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.

Enacting power and constructing gender in cervical cancer screening encounters between transmasculine patients and health care providers.

Transmasculine people are at risk of cervical cancer but have lower rates of cervical cancer screening than cisgender women. Disaffirmation of the patient's gender and unequal power dynamics between patient and provider during screening contribute to patient unwillingness to be screened. The mechanisms by which the balance of power may be shifted between patient and provider, and by which gender is constructed during the Pap test, are not well understood. A qualitative study using a modified grounded theory approach was undertaken to analyse patient interview and provider interview and focus group data pertaining to power and gender in the context of cervical cancer screening among transmasculine individuals. The study was conducted at an LGBTQ-focussed health centre in Boston, USA. Processes by which power is enacted included constraining or affirming patient choice, mitigating or exacerbating vulnerability, and self-advocacy. Gendering processes included naming patients and their bodies, invoking gender norms, de-gendering/re-gendering Pap tests, and othering or normalising trans bodies. The interplay between these processes promotes or constrains patient agency over body and health, impacting patient care, patient-provider interaction, and service utilisation. Understanding patient and provider roles in power and gender dynamics are critical for the provision of patient-centred care.

Correction to: Risk and protective factors for mental health morbidity in a community sample of female-to-male trans-masculine adults.

Following publication of the original article [1], we have been notified of the below corrections.

Risk and protective factors for mental health morbidity in a community sample of female-to-male trans-masculine adults.

BACKGROUND: Trans-masculine (TM) individuals, who are assigned female sex at birth and identify along the masculine gender spectrum, face mental health disparities relative to cisgender people. Limited research has sought to explore the multi-level risk and protective factors associated with mental health morbidity for TM populations. METHODS: Between August 2015-September 2016, 150 TM adults were enrolled in a one-time biobehavioral health study. A survey assessed socio-demographics, past 12-month everyday discrimination, lifetime intimate partner violence (IPV), resilience (using the Brief Resilience Scale), and other factors. Bivariate and multivariable logistic regression analyses examined associations between participant characteristics and four mental health statuses: post-traumatic stress disorder (PTSD), depression, anxiety, and non-suicidal self-injury (NSSI). RESULTS: In this sample (76.7% had a binary gender identity, i.e., man or transgender man; 74.7% were white, 70.0% were under age 30 years), 42.2% had PTSD based on past 30-day symptoms; 25.7% had depression based on past 7-day symptoms; 31.1% had anxiety based on past 7-day symptoms; and 31.3% had engaged in NSSI within the past 12-months. Results from multivariable models: 1) PTSD: unemployment, lifetime IPV and past 12-month discrimination were each associated with increased odds of PTSD, while having a partner was associated with the reduced odds of PTSD. 2) Depression: lower educational attainment and past 12-month discrimination were each associated with the increased odds of depression, while greater resilience was associated with the reduced odds of depression. 3) Anxiety: low annual household income and past 12-month discrimination were each associated with the increased odds of anxiety, while resilience was associated with the reduced odds of anxiety. 4) NSSI: past 12-month discrimination was associated with the increased odds of past 12-month NSSI, while higher age and greater resilience was associated with the reduced odds of NSSI (all p-values < 0.05). CONCLUSIONS: Unemployment, low income, limited education, everyday discrimination, and violence were risk factors for poor mental health, while being in a relationship, higher age, and personal resilience were protective against mental health morbidity. Findings highlight the need for interventions to address the individual, interpersonal, and societal factors that may be driving poor mental health in this population.

Integration of pharmacotherapy for alcohol use disorder treatment in primary care settings: A scoping review.

BACKGROUND: Alcohol use disorder (AUD) represents the most prevalent addiction in the United States. Integration of AUD treatment in primary care settings would expand care access. The objective of this scoping review is to examine models of AUD treatment in primary care that include pharmacotherapy (acamprosate, disulfiram, naltrexone). METHODS: The team undertook a search across MEDLINE, PsycINFO, CINAHL, the Cochrane Central Register of Controlled Trials, and Web of Science on May 21, 2021. Eligibility criteria included: patient population ≥ 18 years old, primary care-based setting, US-based study, presence of an intervention to promote AUD treatment, and prescription of FDA-approved AUD pharmacotherapy. Study design was limited to controlled trials and observational studies. We assessed study bias using a modified Oxford Centre for Evidence-based Medicine Rating Framework quality rating scheme. RESULTS: The qualitative synthesis included forty-seven papers, representing 25 primary studies. Primary study sample sizes ranged from 24 to 830,825 participants and many (44 %) were randomized controlled trials. Most studies (80 %) included a nonpharmacologic intervention for AUD: 56 % with brief intervention, 40 % with motivational interviewing, and 12 % with motivational enhancement therapy. A plurality of studies (48 %) included mixed pharmacologic interventions, with administration of any combination of naltrexone, acamprosate, and/or disulfiram. Of the 47 total studies included, 68 % assessed care initiation and engagement. Fewer studies (15 %) explored practices surrounding screening for or diagnosing AUD. Outcome measures included receipt of pharmacotherapy and alcohol consumption, which about half of studies included (53 % and 51 %, respectively). Many of these outcomes showed significant findings in favor of integrated care models for AUD. CONCLUSIONS: The integration of AUD pharmacotherapy in primary care settings may be associated with improved process and outcome measures of care. Future research should seek to understand the varied experiences across care integration models.

Alcohol Use Disorder Treatment in Sexually and Gender Diverse Patients: A Retrospective Cohort Study.

Objective: While sexually and gender diverse (SGD) people have higher odds of alcohol use disorder (AUD) compared to heterosexual and cisgender people, AUD treatment access and use disparities are not well characterized. The purpose of this study is to assess differences in AUD treatment among SGD versus non-SGD populations.Methods: A retrospective cohort study was performed using data from a federally qualified health center electronic health record system in Boston, Massachusetts. Patients were 18 years or older with an International Classification of Diseases (ICD)-9 or ICD-10 AUD diagnosis and any clinic visit from January 2013 until June 2021 (N = 3,607). Treatment for AUD was identified using binary variables for medication prescription orders and visits for AUD.Results: Among patients identifying as lesbian/gay, 6.9% had an AUD diagnosis, as compared to 2.6% of patients identifying as straight/heterosexual (P < .001). The prevalence of AUD was higher in the gender diverse group as compared to the cisgender group (5.5% vs 4.4%, P < .001). There were no significant differences in receipt of a prescription for injectable naltrexone, acamprosate, or disulfiram between SGD and non-SGD patients. For oral naltrexone, 16.1% of sexually diverse patients received a prescription, as compared to 9.8% of straight/heterosexual patients (P < .001). For visits, both the straight/heterosexual cohort and the cisgender cohorts had the lowest proportion of AUD-related pharmacotherapy and individual psychotherapy visits, as compared to SGD cohorts.Conclusions: SGD patients had higher proportions of AUD diagnosis and AUD care utilization through behavioral health as compared to non-SGD patients.

Evaluating the association between COVID-19 and psychiatric presentations, suicidal ideation in an emergency department.

OBJECTIVE: To estimate the association between COVID-19 and Emergency Department (ED) psychiatric presentations, including suicidal ideation. METHODS: Using an interrupted time series design, we analyzed psychiatric presentations using electronic health record data in an academic medical center ED between 2018 and 2020. We used regression models to assess the association between the onset of the COVID-19 outbreak and certain psychiatric presentations. The period February 26-March 6, 2020 was used to define patterns in psychiatric presentations before and after the coronavirus outbreak. RESULTS: We found a 36.2% decrease (unadjusted) in ED psychiatric consults following the coronavirus outbreak, as compared to the previous year. After accounting for underlying trends, our results estimate significant differential change associated with suicidal ideation and substance use disorder (SUD) presentations following the outbreak. Specifically, we noted a significant differential increase in presentations with suicidal ideation six weeks after the outbreak (36.4 percentage points change; 95% CI: 5.3, 67.6). For presentations with SUD, we found a differential increase in the COVID-19 time series relative to the comparison time series at all post-outbreak time points and this differential increase was significant three weeks (32.8 percentage points; 95% CI: 4.0, 61.6) following the outbreak. Our results estimate no differential changes significant at the P value < 0.05 level associated with affective disorder or psychotic disorder presentations in the COVID-19 time series relative to the comparator time series. CONCLUSIONS: The COVID-19 outbreak in Boston was associated with significant differential increases in ED presentations with suicidal ideation and SUD.

Trends in suicidal ideation in an emergency department during COVID-19.

OBJECTIVE: This study aims to detail changes in presentations at a United States Emergency Department for suicidality before and after the outbreak of COVID-19. METHODS: A retrospective chart review was conducted of all adult patients who presented to an ED with suicidality and underwent psychiatric consultation during the study period. The cohorts consisted of patients who presented between December 2018 - May 2019 and December 2019 - May 2020. Information was collected on demographics, characteristics of suicidality, reasons for suicidality and disposition. The first wave from March - May 2020 was examined, using a difference-in-differences design to control for factors other than COVID-19 that may have influenced the outcomes' trend. RESULTS: Immediately following the pandemic outbreak there was a statistically significant increase in the proportion of undomiciled patients represented in visits for suicidality (40.7% vs. 57.4%; p-value <0.001). In addition, the proportion of patient visits attributed to social (18.0% vs. 29.2%; p-value 0.003) and structural (14.2% vs. 26.4%; p value <0.001) reasons for suicidality increased. Conversely, the proportion of visits due to psychiatric symptoms (70.5% vs 50.0%; p-value <0.001) decreased. Furthermore, patient visits were more likely to result in a medical admission (2.1% vs. 8.3%; p-value 0.002) and less likely to result in a psychiatric admission (68.4% vs 48.6%; p-value <0.001) during the initial phase of the pandemic. CONCLUSIONS: COVID-19 was associated with increased ED presentations for suicidality among undomiciled patients, as well as greater likelihood of social and structural reasons driving suicidality among all visits.

Planning and implementing sexual orientation and gender identity data collection in electronic health records.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people experience significant health disparities across the life course and require health care that addresses their unique needs. Collecting information on the sexual orientation and gender identity (SO/GI) of patients and entering SO/GI data in electronic health records has been recommended by the Institute of Medicine, the Joint Commission, and the Health Resources and Services Administration as fundamental to improving access to and quality of care for LGBTQ people. Most healthcare organizations, however, have yet to implement a system to collect SO/GI data due to multiple barriers. This report addresses those concerns by presenting recommendations for planning and implementing high-quality SO/GI data collection in primary care and other health care practices based on current evidence and best practices developed by a federally qualified health center and leader in LGBTQ health care.

Psychiatric Epidemiology of Transgender and Nonbinary Adult Patients at an Urban Health Center.

PURPOSE: Transgender and nonbinary people have an increased burden of psychiatric problems compared with the general population. Data are needed to understand factors associated with psychiatric diagnoses, acuity in terms of suicide attempts and level-of-care escalation, and outpatient engagement among transgender and nonbinary adults. METHODS: We conducted a retrospective review of records from 201 transgender and nonbinary adults who presented for primary care at a health center. Regression models were fit to examine factors associated with psychiatric diagnoses, substance use disorders (SUDs), acuity, and outpatient behavioral health engagement. RESULTS: Male sex assignment at birth was associated with decreased odds of a psychiatric diagnosis (odds ratio [OR] 0.40, 95% confidence interval [CI]: 0.20-0.81). Increased odds of SUDs were associated with later hormone initiation (OR 1.04, 95% CI: 1.01-1.08) and suicide attempt (OR 5.79, 95% CI: 2.08-16.15). Increased odds of higher acuity were associated with alcohol use disorder (OR 31.54, 95% CI: 5.73-173.51), post-traumatic stress disorder (OR 18.14, 95% CI: 2.62-125.71), major depressive disorder (MDD) (OR 6.62, 95% CI: 1.72-25.44), and absence of psychiatrist integration into primary medical care (OR 4.52, 95% CI: 1.26-16.22). Increased odds of outpatient behavioral health engagement were associated with case management utilization (OR 10.73, 95% CI: 1.32-87.53), anxiety disorders (OR 15.84, 95% CI: 2.00-125.72), and MDD (OR 10.45, 95% CI: 2.28-47.98). CONCLUSION: Psychiatric disorders were highly prevalent among transgender and nonbinary adult patients. Novel findings include associations of lack of psychiatrist integration into primary care with acuity and of case management utilization with outpatient behavioral health engagement.

Participation in Accountable Care Organizations Among Hospitals Offering Substance Use Disorder and Mental Health Services.

Accountable care organizations (ACOs) can potentially improve value in behavioral health care. However, little is known about the likelihood of ACO participation among hospitals with behavioral health services. The authors explore statistical predictors of ACO participation among hospitals, particularly among those offering behavioral health services. After adjusting for other hospital characteristics, the analysis found that behavioral health specialty hospitals were less likely to participate in an ACO and general medical-surgical hospitals with behavioral health services were more likely to participate, compared with general medical-surgical hospitals without behavioral health services. A better understanding is needed of barriers to ACO participation within behavioral health specialty hospitals and how ACO participation may affect quality of behavioral health care.