Strategies to Mitigate Clinician Implicit Bias Against Sexual and Gender Minority Patients.

BACKGROUND: Implicit bias is an ingrained, unconscious cultural stereotype that can negatively affect a person's interactions with members of stigmatized groups, including sexual and gender minorities. Clinician implicit biases may negatively impact the quality of patient care. METHODS: This article uses 4 case scenarios to illustrate how implicit bias among psychiatrists and other clinicians can affect patient-clinician communication and diminish the quality of health care provided to sexual and gender minority people. We offer strategies for clinicians to recognize, challenge, and address implicit bias. DISCUSSION: Through continuing education, self-reflection, and practice, psychiatrists and other clinicians can improve communication and foster more affirming care experiences for their sexual and gender minority patients, with the goal of addressing and ultimately eliminating sexual and gender minority health disparities.

Screening Pelvic Examinations in Adult Women: Grand Rounds Discussion From the Beth Israel Deaconess Medical Center.

Pelvic examinations have historically been a part of regular preventive care. However, because women can now be screened for cervical cancer at intervals up to every 5 years, the question of whether women need to be seen annually for routine pelvic examinations has arisen. In July 2014, the American College of Physicians (ACP) issued a guideline presenting the available evidence on screening for pathologic conditions using pelvic examination in adult, asymptomatic women at average risk. The American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice had previously issued a committee opinion in August 2012 on the need for annual examinations and provided guidelines on important elements of this procedure, including when to examine asymptomatic women. ACOG reaffirmed its initial position after publication of the ACP guideline. The guidelines differ-the ACP guideline recommends against and the ACOG committee opinion recommends in favor of routine annual pelvic examination. This paper summarizes a discussion between an internist and a gynecologist on how they would balance these recommendations in general and what they would suggest for an individual patient.

Sexual Orientation Identity Disparities in Awareness and Initiation of the Human Papillomavirus Vaccine Among U.S. Women and Girls: A National Survey.

BACKGROUND: Lesbians and bisexual women are at risk for human papillomavirus (HPV) infection from female and male sexual partners. OBJECTIVE: To examine the association between sexual orientation identity and HPV vaccination among U.S. women and girls. DESIGN: Cross-sectional, using 2006-2010 National Survey of Family Growth data. SETTING: U.S. civilian noninstitutionalized population. PARTICIPANTS: The 2006-2010 National Survey of Family Growth used stratified cluster sampling to establish a national probability sample of 12,279 U.S. women and girls aged 15 to 44 years. Analyses were restricted to 3253 women and girls aged 15 to 25 years who were asked about HPV vaccination. MEASUREMENTS: Multivariable logistic regression was used to obtain prevalence estimates of HPV vaccine awareness and initiation adjusted for sociodemographic and health care factors for each sexual orientation identity group. RESULTS: Among U.S. women and girls aged 15 to 25 years, 84.4% reported having heard of the HPV vaccine; of these, 28.5% had initiated HPV vaccination. The adjusted prevalence of vaccine awareness was similar among heterosexual, bisexual, and lesbian respondents. After adjustment for covariates, 8.5% (P = 0.007) of lesbians and 33.2% (P = 0.33) of bisexual women and girls who had heard of the vaccine had initiated vaccination compared with 28.4% of their heterosexual counterparts. LIMITATION: Self-reported, cross-sectional data, and findings may not be generalizable to periods after 2006 to 2010 or all U.S. lesbians aged 15 to 25 years (because of the small sample size for this group). CONCLUSION: Adolescent and young adult lesbians may be less likely to initiate HPV vaccination than their heterosexual counterparts. Programs should facilitate access to HPV vaccination services among young lesbians. PRIMARY FUNDING SOURCE: National Cancer Institute.

The High Prevalence of Diabetes in a Large Cohort of Patients Drawn From Safety Net Clinics.

INTRODUCTION: Underserved populations have been overlooked or underrepresented in research based on data from diabetes registries. We estimated diabetes prevalence using a cohort developed from the electronic health records of 3 networks of safety net clinics that provide care to underserved populations. METHODS: ADVANCE (Accelerating Data Value Across a National Community Health Center Network) is a partnership of the OCHIN Community Health Information Network (OCHIN), the Health Choice Network (HCN), and the Fenway Health Institute (FHI), representing 97 federally qualified health centers (FQHCs) and 744 clinic sites in 22 US states. Among 952,316 adults with a body mass index (BMI) measurement and at least 2 outpatient visits in 2012 to 2014, we calculated diabetes prevalence using outpatient diagnoses, diagnostic laboratory results, or dispenses of anti-hyperglycemic agents no more than 730 days apart. We calculated prevalence by age, sex, race, Hispanic ethnicity, and BMI class. RESULTS: The crude prevalence of diabetes was 14.4%. Men had a higher prevalence than women (16.5% vs 13.2%); diabetes prevalence increased across age categories. White patients had the lowest prevalence (11.4%) and Hawaiian/Pacific Islanders, the highest prevalence (21.9%), with prevalence ranging from 15.2% to 16.5% for other race/ethnicities. The association between BMI class and diabetes prevalence was similar across all racial/ethnic groups. CONCLUSION: The ADVANCE diabetes cohort offers an opportunity to conduct epidemiologic and comparative effectiveness research on underserved and underrepresented individuals, who have a higher prevalence of diabetes than the general US population.

Effect of testosterone therapy on breast tissue composition and mammographic breast density in trans masculine individuals.

Objective: Determine the association between TT and breast tissue composition and breast tissue density in trans masculine individuals (TMIs). Design: This is a cross-sectional study. Setting: TMIs (n=444) underwent chest-contouring surgeries to treat their gender dysphoria between 2013 and 2019 at an urban medical center. Participants: Of the 444 TMIs, 425 had pathology images analyzed by our deep-learning algorithm to extract breast tissue composition. A subset of 42/444 TMIs had mammography prior to surgery; mammography files were available for 25/42 TMIs and analyzed using a breast density software, LIBRA. Main Outcomes and Measures: The first outcome was the association of duration of TT and breast tissue composition assessed by pathologists (categories of lobular atrophy and stromal composition) or by our algorithm (% epithelium, % fibrous stroma, and % fat). The second outcome is the association of TT and breast density as assessed by a radiologist (categorical variable) or by LIBRA (percent density, absolute dense area, and absolute non-dense area). Results: Length of TT was associated with increasing degrees of lobular atrophy ( p <0.001) but not fibrous content ( p =0.821) when assessed by the pathologists. Every six months of TT was associated with decreased amounts of both epithelium (exp(ß)=0.97, 95% CI 0.95-0.98, adj p =0.005) and stroma (exp(ß)=0.99, 95% CI 0.98-1.00, adj p =0.051), but not fat (exp(ß)=1.01, 95%CI 0.98-1.05, p =0.394) in fully adjusted models. There was no association between TT and radiologist's breast density assessment ( p =0.575) or LIBRA measurements ( p >0.05). Conclusions: TT decreases breast epithelium and fibrous stroma, thus potentially reducing the breast cancer risk of TMIs. Further studies are warranted to elucidate the effect of TT on breast density and breast cancer risk. Summary Box: Very little is known about the effect of gender-affirming testosterone therapy on cancer risks, such as breast cancer.Epidemiological studies had different conclusions about the association between testosterone and breast cancer in cisgender women (positive association) and trans masculine individuals (inverse association).More laboratory-based research are needed to understand the effect of testosterone on breast cancer risk in the understudied trans masculine population.Our study provides quantitative histological evidence to support prior epidemiological reports that testosterone may reduce breast cancer risk in trans masculine individuals.

Lichen sclerosus in a breast cancer survivor on an aromatase inhibitor: a case report.

Lichen sclerosus is a commonly misdiagnosed disease that is characterized by thinned, hypopigmented, crinkled skin that often forms a figure-eight shape around the vaginal and anal openings. We present a case of advanced lichen sclerosus in a 53-year-old female patient prescribed a nonsteroidal aromatase inhibitor after the excision of a breast cancer tumor. We present a diagnostic approach to lichen sclerosus by recognizing its common figure-eight pattern, and we review the known causes and treatment of lichen sclerosus. Research has shown that lichen sclerosus is more common in low estrogen states, and thus it is logical that aromatase inhibitors could increase a patient's risk for developing this disease. We therefore propose that all patients prescribed aromatase inhibitors undergo regular vulvo-vaginal exams to rule out lichen sclerosus and other hypoestrogen-related vulvo-vaginal problems.

Trauma-Informed Care for Hospitalized Adolescents.

Purpose of Review: Exposure to trauma accelerates during the adolescence, and due to increased behavioral and psychiatric vulnerability during this developmental period, traumatic events during this time are more likely to cause a lasting impact. In this article, we use three case studies of hospitalized adolescents to illustrate the application of trauma-informed principles of care with this unique population. Recent Findings: Adolescents today are caught in the crosshairs of two syndemics-racism and other structural inequities and the COVID-19 pandemic. Increased hospitalizations and mental health diagnoses during the past two years signal toxic levels of stress affecting this group. Trauma-informed care promotes health, healing, and equity. Summary: This concept of the "trauma-informed approach" is still novel; through examples and practice, providers can learn to universally apply the trauma-informed care framework to every patient encounter to address the harmful effects of trauma and promote recovery and resilience.

Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients.

BACKGROUND: High-risk human papillomavirus (hrHPV) causes virtually all cervical cancers. Trans masculine (TM) people (those assigned female at birth who identify with a gender other than female) have low uptake of conventional cervical cancer screening. Self-collected hrHPV DNA testing has high levels of acceptability among cisgender (non-transgender) females and may support increased cervical cancer screening uptake in TM individuals. OBJECTIVE: To assess the test performance and acceptability of self-collected vaginal specimens in comparison to provider-collected cervical swabs for hrHPV DNA detection in TM individuals ages 21-64 years. METHODS: Between March 2015-September 2016, 150 TM participants with a cervix (mean age = 27.5 years; SD = 5.7) completed a one-time study visit comprised of a self-report survey, self-collected vaginal HPV DNA swab, clinician-administered cervical HPV swab, and brief interview on acceptability of clinical procedures. Participants were randomized to complete either self- or provider-collection first to minimize ordering effects. Self- and provider-collected samples were tested for 13 hrHPV DNA types using a DNA Hybridization Assay. The primary outcome variable was the concordance (kappa statistic) and performance (sensitivity, specificity) of self-collected vaginal HPV DNA specimens versus provider-collected cervical HPV swabs as the gold standard. RESULTS: Of the 131 participants completing both the self- and provider-collected HPV tests, 21 cases of hrHPV were detected by the provider cervical swab (gold standard; 16.0% hrHPV prevalence); 15 of these cases were accurately detected by the self-collected vaginal swab (71.4% concordance) (Kappa = 0.75, 95% Confidence Interval [CI]: 0.59, 0.92; p<0.001). Compared to the provider-collected cervical hrHPV DNA sample (gold standard), the self-collected vaginal hrHPV DNA test demonstrated a sensitivity of 71.4% (95% CI: 0.52, 0.91; p = 0.0495) and specificity of 98.2% (95% CI: 0.96, 1.00; p<0.0001). Over 90% of participants endorsed a preference for the self-collected vaginal swab over provider-collected cervical swab. CONCLUSION: Self-collected vaginal swabs are highly acceptable to TM as a means to test for hrHPV DNA. Test performance of this self-collection method for hrHPV detection in TM is consistent with previous studies in cisgender females. Self-collected vaginal swab testing for hrHPV DNA represents a reasonable and patient-centered strategy for primary cervical cancer screening in TM patients unwilling to undergo provider collection of specimens via speculum exam.

A 60-year-old woman with sexual difficulties.

A growing body of evidence is available to guide care for women with sexual concerns. This article considers the case of a 60-year-old woman who with menopause developed decreased libido, rapidity of sexual arousal, and intensity of orgasm. She requests information about strategies to optimize sexual function. Effects of aging and menopause on female sexual response are reviewed and an evaluation approach presented to help clinicians respond productively to women who request intervention. The effectiveness and safety of different treatment options are discussed, including education, lifestyle changes, counseling, medications, mechanical devices, and pelvic floor exercises; recommendations are made to help postmenopausal women maximize sexual pleasure and satisfaction.

Do ask, do tell.

As a consequence of bias and ignorance within the medical profession, lesbians and gay men frequently receive suboptimal health care. Knowledge of each patient's sexual orientation and behaviors is critical for the development of a productive therapeutic relationship, accurate risk assessment, and the provision of pertinent preventive counseling. However, clinicians often forget to ask about this information, and many lesbians and gay men are reticent to reveal the truth. I present vignettes from my personal experiences as a lesbian patient and doctor to illustrate the importance of creating an environment in which such disclosure can occur and to portray the challenges and rewards of coming out as a gay physician.