Variability in Medicaid Coverage for Gender-affirming Surgeries Across U.S. States.

OBJECTIVE: To describe the current Medicaid coverage landscape for gender-affirming surgery across the United States at the procedure level and identify factors associated with coverage. BACKGROUND: Medicaid coverage for gender-affirming surgery differs by state, despite a federal ban on gender identity-based discrimination in health insurance. States that cover gender-affirming surgery also differ in which procedures are included in Medicaid coverage, leading to confusion among patients and clinicians. METHODS: State Medicaid policies in 2021 for gender-affirming surgery were queried for each of the 50 states and the District of Columbia (D.C.). State partisanship, state-level Medicaid protections, and coverage of gender-affirming procedures in 2021 were recorded. The linear correlation between electorate partisanship and total procedures covered was assessed. Pairwise t tests were used to compare coverage based on state partisanship and the presence or absence of state-level Medicaid protections. RESULTS: Medicaid coverage for gender-affirming surgery was covered in 30 states and Washington, D.C. The most commonly covered procedures were genital surgeries and mastectomy (n = 31), followed by breast augmentation (n = 21), facial feminization (n = 12), and voice modification surgery (n = 4). More procedures were covered in Democrat-controlled or leaning states, as well as in states with explicit protections for gender-affirming care in Medicaid coverage. CONCLUSIONS: Medicaid coverage for gender-affirming surgery is patchwork across the United States and is especially poor for facial and voice surgeries. Our study provides a convenient reference for patients and surgeons detailing which gender-affirming surgical procedures are covered by Medicaid within each state.

On the Frontlines: Protecting and Advancing Gender-Affirming Care in a Hostile Sociopolitical Environment.

Since 2020, there has been a significant cultural and political backlash in the USA to growing acceptance of gender diversity and gender-affirming care. Legislative attacks, particularly targeting gender-affirming care access for transgender and gender diverse youth, have occurred in a media environment rife with misinformation and disinformation. Even in states where a ban is not enacted, we have seen significant harm caused by such misinformation and disinformation, to transgender and gender diverse patients, their families, and clinicians who provide this important and much needed care, in the form of clinic closures and disruption of services. In this hostile sociopolitical environment, we present strategies for health care organizations and workers to continue to provide this lifesaving care thoughtfully, to safeguard the protections currently in place, and to continue to advocate for patients, families, and health care staff.

Health Care Discrimination and Care Avoidance Due to Patient-Clinician Identity Discordance Among Sexual and Gender Minority Adults.

Sexual and gender minority (SGM) adults experience poor health outcomes, in part due to frequent avoidance of necessary health care. Little is known, however, about factors contributing to patterns of health care utilization in this population. Using national data from the All of Us Research Program, this study evaluated the prevalence of care avoidance due to patient-clinician identity discordance (PCID) and its association with health care discrimination among SGM adults. Sexual minority (20.0% vs 9.4%; adjusted rate ratio [aRR] = 1.58; 95% CI, 1.49-1.67, P <0.001) and gender minority adults (34.4% vs 10.3%; aRR = 2.00; 95% CI, 1.79-2.21, P <0.001) were significantly more likely than their non-SGM counterparts to report care avoidance due to PCID. Exposure to health care discrimination was also more prevalent in this population and was dose-dependently associated with significantly higher rates of PCID-based care avoidance. Study findings highlight the importance of diversifying the health care workforce, expanding SGM-related clinical training, and preventing health care discrimination against SGM patients.

Closing the Dissemination Gap: Accessible Toolkits for the Rapid Replication of Evidence-Informed Interventions to Improve Health Outcomes Among People with HIV.

Despite advances in HIV care and treatment in the U.S., disparities in outcomes along the HIV care continuum persist. The widespread replication of effective and sustainable interventions that prioritize the engagement of underserved populations has been identified as a promising path to ending the HIV epidemic in the U.S. Intervention dissemination products, however, rarely provide the comprehensive and accessible information needed to replicate interventions within community settings. To bridge the divide between research and community-based implementation, the Using Evidence-informed Interventions to Improve Health Outcomes among People Living with HIV (E2i) initiative-grounded in the HIV/AIDS Bureau Implementation Science Framework-created a suite of tools to promote the rapid replication of interventions focused on transgender women, Black men who have sex with men, behavioral health integration, and identifying and addressing trauma. The resulting dissemination products are detailed and digestible multimedia toolkits that follow adult learning theory principles and align with the Template for Intervention Description and Replication criteria for adapting non-pharmacological interventions. Each E2i toolkit consists of five components: implementation guides, narrative videos of site implementation, best practice demonstration videos, interactive learning modules, and recruitment posters and brochures. Over 2 years (2022-2024), the E2i toolkit webpages amassed 7703 unique users and 17,666 pageviews. These toolkits can serve as a blueprint for designing comprehensive and accessible dissemination products for replication of HIV interventions in care settings. Dissemination products that bridge the gap between intervention research and replication in community settings are a crucial missing tool for ending the HIV epidemic.

A Peer-to-Peer Collaborative Learning Approach for the Implementation of Evidence-Informed Interventions to Improve HIV-Related Health Outcomes.

The nationwide scale-up of evidence-based and evidence-informed interventions has been widely recognized as a crucial step in ending the HIV epidemic. Although the successful delivery of interventions may involve intensive expert training, technical assistance (TA), and dedicated funding, most organizations attempt to replicate interventions without access to focused expert guidance. Thus, there is a grave need for initiatives that meaningfully address HIV health disparities while addressing these inherent limitations. Here, the Health Resources and Services Administration HIV/AIDS Bureau (HRSA HAB) initiative Using Evidence-Informed Interventions to Improve HIV Health Outcomes among People Living with HIV (E2i) piloted an alternative approach to implementation that de-emphasized expert training to naturalistically simulate the experience of future HIV service organizations with limited access to TA. The E2i approach combined the HAB-adapted Institute for Healthcare Improvement's Breakthrough Series Collaborative Learning Model with HRSA HAB's Implementation Science Framework, to create an innovative multi-tiered system of peer-to-peer learning that was piloted across 11 evidence-informed interventions at 25 Ryan White HIV/AIDS Program sites. Four key types of peer-to-peer learning exchanges (i.e., intervention, site, staff role, and organization specific) took place at biannual peer learning sessions, while quarterly intervention cohort calls and E2i monthly calls with site staff occurred during the action periods between learning sessions. Peer-to-peer learning fostered both experiential learning and community building and allowed site staff to formulate robust site-specific action plans for rapid cycle testing between learning sessions. Strategies that increase the effectiveness of interventions while decreasing TA could provide a blueprint for the rapid uptake and integration of HIV interventions nationwide.

Lower levels of social support are associated with risk for future suicide attempts in a clinical sample of transgender and gender diverse adults.

PURPOSE: Transgender and gender diverse (TGD) adults are disproportionately affected by suicide. Social support and connection to the broader TGD community may help lower TGD adults' odds of having a suicide attempt (SA). The current study examined whether baseline levels of social support and community connectedness were associated with TGD adult's prospective odds of having a SA over 12 months of follow-up. METHODS: Longitudinal data for the current study came from a patient cohort of TGD adults enrolled in the LEGACY Project. Descriptive statistics and an attrition analysis were used to examine characteristics of the cohort and missingness over time. Logistic generalized estimating equation models were used to examine factors associated with patients' odds of having a past 6-month SA at 6- or 12-month follow-up. RESULTS: During the 12-month follow-up period, a total of 26 patients (3.1%; N = 830) reported having a SA. The 6-month incidence of SAs was approximately 2% at both 6- and 12-months of follow-up (6 months: N = 830; 12 months: N = 495). Baseline factors associated with increased odds of a future SA included gender identity (transfeminine vs. transmasculine: adjusted odds ratio [aOR] = 3.73, 95% confidence interval [CI] = 1.26-11.08; nonbinary vs. transmasculine: aOR = 3.09, 95% CI = 1.03-9.21), having a prior SA (aOR = 6.44, 95% CI = 2.63-15.79), and having moderate vs. high perceived social support (aOR = 4.25, 95% CI = 1.65-10.90). CONCLUSION: Lower levels of social support are associated with risk for future suicide attempts among TGD adults. Findings may inform screening practices for future suicide risk and the development of interventions to improve mental health outcomes for TGD adults.

Decreased Anogenital Gonorrhea and Chlamydia in Transgender and Gender Diverse Primary Care Patients Receiving Gender-Affirming Hormone Therapy.

BACKGROUND: Transgender and gender diverse (TGD) adults in the U.S. experience health disparities, including in anogenital sexually transmitted infections (STI). Gender-affirming hormone therapy (GAHT) is known to be medically necessary and improve health. Few studies have assessed the effect of GAHT on STI diagnoses. OBJECTIVE: To evaluate the effect of GAHT delivered in primary care as an intervention to improve STI outcomes for TGD adults. DESIGN: LEGACY is a longitudinal, multisite cohort study of adult TGD primary care patients from two federally qualified community health centers in Boston, MA, and New York, NY. PARTICIPANTS: Electronic health record data for eligible adult TGD patients contributed to the LEGACY research data warehouse (RDW). A total of 6330 LEGACY RDW patients were followed from 2016 to 2019, with 2555 patients providing STI testing data. MAIN MEASURES: GAHT exposure was being prescribed hormones, and the clinical outcome was anogenital gonorrhea or chlamydia diagnoses. Log-Poisson generalized estimating equations assessed the effect of prescription GAHT on primary outcomes, adjusting for age, race, ethnicity, gender identity, poverty level, health insurance, clinical site, and cohort years. KEY RESULTS: The median age was 28 years (IQR = 13); the racial breakdown was 20.4% Black, 8.1% Multiracial, 6.9% Asian/Pacific Islander, 1.8% Other; 62.8% White; 21.3% Hispanic/Latinx; 47.0% were assigned female at birth, and 16.0% identified as nonbinary. 86.3% were prescribed hormones. Among those tested, the percentage of patients with a positive anogenital STI diagnosis ranged annually from 10.0 to 12.5% between 2016 and 2019. GAHT prescription was associated with a significant reduction in the risk of anogenital STI diagnosis (aRR = 0.75; 95% CI = 0.59-0.96) over follow-up. CONCLUSIONS: GAHT delivered in primary care was associated with less STI morbidity in this TGD cohort over follow-up. Patients may benefit from individualized and tailored clinical care alongside GAHT to optimize STI outcomes.

Sexual Orientation and Gender Identity Data Completeness at US Federally Qualified Health Centers, 2020 and 2021.

Objectives. To assess the performance of US federally qualified health centers (FQHCs) after 6 years of required sexual orientation and gender identity (SOGI) data reporting and update estimated proportions of sexual and gender minorities cared for at FQHCs. Methods. We conducted secondary analyses of data reported to the 2020 and 2021 Uniform Data System from 1297 FQHCs caring for nearly 30 000 000 patients annually. We used multivariable logistic regression to explore FQHC-level and patient-level factors associated with SOGI data completeness. Results. SOGI data were missing for 29.1% and 24.0% of patients, respectively. Among patients with reported SOGI data, 3.5% identified as sexual minorities and 1.5% identified as gender minorities. Southern FQHCs and those caring for more low-income and Black patients were more likely to have above-average SOGI data completeness. Larger FQHCs were more likely to have below-average SOGI data completeness. Conclusions. Substantial increases in SOGI data completeness at FQHCs over 6 years reflect the success of reporting mandates. Future research is needed to identify other patient-level and FQHC-level factors contributing to residual levels of SOGI data missingness. (Am J Public Health. 2023;113(8):883-892. https://doi.org/10.2105/AJPH.2023.307323).

Research and engagement considerations for alcohol use telehealth services within HIV care: a qualitative exploration in federally qualified health centers.

The prevalence of alcohol misuse is high among people with HIV (PWH); however, access to and utilization of evidence-based alcohol misuse interventions remain limited. Telehealth is one treatment approach with the potential for enhancing substance use disorder treatment utilization for PWH served by Federally Qualified Health Centers (FQHCs). However, questions remain regarding barriers to alcohol-focused telehealth service integration and telehealth research in FQHCs. This study employed qualitative methods, guided by the Dynamic Sustainability Framework, to evaluate barriers and cultural factors impacting FQHC telehealth integration. Eighteen qualitative interviews were completed with staff and leaders across four FQHCs. Interviews were analyzed using directed content analysis, and codes were organized into a priori and emergent themes. Key themes included the presence of common workflows for referring clients to substance use disorder treatment; existing research workflows and preferences for active project staff involvement; telehealth barriers including exacerbation of healthcare disparities and high provider turnover; and the importance of cultural humility and telehealth adaptations for sexual, gender, racial and ethnic minority clients. Findings from this study will inform the development of an alcohol-focused telehealth implementation strategy for a Hybrid Type 1 implementation effectiveness trial to enhance FQHC substance use disorder treatment.Trial registration: ClinicalTrials.gov identifier: NCT02563574..

Integrating LGBTQIA + Community Member Perspectives into Medical Education.

ProblemLGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and all sexual and gender minorities) people have unique health care needs related to their sexual orientation, gender identity and expression, and sex development. However, medical education has historically excluded LGBTQIA + health-related content in formal curricula. It is common for medical students to interact with diverse patient populations through clinical rotations; however, access to and knowledge about LGBTQIA + patients is inconsistently prioritized in medical schools. This is especially true for LGBTQIA + patients with intersecting historically marginalized identities, such as people of color and people with disabilities. Learning from and listening to medically underserved community members can help both medical students and educators better understand the unique health needs of these communities, and address implicit biases to improve health care and outcomes for their patients. Intervention: To address the lack of LGBTQIA + health-related content in medical education and improve access to and knowledge about LGBTQIA + patients, LGBTQIA + community members' perspectives and lived experiences were integrated into undergraduate medical education via four primary methods: Community Advisory Groups, community panel events, standardized patients, and community member interviews. Context: LGBTQIA + community members' perspectives and lived experiences were integrated into medical education at Harvard Medical School (HMS) as part of the HMS Sexual and Gender Minority Health Equity Initiative. Impact: LGBTQIA + community members' perspectives and lived experiences were successfully integrated into multiple aspects of medical education at HMS. During this process, we navigated challenges in the following areas that can inform similar efforts at other institutions: representation of diverse identities and experiences, meeting and scheduling logistics, structural barriers in institutional processes, and implementation of community member recommendations. Lessons Learned: Based on our experiences, we offer recommendations for integrating LGBTQIA + community members' perspectives into medical education. Engaging community members and integrating their perspectives into medical education will better enable medical educators at all institutions to teach students about the health care needs of LGBTQIA + communities, and better prepare medical students to provide affirming and effective care to their future patients, particularly those who are LGBTQIA+.

Interventions for addressing trauma among people with HIV: a narrative review.

Traumatic experiences are disproportionately prevalent among people with HIV and adversely affect HIV-related health outcomes. As part of a national cooperative agreement funded by the Health Resources and Services Administration's HIV/AIDS Bureau, we searched the literature for interventions designed to address trauma among people with HIV in the U.S. Our search yielded 22 articles on 14 studies that fell into five intervention categories: expressive writing, prolonged exposure therapy, coping skills, cognitive-behavioral approaches integrated with other methods, and trauma-informed care. Thematic elements among the interventions included adaptating existing interventions for subpopulations with a high burden of trauma and HIV, such as transgender women and racial/ethnic minorities; addressing comorbid substance use disorders; and implementing organization-wide trauma-informed care approaches. Few studies measured the effect of the interventions on HIV-related health outcomes. To address the intersecting epidemics of HIV and trauma, it is critical to continue developing, piloting, and evaluating trauma interventions for people with HIV, with the goal of wide-scale replication of effective interventions in HIV settings.

Envisioning a future for transgender and gender-diverse people beyond the DSM.

This editorial describes current considerations regarding psychiatric diagnoses for transgender and gender-diverse (TGD) people. In addition to offering an assessment of the limitations in current diagnostic standards, the authors articulate a vision for psychiatric practice marked by renewed commitment to an affirmative framework that reduces stigma.

Sexual Orientation and Gender Identity Data Collection at US Health Centers: Impact of City-Level Structural Stigma in 2018.

Objectives. To examine the relationship between city-level structural stigma pertaining to sexual orientation and gender identity (SOGI) and completeness of patient SOGI data collection at US federally qualified health centers (FQHCs). Methods. We used the Human Rights Campaign's Municipal Equality Index to quantify city-level structural stigma against sexual and gender minority people in 506 US cities across 49 states. We ascertained the completeness of SOGI data collection at FQHCs from the 2018 Uniform Data System, which describes FQHC patient demographics and service utilization. We included FQHCs in cities captured by the structural stigma index in multinomial generalized linear mixed models to examine the relationship between city-level structural stigma and SOGI data completeness. Results. FQHCs in cities with more protective sexual orientation nondiscrimination policies reported more complete patient sexual orientation data (adjusted odds ratio [AOR] = 1.6; 95% confidence interval [CI] = 1.2, 2.1). This association was also found for gender identity nondiscrimination policies and gender identity data collection (AOR = 1.7; 95% CI = 1.3, 2.2). Conclusions. Municipal sexual and gender minority nondiscrimination laws are associated with social and municipal environments that facilitate patient SOGI data collection.(Am J Public Health. 2021;111(11):2059-2063. https://doi.org/10.2105/AJPH.2021.306414).

A Blueprint for Planning and Implementing a Transgender Health Program.

Transgender and gender-diverse people face multiple barriers to accessing appropriate health care, including denial of service, harassment, and lack of clinician knowledge. This article presents a blueprint for planning and implementing a transgender health program within a primary care practice in order to enhance the capacity of the health care system to meet the medical and mental health needs of this underserved population. The steps described, with emphasis on elements specific to transgender care, include conducting a community needs assessment, gaining commitment from leadership and staff, choosing a service model and treatment protocols, defining staff roles, and creating a welcoming environment.

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.

Public Health Detailing for Human Immunodeficiency Virus Pre-exposure Prophylaxis.

Despite the promise of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP), PrEP remains underutilized, often due to clinician factors. Academic or public health detailing is a process by which university and/or government groups employ the marketing practices of pharmaceutical companies to improve clinical practice. We describe the novel application of detailing to increase PrEP prescribing and related care in New York City and New England. Detailing can play a crucial role in PrEP implementation.

Factors associated with anal cancer screening follow-up by high-resolution anoscopy.

OBJECTIVES: High-resolution anoscopy (HRA) is a potential screening method for detection of anal cancer precursors. We evaluated factors associated with adherence to recommended HRA follow-up time intervals among men who have sex with men (MSM). METHODS: We employed a retrospective, observational cohort study with 155 MSM screened by HRA between 1 April 2011 and 31 March 2016 at a Federally Qualified Health Centre in Boston, Massachusetts. RESULTS: The sample was 80% white, with a median age of 48 (non-normal distribution, IQR 15). All patients were assigned male sex at birth and none identified as transgender. Fifty patients (32%) followed up with a HRA appointment within 6 months of previous HRA detection of anal high-grade squamous intraepithelial lesion (HSIL). Among patients, 112 (72%) were HIV infected, 56 (36%) had a syphilis diagnosis during the study period, 89 (57.4%) had initiated Hepatitis A or B vaccination series, 70 (45.2%) accessed case management services and 19 (12.3%) utilised pre-exposure prophylaxis (PrEP). In bivariate analysis, patients who underwent recommended follow-up HRA within 6 months of HSIL diagnosis were less likely to report: case management utilisation (p=0.023), initiation of Hepatitis A or B vaccination (p=0.047), HIV diagnosis (p<0.001) and syphilis diagnosis (p=0.001), but were more likely to use HIV PrEP (p<0.001). In binomial logistic regression modelling after adjusting for age and race/ethnicity, patients who had follow-up with HRA within a recommended period of 6 months after HSIL diagnosis were less likely to have initiated Hepatitis A or B vaccination (adjusted OR 0.43, 95% CI 0.20 to 0.94), more likely to use PrEP (adjusted OR 4.47, 95% CI 1.30 to 15.49) and less likely to have a syphilis diagnosis (adjusted OR 0.34, 95% CI 0.14 to 0.86). CONCLUSIONS: Three-quarters of patients with HSIL did not have follow-up HRA within the clinic's recommended follow-up period of 6 months following HSIL diagnosis by HRA. Future studies ought to explore whether addressing anal health during other STI-related care helps improve adherence to recommended time intervals for follow-up HRA. Given the high prevalence of STI and PrEP use, studies might also evaluate whether integrating HRA follow-up with other sexual health screenings helps improve adherence to recommended HRA follow-up.