Care of Sexual and Gender Minorities in the Emergency Department: A Scoping Review.

STUDY OBJECTIVE: This scoping review was conducted to collate and summarize the published research literature addressing sexual and gender minority care in the emergency department (ED). METHODS: Using PRISMA-ScR criteria, an electronic search was conducted of CINAHL, Embase, Ovid Medline, and Web of Science for all studies that were published after 1995 involving sexual and gender minorities, throughout all life stages, presenting to an ED. We excluded non-US and Canadian studies and editorials. Titles and abstracts were screened, and full-text review was performed independently with 4 reviewers. Abstraction focused on study design, demographics, and outcomes, and the resulting data were analyzed using an ad hoc iterative thematic analysis. RESULTS: We found 972 unique articles and excluded 743 after title and abstract screening. The remaining 229 articles underwent full-text review, and 160 articles were included. Themes identified were HIV in sexual and gender minorities (n=61), population health (n=46), provider training (n=29), ED avoidance or barriers (n=23), ED use (n=21), and sexual orientation/gender identity information collection (n=9). CONCLUSION: The current literature encompassing ED sexual and gender minority care cluster into 6 themes. There are considerable gaps to be addressed in optimizing culturally competent and equitable care in the ED for this population. Future research to address these gaps should include substantial patient stakeholder engagement in all aspects of the research process to ensure patient-focused outcomes congruent with sexual and gender minority values and preferences.

"It's kind of hard to go to the doctor's office if you're hated there." A call for gender-affirming care from transgender and gender diverse adolescents in the United States.

Research has identified discrimination and a lack of knowledgeable providers as major barriers for transgender and gender diverse (TGD) individuals seeking care, which contributes to greater stress and significant health disparities affecting this population. However, research involving TGD youth is limited. The aim of this study, therefore, was to describe TGD adolescents' experiences, concerns and needs in healthcare settings, including their feedback on themes previously identified by healthcare providers (i.e. discomfort with gender-related topics, reasons for not asking patients about gender and previous training regarding gender diversity). The authors conducted semi-structured interviews with 12 TGD-identified adolescents aged 14-17, living in Minnesota, USA in 2017-2018. Inductive thematic analysis was used to summarise participant comments into themes and subthemes. Two main themes were directly relevant to concerns and needs of TGD youth in healthcare settings and their views on healthcare providers' concerns: (a) asking about gender and pronouns and (b) training for healthcare providers. Findings suggest the need for revisions to clinic materials, infrastructure and protocols. Adding training to all general medical and nursing education to increase knowledge, comfort and competence around gender identity would further improve care and ultimately reduce healthcare disparities affecting TGD youth.

Health Insurance and Mental Health Care Utilization Among Adults Who Identify as Transgender and Gender Diverse.

OBJECTIVE: Transgender people are less likely to have health insurance, which has been associated with reduced utilization of health care. In the current study, the authors sought to assess the role of health insurance in mental health care utilization among transgender individuals. METHODS: A total of 4,334 adults who self-identified as transgender or gender diverse (neither male nor female) participated in the 2017 Trans Lifeline Mental Health Survey, which included self-report measures of current insurance type and lifetime history of having seen a therapist or psychiatric provider. Logistic regression analyses assessed the association of insurance status with lifetime utilization of a mental health therapist or psychiatric provider. RESULTS: Although only 8% of the sample were uninsured, these individuals were significantly less likely to have seen a therapist or psychiatric provider in their lifetime compared with those with health insurance, even after the analyses were adjusted for sociodemographic factors. Conversely, those with insurance through the military or the Veterans Health Administration were more than twice as likely as those with employer-provided insurance to have seen a therapist or psychiatric provider. There were no significant differences in mental health care utilization between those with employer-provided insurance versus public or privately purchased insurance. CONCLUSIONS: Rates of being uninsured were lower than in earlier assessments of transgender adults and adults who identify as gender diverse. However, type of health insurance also appeared to be a notable structural factor contributing to disparities in mental health care utilization among transgender individuals.

Providing Patient-Centered Perinatal Care for Transgender Men and Gender-Diverse Individuals: A Collaborative Multidisciplinary Team Approach.

BACKGROUND: Little is documented about the experiences of pregnancy for transgender and gender-diverse individuals. There is scant clinical guidance for providing prepregnancy, prenatal, intrapartum, and postpartum care to transgender and gender-diverse people who desire pregnancy. CASE: Our team provided perinatal care to a 20-year-old transgender man, which prompted collaborative advocacy for health care systems change to create gender-affirming patient experiences in the perinatal health care setting. CONCLUSION: Systems-level and interpersonal-level interventions were adopted to create gender-affirming and inclusive care in and around pregnancy. Basic practices to mitigate stigma and promote gender-affirming care include staff trainings and query and use of appropriate name and pronouns in patient interactions and medical documentation. Various factors are important to consider regarding testosterone therapy for transgender individuals desiring pregnancy.

Treatment of patients with HIV or hepatitis C by pharmacist clinicians in a patient-centered medical home.

PURPOSE: This report describes an innovative pharmacy practice model assisting in the care of patients living with or at risk of acquiring human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV). SUMMARY: In the state of New Mexico, pharmacists can obtain prescribing privileges through a Pharmacist Clinician (PhC) license. The license allows PhCs to assess patients, order laboratory/diagnostic tests, prescribe medication, and bill select insurances. PhCs have developed a practice model for patients living with or at risk of HIV and/or HCV at a Level 3 National Committee for Quality Assurance Patient-Centered Medical Home in Albuquerque, New Mexico. In 2015, 5 PhCs, employed part time, were involved with 8 different clinics: (1) HIV Adherence and Complex Care, (2) HIV Transitions of Care, (3) HCV Mono- and Co-Infection, (4) HIV Pre-Exposure Prophylaxis (PrEP), (5) HIV Primary Care and Cardiovascular Risk Reduction, (6) Young Adult Clinic, (7) Perinatal HIV, and (8) Pediatric HIV. In 2015, PhCs at the clinic billed for 774 direct patient encounters. CONCLUSION: Pharmacists with the PhC license are able to provide high-quality medical care to patients living with or at risk of HIV and/or HCV infections within an interprofessional medical home model.

Barriers to Care Among Transgender and Gender Nonconforming Adults.

Policy Points: Transgender and gender nonconforming (GNC) adults may experience barriers to care for a variety of reasons, including discrimination and lack of awareness by providers in health care settings. In our analysis of a large, population-based sample, we found transgender and GNC adults were more likely to be uninsured and have unmet health care needs, and were less likely to have routine care, compared to cisgender (nontransgender) women. Our findings varied by gender identity. More research is needed on transgender and GNC populations, including on how public policy and provider awareness affects health care access and health outcomes differentially by gender identity. CONTEXT: Very little population-based research has examined health and access to care among transgender populations. This study compared barriers to care between cisgender, transgender, and gender nonconforming (GNC) adults using data from a large, multistate sample. METHODS: We used data from the 2014-2015 Behavioral Risk Factor Surveillance System to estimate the prevalence of having no health insurance, unmet medical care needs due to cost, no routine checkup, and no usual source of care for cisgender women (n = 183,370), cisgender men (n = 131,080), transgender women (n = 724), transgender men (n = 449), and GNC adults (n = 270). Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) for each barrier to care while adjusting for sociodemographic characteristics. FINDINGS: Transgender and GNC adults were more likely to be nonwhite, sexual minority, and socioeconomically disadvantaged compared to cisgender adults. After controlling for sociodemographic characteristics, transgender women were more likely to have no health insurance (OR = 1.60; 95% CI = 1.07-2.40) compared to cisgender women; transgender men were more likely to have no health insurance (OR = 2.02; 95% CI = 1.25-3.25) and no usual source of care (OR = 1.84; 95% CI = 1.18-2.88); and GNC adults were more likely to have unmet medical care needs due to cost (OR = 1.93; 95% CI = 1.02-3.67) and no routine checkup in the prior year (OR = 2.41; 95% CI = 1.41-4.12). CONCLUSIONS: Transgender and GNC adults face barriers to health care that may be due to a variety of reasons, including discrimination in health care, health insurance policies, employment, and public policy or lack of awareness among health care providers on transgender-related health issues.

Supporting the Health and Well-Being of Transgender Students.

Throughout the United States, there has been a rise in public discourse about transgender people and transgender issues. Much of this attention stems from passed and proposed anti-LGBTQ (lesbian, gay, bisexual, transgender, queer or questioning) legislation, including "bathroom bills" that would require transgender people to use public facilities corresponding with the sex designated on their birth certificates. With the recent discussion and legislation impacting school-aged children and adolescents, what does this mean for school nurses and how can they care and advocate for their transgender students? In this article, we aim to empower school nurses to join the discussion, advocate for inclusive and equitable school policies, and deliver gender-affirming care to transgender students. We will explain transgender identities; transgender-related stigma, prejudice, discrimination, and health concerns; gender-affirming approaches in caring for transgender youth; and implications for school nurses. School nurses play a key role in creating a space that is welcoming and affirming where transgender students can thrive.

What the Primary Care Pediatrician Needs to Know About Gender Incongruence and Gender Dysphoria in Children and Adolescents.

The recognition and acknowledgment that gender identity and birth-assigned sex may be incongruent in children and adolescents have evolved in recent decades. Transgender care for children and adolescents has developed and is now more widely available. Controversies exist, however, around clinical management of gender dysphoria and gender incongruence in children and adolescents. Clinical guidelines are consensus based and research evidence is limited. Puberty suppression as part of clinical management has become a valuable element of adolescent transgender care, but long-term evidence of success is limited. These uncertainties should be weighed against the risk of harming a transgender adolescent when medical intervention is denied.

Addressing Health Disparities via Coordination of Care and Interprofessional Education: Lesbian, Gay, Bisexual, and Transgender Health and Oral Health Care.

Lesbian, gay, bisexual, and transgender (LGBT) persons are a diverse group, but they share a common need for competent, accessible health care, dispensed without intolerance and with an understanding of their unique health needs. Dental practitioners need to understanding that LGBT persons have distinctive health (and oral health) needs. This article reviews the literature on oral and overall health of LGBT persons in the United States, and discusses ways in which dentists can improve the health care they provide to this vulnerable population, including how interprofessional education and collaborative practice may help to reduce oral health disparities within this group.

Education Creates Welcoming Environment for Transgender Patients.

The ED often is the access point of choice for transgender patients who may be reluctant to interact with providers. Experts say there is a need for training and education of how to present a gender-affirming healthcare environment. Recommended steps include a review of policies, along with corresponding changes to electronic and paper intake forms to ensure that the language used is inclusive of all genders. While blanket discrimination may be declining, experts note that some providers are uncertain about how to interact with a transgender patient. It's always best to ask patients for their preferred name and pronoun and to repeat this exercise every three to six months for return patients, as gender identify can be fluid. To ease anxiety for transgender patients, consider developing a navigator program that will pair any transgender patient who requests the service with a trained advocate who can support and guide the patient through the system.

Challenging cisgenderism in the ageing and aged care sector: Meeting the needs of older people of trans and/or non-binary experience.

Recent Australian legislative and policy changes can benefit people of trans and/or non-binary experience (e.g. men assigned female with stereotypically 'female' bodies, women assigned male with stereotypically 'male' bodies, and people who identify as genderqueer, agender [having no gender], bi-gender [having two genders] or another gender option). These populations often experience cisgenderism, which previous research defined as 'the ideology that invalidates people's own understanding of their genders and bodies'. Some documented forms of cisgenderism include pathologising (treating people's genders and bodies as disordered) and misgendering (disregarding people's own understanding and classifications of their genders and bodies). This system of classifying people's lived experiences of gender and body invalidation is called the cisgenderism framework. Applying the cisgenderism framework in the ageing and aged care sector can enhance service providers' ability to meet the needs of older people of trans and/or non-binary experience.

It is more than sex and clothes: Culturally safe services for older lesbian, gay, bisexual, transgender and intersex people.

This paper outlines the development of culturally safe services for older lesbian, gay, bisexual, transgender and intersex people. It draws on a framework for cultural safety, developed in New Zealand which incorporates an understanding of how history, culture and power imbalances influence the relationship between service providers and Maori people. This has been adapted to the needs of older lesbian, gay, bisexual, transgender and intersex Australians.

Understanding the experiences and needs of lesbian, gay, bisexual and trans Australians living with dementia, and their partners.

AIM: To outline the experiences and needs of lesbian, gay, bisexual and trans (LGBT) Australians living with dementia - and their partners. METHODS: In-depth interviews were conducted with LGBT people, their partners and service providers. RESULTS: LGBT people living with dementia experience unique challenges including the failure of some families of origin and service providers to understand and value their sexual orientation or gender identity. The fear of discrimination by service providers results in greater reliance on intimate partners for care and compounds social isolation. CONCLUSIONS: The unique experiences of LGBT people with dementia are not well understood. There is a need to recognise historical experiences, including familial relationships, and provide advocacy to ensure sexual and gender rights are not violated. There is also a need to ensure that the experiences and perspectives of LGBT people living with dementia inform the development of services.

Baseline Physiologic and Psychosocial Characteristics of Transgender Youth Seeking Care for Gender Dysphoria.

PURPOSE: The purpose of this study was to describe baseline characteristics of participants in a prospective observational study of transgender youth (aged 12-24 years) seeking care for gender dysphoria at a large, urban transgender youth clinic. METHODS: Eligible participants presented consecutively for care at between February 2011 and June 2013 and completed a computer-assisted survey at their initial study visit. Physiologic data were abstracted from medical charts. Data were analyzed by descriptive statistics, with limited comparisons between transmasculine and transfeminine participants. RESULTS: A total of 101 youth were evaluated for physiologic parameters, 96 completed surveys assessing psychosocial parameters. About half (50.5%) of the youth were assigned a male sex at birth. Baseline physiologic values were within normal ranges for assigned sex at birth. Youth recognized gender incongruence at a mean age of 8.3 years (standard deviation = 4.5), yet disclosed to their family much later (mean = 17.1; standard deviation = 4.2). Gender dysphoria was high among all participants. Thirty-five percent of the participants reported depression symptoms in the clinical range. More than half of the youth reported having thought about suicide at least once in their lifetime, and nearly a third had made at least one attempt. CONCLUSIONS: Baseline physiologic parameters were within normal ranges for assigned sex at birth. Transgender youth are aware of the incongruence between their internal gender identity and their assigned sex at early ages. Prevalence of depression and suicidality demonstrates that youth may benefit from timely and appropriate intervention. Evaluation of these youth over time will help determine the impact of medical intervention and mental health therapy.

Transgender and gender nonconforming adolescent care: psychosocial and medical considerations.

PURPOSE OF REVIEW: Transgender individuals display incongruence between their assigned birth sex and their current gender identity, and may identify as male, female, or being elsewhere on the gender spectrum. Gender nonconformity describes an individual whose gender identity, role, or expression is not typical for individuals in a given assigned sex category. This update highlights recent literature pertaining to the psychosocial and medical care of transgender and gender nonconforming (TGN) adolescents with applications for the general practitioner. RECENT FINDINGS: The psychological risks and outcomes of TGN adolescents are being more widely recognized. Moreover, there is increasing evidence that social and medical gender transition reduces gender dysphoria, defined as distress that accompanies the incongruence between one's birth sex and identified gender. Unfortunately, lack of education about TGN adolescents in medical training persists. SUMMARY: Recent literature highlights increased health risks in TGN adolescents and improved outcomes following gender dysphoria treatment. It is important for clinicians to become familiar with the range of treatment options and referral resources available to TGN adolescents in order to provide optimal and welcoming care to all adolescents.