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Valentine SE, Gell-Levey IM, Godfrey LB, Livingston NA. The Associations Between Gender Minority Stressors and PTSD Symptom Severity Among Trauma-Exposed Transgender and Gender Diverse Adults. J Trauma Dissociation 2024; 25:422-435. [PMID: 38436077 PMCID: PMC11192609 DOI: 10.1080/15299732.2024.2323977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 11/20/2023] [Indexed: 03/05/2024]
Abstract
This study investigates associations between minority stressors, traumatic stressors, and post-traumatic stress disorder (PTSD) symptom severity in a sample of transgender and gender diverse (TGD) adults. We utilized surveys and clinical interview assessments to assess gender minority stress exposures and responses, and PTSD. Our sample (N = 43) includes adults who identified as a minoritized gender identity (i.e., 39.5% trans woman or woman, 25.6% trans man or man, 23.3% genderqueer or nonbinary, 11.6% other identity). All participants reported at least one traumatic event (i.e., life threat, serious injury, or sexual harm). The most common trauma events reported by the sample were sexual (39.5%) and physical violence (37.2%), with 40.9% of participants anchoring their symptoms to a discrimination-based event. PTSD symptom severity was positively correlated with both distal (r = 0.36, p = .017) and proximal minority stressors (r = 0.40, p < .01). Distal minority stress was a unique predictor of current PTSD symptom severity (b = 0.94, p = .017), however, this association was no longer significant when adjusting for proximal minority stress (b = 0.18, p = 0.046). This study suggests that minority stress, especially proximal minority stress, is associated with higher PTSD symptom severity among TGD adults.
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Affiliation(s)
- Sarah E. Valentine
- Department of Psychiatry, Boston Medical Center, Boston, MA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA
| | | | | | - Nicholas A. Livingston
- Department of Psychiatry, Boston University School of Medicine, Boston, MA
- National Center for PTSD, Behavioral Science Division, Boston, MA
- US Department of Veteran Affairs, VA Boston Healthcare System, Boston, MA
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Godwin EG, Moore LM, Sansfaçon AP, Nishman MM, Rosal MC, Katz-Wise SL. Experiences of cisgender youth with a transgender and/or nonbinary sibling. FAMILY PROCESS 2024; 63:1025-1045. [PMID: 38171537 DOI: 10.1111/famp.12957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 10/15/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024]
Abstract
While recent research has begun to address the effects of family support on transgender and/or nonbinary youth (TNY), almost no studies have directly examined how cisgender siblings in families with TNY navigate their sibling's gender disclosure and affirmation within both their families and their larger communities. We conducted an exploratory secondary analysis of in-person, semi-structured interviews with 15 adolescent and young adult siblings (age 13-24 years) of TNY from the northeastern United States from the baseline wave of the community-based, longitudinal, mixed methods Trans Teen and Family Narratives Project. Interview transcripts were analyzed using immersion/crystallization and template organizing approaches. Analyses yielded three main themes: gender-related beliefs and knowledge, peri- and post-disclosure family dynamics, and assessing responses to their sibling. Subthemes included anticipation of their sibling's TN identity, expectations post-disclosure, participants' level of involvement in gender-related family processes, perceptions of changes in family relationships, concern for their sibling (including a high degree of attunement to gender-affirming name and pronoun usage), and concern for themselves. Findings from this study suggest the need to engage directly with siblings of TNY to further elucidate their intrapersonal, intra-familial, and extra-familial experiences related to having a TN sibling and determine their unique support needs. Implications for families, clinicians, and communities are discussed.
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Affiliation(s)
- Eli G Godwin
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Lb M Moore
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Annie Pullen Sansfaçon
- School of Social Work and the Centre for Public Health Research, University of Montréal, Montréal, Quebec, Canada
| | | | - Milagros C Rosal
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Sabra L Katz-Wise
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Juster RP, Rutherford C, Keyes K, Hatzenbuehler ML. Associations Between Structural Stigma and Allostatic Load Among Sexual Minorities: Results From a Population-Based Study. Psychosom Med 2024; 86:157-168. [PMID: 38345315 DOI: 10.1097/psy.0000000000001289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
OBJECTIVE Structural forms of stigma and discrimination are associated with adverse health outcomes across numerous stigmatized groups, including lesbian, gay, and bisexual (LGB) individuals. However, the biological consequences of structural stigma among LGB populations are understudied. To begin to address this gap, we assessed associations between indicators of structural stigma (i.e., state-level policies) targeting LGB individuals and allostatic load (AL) indices representing physiological dysregulations. METHODS Pooled data from the continuous 2001-2014 National Health and Nutritional Examination Survey were analyzed (LGB: n = 864; heterosexual: n = 20,310). Ten state-level LGB-related policies (e.g., employment nondiscrimination protections, same-sex marriage) were used to operationalize structural stigma. A sex-specific AL index representing 11 immune, metabolic, and cardiovascular biomarkers was estimated. Multilevel models were used to examine associations between structural stigma and AL, net of nine individual-level characteristics (e.g., education, race/ethnicity, age, and health behaviors). RESULTS Sexual minority men living in states with low levels of structural stigma experienced significantly lower AL ( β = -0.45, p = .02) compared with sexual minority men living in states with high structural stigma (i.e., fewer protective policies). There was no significant association between structural stigma and AL among sexual minority women. CONCLUSIONS By demonstrating direct associations between structural stigma and indices of physiological dysregulation, our findings provide a mechanistic understanding of how the social environment can "get under the skin and skull" for sexual minority men in the United States. Future research should explore whether these mechanisms generalize to other marginalized groups exposed to structural stigma.
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Affiliation(s)
- Robert-Paul Juster
- From the Department of Psychiatry and Addiction (Juster), University of Montreal; Research Center of the Montreal Mental Health University Institute (Juster), Montreal, Quebec, Canada; Department of Epidemiology, Mailman School of Public Health, Columbia University (Rutherford, Keyes), New York, New York; and Department of Psychology, Harvard University (Hatzenbuehler), Cambridge, Massachusetts
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Lad SU, Sinopoli J, Khong B, Conroy B, Perzynski AT, Del Rincon JP. Clinical and sociodemographic characteristics as predictors for quality of life in transmasculine and transfeminine individuals receiving gender-affirming hormone therapy. Soc Sci Med 2024:116734. [PMID: 38490912 DOI: 10.1016/j.socscimed.2024.116734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 02/14/2024] [Accepted: 02/26/2024] [Indexed: 03/17/2024]
Abstract
Healthcare systems and providers have increasingly acknowledged the role and impact of social determinants in overall health. However, gender-diverse individuals face persistent health disparities due to their identities. There is limited research on the impact of clinical and sociodemographic characteristics on mood and quality of life (QoL) for transgender (TG) individuals. Our study aims to understand and better elucidate social and clinical characteristics of transmasculine (TM) and transfeminine (TF) individuals and their impact on quality of life and depressive symptoms. In this cross-sectional study, 298 TF and TM individuals on gender-affirming hormone therapy (GAHT) were surveyed about their demographic characteristics (age, gender identity, body mass index (BMI), and education), social needs, mood, and quality of life. Multivariable regression modelling was performed to assess the effect of each variable listed above on three domains of QoL (psychological, environmental, and physical) as well as depressive symptoms. We find that QoL scores are similar between TM and TF individuals, with scores in the psychological domain particularly low in both cohorts. TM individuals report higher rates of stress and restroom avoidance than TF individuals. In particular, psychological well-being (measured by the psychological domain of QoL and depressive symptoms) is significantly associated with increased BMI, financial instability, and stress in TM individuals while for TF individuals, psychological well-being is associated with stress and social integration. These data suggest that social circumstances are key drivers of QoL and psychological well-being among gender-diverse individuals receiving GAHT with specific differences between TF and TM individuals. This information may be utilized by healthcare providers and policymakers to address and improve clinical care and social policies to improve health equity for gender-diverse individuals.
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Affiliation(s)
- Saloni U Lad
- Cleveland Clinic Lerner College of Medicine, 9501 Euclid Ave., Cleveland, OH, 44195, USA.
| | - Jacob Sinopoli
- The Chester Summer Scholars Program, MetroHealth Medical System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA; Case Western Reserve University, Cleveland, OH, USA.
| | - Brian Khong
- Department of Medicine, MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
| | - Britt Conroy
- Case Western Reserve University, Cleveland, OH, USA; Department of Urology and Family Medicine & Community Health, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, 44106, USA.
| | - Adam T Perzynski
- Center for Healthcare Research and Policy, Case Western Reserve University at MetroHealth, 10900 Euclid Ave., Cleveland, OH, 44106, USA.
| | - Juan P Del Rincon
- Case Western Reserve University, Cleveland, OH, USA; Department of Medicine, MetroHealth System, Cleveland, OH, USA; Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA.
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5
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Price MA, Hollinsaid NL, McKetta S, Mellen EJ, Rakhilin M. Structural transphobia is associated with psychological distress and suicidality in a large national sample of transgender adults. Soc Psychiatry Psychiatr Epidemiol 2024; 59:285-294. [PMID: 37165214 PMCID: PMC10171731 DOI: 10.1007/s00127-023-02482-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 04/17/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Transgender adults face increasingly discriminatory laws/policies and prejudicial attitudes in many regions of the United States (US), yet research has neither quantified state-level transphobia using indicators of both, nor considered their collective association with transgender adults' psychological wellbeing, hindering the identification of this potential social determinant of transgender mental health inequity. METHODS We therefore used factor analysis to develop a more comprehensive structural transphobia measure encompassing 29 indicators of transphobic laws/policies and attitudes at the state level, which we linked to individual-level mental health data from a large national sample of 27,279 transgender adults (ages 18-100) residing in 45 US states and the District of Columbia (DC). RESULTS Controlling for individual- (i.e., demographics), interpersonal- (i.e., perceived discrimination), and state- (i.e., income inequality, religiosity) level covariates, transgender adults from US states with higher (vs. lower) levels of structural transphobia reported more severe past-month psychological distress and were more likely to endorse past-year and lifetime suicidal thoughts, plans, and attempts. CONCLUSION Findings provide novel evidence that state-level transphobic laws/policies and attitudes collectively shape a range of important mental health outcomes among transgender adults in the US. Multilevel intervention strategies, such as affirming mental health treatments, provider-training interventions, and supportive legislation, are needed to address structural transphobia's multifaceted nature and negative mental health consequences.
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Affiliation(s)
- Maggi A Price
- School of Social Work, Boston College, McGuinn Hall 126, 275 Beacon St., Chestnut Hill, MA, 02467, USA.
- Department of Psychology, Harvard University, Cambridge, MA, USA.
| | | | - Sarah McKetta
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
| | - Emily J Mellen
- Department of Psychology, Harvard University, Cambridge, MA, USA
| | - Marina Rakhilin
- School of Social Work, Boston College, McGuinn Hall 126, 275 Beacon St., Chestnut Hill, MA, 02467, USA
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Hatzenbuehler ML, Lattanner MR, McKetta S, Pachankis JE. Structural stigma and LGBTQ+ health: a narrative review of quantitative studies. Lancet Public Health 2024; 9:e109-e127. [PMID: 38307678 DOI: 10.1016/s2468-2667(23)00312-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 02/04/2024]
Abstract
Health disparities related to sexual orientation and gender identity exist across multiple outcomes. Scholarship has begun to evaluate whether structural stigma-ie, societal-level conditions, cultural norms, and institutional policies that constrain opportunities, resources, and wellbeing-contributes to health burdens among LGBTQ+ individuals. We conducted a comprehensive review of quantitative studies examining this hypothesis. We found 98 articles that linked objective (ie, non-self-reported) measures of structural stigma to mental (n=57), behavioural (ie, substance use; n=27; HIV/AIDS or sexually transmitted infection; n=20), and physical (n=20) health outcomes. There was generally consistent evidence that structural stigma increases risk of poor health among LGBTQ+ individuals. Several methodological strengths were identified, including the use of multiple measures (eg, laws or policies [59%, 58 of 98]), designs (eg, quasi-experiments [21%, 21 of 98]), and samples (eg, probability-based [56%, 55 of 98]). However, important gaps exist. Just over half of studies included area-level covariates or non-LGBTQ+ comparison groups, which are necessary to address alternative explanations for the observed associations. Additionally, while studies (n=90) have begun to identify candidate mechanisms, only nine (10%) formally tested mediation. We offer suggestions for future research to advance this literature, which has implications not only for the identification of structural determinants of LGBTQ+ health but also for the development of public health interventions that reduce LGBTQ+ health disparities.
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Affiliation(s)
| | - Micah R Lattanner
- Department of Public Health, Santa Clara University, Santa Clara, CA, USA
| | - Sarah McKetta
- Department of Population Medicine, Harvard University, Boston, MA, USA
| | - John E Pachankis
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
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Singh RS, Landes SJ, Willging CE, Abraham TH, McFrederick P, Kauth MR, Shipherd JC, Kirchner JE. Implementation of LGBTQ+ affirming care policies in the Veterans Health Administration: preliminary findings on barriers and facilitators in the southern United States. Front Public Health 2024; 11:1251565. [PMID: 38352130 PMCID: PMC10861648 DOI: 10.3389/fpubh.2023.1251565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 12/14/2023] [Indexed: 02/16/2024] Open
Abstract
Background In the United States Department of Veterans Affairs (VA), veterans who are lesbian, gay, bisexual, transgender, queer, and similar gender and sexual minoritized people (LGBTQ+) experience health disparities compared to cisgender, heterosexual veterans. VA's LGBTQ+ Health Program created two healthcare policies on providing LGBTQ+ affirming care (healthcare that is inclusive, validating, and understanding of the LGBTQ+ population). The current project examines providers' barriers and facilitators to providing LGBTQ+ affirming care and LGBTQ+ veterans' barriers and facilitators to receiving LGBTQ+ affirming care. Methods Data collection and analysis were informed by the Consolidated Framework for Implementation Research, which was adapted to include three health equity domains. Data collection involved telephone interviews conducted with 11 VA providers and 12 LGBTQ+ veterans at one rural and one urban VA medical center, and one rural VA community clinic. Qualitative data were rapidly analyzed using template analysis, a data reduction technique. Results Providers described limited education, limited time, lack of experience with the population, and a lack of awareness of resources as barriers. Providers discussed comfort with consulting trusted peers, interest in learning more about providing LGBTQ+ affirming care, and openness and acceptance of the LGBTQ+ community as facilitators. LGBTQ+ veterans described a lack of provider awareness of their needs, concerns related to safety and discrimination, and structural discrimination as barriers. LGBTQ+ veterans described positive relationships with providers, knowledge of their own healthcare needs, and ability to advocate for their healthcare needs as facilitators. Although VA's LGBTQ+ affirming care policies are in place, providers and veterans noted a lack of awareness regarding specific healthcare processes. Conclusion Allowing more time and capacity for education and engaging LGBTQ+ veterans in determining how to improve their healthcare may be the path forward to increase adherence to LGBTQ+ affirming care policies. Engaging patients, especially those from marginalized backgrounds, in strategies focused on the uptake of policy may be a path to improve policy implementation. It is possible that creating truly collaborative structures in which patients, staff, providers, leadership, and policymakers can work together towards policy implementation may be a useful strategy. In turn, improved policy implementation would result in increased physical and mental health for LGBTQ+ veterans.
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Affiliation(s)
- Rajinder Sonia Singh
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
- South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States
| | - Sara J. Landes
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
- South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States
| | - Cathleen E. Willging
- Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, NM, United States
| | - Traci H. Abraham
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States
- Clinical Outcome Assessments, Clinical Outcomes Solutions, Chicago, IL, United States
| | - Pamela McFrederick
- South Central VA Health Care Network, Ridgeland, MS, United States
- LGBTQ+ Health Program, Department of Veterans Affairs, Washington, DC, United States
| | - Michael R. Kauth
- LGBTQ+ Health Program, Department of Veterans Affairs, Washington, DC, United States
- Baylor College of Medicine, Houston, TX, United States
| | - Jillian C. Shipherd
- LGBTQ+ Health Program, Department of Veterans Affairs, Washington, DC, United States
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States
| | - JoAnn E. Kirchner
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
- South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States
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Zubizarreta D, Trinh MH, Reisner SL. Quantitative approaches to measuring structural cisgenderism. Soc Sci Med 2024; 340:116437. [PMID: 38000173 DOI: 10.1016/j.socscimed.2023.116437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023]
Abstract
There is rapidly growing interest in understanding the impacts of structural cisgenderism on health and health inequities for transgender and nonbinary populations. This growing interest has led to an influx of novel measures of structural cisgenderism. In this commentary, we discuss and identify gaps in existing measures and offer considerations for the development of future measures. Developing and utilizing valid measures of structural cisgenderism is crucial to quantify its impacts on health and health inequities, and to inform public health interventions, laws, and policies to eliminate gender identity and modality-based health inequities.
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Affiliation(s)
- Dougie Zubizarreta
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Mai-Han Trinh
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sari L Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA, USA; The Fenway Institute, Fenway Health, Boston, MA, USA
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Zollweg SS, Belloir JA, Drabble LA, Everett B, Taylor JY, Hughes TL. Structural stigma and alcohol use among sexual and gender minority adults: A systematic review. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 8:100185. [PMID: 37663525 PMCID: PMC10474584 DOI: 10.1016/j.dadr.2023.100185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 08/06/2023] [Accepted: 08/16/2023] [Indexed: 09/05/2023]
Abstract
Background Sexual and gender minority (SGM) people are more likely than their cisgender, heterosexual counterparts to report negative alcohol-related outcomes. Although the association between individual- and interpersonal-level minority stressors and negative alcohol-related outcomes among SGM people is well-established, structural-level minority stressors are understudied. This systematic review examined structural-level stigma and alcohol-related outcomes among SGM people to inform future research, interventions, and policy. Methods We used five electronic databases to search for studies published between January 2010 and May 2022 that examined associations between structural stigma and alcohol use among SGM adults in the United States. Peer-reviewed, quantitative studies available in English were included. We conducted quality appraisal using the Joanna Briggs Institute checklist. Results The final sample included 11 studies. Overall, there was moderate to strong support for a positive association between structural stigma and negative alcohol-related outcomes among SGM people, with differences by gender, sexual identity, race, and ethnicity. All studies used cross-sectional designs, and nearly half utilized non-probability samples. Transgender and nonbinary people, SGM people of color, and sexual identity subgroups beyond gay, lesbian, and heterosexual were underrepresented. Structural stigma was most commonly measured as a state-level index. Alcohol measures were heterogeneous. Multilevel stigma and resiliency factors were understudied. Conclusions Addressing structural stigma is critical in reducing negative alcohol-related outcomes and inequities among SGM people. Research is needed that includes probability samples, longitudinal designs, and samples that reflect the diversity of SGM people. Future studies should examine the influence of multilevel stigma and resiliency factors on alcohol-related outcomes.
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Affiliation(s)
- Sarah S. Zollweg
- Columbia University School of Nursing, 560 W. 168th St., New York, NY, 10032, USA
- National Clinician Scholars Program, David Geffen School of Medicine, University of California, Los Angeles, CA, 1100 Glendon Ave, Suite 900, Los Angeles, CA 90024
| | - Joseph A. Belloir
- Columbia University School of Nursing, 560 W. 168th St., New York, NY, 10032, USA
| | - Laurie A. Drabble
- San Jose State University College of Health and Human Sciences, One Washington Square, San Jose, CA, 95192, USA
- Alcohol Research Group, Public Health Institute, 6001 Shellmound St., #450, Emeryville, CA, 94608, USA
| | - Bethany Everett
- University of Utah, Department of Sociology, 380 S. 1530 E, Salt Lake City, UT, 84112, USA
| | - Jacquelyn Y. Taylor
- Columbia University School of Nursing, 560 W. 168th St., New York, NY, 10032, USA
| | - Tonda L. Hughes
- Columbia University School of Nursing, 560 W. 168th St., New York, NY, 10032, USA
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10
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Tran NK, Lunn MR, Schulkey CE, Tesfaye S, Nambiar S, Chatterjee S, Kozlowski D, Lozano P, Randal FT, Mo Y, Qi S, Hundertmark E, Eastburn C, Pho AT, Dastur Z, Lubensky ME, Flentje A, Obedin-Maliver J. Prevalence of 12 Common Health Conditions in Sexual and Gender Minority Participants in the All of Us Research Program. JAMA Netw Open 2023; 6:e2324969. [PMID: 37523187 PMCID: PMC10391317 DOI: 10.1001/jamanetworkopen.2023.24969] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Abstract
Importance Limited data describe the health status of sexual or gender minority (SGM) people due to inaccurate and inconsistent ascertainment of gender identity, sex assigned at birth, and sexual orientation. Objective To evaluate whether the prevalence of 12 health conditions is higher among SGM adults in the All of Us Research Program data compared with cisgender heterosexual (non-SGM) people. Design, Setting, and Participants This cross-sectional study used data from a multidisciplinary research consortium, the All of Us Research Program, that links participant-reported survey information to electronic health records (EHR) and physical measurements. In total, 372 082 US adults recruited and enrolled at an All of Us health care provider organization or by directly visiting the enrollment website from May 31, 2017, to January 1, 2022, and were assessed for study eligibility. Exposures Self-identified gender identity and sexual orientation group. Main Outcomes and Measures Twelve health conditions were evaluated: 11 using EHR data and 1, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), using participants' physical measurements. Logistic regression (adjusting for age, income, and employment, enrollment year, and US Census division) was used to obtain adjusted odds ratios (AORs) for the associations between each SGM group and health condition compared with a non-SGM reference group. Results The analytic sample included 346 868 participants (median [IQR] age, 55 [39-68] years; 30 763 [8.9%] self-identified as SGM). Among participants with available BMI (80.2%) and EHR data (69.4%), SGM groups had higher odds of anxiety, depression, HIV diagnosis, and tobacco use disorder but lower odds of cardiovascular disease, kidney disease, diabetes, and hypertension. Estimated associations for asthma (AOR, 0.39 [95% CI, 0.24-0.63] for gender diverse people assigned male at birth; AOR, 0.51 [95% CI, 0.38-0.69] for transgender women), a BMI of 25 or higher (AOR, 1.65 [95% CI, 1.38-1.96] for transgender men), cancer (AOR, 1.15 [95% CI, 1.07-1.23] for cisgender sexual minority men; AOR, 0.88 [95% CI, 0.81-0.95] for cisgender sexual minority women), and substance use disorder (AOR, 0.35 [95% CI, 0.24-0.52] for gender diverse people assigned female at birth; AOR, 0.65 [95% CI, 0.49-0.87] for transgender men) varied substantially across SGM groups compared with non-SGM groups. Conclusions and Relevance In this cross-sectional analysis of data from the All of Us Research Program, SGM participants experienced health inequities that varied by group and condition. The All of Us Research Program can be a valuable resource for conducting health research focused on SGM people.
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Affiliation(s)
- Nguyen K Tran
- The PRIDE Study/PRIDEnet, Departments of Medicine and of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Mitchell R Lunn
- The PRIDE Study/PRIDEnet, Departments of Medicine and of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - Claire E Schulkey
- All of Us Research Program, Office of the Director, National Institutes of Health, Bethesda, Maryland
| | | | | | | | | | - Paula Lozano
- Center for Asian Health Equity, The University of Chicago Medicine, Chicago, Illinois
- Asian Health Coalition, Chicago, Illinois
| | - Fornessa T Randal
- Center for Asian Health Equity, The University of Chicago Medicine, Chicago, Illinois
- Asian Health Coalition, Chicago, Illinois
| | - Yicklun Mo
- Center for Asian Health Equity, The University of Chicago Medicine, Chicago, Illinois
- Asian Health Coalition, Chicago, Illinois
| | - Siya Qi
- Center for Asian Health Equity, The University of Chicago Medicine, Chicago, Illinois
- Asian Health Coalition, Chicago, Illinois
| | - Ell Hundertmark
- The PRIDE Study/PRIDEnet, Departments of Medicine and of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
- Division of Gynecology and Gynecologic Specialties, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Chloe Eastburn
- The PRIDE Study/PRIDEnet, Departments of Medicine and of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
- Los Angeles LGBT Center, Los Angeles, California
| | - Anthony T Pho
- The PRIDE Study/PRIDEnet, Departments of Medicine and of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Zubin Dastur
- The PRIDE Study/PRIDEnet, Departments of Medicine and of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
- Division of Gynecology and Gynecologic Specialties, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Micah E Lubensky
- The PRIDE Study/PRIDEnet, Departments of Medicine and of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
- Department of Community Health Systems, University of California, San Francisco
| | - Annesa Flentje
- The PRIDE Study/PRIDEnet, Departments of Medicine and of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
- Department of Community Health Systems, University of California, San Francisco
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Juno Obedin-Maliver
- The PRIDE Study/PRIDEnet, Departments of Medicine and of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
- Division of Gynecology and Gynecologic Specialties, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
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11
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Falck F, Bränström R. The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes. BMC Public Health 2023; 23:1031. [PMID: 37259082 DOI: 10.1186/s12889-023-15856-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 05/09/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND According to the minority stress theory, stigma affects the health of marginalized populations. Previous stigma research has focused on the health effects of individual and interpersonal stigma, paying less attention to structural factors. Laws on legal gender recognition affect the lives of transgender individuals in unique ways. The fact that these laws and population attitudes vary greatly between European countries, offer a unique opportunity to study the role of structural stigma in the lives of transgender individuals. Little is known about how transgender specific structural stigma relates to individual health determinants. Consequently, the aim of this study was to explore the association between structural stigma and access to gender affirming care, gender identity disclosure in health care, and experiences of discrimination in health care across 28 European countries. METHODS By using multilevel regression, we combined data on health seeking behavior, transgender identity disclosure to health care providers, and experiences of discrimination in health care from 6,771 transgender individuals participating in the 2012 European Union Lesbian, Gay, Bisexual and Transgender survey with a structural stigma measure, consisting of population attitudes towards transgender individuals as well as national legislation on gender recognition. Reasons to refrain from seeking care and discrimination in health care were assessed by categorizing countries as low or high in structural stigma and using Chi-square statistics. RESULTS Country-level structural stigma was negatively associated experiences of seeking gender affirming care and positively associated with concealment of being transgender to health care providers. Identity concealment was associated with a lower likelihood of exposure to discrimination in the health care setting across countries regardless of their level of structural stigma. The most prevalent reasons to forgo gender affirming care were shared between low and high structural stigma country groups and centered around fear. CONCLUSION The results highlight the importance of changing stigmatizing legislation and population attitudes to promote access to gender affirming care as well as openness of being transgender towards providers. Measures to decrease discrimination in the health care setting are warranted in high as well as in low structural stigma countries.
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Affiliation(s)
- Felicitas Falck
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, CAP Research Centre, Stockholm, Sweden.
- ANOVA Clinic, Karolinska University Hospital Stockholm, Norra Stationsgatan 69, 171 76, Stockholm, Sweden.
| | - Richard Bränström
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Nobels väg 9, 17177, Stockholm, Sweden
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12
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Blosnich JR. Costs of (In)visibility: Issues of Disclosure and Data for Health Equity Research with Sexual and Gender Minority Veterans. Health Equity 2023; 7:338-341. [PMID: 37284529 PMCID: PMC10240312 DOI: 10.1089/heq.2023.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 06/08/2023] Open
Abstract
Sexual and gender minority (SGM) veterans experience numerous disparities in health conditions, behavioral risks, and social adversities compared with non-SGM veterans. Although survey data have illuminated these differences, SGM veterans remain largely invisible in administrative data such as electronic health records due to lack of sexual orientation and gender identity information. Administrative data hold promise for propelling SGM health equity research, but several issues must be addressed, including weighing the benefits and threats of visibility for SGM people in data sets that are tied to receipt of services.
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Affiliation(s)
- John R. Blosnich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
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13
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Workman TE, Goulet JL, Brandt CA, Lindemann L, Skanderson M, Warren AR, Eleazer JR, Kronk C, Gordon KS, Pratt-Chapman M, Zeng-Treitler Q. Temporal and Geographic Patterns of Documentation of Sexual Orientation and Gender Identity Keywords in Clinical Notes. Med Care 2023; 61:130-136. [PMID: 36511399 PMCID: PMC9931630 DOI: 10.1097/mlr.0000000000001803] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Disclosure of sexual orientation and gender identity correlates with better outcomes, yet data may not be available in structured fields in electronic health record data. To gain greater insight into the care of sexual and gender-diverse patients in the Veterans Health Administration (VHA), we examined the documentation patterns of sexual orientation and gender identity through extraction and analyses of data contained in unstructured electronic health record clinical notes. METHODS Salient terms were identified through authoritative vocabularies, the research team's expertise, and frequencies, and the use of consistency in VHA clinical notes. Term frequencies were extracted from VHA clinical notes recorded from 2000 to 2018. Temporal analyses assessed usage changes in normalized frequencies as compared with nonclinical use, relative growth rates, and geographic variations. RESULTS Over time most terms increased in use, similar to Google ngram data, especially after the repeal of the "Don't Ask Don't Tell" military policy in 2010. For most terms, the usage adoption consistency also increased by the study's end. Aggregated use of all terms increased throughout the United States. CONCLUSION Term usage trends may provide a view of evolving care in a temporal continuum of changing policy. These findings may be useful for policies and interventions geared toward sexual and gender-diverse individuals. Despite the lack of structured data, the documentation of sexual orientation and gender identity terms is increasing in clinical notes.
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Affiliation(s)
- Terri Elizabeth Workman
- Biomedical Informatics Center, The George Washington University, Washington, DC
- Washington DC VA Medical Center, Washington, DC
| | - Joseph L. Goulet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Cynthia A. Brandt
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Luke Lindemann
- VA Connecticut Healthcare System, West Haven, CT
- Department of Psychology, Yale University, New Haven, CT
| | | | | | - Jacob R. Eleazer
- VA Connecticut Healthcare System PRIME Center, West Haven, CT
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | | | - Kirsha S. Gordon
- VA Connecticut Healthcare System, West Haven, CT
- Yale School of Medicine, New Haven, CT
| | | | - Qing Zeng-Treitler
- Biomedical Informatics Center, The George Washington University, Washington, DC
- Washington DC VA Medical Center, Washington, DC
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14
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Matson TE, Harris AHS, Chen JA, Edmonds AT, Frost MC, Rubinsky AD, Blosnich JR, Williams EC. Influence of a national transgender health care directive on receipt of alcohol-related care among transgender Veteran Health Administration patients with unhealthy alcohol use. J Subst Abuse Treat 2022; 143:108808. [PMID: 35715286 DOI: 10.1016/j.jsat.2022.108808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 04/16/2022] [Accepted: 05/20/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Transgender persons are vulnerable to under-receipt of recommended health care due to chronic exposure to systemic stressors (e.g., discriminatory laws and health system practices). Scant information exists on receipt of alcohol-related care for transgender populations, and whether structural interventions to reduce transgender discrimination in health care improve receipt of recommended treatment. This study evaluated the effect of the Veteran Health Administration (VA) Transgender Healthcare Directive-a national policy to reduce structural discrimination-on receipt of evidence-based alcohol-related care for transgender VA patients with unhealthy alcohol use. METHODS The study used an interrupted time series with control design to compare monthly receipt of alcohol-related care among transgender patients with unhealthy alcohol use (Alcohol Use Disorders Identification Test Consumption ≥5) documented in their electronic health record before (10/1/2009-5/31/2011) and after (7/1/2011-7/31/2017) implementation of VA's Transgender Healthcare Directive. A propensity-score matched sample of non-transgender patients with unhealthy alcohol use served as a comparison group to control for concurrent secular trends. Mixed effects segmented logistic regression models estimated changes in level and slope (i.e., rate of change) in receipt of any evidence-based alcohol-related care, including brief intervention, specialty addictions treatment, and alcohol use disorder medications. RESULTS The matched sample (mean age = 47.5 [SD = 15.0]; 75% non-Hispanic White race/ethnicity) included 2074 positive alcohol screens completed by 1377 transgender patients and 6,l99 positive alcohol screens completed by 6185 non-transgender patients. Receipt of alcohol-related care increased for transgender patients from 78.5% (95% CI: 71.3%-85.6%) at the start of study to 83.0% (75.9%-90.1%) immediately before the directive and decreased slightly from 81.6% (77.4%-85.9%) immediately after the directive to 80.1% (76.8-85.4) at the end of the study. Changes in level and slope comparing periods before and after the directive were not statistically significant, nor were they statistically significantly different from the matched sample of non-transgender patients. CONCLUSIONS Health systems must urgently employ and evaluate policies to address structural stigma that produces and reproduces disparities in health and health care. Although VA's directive was not associated with increased receipt of alcohol-related care, that receipt of alcohol-related care among transgender patients is comparable to non-transgender patients is promising.
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Affiliation(s)
- Theresa E Matson
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Kaiser Permanente Washington Health Research Institute, Seattle, WA 98101, USA.
| | - Alex H S Harris
- Center for Innovation to Implementation, Veterans Affairs (VA) Palo Alto Healthcare System, Menlo Park, CA 94304, USA; Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Jessica A Chen
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA 98195, USA.
| | - Amy T Edmonds
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA.
| | - Madeline C Frost
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA.
| | - Anna D Rubinsky
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94158, USA.
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W. 34(th) St., Los Angeles, CA 90089, USA; Health Services Research & Development (HSR&D) Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA 15219, USA.
| | - Emily C Williams
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA.
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15
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Hollinsaid NL, Price MA, Hatzenbuehler ML. Transgender-Specific Adolescent Mental Health Provider Availability is Substantially Lower in States with More Restrictive Policies. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2022:1-12. [PMID: 36369805 DOI: 10.1080/15374416.2022.2140433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Transgender adolescents experience adversity accessing mental healthcare, which is exacerbated by transgender-specific mental health provider shortages in the United States. Factors associated with variability in transgender-specific mental health provider availability across states - especially at the macro-social level - have yet to be identified, hindering efforts to address these shortages. To remedy this gap, we queried whether transgender-specific adolescent mental health provider availability varied by states' transgender-specific policy climate. METHOD We quantified states' policy climate by factor-analyzing tallies of the presence/absence of 33 transgender-specific state laws/policies in six domains: parental/relationship recognition, nondiscrimination, education, healthcare, criminal justice, and identity documentation. We then tested whether states' transgender-specific policy climate was associated with rates of transgender-specific adolescent mental health providers - identified via Psychology Today - per transgender adolescent in all 50 states and the District of Columbia. RESULTS Transgender-specific adolescent mental health provider availability was substantially lower in states with more restrictive laws/policies for transgender people (rate ratio = 0.65, 95% CI [0.52, 0.81], p = .00017), controlling for state-level conservatism, religiosity, and urbanicity. States' transgender-specific policy climate was unrelated to rates of adolescent Attention-Deficit/Hyperactivity Disorder-specialty providers, Oppositional Defiant Disorder-specialty providers, and youth mental health provider shortages broadly, providing evidence for result specificity. CONCLUSIONS Transgender adolescents appear to have access to considerably fewer transgender-specific mental health providers in states with more restrictive laws/policies for transgender people, which may compound their already high mental health burden in these contexts. Intervention and policy efforts are needed to address these shortages, particularly in states with increasingly prohibitive laws/policies targeting transgender adolescents.
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Affiliation(s)
| | - Maggi A Price
- Department of Psychology, Harvard University
- School of Social Work, Boston College
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16
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Terrell KR, Zeglin RJ, Palmer RE, Niemela DRM, Quinn N. The Tsunamic Model of LGBTQ+ Deaths of Despair: A Systemic Review to Identify Risk Factors for Deaths of Despair Among LGBTQ+ People. JOURNAL OF HOMOSEXUALITY 2022; 69:2167-2187. [PMID: 34085902 DOI: 10.1080/00918369.2021.1935620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The term Deaths of Despair (DOD) was introduced to capture the phenomenon of mortality associated with suicide, drug overdose, and alcoholic liver disease. The LGBTQ+ population consistently evidences disproportionately high rates of DOD. This study reviewed the literature on DOD within this community to create a conceptual model that identifies risk factors that work together to potentiate DOD in the LGBTQ+ community. Ten DOD-Related Factors were identified and used to create The Tsunamic Model of LGBTQ+ Deaths of Despair. DOD-Related Factors include: (1) Stigma, (2) Demographics, (3) Identity Development, (4) Internalized Homophobia, (5) Depression, (6) Victimization, (7) Isolation/Rejection, (8) Sensation Seeking, (9) Risky Behavior, and (10) Uninformed Care. Each factor is associated with increased risk for DOD among the LGBTQ+ community. This model can help health professionals by providing a framework for prevention and early intervention programs.
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Affiliation(s)
- Kassie R Terrell
- Department of Public Health, University of North Florida, Jacksonville, Florida, USA
| | - Robert J Zeglin
- Department of Public Health, University of North Florida, Jacksonville, Florida, USA
| | - Reagan E Palmer
- Department of Public Health, University of North Florida, Jacksonville, Florida, USA
| | - Danielle R M Niemela
- Department of Public Health, University of North Florida, Jacksonville, Florida, USA
| | - Nathan Quinn
- Department of Public Health, University of North Florida, Jacksonville, Florida, USA
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17
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Strenth CR, Pagels P, SoRelle JA, Gonzalez L, Day PG, Gimpel NE, Levy Kamugisha EI, Moore RM, Arnold EM. Predictors of mood or anxiety problems among transgender individuals seeking hormone therapy. Fam Pract 2022; 40:273-281. [PMID: 36250448 DOI: 10.1093/fampra/cmac111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Mental health needs of transgender individuals can be complex with individual, social, and medical factors impacting symptoms. This study examines predictors of mood or anxiety problems among transgender individuals seeking hormone therapy (HT). METHODS A retrospective chart review was conducted at 2 clinics providing gender-affirming HT. Cross-sectional data from initial patient encounters (N = 311) were used in this study. Bivariate correlations and multiple logistic regression analyses were carried out. RESULTS Transgender women (TW) were 2.2 times more likely to have mood or anxiety problems while transgender men (TM) were 2.6 times more likely as the number of medical comorbidities increased. For both TW and TM, White race significantly increased the likelihood of mood or anxiety problems. Neither previous nor current HT were associated with mood or anxiety problems for TW and TM. However, receiving multiple gender-affirming procedures decreased the likelihood of mood or anxiety problems for TM. CONCLUSIONS Gender-affirming care and addressing comorbidities can be important aspects of mental health needs for transgender individuals.
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Affiliation(s)
- Chance R Strenth
- Department of Family and Community Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Patti Pagels
- Department of Family and Community Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Jeffrey A SoRelle
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, United States
| | - Leo Gonzalez
- Department of Family and Community Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Philip G Day
- Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Nora E Gimpel
- Department of Family and Community Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Emily I Levy Kamugisha
- Department of Family and Community Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Rachel M Moore
- Department of Family and Community Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Elizabeth Mayfield Arnold
- Department of Family and Community Medicine, UT Southwestern Medical Center, Dallas, TX, United States
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18
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O’Leary KB, Marcelli M. Mental Health Outcomes Among Transgender Veterans and Active-Duty Service Members in the United States: A Systematic Review. Fed Pract 2022; 39:418-425. [PMID: 36744015 PMCID: PMC9896366 DOI: 10.12788/fp.0321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background It has been shown that veterans and active-duty service members may experience worse mental health outcomes compared with civilians and nonveterans. In addition, transgender veterans and service members face unique challenges. We conducted a systematic review of articles presenting data on mental health outcomes in transgender veterans and active-duty service members. Outcomes examined in this review include symptoms of depression, anxiety, and posttraumatic stress disorder, suicidality, substance use, and military sexual trauma. Observations In the military, transgender individuals face stigma and discrimination. Transgender veterans and service members have worse mental health outcomes and higher odds of suicidality compared with their cisgender counterparts. Drug and alcohol use disorders are more prevalent among transgender veterans compared with cisgender veterans. Transgender veterans are also more likely to report military sexual trauma than cisgender veterans. Conclusions In the literature, evidence exists that transgender veterans and service members experience worse mental health outcomes than their cisgender counterparts. Additional research is required to measure the effect of gender-affirming care on health outcomes among transgender veterans and active-duty service members to better serve this population and provide optimal care.
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Affiliation(s)
| | - Marco Marcelli
- Baylor College of Medicine, Houston, Texas,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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19
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Prevalence of social and economic stressors among transgender veterans with alcohol and other drug use disorders. SSM Popul Health 2022; 19:101153. [PMID: 35813187 PMCID: PMC9260617 DOI: 10.1016/j.ssmph.2022.101153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 11/21/2022] Open
Abstract
Transgender persons have high rates of alcohol and other drug use disorders (AUD and DUD, respectively) and commonly experience social and economic stressors that may compound risk for adverse substance-related outcomes. National VA electronic health record data were extracted for all outpatients in each facility with documented alcohol screening 10/1/09–7/31/17. We describe the prevalence of eight individual-level social and economic stressors (barriers to accessing care, economic hardship, housing instability, homelessness, social and family problems, legal problems, military sexual trauma, and other victimization) among transgender patients with and without AUD and DUD (alone and in combination), overall and compared to cisgender patients in a national sample of VA outpatients. Among 8,872,793 patients, 8619 (0.1%) were transgender; the prevalence of AUD, DUD, and both was 8.6%, 7.2%, and 3.1% among transgender patients and 6.1%, 3.9%, and 1.7% among cisgender patients, respectively. Among all patients, prevalence of stressors was higher among those with AUD, DUD, or both, relative to those with neither. Within each of these groups, prevalence was 2–3 times higher among transgender compared to cisgender patients. For instance, prevalence of housing instability for transgender vs. cisgender patients with AUD, DUD, and both was: 40.8% vs 24.1%, 45.8% vs. 36.6%, and 57.4% vs. 47.0%, respectively. (all p-values <0.001). Social and economic stressors were prevalent among patients with AUD, DUD, or both, and the experience of these disorders and social and economic stressors was more common among transgender than cisgender patients in all groups. Further research regarding experiences of transgender persons and influences of stressors on risk of AUD and DUD, substance-related outcomes, and treatment uptake are needed. Routine screening for social and economic stressors among patients with substance use disorders (SUDs) could improve equitable substance-related care and outcomes. Treatment of SUDs among all persons should consider social and economic risk factors. Social and economic stressors are understudied in transgender persons with SUD. Social and economic stressors were greater in persons with SUD than those without. Concurrent stressors and SUD were 2–3x higher for trans-than cis-gender patients. Transphobia may be a fundamental cause of disparities in SUD and stressors. SUD treatment should address social and economic stressors.
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20
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Tran NK, Baker KE, Lett E, Scheim AI. State-level heterogeneity in associations between structural stigma and individual healthcare access: A multilevel analysis of transgender adults in the United States. J Health Serv Res Policy 2022; 28:109-118. [PMID: 36040166 DOI: 10.1177/13558196221123413] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE State-level variation in how restrictive policies affect health care access for transgender populations has not been widely studied. Therefore, we assessed the association between structural stigma and four measures of individual health care access among transgender people in the United States, and the extent to which structural stigma explains state-level variability. METHODS Data were drawn from the 2015-2019 Behavioral Risk Factor Surveillance System and the Human Rights Campaign's State Equality Index. We calculated weighted proportions and conducted multilevel logistic regression of individual heterogeneity and discriminatory accuracy. RESULTS An increase in the structural stigma score by one standard deviation was associated with lower odds of health care coverage (OR = 0.80; 95% CI: 0.66, 0.96) after adjusting for individual-level confounders. Approximately 11% of the total variance for insurance coverage was attributable to the state level; however, only 18% of state-level variability was explained by structural stigma. Adding Medicaid expansion attenuated the structural stigma-insurance association and explained 22% of state-level variation in health insurance. For the remaining outcomes (usual source of care, routine medical check-up, and cost-related barriers), we found neither meaningful associations nor considerable between-state variability. CONCLUSIONS Our findings support the importance of Medicaid expansion and transgender-inclusive antidiscrimination protections to enhance health care insurance coverage. From a measurement perspective, however, additional research is needed to develop and validate measures of transgender-specific structural stigma to guide future policy interventions.
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Affiliation(s)
- Nguyen K Tran
- Doctoral Fellow, Department of Epidemiology and Biostatistics, 582373Drexel University, USA
| | - Kellan E Baker
- Executive Director, Whitman-Walker Institute, USA.,Associate Faculty Department of Health Policy and Management, 25802Johns Hopkins Bloomberg School of Public Health, USA
| | - Elle Lett
- Senior Fellow, Center for Applied Transgender Studies, USA.,Postdoctoral Fellow, Computational Health Informatics Program, Boston Children's Hospital, USA.,Doctor of Medicine Candidate, Perelman School of Medicine, 6572University of Pennsylvania, USA
| | - Ayden I Scheim
- Assistant Professor, Department of Epidemiology and Biostatistics, 582373Drexel University, USA.,Adjunct Assistant Professor, Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Canada
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21
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Lynch KE, Livingston NA, Gatsby E, Shipherd JC, DuVall SL, Williams EC. Alcohol-attributable deaths and years of potential life lost due to alcohol among veterans: Overall and between persons with minoritized and non-minoritized sexual orientations. Drug Alcohol Depend 2022; 237:109534. [PMID: 35717789 DOI: 10.1016/j.drugalcdep.2022.109534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Unhealthy alcohol use is disproportionally experienced by individuals with minoritized sexual orientations. Unlike the general US population, for whom the burden of alcohol as it relates to mortality is consistently monitored across time with national survey data, the impact of unhealthy alcohol use among veterans with minoritized sexual orientations, for whom addressing substance use is a national priority, is largely unknown. METHODS Using Alcohol Use Disorders Identification Test Consumption data from the Department of Veterans Affairs electronic health record and underlying cause of death from National Death Index from 2014 to 2018 we quantified alcohol consumption and related mortality among veterans with (n = 102,085) and without minoritized sexual orientations (n = 5300,521). Age adjusted rates of alcohol attributed deaths (AAD) per 100,000 persons and years of potential life lost (YPLL) were estimated by sexual orientation, sex, and sexual orientation stratified by sex. RESULTS Alcohol attributable deaths (n = 21,861) were higher among veterans with minoritized sexual orientations than veterans without after adjustment for age (486.5 deaths/100,000 versus 309.7 deaths/100,000, respectively). Veterans with minoritized sexual orientations also experienced more YPLL (13,772.8 years/100,000 versus 7618.9 years/100,000). Years of potential life lost per AAD was higher in women (33.2 years) than men (18.7 years). CONCLUSIONS Alcohol consumption results in substantial disability and death among veterans, particularly veterans with minoritized sexual orientations. Findings suggest need for increased alcohol-related services for all VA patients, and potential targeted approaches to for veterans with minoritized sexual orientations and women to offset risk for, and years of potential life lost from, alcohol attributable death.
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Affiliation(s)
- Kristine E Lynch
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA; Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, USA.
| | - Nicholas A Livingston
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130, USA; Department of Psychiatry, Boston University School of Medicine, 720 Harrison Avenue, Boston, MA 02118, USA
| | - Elise Gatsby
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA
| | - Jillian C Shipherd
- Department of Psychiatry, Boston University School of Medicine, 720 Harrison Avenue, Boston, MA 02118, USA; Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130, USA; LGBTQ+ Health Program, Veterans Health Administration, 810 Vermont Avenue NW, Washington, DC 20420, USA
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA; Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, School of Public Health, University of Washington, 3980 15th Avenue NW, Seattle, WA 98195, USA; Health Services Research & Development, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound 1660 S Columbian Way, Seattle, WA 98108, USA
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22
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Shenkman G. Winds of change: Will current amendments to Israeli laws discriminating against LGBTQ+ individuals positively affect their mental health? Psychiatry Res 2022; 313:114607. [PMID: 35561534 DOI: 10.1016/j.psychres.2022.114607] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 05/04/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Geva Shenkman
- Baruch Ivcher School of Psychology, Reichman University (IDC Herzliya), Herzliya 4610101, Israel.
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23
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Pinna F, Paribello P, Somaini G, Corona A, Ventriglio A, Corrias C, Frau I, Murgia R, El Kacemi S, Galeazzi GM, Mirandola M, Amaddeo F, Crapanzano A, Converti M, Piras P, Suprani F, Manchia M, Fiorillo A, Carpiniello B. Mental health in transgender individuals: a systematic review. Int Rev Psychiatry 2022; 34:292-359. [PMID: 36151828 DOI: 10.1080/09540261.2022.2093629] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Several lines of evidence indicate the prevalence of mental health disorders in Transgender (TG) individuals is higher than that of cisgender individuals or the general population. In this systematic review, we aim to propose a summary of some of the most significant research investigating mental health disorders' prevalence among this population. We performed a double-blind systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting (PRISMA) on PUBMED/MEDLINE and SCOPUS, specifically using peer-reviewed articles examining the mental health status of transgender (TG) individuals. This review did not exclude any research based on publication date. The last search was performed in February 2022. The employed search strategy led to the selection of 165 peer-reviewed articles. The majority of these papers presented a cross-sectional design with self-reported diagnoses and symptoms, signaling a significant prevalence of mental health disorders amongst TG Individuals. Of the reviewed articles, 72 examined the prevalence of mood and anxiety disorders; 8 examined eating disorders; 43 examined the prevalence of suicidal or self-harm ideation or behaviors; 5 papers examined the prevalence of trauma and stress-related disorders; 10 examined the frequency of personality disorders; 44 examined substance use disorders; and 9 papers examined the prevalence of autism spectrum disorder. Finally, 22 studies reported on the prevalence of TG individuals diagnosed with co-morbid mental health disorders or unspecified mental disorders. Our findings coincide with existing research, which indicates TG individuals do experience a higher prevalence of mental health disorders than that of the general population or cisgender individuals. However, further research is needed to address the existing gaps in knowledge.
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Affiliation(s)
- Federica Pinna
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Pasquale Paribello
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Giulia Somaini
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Alice Corona
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Antonio Ventriglio
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Carolina Corrias
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Ilaria Frau
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Roberto Murgia
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Sabrina El Kacemi
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Gian Maria Galeazzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Dipartimento ad attività integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Massimo Mirandola
- Department of Diagnostics and Public Health, Infectious Diseases Section, University of Verona, Verona, Italy.,School of Sport and Health Sciences, University of Brighton, Brighton, UK
| | - Francesco Amaddeo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Andrea Crapanzano
- Department of Counseling, San Francisco State University, San Francisco, California, USA
| | - Manlio Converti
- Dipartimento di salute mentale, ASL Napoli 2 Nord, Naples, Italy
| | - Paola Piras
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Federico Suprani
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
| | - Mirko Manchia
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy.,Department of Pharmacology, Dalhousie University, Halifax, NS, Canada
| | - Andrea Fiorillo
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Bernardo Carpiniello
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital of Cagliari, Cagliari, Italy
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24
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Wolford-Clevenger C, Hill SV, Cropsey K. Correlates of Tobacco and Nicotine Use Among Transgender and Gender Diverse People: A Systematic Review Guided by the Minority Stress Model. Nicotine Tob Res 2022; 24:444-452. [PMID: 34375426 DOI: 10.1093/ntr/ntab159] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 08/05/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION ransgender and gender diverse (TGD) people have a higher prevalence of tobacco and nicotine use compared to their cisgender peers. AIMS AND METHODS Using the minority stress model as a guide, we conducted a systematic review of correlates of tobacco and nicotine use among TGD people. We reviewed the literature from Pubmed, PsycINFO, and CINAHL between April 1, 1995 and April 20, 2021. Article inclusion criteria were the following: written in English, reported empirical data, sampled exclusively or reported separate outcomes for transgender/gender diverse people, and reported correlates of tobacco or nicotine use, broadly defined. The first and second authors reviewed the articles retrieved from the search and from gray literature (relevant listserv solicitations) for inclusion. They then reviewed references of any included articles for additional candidate articles.Results: This resulted in 35 articles for review, which were synthesized in a qualitative fashion. The overall quality of the articles was fair, with the articles ranging from poor to fair quality and using primarily cross-sectional design and survey methods. CONCLUSIONS Overall, the literature demonstrated external minority stressors were mostly researched (and supported) correlates of tobacco and nicotine use among TGD people. There is a critical need for higher quality research, such as longitudinal or experimental designs, to improve our understanding and prevention of tobacco and nicotine use in this population. IMPLICATIONS This systematic review used the minority stress model as a guide to understand correlates of tobacco and nicotine use among transgender and gender diverse people. Literature of fair quality demonstrated that external minority stressors were the most researched and supported correlates of tobacco and nicotine use within the framework of the minority stress model. This review demonstrated a critical need for higher quality research, such as longitudinal or experimental designs, to improve our understanding and prevention of tobacco and nicotine use in this population. Preliminary findings from the limited literature highlight factors that may be relevant to target with this population, including general/environmental stressors and external minority stressors such as discrimination.
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Affiliation(s)
- Caitlin Wolford-Clevenger
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Samantha V Hill
- Department of Pediatrics, Division of Adolescent Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Karen Cropsey
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, USA
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25
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Lacombe-Duncan A, Olawale R. Context, Types, and Consequences of Violence Across the Life Course: A Qualitative Study of the Lived Experiences of Transgender Women Living With HIV. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:2242-2266. [PMID: 32639854 DOI: 10.1177/0886260520935093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Violence is a known driver of HIV vulnerability among transgender (trans) women, who are disproportionately impacted by HIV globally. Violence is also a barrier to accessing HIV prevention, treatment, and support. Yet, little is known about the everyday experiences of violence faced by trans women living with HIV, who live at the intersection of a marginalized gender identity and physical health condition. To address this gap, this study draws on semi-structured, individual interviews conducted 2017-2018 with a purposive sample (selected based on diverse identities) of trans women living with HIV (n = 11) participating in a large, community-based cohort study in three Canadian provinces. Framework analysis was used to identify key themes, patterns within themes between participants, and patterns across themes among participants. Findings showed that trans women living with HIV experience specific contexts of violence shaped at the intersection of stigma based on gender identity, gender expression, and HIV status, among other identities/experiences. Violence experienced in childhood (e.g., familial rejection, bullying) increased trans women's likelihood of being exposed to a violent social context in young adulthood (e.g., state violence perpetuated by the police, interpersonal violence perpetuated by sexual partners, and community violence perpetuated by society-at-large/the general public), which increased trans women's HIV vulnerability; once living with HIV trans women were subjected to discursive violence from healthcare providers. These multiple forms of violence have serious consequences for trans women living with HIV's ongoing social, mental, and physical well-being. The findings suggest that interventions are urgently needed to reduce violence against trans women in childhood and young adulthood, in addition to reducing violence against trans women living with HIV perpetuated by healthcare providers in adulthood, to both proactively and responsively promote their safety, health, and well-being.
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26
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Livingston NA, Lynch KE, Hinds Z, Gatsby E, DuVall SL, Shipherd JC. Identifying Posttraumatic Stress Disorder and Disparity Among Transgender Veterans Using Nationwide Veterans Health Administration Electronic Health Record Data. LGBT Health 2022; 9:94-102. [PMID: 34981963 DOI: 10.1089/lgbt.2021.0246] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Purpose: The prevalence of posttraumatic stress disorder (PTSD) and other psychiatric disorders is high among military veterans and even higher among transgender veterans. Prior prevalence estimates have become outdated, and novel methods of estimation have since been developed but not used to estimate PTSD prevalence among transgender veterans. This study provides updated estimates of PTSD prevalence among transgender and cisgender veterans. Methods: We examined Veterans Health Administration (VHA) medical record data from October 1, 1999 to April 1, 2021 for 9995 transgender veterans and 29,985 cisgender veteran comparisons (1:3). We matched on age group at first VHA health care visit, sex assigned at birth, and year of first VHA visit. We employed both probabilistic and rule-based algorithms to estimate the prevalence of PTSD for transgender and cisgender veterans. Results: The prevalence of PTSD was 1.5-1.8 times higher among transgender veterans. Descriptive data suggest that the prevalence of depression, schizophrenia, bipolar disorder, alcohol and non-alcohol substance use disorders, current/former smoking status, and military sexual trauma was also elevated among transgender veterans. Conclusion: The PTSD and overall psychiatric burden observed among transgender veterans was significantly higher than that of their cisgender peers, especially among recent users of VHA care. These PTSD findings are consistent with prior literature and minority stress theory, and they were robust across probabilistic and two rule-based methods employed in this study. As such, enhanced and careful screening, outreach, and evidence-based practices are recommended to help reduce this disparity among transgender veterans.
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Affiliation(s)
- Nicholas A Livingston
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kristine E Lynch
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Zig Hinds
- Behavioral Science Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Elise Gatsby
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Scott L DuVall
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jillian C Shipherd
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA.,Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA.,LGBTQ+ Health Program, Veterans Health Administration, Washington, District of Columbia, USA
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27
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Kemp B, Grumbach JM, Montez JK. U.S. State Policy Contexts and Physical Health among Midlife Adults. SOCIUS : SOCIOLOGICAL RESEARCH FOR A DYNAMIC WORLD 2022; 8:10.1177/23780231221091324. [PMID: 36268202 PMCID: PMC9581408 DOI: 10.1177/23780231221091324] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
This study examines how state policy contexts may have contributed to unfavorable adult health in recent decades. It merges individual-level data from the 1993-2016 Behavioral Risk Factor Surveillance System (n=2,166,835) with 15 state-level policy domains measured annually on a conservative to liberal continuum. We examined associations between policy domains and health among adults ages 45-64 years and assess how much of the associations is accounted by adults' socioeconomic, behavioral/lifestyle, and family factors. A more liberal version of the civil rights domain was associated with better health. It was disproportionately important for less-educated adults and women, and its association with adult health was partly accounted by educational attainment, employment, and income. Environment, gun safety, and marijuana policy domains were, to a lesser degree, predictors of health in some model specifications. In sum, health improvements require a greater focus on macro-level factors that shape the conditions in which people live.
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28
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Walter-McCabe H, Chen A. EDITORS' INTRODUCTION: Transgender Health Equity and the Law. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2022; 50:401-408. [PMID: 36398648 PMCID: PMC9679591 DOI: 10.1017/jme.2022.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The sheer gamut of issues impacting transgender health equity may seem overwhelming. This article seeks to introduce readers to the breadth of topics addressed in this symposium edition, exemplifying that transgender health equity is a global issue that demands an interdisciplinary approach.
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29
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Considerations for Transgender Population Health Research Based on US National Surveys. Ann Epidemiol 2021; 65:65-71. [PMID: 34757013 DOI: 10.1016/j.annepidem.2021.10.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/24/2021] [Accepted: 10/22/2021] [Indexed: 11/23/2022]
Abstract
Transgender identities and health are highly politicized in the United States leading to restrictions on relevant data collection in national health surveillance systems. This has serious implications on transgender population health research; an urgent area of study given the systemic discrimination faced by transgender individuals and the resultant social and health inequities. In this precarious political climate, obtaining high-quality data for research is challenging and in recent years, two data sources have formed the foundation of transgender health research in the United States, namely the 2015 United States Transgender Study and the Behavioral Risk Factor Surveillance System (BRFSS) after the launch of the optional Sexual Orientation and Gender Identity Module in 2014. While useful, there are serious challenges to using these data to study transgender health, specifically related to survey weighting methodologies, ascertainment of gender identity, and study design. In this article, we detail these challenges and discuss the strengths and weaknesses of various methodological approaches that have been implemented as well as clarify several common errors that exist in the literature. We feel that this contribution is necessary to provide accurate interpretation of the evidence that currently informs policy and priority setting for transgender population health and will provide vital insights for future studies with these now ubiquitous sources of data in the field.
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30
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Christian LM, Cole SW, McDade T, Pachankis JE, Morgan E, Strahm AM, Kamp Dush CM. A biopsychosocial framework for understanding sexual and gender minority health: A call for action. Neurosci Biobehav Rev 2021; 129:107-116. [PMID: 34097981 PMCID: PMC8429206 DOI: 10.1016/j.neubiorev.2021.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/26/2021] [Accepted: 06/01/2021] [Indexed: 12/29/2022]
Abstract
The number of US adults identifying as lesbian, gay, bisexual, transgender, or a different sexual identity has doubled since 2008, and about 40 % of the sexual and gender minority population identify as people of color. Minority stress theory posits that sexual and gender minorities are at particular risk for stress via stigma and discrimination at the structural, interpersonal, and individual levels. This stress, in turn, elevates the risk of adverse health outcomes across several domains. However, there remains a conspicuously limited amount of research on the psychoneuroimmunology of stress among sexual and gender minorities. We developed the Biopsychosocial Minority Stress Framework which posits that sexual minority status leads to unique experiences of minority stress which results in adverse health behavioral factors, elevated psychological distress and sleep disturbance, and immune dysregulation. Moderators in the model include both individual differences and intersectional identities. There is a crucial need to understand the biological-psychological axis of stress among the increasingly visible sexual and gender minority population to increase their health, longevity, and quality of life.
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Affiliation(s)
- Lisa M Christian
- Department of Psychiatry & Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA; The Institute for Behavioral Medicine Research, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Steve W Cole
- Department of Psychiatry & Biobehavioral Sciences and Medicine, UCLA School of Medicine, Los Angeles, CA, USA
| | - Thomas McDade
- Department of Anthropology, Northwestern University, Evanston, IL, USA; Institute for Policy Research, Northwestern University, Evanston, IL, USA; Child and Brain Development Program, Canadian Institute for Advanced Research, Toronto, ON, Canada
| | - John E Pachankis
- Yale School of Public Health, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Ethan Morgan
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Anna M Strahm
- Department of Psychiatry & Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA; The Institute for Behavioral Medicine Research, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Claire M Kamp Dush
- Minnesota Population Center, University of Minnesota, Minneapolis, MN, USA; Department of Sociology, University of Minnesota, Minneapolis, MN, USA
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31
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Hisle-Gorman E, Schvey NA, Adirim TA, Rayne AK, Susi A, Roberts TA, Klein DA. Mental Healthcare Utilization of Transgender Youth Before and After Affirming Treatment. J Sex Med 2021; 18:1444-1454. [PMID: 37057453 DOI: 10.1016/j.jsxm.2021.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/12/2021] [Accepted: 05/14/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Transgender and gender-diverse (TGD) adolescents experience increased mental health risk compared to cisgender peers. Limited research suggests improved outcomes following gender-affirmation. This study examined mental healthcare and psychotropic medication utilization among TGD youth compared to their siblings without gender-related diagnoses and explored utilization patterns following gender-affirming care. METHOD This retrospective cohort study used military healthcare data from 2010-2018 to identify mental healthcare diagnoses and visits, and psychotropic medication prescriptions among TGD youth who received care for gender dysphoria before age 18, and their siblings. Logistic and Poisson regression analyses compared mental health diagnosis, visits, and psychotropic prescriptions of TGD youth to their siblings, and compared healthcare utilization pre- and post-initiation of gender-affirming pharmaceuticals among TGD adolescents. RESULTS 3,754 TGD adolescents and 6,603 cisgender siblings were included. TGD adolescents were more likely to have a mental health diagnosis (OR 5.45, 95% CI [4.77-6.24]), use more mental healthcare services (IRR 2.22; 95% CI [2.00-2.46]), and be prescribed more psychotropic medications (IRR = 2.57; 95% CI [2.36-2.80]) compared to siblings. The most pronounced increases in mental healthcare were for adjustment, anxiety, mood, personality, psychotic disorders, and suicidal ideation/attempted suicide. The most pronounced increased in psychotropic medication were in SNRIs, sleep medications, anti-psychotics and lithium. Among 963 TGD youth (Mage: 18.2) using gender-affirming pharmaceuticals, mental healthcare did not significantly change (IRR = 1.09, 95% CI [0.95-1.25]) and psychotropic medications increased (IRR = 1.67, 95% CI [1.46-1.91]) following gender-affirming pharmaceutical initiation; older age was associated with decreased care and prescriptions. CONCLUSION Results support clinical mental health screening recommendations for TGD youth. Further research is needed to elucidate the longer-term impact of medical affirmation on mental health, including family and social factors associated with the persistence and discontinuation of mental healthcare needs among TGD youth. Hisle-Gorman E, Schvey NA, Adirim TA, et al. Mental Healthcare Utilization of Transgender Youth Before and After Affirming Treatment. J Sex Med 2021;18:1444-1454.
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Affiliation(s)
- Elizabeth Hisle-Gorman
- Department of Pediatrics, Uniformed Services University, Bethesda, MD; Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD, USA.
| | - Natasha A Schvey
- Department of Medical and Clinical Psychology, Uniformed Services University, Bethesda, MD, USA
| | - Terry A Adirim
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD; Department of Defense, Washington, DC, USA
| | - Anna K Rayne
- Department of Family Medicine, Fort Belvoir Community Hospital, Fort Belvoir, VA, USA
| | - Apryl Susi
- Department of Pediatrics, Uniformed Services University, Bethesda, MD; Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD, USA
| | - Timothy A Roberts
- Division of Adolescent Medicine, Children's Mercy Kansas City; Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - David A Klein
- Department of Pediatrics, Uniformed Services University, Bethesda, MD; Department of Family Medicine, Uniformed Services University, Bethesda, MD, USA
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32
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Williams EC, Chen JA, Frost MC, Rubinsky AD, Edmonds AT, Glass JE, Lehavot K, Matson TE, Wheat CL, Coggeshall S, Blosnich JR. Receipt of evidence-based alcohol-related care in a national sample of transgender patients with unhealthy alcohol use: Overall and relative to non-transgender patients. J Subst Abuse Treat 2021; 131:108565. [PMID: 34274175 DOI: 10.1016/j.jsat.2021.108565] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/29/2021] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND/OBJECTIVE Evidence-based alcohol-related care-brief intervention for all patients with unhealthy alcohol use and specialty addictions treatment and/or pharmacotherapy for patients with alcohol use disorder (AUD)-should be routinely offered. Transgender persons may be particularly in need of alcohol-related care, given common experiences of social and economic hardship that may compound the adverse effects of unhealthy alcohol use. We examined receipt of alcohol-related care among transgender patients compared to non-transgender patients in a large national sample of Veterans Health Administration (VA) outpatients with unhealthy alcohol use. METHODS We extracted electronic health record data for patients from all VA facilities who had an outpatient visit 10/1/09-7/31/17 and a documented positive screen for unhealthy alcohol use (AUDIT-C ≥ 5). We identified transgender patients with a validated approach using transgender-related diagnostic codes. We fit modified Poisson models, adjusted for demographics and comorbidities, to estimate the average predicted prevalence of brief intervention (documented 0-14 days following most recent positive screening), specialty addictions treatment for AUD (documented 0-365 days following screening), and filled prescriptions for medications to treat AUD (documented 0-365 days following screening) for transgender patients, and compared to that of non-transgender patients. RESULTS Among transgender Veterans with unhealthy alcohol use (N = 1392), the adjusted prevalence of receiving brief intervention was 75.4% (95% CI 72.2-78.5), specialty addictions treatment for AUD was 15.7% (95% CI 13.7-17.7), and any AUD pharmacotherapy was 19.0% (95% CI 17.1-20.8). Receipt of brief intervention did not differ for transgender relative to non-transgender patients (Prevalence Ratio [PR] 1.01, 95% CI 0.98-1.04, p = 0.574). However, transgender patients were more likely to receive specialty addictions treatment (PR 1.24, 95% CI 1.12-1.37, p < 0.001) and pharmacotherapy (PR 1.16, 95% CI 1.06-1.28, p = 0.002). CONCLUSIONS Findings suggest the majority of transgender VHA patients with unhealthy alcohol use receive brief intervention, though a quarter still do not. Nonetheless, rates of specialty addictions treatment and pharmacotherapy are low overall, although transgender patients may be receiving this care at greater rates than non-transgender patients. Further research is needed to investigate these findings and to increase receipt of evidence-based care overall.
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Affiliation(s)
- Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA.
| | - Jessica A Chen
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA 98195, USA
| | - Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Anna D Rubinsky
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Amy T Edmonds
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Joseph E Glass
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA 98195, USA; Kaiser Permanente Washington Health Research Institute, Seattle, WA 98101, USA
| | - Keren Lehavot
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA 98195, USA
| | - Theresa E Matson
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA 98195, USA; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA; Kaiser Permanente Washington Health Research Institute, Seattle, WA 98101, USA
| | - Chelle L Wheat
- Primary Care Analytics Team, Department of Veterans Affairs, Seattle, WA 98108, USA
| | - Scott Coggeshall
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98108, USA
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA; Health Services Research & Development (HSR&D) Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Frost MC, Blosnich JR, Lehavot K, Chen JA, Rubinsky AD, Glass JE, Williams EC. Disparities in Documented Drug Use Disorders Between Transgender and Cisgender U.S. Veterans Health Administration Patients. J Addict Med 2021; 15:334-340. [PMID: 33252409 PMCID: PMC8384140 DOI: 10.1097/adm.0000000000000769] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Transgender people-those whose gender identity differs from their sex assigned at birth-are at risk for health disparities resulting from stressors such as discrimination and violence. Transgender people report more drug use than cisgender people; however, it is unclear whether they have higher likelihood of drug use disorders. We examined whether transgender patients have increased likelihood of documented drug use disorders relative to cisgender patients in the national Veterans Health Administration (VA). METHODS Electronic health record data were extracted for VA outpatients from 10/1/09 to 7/31/17. Transgender status and past-year documentation of drug use disorders (any, opioid, amphetamine, cocaine, cannabis, sedative, hallucinogen) were measured using diagnostic codes. Logistic regression models estimated odds ratios for drug use disorders among transgender compared to cisgender patients, adjusted for age, race/ethnicity and year. Effect modification by presence of ≥1 mental health condition was tested using multiplicative interaction. RESULTS Among 8,872,793 patients, 8619 (0.1%) were transgender. Transgender patients were more likely than cisgender patients to have any drug use disorder (Adjusted Odds Ratio [aOR] 1.67, 95% confidence interval [CI] 1.53-1.83), amphetamine (aOR 2.22, 95% CI 1.82-2.70), cocaine (aOR 1.59, 95% CI 1.29-1.95), and cannabis (aOR 1.82, 95% CI 1.62-2.05) use disorders. There was no significant interaction by presence of ≥1 mental health condition. CONCLUSIONS Transgender VA patients may have higher likelihood of certain drug use disorders than cisgender VA patients, particularly amphetamine use disorder. Future research should explore mechanisms underlying disparities and potential barriers to accessing treatment and harm reduction services faced by transgender people.
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Affiliation(s)
- Madeline C. Frost
- Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108
| | - John R. Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA
- Health Services Research & Development (HSR&D) Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Keren Lehavot
- Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108
- Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA, USA
| | - Jessica A. Chen
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108
- Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA, USA
| | - Anna D. Rubinsky
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Joseph E. Glass
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101
| | - Emily C. Williams
- Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle WA 98108
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Lewis T, Doyle DM, Barreto M, Jackson D. Social relationship experiences of transgender people and their relational partners: A meta-synthesis. Soc Sci Med 2021; 282:114143. [PMID: 34174577 DOI: 10.1016/j.socscimed.2021.114143] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/11/2021] [Accepted: 06/11/2021] [Indexed: 12/01/2022]
Abstract
RATIONALE Social relationships are important in bolstering health and well-being for everyone in the general population. For transgender people, strong supportive social relationships may be paramount to their overall health and well-being due to their marginalised status in society. OBJECTIVE This review aimed to investigate what is currently known about the social relationship experiences of transgender people and their relational partners (e.g., family members, romantic partners). METHODS Thirty-nine qualitative papers were extracted from Web of Science, Scopus, Cochrane, and PubMed that related to social relationships of transgender people. These papers were analysed via a qualitative meta-synthesis. RESULTS Forty-nine second-order themes were identified, initially organised into relational partner clusters (e.g., family, friends, work colleagues) for specific phenomena, then these were synthesized into five overarching conceptual themes: (1) Development of relationships through transition and beyond, (2) Coping strategies of transgender people and their relational partners, (3) Reciprocal support in social relationships, (4) Stigma enacted and ameliorated interpersonally, and (5) Influence of stigma on social health and well-being. DISCUSSION AND CONCLUSIONS These overarching themes show the potential characteristics that assist in the health-buffering role of social relationships for transgender people and their relational partners. Of particular note, stigma was reported as a common negative experience by transgender people and their relational partners, and open communicative social relationships had positive effects on self-conceptualisations of identity, which were inferred to protect against the damaging effects of stigma. We discuss the various implications and applications of this meta-synthesis to future research and clinical settings as well as how it can inform healthcare policy to support transgender people.
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Affiliation(s)
- Tom Lewis
- University of Exeter, Department of Psychology, Washington Singer Laboratories, Perry Road, EX4 4QG, UK.
| | - David Matthew Doyle
- University of Exeter, Department of Psychology, Washington Singer Laboratories, Perry Road, EX4 4QG, UK
| | - Manuela Barreto
- University of Exeter, Department of Psychology, Washington Singer Laboratories, Perry Road, EX4 4QG, UK
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Progovac AM, Tran NM, Mullin BO, De Mello Libardi Maia J, Creedon TB, Dunham E, Reisner SL, McDowell A, Bird N, Sánchez Román MJ, Dunn M, Telingator C, Lu F, Breslow AS, Forstein M, Cook BL. Elevated Rates of Violence Victimization and Suicide Attempt Among Transgender and Gender Diverse Patients in an Urban, Safety Net Health System. WORLD MEDICAL & HEALTH POLICY 2021. [DOI: 10.1002/wmh3.403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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36
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Holland-Deguire C, Rabalais A, Soe K, Anderson E, Shivakumar G. Transitioning from the Battlefield: A Theoretical Model for the Development of Posttraumatic Stress Disorder (PTSD) in Gender Diverse Veterans. JOURNAL OF VETERANS STUDIES 2021. [DOI: 10.21061/jvs.v7i1.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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37
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Williams EC, Frost MC, Rubinsky AD, Glass JE, Wheat CL, Edmonds AT, Chen JA, Matson TE, Fletcher OV, Lehavot K, Blosnich JR. Patterns of Alcohol Use Among Transgender Patients Receiving Care at the Veterans Health Administration: Overall and Relative to Nontransgender Patients. J Stud Alcohol Drugs 2021. [PMID: 33573731 DOI: 10.15288/jsad.2021.82.132] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Alcohol use is understudied among transgender persons--persons whose sex differs from their gender identity. We compare patterns of alcohol use between Veterans Health Administration (VA) transgender and nontransgender outpatients. METHOD National VA electronic health record data were used to identify all patients' last documented Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screen (October 1, 2009-July 31, 2017). Transgender patients were identified using diagnostic codes. Logistic regression models estimated four past-year primary outcomes: (a) alcohol use (AUDIT-C > 0); (b) unhealthy alcohol use (AUDIT-C ≥ 5); (c) high-risk alcohol use (AUDIT-C ≥ 8); and (d) heavy episodic drinking (HED; ≥6 drinks on ≥1 occasion). Two secondary diagnostic-based outcomes, alcohol use disorder (AUD) and alcohol-specific conditions, were also examined. RESULTS Among 8,872,793 patients, 8,619 (0.10%) were transgender. For transgender patients, unadjusted prevalence estimates were as follows: 52.8% for any alcohol use, 6.6% unhealthy alcohol use, 2.8% high-risk use, 10.4% HED, 8.6% AUD, and 1.3% alcohol-specific conditions. After adjustment for demographic characteristics, transgender patients had lower odds of patient-reported alcohol use but higher odds of alcohol-related diagnoses compared with nontransgender patients. Differences in alcohol-related diagnoses were attenuated after adjustment for comorbid conditions and utilization. CONCLUSIONS This is the largest study of patterns of alcohol use among transgender persons and among the first to directly compare patterns to nontransgender persons. Findings suggest nuanced associations with patterns of alcohol use and provide a base for further disparities research to explore alcohol use within the diverse transgender community. Research with self-reported measures of gender identity and sex-at-birth and structured assessment of alcohol use and disorders is needed.
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Affiliation(s)
- Emily C Williams
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington.,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Madeline C Frost
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington.,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Anna D Rubinsky
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Chelle L Wheat
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Amy T Edmonds
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington.,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Jessica A Chen
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington.,Department of Psychiatry and Behavioral Science, University of Washington, Seattle, Washington
| | - Theresa E Matson
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington.,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Olivia V Fletcher
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Keren Lehavot
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington.,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Psychiatry and Behavioral Science, University of Washington, Seattle, Washington
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California.,Health Services Research & Development (HSR&D) Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Kurth AE, Puckett JA, Anderson-Carpenter KD. Legislation restricting access to public restrooms and changing facilities for transgender individuals in Texas (US): A qualitative analysis of testimony. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2021; 22:440-453. [PMID: 37808527 PMCID: PMC10553368 DOI: 10.1080/26895269.2021.1905580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
An alarming amount of legislation in the United States has sought to restrict the rights of transgender people, often targeting access to public spaces or restrooms. One example of this legislation is the Texas Privacy Act (Senate Bill 6; 2017), which detailed "regulations and policies for entering or using a bathroom or changing facility" (Texas Legislature Online).Aims: The hearing for SB 6 included over 18 hours of public testimony, which we analyzed to better understand arguments for and against this bill.Methods: We conducted a thematic analysis of this public testimony.Results: Supporters of SB 6 frequently framed their arguments in terms of safety and security, economic impact, and privacy and dignity. Those opposing SB 6 focused on discrimination, safety and security, and the effects of transgender people being forced into the wrong facilities.Discussion: These findings can aid in understanding education that may help to combat viewpoints that lead to passing such legislation and contributes to understanding how legal policies shape views of gender.
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Affiliation(s)
- Aren E Kurth
- Department of Psychology, Michigan State University, East Lansing, Michigan, USA
| | - Jae A Puckett
- Department of Psychology, Michigan State University, East Lansing, Michigan, USA
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Kaniuka AR, Bowling J. Suicidal self-directed violence among gender minority individuals: A systematic review. Suicide Life Threat Behav 2021; 51:212-219. [PMID: 33876492 DOI: 10.1111/sltb.12696] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/16/2020] [Accepted: 03/25/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Gender minority individuals represent a population at increased risk for suicidal self-directed violence (SDV). However, traditional models of suicidal SDV fail to consider gender minority population-specific factors that may buffer or exacerbate risk; further, while sexual and gender minority (SGM) health disparity frameworks may be extended suicidal SDV outcomes among gender minority individuals, little research exists bridging the gap between suicidal SDV research and SGM health disparity research. Thus, the current study sought to identify factors from SGM health disparity models related to suicidal SDV among gender minority individuals. METHOD The current study presents a synthesis of peer-reviewed publications (n = 11) that were informed by an SGM health framework and specifically examined suicidal SDV among adult gender minority individuals within the United States. RESULTS Factors from SGM health disparity models related to suicidal SDV outcomes included the following: 1) gender minority identity-related factors; 2) gender minority-related rejection, discrimination, harassment, and victimization; 3) structural stigma; and 4) resilience factors. CONCLUSIONS Findings support the applicability of SGM health disparity concepts to suicidal SDV outcomes among gender minority individuals. Future longitudinal research with more diverse participants examining the impact of intersectionality of identity and predictive model fit is warranted.
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Affiliation(s)
- Andrea R Kaniuka
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Jessamyn Bowling
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC, USA
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40
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Boyer TL, Youk AO, Haas AP, Brown GR, Shipherd JC, Kauth MR, Jasuja GK, Blosnich JR. Suicide, Homicide, and All-Cause Mortality Among Transgender and Cisgender Patients in the Veterans Health Administration. LGBT Health 2021; 8:173-180. [PMID: 33544021 DOI: 10.1089/lgbt.2020.0235] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: This study examines the differences in suicide, homicide, and all-cause mortality between transgender and cisgender Veterans Health Administration (VHA) patients. Methods: VHA electronic medical record data from October 1, 1999 to December 31, 2016 were used to create a sample of transgender and cisgender patients (n = 32,441). Cox proportional hazard regression was used to evaluate differences in survival time (date of birth to death date/study end). Death data were from the National Death Index. Results: Transgender patients had more than twofold greater hazard of suicide than cisgender patients (adjusted hazard ratio [aHR] = 2.77, 95% confidence interval [CI] = 1.88-4.09), especially among younger (18-39 years) (aHR = 3.35, 95% CI = 1.30-8.60) and older (≥65 years) patients (aHR = 9.48, 95% CI = 3.88-23.19). Alternatively, transgender patients had an overall lower hazard of all-cause mortality (aHR = 0.90, 95% CI = 0.84-0.97) compared with cisgender patients, which was driven by patients 40-64 years old (aHR = 0.78, 95% CI = 0.72-0.86) and reversed by those 65 years and older (aHR = 1.17, 95% CI = 1.03-1.33). Conclusion: Transgender patients' hazard of suicide mortality was significantly greater than that of cisgender VHA patients.
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Affiliation(s)
- Taylor L Boyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Ada O Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ann P Haas
- Department of Health Sciences, Lehman College, City University of New York, Bronx, New York, USA
| | - George R Brown
- Mountain Home VA Medical Center, Johnson City, Tennessee, USA.,Department of Psychiatry and Behavioral Sciences, East Tennessee State University, Johnson City, Tennessee, USA
| | - Jillian C Shipherd
- Lesbian, Gay, Bisexual, and Transgender Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, District of Columbia, USA.,National Center for Post-traumatic Stress Disorder, VA Boston Healthcare System, Boston, Massachusetts, USA.,Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michael R Kauth
- Lesbian, Gay, Bisexual, and Transgender Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, District of Columbia, USA.,South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Psychiatry, Baylor College of Medicine, Houston, Texas, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers VA Medical Center, Bedford, Massachusetts, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - John R Blosnich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
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Sherman ADF, McDowell A, Clark KD, Balthazar M, Klepper M, Bower K. Transgender and gender diverse health education for future nurses: Students' knowledge and attitudes. NURSE EDUCATION TODAY 2021; 97:104690. [PMID: 33279814 PMCID: PMC8049084 DOI: 10.1016/j.nedt.2020.104690] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/12/2020] [Accepted: 11/23/2020] [Indexed: 05/11/2023]
Abstract
BACKGROUND Compared to cisgender peers, transgender and gender diverse (TGD) people experience significant health disparities associated with discrimination and limited access to appropriate care in healthcare settings. Nurses represent the largest segment of the United States (US) healthcare workforce; however, US nursing programs only dedicate approximately 2.12 h to Lesbian, Gay, Bisexual, and TGD (LGBT)-related content. OBJECTIVES/DESIGN/SETTING/PARTICIPANTS To fill the gap in TGD-related nursing education, the Transgender Curriculum Integration Project (TCIP) developed and integrated an evidence-based curriculum specific to TGD health into the pre-licensure accelerated Bachelor's in Nursing Science (BSN) program at Johns Hopkins School of Nursing. The purpose of this study was to assess the preliminary efficacy and feasibility (i.e., attrition, engagement, acceptability) of the TCIP in improving the TGD-related health knowledge and attitudes among a sample of pre-licensure nursing students. METHODS TCIP utilized a self-administered online survey to assess students' knowledge and attitudes about TGD health prior to (time point 1) and following (time points 2 and 3) the integration of TGD-specific content into five nursing pre-licensure courses. Rank-based nonparametric testing using Kruskal-Wallis H and Mann-Whitney U were conducted to determine if there were statistically significant differences in responses between the three time points. Thematic content analysis was used to determine themes present among short answers. RESULTS Findings indicate TGD-specific content improved student's gender sensitivity overtime, with improvements in self-reported skills in providing care for TGD people and knowledge of additional TGD-specific resources. However, gender sensitivity remains low among student's and students requested more TGD content suggesting room for further improvement. CONCLUSIONS Findings support the efficacy of TCIP and highlight complexities of curricular change that can guide future curricular integration and evaluation in nursing programs nation-wide.
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Affiliation(s)
- Athena D F Sherman
- Emory University, The Nell Hodgson Woodruff School of Nursing, 1520 Clifton Rd., Atlanta, GA 30322, United States of America.
| | - Alex McDowell
- Mongan Institute for Health Policy, Massachusetts General Hospital, 100 Cambridge Street, Boston, MA 02114, United States of America.
| | - Kristen D Clark
- University of California, San Francisco, School of Nursing, 2 Koret Way, San Francisco, CA 94143, United States of America.
| | - Monique Balthazar
- Emory University Nell Hodgson Woodruff School of Nursing, 1520 Clifton Rd., Atlanta, GA 30322, United States of America.
| | - Meredith Klepper
- Johns Hopkins University School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, United States of America.
| | - Kelly Bower
- Johns Hopkins School of Nursing, 525 N. Wolfe Street, Baltimore, MD 21205, United States of America.
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Williams EC, Frost MC, Rubinsky AD, Glass JE, Wheat CL, Edmonds AT, Chen JA, Matson TE, Fletcher OV, Lehavot K, Blosnich JR. Patterns of Alcohol Use Among Transgender Patients Receiving Care at the Veterans Health Administration: Overall and Relative to Nontransgender Patients. J Stud Alcohol Drugs 2021; 82:132-141. [PMID: 33573731 PMCID: PMC7901266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/26/2020] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE Alcohol use is understudied among transgender persons--persons whose sex differs from their gender identity. We compare patterns of alcohol use between Veterans Health Administration (VA) transgender and nontransgender outpatients. METHOD National VA electronic health record data were used to identify all patients' last documented Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screen (October 1, 2009-July 31, 2017). Transgender patients were identified using diagnostic codes. Logistic regression models estimated four past-year primary outcomes: (a) alcohol use (AUDIT-C > 0); (b) unhealthy alcohol use (AUDIT-C ≥ 5); (c) high-risk alcohol use (AUDIT-C ≥ 8); and (d) heavy episodic drinking (HED; ≥6 drinks on ≥1 occasion). Two secondary diagnostic-based outcomes, alcohol use disorder (AUD) and alcohol-specific conditions, were also examined. RESULTS Among 8,872,793 patients, 8,619 (0.10%) were transgender. For transgender patients, unadjusted prevalence estimates were as follows: 52.8% for any alcohol use, 6.6% unhealthy alcohol use, 2.8% high-risk use, 10.4% HED, 8.6% AUD, and 1.3% alcohol-specific conditions. After adjustment for demographic characteristics, transgender patients had lower odds of patient-reported alcohol use but higher odds of alcohol-related diagnoses compared with nontransgender patients. Differences in alcohol-related diagnoses were attenuated after adjustment for comorbid conditions and utilization. CONCLUSIONS This is the largest study of patterns of alcohol use among transgender persons and among the first to directly compare patterns to nontransgender persons. Findings suggest nuanced associations with patterns of alcohol use and provide a base for further disparities research to explore alcohol use within the diverse transgender community. Research with self-reported measures of gender identity and sex-at-birth and structured assessment of alcohol use and disorders is needed.
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Affiliation(s)
- Emily C. Williams
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Madeline C. Frost
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Anna D. Rubinsky
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Joseph E. Glass
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Chelle L. Wheat
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Amy T. Edmonds
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Jessica A. Chen
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Department of Psychiatry and Behavioral Science, University of Washington, Seattle, Washington
| | - Theresa E. Matson
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Olivia V. Fletcher
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Keren Lehavot
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Psychiatry and Behavioral Science, University of Washington, Seattle, Washington
| | - John R. Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California
- Health Services Research & Development (HSR&D) Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Lett E, Dowshen NL, Baker KE. Intersectionality and Health Inequities for Gender Minority Blacks in the U.S. Am J Prev Med 2020; 59:639-647. [PMID: 32792281 PMCID: PMC7577994 DOI: 10.1016/j.amepre.2020.04.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Gender minority blacks represent the intersection of multiply marginalized populations that experience severe health inequities in the U.S. However, few studies focus on the unique health experiences of this multiply disadvantaged population. This study quantifies the health inequities experienced by gender minority blacks in the U.S. using an intersectional framework. METHODS This cross-sectional study analyzed data in 2018/2019 from the Behavioral Risk Factor Surveillance System, including all cisgender black, gender minority black, and gender minority white survey respondents who completed the gender identity module between 2014 and 2018. Investigators compared demographics, healthcare access, behavioral risk factors, chronic conditions, and perceived health status of gender minority blacks with those of cisgender blacks and gender minority whites. RESULTS In the primary analysis of weighted survey data, gender minority blacks were more likely to report experiencing severe mental distress (AOR=1.99, 95% CI=1.14, 3.47, p=0.02), longer periods of being physically or mentally unwell (adjusted RR=1.36, 95% CI=1.17, 1.59, p<0.001), and longer periods of activity limitations owing to poor health (adjusted RR=1.53, 95% CI=1.01, 1.41, p=0.003) than cisgender blacks. In a matched analysis, gender minority blacks had worse self-reported health than both cisgender blacks (OR=1.32, 95%: CI=1.05, 1.67, p=0.02) and gender minority whites (OR=1.53, 95% CI=1.15, 2.04, p=0.003). CONCLUSIONS Gender minority blacks have health experiences that are distinct from those of both the cisgender black and gender minority populations with which they intersect. Health policies and programs, including data collection efforts, must specifically consider this multiply marginalized population to effectively advance health equity.
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Affiliation(s)
- Elle Lett
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Nadia L Dowshen
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Craig-Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kellan E Baker
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Park KJ, Cho SH. The transgender organ donor: New frontiers in advocacy for mental health providers. JOURNAL OF GAY & LESBIAN MENTAL HEALTH 2020. [DOI: 10.1080/19359705.2020.1798701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Kelly J. Park
- Department of Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California (USC)/Los Angeles County + USC Medical Center, Los Angeles, California, USA
| | - Stephanie H. Cho
- Department of Psychiatry and the Behavioral Sciences, Keck Medicine of the University of Southern California, Los Angeles, California, USA
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McDowell A, Raifman J, Progovac AM, Rose S. Association of Nondiscrimination Policies With Mental Health Among Gender Minority Individuals. JAMA Psychiatry 2020; 77:952-958. [PMID: 32374362 PMCID: PMC7203670 DOI: 10.1001/jamapsychiatry.2020.0770] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In the past decade, many states have implemented policies prohibiting private health insurers from discriminating based on gender identity. Policies banning discrimination have the potential to improve access to care and health outcomes among gender minority (ie, transgender and gender diverse) populations. OBJECTIVE To evaluate whether state-level nondiscrimination policies are associated with suicidality and inpatient mental health hospitalizations among privately insured gender minority individuals. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, difference-in-differences analysis comparing changes in mental health outcomes among gender minority enrollees before and after states implemented nondiscrimination policies in 2009-2017 was conducted. A sample of gender minority children and adults was identified using gender minority-related diagnosis codes obtained from private health insurance claims. The present study was conducted from August 1, 2018, to September 1, 2019. EXPOSURE Living in states that implemented policies banning discrimination based on gender identity in 2013, 2014, 2015, and 2016. MAIN OUTCOMES AND MEASURES The primary outcome was suicidality. The secondary outcome was inpatient mental health hospitalization. RESULTS The study population included 28 980 unique gender minority enrollees (mean [SD] age, 26.5 [15] years) from 2009 to 2017. Relative to comparison states, suicidality decreased in the first year after policy implementation in the 2014 policy cohort (odds ratio [OR], 0.72; 95% CI, 0.58-0.90; P = .005), the 2015 policy cohort (OR, 0.50; 95% CI, 0.39-0.64; P < .001), and the 2016 policy cohort (OR, 0.61; 95% CI, 0.44-0.85; P = .004). This decrease persisted to the second postimplementation year for the 2014 policy cohort (OR, 0.48; 95% CI, 0.41-0.57; P < .001) but not for the 2015 policy cohort (OR, 0.81; 95% CI, 0.47-1.38; P = .43). The 2013 policy cohort experienced no significant change in suicidality after policy implementation in all 4 postimplementation years (2014: OR, 1.19; 95% CI, 0.85-1.67; P = .31; 2015: OR, 0.94; 95% CI, 0.73-1.20; P = .61; 2016: OR, 0.82; 95% CI, 0.65-1.03; P = .10; and 2017: OR, 1.29; 95% CI, 0.90-1.88; P = .18). Mental health hospitalization rates generally decreased or stayed the same for individuals living in policy states vs the comparison group. CONCLUSIONS AND RELEVANCE Implementation of a state-level nondiscrimination policy appears to be associated with decreased or no changes in suicidality among gender minority individuals living in states that implemented these policies from 2013 to 2016. Given high rates of suicidality among gender minority individuals in the US, health insurance nondiscrimination policies may offer a mechanism for reducing barriers to care and mitigating discrimination.
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Affiliation(s)
- Alex McDowell
- PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Julia Raifman
- Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts
| | - Ana M. Progovac
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Sherri Rose
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Kameg B. Gender Dysphoria in United States Veterans and Military Personnel: Historical Context and Current Policies. J Psychosoc Nurs Ment Health Serv 2020; 58:5-8. [PMID: 32286667 DOI: 10.3928/02793695-20200403-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 03/04/2020] [Indexed: 11/20/2022]
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Progovac AM, Mullin BO, Dunham E, Reisner SL, McDowell A, Sanchez Roman MJ, Dunn M, Telingator CJ, Lu FQ, Breslow AS, Forstein M, Cook BL. Disparities in Suicidality by Gender Identity Among Medicare Beneficiaries. Am J Prev Med 2020; 58:789-798. [PMID: 32156489 PMCID: PMC7246148 DOI: 10.1016/j.amepre.2020.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Suicidality is higher for gender minorities than the general population, yet little is known about suicidality in disabled or older adult gender minorities. METHODS This study used 2009-2014 Medicare claims to identify people with gender identity-related diagnosis codes (disabled, n=6,678; older adult, n=2,018) and compared their prevalence of suicidality with a 5% random non-gender minority beneficiary sample (disabled, n=535,801; older adult, n=1,700,008). Correlates of suicidality were assessed (via chi-square) for each of the 4 participant groups separately, and then disparities within eligibility status (disabled or older adult) were assessed using logistic regression models, adjusting first for age and mental health chronic conditions and then additionally for Medicaid eligibility, race/ethnicity, or U.S. region (each separately). The primary hypotheses were that gender minority beneficiaries would have higher suicidality but that suicidality disparities would persist after adjusting for covariates. Data were analyzed between 2017 and 2019. RESULTS Gender minority beneficiaries had higher unadjusted suicidality than non-gender minority beneficiaries in the disabled cohort (18.5% vs 7.1%, p<0.001). Significant suicidality predictors in all 4 groups included the following: age (except in older adult gender minorities), Medicaid eligibility, depression or behavioral health conditions, avoidable hospitalizations, and violence victimization. In age- and mental health-adjusted logistic regression models, gender minorities had higher odds of suicidality than non-gender minority beneficiaries (disabled, OR=1.95, p<0.0001; older adult, OR=2.10, p<0.0001). Disparities were not attenuated after adjusting for Medicaid eligibility, race/ethnicity, or region. CONCLUSIONS Heightened suicidality among identified gender minority Medicare beneficiaries highlights a pressing need to identify and reduce barriers to wellness in this population.
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Affiliation(s)
- Ana M Progovac
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.
| | - Brian O Mullin
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Emilia Dunham
- Office of Behavioral Health, MassHealth, Boston, Massachusetts
| | - Sari L Reisner
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Alex McDowell
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts; Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Maria Jose Sanchez Roman
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts; Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
| | | | - Cynthia J Telingator
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Frederick Q Lu
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Aaron Samuel Breslow
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts; PRIME Center for Health Equity, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Marshall Forstein
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Benjamin Lê Cook
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; PRIME Center for Health Equity, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Holt NR, King RE, Mocarski R, Woodruff N, Hope DA. Specialists in Name or Practice? The Inclusion of Transgender and Gender Diverse Identities in Online Materials of Gender Specialists. JOURNAL OF GAY & LESBIAN SOCIAL SERVICES 2020; 33:1-15. [PMID: 34140762 PMCID: PMC8204661 DOI: 10.1080/10538720.2020.1763225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Recommendations for health care providers working with transgender and gender diverse (TGD) individuals emphasize affirming clients' identities, such as using correct pronouns and name, however it is unknown how often gender specialists adhere to such recommendations. Websites and intake forms of gender specialists were coded for use of affirming language, asking for pronouns and chosen name, and mention of TGD specialties and resources. Most websites identified the provider's specialty to work with TGD individuals, though much fewer provided additional resources concerning TGD issues and only half of intake forms included affirming language. Given previous research that has demonstrated providers working in states with legal protections for TGD individuals use affirming language more often than providers in locales without protections, association with state legal climate is also examined.
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Affiliation(s)
- Natalie R Holt
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnett Hall, Lincoln, NE 68588-03011
| | - Robyn E King
- Department of Counseling and School Psychology, University of Nebraska at Kearney, Kearney, Nebraska
| | - Richard Mocarski
- Department of Communication, University of Nebraska at Kearney, Kearney, Nebraska
| | - Nathan Woodruff
- Trans Collaborations Local Community Board, Lincoln, Nebraska
| | - Debra A Hope
- Department of Psychology, University of Nebraska-Lincoln, 238 Burnett Hall, Lincoln, NE 68588-03011
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Underhill K. Perceptions of Protection under Nondiscrimination Law. AMERICAN JOURNAL OF LAW & MEDICINE 2020; 46:21-54. [PMID: 32460651 DOI: 10.1177/0098858820919551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Nondiscrimination rules-statutes, regulations, and soft law protections-are critical for reducing health and health care disparities. Although scholarship has interrogated how nondiscrimination rules affect behavior by discriminators, comparatively little has considered how protections can affect choices made by members of protected groups. A number of states and some interpretations of federal law protect people from discrimination on the basis of sexual orientation. This Article seeks to identify relationships between actual state law, perceived state law, and experiences of discrimination and medical mistrust. This Article reports the results of a national cross-sectional survey of over 3,000 men using Grindr to meet male partners. Participants scored comparable to chance in knowledge about state nondiscrimination protections, with "optimistic errors" (erroneous beliefs that one was protected) significantly more common than pessimistic errors. Perceptions of protection were significantly correlated with lower medical mistrust and greater uptake of care, as well as lower perceived barriers to disclosure and care-seeking. Actual state law protections, however, were significant predictors of having had discussions with providers that depended on disclosure of sexual behavior or orientation. Building on these results, this Article considers pathways by which nondiscrimination law may exert welcome mat (and "unwelcome mat") effects.
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Affiliation(s)
- Kristen Underhill
- Associate Professor of Law, Columbia Law School. Associate Professor of Population & Family Health, Mailman School of Public Health, Columbia University. J.D., Yale Law School; D.Phil., University of Oxford. This research was funded by K01-MH093273 from the National Institute of Mental Health. I am grateful to the study participants for sharing their thoughts and experiences. I am also grateful to the peer reviewers and commentators at the American Society of Law, Medicine & Ethics Health Law Professors Conference; the Behavioral Law and Economics conference; the Columbia Faculty Workshop; the Harvard Health Law Workshop; the Mailman School Department of Population & Family Health; the Penn State Health Services Research Colloquium; and the Regional Health Law Works-in-Progress Retreat for valuable feedback on this work. I thank Leo Beletsky, I. Glenn Cohen, Carl Coleman, Mark Hatzenuehler, Suzanne Goldberg, Bert Huang, Craig Konnoth, Terry McGovern, Adam Muchmore, Govind Persad, and Brian Sheppard for helpful comments and discussion. I am grateful to Kenneth H. Mayer, Don Operario, Kate Guthrie, Peter Salovey, Christopher Kahler, and Sarah K. Calabrese for guidance and collaboration on the K01 study that included this survey. All errors herein are my own
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Cicero EC, Reisner SL, Merwin EI, Humphreys JC, Silva SG. The health status of transgender and gender nonbinary adults in the United States. PLoS One 2020; 15:e0228765. [PMID: 32084144 PMCID: PMC7034836 DOI: 10.1371/journal.pone.0228765] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 01/23/2020] [Indexed: 12/16/2022] Open
Abstract
The goal of this exploratory study was to delineate health differences among transgender subpopulations (transgender women/TW, transgender men/TM, gender nonbinary/GNB adults). 2015 Behavioral Risk Factor Surveillance System data were analyzed to compare the health of three groups (TW:N = 369; TM:N = 239; GNB:N = 156). Logistic regression and adjusted odds ratios were used to determine whether health outcomes (fair/poor health, frequent physical and mental unhealthy days, chronic health conditions, and health problems/impairments) are related to group and its interaction with personal characteristics and socioeconomic position. Group was a significant predictor of fair/poor health and frequent mental unhealthy days, revealing significant health differences between the transgender groups. The odds of poor/fair health were approximately 2.5 times higher in TM and GNB adults relative to TW. The odds of frequent mental unhealthy days for TM were approximately 1.5-2 times greater than TW and GNB adults. Among those with health insurance, the odds of fair/poor health for GNB adults was more than 1.5-2 times higher that of TM and TW. Among those without health insurance, TM had over 7 times greater odds of fair/poor health than TW. This study underscores the importance of classifying and examining the health of the transgender population as unique subpopulations, as notable health differences were discovered. TM and GNB adults have significant health concerns, requiring the attention of clinical interventions aimed at promoting health and preventing illness.
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Affiliation(s)
- Ethan C. Cicero
- Department of Community Health Systems, University of California San Francisco School of Nursing, San Francisco, California, United States of America
| | - Sari L. Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Fenway Health, The Fenway Institute, Boston, Massachusetts, United States of America
| | - Elizabeth I. Merwin
- School of Nursing, Duke University, Durham, North Carolina, United States of America
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, Texas, United States of America
| | - Janice C. Humphreys
- School of Nursing, Duke University, Durham, North Carolina, United States of America
| | - Susan G. Silva
- School of Nursing, Duke University, Durham, North Carolina, United States of America
- School of Medicine, Duke University, Durham, North Carolina, United States of America
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