Multidisciplinary approach to imaging for gender-affirming surgery: engaging surgeons, radiologists, and patients to ensure a positive imaging experience

Improving radiology information systems for inclusivity of transgender and gender-diverse patients: what are the problems and what are the solutions? A systematic review

INTRODUCTION

In medical radiation science (MRS), radiology information systems (RISs) record patient information such as name, gender and birthdate. The purpose of RISs is to ensure the safety and well-being of patients by recording patient data accurately. However, not all RISs appropriately capture gender, sex or other related information of transgender and gender-diverse (TGD) patients, resulting in non-inclusive and discriminatory care. This review synthesises the research surrounding the limitations of RISs preventing inclusivity and the features required to support inclusivity and improve health outcomes.

METHODS

Studies were retrieved from three electronic databases (Scopus, PubMed and Embase). A quality assessment was performed using the Johns Hopkins Nursing Evidence-Based Practice Research and Non-Research Evidence Appraisal Tools. A thematic analysis approach was used to synthesise the included articles.

RESULTS

Eighteen articles were included based on the predetermined eligibility criteria. The pool of studies included in this review comprised primarily of non-research evidence and reflected the infancy of this research field and the need for further empirical evidence. The key findings of this review emphasise how current systems do not record the patient's name and pronouns appropriately, conflate sex and gender and treat sex and gender as a binary concept.

CONCLUSION

For current systems to facilitate inclusivity, they must implement more comprehensive information and data models incorporating sex and gender and be more flexible to accommodate the transient and fluid nature of gender. However, implementation of these recommendations is not without challenges. Additionally, further research focused on RISs is required to address the unique challenges MRS settings present to TGD patients.

Educating Radiology Stakeholders on Relevant Health Issues and Terminology Regarding LGBTQIA+ Patients in 2023

RATIONALE AND OBJECTIVES

Over 20% of the Lesbian, Gay, Bisexual, Queer or Questioning, Intersex, Asexual or Ally, and more (LGBTQIA+) community reports experiencing discrimination upon accessing health care, causing many to defer access to care and resulting in poorer outcomes. While members of this community routinely undergo imaging studies, little formal education exists within the field of radiology to review the unique health care needs of this population and the specific relevance to imaging, in addition to actionable methods to promote inclusion.

MATERIALS AND METHODS

A 1-hour educational conference was held for a cohort of radiology resident physicians at our institution, in which topics including LGBTQIA+ health care disparities, clinical nuances relevant to the field of radiology, and actionable suggestions that both academic and private-practice centers can adopt to foster inclusion were presented. All attendees were required to complete a 12-question, multiple-choice preconference and postconference examination.

RESULTS

Median prelecture and postlecture quiz scores for four first-year radiology residents were 29% and 75%, for two second-year radiology residents were 29% and 63%, for two third-year radiology residents were 17% and 71%, and for three fourth-year radiology residents were 42% and 80%.

CONCLUSION

Multiple areas of opportunity to foster LGBTQIA+ inclusion at the provider and administration levels currently exist throughout the field of radiology. A radiology-focused education module regarding clinical nuances, health care inequities, and ways to foster an inclusive environment with the LGBTQIA+ community is an effective way to promote learner knowledge.

Journeying Through the Hurdles of Gender-Affirming Care Insurance: A Literature Analysis

Gender-affirming surgery (GAS) has been proven to be successful in the treatment of gender dysphoria. The benefits of providing insurance coverage for transition-related surgeries far surpass the costs of suffering from persistent gender dysphoria, including many positive health outcomes such as decreased rates of substance use, psychiatric illness, and suicide. Despite being deemed a medical necessity, discrepancies in access to treatment and insurance coverage for GAS persist. The purpose of this review is to understand the impact of limited insurance coverage on the well-being of transgender patients. A comprehensive search was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in SCOPUS and PubMed databases using the terms "insurance" AND "gender affirming surgery." Articles in non-English languages were excluded. Data related to variations in insurance coverage for GAS in the United States were collected. Of the 67 articles reviewed, 29 met the inclusion criteria. When compared to the general population, individuals who identify as transgender have higher rates of being uninsured as of 2020, with only 30 states in the United States providing insurance coverage for transgender and gender non-binary people. Of the 30 states, only 18 provide coverage for GAS, with chondrolaryngoplasty having the highest prevalence of coverage. As evidenced in our review, the persistence of complex insurance regulations impedes transgender individuals' access to equitable care. Overall, this literature review elucidates the variability in insurance coverage as it relates to gender-affirming care. Furthermore, this review highlights the need for additional health policy reforms, in addition to improving physician awareness regarding the hurdles of navigating the insurance world as a transgender patient.

Imaging Care for Transgender and Gender Diverse Patients: Best Practices and Recommendations

Transgender and gender diverse (TGD) people experience health disparities, and many avoid necessary medical care because of fears of discrimination or mistreatment. Disparate care is further compounded by limited understanding of gender-affirming hormone therapy (GAHT) and gender-affirming surgery among the medical community. Specific to radiology, TGD patients report more negative imaging experiences than negative general health encounters, highlighting the need for guidance and best practices for inclusive imaging care. A patient's imaging journey provides numerous opportunities for improvement. Inclusive practice in a radiology department starts with ordering and scheduling the examination, facilitated by staff education on appropriate use of a patient's chosen name, gender identity, and pronouns. Contemporary electronic health record systems have the capacity for recording detailed sexual orientation and gender identity data, but staff must be trained to solicit and use this information. A welcoming environment can help TGD patients to feel safe during the imaging experience and may include institutional nondiscrimination policies, gender-neutral signage, and all-gender single-user dressing rooms and bathrooms. Image acquisition should be performed using trauma-informed and patient-centered care. Finally, radiologists should be aware of reporting considerations for TGD patients, such as avoiding the use of gender in reports when it is not medically relevant and using precise, respectful language for findings related to GAHT and gender-affirming surgical procedures. As a field, radiology has a range of opportunities for improving care delivery for TGD patients, and the authors summarize recommended best practices. See the invited commentary by Stowell in this issue. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Re-defining gender diversity through an equitable and inclusive lens

Gender diversity in radiology has centered on the societal construct of the gender binary, with significant work focused on increasing the number of women in radiology. Along with this critically important goal, it is imperative that we acknowledge gender is more expansive than a binary category because it represents a spectrum of gender identities. The discussion of this spectrum is lacking in our conversations around gender diversity and equity in radiology. Addressing equity for people of all gender identities is beneficial for us all. We define three key areas of focus: (1) improving fundamental knowledge about gender diversity and application of this knowledge in education, (2) recruiting and retaining gender-diverse physicians and (3) specific diversity, equity and inclusion (DEI) policy to support gender-affirming environments. Improved understanding and inclusion of the full spectrum of gender in these areas will improve diversity and equity, and, in turn, enhance creativity and innovation in radiology.

Gender-Inclusive Fellowship Naming and Equity, Diversity, and Inclusion in Radiology: An Analysis of Radiology Department Websites in Canada and the United States

Purpose: Transgender and gender non-binary (TGNB) individuals face numerous inequalities in healthcare and there is substantial work to be done in fostering TGNB culturally competent care in radiology. A radiology department's online presence and use of gender-inclusive language are essential in promoting an environment of equity, diversity, and inclusion (EDI). The naming of radiology fellowships and continuing medical education (CME) courses with terminology such as "Women's Imaging" indicates a lack of inclusivity to TGNB patients and providers, which could result in suboptimal patient care. Methods: We conducted a cross-sectional analysis of all institutions in Canada and the United States (US) offering training in Breast Imaging, Women's Imaging, or Breast and Body Imaging. Data was collected from each institution's radiology department website pertaining to fellowship names, EDI involvement, and CME courses. Results: 8 Canadian and 71 US radiology fellowships were identified. 75% of Canadian and 90% of US fellowships had gender-inclusive names. One (12.5%) Canadian and 29 (41%) US institutions had EDI Committees mentioned on their websites. Among institutions publicly displaying CME courses about breast/body or women's imaging, gender-inclusive names were used in only 1 (25%) of the Canadian CME courses, compared to 81% of the US institutions. Conclusions: Most institutions in Canada and the US have gender-inclusive names for their radiology fellowships pertaining to breast and body imaging. However, there is much opportunity to and arguably the responsibility for institutions in both countries to increase the impact and visibility of their EDI efforts through creation of department-specific committees and CME courses.