Engaging Black sexual minority women in breast cancer research: Lessons in community partnerships.

BACKGROUND: Black sexual minority women (BSMW) face significant breast cancer health inequities and are underrepresented in health research because of historical and present-day exclusion. However, there exists no peer-reviewed literature on best practices for the inclusion of BSMW in cancer research. "Our Breast Health: The Access Project" was a national primary data collection study in June 2018 through October 2019 that aimed to identify facilitators and barriers to breast cancer care among BSMW, and that successfully recruited the highest number of BSMW for any national breast cancer screening study at the time of its publication. METHODS: The present analysis highlights best practices for reaching BSMW by examining by how effective various recruitment sources were at recruiting BSMW. Recruitment partners were grouped into several categories: (1) cancer focused, (2) Black women or sexual minority women focused, (3) BSMW focused, (4) social media, and (5) other. Then logistic regression was used to estimate the odds that a particular recruitment source category could recruit BSMW compared with other categories. RESULTS: Partnerships with community-based organizations led by and intended for BSMW were the most successful at recruiting BSMW, demonstrating the importance of an intersectional approach to recruitment. Community-based organizations focused on BSMW specifically were 26 times more successful in recruiting BSMW to the study compared with recruiting Black women who were not sexual minorities (odds ratio, 26.43 [95% CI, 7.50-93.10]). CONCLUSIONS: Successful recruitment enables breast cancer research grounded in the perspectives of BSMW, which can generate key findings that have the potential to remedy longstanding health inequities for this population.

Experiences of and resistance to multiple discrimination in health care settings among transmasculine people of color.

BACKGROUND: Research shows that transmasculine people experience discrimination based on their gender identity and/or expression (i.e., cissexism) while obtaining health care. However, studies examining the experience of other forms of discrimination in health care settings among diverse subgroups of transmasculine individuals, including those from minoritized racial/ethnic backgrounds, are very limited. METHODS: Guided by intersectionality, we designed a qualitative research study to explore how transmasculine people of color experience-and resist-multiple, intersecting forms of discrimination in health care settings. Guided by a purposive sampling strategy, we selected 19 transmasculine young adults of color aged 18-25 years to participate in 5 mini-focus groups conducted between February and May 2019 in Boston, MA. Focus group transcripts were analyzed using a template style approach to thematic analysis that involved both deductive and inductive coding using a codebook. Coded text fragments pertaining to participants' experiences of health care discrimination were clustered into themes and sub-themes. RESULTS: Transmasculine people of color described experiencing notable challenges accessing physical and mental health care as a result of structural barriers to identifying health care providers with expertise in transgender health, finding providers who share one or more of their social positions and lived experiences, and accessing financial resources to cover high health care costs. Further, participants discussed anticipating and experiencing multiple forms of interpersonal discrimination-both independently and simultaneously-in health care settings, including cissexism, racism, weight-based discrimination, and ableism. Moreover, participants described the negative impact of anticipating and experiencing multiple interpersonal health care discrimination on their health care utilization, quality of care, and mental and physical health. Lastly, participants discussed using various strategies to resist the multiple, intersecting forms of discrimination they encounter in health care settings, including setting boundaries with health care providers, seeking care from competent providers with shared social positions, engaging in self-advocacy, drawing on peer support during health care visits, and obtaining health information through their social networks. DISCUSSION: Efforts are needed to address cissexism, racism, weight-based discrimination, ableism, and other intersecting forms of discrimination in clinical encounters, health care institutions and systems, and society in general to advance the health of transmasculine people of color and other multiply marginalized groups.

"Making a Way Out of No Way:" Understanding the Sexual and Reproductive Health Care Experiences of Transmasculine Young Adults of Color in the United States.

Research focusing on the specific and unique sexual and reproductive health care experiences of transmasculine young adults of color are extremely scarce. We conducted five focus group discussions with 19 Black, Latinx, Asian, Native, and other transmasculine individuals of color aged 18-25 years in the greater Boston area. Using thematic analysis, we found that transmasculine young adults of color experienced cissexism, heterosexism, and racism in accessing and utilizing sexual and reproductive health services. These multiple forms of discrimination undermined participants' receipt of high-quality sexual and reproductive health information and care from competent health care providers who shared their lived experiences. Participants relied on support from their lesbian, gay, bisexual, transgender, and queer peers to obtain needed sexual and reproductive health resources and minimize harm during clinical encounters. Multilevel interventions are needed to promote access to person-centered and structurally competent sexual and reproductive health care among transmasculine young adults of color.

Supplementing Substance Use Prevention With Sexual Health Education: A Partner-Informed Approach to Intervention Development.

Supplementing substance use prevention with sexual health education would allow educators to address the risk and protective factors that influence both health issues. This streamlined approach may minimize the inefficiencies of multisession, single-purpose interventions. Our team developed a supplemental sexual and reproductive health (SRH) unit to align with an existing evidence-based intervention, LifeSkills Training (LST). This goal of this article is to describe our process, final product, lessons learned, and future directions. Our partner-informed approach took place across three key phases: (1) formative insights, (2) unit development, and (3) pilot implementation. The final supplemental SRH unit is ten, 45-minute sessions offered to seventh- and eighth-grade students and includes a set of learning objectives that are aligned with individual sessions. The supplemental SRH unit also mirrors existing LST modules in length, flow, layout, facilitator instructions, focus on prevention, and utilization of a student workbook. Lessons learned include strategies to effectively incorporate a wide range of ongoing feedback from multiple sources and quickly respond to staff turnover. This partnership approach serves as a model for researchers and practitioners aiming to extend the reach of existing evidence-based programs.

Delays in breast cancer care by race and sexual orientation: Results from a national survey with diverse women in the United States.

BACKGROUND: Despite known differences in breast cancer by both race and sexual orientation, data on the intersectional experiences of Black sexual minority women (BSMW) along the care continuum are scant. This study sought to understand delays in breast cancer care by examining the intersection of race and sexual orientation. METHODS: This online, cross-sectional survey enrolled racially and sexually diverse women aged ≥ 35 years who had been diagnosed with breast cancer within the prior 10 years or had an abnormal screening in the prior 24 months. The authors calculated summary statistics by race/sexual orientation categories, and they conducted univariate and multivariable modeling by using multiple imputation for missing data. RESULTS: BSMW (n = 101) had the highest prevalence of care delays with 5.17-fold increased odds of a care delay in comparison with White heterosexual women (n = 298) in multivariable models. BSMW reported higher intersectional stigma and lower social support than all other groups. In models adjusted for race, sexual orientation, and income, intersectional stigma was associated with a 2.43-fold increase in care delays, and social support was associated with a 32% decrease in the odds of a care delay. CONCLUSIONS: Intersectional stigma may be an important driver of breast cancer inequities for BSMW. Reducing stigma and ensuring access to appropriate social support that addresses known barriers can be an important approach to reducing inequities in the breast cancer care continuum.

Beyond Black and White: race and sexual identity as contributors to healthcare system distrust after breast cancer screening among US women.

OBJECTIVE: Healthcare system distrust (HCSD) has been linked to poor breast cancer outcomes. Previous HSCD analyses have focused on Black-White disparities; however, focusing only on race ignores the complex set of factors that form identity. We quantified the contributions of race and sexual minority (SM) identity to HCSD among US women who had received breast cancer screening. METHODS: This cross-sectional study used intersectionality decomposition methods to assess the degree to which racial and SM identity contributed to disparate responses to the validated 9-item HCSD Scale. The sample included online survey participants identifying as a Black or White woman living in the US, with a self-reported abnormal breast cancer screening result in the past 24 months and/or breast cancer diagnosis since 2011. RESULTS: Of 649 participants, 49.4% of Black SM women (n = 85) were in the highest HCSD tertile, followed by 37.4% of White SM women (n = 123), 24.4% of Black heterosexual women (n = 156), and 19% of White heterosexual women. Controlling for age, 72% of the disparity in HCSD between Black SM women and White heterosexual women was due to SM status, 23% was due to racial identity, and 3% was due to both racial and SM identity. CONCLUSIONS: SM identity emerged as the largest driver of HCSD disparities; however, the combined racial and SM disparity persisted. Excluding sexual identity in HCSD studies may miss an important contributor. Interventions designed to increase the HCS's trustworthiness at the provider and system levels should address both racism and homophobia.

"Some of us, we don't know where we're going to be tomorrow." Contextual factors affecting PrEP use and adherence among a diverse sample of transgender women in San Francisco.

Transgender women (TW) are disproportionately affected by HIV. Antiretroviral pre-exposure prophylaxis (PrEP) can reduce TW's vulnerability to HIV, but PrEP uptake has been limited among TW. To explore barriers to PrEP uptake, the study team conducted two semi-structured focus groups with TW in San Francisco at risk for HIV acquisition. A within-case, across-case approach was used to code and analyze emerging themes. Focus group participants were racially and ethnically diverse. A few participants in both groups had heard of PrEP, but some had not. Several said that their health care providers had not told them about PrEP. Participants in both groups had questions about side effects. They expressed medical mistrust and said poverty is an important context for their lives. They described a need for gender affirming health care services and raised concerns about interactions of PrEP with feminizing hormones. Information about side effects and interactions between gender affirming hormones and PrEP need to be explicitly addressed in PrEP education campaigns focusing on TW. Health care institutions and health departments should train clinical staff how to provide affirming care. Gender identity nondiscrimination laws and policies could improve transgender people's ability to earn a living and access health care.

Recruiting, Facilitating, and Retaining a Youth Community Advisory Board to Inform an HIV Prevention Research Project with Sexual and Gender Minority Youth.

Sexual and gender minority (SGM) youth are at disproportionate risk of acquiring HIV, and as such, SGM youth should be meaningfully engaged in research aimed at developing effective, tailored HIV interventions. Youth Community Advisory Boards (YCABs) are an important element of community-engaged research and support the development of community-informed interventions. This article describes recruitment, facilitation, and retention of a YCAB composed of SGM youth in Greater Boston, to inform a national HIV prevention research project. These lessons can serve as a guide to future researchers who want to form YCABs as part of community-engaged research.

Preparing Doctors in Training for Health Activist Roles: A Cross-Institutional Community Organizing Workshop for Incoming Medical Residents.

INTRODUCTION: Physicians are increasingly being called on to address inequities created by social and structural determinants of health, yet few receive training in specific leadership skills that allow them to do so effectively. METHODS: We developed a workshop to introduce incoming medical interns from all specialties at Boston-area residency programs to community organizing as a framework for effective physician advocacy. We utilized didactic sessions, video examples, and small-group practice led by trained coaches to familiarize participants with one community organizing leadership skill-public narrative-as a means of creating the relationships that underlie collective action. We offered this 3-hour, cross-institutional workshop just prior to intern orientation and evaluated it through a postworkshop survey. RESULTS: In June 2019, 51 residents from 13 programs at seven academic medical centers attended this workshop. In the postworkshop survey, participants agreed with positive evaluative statements about the workshop's value and impact on their knowledge, with a mean score on all items of over 4 (5-point Likert scale, 1 = strongly disagree, 5 = strongly agree; response rate: 34 of 51). Free-text comments emphasized the workshop's effectiveness in evoking positive feelings of solidarity, community, and professional identity. DISCUSSION: The workshop effectively introduced participants to community organizing and public narrative, allowed them to apply the principles of public narrative by developing their own stories of self, and demonstrated how these practices can be utilized in physician advocacy. The workshop also connected participants to their motivations for pursuing medicine and stimulated interest in more community organizing training.

Perspectives on Sexual Health, Sexual Health Education, and HIV Prevention From Adolescent (13-18 Years) Sexual Minority Males.

INTRODUCTION: Adolescent sexual minority males (ASMM) are at disproportionate risk of HIV infection. The purpose of this study was to assess ASMM's attitudes about sexual health, barriers/facilitators to accessing HIV prevention, and actual versus ideal interactions for receiving sexual health care and information. METHOD: Two online and two in-person focus groups were conducted with ASMM from across the United States. Qualitative data were analyzed using content analysis. RESULTS: Twenty-one racially diverse ASMM participated (average age = 16.4 years). Online focus groups were superior for reaching the target population. Four themes emerged: 1: identity formation and sources of support, 2: challenges to obtaining sexual health information, 3: attitudes/beliefs about sex and sexual behaviors, and 4: barriers to HIV prevention. DISCUSSION: These findings illustrate current gaps in sexual health knowledge, as well as barriers and facilitators to obtaining sexual health information, sexual health care, and affirming education and support for ASMM.

Transgender Youth Experiences and Perspectives Related to HIV Preventive Services.

BACKGROUND: In the United States, transgender youth are at especially high risk for HIV infection. Literature regarding HIV prevention strategies for this vulnerable, often-hidden population is scant. Before effective, population-based HIV prevention strategies may be adequately developed, it is necessary to first enhance the contextual understanding of transgender youth HIV risk and experiences with HIV preventive services. METHODS: Two 3-day, online, asynchronous focus groups were conducted with transgender youth from across the United States to better understand participant HIV risk and experiences with HIV preventive services. Participants were recruited by using online advertisements posted via youth organizations. Qualitative data were analyzed by using content analysis. RESULTS: A total of 30 transgender youth participated. The average age was 18.6 years, and youth reported a wide range of gender identities (eg, 27% were transgender male, 17% were transgender female, and 27% used ≥1 term) and sexual orientations. Four themes emerged: (1) barriers to self-efficacy in sexual decision-making; (2) safety concerns, fear, and other challenges in forming romantic and/or sexual relationships; (3) need for support and education; and (4) desire for affirmative and culturally competent experiences and interactions (eg, home, school, and health care). CONCLUSIONS: Youth discussed experiences and perspectives related to their gender identities, sexual health education, and HIV preventive services. Findings should inform intervention development to improve support and/or services, including the following: (1) increasing provider knowledge and skills to provide gender-affirming care, (2) addressing barriers to services (eg, accessibility and affordability as well as stigma and discrimination), and (3) expanding sexual health education to be inclusive of all gender identities, sexual orientations, and definitions of sex and sexual activity.

Youth-Serving Professionals' Perspectives on HIV Prevention Tools and Strategies Appropriate for Adolescent Gay and Bisexual Males and Transgender Youth.

INTRODUCTION: HIV disproportionally burdens adolescent men who have sex with men (AMSM) and transgender youth. This study explores barriers and facilitators that professionals face in delivering HIV preventive services and education. METHODS: Adolescent health providers (nurse practitioners, physicians, and other), school nurses, youth workers, and school educators were recruited nationally for this qualitative study. RESULTS: Thirty-four professionals participated. Common categories identified across professional group were (1) effective strategies for building trust with youth, (2) perceived barriers/facilitators to sexual health communication, (3) perceived barriers/facilitators to effective HIV prevention, and (4) preferred content for HIV prevention tools. DISCUSSION: Key elements for developing multidisciplinary resources to support AMSM and transgender youth should include (1) web-based or easily accessible sexual health educational materials, (2) resources for referrals, (3) trainings to support competence in caring for sexual and gender minority youth, and (4) guidance for navigating policies or eliciting policy change.

Advocacy for Gender Affirming Care: Learning from the Injectable Estrogen Shortage.

Hormone therapy is medically necessary for many transgender individuals. The U.S. Food and Drug Administration (FDA) and pharmaceutical companies' failure to guarantee a supply of injectable estrogen in 2016 and 2017 for transgender individuals is a violation of their right to comprehensive medical treatment, free of discrimination. A series of advocacy actions eventually led to all formulations of injectable estrogen being restored to market; however, long-term solutions to supply interruptions of injectable estrogen are needed. Long-term solutions should address the lack of federally funded research and, consequently, evidence-based practice on hormone therapy for gender affirmation.