Health Care Experiences of Patients with Nonbinary Gender Identities

Evaluation of Gender-Identity Inclusive Language Used in U.S. Hospital Breastfeeding Education Materials

Purpose: To assess the use of gender-identity inclusive language in breastfeeding education materials publicly available on U.S. Hospital websites. Methods: Hospitals were identified through the American College of Obstetricians and Gynecologists website. Breastfeeding education materials were searched online at each hospital. The first breastfeeding material on each website was used for our evaluation. Gender-identity inclusive versus traditional sexed language terms were curated a priori by referencing the National Institutes of Health and American Psychological Associations' guidelines. Education materials were categorized into: (1) "gender-identity inclusive language," (2) "mix of inclusive and traditional sexed language," or (3) "traditional sexed language." Frequencies of the type of language and specific gender-related terms were calculated. Results: In total, n = 112 hospitals with publicly available breastfeeding education materials were included. Most hospitals used both traditional sexed and inclusive language (69%, n = 77), followed by only traditional language (31%, n = 35). None of the hospitals used solely gender-identity inclusive language. One hospital provided material "intended for LGBTQI+" populations. Conclusion: Education materials provided by hospitals for breastfeeding do not utilize gender-identity inclusive language As such, there remains uncertainty and hesitancy on how to provide appropriate breastfeeding education for all persons who identify as transgender and/or non-binary, yet choose or are able to breastfeed. Further research in this area could ascertain the impacts of using gender-identity inclusive language in breastfeeding education materials for the general, transgender, or non-binary populations.

Healthcare experiences of LGBTQ+ people: non-binary people remain unaffirmed

Introduction

Lesbian, gay, bisexual, transgender, queer, and all sexually and gender diverse (LGBTQ+) people experience discrimination across many contexts, including healthcare environments. While some research has shown transgender people and non-binary people often endure higher rates of marginalization than cisgender, sexually diverse people, past data are limited.

Methods

A sample of LGBTQ+ people (N = 173) in the United States completed an anonymous, online, self-reported survey, which included the Consumer Assessment of Healthcare Providers and Systems and healthcare experience questions. Groups, including people who identified as cisgender, sexually diverse (n = 116), transgender (n = 24), and non-binary (n = 33), were compared using chi-square and multivariate analysis of covariance tests.

Results

Compared to cisgender, sexually diverse people, non-binary people were less likely to report feeling comfortable with a physical exam, having good mental health, respected by providers, that providers had adequate medical information, that providers could care for someone going through gender affirmation, and that hospital staff were comfortable interacting with them. Additionally, non-binary people were more likely to report hospital staff misgendering them.

Discussion

These unique LGBTQ+ subgroup differences may be secondary to identity-specific stigma that non-binary people face. More international studies are needed to elucidate these subgroup-specific healthcare experiences across LGBTQ+ identities.

Identifying Strategies for the Use of Gender and Sex Language in Clinical One-Liners

Purpose: The "one-liner," commonly used in clinical communications, summarizes a patient's identity, presenting condition, medical history, and clinical findings. Imprecise, inconsistent use of gender and sex information in one-liners threatens the provision of affirming care to transgender, nonbinary, gender-expansive, and intersex patients and may exacerbate health care disparities. This study aimed to generate guidance for communicating gender and sex information in one-liners. Methods: This is an explanatory sequential, equal status mixed methods study of transgender, nonbinary, gender-expansive, and intersex people and clinicians caring for this population. Survey participants rated one-liners on a five-point Likert-type scale of appropriateness, considering affirmation and clinical utility, and provided open-ended comments. We conducted two focus groups with survey respondents to explore survey results and performed a thematic analysis of survey comments and focus group transcripts. Results: Survey respondents included 57 clinicians and 80 nonclinicians. One-liners containing patient pronouns were rated most appropriate, and appropriate patient descriptors included self-described gender identity or gender-neutral terms. In scenarios where patient sex information was not pertinent to the chief concern (CC), one-liners containing no sex information were rated most appropriate. Four themes were identified: inclusion of sex information based on relevance to the CC, accurate patient representation, influence of clinical setting, and risk of harm from inaccurate one-liners. Conclusion: This study generated data to support the appropriate use of gender and sex language in one-liners. Clinicians, educators, and trainees may use these findings to compose one-liners that are affirming and clinically useful for patients of diverse gender and sex identities.

Analysis of Diagnostic Delay and its Impact on Lung Cancer Survival: Results From the Spanish Thoracic Tumor Registry

BACKGROUND

Early detection is crucial to improve lung cancer survival rates. Delays in diagnosis might negatively impact the prognosis of the disease. This study aims to analyze the diagnostic delay in lung cancer patients and describe if there is an association between delay and survival.

METHODS

The data source used was the Thoracic Tumor Registry of the Spanish Lung Cancer Group. This analysis was restricted to lung cancer cases with information on the first date of consultation by symptoms and date of diagnosis. The delay was calculated as the number of days between the two dates. A descriptive analysis was performed, and ordinal logistic regressions were fitted with delay as the dependent variable. Kaplan-Meier survival analysis and Cox regression were performed.

RESULTS

22,755 lung cancer cases were included. Never smokers were 1.16 (95%CI: 1.06-1.27) times more likely to register longer delay than smokers. Stage 0-I-II cases had a 3.09 (95%CI: 2.88-3.32) higher risk of longer delay compared to III-IV stages. Overall, 5-year survival rate after diagnosis was 23.64% (95%CI: 22.88-24.41). In those categorized as having the shortest delay 5-year survival was 17.67% (95%CI: 16.31-19.07) and in the extreme delay it was 32.98% (95%CI: 31.28-34.69) (p<0.001). Adjusted mortality risk was higher in those with the shortest delay (HR 1.36, CI95%: 1.30-1.43) in comparison with the extreme delay.

CONCLUSIONS

Diagnostic delay is short among Spanish lung cancer patients, indicating a relatively quick diagnostic process. Extreme delays appear to be associated with higher survival rates, possibly attributed to slow-growing tumors, earlier stage at diagnosis or basically the natural history of this disease.

Gender- and Sexuality-Minoritised Adolescents in DBT: A Reflexive Thematic Analysis of Minority-Specific Treatment Targets and Experience

Gender- and sexuality-minoritised (GSM) adolescents are at increased risk of self-harm and suicidal behaviours compared to their cisgender and heterosexual peers. This increased risk is thought to be explained in part by exposure to stigma and societal oppression. Dialectical Behaviour Therapy (DBT) is an evidence-based intervention for self-harm and suicidal behaviour that may have advantages for supporting GSM young people in distress. No study has yet sought to understand what GSM-associated difficulties may be important to consider in DBT for adolescents, or the experiences of GSM young people in a standard DBT programme. Therefore, this study aimed to understand the experiences of GSM young people in DBT and what difficulties and dilemmas associated with their gender and sexuality diversity were thought by them to be important to target in DBT. Qualitative interviews were conducted with 14 GSM young people in a comprehensive DBT programme and were analysed using Reflexive Thematic Analysis. The analysis was supported by two further GSM young people who had finished DBT. The findings were split into three overarching themes (Identity, Impact of Others, and Space for Sexual and Gender Identity in DBT), each with themes within. The identity-based theme included "identity confusion and acceptance"; the relationship-based themes included "cis-Heterosexism" and "community connectedness"; and the space within DBT themes included "negotiating focus and targeting in DBT" and "creating safety in DBT". Findings are discussed in relation to implications and recommendations for therapists working with GSM young people within and outside of DBT.

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.

Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy

Importance

There has been increasing legislative interest in regulating gender-affirming surgery, in part due to the concern about decisional regret. The regret rate following gender-affirming surgery is thought to be approximately 1%; however, previous studies relied heavily on ad hoc instruments.

Objective

To evaluate long-term decisional regret and satisfaction with decision using validated instruments following gender-affirming mastectomy.

Design, Setting, and Participants

For this cross-sectional study, a survey of patient-reported outcomes was sent between February 1 and July 31, 2022, to patients who had undergone gender-affirming mastectomy at a US tertiary referral center between January 1, 1990, and February 29, 2020.

Exposure

Decisional regret and satisfaction with decision to undergo gender-affirming mastectomy.

Main Outcomes and Measures

Long-term patient-reported outcomes, including the Holmes-Rovner Satisfaction With Decision scale, the Decision Regret Scale, and demographic characteristics, were collected. Additional information was collected via medical record review. Descriptive statistics and univariable analysis using Fisher exact and Wilcoxon rank sum tests were performed to compare responders and nonresponders.

Results

A total of 235 patients were deemed eligible for the study, and 139 responded (59.1% response rate). Median age at the time of surgery was 27.1 (IQR, 23.0-33.4) years for responders and 26.4 (IQR, 23.1-32.7) years for nonresponders. Nonresponders (n = 96) had a longer postoperative follow-up period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] vs 3.6 [IQR, 2.7-5.3] years, respectively; P = .002). Nonresponders vs responders also had lower rates of depression (42 [44%] vs 94 [68%]; P < .001) and anxiety (42 [44%] vs 97 [70%]; P < .001). No responders or nonresponders requested or underwent a reversal procedure. The median Satisfaction With Decision Scale score was 5.0 (IQR, 5.0-5.0) on a 5-point scale, with higher scores noting higher satisfaction. The median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) on a 100-point scale, with lower scores noting lower levels of regret. A univariable regression analysis could not be performed to identify characteristics associated with low satisfaction with decision or high decisional regret due to the lack of variation in these responses.

Conclusions and Relevance

In this cross-sectional survey study, the results of validated survey instruments indicated low rates of decisional regret and high levels of satisfaction with decision following gender-affirming mastectomy. The lack of dissatisfaction and regret impeded the ability to perform a more complex statistical analysis, highlighting the need for condition-specific instruments to assess decisional regret and satisfaction with decision following gender-affirming surgery.

"Entre Nosotras:" a qualitative study of a peer-led PrEP project for transgender latinas

BACKGROUND

Uptake of HIV pre-exposure prophylaxis (PrEP) remains low among transgender people as compared to other subgroups, despite high rates of HIV acquisition. In California, Latinx people comprise 40% of the population and Latina transgender women experience some of the highest burden of HIV of any subgroup, indicating a critical need for appropriate services. With funding from the California HIV/AIDS Research Programs, this academic-community partnership developed, implemented, and evaluated a PrEP project that co-located HIV services with gender affirming care in a Federally Qualified Heath Center (FQHC). Trans and Latinx staff led intervention adaptation and activities.

METHODS

This paper engages qualitative methods to describe how a PrEP demonstration project- Triunfo- successfully engaged Spanish-speaking transgender Latinas in services. We conducted 13 in-depth interviews with project participants and five interviews with providers and clinic staff. Interviews were conducted in Spanish or English. We conducted six months of ethnographic observation of intervention activities and recorded field notes. We conducted thematic analysis.

RESULTS

Beneficial elements of the intervention centered around three intertwined themes: creating trusted space, providing comprehensive patient navigation, and offering social support "entre nosotras" ("between us women/girls"). The combination of these factors contributed to the intervention's success supporting participants to initiate and persist on PrEP, many of whom had previously never received healthcare. Participants shared past experiences with transphobia and concerns around discrimination in a healthcare setting. Developing trust proved foundational to making participants feel welcome and "en casa/ at home" in the healthcare setting, which began from the moment participants entered the clinic and continued throughout their interactions with staff and providers. A gender affirming, bilingual clinician and peer health educators (PHE) played a critical part in intervention development, participant recruitment, and patient navigation.

CONCLUSIONS

Our research adds nuance to the existing literature on peer support services and navigation by profiling the multifaced roles that PHE served for participants. PHE proved instrumental to empowering participants to overcome structural and other barriers to healthcare, successfully engaging a group who previously avoided healthcare in clinical settings.

MDMA-assisted psychotherapy; Inclusion of transgender and gender diverse people in the frontiers of PTSD treatment trials

Introduction

Transgender and gender diverse (TGD) people experience stigma, discrimination, trauma, and post-traumatic stress disorder (PTSD) at higher rates compared to the general population; however, TGD people have been underrepresented in PTSD research. Clinical trials of 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy demonstrate promising safety and efficacy for the treatment of PTSD. Issues related to equitable access, power imbalances in the therapeutic relationship, and vulnerable states of consciousness occasioned by MDMA are magnified when working with people affected by structural vulnerabilities and health disparities, and community engagement in research planning and implementation is essential. To inform the inclusion and safety of TGD people in future MDMA-assisted psychotherapy research, the aims of the current study were to: characterize TGD experiences with trauma-related mental health care, assess openness of TGD people to participate in experimental PTSD research, and to gather specific feedback on protocol design for conducting MDMA-assisted psychotherapy with TGD people.

Materials and methods

We conducted three virtual focus group discussions (FGDs) with 5-6 participants each (N = 17). Eligible TGD participants had a history of receiving trauma-related mental health care. Each FGD was facilitated by two licensed clinicians who identified as TGD. Qualitative data analysis was conducted via an iterative process of identification of recurrent patterns and themes.

Results

We have identified several key issues TGD people face when seeking and engaging in trauma-related mental health care, including barriers to receiving adequate gender-affirming and trauma-informed mental health care and frustration with providers lacking cultural humility. Suggested amendments to MDMA-assisted psychotherapy protocols include: routine collection of trans-inclusive gender identity data, implementing an explicit gender-affirming treatment approach, ensuring a culturally safe setting, and diversifying co-therapy dyads.

Discussion

The inclusion of TGD voices in early conversations about emerging experimental PTSD interventions promotes equitable access, in the context of health and healthcare disparities, and helps researchers understand the needs of the community and tailor research to meet those needs. Through an ongoing conversation with the TGD community, we aim to incorporate a gender-affirming approach into existing research protocols and inform future applications of MDMA-assisted psychotherapy in addressing the effects of minority stress and boosting resilience.

Care across the gender spectrum: A transgender health curriculum in the Obstetrics and Gynecology clerkship

BACKGROUND

A lack of undergraduate medical curricula on providing healthcare to transgender and gender diverse (TGD) patients has contributed to significant health disparities for TGD communities. To address this gap, we designed and evaluated a novel curriculum to train Obstetrics and Gynecology (OB/GYN) clerkship students in caring for TGD patients.

METHODS

Following Kern's 6-step method for curriculum development, we created a two-part curriculum on TGD healthcare topics - an online module on gender-affirming care, followed by a series of interactive cases on TGD-specific health topics. Undergraduate medical students completing their core OB/GYN clerkships at a university academic medical center (January-December 2021) were invited to complete this curriculum. Participants completed pre/post assessment surveys to assess their experience caring for TGD patients, as well as a scored knowledge assessment before and after completing the curriculum.

RESULTS

Sixty-five students participated in this curricular assessment. Prior to completing the module, 45% agreed that they had received adequate TGD health training. Following module completion, students reported increased comfort in caring for transgender patients (49.2% vs. 81.5%; p < .001) and endorsed an improved fund of knowledge of both healthcare maintenance for TGD patients (61.5% vs. 100%; p < .001) and gender affirming medical therapies (60.0% vs. 96.9%; p < .001). Knowledge scores increased from a mean of 9.65 (1.81) to 12.5 (2.20) out of 15 (p < .001). In post-assessment surveys, 95% of participants agreed that the module was helpful for their learning. Qualitatively, students suggested longitudinal integration of TGD-topics into the pre-clinical curriculum, and expanded opportunities to practice patient counseling.

CONCLUSION

The findings of this study support the need for student education on TGD health. Integration of interactive, case-based TGD-care curricula into clinical training may increase medical students' knowledge and comfort in caring for TGD patients. Ongoing efforts to integrate TGD health training into undergraduate medical student curricula are necessary.

"Truly Listen to Us": Recommendations for Health Professionals to Bolster Wellbeing of Nonbinary Individuals

Trans-affirming providers play significant roles in the health and wellbeing of nonbinary individuals. Yet, healthcare mistreatment is well-documented among gender-diverse patients, leading to clients withholding information and avoiding care for fear of experiencing bias. Concurrently, healthcare providers report feeling ill-equipped to serve nonbinary patients, often perpetuating cisnormative binary attitudes. The literature has established the challenges to accessing healthcare and the need for gender-affirming care. However, little is known about nonbinary people's perspectives on how best to deliver gender-affirming care that is inclusive of nonbinary patients. This participatory action PhotoVoice study identified community member recommendations for healthcare providers to bolster the wellbeing of nonbinary individuals through improved access to gender-affirming healthcare. Data were collected through group discussions, photography, and photo-elicitation interviews. Drawing upon research results, the authors identify recommendations for improving interpersonal care, increasing access to gender-affirming care, and advocating for related environmental and policy changes.

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.