Sexual Minority Women's Experiences With Sexual Identity Disclosure in Contraceptive Care

Being Out: Impact of Disclosure on Sexual and Reproductive Healthcare Receipt in a Sample of Sexual Minority Women and Gender Diverse Youth

PURPOSE

Sexual minority women and gender diverse youth in the United States experience disparities in sexual and reproductive health. We evaluated whether sexual partner type, identity, and attraction were associated with healthcare disclosure, and whether healthcare disclosure was associated with sexual and reproductive healthcare receipt in a sample of sexual minority and gender diverse youth aged 18-24 years assigned female at birth.

METHODS

103 youth assigned female at birth completed a behavioral health survey. Data were analyzed to determine whether healthcare disclosure was associated with receipt of the human papillomavirus (HPV) vaccine, human immunodeficiency virus (HIV) testing, contraception method, and long-acting reversible contraception. We examined whether sexual partner type, identity, and attraction were associated with healthcare disclosure.

RESULTS

Over half of the 103 participants self-identified as Black (78%) and had at least one female partner (55%); 14.6% identified as gender diverse. 51.5% received an HPV vaccine, 52.4% were HIV tested in the last year, 38.8% received any contraception method, and 19.4% received long-acting reversible contraception. The majority (63.1%) of youth reported healthcare disclosure. Healthcare disclosure was associated with sexual and reproductive healthcare receipt. Participants who had only male partners, identified as heterosexual or were unsure of their sexual identity were less likely to disclose their sexual orientation and receive HIV and HPV services.

DISCUSSION

Reducing barriers to healthcare disclosure and care receipt will be critical to overcoming sexual and reproductive health disparities for all youth.

Client Perspectives on Contraceptive Care: A Systematic Review

INTRODUCTION

Contraceptive care is an opportunity for providers to help clients achieve their reproductive health goals. Client-centeredness is a core element of quality care; however, evidence suggests that the provision of client-centered contraceptive counseling needs improvement. This systematic review summarizes recent evidence on client preferences related to contraceptive care, including how client-centered approaches inform outcomes.

METHODS

A systematic review was conducted in PubMed, Cochrane Database of Systematic Reviews, and Scopus to identify articles published between December 1, 2016 and May 1, 2023. Studies that explored client preferences related to contraceptive counseling, education, and/or care, and how client-centered approaches impact clients' perceived experiences with their care were included.

RESULTS

Thirty-nine unique studies met inclusion criteria. Clients want a range of information about contraceptive methods tailored to their preferences through a variety of formats, before, during, and after their appointment. Clients desired providers with similar demographic backgrounds (gender, race, ethnicity) and life experiences (menstruation, contraceptive use, carceral system encounters) to themselves, and who are willing to offer continuous care. Clients reported greater satisfaction when providers engaged in shared decision-making, utilized decision support tools, and supported their autonomy, including prioritizing their family-building goals. When providers shared personal preferences or pressured clients to select one method over another, clients in turn, reported feeling conflicted about which method to select and some subsequently declined using any method.

DISCUSSION

The variation in client preferences highlight the importance of offering tailored, comprehensive information that supports decision-making, prioritizes client autonomy, and recognizes positive interpersonal relationships with providers.

TRIAL REGISTRATION

Prospero: CRD42023414456 https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=414456.

An examination of the independent and intersectional effects of racial and heterosexist medical mistrust on timing of sexual/reproductive health care visits among Black sexual minority women in the USA

Experiences of racism and heterosexism in medical settings are social and systemic barriers to 'on-time' receipt of sexual and reproductive health services among women with both racial and sexual minority identities. Medical mistrust based on experiences related to these dual identities is associated with avoidance and delays in care. However, investigators are just beginning to apply an intersectional lens to quantitatively understanding such barriers. The purpose of this study was to examine the independent and interaction effects of racial and heterosexist medical mistrust on timing of sexual/reproductive health care among Black sexual minority women who have sex with women and men. A total of 320 women participated in an online study of factors affecting sexual health in this population. Ordinal logistic regression was used to assess the independent and interaction effects of racial and heterosexist medical mistrust on self-reported time since last sexual/reproductive health visit. Results indicated an interaction between the two types of medical mistrust. Research on Black women who have sex with women and men's experiences of racism and heterosexism in the US healthcare system can lead to the development of the comprehensive training programmes needed to alleviate medical mistrust among women with racial and sexual minority identities.

A qualitative exploration of gynaecological healthcare experiences of lesbian, gay, bisexual, transgender, queer people assigned female at birth

BACKGROUND

Lesbian, gay, bisexual, transgender, queer, asexual/aromantic (LGBTQA+) people, assigned female at birth (AFAB), experience disproportionately poorer gynaecological healthcare outcomes compared to their cisgender, heterosexual peers. The barriers to gynaecological care remain poorly understood. In a step toward bridging this gap, the current study explored the lived gynaecological healthcare experiences of Australian LGBTQA+ AFAB people and the barriers they experience in accessing care.

MATERIALS AND METHODS

Semi-structured interviews were conducted with 22 LGBTQA+ AFAB people. An inductive thematic qualitative design was used to explore the lived experiences and identify themes associated with the reported experiences.

RESULTS

Thematic analysis identified seven themes related to experiences in accessing gynaecological healthcare, including discrimination, fear, perceived provider or cultural incompetency, accessibility, and gender identity. Several sub-themes were also identified such as refusal of care, microaggression, misgendering, and patient as educator.

CONCLUSIONS

Participants suggested that barriers to care could be alleviated by the integration of LGBTQA+ specific healthcare training into the university-level medical curriculum and professional development programs that address cultural competency and inclusive healthcare. These preliminary findings inform the necessity for the development of evidence-based practice guidelines that specifically address the unique and diverse needs of the LGBTQA+ AFAB population.

The status of person-centered contraceptive care in the United States: Results from a nationally representative sample

CONTEXT

The Person-Centered Contraceptive Care measure (PCCC) evaluates patient experience of contraceptive counseling, a construct not represented within United States surveillance metrics of contraceptive care. We explore use of PCCC in a national probability sample and examine predictors of person-centered contraceptive care.

METHODS

Among 2228 women from the 2017-2019 National Survey of Family Growth who reported receiving contraceptive care in the last year, we conducted univariate and multivariable linear regression to identify associations between individual characteristics and PCCC scores.

RESULTS

PCCC scores were high (x ¯ : 17.84, CI: 17.59-18.08 on a 4-20 scale), yet varied across characteristics. In adjusted analyses, Hispanic identity with Spanish language primacy and non-Hispanic other or multiple racial identities were significantly associated with lower average PCCC scores compared to those of non-Hispanic white identity (B = -1.232 [-1.970, -0.493]; B = -0.792 [-1.411, -0.173]). Gay, lesbian, or bisexual identity was associated with lower average PCCC scores compared to heterosexual (B = -0.673 [-1.243, -0.103]). PCCC scores had a positive association with incomes of 150%-299% and ≥300% of the federal poverty level compared to those of income <150% (150%-299%: B = 0.669 [0.198, 1.141]; ≥300%: B = 0.892 [0.412, 1.372]). Cannabis use in the past year was associated with lower PCCC scores (B = -0.542 [-0.971, -0.113]).

CONCLUSIONS

The PCCC can capture differential experiences of contraceptive care to monitor patient experience and to motivate and track care quality over time. Differences in reported quality of care have implications for informing national priorities for contraceptive care improvements.

Using the Community Readiness Model and Stakeholder Engagement to Assess a Health System's Readiness to Provide LGBTQ+ Healthcare: A Pilot Study

Background

Despite broad social and policy changes over the past several decades, many LGBTQ+ people face barriers to healthcare and report mistreatment and disrespect in healthcare settings. Few health systems level interventions have been shown to improve sexuality- and gender-related health disparities. Using the Community Readiness Model, we developed and implemented a rigorous assessment and priority-setting intervention at one mid-sized health system in the midwestern US. We evaluated the system's readiness to provide LGBTQ+ healthcare and developed immediate action steps that are responsive to local context. We engaged diverse stakeholder groups throughout the process.

Methods

Led by the Community Readiness Model, we identified key groups within the health system and conductedstructured interviews with 4-6 key informants from each group. Two trained scorers external to the study team individually scored each interview on a numerical scale ranging from 1 (no awareness of the problem) to 9 (community ownership of the problem) and discussed and reconciled scores. Group scores were averaged for each dimension of readiness and overall readiness, and then triangulated with stakeholders to ensure they reflected lived experiences. Finally, specific recommendations were generated to match the needs of the system and move them towards higher levels of readiness.

Results

We convened an advisory committee of LGBTQ+ patients of the health system and a panel of local experts on LGBTQ+ wellness. Both groups contributed significantly to research processes. 28 interviews across 6 staff subcommunities indicated readiness levels ranging from "3: Vague Awareness" of the issue, and the "4: Preplanning" stage. Discrepancies across staff groups and dimensions of readiness suggested areas of focus for the health system. The evaluation process led to immediately actionable recommendations for the health system.

Conclusions

This pilot study demonstrates the potential impact of the Community Readiness Model on improving health systems' readiness to provide LGBTQ+ healthcare. This model combines strengths from community-based research and implementation science approaches to form an intervention that can be widely disseminated and maintain the flexibility and agility to meet local needs. Future research will evaluate changes in readiness at the same health system and test the process in additional health systems.

Meeting Preferences for Specific Contraceptive Methods: An Overdue Indicator

Fertility surveys have rarely asked people who are using contraception about the contraceptive method they would like to be using, implicitly assuming that those who are contracepting are using the method they want. In this commentary, we review evidence from a small but growing body of work that oftentimes indicates this assumption is untrue. Discordant contraceptive preferences and use are relatively common, and unsatisfied preferences are associated with higher rates of method discontinuation and subsequent pregnancy. We argue that there is opportunity to center autonomy and illuminate the need for and quality of services by building on this research and investing in the development of survey items that assess which method people would like to use, as well as their reasons for nonpreferred use. The widespread adoption of questions regarding method preferences could bring indicators of reproductive health services into closer alignment with the needs of the people they serve.

A secondary mixed methods analysis examining midwives' responses regarding patient sexual orientation and gender identity (SOGI) disclosure

OBJECTIVE

Recent research suggests that midwives generally have positive attitudes towards sexual and gender minority (SGM) clients; however, little research has examined whether and how these attitudes translate into specific clinical practices. In this study, we performed a secondary mixed methods analysis to examine midwives' beliefs and practices regarding the importance of asking and knowing their patients' sexual orientation and gender identity (SOGI).

METHODS

A confidential, anonymous paper survey was mailed to all midwifery practice groups (n = 131) in Ontario, Canada. Participants were midwives who were members of the Association of Ontario Midwives who responded to the survey (n = 267). Sequential explanatory mixed methods analysis was employed: quantitative SOGI questions were analyzed first, followed by qualitative open response comments to explain and contextualize the quantitative findings.

FINDINGS

Midwives' responses indicated that it was not important to know or ask about clients' SOGI because (1) it is not necessary to be able to provide the best care to everyone, and (2) the onus is on the client to disclose SOGI. Midwives indicated that they would like more training and knowledge to be able to confidently care for SGM.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Midwives' hesitancy to ask or know SOGI demonstrates that positive attitudes do not necessarily translate into current best practices for obtaining SOGI data in the context of SGM care provision. Midwifery education and training programs should address this gap.

An intersectional analysis of contraceptive types chosen among sexual minority women: A nationally representative study

OBJECTIVE

The purpose of this study is to use an intersectional approach in which race, insurance, care setting, and disclosure of sexual orientation to a provider are used to assess patterns of contraceptive use in sexual minority women.

STUDY DESIGN

This study analyzes cross-sectional data from the 2011-2019 National Survey of Family Growth (NSFG). Sexual orientation of 21,075 respondents' data was used to investigate contraceptive use in sexual minority women, specifically lesbian and bisexual women, as compared to heterosexual women, controlling for variables such as race, age, and socioeconomic factors.

RESULTS

Black and Hispanic lesbian women (adjusted odds ratio [aOR] = 0.39 confidence interval [CI] 0.20-0.76 and aOR = 0.44 CI 0.23-0.82, respectively) and Hispanic and Other Race bisexual women use hormonal contraceptive methods less than their White lesbian and bisexual peers (aOR = 0.45 CI 0.29-0.69 and aOR = 0.43 CI 0.20-0.94). Care setting was not correlated with long-acting reversible contraceptive methods (LARC; such as intra-uterine device, hormonal implants) or prescription-based hormonal methods (such as oral contraceptive pills, injectables, vaginal rings, and patches) in lesbian women (aOR = 2.92 CI 0.60-14.2 and aOR = 1.43 CI 0.47-4.38, respectively) or bisexual women (aOR = 0.90 CI 0.48-1.58 and aOR = 0.83 CI 0.37-1.86), but it was for straight women (aOR = 1.28 CI 1.03-1.59 and aOR = 0.68 CI 0.53-0.86). Similarly, insurance status did not correlate with contraceptive patterns in sexual minority women. Importantly, adjusting for nationally representative data did not impact the results; in other words, the odds ratios after adjusting yielded the same results as before adjustment.

CONCLUSIONS

Insurance and care setting are important determinants of straight women's contraceptive use patterns with fewer effects seen among sexual minority women. These findings support previous work and indicate that known advantages of insurance coverage or use of public clinics may not positively impact sexual minority women as much as they do straight women. Provider awareness of sexual identity and sexual orientation is important for adequate contraceptive care.

IMPLICATIONS

While prior research has presented findings on sexual minority women contraceptive use, to our knowledge there are limited studies that address the social and demographic implications for contraceptive use in this population.

Racial/Ethnic and Sexual Orientation Identity Differences in the Receipt of a Sexual History Assessment from a Health Care Provider among Women in the United States

BACKGROUND

Differential sexual history assessment, whereby certain groups are more or less likely to be asked questions about their sexual behavior by a health care provider, may lead to differential sexual health care and counseling.

METHODS

Using nationally representative data from the 2013 through 2019 waves of the National Survey of Family Growth, we examined racial/ethnic and sexual orientation identity differences in receiving a sexual history assessment from a health care provider in the last 12 months among U.S. women aged 15-44 years (N = 14,019).

RESULTS

Adjusting for survey wave, Black and Latina heterosexual women; White, Black, and Latina bisexual women; and Black or Latina lesbian women had higher odds (odds ratio range, 1.47 [Latina heterosexual] to 2.71 [Black bisexual]) of having received a sexual history assessment in the last 12 months compared with White heterosexual women. All differences except for those among Black or Latina lesbian women persisted after controlling for demographic, socioeconomic, and health care factors (odds ratio range, 1.43 [Latina heterosexual] to 2.14 [Black bisexual]). Of note, Black bisexual women, about whom providers may hold biased assumptions of promiscuity rooted in both racism and biphobia, had the highest predicted probability of being asked about their sexual behavior by a provider.

CONCLUSIONS

Person-centered, structurally competent, and anti-oppressive practices and programs aimed at combating bias, stigma, and discrimination in the health care system and facilitating an inclusive clinic environment for all patients are needed to address differences in the provision of sexual health services and promote sexual health equity.

Contraceptive Care Disparities Among Sexual Orientation Identity and Racial/Ethnic Subgroups of U.S. Women: A National Probability Sample Study

Background: Sexual minority women may use contraception for various reasons but face notable barriers to contraceptive care, including stigma and discrimination. However, studies examining sexual orientation disparities in contraceptive care have largely relied on nonprobability samples of predominately White women and may thus not be generalizable to U.S. women overall or Black and Latina women in particular. Materials and Methods: Using data from the 2006 to 2017 National Survey of Family Growth, a large national probability sample of U.S. women 15-44 years of age (N = 25,473), we used multivariable logistic regression to estimate adjusted odds ratios for receiving a contraceptive method or prescription and contraceptive counseling from a health care provider in the past year among sexual orientation identity and racial/ethnic subgroups of heterosexual, bisexual, and lesbian White, Black, and Latina women relative to White heterosexual women. Results: Among women overall, 33.9% had received contraception and 18.3% had obtained contraceptive counseling. Black (odds ratio [OR] = 0.73, 95% confidence interval [CI]: 0.65-0.82) and Latina (OR = 0.73, 95% CI: 0.64-0.82) heterosexual women, White (OR = 0.80, 95% CI: 0.65-0.99) and Black (OR = 0.43, 95% CI: 0.32-0.58) bisexual women, and White (OR = 0.23, 95% CI: 0.13-0.43), Black (OR = 0.19, 95% CI: 0.09-0.40), and Latina (OR = 0.08, 95% CI: 0.03-0.22) lesbian women had significantly lower adjusted odds of receiving contraception compared with White heterosexual women. White (OR = 0.36, 95% CI: 0.15-0.85), Black (OR = 0.42, 95% CI: 0.18-0.98), and Latina (OR = 0.22, 95% CI: 0.09-0.53) lesbian women also had significantly lower adjusted odds of obtaining contraceptive counseling relative to White heterosexual women. Conclusions: Policies, programs, and practices that facilitate access to person-centered contraceptive care among marginalized sexual orientation identity and racial/ethnic subgroups of U.S. women are needed to promote reproductive health equity.

"The Health System Just Wasn't Built for Us": Queer Cisgender Women and Gender Expansive Individuals' Strategies for Navigating Reproductive Health Care

BACKGROUND

The LGBTQ health disparities literature documents barriers to comprehensive and queer-inclusive care. Queer cisgender women and gender expansive individuals assigned female at birth experience myriad health disparities related to reproductive health, in part owing to the health care system. However, few studies have examined how queer individuals cope with and overcome barriers to queer-competent reproductive health care. This study aims to understand the strategies queer cisgender women and gender expansive individuals use to meet their reproductive health needs.

METHODS

Investigators conducted interviews with 22 queer cisgender women and gender expansive individuals assigned female at birth about their experiences seeking reproductive health care services. We used inductive coding and thematic analysis to identify themes related to meeting reproductive health and health care needs.

RESULTS

Findings highlight the prevalence of negative and harmful experiences while seeking reproductive health care. In response to these negative experiences, individuals developed active strategies to meet their health needs, including seeking information and community, seeking alternative models of care, and managing identity disclosure. Importantly, these strategies varied in effectiveness, depending on participants' social and economic advantage.

CONCLUSIONS

Queer individuals face numerous barriers to queer-competent reproductive health care when seeking reproductive health services. While queer patients are often resilient and creative, developing strategies to get their needs met, the presence of such strategies highlights the need for structural changes in the health system to better serve queer patients.

Correlates of sexual minority women's sexual behavior

Sexual minority women (SMW) experience sociocultural barriers to healthcare access and utilization. A common misconception is that SMW are at lower risk for sexually transmitted infections (STIs). Such stereotypes, coupled with prioritization of reproductive health care for heterosexual women and STI prevention for men, contribute to fewer STI testing and appropriate reproductive examinations for SMW. Thus, this study examined SMW's current sexual behaviors, protective mechanisms, and STI history. Data was collected 2018 and 2019 during a weekend festival. Utilizing the cross-sectional design, 90 surveys were completed. The findings indicated that 70% of respondents were not utilizing protective mechanisms for same-sex behaviors; 13% had never been tested for an STI; and of those tested, 1 in 4 were diagnosed with an STI in their lifetime. Participants that engaged in bisexual behaviors were more likely to engage in genital-to-genital repetitive contact (p < .05). SMW with higher education were more likely to be screened for STIs (p < .01). This study highlights the variation of sexual and testing behaviors that SMW exhibit. Safer sex information and STI testing aimed at SMW should be led by healthcare providers. Thus, a national training curriculum geared toward healthcare providers to promote culturally appropriate care is suggested.

Pregnancy (im)possibilities: identifying factors that influence sexual minority women's pregnancy desires

Sexual minority women (SMW) face both increased risk for unintended pregnancy and barriers to achieving wanted pregnancy, but little research investigates SMW's pregnancy desires. To fill this gap, we conducted five focus groups and 11 in-depth interviews with 20-30-year-old SMW in three US cities. Findings highlight that the heteronormative pregnancy planning paradigm lacks salience for SMW. While some SMW clearly wish to avoid pregnancy, many others are unsure, and factors influencing this uncertainty include relationship context, anticipating logistical barriers, and discord between queer identity and pregnancy.

Sexual Minority Women and Contraceptive Use: Complex Pathways Between Sexual Orientation and Health Outcomes

Compared with their heterosexual peers, sexual minority women (SMW; e.g., queer, bisexual, lesbian, pansexual) have an elevated risk for unintended pregnancy.A team of social science and clinical researchers qualitatively documented the multilevel pathways leading to this disparity, particularly the contexts of contraceptive use. From August 2017 to April 2018, we conducted focus groups and interviews with young adult cisgender SMW in 3 cities: Chicago, Illinois; Madison, Wisconsin; and Salt Lake City, Utah.Most participants reported experience with both penile-vaginal intercourse and contraception. However, they faced several queer-specific barriers to preventing unwanted pregnancy, including a comparative lack of self-concept as contraceptive users, fear of stigma from both queer and health care communities, use of less-effective methods because of infrequent penile-vaginal intercourse and a sense that longer-acting methods were "overkill," and previous experiences of discrimination such as homophobia and gender-based violence. However, participants also reported ways that contraception could align with queer identity, including both taking advantage of noncontraceptive benefits and framing contraception as sex- and queer-positive. These facilitators can inform future efforts to help SMW better meet their pregnancy prevention needs.