A Systematic Review of the Health and Healthcare Inequalities for People with Intersex Variance

LGBTQIA health in medical education: a national survey of Australian medical students

PURPOSE

Lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA) individuals experience poorer health outcomes than other individuals. Insufficient LGBTQIA health education of doctors in existing medical curricula contributes to these outcomes. We sought to explore medical students' experiences of content coverage and mode of delivery, as well as their preparedness, attitudes and learning needs regarding LGBTQIA health education in Australia.

METHODS

Using a conceptual framework specific to curricular development, we adapted a previous cross-sectional national survey. This included 28 questions (analysed statistically) and 5 free text responses (analysed deductively using Braun and Clarke's thematic analysis framework). Data was compared between LGBTQIA and non-LGBTQIA respondents, and clinical and preclinical students.

RESULTS

There were 913 participants from 21 of 23 medical schools, with most preclinical (55%) and clinical (89%) students reporting no teaching specific to LGBTQIA health. Reported content coverage was highest for sexual history taking (30%), and especially low for transgender and intersex health (< 16%), and intersectional LGBTQIA health (< 7%). Participants had positive attitudes towards LGBTQIA health, with 89% agreeing LGBTQIA topics were important and need to be covered in detail. Students desired longitudinal integration of LGBTQIA content, and LGBTQIA community involvement and case-based teaching that allows for interaction and questions. Self-perceived competency was low in all LGBTQIA health topics, although LGBTQIA participants reported higher preparedness than non-LGBTQIA participants.

CONCLUSIONS

Majority of survey participants reported limited teaching of LGBTQIA health-specific content, highlighting the limited coverage of LGBTQIA health in Australian medical schools. Participants expressed positive attitudes towards LGBTQIA content and broadly agreed with statements supporting increased integration of LGBTQIA health content within medical curricula.

Inclusion of Sex and Gender to Improve the State of the Science in Women's Health

ABSTRACT

The influence of sex and gender-related factors on health and disease at all levels of scale, across all health conditions, and throughout the entire life course is increasingly clear. A series of policies instituted by the National Institutes of Health (NIH) that require researchers to include appropriate populations and to analyze the data accordingly have strengthened the evidence base around the health of women. Translating these advances to the entire research ecosystem can catalyze rigorous biomedical discovery that can improve health. We encourage journals, publishers, and funders to align their policies and expectations regarding sex and gender considerations in research with those of the NIH and other international funding agencies.

Navigating Mental Health Frontiers: A Scoping Review of Accessibility for Rural LGBTIQA+ Communities

Mental healthcare for LGBTQIA+ populations in rural areas remains unequal, despite societal progress toward inclusivity. This review examines the specific obstacles faced in rural areas, such as limited services, workforce deficiencies, and travel burdens for treatment, which exacerbate existing mental health inequities. By following the Joanna Briggs Institute methodology, an exploration of SCOPUS, EBSCO Host (All), and Ovid databases yielded 2373 articles. After careful screening, 21 articles from five countries were selected, primarily using qualitative interviews and quantitative online surveys. Analysis through the Lévesque framework reveals the complex challenges faced by LGBTQIA+ individuals in rural mental healthcare. Discrepancies in approachability, acceptability, availability, affordability, and appropriateness were identified. Geographical isolation, discrimination, and a lack of LGBTQIA+-attuned professionals further compound these issues. Societal stigma, discrimination, and economic constraints hinder individuals from accessing and engaging in mental health services. This study highlights the need for purposeful interventions to improve rural mental health access for sexual and gender minorities.

Caring for sexual and gender minority patients with genitourinary cancer: A primer for inclusive practices

Recognizing sexual orientation and gender identity (SOGI) is paramount in the management of genitourinary cancers, as sexual and gender minority (SGM) individuals encounter unique healthcare challenges leading to disparities. SGM patients often confront systemic barriers, provider biases, and scarcity of tailored resources, resulting in diminished satisfaction and adverse health outcomes. The evaluation and treatment of genitourinary cancers in SGM patients demand a nuanced, multidisciplinary approach that focuses on the unique health determinants often overlooked by the healthcare system. This review highlights recommendations for the inclusivity of SGM patients within the clinic, from inclusive signage to gender inclusive language. For the evaluation and treatment of SGM patients with genitourinary cancers, it is recommended to employ organ-based language, to utilize validated questionnaires encompassing mental health, sexual behavior, and patient-reported outcomes, and to provide timely referrals to social work and onco-fertility when appropriate. Ultimately, approaching inclusivity through education targeted at both SGM patients and healthcare providers is pivotal for centering care around the patient, improving the quality of life and outcomes for SGM patients facing genitourinary cancers.

Policy and laboratory practice: How quality control procedures for genetic testing perpetuate biological essentialism and discrimination against transgender, gender diverse, and intersex people

Transgender, gender diverse, and intersex (TGDI) individuals face significant health disparities due to individual and systemic experiences of discrimination, impacting their access to healthcare. While clinical genetic testing has become increasingly accessible to the general population, the field of clinical genetics perpetuates a narrative of biological essentialism, which creates barriers for TGDI patients. Biological essentialism upholds that sex is a binary, fixed, and innate characteristic, a misconception that has been historically weaponized against the TGDI community in both individual experiences of discrimination and anti-trans legislation, among other systemic forms of oppression. Rejecting this discriminatory framework requires careful consideration of, and changes to, long-established practices that often go unquestioned, such as quality control metrics in genetic testing, in order to improve TGDI patients' outcomes and access to genetic services. The sex-check, comparing an individuals reported sex against their sex chromosomes, is an example of how laboratory genetics practices reinforce the narrative that sex is determined purely by chromosomal composition. Additionally, the sex-check "outs" TGDI people in clinical settings, creating a discriminatory and unsafe environment for these patients. Alternative quality control procedures and inclusive practices, such as clearer delineation of sex and gender on test requisition forms, are proposed to improve TGDI patient experiences. Genetic counselors and other clinical providers have a responsibility to address historical discrimination and advocate for changes to laboratory practice, so as to create affirming experiences for TGDI patients.

Mapping research on LGBT+ persons' health: a bibliometric analysis

AIMS

Lesbian, gay, bisexual, transgender and other people (LGBT+) individuals may have a greater risk of experiencing mental and physical health issues. In the past years, the predominant theme of research was HIV/AIDS and sexually transmitted infections (STIs). This study aimed to explore the most recent patterns in medical research concerning LGBT+ persons.

METHODS

A bibliometric analysis using Biblioshiny was conducted. Based on previous studies, years of observation ranged between 2008 and 2021. Web of Science Core Collection was used.

RESULTS

A total of 31,039 articles were selected. Top journals centered around HIV/AIDS and STIs (n = 6), followed by sexual behaviors/sexuality (n = 2) and LGBT+ health (n = 2). The US led in research output (n = 16,249). Papers were categorized into three main clusters (which showed different evolution across time): one addressing HIV/AIDS, STIs, and sexual behaviors, another focusing on mental health, discrimination, and stigma, and a third, smaller cluster examining transgender, intersex, and gender-diverse health.

CONCLUSIONS

This article highlighted a growth in LGBT+ health research, uncovering research disparities among countries. While HIV/AIDS and STIs still dominated, a crucial theme concerning mental health, discrimination, and stigma has been rising. Declining interest in gender-diverse health, and disparities in research attention to different LGBT+ subgroups, underscored the need for more comprehensive and inclusive research to address complex health disparities.

Epidemiology of Intensive Care Patients Classified as a Third Sex in Australia and New Zealand

BACKGROUND

Patient sex affects treatment and outcomes in critical illness. Previous studies of sex differences in critical illness compared female and male patients. In this study, we describe the group of patients classified as a third sex admitted to ICUs in Australia and New Zealand.

RESEARCH QUESTION

What are the admission characteristics and outcomes of ICU patients classified as belonging to a third sex group compared with patients classified as female or male?

STUDY DESIGN AND METHODS

Retrospective observational study of admissions to 200 ICUs, recorded in the Australian and New Zealand Intensive Care Society's Adult Patient Database from 2018 to 2022. We undertook mixed effect logistic regression to compare hospital mortality across the sex groups, adjusted for illness severity, diagnosis, treatment limitation, year, and hospital.

RESULTS

We examined 892,161 admissions, of whom 525 (0.06%) were classified as third sex. Patients classified as third sex were represented across all diagnostic categories, jurisdictions, and hospital types. On average, they were younger than the groups classified as female (59.2 ± 20.0 vs 61.3 ± 18.4 years; P = .02) or male (63.2 ± 16.7 years; P < .001), respectively. Patients classified as third sex were more likely to be admitted after orthopedic surgery (10.1% third sex admissions [95% CI, 7.7%-13.0%]; 6.2% female [95% CI, 6.1%-6.3%]; 4.8% male [95% CI, 4.7%-4.9%]) and drug overdose (8.8% third sex admissions [95% CI, 6.5%-11.5%]; 4.2% female [95% CI, 4.1%-4.2%]; 3.1% male [95% CI, 3.0%-3.1%]). There was no difference in the adjusted hospital mortality of patients classified as third sex compared with the other groups.

INTERPRETATION

Patients classified as third sex composed a small minority group of adult ICU patients. This group had a different diagnostic case mix but similar outcomes to the groups classified as female or male. Further characterizing a third sex group will require improved processes for recording sex and gender in health records.

Navigating the complexities of adult healthcare for individuals with variations of sex characteristics: from paediatric emergencies to a sense of abandonment

Intersex people and those with variations of sex characteristics face significant health and social issues. This paper analyses the complexities of adult healthcare for this diverse population, including the root causes of deficiencies in care provision. Many minors with variations of sex characteristics are subjected to irreversible, non-consensual medical interventions, which can have negative effects on their health and wellbeing as adults. This 'emergency' approach to intersex paediatric healthcare has been challenged since the 1990s, but there is still a lack of understanding about how the paradigm affects adult care. This paper aims to raise awareness of the health challenges faced by adults with variations of sex characteristics. It identifies themes related to the challenges associated with accessing appropriate adult care, including the repercussions of childhood treatment, the lack of transitional services and psychological support, the limited general medical knowledge about variations of sex characteristics, and the reluctance to access services due to fear of stigma or past medical trauma. The paper indicates the need for more attention to intersex people's health needs as adults, moving away from attempts to 'fix' them as minors towards approaches which consider and provide for their diverse healthcare needs in a broader temporal context.

Medical Mistrust Mediates the Relationship Between Nonconsensual Intersex Surgery and Healthcare Avoidance Among Intersex Adults

BACKGROUND

Intersex individuals experience poor health due, in part, to healthcare avoidance. Nonconsensual intersex surgery may contribute to medical mistrust and avoidance among intersex populations.

PURPOSE

The purpose of this study was to explore the relationship between nonconsensual surgery and healthcare avoidance among intersex populations and to examine if medical mistrust mediates this relationship.

METHODS

Data for this cross-sectional study were collected in 2018 and analyzed in 2022. Participants completed a survey collecting information on demographics, medical mistrust, history of nonconsensual surgery, and history of postponing healthcare. One hundred nine participants with valid responses to all regression model variables were included in the study. Multivariable logistic regression models controlling for age, race, and income, examined the relationship between nonconsensual surgery and postponing preventive and emergency healthcare. Mediation analyses of cross-sectional data examined whether medical mistrust mediated the relationship between nonconsensual surgery and postponing preventive and emergency healthcare.

RESULTS

Mean medical mistrust score was 2.8 (range = 1-4; standard deviation = 0.8), 49.7% of participants had nonconsensual surgery in their lifetime, 45.9% postponed emergency healthcare, and 61.5% postponed preventive healthcare in their lifetime. Nonconsensual surgery was associated with increased odds of delaying preventive (adjusted odds ratio [AOR] = 4.17; confidence interval [CI] = 1.76-9.88; p = .016) and emergency healthcare (AOR = 4.26; CI = 1.71-10.59; p = .002). Medical mistrust mediated the relationship between nonconsensual surgery and delaying preventive (indirect effect = 1.78; CI = 1.16-3.67) and emergency healthcare (indirect effect = 1.66; CI = 1.04-3.30).

CONCLUSIONS

Nonconsensual surgery contributed to healthcare avoidance in this intersex population by increasing medical mistrust. To decrease healthcare avoidance, intersex health promotion interventions should restrict nonconsensual surgery and build trust through trauma-informed care.

Mental health challenges experienced by LGBTI+ community in Gaborone: A phenomenological study

Background

Mental health challenges have affected the entire global population including individuals identifying as lesbian, gay, bisexual, transgender, intersex and others (LGBTI+). There is documented evidence of a high prevalence of mental health challenges among LGBTI+ community across the globe, but in Botswana there is dearth of literature pertaining to the phenomenon of LGBTI+ mental health challenges.

Aim

The study was aimed at exploring and describing the mental health challenges experienced by some people identifying as the LGBTI+ community in Gaborone, Botswana.

Setting

The study was conducted in Gaborone in Botswana.

Methods

The study adopted a qualitative, phenomenological, descriptive design with 15 participants identified through snowball sampling. LEGABIBO, the LGBTI+ advocacy organisation, served as gatekeeper after Health Research and Development Division under the Ministry of Health and Wellness gave the ethical clearance of the study. Data were collected through unstructured telephonic interviews and recorded with a digital voice recorder.

Results

The study established that some LGBTI+ individuals experienced mental health challenges like experiences of depression, experiences of gender dysphoria, and loneliness and isolation.

Conclusion

It is concluded that individuals identifying as LGBTI+ experience mental health challenges that stem from being stigmatised and discriminated among others.

Contribution

The findings of the study provide information that may be used in dealing with mental health issues of individuals identifying as LGBTI+. Furthermore, the findings may inform nursing practice, research and education issues on LGBTI+ as well as influence health policy in addressing the mental health issues of those identifying as LGBTI+.

Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement

Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.

A Call to Action for Improving LGBTQIA2S+ Inclusive Policies and Practices in Educating Science and Medical Professionals

Based on Nature's novel sex and gender guidelines, we share a call to action to enact policy changes in medical and scientific education. We conducted a literature search of current policies and practices affecting sex and gender minorities. Our work indicated a scarcity of guidelines and curricula dedicated to standardizing LGBTQIA2S+ topics. Educational policies must be enacted to ensure that sex and gender guidelines are implemented across all institutions as it impacts the future of healthcare and science. It is essential that sex and gender considerations be mandated topics in both medical and scientific education.

Prevalence of alcohol use amongst sexual and gender minority (LGBTQ+) communities in the UK: a systematic scoping review

BACKGROUND

globally, alcohol use rates vary by sexual orientation and gender identity (SOGI), but UK government statistics on alcohol use in the LGBTQ+ population are missing.

AIM

this systematic scoping review determined the prevalence of alcohol use amongst gender and sexual minority people in the UK.

METHODS

empirical UK studies from 2010 onwards reporting the prevalence of alcohol use in SOGI compared with heterosexual/cisgender people were included. Searches in MEDLINE, Embase, Web of Science, PsycINFO, CINAHL, Cochrane Library, Google Scholar, Google, charity websites and systematic reviews were conducted in October 2021, using SOGI, alcohol and prevalence terms. Citation checking was done by two authors, with disagreements resolved through discussion. Data extraction was done by one author (CM) and checked by another (LZ). Quality assessment was performed by study design, sample type and statistical analysis of results. A narrative synthesis was qualitatively combined with a tabular presentation of results.

RESULTS

database and website searches found 6607 potentially relevant citations, and 505 full texts were reviewed with 20 studies included, found in 21 publications and grey literature reports. Most were on sexual orientation, including 12 from large cohort studies. Harmful alcohol use is higher in LGBTQ+ people than heterosexual people in the UK, a result similar to that found in other countries. Qualitative data reflected alcohol's role as emotional support. Fewer asexual people drank alcohol compared with allosexual people, and there were no data available regarding intersex people.

CONCLUSION

funded cohort studies and service providers should routinely collect SOGI data. Standardized reporting of SOGI and alcohol use would improve comparability across studies.

Human rights violations in normalizing procedures on intersex children

Intersex children in Brazil are still subjected to "normalizing" surgical procedures and subsequent bodily interventions to make their bodies conform to binary views of sex. Resolution n. 1,664/2003 of the Brazilian Federal Council of Medicine legitimizes interventions upon intersex bodies, being the only national normative instrument that address the subject. However, the demands of international intersex political activism have denounced how early childhood interventions for sex designation mutilate children's bodies and violate a number of human rights. This research discusses how early, irreversible, and normalizing procedures performed without the intersex person's consent are human rights violations. Based on the concept of epistemic (in)justice, we first look at the disputes surrounding the evidence that underpin medical practices. We demonstrate how such procedures violate human rights to health, body integrity, autonomy, and sexual and reproductive rights, analyzing which strategies were put into place to prevent them. We propose that intersex people be at the center of decisions regarding their bodies, that non-surgical paths be discussed with patients and their family members, and that early, invasive, mutilating, harmful, cosmetic, and unconsented surgical interventions on intersex children be prohibited. Guiding tools must introduce changes into its regulatory bias to, from an interdisciplinary perspective, include bioethical and human rights bodies, as well as intersex activists.

Human rights violations in normalizing procedures on intersex children

Intersex children in Brazil are still subjected to “normalizing” surgical procedures and subsequent bodily interventions to make their bodies conform to binary views of sex. Resolution n. 1,664/2003 of the Brazilian Federal Council of Medicine legitimizes interventions upon intersex bodies, being the only national normative instrument that address the subject. However, the demands of international intersex political activism have denounced how early childhood interventions for sex designation mutilate children’s bodies and violate a number of human rights. This research discusses how early, irreversible, and normalizing procedures performed without the intersex person’s consent are human rights violations. Based on the concept of epistemic (in)justice, we first look at the disputes surrounding the evidence that underpin medical practices. We demonstrate how such procedures violate human rights to health, body integrity, autonomy, and sexual and reproductive rights, analyzing which strategies were put into place to prevent them. We propose that intersex people be at the center of decisions regarding their bodies, that non-surgical paths be discussed with patients and their family members, and that early, invasive, mutilating, harmful, cosmetic, and unconsented surgical interventions on intersex children be prohibited. Guiding tools must introduce changes into its regulatory bias to, from an interdisciplinary perspective, include bioethical and human rights bodies, as well as intersex activists.

Theorising health equity research for people with intersex variance through new materialism

Health inequalities impact sex-variant people in highly differentiated ways. This is evidenced in much academic and activist intersex research documenting the highly specific forms of inequalities arising from misrecognition, discrimination and human rights abuses inherent to pathologised accounts of non-normative bodies. Important theoretical work further interrogates the implications of sex variant subjectivities, identities and bodies for static or binary notions of both sex and gender. In this paper, we aim to contribute further to this scholarship. We draw upon feminist materialist and Deleuzean-informed understandings of materials or matter to rethink debates over sex-variant subjectivities, identities and bodies in relation to inequalities in health. We argue 'the turn to matter' and associated new materialist theories draw attention to the complex, dynamic relational assemblages and entanglements mutually constituting the affective, embodied and socio-material worlds of intersex people. Informed by these theories, we propose that inequalities can be more fully addressed through a new health equity research agenda that is co-produced with sex-variant people. This agenda will enable a fuller exploration of the unsettling but transformative capacities of intersex matters and meanings with the contextually specific understandings of equity in relation to health and health care.

Genitourinary and Sexual Symptoms and Treatments in Transfeminine Individuals: A Qualitative Exploration of Patients' Needs

Introduction

Medical providers may not be familiar with the genitourinary and sexual symptoms of transgender and non-binary (TGNB) individuals. This lack of familiarity may hinder a provider's ability to address these issues as patients may hesitate to report symptoms due to fear of stigma, misgendering, and being treated disrespectfully.

Aim

To describe the array of genitourinary and sexual symptoms in transfeminine individuals.

Methods

Upon institutional review board approval, researchers used semi-structured interviews with 25 transfeminine individuals assigned male at birth to explore urinary and sexual symptoms on a sample of convenience. Participants were recruited and interviews were conducted until saturation was achieved. Two research assistants independently coded all de-identified transcripts and resolved discrepancies.

Outcomes

Thematic codes pertaining to genitourinary and sexual symptoms were defined and assessed in this study.

Results

Some genitourinary symptoms unrelated to hormone therapy or genital gender-affirming surgery (GGAS) included frequency, urgency, nocturia, and incontinence, while those attributed to GGAS included slow stream, spraying, and retention. Sexual symptoms unrelated to hormone therapy or GGAS included sexually transmitted infections, erectile dysfunction, and low libido. Sexual symptoms related to GGAS included delayed ejaculation, penile pain, scar tissue pain, and pain with receptive vaginal penetration.

Clinical Implications

Increased provider awareness of and accountability for the treatment of genital and sexual symptoms of transfeminine individuals.

Strengths and Limitations

Open-ended questions were used to generate a range of responses and perspectives through conversation instead of quantifiable data. Findings are not applicable to all TGNB people since participants were limited to transfeminine adults assigned male at birth only. Recruitment was limited by the sensitive nature of the topic and hard-to-reach populations and relied on convenience through flyers and a chain-referral sampling approach.

Conclusion

Transfeminine individuals experience a wide array of genitourinary and sexual symptoms both similar and different to their cis gender counterparts.

Chung PH, Swaminathan V, Spigner S, et al. Genitourinary and Sexual Symptoms and Treatments in Transfeminine Individuals: A Qualitative Exploration of Patients’ Needs. Sex Med 2022;10:100566.

LGBTQI cancer patients' quality of life and distress: A comparison by gender, sexuality, age, cancer type and geographical remoteness

Background

There is growing acknowledgement of the psycho-social vulnerability of lesbian, gay, bisexual, transgender, queer and/or intersex (LGBTQI) people with cancer. The majority of research to date has focused on cisgender adults with breast or prostate cancer.

Study Aim

This study examined psycho-social factors associated with distress and quality of life for LGBTQI cancer patients and survivors, across a range of sexualities and gender identities, intersex status, tumor types, ages and urban/rural/remote location using an intersectional theoretical framework.

Method

430 LGBTQI people with cancer completed an online survey, measuring distress, quality of life (QOL), and a range of psycho-social variables. Participants included 216 (50.2%) cisgender women, 145 (33.7%) cisgender men, and 63 (14.7%) transgender and gender diverse (TGD) people. Thirty-one (7.2%) participants reported intersex variation and 90 (20%) were adolescents or young adults (AYA), aged 15-39. The majority lived in urban areas (54.4%) and identified as lesbian, gay or bisexual (73.7%), with 10.9% identifying as bisexual, and 10.5% as queer, including reproductive (32.4%) and non-reproductive (67.6%) cancers.

Results

Forty-one percent of participants reported high or very high distress levels, 3-6 times higher than previous non-LGBTQI cancer studies. Higher rates of distress and lower QOL were identified in TGD compared to cisgender people, AYAs compared to older people, those who identify as bisexual or queer, compared to those who identify as lesbian, gay or homosexual, and those who live in rural or regional areas, compared to urban areas. Elevated distress and lower QOL was associated with greater minority stress (discrimination in life and in cancer care, discomfort being LGBTQI, lower outness) and lower social support, in these subgroups. There were no differences between reproductive and non-reproductive cancers. For the whole sample, distress and poor QOL were associated with physical and sexual concerns, the impact of cancer on gender and LGBTQI identities, minority stress, and lack of social support.

Conclusion

LGBTQI people with cancer are at high risk of distress and impaired QOL. Research and oncology healthcare practice needs to recognize the diversity of LGBTQI communities, and the ways in which minority stress and lack of social support may affect wellbeing.

Health intervention experiences and associated mental health outcomes in a sample of LGBTQ people with intersex variations in Australia

People with intersex variation/s have sex characteristics determined by reproductive anatomy or chromosomal, gonadal, or hormonal expressions that are not typical of medical and societal norms for male or female bodies and are widely subjected to irreversible medical interventions at an early age to reinforce sex assignment. These interventions may be accompanied by experiences of lack of autonomy for the individual and, at times, lack of fully informed consent on the part of the individual or their parents/carers. People with intersex variations additionally experience high rates of mental health concerns relating to stigma, discrimination and poor healthcare experiences. The intersections between LGBTQ identities and intersex variations are poorly understood but are important given a high proportion of people with intersex variations identify as LGBTQ. This study explored associations between healthcare experiences and mental health outcomes among 46 LGBTQ people aged between 18 and 67 years old with intersex variations in Australia. Findings provide evidence of associations between suicidal thinking, suicidal attempts, depression or anxiety and negative healthcare experiences, including limited autonomy and consent, and challenges accessing psychological support. These highlight the need for further research and proactive intervention to advance human rights and improve health outcomes for this population.

LGBTQI Inclusive Cancer Care: A Discourse Analytic Study of Health Care Professional, Patient and Carer Perspectives

Background

Awareness of the specific needs of LGBTQI cancer patients has led to calls for inclusivity, cultural competence, cultural safety and cultural humility in cancer care. Examination of oncology healthcare professionals’ (HCP) perspectives is central to identifying barriers and facilitators to inclusive LGBTQI cancer care.

Study Aim

This study examined oncology HCPs perspectives in relation to LGBTQI cancer care, and the implications of HCP perspectives and practices for LGBTQI patients and their caregivers.

Method

357 oncology HCPs in nursing (40%), medical (24%), allied health (19%) and leadership (11%) positions took part in a survey; 48 HCPs completed an interview. 430 LGBTQI patients, representing a range of tumor types, sexual and gender identities, age and intersex status, and 132 carers completed a survey, and 104 LGBTQI patients and 31 carers undertook an interview. Data were analysed using thematic discourse analysis.

Results

Three HCP subject positions – ways of thinking and behaving in relation to the self and LGBTQI patients – were identified:’Inclusive and reflective’ practitioners characterized LGBTQI patients as potentially vulnerable and offered inclusive care, drawing on an affirmative construction of LGBTQI health. This resulted in LGBTQI patients and their carers feeling safe and respected, willing to disclose sexual orientation and gender identity (SOGI) status, and satisfied with cancer care. ‘Egalitarian practitioners’ drew on discourses of ethical responsibility, positioning themselves as treating all patients the same, not seeing the relevance of SOGI information. This was associated with absence of LGBTQI-specific information, patient and carer anxiety about disclosure of SOGI, feelings of invisibility, and dissatisfaction with healthcare. ‘Anti-inclusive’ practitioners’ expressed open hostility and prejudice towards LGBTQI patients, reflecting a cultural discourse of homophobia and transphobia. This was associated with patient and carer distress, feelings of negative judgement, and exclusion of same-gender partners.

Conclusion

Derogatory views and descriptions of LGBTQI patients, and cis-normative practices need to be challenged, to ensure that HCPs offer inclusive and affirmative care. Building HCP’s communicative competence to work with LGBTQI patients needs to become an essential part of basic training and ongoing professional development. Visible indicators of LGBTQI inclusivity are essential, alongside targeted resources and information for LGBTQI people.

Lifespan healthcare transitions among individuals with intersex traits in Canada: a mixed-methods and qualitative study

OBJECTIVES

To: (1) complete an integrative literature review of transition studies that focus on individuals with intersex traits; (2) conduct an environmental scan of the current resources (practice guidelines, policies and procedures) used by healthcare providers working with Canadians with intersex traits; (3) investigate the experiences of Canadians with intersex traits in their healthcare transitions across the lifespan and (4) assess the understanding of healthcare providers about these transitions.

DESIGN

A qualitative prospective community participation study was conducted. It used mixed methods including an environmental scan and semistructured engagement sessions.

SETTING

The environmental scan examined resources available throughout Canada. The engagement sessions took place in British Columbia and Ontario, Canada.

PARTICIPANTS

Sixteen participants were recruited. These included 13 individuals with intersex traits (a heterogeneous group of congenital conditions affecting the development of sex characteristics) and three caregivers.

METHODS

Mixed methods included an integrated literature review, environmental scan and qualitative approaches developed in collaboration with community partners.

RESULTS

The literature review identified gaps in transition care for individuals with intersex traits. The environmental scan uncovered no specific resources used by healthcare providers working with patients with intersex traits, though several general guidelines were used. Engaging providers in the study was problematic. Thematic analysis generated three main themes that emerged from the engagement sessions: (1) transition is a lifespan activity; (2) building personal agency is valuable and (3) well-being promotion is an application of health literacy.

CONCLUSIONS

Transition resources for individuals living in Canada with intersex are scarce. Transitions happen across the lifespan with ownership of thought and actions seen as acts of personal agency. Health literacy skills and knowledge change with increased age, yet the primary source of knowledge often remained important in the individual's autobiographical self.

The harms of medicalisation: intersex, loneliness and abandonment

This article develops loneliness as a political and social justice issue by illustrating the harmful personal and social consequences of the medical jurisdiction over and constitution of variations in sex characteristics. Whilst connections between loneliness, health and illness have been well established, this work customarily identifies the ways illness can lead to, or be caused by, loneliness. Instead, I provide an account of the central role of medicalisation and medical management in producing loneliness. By doing so, I underline the imperative for medical practice to consider its influence upon social and personal, as well as physical, wellbeing. Drawing on stories shared through solicited diaries followed by in-depth interviews with seven people with sex variations and two parents in the UK, I show how accounts of loneliness help to illuminate the violence of abandonment, silencing and marginalisation that often goes unheard, together with hidden or normalised systems of harm.

Building on concepts of ethical loneliness and ontological loneliness, I show how structural violations operate to injure trust and self-worth, leading to social unease. I argue for the importance of people with sex variations finding sites of comfort and acceptance, but note the ways that some forms of medicalisation can inhibit alliances and community formation, despite diagnoses also carrying the potential to facilitate informal support structures and collective identities. By bringing together intersex studies with discourses of loneliness, I develop a better understanding of loneliness as a product of social and systemic violence, and the ways in which medical discourses tie in with larger structures of oppression, coercion and control. This article concludes by underlining the need for structural change in our approach to and understanding of sex variations, and with a call for us to become more attentive to these stories of medical harm, to ensure that they are heard and to seek necessary justice.

Human studies of mitochondrial biology demonstrate an overall lack of binary sex differences: A multivariate meta-analysis

Mitochondria are maternally inherited organelles that play critical tissue-specific roles, including hormone synthesis and energy production, that influence human development, health, and aging. However, whether mitochondria from women and men exhibit consistent biological differences remains unclear, representing a major gap in knowledge. This meta-analysis systematically examined four domains and six subdomains of mitochondrial biology (total 39 measures), including mitochondrial content, respiratory capacity, reactive oxygen species (ROS) production, morphometry, and mitochondrial DNA copy number. Standardized effect sizes (Hedge's g) of sex differences were computed for each measure using data in 2258 participants (51.5% women) from 50 studies. Only two measures demonstrated aggregate binary sex differences: higher mitochondrial content in women's WAT and isolated leukocyte subpopulations (g = 0.20, χ² p = .01), and higher ROS production in men's skeletal muscle (g = 0.49, χ² p < .0001). Sex differences showed weak to no correlation with age or BMI. Studies with small sample sizes tended to overestimate effect sizes (r = -.17, p < .001), and sex differences varied by tissue examined. Our findings point to a wide variability of findings in the literature concerning possible binary sex differences in mitochondrial biology. Studies specifically designed to capture sex- and gender-related differences in mitochondrial biology are needed, including detailed considerations of physical activity and sex hormones.

The Relationship Between Sexual and Gender Stigma and Difficulty Accessing Primary and Mental Healthcare Services Among LGBTQI + Populations in Thailand: Findings from a National Survey

Sexual and gender stigma is a known contributor to population health inequities; however, its impact on healthcare access among sexual and gender minorities (SGM) in Thailand is understudied. Therefore, we sought to examine the level of SGM stigma and its impact on self-reported difficulty accessing primary and mental healthcare services among a nationally recruited sample of lesbian, gay, bisexual, transgender, queer, intersex, and other gender and sexually diverse (LGBTQI +) people in Thailand. A previously validated sexual stigma scale was adapted to ascertain perceived and enacted SGM stigma. Between January and March 2018, 1,350 LGBTQI + participants completed the online survey, and the median age was 27 (quartiles 1, 3: 23, 33) years. In total, 169 (12.5%) and 269 (19.9%) reported difficulty accessing primary and mental healthcare and 365 (27.0%) reported actively concealing their gender expression to access care. In multivariable logistic regression analyses, experiences of enacted stigma were independently associated with difficulty accessing primary (adjusted odds ratio [AOR] = 1.35; 95% confidence interval [CI]: 1.11–1.63) and mental healthcare (AOR = 1.26; 95% CI: 1.07–1.48), while experiences of perceived stigma were independently associated with difficulty accessing mental healthcare only (AOR = 1.20; 95% CI: 1.07–1.34). Our findings call for multi-level interventions to decrease SGM stigma and improve healthcare access among SGM in Thailand.

The relationship between sexual and gender stigma and suicide attempt and ideation among LGBTQI + populations in Thailand: findings from a national survey

PURPOSE

Thailand has one of the highest suicide rates in Southeast Asia; yet, little is known about suicidality among lesbian, gay, bisexual, trans, queer, intersex, and other gender and sexually diverse (LGBTQI +) people living in the region, who may experience elevated risk for suicide. We sought to identify the prevalence of lifetime suicidal attempts and ideation among a nationally recruited sample of LGBTQI + people in Thailand. We further examined the relationship between levels of sexual/gender stigma and suicidal attempt and ideation.

METHODS

Data were derived from a national online survey of Thai LGBTQI + individuals between January and March 2018. Multivariable logistic regression was used to examine the relationship between sexual/gender stigma scales, adapting a previously validated instrument, and suicide attempt and ideation.

RESULTS

Among 1,290 LGBTQI + participants, the median age was 27 years. The prevalence of suicide attempt and ideation was 16.8% and 50.7%, respectively. In multivariable analyses, after adjusting for potential confounders, experiences of perceived and enacted sexual/gender stigma were independently and positively associated with suicide attempt (adjusted odds ratio [AOR] = 1.25; 95% confidence interval CI:1.10-1.41 and AOR = 1.31; 95% CI:1.11-1.55, respectively) and ideation (AOR = 1.30; 95% CI:1.17-1.43 and AOR = 1.34; 95% CI:1.14-1.58, respectively).

CONCLUSION

One-sixth of the sample reported a suicide attempt, while a half reported ever contemplating suicide. Both experiences of perceived and enacted sexual/gender stigma were associated with lifetime suicide attempt and ideation. Multi-level interventions are needed to decrease stigma and in turn suicide among LGBTQ + people in Thailand, including anti-discrimination policies and support for mental health and well-being.

Clinician Advocacy and Intersex Health: A History of Intersex Health Care and the Role of the Clinician Advocate Past, Present, and Future

Throughout the history of Western culture, sex has been reflected as a binary rule, with this binary system affecting self-expression, lifestyle choices, and health outcomes of everyone, but especially those with intersex traits. "Intersex" (or differences of sex development) is an umbrella term used to describe a wide range of natural variations in genitalia, gonads, and chromosome patterns that do not fit typical binary notions of male or female bodies. Currently, people who identify as intersex or as having intersex traits are not provided with the appropriate care needed for their wellbeing. Intersex health care has undergone a great deal of change in the last century, led by intersex leaders and advocates. Clinician advocates have also played a vital role. This article will focus on this history of intersex health care evolution, the role of clinician advocacy, and suggestions for how clinicians can become advocates for improving intersex health care. [Pediatr Ann. 2021;50(9):e359-e365.].

The Health Care of Adults with Differences in Sex Development or Intersex Traits Is Changing: Time to Prepare Clinicians and Health Systems

Historically, the majority of differences in sex development or intersex trait (dsd/I)-specific medical care has been provided by pediatric clinicians, leading to a dearth of adult clinicians qualified to care for this vulnerable population, and pediatricians reticent to transition patients to adult care. Recent changes in routine care of children and infants with dsd/I, including reconsidering the role of early genital surgeries, highlight the critical need to address the gaps in adult dsd/I health care. In this perspective, we describe three key educational and research approaches that can be implemented to build competency to care for adults with dsd/I and improve care across the lifespan.

Assessing the health-related management of people with differences of sex development

PURPOSE

Health care requirements and perception of people with differences of sex development (DSD) have changed enormously since the "Chicago Consensus Conference" in 2005. Therefore, new standards of care and evaluation of care have to be developed.

METHODS

We summarize the social and legal approach to care for DSD during the last two decades and report the main results of European research activities.

RESULTS

The last two decades were accompanied by legal and societal discussion regarding how to deal with a nonbinary concept of sex. This leads to the necessity to assess health care requirements for individuals with DSD in an objective manner. We briefly review the results of the recently funded European research projects dealing with health-related issues in DSD like EU COST Action DSD, I-DSD, and dsd-LIFE, and address the compilation of quality indicators that will be needed to benchmark health care provision and health care-related outcomes.

CONCLUSIONS

The benchmarking process has to be implemented among health care providers for individuals with DSD within the European Reference Networks for Rare Conditions.