Mediation Models of Perceived Medical Heterosexism, Provider–Patient Relationship Quality, and Cervical Cancer Screening in a Community Sample of Sexual Minority Women and Gender Nonbinary Adults

Improving cervical screening rates among sexual minorities: Insights from Aotearoa New Zealand

ISSUE ADDRESSED

Sexual minority women (SMW) experience inequities in health outcomes. The extant literature consistently suggests that SMW are much less likely than their heterosexual peers to engage in cervical screening. Using participant's voices, the focus of this study was to explore the ways in which cervical screening rates for SMW might be improved.

METHODS

An online survey was completed by SMW (N = 177) aged 25-69 based in Aotearoa New Zealand and representing a range of sexual identities, ethnicities, and geographical regions. The analysis presented here was derived from open-ended qualitative responses to a single survey item: What do you think could be done to encourage more SMW (lesbians, wahine takatāpui, bisexual women, etc.) to engage in smear testing?

RESULTS

Analysis of the data generated three main themes around how public health services could encourage more SMW to engage in cervical screening: Inclusive health services, clarity of information, and targeted health promotion.

CONCLUSION

The analysis showed that the inherent heteronormativity among health care professionals and the lack of clear and consistent information specific to SMW may be key factors contributing to lower rates of engagement in screening. SO WHAT?: Given that not engaging in screening is the main risk factor for cervical cancer, it is imperative that active consideration is given to these issues with a view to increasing participation rates among SMW.

Sexual and Reproductive Justice and Health Equity for LGBTQ+ Women

LGBTQ+ women have long been overlooked in sexual and reproductive health research. However, recent research has established that LGBTQ+ women have unique and specific needs that need to be addressed in order to improve effectiveness of sexual health education and practice with this historically and presently underserved population. Informed by a reproductive justice framework coupled with liberation psychology theory, this review discusses the current state of sexual and reproductive health and technologies among LGBTQ+ women. In particular, we focus on a range of HIV prevention and reproductive technologies and their use and promotion, including the internal condom, abortion, oral contraceptives, dapivirine ring, HIV pre-exposure prophylaxis, intrauterine device, and other less studied options, such as the contraceptive sponge. Grounded in an intersectional framing, this review acknowledges the intersecting systems of oppression that affect multiply marginalized women inequitably and disproportionately. A sociohistorical, critical lens is applied to acknowledge the well-documented racist origins of reproductive health technologies and ongoing coercive practices that have led to medical mistrust among marginalized and stigmatized communities, particularly racialized LGBTQ+ women, women with disabilities, and women who are poor or incarcerated. Moreover, we discuss the urgent need to center LGBTQ+ women in research and clinical care, community-engaged health promotion efforts, affirming non-heteronormative sexual health education, and health policies that prioritize autonomy and dismantle structural barriers for this population. We conclude with recommendations and future directions in this area to remedy entrenched disparities in health.

Relationships Among Determinants of Health, Cancer Screening Participation, and Sexual Minority Identity: A Systematic Review

Purpose: To address cancer screening disparities and reduce cancer risk among sexual minority (SM) groups, this review identifies individual, interpersonal, and community/societal determinants of cancer screening (non)participation among differing SM identities. Methods: Seven scientific databases were searched. Inclusion criteria were as follows: (1) used quantitative methods; (2) English language; (3) cancer screening focus; and (4) at least one SM group identified. Articles were excluded if: (1) analysis was not disaggregated by SM identity (n = 29) and (2) quantitative analysis excluded determinants of cancer screening (n = 19). The Sexual and Gender Minority Health Disparities Research Framework guided literature synthesis. Results: Twelve studies addressed cervical (n = 4), breast (n = 3), breast/cervical (n = 3), or multiple cancers (n = 2). Other cancers were excluded due to inclusion/exclusion criteria. The total sample was 20,622 (mean 1525), including lesbian (n = 13,409), bisexual (n = 4442), gay (n = 1386), mostly heterosexual (n = 1302), and queer (n = 83) identities. Studies analyzing individual-level determinants (n = 8) found that socioeconomic status affected cervical, but not breast, cancer screening among lesbian and bisexual participants (n = 2). At the interpersonal level (n = 7), provider-patient relationship was a determinant of cervical cancer screening among lesbian participants (n = 4); a relationship not studied for other groups. Studies analyzing community/societal determinants (n = 5) found that rurality potentially affected cervical cancer screening among lesbian, but not bisexual people (n = 3). Conclusions: This review identified socioeconomic status, provider-patient relationship, and rurality as determinants affecting cancer screening among SM people. While literature addresses diverse SM groups, inclusion/exclusion criteria identified studies addressing cisgender women. Addressing disparities in the identified determinants of cervical cancer screening may improve participation among SM women. Further research is needed to understand determinants of cancer screening unique to other SM groups.

Are women-who-have-sex-with-women an 'at-risk' group for cervical cancer? An exploratory study of women in Aotearoa New Zealand

BACKGROUND

International research consistently indicates that women-who-have-sex-with-women (WSW) are less likely to engage in cervical screening than heterosexual women. In the main, studies have explored rates of engagement and highlighted some reasons for non-engagement. This study extends on this work by exploring perceptions among sexual minority women (WSW) for lower rates of engagement among WSW more generally and is the first study on this topic undertaken in Aotearoa New Zealand.

METHODS

A sample of 177 self-identified WSW domiciled in New Zealand completed an online survey about their engagement in cervical screening, reasons for engaging (or not) in cervical screening, and perceptions of why SMW might be less likely to engage in cervical screening.

RESULTS

Fewer than half of participants had engaged in cervical screening every 3years as recommended, with women who had only ever had sex with other women being significantly less likely to have engaged in screening. A lack of clear information about risk relative to sexual history, heteronormativity, and the invasive nature of screening were the dominant reasons for lower engagement among WSW.

CONCLUSIONS

A legacy of misinformation, and endemic heteronormativity in public health messaging around cervical screening is a significant barrier to engagement in screening for WSW. To increase engagement in screening among WSW, public health information needs to specifically address the needs of WSW.

A Scoping Review of Emerging COVID-19 Health Communication Research in Communication and Media Journals

This article reports a scoping review of emerging research on COVID-19 health communication. We reviewed and analyzed 206 articles published in 40 peer-reviewed communication journals between January 2020 to April 2021. Our review identified key study characteristics and overall themes and trends in this rapidly expanding field of research. Our review of health communication scholarship during the early stages of the COVID-19 pandemic suggests that health communication scholars have risen to the challenges and interrogated important issues in COVID-19 communication at the individual, group, organizational, and societal levels. We identified important gaps that warrant future research attention including experimental research that seeks to test the causal effects of communication, studies that evaluate communication interventions in under-served populations, research on mental health challenges imposed by the pandemic, and investigations on the promise of emerging communication technologies for supporting pandemic mitigation efforts.

Toward Cognitive-Behavioral Therapy for Sexual Minority Women: Voices From Stakeholders and Community Members

Sexual minority women (SMW) experience an elevated risk of mental health problems compared to heterosexual women. However, knowledge gaps remain regarding whether cognitive-behavioral therapy (CBT) interventions meet SMW's mental health needs. Further, virtually no studies have integrated stakeholder (i.e., researchers with content expertise in SMW's health and clinical providers who work with SMW) and community member (i.e., SMW) perspectives to identify CBT approaches that address SMW-specific issues. This study used qualitative data gathered from 39 SMW who reported depression, anxiety, suicidality, and heavy drinking in the past 3 months and 16 content experts and clinical providers to obtain information relevant to enhancing CBT for SMW. In addition, we used thematic analysis to identify themes related to the adaptation and delivery of CBT for SMW. Building on prior literature, this study's findings revealed seven considerations for delivering mental health services to SMW: (1) attending to SMW's diverse gender identities and expressions; (2) focusing on SMW's nonbinary stressors; (3) formulating SMW's gender-based stressors within a feminist framework; (4) applying intersectionality frameworks; (5) incorporating issues of diversity, multiculturalism, and social justice; (6) addressing the role of trauma exposure; and (7) addressing the role of alcohol use in SMW's lives. These considerations are reviewed in terms of their implications for clinical practice, with a focus on enhancing applications of existing CBT interventions, to best respond to the unique needs of this population.

Exploring Factors Affecting Patient-Provider Interactions and Healthcare Engagement Among a Diverse Sample of Women Who Have Sex with Women in New York City

Women who have sex with women (WSW) have lower rates of engagement in health care and preventive screenings than women who have sex exclusively with men. Existing literature provides limited insight into how intersecting and overlapping identities, such as race, ethnicity, sexual orientation, gender identity, and identities related to gender expression, may shape individuals' experiences within health care. We conducted qualitative interviews in New York City with 30 people who identified as women, reported sex with people who identify as women, were age 18-65, and were diverse in race, ethnicity, and sexual orientation and gender identity. The semi-structured questionnaire asked participants about positive and negative healthcare experiences to elicit what could encourage or prevent seeking care, with a focus on provider-related factors. Factors that led to positive healthcare experiences included having a provider who was knowledgeable about LGBTQ experience and health and who affirmed their sexuality, gender identity, and other intersecting identities. Factors that contributed to negative healthcare experiences included poor interactions with providers, and providers' perceived heteronormativity and lack of awareness of WSW healthcare needs. WSW of different races, ethnicities, sexual orientations, and gender identities seek validating healthcare experiences that acknowledge and affirm their identities. We present a visual summary of the main thematic factors that contributed to positive and negative WSW healthcare experiences. Increasing access to care requires training providers on how to engage WSW patients, including WSW of diverse race/ethnicity and gender identity and expression.

The intersection of sexual orientation with race and ethnicity in cervical cancer screening

BACKGROUND

Cervical cancer screening is recommended for those with a cervix who are 21 to 65 years old, with specific timelines being dependent on individual risk. This study compared rates of ever undergoing Papanicolaou (Pap) testing at the intersection of self-reported sexual minority (SM) status and race/ethnicity.

METHODS

Data from the National Health Interview Survey (2015 and 2018) were used to examine cervical cancer screening disparities. Natal females without a history of hysterectomy who were 21 to 65 years old and had reported their sexual orientation and Pap testing history were included. Demographic and health characteristics were summarized with descriptive statistics. To adjust for differences in confounding variables between groups, propensity score-based inverse probability of treatment weighting (IPTW) was performed. IPTW-adjusted multivariable logistic regression models estimated odds of ever undergoing a Pap test by sexual orientation alone and with race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic).

RESULTS

SM persons (n = 877) had significantly reduced odds of ever undergoing Pap testing (odds ratio, 0.54; 95% confidence interval, 0.42-0.70) in comparison with heterosexual persons (n = 17,760). When the intersection of sexual orientation and race/ethnicity was considered, non-Hispanic White SM participants and Hispanic SM participants had reduced odds of ever undergoing Pap testing in comparison with non-Hispanic White heterosexual participants. No significant differences were observed between non-Hispanic White heterosexual participants and participants of non-Hispanic Black SM or Hispanic heterosexual identities.

CONCLUSIONS

SM participants were significantly less likely to have ever undergone a Pap test in comparison with heterosexual participants, with Hispanic SM participants having the lowest uptake. Future studies should further examine the roles of systemic discrimination and other key drivers of these disparities.

Prevalence of Chronic Pelvic Pain by Sexual Orientation in a Large Cohort of Young Women in the United States

BACKGROUND

Sexual minority (lesbian, bisexual, mostly heterosexual) young women face many sexual and reproductive health disparities, but there is scant information on their experiences of chronic pelvic pain, including an absence of information on prevalence, treatment, and outcomes.

AIM

The purpose of this study was to describe the characteristics of chronic pelvic pain experiences of young women by sexual orientation identity and gender of sexual partners.

METHODS

The analytical sample consisted of a nationwide sample of 6,150 U.S. young women (mean age = 23 years) from the Growing Up Today Study who completed cross-sectional questionnaires from 1996 to 2007.

OUTCOMES

Age-adjusted regression analyses were used to examine groups categorized by sexual orientation identity (completely heterosexual [ref.], mostly heterosexual, bisexual, lesbian) and gender of sexual partner (only men [ref.], no partners, both men, and women). We examined differences in lifetime and past-year chronic pelvic pain symptoms, diagnosis, treatment, and quality of life outcomes. Sensitivity analyses also examined the role of pelvic/gynecologic exam history and hormonal contraceptive use as potential effect modifiers.

RESULTS

Around half of all women reported ever experiencing chronic pelvic pain, among whom nearly 90% had past-year chronic pelvic pain. Compared to completely heterosexual women, there was greater risk of lifetime chronic pelvic pain among mostly heterosexual (risk ratio [RR] = 1.30, 95% confidence interval [CI]: 1.22-1.38), bisexual (RR = 1.30, 95% CI: 1.10-1.52), and lesbian (RR = 1.23, 95% CI: 1.00-1.52) young women. Additionally, compared to young women with only past male sexual partners, young women who had both men and women as past sexual partners were more likely to report chronic pelvic pain interfered with their social activities (b = 0.63, 95% CI: 0.25-1.02), work/school (b = 0.55, 95% CI: 0.17-0.93), and sex (b = 0.53, 95% CI: 0.05-1.00).

CLINICAL IMPLICATIONS

Healthcare providers, medical education, and field-wide standards of care should be attentive to the way sexual orientation-based healthcare disparities can manifest into differential prognosis and quality of life outcomes for women with chronic pelvic pain (particularly bisexual women).

STRENGTHS & LIMITATIONS

Our study is the first to examine a variety of chronic pelvic pain outcomes in a nationwide U.S. sample across different outcomes (ie, past-year and lifetime). Though limited by sample homogeneity in terms of age, race, ethnicity, and gender, findings from this article provide foundational insights about chronic pelvic pain experiences of sexual minority young women.

CONCLUSION

Our key finding is that sexual minority women were commonly affected by chronic pelvic pain, and bisexual women face pain-related quality of life disparities. Tabaac AR, Chwa C, Sutter ME, et al. Prevalence of Chronic Pelvic Pain by Sexual Orientation in a Large Cohort of Young Women in the United States. J Sex Med 2022;19:1012-1023.

The interaction of sexual orientation and provider-patient communication on sexual and reproductive health in a sample of U.S. women of diverse sexual orientations

OBJECTIVE

Our goal was to examine associations among provider-patient communication, past-year contraceptive use and lifetime sexually transmitted infection.

METHODS

Data were analyzed cross-sectionally from 22,554 women in the Growing Up Today Study and Nurses' Health Study 3 between the follow-up period of 1996-2020. We used multivariable Poisson regression models adjusted for race/ethnicity, age in years, study cohort, and region of residence to obtain risk ratio (RR) associations and 95% confidence intervals (CI).

RESULTS

Provider-patient communication was associated with higher likelihood of using all methods of past-year contraceptive use (RRs ranging from 1.11 to 1.63) and lifetime STI diagnosis (RRs ranging from 1.18 to 1.96). Completely heterosexual women with no same-sex partners (referent) were 13% more likely than lesbians and 4% less likely than other groups to report a provider ever discussed their SRH. Significant interactions emerged between sexual minority status and provider-patient communication. Sexual minority women whose providers discussed their SRH were less likely to report contraceptive non-use in the past year (p < .0001).

CONCLUSION

Provider-patient communication may benefit sexual minority women's contraceptive practices and engagement with STI testing.

PRACTICE IMPLICATIONS

Differences in provider-patient SRH discussion by sexual orientation indicate lesbian women are not receiving the same attention in clinical encounters.

Cross-sectional study of psychosocial well-being among lesbian, gay, bisexual, and heterosexual gynecologic cancer survivors

Background

Delays in care and increased risk for mental health diagnoses put individuals identifying as a sexual minority with cancer at risk for decreased quality of life.

Aim

To assess psychosocial health among sexual minority gynecologic cancer survivors, we compared self‐reported quality of life and psychosocial measures between individuals diagnosed with gynecologic cancers identifying as lesbian/gay/bisexual (LGB) and heterosexual.

Methods and Results

English‐speaking adults with gynecologic cancers were invited to participate in an ongoing cohort survey study. Quality of life and psychosocial measures included the Functional Assessment of Cancer Therapy‐General, Distress Thermometer (distress), Patient Health Questionnaire‐8 (depression), General Anxiety Disorder‐7 (anxiety), and Post‐traumatic Stress Disorder Checklist for DSM‐5 (post‐traumatic stress disorder; PTSD). Measures were compared by self‐reported sexual orientation (heterosexual vs. LGB) using descriptive statistics (frequencies and means) and linear and logistic regression models, adjusting for college education.

Of 814 patients invited, 457 enrolled (56.1%) and 401 (92.6%) completed the survey and provided information on their sexuality. All but one self‐identified as cisgender women and 22 (5.5%) as LGB. LGB participants were more likely to have completed college (68.2% vs. 40.1%, p = .009) but were otherwise similar across demographic and clinical characteristics. Quality of life and distress scores were similar between groups. LGB participants, compared to heterosexual, reported higher rates of depression (31.8% vs. 10.6%, adjusted odds ratio [OR] = 4.1 [95% confidence interval [CI]: 1.6–11.0], p = .004), anxiety (25.0% vs. 7.1%, adjusted OR = 5.4 [95% CI: 1.7–16.7], p= .004), and PTSD (13.6% vs. 3.5%, adjusted OR = 4.2 [95% CI: 1.1–16.3], p = .04).

Conclusion

LGB participants reported poorer emotional health following a gynecologic cancer diagnosis than heterosexual participants. Our data suggest this population may need additional resources and support during and after their cancer diagnosis. Future work is needed to identify additional risk factors and the underlying sources of these disparities in order to improve patient care and wellness in this population.

Qualitative socioecological factors of cervical cancer screening use among transgender men

•

Attendance to cervical cancer screening is related to gender identity development.

•

Provider attitudes are critical to improving cancer screening for transgender men.

•

Healthcare public physical spaces can promote cancer screening for transgender men.

Lack of attendance to cervical cancer screening (CCS) services is the most attributable factor to the development of cervical cancer. Transgender men, individuals whose gender identity does match with their natal female sex, use CCS less often than the general female population. The underlying reasons for deficient CCS among transgender men relate mostly to their stigmatized identity, such as discrimination and unwelcoming healthcare environments. However, additional research is needed to expand our understanding of this complex issue. This exploratory qualitative research study aimed to identify the determinants of CCS from the perspective of transgender men. Twenty transgender men ages 21–65 were conveniently sampled to participate in a semi-structured interview in 2018. The data were analyzed using a deductive-inductive content analysis approach and the results were sorted into a socioecological framework (SEM). The participants were mostly non-Hispanic and white. The mean age was 33, and 55% of the sample had attended CCS in the last three years. Eight overarching factors were identified in the data. Each factor included descriptive sub-factors. At the institutional and interpersonal SEM levels, factors related to healthcare providers and healthcare organizations. At the individual level, factors related to past negative experiences, gender identity development, and socioeconomic status. To the investigators’ knowledge, this is the first study to report the relationship between gender identity development and CCS behaviors. Gender identity development refers to the transition or coming-out process and gender dysphoria. This suggests that attendance to CCS services change as a transgender person’s identity evolves.

Sexual orientation inequalities during provider-patient interactions in provider encouragement of sexual and reproductive health care

The human papillomavirus (HPV) vaccination, sexually transmitted infection (STI) tests, and Papanicolaou (Pap) testing rates vary by sexual orientation, which may be due in part to healthcare providers (HCP) recommending this care unevenly. Data (N = 17,675) came from the Growing Up Today Study (GUTS) (N = 8039) and Nurses' Health Study 3 (NHS3) (N = 9636). Among participants who met clinical guidelines to receive the care in question, we estimated the probability of an HCP encouraging participants to have the HPV vaccination, STI tests, or Pap test. Regardless of sexual orientation, participants whose HCP knew their sexual orientation were more likely to have been encouraged to get care compared to those whose HCP did not know the participant's sexual orientation. Sexual minority men and women were more likely to be encouraged to obtain HPV vaccination, STI tests, and Pap test than same-gender, completely heterosexuals with no same-sex partners, with some variation by gender and the care in question. Lesbian women were the sole sexual orientation subgroup that was less likely to be encouraged to receive care (HPV vaccination and Pap test) than their same gender, completely heterosexual counterparts with no same-sex partners (odds ratio [95% confidence interval]: 0.90 [0.80-1.00] and 0.94 [0.91-0.98], respectively). The differences across sexual orientation in HCPs' encouragement of care indicate a possible explanation for differences in utilization across sexual orientation. Across the US, HCPs under-encourage HPV vaccination, STI tests, and Pap test for all sexual orientation groups. Lesbian patients appear to be at high risk of under-encouragement for the Pap test.