An Interdisciplinary Approach to Lesbian, Gay, Bisexual, and Transgender Clinical Competence, Professional Training, and Ethical Care: Introduction to the Special Issue

Sexual Orientation-Specific Policies Are Associated With Prenatal Care Use in the First Trimester Among Sexual Minority Women: Results From a Prospective Cohort Study

BACKGROUND

Previous research has shown sexual minority women (SMW) are more likely to report multiple maternal and infant health outcomes compared to heterosexual women and that these outcomes are moderated by the policy environment. Little is known, however, about prenatal care use disparities or the social determinants of prenatal care use for SMW.

PURPOSE

To examine the relationship between sexual orientation-specific policies that confer legal protections (e.g., hate crime protections, housing discrimination, same-sex marriage) and prenatal care use among women using a prospective, population-based data set.

METHODS

Using the National Longitudinal Study of Adolescent to Adult Health and logistic regression, we link measures of state policies to the use of prenatal care in the first trimester among women who had live births. The use of prospective data allows us to adjust for covariates associated with preconception care use prior to pregnancy (n = 586 singleton births to SMW; n = 4,539 singleton births to heterosexual women).

RESULTS

Sexual orientation-specific policies that conferred protections were associated with increased use of prenatal care among pregnancies reported by SMW (OR = 1.86, 95% CI 1.16, 2.96). In fact, in states with zero protections, we found no differences in prenatal care use by sexual minority status; however, in states with two or more protective policies, SMW were more likely to access prenatal care in the first trimester than heterosexual women. There was no relationship between sexual orientation-specific policy environments and prenatal care use among pregnancies reported by heterosexual women.

CONCLUSIONS

Recent research has documented that SMW are more likely to have adverse perinatal and obstetrical outcomes than their heterosexual peers. These findings suggest that Lesbian/Gay/Bisexual-specific policy protections may facilitate the use of prenatal care among SMW, a potentially important pathway to improve reproductive health among this population.

Lesbian, gay, bisexual, and transgender clinical competence of physiotherapy students in Israel

BACKGROUND

Clinical competence encompasses attitudes, skills, and knowledge regarding diverse client groups. Appropriate clinical competence requires an understanding of the cultural context in which healthcare is delivered. In conservative countries such as Israel, there is a noticeable scarcity of information regarding the clinical competency of physiotherapy students (PTSs) in effectively treating lesbian, gay, bisexual and transgender (LGBT) individuals. The objective of this study was to assess the level of LGBT clinical competence among PTSs in Israel.

METHODS

Conducted through an anonymous online self-report survey, this study gathered personal and academic background information and self-reported data on previous LGBT education during undergraduate studies of PTSs. It utilized the Hebrew version of the Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS) questionnaire. Descriptive statistics were computed for all outcome measures. The internal reliability of the LGBT-DOCSS was assessed. Total scores of the LGBT-DOCSS, along with scores in each of the three subscales (clinical preparedness, knowledge, and attitudes), were compared across different levels of religiosity and gender.

RESULTS

The sample comprised of 251 PTSs, with an average age of 25.57 ± 3.07 years (34.7% men, 65.3% women). All students reported a lack of LGBT community-related courses during their undergraduate studies. The translated Hebrew version demonstrated good internal consistency, with Cronbach's alpha ranging from 0.65 to 0.83. The LGBT-DOCSS total score was 4.55 ± 0.61 out of 7, indicating a low level of clinical competency. The highest mean score was in the attitudes subscale (6.55 ± 0.87), which was significantly higher than the scores for the knowledge subscale (3.14 ± 1.46) and clinical preparedness subscale (3.36 ± 0.86). Religiousness was significantly associated with clinical preparedness and attitudes. Men exhibited higher self-reported levels of knowledge and clinical preparedness, albeit with more negative attitudes compare to women. Sexual orientation was significantly associated with clinical competency, with PTSs who identified as heterosexual demonstrating a lower level of clinical competency compared to participants who identified as non-heterosexual.

CONCLUSIONS

In Israel, PTSs demonstrated a low level of clinical competency in terms of self-reported knowledge and self-reported clinical preparedness but contrasting positive attitudes toward the LGBT community. Religiousness, gender and sexual orientation had a significant influence on competency levels.These preliminary findings highlight the urgent necessity to enhance the knowledge of PTSs regarding the LGBT community to improve their clinical competence.

TRIAL REGISTRATION NR

Not applicable.

Lesbian, gay, bisexual, transgender, and queer health-related educational experiences in undergraduate medical curricula among Thai medical schools (LEAD-IN)

PURPOSE

In Thailand, Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) individuals face significant health disparities and discrimination in healthcare. A primary cause is the lack of knowledge among doctors and their negative attitudes towards LGBTQ people. The purpose of this study was to explore the current undergraduate medical curricula of medical schools in Thailand concerning learning outcomes, contents, teaching and learning methods, and assessment methods in the field of LGBTQ health. It also sought to gather opinions from principal stakeholders in curriculum development.

METHODS

The authors employed a mixed-methods approach with a convergent design to conduct the research. Quantitative data were collected from 23 deputy deans of educational affairs using a standardized interview form, and qualitative data were obtained through in-depth interviews with key stakeholders including 16 LGBTQ healthcare receivers, 22 medical students, and three medical teachers. Both datasets were analyzed simultaneously to ensure consistency.

RESULTS

The findings indicate that none of the medical schools had established learning objectives related to LGBTQ healthcare within their curricula. Of the institutions surveyed, 8 out of 15 (53.3%) offered some form of teaching on this topic, aligning with the qualitative data which showed 7 out of 17 institutions (41.2%) provided such education. The most frequently covered topics were gender identity and sexual orientation. Lectures were the predominant teaching method, while multiple-choice questions were the most common assessment format. There was a unanimous agreement among all principal stakeholders on the necessity of integrating LGBTQ healthcare into the M.D. program and the professional standards governed by the Thai Medical Council.

CONCLUSIONS

Although some Thai medical schools have begun to incorporate LGBTQ health into their curricula, the approach does not fully address the actual health issues faced by LGBTQ individuals. Future teaching should emphasize fostering positive attitudes towards LGBTQ people and enhancing communication skills, rather than focusing solely on the cognitive aspects of terminology. Importantly, medical educators should serve as role models in providing competent and compassionate care for LGBTQ patients.

Spiritual support of transgender individuals: a literature review

Spiritual support has been a staple of healthcare before hospitals in western civilizations were established by communities of faith. Research has demonstrated that wellbeing is associated with balanced care for the body, mind, and spirit. Healthcare disparities are being identified as disproportionally impacting transgender and gender nonconforming (TGNC) individuals. The root cause of this disparity is being studied as are medical and wellbeing interventions, including the benefit of spiritual support. This author's objective was two-fold. First, to identify opportunities for extending spiritual support to TGNC individuals in healthcare by chaplains. Secondly, to identify evidence of current spiritual support advocacy initiatives and interventions for TGNC patients in healthcare by chaplains.

Measuring the attitudes of midwives toward sexual and gender minority clients: Results from a Cross-Sectional survey in Ontario

BACKGROUND

In Canada, Ontario midwives provide care to sexual and gender minority (SGM) people. Published literature shows how midwives' attitudes shape the experiences of lesbians, but research examining midwives' attitudes toward SGM people is lacking. Our study measured the attitudes of Ontario midwives toward SGM clients, hypothesizing that attitudes would be positive overall and that there would be no difference in attitudes across practice settings.

METHODS

Paper surveys (n = 926) with an option to respond online were sent to Ontario midwifery practices. We measured midwives' attitudes toward sexual minorities (11 questions, scores ranged from 11 to 55) and gender minorities (9 questions, scores ranged from 9 to 45), with higher scores indicating more positive attitudes. Overall and subgroup analyses were performed.

RESULTS

The 268 completed surveys indicated that midwives' attitudes were positive toward both sexual (mean score 49.2, maximum possible score of 55, ie, 89.4%) and gender minorities (mean score 38.9, maximum possible score of 45, ie, 86.4%). Analyses showed that attitudes toward SGM were associated with midwives' sexual identity and route of entry into the profession (ie, university-based vs bridging programs), but not practice setting.

CONCLUSIONS

Although attitudes of this subset of midwives toward SGM clients were positive, volunteer bias could account for this finding since 32.6% of respondents identified as sexual minorities. Since the attitudes of midwives who entered the profession through the university-based education program were significantly more positive than those who entered through international bridging programs, future research should examine how SGM-related content is integrated into midwifery education and training curricula.

Behavioral Health Provider Attitudes and Beliefs about Sexuality and Intimacy: Findings from a Mixed Method Design

Recovery-oriented services overlook a crucial health domain for persons with severe mental illnesses (SMI): sexuality and intimacy. Though this aspect of social recovery correlates with improved life quality and treatment outcomes, behavioral health (BH) providers avoid such topics. The study's purpose was to obtain an updated snapshot of their attitudes and beliefs about sexuality and intimacy communication. Utilizing a community advisory board, we adapted the Sexual Attitudes and Beliefs Survey (SABS) and distributed it via survey link to a national listserv. We used independent samples t-tests to examine differences on SABS mean scores by gender, age group, educational attainment, and previous training on sexuality and intimacy. We asked open-ended questions and coded responses using content analysis. Participants with more education and previous exposure to training on sexuality and intimacy were more likely to hold open views on communication. Findings offer directions for addressing this neglected aspect of recovery.

Adolescence and Suicide: Subjective Construction of the Suicidal Process in Young Gay and Lesbian Chileans

The association between suicide risk and sexual minority status can be understood from the perspective of the social determinants of health, an approach that requires the development of culturally sensitive knowledge. The aim of this study was to characterize young gay and lesbian people's subjective construction of their experience of having lived and survived a suicidal process. Qualitative interviews were conducted and analyzed as products based on life events. In the participants' accounts, we identified hostile contexts associated with suicide, trajectories associated with gay/lesbian identification processes, and milestones related to victimization experiences as part of the intentionality and rationality of suicide.

LGBTQIA+ invisibility in nursing anatomy/physiology textbooks

Members of the LGBTQIA+ experience health disparities that are compounded by providers that lack cultural competence, i.e., the skills, attitudes, and knowledge to offer culturally sensitive care. Educational efforts focus on increasing LGBTQIA+ representation across undergraduate nursing curricula and the recruitment and retention of members of this community into nursing programs. However, the ways that classroom materials represent LGBTQIA+ people can perpetuate social norms rather than accurate scientific understandings, thus limiting students' development of cultural competence while also driving LGBTQIA+ students from nursing. This study performs a content analysis for LGBTQIA+ inclusion in four widely adopted undergraduate nursing anatomy/physiology textbooks. We identify specific social beliefs that exclude LGBTQIA+ people and compare the different ways these manifested in each of the four textbooks. We argue that the way these books represent LGBTQIA+ people violate the fundamental ethical principles of nursing. Based on our findings, we challenge educators to consider the impact that language, images, and other classroom materials have on LGBTQIA+ students and all students' ability to develop cultural competence.

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.

Using the Generic Model of Psychotherapy to Develop a Culturally-Sensitive Approach to Psychotherapy With Sexual and Gender Minority Patients

This article discusses how the Generic Model of Psychotherapy (Orlinsky and Howard, 1987) can help to organize the psychotherapy research and the knowledge in the field of psychotherapy for sexual and gender minority patients. The structure that this traditional model provides is a good foundation for research in this field, inasmuch as it stresses macrosocial aspects that determine the provision of psychotherapy and contextualize its outcomes. Each one of the main components offered by the Generic Model of Psychotherapy – Determinants, Processes, and Consequences – are specified for psychotherapy with LGBT patients and are illustrated with a selection of already existing research in the field of sexual minorities; they are also stress areas marked by knowledge gaps that require future developments. In addition, a set of questions are proposed to contribute to new studies, including the clinical implications that can be derived from this model.

Longitudinal effects of psychotherapy with transgender and nonbinary clients: A randomized controlled pilot trial

Minority stress has been determined to contribute to some mental health concerns for transgender, nonbinary, and gender nonconforming individuals, yet little is known regarding interventions to decrease the effects of minority stress. The purpose of this pilot study was to assess the feasibility and relative effectiveness of two interventions developed for work with transgender clients. Transgender individuals (N = 20) were recruited to participate in a randomized controlled trial comparing two psychotherapy interventions for transgender adults seeking psychotherapy for a variety of concerns: (a) transgender affirmative psychotherapy (TA) and (b) Building Awareness of Minority Stressors + Transgender Affirmative psychotherapy. Gender-related stress and resilience were assessed before, immediately after, and 6 months following the intervention; psychological distress and working alliance were assessed at these three time points as well as weekly during the intervention. Feasibility and acceptability of the study and psychotherapy interventions were supported. Exploratory analyses indicate improvement in both groups based on general outcome measures; targeted outcome measures indicate a trend of improvement for internalized stigma and nonaffirmation experiences. Results from this study support further evaluation of both treatment arms in a larger randomized controlled trial. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Enhancing primary care services for diverse sexual and gender minority populations: a developmental study protocol

INTRODUCTION

Compared with heterosexual, cisgender populations, sexual and gender minority (SGM) people are more likely to suffer from serious health conditions and insufficient access to health services. Primary care is at the frontlines of healthcare delivery; yet, few clinics have resources or mechanisms in place to meet SGM patient needs. This developmental study protocol focuses on reducing health disparities among SGM patients by identifying, adapting and developing SGM practice guidelines/recommendations and implementation strategies for primary care clinics in urban and rural New Mexico. Using input from patients, healthcare advocates and providers, and researchers, the study will pilot a practice parameter and implementation toolkit to promote SGM-specific cultural competence at multiple service delivery levels.

METHODS AND ANALYSIS

We will recruit providers/staff from four Federally Qualified Health Centers (FQHCs) serving ethnically and geographically diverse communities. Incorporating the Implementation of Change Model and an intersectionality perspective, data collection includes a systematic review of SGM-specific practice guidelines/recommendations, focus groups and semistructured interviews, quantitative surveys and the Nominal Group Technique (NGT) with providers/staff. We will categorise guidelines/recommendations identified through the review by shared elements, use iterative processes of open and focused coding to analyse qualitative data from focus groups, interviews and the NGT, and apply descriptive statistics to assess survey data. Findings will provide the foundation for the toolkit. Focus groups with SGM patients will yield supplemental information for toolkit refinement. To investigate changes in primary care contexts following the toolkit's pilot, we will undertake systematic walkthroughs and document review at the FQHCs, analysing these data qualitatively to examine SGM inclusiveness. The structured data-informed Plan-Do-Study-Act method will enable further revision of the toolkit. Finally, focus groups, interviews and quantitative surveys with providers/staff will highlight changes made in the FQHCs to address SGM patient needs, barriers to sustainment of changes, satisfaction, acceptability, usability and feasibility of the toolkit.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Pacific Institute for Research and Evaluation Institutional Review Board. Informed consent will be obtained from all participants before their involvement in research activities begins. Study results will be actively disseminated through peer-reviewed journals, conference presentations, social media and the internet, and community/stakeholder engagement activities.

Impact of a Formative Program on Transgender Healthcare for Nursing Students and Health Professionals. Quasi-Experimental Intervention Study

BACKGROUND

The field of specific healthcare for transgender people has not been included in the official curriculum of professionals. This causes a lack of knowledge that can be presumed to become a barrier to healthcare. Currently, different methodologies are emerging to achieve meaningful learning for students and professionals. The objective of this study was to evaluate the increase in the level of knowledge of final-year nursing students, applying methodological strategies such as problem-based learning (PBL) and film-forum.

METHODS

59 nursing students were randomly assigned to two intervention groups (G1 = 31 and G2 = 28), and another 57 were assigned to the control group (without specific classes or workshops on the subject of the study). The intervention consisted of a specific training course on transgender issues (TGSC&W, TransGender Specific Course and Workshop), where the type of meaningful learning strategy used depended on the group (G1 = film-forum and G2 = PBL). The study was carried out at the Faculty of Nursing Nuestra Señora de Candelaria of the Canary Islands Health Service. The randomization was done by blindly choosing a computer-generated code.

RESULTS

The main outcome was based on 116 participants, comparing their level of knowledge before and after the workshop. The comparison by pairs shows that there were statistically significant differences (p = 0.000) between those undergoing the methodological interventions and the control group. Statistical significance between film-forum and PBL was not obtained (p = 1.000): Both methodologies increased the level of knowledge, but there was no significant difference between them. The means for satisfaction with the learning methodology used did not show statistically significant differences.

CONCLUSION

The workshop carried out was highly effective and significant in terms of increasing knowledge. No significant differences were observed in the level of knowledge, or in the degree of satisfaction, between the two methodologies used (PBL and film-forum).

Learning about culturally humble care of sexual and gender minority patients

Each day, nurses care for patients from diverse cultures and backgrounds, including those who self-identify as lesbian, gay, bisexual, transgender, or queer. To facilitate productive health partnerships, nurses need to be aware of a patient's sexual orientation, gender identity, and expression. Prelicensure nursing students employed cultural humility with the use of a video and a guided discussion. The purpose of this article is to describe teaching strategies that can be used by other nurse educators.

American Academy of Neurology members' preparedness to treat sexual and gender minorities

Objective

To measure the attitudes and knowledge of American Academy of Neurology (AAN) member neurologists in caring for sexual and gender minority (SGM) patients (e.g., those who identify in the lesbian, gay, bisexual, transgender, queer, or questioning [LGBTQ+] spectrum) to inform future educational offerings.

Methods

A questionnaire was created in an iterative process by the LGBTQ+ Survey Task Force, consisting of 21 questions examining self-reported knowledge, attitudes, and clinical preparedness in caring for SGM patients. Participants responded to each statement with a 5-point Likert scale (“strongly disagree” to “strongly agree”). The survey was distributed via electronic and conventional mail to a random, representative sample of 1,000 AAN members.

Results

The response rate was 13.5% (n = 135). Most respondents (60%–66%) were aware of local and national barriers that inhibit SGM individuals from using health care services; the majority (73%–91%) felt comfortable assessing SGM patients. Over half believed sexual orientation (SO) and gender identity (GI) to be social determinants of health (61% and 57%, respectively). Yet a third would not tailor neurologic care based on a patient's SGM identity, and 43% believed that SO/GI has no bearing on the management of neurologic illness.

Conclusions

Most neurologists surveyed were aware of overarching barriers to care experienced by SGM individuals; however, a minority of respondents recognized the intersection of SGM identity with neurologic health. Our results highlight awareness gaps that could be addressed via targeted educational opportunities, ensuring that neurologists provide high-quality neurologic care to patients of all sexual orientations and gender identities.

Increasing cultural competence with LGBTQ patients

Many nurses practicing today lack basic education about LGBTQ (lesbian, gay, bisexual, transgender, queer) patient care. How can they better prepare to care for this population? This article provides insight on LGBTQ people, their health risks and disparities, and how nurses can work with LGBTQ patients to improve outcomes.