Examining clinicians' experiences providing sexual health services for LGBTQ youth: considering social and structural determinants of health in clinical practice

Acceptability of integrating mental health and substance use care within sexual health services among young sexual and gender minority men in Vancouver, Canada

BACKGROUND

Despite well-established evidence showing that young sexual and gender minority (SGM) men experience disproportionate mental health and substance use inequities, few sexual health services provide mental health and substance use care. This qualitative study examined the experiences and perspectives about integrated care models within sexual health services among young SGM men experiencing mental health and substance use challenges.

METHODS

Semi-structured interviews were conducted with 50 SGM men aged 18-30 years who reported using substances with sex in Vancouver, Canada. Interviews were analyzed using thematic analysis.

RESULTS

Three themes were identified: 1) participants asserted that their sexual health, mental health and substance use-related health needs were interrelated and that not addressing all three concurrently could result in even more negative health outcomes. These concurrent health needs were described as stemming from the oppressive social conditions in which SGM men live. 2) Although sexual health clinics were considered a safe place to discuss sexual health needs, participants reported not being invited by health providers to engage in discussions about their mental health and substance use health-related needs. Participants also perceived how stigmas associated with mental health and substance use limited their ability to express and receive support. 3) Participants identified key characteristics they preferred and wanted within integrated care, including training for health providers on mental health and SGM men's health and connections (e.g., referral processes) between services. Participants also recommended integrating social support programs to help them address SGM-related social challenges.

CONCLUSION

Our findings highlight that SGM men's sexual health, mental health and substance use-related health needs and preferences are interrelated and should be addressed together. Tailored training and resources as well as structural adaptations to improve communication channels and collaborative connections between health providers are required to facilitate the development of integrated care for young SGM men.

Development of best practice guidelines for clinical and community service providers to prevent suicide in LGBTQA+ young people: A Delphi expert consensus study

OBJECTIVE

The aim of this study was to develop best practice guidelines for preventing suicide and reducing suicidal thoughts and behaviours in LGBTQA+ young people (lesbian, gay, bisexual, trans, queer/questioning, asexual, and those of other diverse sexualities and genders) within clinical and community service settings in Australia.

METHODS

We conducted a Delphi expert consensus study. A systematic literature search and interviews with key informants informed an initial 270-item questionnaire. Two expert panels completed the questionnaire, delivered over two rounds: (1) Australian professionals with expertise in LGBTQA+ mental health/suicide prevention and (2) Australian LGBTQA+ young people aged 14-25 with lived experience of suicidal thoughts and/or behaviours. Items endorsed as 'essential' or 'important' by >80% of both expert panels were included in the guidelines.

RESULTS

A total of 115 people participated in the Delphi process; n = 52 professionals completed Round 1, and n = 42 completed Round 2; n = 63 LGBTQA+ young people completed Round 1, and n = 50 completed Round 2. A total of 290 items were included in the guidelines and grouped into: (1) general principles for creating an affirming and inclusive environment for LGBTQA+ young people; (2) assessing suicide risk and working with suicidal LGBTQA+ young people; (3) considerations for specific LGBTQA+ populations; and (4) advocating for LGBTQA+ young people.

CONCLUSION

These guidelines are the first of their kind in Australia. They provide practical support to service providers regardless of prior training in LGBTQ+ identities or mental health, with the aim of reducing suicidal thoughts and behaviours, and preventing suicide, in LGBTQA+ young people.

Whose Role is It Anyway? Sexual Racism and Sexual Positioning Among Young Sexual Minority Black Men

Racialized Sexual Discrimination (RSD), also referred to as "sexual racism," is widely reported among young sexual minority Black men (YSMBM). Though RSD is driven in part by sexual scripts and racial stereotypes, little is known about YSMBM's experiences with RSD with respect to their sexual positioning roles. Using data from a cross-sectional web-survey of YSMBM (N = 726), a multivariate Kruskal Wallis test was conducted comparing YSMBM who identified as mostly bottom, versatile, or mostly top, on the degree to which they were affected by four RSD experiences, as well as the frequency with which they encountered these experiences. Men identifying as mostly bottom reported significantly stronger negative reactions to same-race rejection and encountering sexual role assumptions than men identifying as mostly top. Men identifying as versatile encountered same-race rejection significantly more frequently than men identifying as mostly top. Men identifying as mostly bottom encountered White superiority significantly more frequently than men identifying as mostly top. RSD may impact YSMBM differentially based on sexual position. These findings may have implications for culturally competent clinical practice, as well as analytic implications (e.g., estimating more complex statistical models) for sexual racism research, which remains an important yet underexamined field in the health sciences.

Barriers and Facilitators to Accessing Sexual and Reproductive Health Services Among Transgender People: A Meta-Synthesis

The availability and accessibility of sexual and reproductive health (SRH) services for transgender individuals are crucial. This population is deprived of health care due to rejection, stigma, gender-based discrimination, confidentiality, and violence. This review attempts to provide readers with an account of the fundamental problems that the transgender population faces regarding experiences of SRH. This meta-synthesis review applied the Social-Ecological Model (SEM) to address trans individuals' SRH factors. The databases were searched using "SRH" and "transgender" keywords. Fifty studies were finally selected. All studies were qualitative, including 36 semi-structured/ in-depth interviews, two focus group studies, and 12 interviews and focus group studies. The Social-Ecological Model application illustrates the impact of individual, interpersonal, institutional, and social factors on the condition of SRH among transgender individuals. This meta-synthesis reinforces multiple levels of factors that influence the SRH of transgender individuals. These include limited information, lack of awareness, low socioeconomic status, stigma and discrimination, and social deprivation. Interventions are urgently needed to provide better sexual and reproductive well-being for transgender individuals.

Awareness of LGBTQ+ health disparities: A survey study of complementary integrative health providers

OBJECTIVE

The purpose of this study was to survey awareness of lesbian, gay, bisexual, transgender, queer/questioning, plus health disparities among complementary integrative health providers; chiropractors, naturopaths, acupuncturists, and massage therapists and secondly, examine how providers' sexual and gender identity correlated with that awareness.

METHODS

An electronic survey was designed, which included demographic questions as well as closed-ended and Likert response items to measure provider awareness of LGBTQ+ patients and the health disparities they experience. Kruskal-Wallis H tests with pairwise comparisons were used to evaluate the differences between defined groups and their awareness of health disparities of LGBTQ+ adults and youth.

RESULTS

The survey showed that most complementary integrative health care providers agreed that LGBTQ+ individuals experience discrimination and health disparities. However, providers are unaware of the specific disparities experienced in this population, including increased risk of substance abuse and mental health issues. Pairwise comparison tests demonstrated that providers that identify as a part of the LGBTQ+ community are often more aware of disparities than their heterosexual cisgender counterparts.

CONCLUSION

Complementary integrative health care providers demonstrated some general awareness of LGBTQ+ health disparities yet most providers lacked awareness of specific disparities that pose major health risks for this community. Cultural competency training specific to LGBTQ+ individuals is lacking and may explain some of the findings in this study. This suggests that education is needed, both in professional educational programs and in the health care community by way of conferences, webinars, and other opportunities.

"Oh! How Modern! And... Are You Ok with That?": Consensually Non-Monogamous People's Experiences When Accessing Sexual Health Care

The current research explored consensually non-monogamous peoples' experiences accessing sexual healthcare. Using a mixed method approach, a sample of 67 consensually non-monogamous individuals (48% Polyamorous; 42% Relationship Anarchy/Solo polyamory; 6% Swingers; 4% Uncategorized) reported having significantly lower rates of trust in healthcare professionals compared to standardized scores. Sixty-three percent of participants reported disclosing their relationship status to a clinician when accessing sexual health services, whereas 37% sometimes or never disclosed. Qualitative responses identified that some participants reported a willingness to be open about their relationships, but many chose to "pass" as monogamous to both simplify and streamline their interactions as well as to avoid potential stigma. Participants reported a wide range of experiences with clinicians from those who were accepting and professional, to some who displayed prejudice and withheld treatment. This research outlines some of the experiences and challenges presented to consensual non-monogamists when accessing sexual healthcare as well as providing suggestions for clinicians to help remove some of the barriers to appropriate patient care.

Standardized Patients in Medical Education: A Review of the Literature

The concept of standardized patients (SPs) was first introduced in the 1960s by Dr. Howard Barrows of the University of Southern California and has been applied in medical school education since that time. This practice has allowed medical students to practice skills on live persons who are teachers rather than on real patients, who may be endangered by their emerging skills. Previous studies supported the use of SPs but did not measure whether they improved clinical competence or students' confidence in their skills. This literature review evaluated whether current medical education literature supports or refutes the use of SPs compared to other modalities such as simulated patients (SiPs) and virtual reality (VR) in the improvement of student confidence, clinical performance, and interpersonal communication skills. The research questions posed for this review were as follows: do medical students in their first two years of education who have practiced skills using SPs have more self-confidence in their ability to perform skills on real patients than those students who did not use SPs, do medical students in their third and fourth years of medical school have higher clinical competency with sensitive patient examinations after using SPs in their first two years of medical education than those students who did not use SPs, and do medical students who have used SPs for discussing sensitive issues have better interpersonal skills when they encounter real patients in the clinical setting than those who have not used SPs? The methodology for this descriptive, systematic review of the literature was organized using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart to describe how articles were collected and synthesized to evaluate the variables under study. The results of this study revealed that students learned the most when SPs were used because they were able to teach students the skills that they needed in a safe learning environment. Medical students performing sensitive patient examinations with SPs learned not only how to perform the examinations but also how to improve their communication with patients. Students and residents reported increased confidence and clinical competence when performing new skills with SPs rather than with peer practice, virtual reality, or real patients in a clinical setting. Although the utilization of SPs has been studied in multiple ways and found to be a powerful tool in the education of undergraduate medical students and interns, there is still much study to be done to address the human needs of real patients. Gaps in this literature included small sample sizes, a lack of standardized assessment tools, and the need to include a multidisciplinary approach that addresses cultural awareness and appreciation. The authors found limited studies analyzing the effect the coronavirus disease 2019 (COVID-19) pandemic had on the use of SPs in medical school education. Continued scientific inquiry in post-pandemic medical education is an essential component for dissemination as most schools have reintroduced the use of SPs, which strengthens the concept that their use is superior to the other simulation methods used when SPs were not available.

Interactions Between Health Professionals and Lesbian, Gay and Bisexual Patients in Healthcare Settings: A Systematic Review

The ways in which health professionals (HPs) interact with individuals from sexual minorities can impact their perception of the health service and influence engagement. This systematic literature review aimed to identify and synthesize the qualitative literature exploring interactions between HPs and lesbian, gay and bisexual (LGB) patients in healthcare settings. A search strategy was developed and applied to CINAHL and Medline, inclusion criteria were then applied to results by two screeners with good agreement. Thematic analysis was carried out on papers meeting the inclusion criteria in three stages, beginning with coding the text line-by-line, developing descriptive themes and finally, analytical themes. Electronic searches identified 348 papers with 20 of these meeting the inclusion criteria. Thematic analysis found five themes; HPs' lack of knowledge regarding LGB specific issues, identification of sexual orientation, discomfort in interactions, LGB patients' experience of heteronormative attitudes and perceived judgment or other negative attitudes.

Understanding access to healthcare for gender diverse young people: a critical review of the literature

Gender diverse young people face well-documented physical, mental and sexual health disparities compared to the general population. Differential access to healthcare is a key driver of these inequities and literature highlights high unmet healthcare need among members of this group. Healthcare access has been described through a model that defines five dimensions of health services: approachability; acceptability; availability and accommodation; affordability; and appropriateness; and five abilities of health service consumers that interact with these dimensions: the abilities to perceive, seek, reach, pay and engage. This comprehensive literature review examined barriers to and facilitators of healthcare access among gender diverse young people using the lens provided by this model as it relates to dimensions of access at the health service level and/or the abilities of health service users. We advocate expansion of this model to incorporate demand- and supply-side barriers and facilitators of access, and important structural factors including the gender binary health system framework, intersectionality and stigma. Findings highlight the need for improvements to healthcare provider education and the participatory redesign of health services with a focus on intersectionality, individually-tailored service provision and healthcare that is responsive to the unique needs of gender diverse young people.

Transgender Youths' Sexual Health and Education: A Qualitative Analysis

STUDY OBJECTIVE

To characterize transgender adolescents' sexual behaviors, identities, and their perceived experiences with sex education.

DESIGN

Semi-structured interviews were conducted and addressed sexual experiences and perceptions of sex education received from family, school educators, and healthcare providers. Interviews were audio recorded, transcribed, and analyzed utilizing NVivo 12 software for thematic analysis.

SETTING

Child and adolescent gender services clinic at a Midwestern university-based medical center in the United States.

PARTICIPANTS

30 transgender adolescents between the ages of 15 to 20.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Themes generated during semi-structured interviews.

RESULTS

Sexual orientations were inclusive of attractions to a spectrum of gender identities. Libido was perceived to be impacted by gender-affirming hormone therapy, which was unanticipated for some adolescents. Family and school-based sex education was perceived to be relevant only for heterosexual and cisgender adolescents. Inclusive education for transgender adolescents was desired. Counseling provided by gender-affirming providers on sexual health was trusted and other healthcare providers were perceived to lack training on gender-inclusive care.

CONCLUSION

This study demonstrated that families and school educators did not provide sex education perceived to be applicable to transgender adolescents. Similarly, healthcare providers of transgender adolescents were perceived to not provide inclusive or comprehensive medical care in comparison to physicians who routinely provide gender-affirming care. Gaps in education and healthcare could be improved with sex education outreach or training for families and school educators as well as the development and implementation of professional competencies for pediatricians on transgender adolescent healthcare.

Constructing a web-based health directory for adolescent men who have sex with men: Strategies for development and resource verification

Online health directories are increasingly used to locate health services and community resources, providing contact and service information that assists users in identifying resources that may meet their health and wellness needs. However, service locations require additional vetting when directories plan to refer vulnerable populations. As a tool included as part of a trial of a mobile life skills intervention for cisgender adolescent men who have sex with men (AMSM; ages 13-18), we constructed and verified resources for an online resource directory focused on linking young people to LGBTQ+ friendly and affirming local health and community social services resources. We collected information for 2301 individual directory listings through database and internet searches. To ensure the listings aligned with the project's focus of supporting young sexual minority men, we developed multiple data verification assessments to ensure community appropriateness resulting in verification of 1833 resources suitable for inclusion in our locator tool at project launch (March 2018). We offer lessons learned and future directions for researchers and practitioners who may benefit from adapting our processes and strategies for building culturally-tailored resource directories for vulnerable populations.

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.

Perspectives on inadequate preparation and training priorities for physicians working with sexual minority youth

OBJECTIVES

To understand pediatric and family medicine residents' and practitioners' perceived ability to work with lesbian, gay, bisexual, and queer (LGBQ) youth, assessment of their prior educational experiences, and recommendations for medical training to better prepare physicians to provide quality care to this population.

METHODS

We conducted semi-structured individual interviews with 24 pediatric/family medicine residents (n=20) and practicing physicians (n=4) in the U.S. Recorded interviews were professionally transcribed. Data were analyzed using Grounded Theory and qualitative content analysis approaches.

RESULTS

Most physicians did not feel adequately prepared to provide quality care to LGBQ youth, and many who felt knowledgeable obtained their knowledge from on-the-job experiences of caring for LGBQ patients. Findings regarding physicians' recommendations for implementing a formal training program revealed three themes: (I) medical school training (implemented earlier in medical school within a structured program as part of the normal curriculum), (II) training content (LGBQ-specific health needs, self-awareness of implicit biases, interviewing techniques, and resources), and (III) training strategies (panels of LGBQ patients, role-playing/standardized patients, and online modules).

CONCLUSIONS

Understanding physicians' assessment of abilities and recommendations for training improvements based on their experiences is important for advancing the quality of healthcare for LGBQ youth. Guidance came mostly from residents who recently completed medical school. Thus, their perspectives are especially useful to improve medical education and, ultimately, the care provided to LGBQ youth. Findings suggest a multi-pronged approach that offers several training modalities encompassing individual, intrapersonal, and institutional/systemic/community levels can improve medical school curricula on caring for LGBQ youth.

Correlates of PrEP Uptake Among Young Sexual Minority Men and Transgender Women in New York City: The Need to Reframe "Risk" Messaging and Normalize Preventative Health

Pre-exposure prophylaxis (PrEP) is an effective form of HIV prevention, but young sexual minority men face myriad barriers to PrEP uptake. Participants (n = 202) completed a survey on healthcare experiences and beliefs about HIV and PrEP. While 98% of the sample knew about PrEP, only 23.2% reported currently taking PrEP. Participants were more likely to be taking PrEP if they received PrEP information from a healthcare provider and endorsed STI-related risk compensation. Conversely, PrEP uptake was less likely among those with concerns about medication use and adherence. While there were no racial/ethnic differences in PrEP uptake, there were differences in correlates of PrEP use for White participants and participants of color. To facilitate PrEP uptake, clinicians should provide PrEP education and screen all patients for PrEP candidacy. Additionally, public health messaging must reframe HIV "risk", highlight benefits of STI testing, and emphasize the importance of preventive healthcare for SMM.

Exchanging a "Gnawing Thought for "Taking a Pill Once a Day": Examining Sexual Minority Men's Experiences With PrEP and Mental Health in a Universal PrEP Access Context

This study explores how universal access to and taking no-cost preexposure prophylaxis (PrEP), which effectively prevents HIV acquisition, may impact the mental health-related experiences of sexual minority men, including HIV-related anxiety. We employed community-based and participatory methods to conduct and analyze 27 interviews with sexual minority men in British Columbia, Canada. Before starting PrEP, participants' experiences with sex were highly associated with HIV-related anxiety. Participants stated they did not explicitly initiate PrEP to reduce HIV-related anxiety, yet many described significant reductions of HIV-related anxiety after starting PrEP. Participants described feeling that the sex they were having was safer following their initiation of PrEP, which resulted in increased ability to access heightened experiences of pleasure, desire, and intimacy. PrEP's capacity to impact HIV stigma and health broadly should continue to be explored, particularly given the mental health inequities faced by those who may acquire HIV.

A Nationwide Survey of COVID-19 Testing in LGBTQ+ Populations in the United States

OBJECTIVES

Lesbian, gay, bisexual, transgender, or queer and questioning (LGBTQ+) people and populations face myriad health disparities that are likely to be evident during the COVID-19 pandemic. The objectives of our study were to describe patterns of COVID-19 testing among LGBTQ+ people and to differentiate rates of COVID-19 testing and test results by sociodemographic characteristics.

METHODS

Participants residing in the United States and US territories (N = 1090) aged ≥18 completed an internet-based survey from May through July 2020 that assessed COVID-19 testing and test results and sociodemographic characteristics, including sexual orientation and gender identity (SOGI). We analyzed data on receipt and results of polymerase chain reaction (PCR) and antibody testing for SARS-CoV-2 and symptoms of COVID-19 in relation to sociodemographic characteristics.

RESULTS

Of the 1090 participants, 182 (16.7%) received a PCR test; of these, 16 (8.8%) had a positive test result. Of the 124 (11.4%) who received an antibody test, 45 (36.3%) had antibodies. Rates of PCR testing were higher among participants who were non-US-born (25.4%) versus US-born (16.3%) and employed full-time or part-time (18.5%) versus unemployed (10.8%). Antibody testing rates were higher among gay cisgender men (17.2%) versus other SOGI groups, non-US-born (25.4%) versus US-born participants, employed (12.6%) versus unemployed participants, and participants residing in the Northeast (20.0%) versus other regions. Among SOGI groups with sufficient cell sizes (n > 10), positive PCR results were highest among cisgender gay men (16.1%).

CONCLUSIONS

The differential patterns of testing and positivity, particularly among gay men in our sample, confirm the need to create COVID-19 public health messaging and programming that attend to the LGBTQ+ population.

Current gaps and ideological trends in physician understanding of LGBTQ+ healthcare and its delivery in London, Ontario

This article was migrated. The article was marked as recommended. Purpose Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities have unique healthcare needs that often go unmet. LGBTQ+ patients report higher levels of satisfaction with and are more likely to seek care from providers who possess knowledge of and demonstrate comfort with LGBTQ+ healthcare issues. We sought to determine knowledge of, comfort with, and perceived barriers to providing equitable LGBTQ+ care amongst physicians in London, ON. Methods Anonymous online surveys were distributed to roughly 2400 full- and part-time physicians at the Schulich School of Medicine & Dentistry. Co-investigators independently coded forty-two surveys and conducted a theoretical thematic analysis. Results Physicians were categorized according to their beliefs about the unique health needs of LGBTQ+ populations and the degree to which they possessed corresponding knowledge. Seventeen physicians (42%) believed that LGBTQ+ populations have unique needs and possessed knowledge, sixteen (38%) believed that LGBTQ+ populations have unique needs but lacked knowledge, and nine (21%) denied the existence of unique needs. Across all respondents, competence was lacking in three domains: transgender healthcare, responding to LGBTQ+ identity disclosure, and knowledge of systemic inequities faced by LGBTQ+ communities. Conclusions These findings elucidate knowledge gaps amongst a representative sample of physicians and present opportunities for targeted educational intervention to improve LGBTQ+ care.

A systematic review of decision aids for gender affirming therapy

BACKGROUND

Transgender and gender diverse (TGD) persons considering gender affirming therapy have to make many complex medical decisions, potentially without understanding the associated harms or benefits of hormonal and surgical interventions. Further, clinicians are often unaware of how best to communicate information to persons seeking gender affirming therapy. Patient decision aids have been developed to provide evidence-based information as a way to help people make decisions in collaboration with their clinicians. It is unclear whether such tools exist for persons seeking gender affirming therapy. The objective of our systematic review is to search for and determine the quality of any existing patient decision aids developed for TGD persons considering gender affirming therapy, and the outcomes associated with their use.

METHODS

We adapted a search strategy for databases using two key concepts "decision support intervention/patient decision aid" and "transgender". We also conducted a brief online search of Google and abstracts from relevant conferences to identify any tools not published in the academic literature. Following study selection and data extraction, we used the International Patient Decision Aid Standards instrument (IPDASi) to assess the quality of patient decision aids, and the Standards for UNiversal reporting of patient Decision Aid Evaluations (SUNDAE) checklist to assess the quality of evaluations.

RESULTS

We identified 762 studies; none were identified from Google or conference content. One tool met our inclusion criteria: an online, pre-encounter patient decision aid for transmasculine genital gender-affirming surgery developed in Amsterdam, translated in English and Dutch. The tool met all the IPDASi qualifying criteria, and scored a 17/28 on the certification criteria, and 57/112 on the quality criteria. The efficacy of the patient decision aid has not been evaluated.

CONCLUSIONS

Despite multiple decisions required for gender affirming therapies, only one patient decision aid has been developed for transmasculine genital reconstruction. Further research is required to develop patient decision aids for the multiple decision points along the gender affirming journey.

Inside the doctor's office. Talking about intersex with Italian health professionals

This article explores how health professionals in Italy understand variations of sex characteristics (VSC), also referred to as intersex and/or disorders of sex development (DSD). With estimates of VSC frequency ranging from 0.018% to 1.7%, only a handful of highly specialised medical doctors are considered DSD experts. When addressing the daily health management of children and families who do not live near specialist DSD centres, these experts may refer individuals to the nearest health professional that Italian health services provides, opening up questions regarding how these professionals might act and react when faced with VSC. In this analysis of interview data from 65 Italian general practitioners, paediatricians and psychologists, we address two themes. The first theme discusses participants' previous experiences and case management, with a focus on social, medical and gender biases. The second theme examines health professionals' opinions and perspectives on ongoing conflicts concerning current best care practices. Our results highlight health professionals' cultural and gendered biases, confirming the need to develop specific professional training, guidelines and policies to improve the healthcare of people with VSC.

Structural determinants of stigma across health and social conditions: a rapid review and conceptual framework to guide future research and intervention

INTRODUCTION

Stigma has been identified as a key determinant of health and health inequities because of its effects on access to health-enabling resources and stress exposure. Though existing reports offer in-depth summaries of the mechanisms through which stigma influences health, a review of evidence on the upstream drivers of stigma across health and social conditions has been missing. The objective of this review is to summarize known structural determinants of stigma experienced across health and social conditions in developed country settings.

METHODS

We conducted a rapid review of the literature. English- and French-language peer-reviewed and grey literature works published after 2008 were identified using MEDLINE, Embase, PsycINFO, Google and Google Scholar. Titles and abstracts were independently screened by two reviewers. Information from relevant publications was extracted, and a thematic analysis of identified determinants was conducted to identify broad domains of structural determinants. A narrative synthesis of study characteristics and identified determinants was conducted.

RESULTS

Of 657 publications identified, 53 were included. Ten domains of structural determinants of stigma were identified: legal frameworks, welfare policies, economic policies, social and built environments, media and marketing, pedagogical factors, health care policies and practices, biomedical technology, diagnostic frameworks and public health interventions. Each domain is defined and summarized, and a conceptual framework for how the identified domains relate to the stigma process is proposed.

CONCLUSION

At least 10 domains of structural factors influence the occurrence of stigma across health and social conditions. These domains can be used to structure policy discussions centred on ways to reduce stigma at the population level.

Family Relationships and the Health and Well-Being of Transgender and Gender-Diverse Youth: A Critical Review

Transgender and gender-diverse (TGD) youth experience significant health and well-being disparities compared to their cisgender peers. However, disparities experienced at a population level might be mitigated by individual-level factors such as strong family relationships. Discrete aspects of strong family relationships may impact the health and well-being of TGD youth differently. To date, no systematic review known to us has explored the state of the science regarding the association between family relationships and the health and well-being of TGD adolescents and young adults. As such, our review aimed to (1) compile and present the scientific literature addressing the connection between family relationships and the health and well-being of TGD youth in those families; (2) sort results utilizing the Family Strengths Model; and (3) assess the strength of the literature with evidence-based appraisal tools. Sixteen articles met eligibility criteria (10 quantitative and 6 qualitative). These articles discussed family relationship qualities influencing health and well-being outcomes, including mental health, homelessness, sexual health, and substance use. Three of six qualities of strong families-coping ability, appreciation and affection, and positive communication-were represented in the literature. The risk for bias and study strength appraisals suggest that the available literature is moderately strong overall. Certain characteristics of strong families (commitment, enjoyable time spent together, and spiritual well-being) were underrepresented in the literature. Future research should explore these gaps to ensure that health care and community service providers can deliver the most effective support and care for TGD youth and their families.

Testing the Testers: Are Young Men Who Have Sex With Men Receiving Adequate HIV Testing and Counseling Services?

The United States Centers for Disease Control and Prevention promote HIV testing every 6 months among young men who have sex with men (YMSM) to facilitate entry into the HIV prevention and care continuum. Willingness to be tested may be influenced by testing services' quality. Using a novel mystery shopper methodology, we assessed YMSM's testing experiences in 3 cities and recommend service delivery improvements.

Assessing the youth-friendliness of youth clinics in northern Sweden: a survey analyzing the perspective of the youth

Background

Sweden has nearly 300 youth clinics that have been offering services since the 1970s. However, no evaluation has been done to assess their youth-friendliness. This study aims to assess: i) to what extent youth clinics are perceived as youth-friendly by the young people using them; and ii) if the level of youth friendliness is equally perceived across different sociodemographic groups of users.

Methods

The four northernmost counties of Sweden were included in the study. Of the total identified 22 youth clinics, 20 participated by giving out questionnaires to the youth after their visits to the respective youth clinics. In total 1110 youth participated in the study and answered questions according to the World Health Organization’s criteria of accessibility, equity, respect, privacy and confidentiality, no judgement, and quality. Means and frequencies were calculated, and t-test and ANOVA were used to compare means by sociodemographic variables.

Results

Participants perceived the youth clinics as very youth friendly across the measured domains, with scores as high as 4.8 and 4.9 (of a maximum of 5). Youth clinics were perceived in a similar way regardless of gender, but other sociodemographic factors influenced some of the domains, especially ethnic background.

Conclusions

The perception of youth friendliness in youth clinics was very high. Nonetheless, younger users; users who did not categorize themselves as either heterosexual, homosexual, or bisexual; users with trans-experiences; and users with non-Swedish backgrounds gave youth clinics lower scores for certain domains.

The Impact of Positive Space Training on Students' Communication With LGBTTQ+ Communities

The lesbian, gay, bisexual, transgender, two-spirit, and queer (LGBTTQ+) communities have experienced discrimination from nurses and other health care professionals, resulting in health inequity. The purpose of this study was to examine the impact of positive space training on students' knowledge and comfort level with LGBTTQ+ communities. A quasi-experimental study with surveys and focus groups was conducted with 160 students. All participants perceived an increase in knowledge and comfort in communicating with LGBTTQ+ people after training. Positive space training can be part of the bank of learning strategies we offer students to increase their knowledge and comfort when interacting with LGBTTQ+ communities.

The experiences of gender diverse and trans children and youth considering and initiating medical interventions in Canadian gender-affirming speciality clinics

Background: Canadian specialty clinics offering gender-affirming care to trans and gender diverse children and youth have observed a significant increase in referrals in recent years, but there is a lack of information about the experiences of young people receiving care. Furthermore, treatment protocols governing access to gender-affirming medical interventions remain a topic of debate. Aims: This qualitative research aims to develop a deeper understanding of experiences of trans youth seeking and receiving gender-affirming care at Canadian specialty clinics, including their goals in accessing care, feelings about care and medical interventions they have undergone, and whether they have any regrets about these interventions. Methods: The study uses an adapted Grounded Theory methodology from social determinants of health perspective. Thirty-five trans and gender diverse young people aged 9 to 17 years were recruited to participate in semi-structured interviews through the specialty clinics where they had received or were waiting for gender-affirming medical interventions such as puberty blockers, hormone therapy, and surgery. Results: Young people felt positively overall about the care they had received and the medical interventions they had undergone, with many recounting an improvement in their well-being since starting care. Most commonly shared frustrations concerned delays in accessing interventions due to clinic waiting lists or treatment protocols. Some youth described unwanted medication side-effects and others said they had questioned their transition trajectory at certain moments in the past, but none regretted their choice to undergo the interventions. Discussion : The results suggest that trans youth and gender diverse children are benefiting from medical gender-affirming care they receive at specialty clinics, providing valuable insight into their decision-making processes in seeking care and specific interventions. Providers might consider adjusting aspects of treatment protocols (such as age restrictions, puberty stage, or mental health assessments) or applying them on a more flexible, case-by-case basis to reduce barriers to access.

University students' behaviours towards accessing sexual health information and treatment

Globally, it is widely recognised that young people (those under the age of 25 years) are at a higher risk of developing sexually transmitted infections (STIs). The majority of university students studying in the UK fall within this age bracket, and to help prevent such high incidence of STIs in this age group, it is essential that advice and treatment, if required, are obtained from reliable sources. This study sought to explore sources of sexual heath advice and treatment for students at Welsh universities (n = 3007). The main sources of advice were identified as the internet (49.1%) and GP/family doctors (38.9%), whilst local sexual health clinics (24.9%) and GP/family doctor services (20.2%) were the main sources for treatment in students. Males were more likely than females to report never needing advice (AOR 2.74; CI = 2.24-3.35) or requiring treatment (AOR 1.37; CI = 1.17-1.60). The apparent lack of engagement with these services by male students is a cause for concern, although one possible solution could be to further develop online methods to increase uptake of testing. Furthermore, the popularity of the internet for advice provides a timely reminder that regulation of online sexual health information is critical.

Encountering sexual and gender minority youth in healthcare: an integrative review

AIM

To describe the encounters with sexual and gender minority (SGM) youth in healthcare based on the existing research.

BACKGROUND

The development of sexual orientation and gender identity can create challenges in an SGM youth's life, and they may need support from health professionals. Heteronormativity has been recognised as a barrier to the identification of diversity in sexuality and gender, and no previous literature review has studied heteronormativity thoroughly.

METHODS

An integrative review following Whittemore and Knafl was conducted. A literature search was systematically undertaken in six databases (PubMed/MEDLINE, CINAHL, Cochrane Library, PsycINFO, Eric, and Academic Search Premier). Finally, 18 research articles were included. Data were analysed deductively with the theoretical framework from Stevi Jackson's (2006) article to understand the role of heteronormativity in the healthcare of SGM youth.

FINDINGS

The encounters with SGM youth consisted of two simultaneous themes. Heteronormative care included three elements: (1) the effect of heteronormativity on health professionals' competence to work with SGM youth, (2) false assumptions about SGM youth, and (3) the influence of heteronormativity on encounters with SGM youth. Diversity-affirming care included two elements: (4) the considerateness of health professionals towards SGM youth and (5) inclusive care of SGM youth.

CONCLUSION

This review summarised how SGM youth were encountered in healthcare and how heteronormativity was affecting their healthcare. Furthermore, this review identified elements that supported diversity-affirming care. With diversity-affirming care, SGM youth may access the information and support they need from healthcare. Further research is needed about how diversity-affirming care can be applied to the healthcare of SGM youth and how elements of heteronormative care are occurring globally in the healthcare of SGM youth. The perceptions of transgender and other gender minority youth were under-represented in the studies and research needs to focus more on how they are encountered in healthcare.

Health care equity and access for marginalised young people: a longitudinal qualitative study exploring health system navigation in Australia

Background

Young people have unique social, emotional and developmental needs that require a welcoming and responsive health system, and policies that support their access to health care. Those who are socially or culturally marginalised may face additional challenges in navigating health care, contributing to health inequity. The aim of this study was to understand health system navigation, including the role of technology, for young people belonging to one or more marginalised groups, in order to inform youth health policy in New South Wales, Australia.

Methods

This qualitative longitudinal study involved 2–4 interviews each over 6 to 12 months with marginalised young people aged 12–24 years living in NSW. The analysis used Nvivo software and grounded theory.

Results

We interviewed 41 young people at baseline who were living in rural or remote areas, sexuality and/or gender diverse, refugee, homeless, and/or Aboriginal. A retention rate of over 85% was achieved. Nineteen belonged to more than one marginalised group allowing an exploration of intersectionality. General practitioners (family physicians) were the most commonly accessed service throughout the study period.

Participants were ambivalent about their healthcare journeys. Qualitative analysis identified five themes:

Technology brings opportunities to understand, connect and engage with services

Healthcare journeys are shaped by decisions weighing up convenience, engagement, effectiveness and affordability.

Marginalised young people perceive and experience multiple forms of discrimination leading to forgone care.

Multiple marginalisation makes health system navigation more challenging

The impact of health system complexity and fragmentation may be mitigated by system knowledge and navigation support

Conclusions

The compounding effects of multiple discrimination and access barriers were experienced more strongly for young people belonging to mutiple marginalised groups. We identify several areas for improving clinical practice and policy. Integrating technology and social media into processes that facilitate access and navigation, providing respectful and welcoming services that recognise diversity, improving health literacy and involving professionals in advocacy and navigation support may help to address these issues.

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0941-2) contains supplementary material, which is available to authorized users.

A Multilevel Tailored Web App-Based Intervention for Linking Young Men Who Have Sex With Men to Quality Care (Get Connected): Protocol for a Randomized Controlled Trial

Background

HIV epidemic among young men who have sex with men (YMSM) is characterized by strong racial disparities and concerns about the availability and access to culturally appropriate HIV prevention and care service delivery. Get Connected, a Web-based intervention that employs individual- and system-level tailoring technology to reduce barriers to HIV prevention care (eg, HIV or sexually transmitted infection [STI] testing, pre-exposure prophylaxis [PrEP]), was developed for YMSM (age 15-24 years). This protocol details the design and procedures of a 2-phase project that includes mystery shopping and a randomized controlled trial (RCT) to test the efficacy of Get Connected among YMSM in Philadelphia, Atlanta, and Houston.

Objective

The objective of mystery shopping is to examine the quality of HIV test counseling and PrEP-related referrals for YMSM within local HIV or STI testing sites. The objective of the RCT is to test the efficacy of Get Connected for increasing HIV-negative or HIV-unknown YMSM’s successful uptake of HIV prevention services (eg, routine HIV or STI testing), PrEP awareness, and likelihood to start PrEP (PrEP willingness), compared with those in the control condition, over a 12-month period.

Methods

For Phase 1, we will create a master list of HIV and STI testing sites in each city. We will enroll and train 10-15 mystery shoppers per city; each testing site will be separately visited and assessed by 2 mystery shoppers. After each site visit, the mystery shoppers will complete a site evaluation to record their perceptions of various measures including lesbian, gay, bisexual, transgender, queer visibility and inclusivity, privacy and confidentiality, provider-patient interactions, and clinic environment. For Phase 2, we will enroll 480 YMSM for 12 months across the 3 iTech cities into a 2-arm prospective RCT. Participants randomized to the control condition are directed to the AIDSVu.org testing site locator. Participants randomized to the intervention condition will be granted access to a Web app with content tailored to their specific demographic characteristics (eg, age, race or ethnicity, location, and relationship status), HIV and STI risk behaviors (eg, HIV and STI testing history, substance use, communication with partners regarding status) and sociocultural context (eg, homelessness, incarceration). Study assessments will occur at enrollment and at 1, 3, 6, 9, and 12 months postenrollment.

Results

Get Connected research activities began in September 2016 and are ongoing. To date, institutional review board (IRB) submission is complete and IRB authorization agreements are pending at several other universities.

Conclusions

The deployment of Get Connected through a mobile-optimized Web app seeks to optimize the intervention’s acceptability, accessibility, availability, and long-term affordability among YMSM.

Trial Registration

ClinicalTrials.gov (NCT03132415); https://clinicaltrials.gov/ct2/show/NCT03132415 (Archived by WebCite at http://www.webcitation.org/70j4gSFbZ)

Registered Report Identifier

RR1-10.2196/10444

A Qualitative Investigation of Healthcare Engagement Among Young Adult Gay Men in New York City: A P18 Cohort Substudy

PURPOSE

We used in-depth interviews with a cohort of young adult gay men (YAGM) to provide a more detailed understanding of their current healthcare engagement, including experiences with the healthcare system, provider knowledge of healthcare needs, and desired provider characteristics.

METHODS

Qualitative interviews were conducted with a sample of 40 YAGM in New York City. The interview guide examined healthcare engagement across key developmental stages: childhood (birth-12), adolescence (13-18), young adulthood (19-22), and the present (23-26). All transcripts were coded using a consensual qualitative research approach to identify crosscutting topics. The interviews were conducted between September and October 2015.

RESULTS

The following topics were identified: experiences with the healthcare system, provider knowledge of healthcare needs, and desired provider characteristics. Common barriers to healthcare access were financial concerns, lack of insurance, and dissatisfaction with the care provided. Reasons for dissatisfaction with care were based on perceptions of providers' anti-gay attitudes, judgment of same-sex sexual behavior, and lack of provider knowledge about YAGM's health needs. This often led men in this study to seek sexual healthcare from providers other than their primary care provider. When asked about desired provider characteristics, participants noted that basic demographics were of less importance than skills-based characteristics such as rapport, comfort discussing sexual health issues, and knowledge of YAGM's health.

CONCLUSION

YAGM have unique challenges to engaging in healthcare, including provider stigma and lack of provider knowledge of YAGM's health needs, which are not faced by other young adult populations. The results from this study highlight the need for more extensive and standardized training in medical school and as part of continuing medical education for healthcare providers.

Barriers and enablers to sexual health service use among university students: a qualitative descriptive study using the Theoretical Domains Framework and COM-B model

BACKGROUND

University students are within the age group at highest risk for acquiring sexually transmitted infections and other negative health outcomes. Despite the availability of sexual health services at university health centres to promote sexual health, many students delay or avoid seeking care. This study aimed to identify the perceived barriers and enablers to sexual health service use among university undergraduate students.

METHODS

We used a qualitative descriptive design to conduct semi-structured focus groups and key informant interviews with university students, health care providers, and university administrators at two university health centres in Nova Scotia, Canada. The semi-structured focus group and interview guides were developed using the Theoretical Domains Framework and COM-B Model. Data were analyzed using a directed content analysis approach, followed by inductive thematic analysis.

RESULTS

We conducted 6 focus groups with a total of 56 undergraduate students (aged 18-25) and 7 key informant interviews with clinicians and administrators. We identified 10 barriers and enablers to sexual health service use, under 7 TDF domains: knowledge; memory, attention and decision-making processes; social influences; environmental context and resources; beliefs about consequences; optimism; and emotion. Key linkages between students' social opportunity and motivation were found to influence students' access of sexual health services.

CONCLUSIONS

We identified barriers and enablers related to students' capability, opportunity and motivation that influence sexual health service use. We will use these findings to design an intervention that targets the identified barriers and enablers to improve students' use of sexual health services, and ultimately, their overall health and well-being.

How Marginalized Young People Access, Engage With, and Navigate Health-Care Systems in the Digital Age: Systematic Review

PURPOSE

This systematic review examines how marginalized young people access and engage with health services and navigate health-care systems in high-income countries.

METHODS

Medline, CINAHL, PsychInfo, The University of Sydney Library database, and Google Scholar were searched to identify qualitative and quantitative original research, published from 2006 to 2017, that focused on selected definitions of marginalized young people (12 to 24 years), their parents/carers, and/or health professionals working with these populations. A thematic synthesis was undertaken identifying themes across and between groups on barriers and/or facilitators to access, engagement, and/or navigation of health-care systems.

RESULTS

Of 1,796 articles identified, 68 studies in the final selection focused on marginalized young people who were homeless (n = 20), living in rural areas (n = 14), of refugee background (n = 11), gender and/or sexuality diverse (n = 11), indigenous (n = 4), low income (n = 4), young offenders (n = 2), or living with a disability (n = 2). Studies were from the United States, Australia, Canada, United Kingdom, New Zealand, and Portugal, including 44 qualitative, 16 quantitative, and 8 mixed-method study types. Sample sizes ranged from 3 to 1,388. Eight themes were identified relating to ability to recognize and understand health issues; service knowledge and attitudes toward help seeking; structural barriers; professionals' knowledge, skills, attitudes; service environments and structures; ability to navigate the health system; youth participation; and technology opportunities.

CONCLUSIONS

Marginalized young people experience barriers in addition to those common to all young people. Future studies should consider the role of technology in access, engagement, and health system navigation, and the impact of intersectionality between marginalized groups.

Use of GetCheckedOnline, a Comprehensive Web-based Testing Service for Sexually Transmitted and Blood-Borne Infections

Background

The British Columbia Centre for Disease Control implemented a comprehensive Web-based testing service GetCheckedOnline (GCO) in September 2014 in Vancouver, Canada. GCO’s objectives are to increase testing for sexually transmitted and blood-borne infections (STBBIs), reach high-prevalence populations facing testing barriers, and increase clinical STI service capacity. GCO was promoted through email invitations to provincial STI clinic clients, access codes to clients unable to access immediate clinic-based testing (deferred testers), and a campaign to gay, bisexual, and other men who have sex with men (MSM).

Objective

The objective of the study was to report on characteristics of GCO users, use and test outcomes (overall and by promotional strategy) during this pilot phase.

Methods

We used GCO program data, website metrics, and provincial STI clinic records to describe temporal trends, progression through the service pathway, and demographic, risk, and testing outcomes for individuals creating GCO accounts during the first 15 months of implementation.

Results

Of 868 clients creating accounts, 318 (36.6%) submitted specimens, of whom 96 (30.2%) tested more than once and 10 (3.1%) had a positive STI diagnosis. The proportion of clients submitting specimens increased steadily over the course of the pilot phase following introduction of deferred tester codes. Clients were diverse with respect to age, gender, and ethnicity, although youth and individuals of nonwhite ethnicity were underrepresented. Of the 506 clients completing risk assessments, 215 (42.5%) were MSM, 89 (17.6%) were symptomatic, 47 (9.3%) were STI contacts, 232 (45.8%) reported condomless sex, 146 (28.9%) reported ≥4 partners in the past 3 months, and 76 (15.0%) reported a recent STI. A total of 63 (12.5%) GCO clients were testing for the first time. For 868 accounts created, 337 (38.8%) were by clinic invitations (0 diagnoses), 298 (34.3%) were by deferred testers (6 diagnoses), 194 (22.4%) were by promotional campaign (3 diagnoses), and 39 (4.5%) were by other means (1 diagnosis).

Conclusions

Our evaluation suggests that GCO is an acceptable and feasible approach to engage individuals in testing. Use by first-time testers, repeated use, and STI diagnosis of individuals unable to access immediate clinic-based testing suggest GCO may facilitate uptake of STBBI testing and earlier diagnosis. Use by MSM and individuals reporting sexual risk suggests GCO may reach populations with a higher risk of STI. Motivation to test (eg, unable to access clinical services immediately) appears a key factor underlying GCO use. These findings identify areas for refinement of the testing model, further promotion, and future research (including understanding reasons for drop-off through the service pathway and more comprehensive evaluation of effectiveness). Increased uptake and diagnosis corresponding with expansion of the service within British Columbia will permit future evaluation of this service across varying populations and settings.

Caring for Lesbian, Gay, Bisexual, Transgender, and Questioning Youth in Inclusive and Affirmative Environments

Lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ) youth may experience interpersonal and structural stigma within the health care environment. This article begins by reviewing special considerations for the care of LGBTQ youth, then turns to systems-level principles underlying inclusive and affirming care. It then examines specific strategies that individual providers can use to provide more patient-centered care, and concludes with a discussion of how clinics and health systems can tailor clinical services to the needs of LGBTQ youth.

Pharmacotherapy Considerations in the Management of Transgender Patients: A Brief Review

Transgender and transsexual individuals have unique health care needs and risks compared with the population at large. It is estimated that 1 in 100,000 individuals in the United States is a transgender woman and 1 in 400,000 is a transgender man, although these estimates of prevalence are likely conservative. Transgender individuals are at an increased risk of tobacco, alcohol, and substance abuse; they have an increased lifetime suicide attempt risk; and they are more likely to experience significant stressors in their lives. Transgender patients may elect to transition their appearance to the gender with which they identify. Hormone treatment (and possibly sex reassignment surgery) is a significant part of this transition, and pharmacists must understand the pharmacotherapeutic principles involved so they can better recommend therapeutic agents, provide dosing recommendations, and anticipate and manage adverse effects. It is critical to be culturally sensitive when providing care for transgender patients including using their preferred gender identity, preferred names, and preferred pronouns. It is also essential to be able to identify transgender and transsexual patients correctly within electronic health records to ensure that appropriate care and monitoring are provided. For pharmacists, this means they should know the biologic sex for performing calculations such as creatinine clearance and to prevent teratogenic agents from reaching a transgender or transsexual man who could be pregnant or is capable of becoming pregnant. Promoting knowledge of transgender health issues will enable pharmacists to provide better, more holistic care to their transgender patients.

Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth

PURPOSE

Few transgender youth eligible for gender-affirming treatments actually receive them. Multidisciplinary gender clinics improve access and care coordination but are rare. Although experts support use of pubertal blockers and cross-sex hormones for youth who meet criteria, these are uncommonly offered. This study's aim was to understand barriers that transgender youth and their caregivers face in accessing gender-affirming health care.

METHODS

Transgender youth (age 14-22 years) and caregivers of transgender youth were recruited from Seattle-based clinics, and readerships from a blog and support group listserv. Through individual interviews, focus groups, or an online survey, participants described their experiences accessing gender-affirming health care. We then used theoretical thematic analysis to analyze data.

RESULTS

Sixty-five participants (15 youth, 50 caregivers) described barriers spanning six themes: (1) few accessible pediatric providers are trained in gender-affirming health care; (2) lack of consistently applied protocols; (3) inconsistent use of chosen name/pronoun; (4) uncoordinated care and gatekeeping; (5) limited/delayed access to pubertal blockers and cross-sex hormones; and (6) insurance exclusions.

CONCLUSIONS

This is the first study aimed at understanding perceived barriers to care among transgender youth and their caregivers. Themed barriers to care led to the following recommendations: (1) mandatory training on gender-affirming health care and cultural humility for providers/staff; (2) development of protocols for the care of young transgender patients, as well as roadmaps for families; (3) asking and recording of chosen name/pronoun; (4) increased number of multidisciplinary gender clinics; (5) providing cross-sex hormones at an age that permits peer-congruent development; and (6) designating a navigator for transgender patients in clinics.

HIV stigma and the experiences of young men with voluntary and routine HIV testing

As routine HIV testing approaches are implemented to enhance participation rates in HIV testing, it is often widely believed that these approaches are socially and ethically justifiable given the underlying assumption that these practices will result in the widespread reduction of HIV-related stigma. Nonetheless, a variety of empirical and theoretical gaps on how HIV testing practices may impact on HIV stigma remain, raising questions about the social underpinnings of the public health rationale. We draw on 50 interviews with 18-24 year-old men to determine how HIV-related stigma is experienced differentially across subgroups of young men in relation to both voluntary and routine testing practices. The men's experiences with routine testing highlight how (mis)interpretations of universal, routine testing practices may serve to (unintentionally) burden disadvantaged subgroups of men; however, when these practices are adequately explicated, the universal dimension of a routine offer greatly diminished these concerns. These findings also show that, under the right conditions, a routine offer can provide transformative opportunities for individuals to reconceptualise their expectations over HIV and HIV-related stigma.

Acceptability and preliminary efficacy of a tailored online HIV/STI testing intervention for young men who have sex with men: the Get Connected! program

Southeast Michigan accounts for over 70 % of all HIV/STI cases in the state, with young men who have sex with men (YMSM) between the ages of 13 and 24 encumbering the largest burden in HIV/STI incidence. Using community-based participatory research principles, we developed and pilot tested a web-based, randomized control trial seeking to promote HIV/STI testing ("Get Connected!") among YMSM (N = 130; ages 15-24). Randomized participants completed a baseline assessment and shown a test-locator condition (control) or a tailored, personalized site (treatment). At 30-day follow-up, we found high acceptability among YMSM in both conditions, yet higher credibility of intervention content among YMSM in the treatment group (d = .55). Furthermore, 30 participants reported testing by following, with the majority of these participants (73.3 %; n = 22) completing the treatment condition, a clinically meaningful effect (d = .34) suggesting preliminary efficacy for the intervention. These results demonstrate the potential of the intervention, and suggest that a larger efficacy trial may be warranted.

Acceptability and preliminary efficacy of a tailored online HIV/STI testing intervention for young men who have sex with men: the Get Connected! program

Southeast Michigan accounts for over 70 % of all HIV/STI cases in the state, with young men who have sex with men (YMSM) between the ages of 13 and 24 encumbering the largest burden in HIV/STI incidence. Using community-based participatory research principles, we developed and pilot tested a web-based, randomized control trial seeking to promote HIV/STI testing ("Get Connected!") among YMSM (N = 130; ages 15-24). Randomized participants completed a baseline assessment and shown a test-locator condition (control) or a tailored, personalized site (treatment). At 30-day follow-up, we found high acceptability among YMSM in both conditions, yet higher credibility of intervention content among YMSM in the treatment group (d = .55). Furthermore, 30 participants reported testing by following, with the majority of these participants (73.3 %; n = 22) completing the treatment condition, a clinically meaningful effect (d = .34) suggesting preliminary efficacy for the intervention. These results demonstrate the potential of the intervention, and suggest that a larger efficacy trial may be warranted.

Gay and bisexual men's awareness and knowledge of treatment as prevention: findings from the Momentum Health Study in Vancouver, Canada

Introduction

Awareness and knowledge of treatment as prevention (TasP) was assessed among HIV-positive and HIV-negative gay, bisexual and other men who have sex with men (GBMSM) in Vancouver, Canada.

Methods

Baseline cross-sectional survey data were analyzed for GBMSM enrolled, via respondent-driven sampling (RDS), in the Momentum Health Study. TasP awareness was defined as ever versus never heard of the term “TasP.” Multivariable logistic regression identified covariates of TasP awareness. Among those aware of TasP, men's level of knowledge of TasP was explored through an examination of self-perceived knowledge levels, risk perceptions and short-answer definitions of TasP which were coded as “complete” if three TasP-related components were identified (i.e. HIV treatment, viral suppression and prevention of transmission). Information source was also assessed. Analyses were stratified by HIV status and RDS adjusted.

Results

Of 719 participants, 23% were HIV-positive, 68% Caucasian and median age was 33 (Interquartile range (IQR) 26,47). Overall, 46% heard of TasP with differences by HIV status [69% HIV-positive vs. 41% HIV-negative GBMSM (p<0.0001)]. In adjusted models: HIV-positive GBMSM were more likely to have heard of TasP if they were Canadian born, unemployed, not using party drugs and had higher CD4 counts; HIV-negative GBMSM were more likely to have heard of TasP if they were Caucasian (vs. Aboriginal), students, had higher education, a regular partner and multiple sexual partners. Among those aware of TasP 91% of HIV-positive and 69% of HIV-negative GBMSM (p<0.0001) felt they knew “a lot” or “a bit in general” about TasP; 64 and 41% (p=0.002) felt HIV treatment made the risk of transmission “a lot lower”; and 21 and 13% (p<0.0001) demonstrated “complete” TasP definitions. The leading information source was doctors (44%) for HIV-positive GBMSM and community agencies (38%) for HIV-negative GBMSM, followed by gay media for both populations (34%).

Conclusions

Nearly half of GBMSM in this study reported having heard of TasP, yet only 14% demonstrated complete understanding of the concept. Variations in TasP awareness and knowledge by HIV status, and key socio-demographic, behavioural and clinical factors, highlight a need for health communication strategies relevant to diverse communities of GBMSM in order to advance overall TasP health literacy.

Prevalence of Non-Volitional Sex Types and Associated Factors: A National Sample of Young People

BACKGROUND

Non-volitional sex (NVS) in young people continues to be a major public health problem with long-term negative health outcomes. For the first time, the prevalence of different types of NVS and associated factors are compared between young people with same-sex sexual activities and those who have not.

METHODS

We obtained data from 10,401 young women and men (aged 12 to 25 years) who participated in a population study on sexual health, the Netherlands. We calculated and compared the prevalence of six types of NVS between women who had sex with men (yWSM) or women (yWSW), and men who had sex with women (yMSW) or men (yMSM). In sexually experienced participants (n = 5986) logistic regression analyses were applied to assess associations with NVS by assault or penetration. Analyses were weighted to represent the Dutch population.

RESULTS

The prevalence of NVS ranged from 1% to 61%, depending on type. Prevalence was higher for young women (any: 40.6%) than men (any: 20.4%), and highest for yMSM and yWSW. Prevalence of NVS by assault or penetration was related to a range of socio-demographic, behavioral and social factors, which were largely similar regardless of sex or same-sex-experiences. The NVS perpetrators were in over 70% of cases known to the victim; 1 in 4 cases of NVS by penetration were accompanied by violence.

CONCLUSION

A substantial proportion of young people in the Netherlands have experienced NVS. Medical professionals, educators and caregivers should integrate services to continue to address NVS by targeting young people's multifaceted risk profiles and evidenced based interventions for doing so are needed.