the effects of exogenous hormones such as estradiol, testosterone, and progesterone has a direct translational benefit for TNG individuals on gender-affirming hormone therapies (GAHTs). Despite this potential, endocrinological health care for TNG individuals remains largely unimproved. Here, we outline important areas of translational research that could address the unique health care needs of TNG individuals on GAHT. We highlight key biomedical questions regarding GAHT that can be investigated using animal models. We discuss how contemporary research fails to address the needs of GAHT users and identify equitable practices for cisgender scientists engaging with this work. We conclude that if necessary and important steps are taken to address these issues, translational research on GAHTs will greatly benefit the health care outcomes of TNG people.

The impact of sources of stigma on health care avoidance among gay and bisexual men in Australia

Stigma has a negative impact on health and wellbeing for gay and bisexual men (GBM). There is little research which assesses whether stigma from various sources affects access to different health care services. Further, those people who pay more attention to their stigmatised condition may be more likely to avoid health services. This study aimed to assess the association between sources of stigma and health care avoidance amongst a sample of GBM, as well as the role of heightened stigma sensitivity. The sample consisted of 1116 GBM in Australia who completed an online survey. Findings illustrate that those reporting any stigma were more likely to avoid health care services, while avoiding different types of health care was related to the source of the stigma. Greater stigma sensitivity was associated with avoidance of all health care services. GBM may come to health services with complex and potentially recurrent experiences of stigma. Working on the assumption that clients have a history of negative experiences in health care will increase the ability of services to work sensitively with GBM clients and ensure that access to health care amongst this group is increased.

Expectation of Rejection and Its Association with Health Care Avoidance and Delay Among 2175 Korean Lesbian, Gay, and Bisexual Adults: A Nationwide Cross-Sectional Survey

Purpose: The study examined an association between expectation of rejection and health care avoidance and delay (HAD) among lesbian, gay, and bisexual (LGB) adults in South Korea. Methods: We analyzed data from a nationwide cross-sectional survey of 2175 South Korean LGB adults, which was approved by the Korea University Institutional Review Board. We categorized expectation of rejection into tertiles ("low," "medium," and "high" levels) and investigated its association with past 12-month HAD using multivariate modified Poisson regression. Results: After adjusting for covariates, including experiences of discrimination, participants with high levels of expectation of rejection had 1.38-times (95% confidence interval: 1.16-1.65) higher prevalence of HAD compared with those with low levels. Conclusion: Living in anticipation of rejection can negatively impact LGB adults' health care utilization.

Concerns on healthcare access, utilization and safety due to COVID-19 among American adults with vision loss

Background

Limited studies have indicated that Americans with vision loss are differentially impacted by COVID-19.

Objective

We examined concerns with healthcare and safety among Americans with vision loss during the early phase of the pandemic (April 2020).

Methods

The Flatten Inaccessibility Survey assessed the impact of COVID-19 on healthcare (pharmacy access, maintenance of eyecare regimen, caregiver access, and resource denial) and safety (social distancing, clean surfaces, and touching public signage) concerns among Americans with low vision or who were blind. Multivariable logistic regression was used to determine associations between respondent characteristics and each concern.

Results

A total of 1921 adults responded to the survey, of whom 65% were blind and 35% had low vision. Most respondents were female (63%) and white (74%). Respondents with additional disabilities/comorbidities were more likely to report healthcare access concerns (pharmacy access, eyecare regimen, caregiver access, and ventilator access) and safety concerns (social distance, clean surfaces, and touching signage) than those with vision loss alone. In addition, females, those identifying as “other” gender, older individuals, and people with adult onset of vision impairment were more likely to experience COVID-19–related concerns and challenges related to healthcare and overall safety.

Conclusion

These results suggest that while Americans with vision loss have been differentially impacted by COVID-19, adults with vision loss and additional disabilities/comorbidities are more likely to have concerns with healthcare and safety than those with vision loss alone.

Sexual minorities are at elevated risk of cardiovascular disease from a younger age than heterosexuals

Cardiovascular disease is the leading cause of death worldwide. In this study, we assessed factors related to cardiovascular disease risk and outcomes among sexual minorities (SM). Data from multiple waves of the PATH study were used in this analysis. Multivariable regression models were used to assess the association between sexual identity and: tobacco or e-cigarette use, adverse cardiovascular events, and age at first diagnosis of adverse cardiovascular disease events. In our sample (N = 23,205), 1,660 (7.15%) participants identified as SM. SM men, relative to heterosexual men, are more likely to be diagnosed with high blood pressure (aRR = 1.27; 95% CI 1.10, 1.47), high cholesterol (aRR = 1.32; 95% CI: 1.12, 1.55), congestive heart failure (aRR = 2.29; 95% CI 1.13, 4.65), stroke (aRR = 2.39; 95% CI: 1.14, 5.04), heart attack (aRR = 2.40; 95% CI 1.42, 4.04), and other heart conditions (aRR = 1.52; 95% CI: 1.06, 2.18). Although no simple differences were observed among SM women compared to heterosexual women, SM women were more likely to be diagnosed at a younger age for high blood pressure (aRR = -0.69; 95% CI - 1.08, - 0.29), high cholesterol (aRR = -0.77; 95% CI - 1.15, - 0.38), stroke (aRR =  - 1.04; 95% CI - 1.94, - 0.13), and heart attack (aRR =  - 1.26; 95% CI - 2.42, - 0.10). SM men were only diagnosed at a younger age for stroke (aRR =  - 1.18; 95% CI - 2.06, - 0.30). Compared to heterosexuals, sexual minorities are at higher risk for cardiovascular disease, more likely to develop cardiovascular disease at an earlier age, and more likely to use tobacco products. Future research should focus on decreasing cardiovascular risk among sexual minorities including reducing tobacco use and stress. Screening recommendations for sexual minority populations should also be reviewed in light of a growing body of literature suggesting elevated risk from a young age.

Critical issues in cognitive behavioural therapy (CBT) with gender and sexual minorities (GSMs)

In a cisheteronormative culture, gender and sexual minorities (GSMs) may experience additional challenges that get in the way of a meaningful life. It is crucial that clinicians are mindful of these challenges and cognizant about the specificities of clinical work with GSMs. This article points out how societal structure interferes with mental health, and clarifies what clinicians must take into account when using affirmative cognitive behavioural therapy (CBT) interventions. Knowledge of up-to-date terminology and use of affirmative language are the first steps that contribute to clients’ experience of respect, which is paramount for the development of a good therapeutic relationship. Considering a conceptual framework of minority stress to understand vulnerability in GSM, specificities in formulation and key psychological processes are discussed. Moreover, guidelines and practical tools for intervention are presented within a CBT approach. Some reflections on therapists’ own personal biases are encouraged, in order to increase the efficacy of interventions.

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Healthcare Mistreatment, State-Level Policy Protections, and Healthcare Avoidance Among Gender Minority People

INTRODUCTION

This study examined whether past experiences of mistreatment in healthcare were associated with greater healthcare avoidance due to anticipated mistreatment among gender minority (GM) people. We evaluated whether state-level healthcare policy protections moderated this relationship.

METHODS

Data from the 2018 Annual Questionnaire of The PRIDE Study, a national longitudinal study on sexual and gender minority people's health, were used in these analyses. Logistic regression modeling tested relationships between lifetime healthcare mistreatment due to gender identity or expression and past-year healthcare avoidance due to anticipated mistreatment among GM participants. Interactions between lifetime healthcare mistreatment and state-level healthcare policy protections and their relationship with past-year healthcare avoidance were tested.

RESULTS

Participants reporting any lifetime healthcare mistreatment had greater odds of past-year healthcare avoidance due to anticipated mistreatment among gender expansive people (n = 1290, OR = 4.71 [CI]: 3.57-6.20), transfeminine people (n = 263, OR = 10.32 [CI]: 4.72-22.59), and transmasculine people (n = 471, OR = 3.90 [CI]: 2.50-6.13). Presence of state-level healthcare policy protections did not moderate this relationship in any study groups.

CONCLUSIONS

For GM people, reporting lifetime healthcare mistreatment was associated with healthcare avoidance due to anticipated mistreatment. State-level healthcare policy protections were not a moderating factor in this relationship. Efforts to evaluate the implementation and enforcement of state-level policies are needed. Continued efforts to understand instances of and to diminish healthcare mistreatment of GM people are recommended.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13178-022-00748-1.

Experiences of Transgender Participants in Emergency Departments: Findings from the OutLook Study

Purpose: Even in cases of medical emergency, mistreatment and negative experiences in life or in medical settings can deter trans patients from seeking necessary care. The purpose of this study was to identify factors associated with trans persons' emergency department (ED) avoidance in the mixed urban-rural Region of Waterloo, Ontario, Canada. Methods: The OutLook Study was a community-based partnership that created an online, cross-sectional questionnaire for lesbian, gay, bisexual, transgender, and other sexual and gender minority community members. Participants in this analysis were 16 years of age or older, lived, worked, or attended school in Waterloo Region, and identified as trans (n=112). Binary logistic regression was used to test associations between sociodemographic, resilience, and risk variables, and ED avoidance. Sociodemographic variables statistically significant at p<0.05 at the bivariate level were included as controls to explore different combinations of resilience and risk factor in multivariable models. Results: Participants reporting complete or partially complete medical transitions were more likely to report ED avoidance, compared to those who had not initiated medical transition. Elevated transphobia was associated with greater likelihood of avoidance. However, increasing levels of social support decreased the likelihood of avoidance. In multivariable models, social support, support from a special person, and transphobia were always significant, regardless of controlled variables. Conclusion: Transphobia-enacted in the contexts of everyday life and health care-can deter patients from seeking care. Patient-centered care requires careful attention to trans identity and health needs, especially in emergency settings. In the absence of structural changes, providers can take steps to mitigate the erasure and discrimination trans patients experience and anticipate when accessing EDs.

Transgender and Nonbinary Experiences of Victimization in Health care

Transgender and nonbinary (TNB) individuals experience high rates of myriad types of victimization, including in health care settings. Many TNB people avoid medical visits for fear of mistreatment and, when they do visit a provider, report negative experiences (e.g., denial of services, misgendering, verbal abuse). These negative experiences are heightened for TNB individuals who have an intersecting marginalized identity (e.g., low socioeconomic status, disability). Using data from the 2015 United States Transgender Survey, the largest survey of TNB individuals in the United States to date, the present study examines differential experiences of victimization in health care settings by TNB identity and other demographics (i.e., race, age, class, educational level, disability). A series of multivariate logistic regressions were run to determine adjusted odds ratios (AORs) for TNB individuals recently (i.e., in the past year) experiencing four forms of victimization: (a) doctor/health care provider used harsh or abusive language; (b) doctor/health care provider was physically rough or abusive; (c) patient was verbally harassed in health care setting; and (d) patient experienced unwanted sexual contact in health care setting. Frequency of victimization varied by gender identity and type of victimization; the most prevalent form was verbal harassment by a doctor/provider (5.84%) and the least prevalent was unwanted sexual contact in a health care setting (1.20%). Although findings varied by form of violence, generally, regression models demonstrated elevated odds of experiencing some form of health care victimization for those who were transgender compared with genderqueer, biracial/multiracial compared with White, low income compared with higher income, and disabled compared to non-disabled. In addition, odds ratios for victimization increased with age and, for some forms, increased with low educational attainment. We discuss the need for increased mandatory trainings for providers to reduce discriminatory and violent behavior toward TNB patients, as well as intersectional research to better ascertain the extent and nuance of victimization within TNB health care.

A biopsychosocial framework for understanding sexual and gender minority health: A call for action

The number of US adults identifying as lesbian, gay, bisexual, transgender, or a different sexual identity has doubled since 2008, and about 40 % of the sexual and gender minority population identify as people of color. Minority stress theory posits that sexual and gender minorities are at particular risk for stress via stigma and discrimination at the structural, interpersonal, and individual levels. This stress, in turn, elevates the risk of adverse health outcomes across several domains. However, there remains a conspicuously limited amount of research on the psychoneuroimmunology of stress among sexual and gender minorities. We developed the Biopsychosocial Minority Stress Framework which posits that sexual minority status leads to unique experiences of minority stress which results in adverse health behavioral factors, elevated psychological distress and sleep disturbance, and immune dysregulation. Moderators in the model include both individual differences and intersectional identities. There is a crucial need to understand the biological-psychological axis of stress among the increasingly visible sexual and gender minority population to increase their health, longevity, and quality of life.

The lesbian, gay, bisexual and transgender communities' mental health care needs and experiences of mental health services: An integrative review of qualitative studies

WHAT IS KNOWN ON THE SUBJECT?: There is evidence that the LGBT communities experience greater health disparities, particularly in relation to their mental health needs. The LGBT communities are often faced with stigma and discrimination within mental health services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: People within the LGBT communities have identified that their experiences of mental health services reinforce stigma and lack an understanding of their specific needs. Their needs can be addressed by mental health services that challenge heteronormative assumptions and promote self-acceptance and equity. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The existing heteronormative culture in mental health nursing practice needs to be challenged. Practice needs to demonstrate self-awareness of personal and societal LGBT biases, prejudices, and stigma. Practice needs to demonstrate knowledge of important LGBT health care and psychosocial issues. Practice needs to reflect LGBT clinical skills grounded in professional ethics, guidelines, and standards of care.

ABSTRACT

INTRODUCTION: The lesbian, gay, bisexual and transgender (LGBT) communities are a minority population that experience a range of health disparities, including mental health. Because these groups have higher rates of mental disorder than the general population it is, therefore, pertinent to identify their specific mental health needs and their experiences when accessing mental health care.

AIM

To identify the mental health needs of the LGBT communities and their experiences of accessing mental health care.

METHODS

An integrative review of qualitative studies was conducted.

RESULTS

A total of fourteen studies were selected for this review. The studies identified that participants' experiences of accessing mental health care were related to (a) experiencing stigma and (b) staff's lack of knowledge and understanding of LGBT people's needs. They identified a need for mental health care that promotes the principles of equity, inclusion and respect for diversity.

DISCUSSION

The LGBT communities while not a homogenous group, face unique challenges when dealing with their mental health needs. Services that promote health equity and self-acceptance are important for this group.

IMPLICATIONS FOR PRACTICE

It is vital that mental health nursing education incorporate models that promote equity, inclusion and respect for diversity regarding this group of people.

Mistreatment in Medical Care and Psychological Distress among Asian Americans

Although studies have shown that discrimination is linked to poor mental health, less is known about this relationship in the context of healthcare and how it varies for different Asian subgroups. The aim of this study was to examine the relationships between mistreatment in medical care and psychological distress among a diverse sample of Asian Americans. Data were drawn from the 2015-2017 California Health Interview Survey. A series of regression models were estimated to test the association between mistreatment in medical care and psychological distress. Various Asian subgroups showed different levels of psychological distress. Mistreatment in medical care was also linked to worse mental health. Findings, however, did not show significant differences in the interaction between mistreatment and ethnicity on psychological distress. This study advances knowledge on the experiences of Asian Americans and contributes to the literature showing the impact of discrimination on mental health.

A retrospective on fundamental cause theory: State of the literature, and goals for the future

Fundamental Cause Theory (FCT) was originally proposed to explain how socioeconomic inequalities in health emerged and persisted over time. The concept was that higher socioeconomic status helped some people to avoid risks and adopt protective strategies using flexible resources - knowledge, money, power, prestige and beneficial social connections. As a sociological theory, FCT addressed this issue by calling on social stratification, stigma, and racism as they affected medical treatments and health outcomes. The last comprehensive review was completed a decade ago. Since then, FCT has been tested, and new applications have extended central features. The current review consolidates key foci in the literature in order to guide future research in the field. Notable themes emerged around types of resources and their usage, approaches used to test the theory, and novel extensions. We conclude that after 25 years of use, there remain crucial questions to be addressed.

Breast Cancer Risk and Screening in Transgender Persons: A Call for Inclusive Care

The Society of Surgical Oncology is committed to reducing health disparities adversely affecting sexual and gender minorities. Transgender persons represent a socially disadvantaged group who frequently experience discrimination and receive disparate care, resulting in suboptimal cancer outcomes. The rate of breast cancer development in transgender individuals differs from rates observed in their cisgender counterparts, however there is little evidence to quantify these differences and guide evidence-based screening and prevention. There is no consensus for breast cancer screening guidelines in transgender patients. In this review, we discuss barriers to equitable breast cancer care, risk factors for breast cancer development, and existing data to support breast cancer screening in transgender men and women.

Opioid pain medication misuse, concomitant substance misuse, and the unmet behavioral health treatment needs of transgender and gender diverse adults

BACKGROUND

Limited research has explored risk factors for opioid pain medication misuse, concomitant substance misuse, and the unmet behavioral health treatment (BHTx) needs of transgender and gender diverse (TGD) adults.

METHODS

In 2019, TGD adults (N = 562) in Massachusetts and Rhode Island were purposively recruited and completed a psychosocial and behavioral health survey (95 % online; 5% in-person). Multivariable logistic regression was used to examine factors associated with past 12-month opioid pain medication misuse and unmet BHTx needs.

RESULTS

Overall, 24.4 % of participants were trans women; 32.0 % trans men; and 43.6 % were non-binary. Past-year substance misuse included: marijuana (56.8 %), hazardous drinking (37.5 %), hallucinogens (9.8 %), benzodiazepines (8.2 %), and opioid pain medication (8.0 %). Among participants with past-year substance misuse and BHtx need (n = 326), 81.3 % received BHtx and 18.7 % had unmet BHtx needs. Being a trans woman, having HIV, stigma in healthcare, and number of substances misused were associated with increased odds of past-year opioid pain medication misuse; high social connectedness was associated with decreased odds of opioid pain medication misuse (p-values<0.05). Younger age, stigma in healthcare, and misusing opioid pain medications were associated with increased odds of unmet BHTx needs; post-traumatic stress disorder and family support were associated with decreased odds of unmet BHtx needs (p-values<0.05).

CONCLUSIONS

Addressing disparities in opioid pain medication misuse among TGD people requires systematic improvements in healthcare access, including efforts to create TGD-inclusive BHtx environments with providers who are equipped to recognize and treat the social and structural drivers of TGD health inequities, including opioid pain medication misuse.

Does Discrimination Affect Whether Transgender People Avoid or Delay Healthcare?: A Nationwide Cross-sectional Survey in South Korea

This study examined the association between perceived discrimination and healthcare avoidance and delay (HAD) among transgender adults in South Korea (hereafter Korea). We conducted a nationwide cross-sectional survey of 244 Korean transgender adults in 2017. Discrimination within the last 12 months was categorized into four groups based on the reason(s) of discrimination experienced: (1) 'never experienced' discrimination, (2) 'only due to transgender identity,' (3) 'due to reason(s) other than transgender identity,' and (4) 'due to both transgender identity and other reason(s).' Korean transgender adults who experienced discrimination 'only due to transgender identity' and 'due to both transgender identity and other reason(s)' reported 1.91-times (95% CI 1.02-3.55) and 1.96-times (95% CI 1.32-2.92) higher prevalence of past 12-month HAD, respectively, than those who had no such experiences. Our findings suggest that institutional efforts are needed to protect transgender people from discrimination, which can contribute to improved access to healthcare among transgender populations in Korea.

'They know better than we doctors do': providers' preparedness for transgender healthcare in Vietnam

While recognition of transgender people has increased in Vietnam, this population continues to face significant stigma and discrimination within their families and in public, including in medical settings. Understanding of transgender health is limited, especially regarding the provision of care to transgender people. This paper explores providers' preparedness for delivering transgender care using data from qualitative interviews with twelve healthcare professionals in Hanoi and Ho Chi Minh City. Drawing on the socio-ecological model, we illustrated multi-level factors that influenced the provision of medical services to transgender people, including restrictive legislation (policy level); shortage of transgender-specific services, and lack of training and guidelines (organisational level); and ambiguous perceptions, inappropriate provider-patient communication, and medical knowledge gaps (individual level). Overall, our study has identified a healthcare environment that is under-prepared to meet the complex health needs of transgender individuals. With this study, we call for intervention strategies beyond individual-level support and emphasise the urgency of allowing medical institutions to provide transgender-specific health services including gender-affirming surgery and hormonal treatments.

Transgender stigma: A critical scoping review of definitions, domains, and measures used in empirical research

RATIONALE

A growing body of transgender (trans) health research has explored the relationship between stigma and health; yet, studies have conceptualized and operationalized anti-trans stigma in multiple ways.

OBJECTIVE

This scoping review aims to critically analyze quantitative measures of anti-trans stigma in the U.S. using a socioecological framework.

METHOD

We organized and appraised measures from 126 included articles according to socioecological level: structural, interpersonal, or individual.

RESULTS

Of the identified articles, 36 measured anti-trans stigma at the structural level (i.e., institutional structures and policies), 102 measured anti-trans at the interpersonal level (i.e., community interactions), and 44 measured anti-trans stigma at the individual level (i.e., internalized or anticipated stigma). Definitions of anti-trans stigma varied substantially across articles. Most measures were adapted from measures developed for other populations (i.e., sexual minorities) and were not previously validated for trans samples.

CONCLUSIONS

Studies analyzing anti-trans stigma should concretely define anti-trans stigma. There is a need to develop measures of anti-trans stigma at all socioecological levels informed by the lived experiences of trans people.

Unmet Expectations in Health Care Settings: Experiences of Transgender and Gender Diverse Adults in the Central Great Plains

Transgender and gender diverse (TGD) individuals face a long-term, multifaceted process if they choose to begin a gender affirmation journey. Decisions to go on hormone therapy and/or have a surgical procedure necessitate the TGD individual to set up an appointment with a health care provider. However, when TGD patients interact with health care practitioners, problems can arise. This article documents and categorizes the types of unmet expectations that are common in the TGD patient-health care provider social dynamic in the Central Great Plains of the United States. Utilizing a community-based participatory research model, qualitative in-depth interviews were conducted with 27 TGD individuals about their health care experiences. From this, the researchers identified four main themes of unmet expectations: probing, gatekeeping, stigmatizing stance, and misgendering/deadnaming. Steps that can be taken by both the health care provider and the TGD individual to have a more successful encounter are discussed.

Comparing the health of non-binary and binary transgender adults in a statewide non-probability sample

BACKGROUND

In the U.S., non-binary refers to transgender people who have a gender identity not aligned with their assigned sex at birth, and who identify outside of the traditional male-female binary, such as genderqueer, genderfluid, or gender nonconforming. Few data are available to characterize the health of non-binary adults.

METHODS

The current study sought to fill this gap by conducting a secondary analysis of data from a non-probability sample of transgender and/or gender nonconforming adults in Massachusetts (sample mean age 32.6 years, 63% female assigned sex at birth; 79.4% white non-Hispanic/Latinx). Multivariable models were fit to compare non-binary (e.g., genderqueer) vs. binary (e.g., man/trans man, woman/trans woman) respondents across a range of social and health indicators.

RESULTS

Overall, 40.9% identified their gender identity as non-binary. Non-binary respondents significantly differed from binary respondents on (all p<0.05): demographics (younger age, more female assigned sex at birth); gender affirmation (older age of identity recognition, lower current uptake of and future desires for medical gender affirmation); healthcare utilization (lower rates of being up-to-date in annual wellness visit, less mental healthcare utilization in past year); mental health and substance use (higher past-week depressive distress, higher hazardous alcohol use); social history (more unstably housed, more current students), violence victimization (lower rates of lifetime intimate partner violence), and social support (less family support).

CONCLUSION

Gender diversity, including whether people endorse a binary or non-binary gender identity, is a prevalent and an important aspect of transgender health. Demographic measures of gender identity that include binary and non-binary response options are recommended to inform future research and clinical care.

Adapting Sexual Configurations Theory to Nursing

Lesbian, gay, bisexual, transgender, and queer/questioning people in the United States experience multiple health disparities related to sexual and reproductive health. Attempts to address these disparities have focused on sexual orientation and gender identity rather than on the specific aspects of sexuality that may be more relevant to an individual's health outcomes. This focus is also incongruent with a holistic approach to health and wellness interventions. We propose an adaptation of sexual configurations theory, a psychological theory with which to accurately describe different aspects of sexuality, to better position nurses to address these important disparity issues. We position sexual configurations theory within a contextual framework that incorporates aspects of trauma theory as a new way to evaluate individual sexuality in a holistic nursing context.