Gender-Related Health Care Discrimination and Human Papillomavirus Vaccination Among Transgender and Nonbinary Young Adults in the United States.

Although transgender and nonbinary (TNB) people can acquire human papillomavirus (HPV), research examining HPV vaccination in these populations is scarce. TNB individuals experience high levels of gender-related health care discrimination, which may undermine HPV vaccine uptake. Using data from a national online survey (N=716), we found a negative association between gender-related health care discrimination and HPV vaccination among transgender women and nonbinary individuals who were assigned male at birth (AMAB; odds ratio [OR]=0.52; 95% confidence interval [CI]: 0.29-0.93). Addressing gender-related health care discrimination may facilitate HPV vaccination and help prevent HPV-related cancers among transgender women and nonbinary AMAB individuals.

Variation in diet quality across sexual orientation in a cohort of U.S. women.

PURPOSE: Extensive prior research has shown that sexual minority women are more likely to have a number of cancer risk factors, thereby putting them at higher risk for cancer than heterosexual women. However, there has been little research evaluating the association between sexual orientation and diet quality. METHOD: Data come from participants (aged 24-54 years) enrolled in Nurses' Health Study 3, an ongoing, U.S.-based cohort study (N = 15,941). We measured diet using recommendations from the Dietary Approach to Stop Hypertension (DASH) and American Health Association (AHA) 2020 Strategic Impact Goals. RESULTS: We found limited evidence of differences across diet quality by sexual orientation. When examining predicted DASH scores, mostly heterosexual [predicted mean score (95% confidence interval), 24.0 (23.8, 24.3)] and lesbian [24.3 (23.8, 24.9)] women had healthier predicted DASH scores than the reference group of completely heterosexual women with no same-sex partners [23.6 (23.5, 23.7)]. Even though certain sexual minority women had overall healthier predict DASH scores, their consumption of certain food groups-low-fat dairy and fruit-was lower than completely heterosexual women with no same-sex partners. When measuring AHA scores, most sexual minority groups (completely heterosexual women with same-sex partners, mostly heterosexual women, and lesbian women) had higher diet quality compared to the reference group of completely heterosexual women with no same-sex partners. CONCLUSION: Sexual minority women, particularly mostly heterosexual women and lesbian women, had healthier diet quality than completely heterosexual women with no same-sex partners. These data suggest that cancer risk factors (e.g., smoking, drinking, and inactivity) other than diet would drive higher cancer rates among sexual minority compared to heterosexual women. Nonetheless, it is critical for all women to improve their diet quality since diet quality was poor among participants of all sexual orientations.

Differences in Tobacco Product Use by Sexual Orientation and Violence Factors Among United States Youth.

OBJECTIVE: To assess differences in the relationship between violence factor exposure and tobacco product pattern use (exclusive and poly), we hypothesized that compared with heterosexuals, sexual minority youth would be more likely to report exclusive-tobacco and poly-tobacco use patterns, and controlling for violence factors would attenuate these associations. STUDY DESIGN: Data from 27 513 US high-school youth were analyzed from the Centers for Disease Control and Prevention's Youth Risk Factor Surveillance System from 2015 and 2017. We fit sex-stratified, weighted, adjusted log-Poisson models to compare past 30-day exclusive combustible, exclusive e-cigarette, and poly-tobacco use in across sexual orientation. Then, models were adjusted for past-year experiences of physical fighting, bullying, attempting suicide, and physical and sexual dating violence. RESULTS: Compared with heterosexual girls with other-sex partners, sexual minority girls were more likely to use exclusive combustible, exclusive e-cigarette, or poly-tobacco products. When adjusting for violence factors, most tobacco use associations were partially attenuated for all sexual minority girls, and completely attenuated for exclusive e-cigarette use among all sexual minority girls. CONCLUSIONS: Sexual minority girls have greater exclusive- and poly-tobacco use compared with heterosexual girls. Tobacco interventions for sexual minority youth should address the risks of poly-tobacco use as well as violence-based risk factors.

Barriers to Gender-affirming Surgery Consultations in a Sample of Transmasculine Patients in Boston, Mass.

Gender diverse people are increasingly pursuing gender-affirming surgery, but little is known about their experiences on accessing care. As part of the baseline assessment for an ongoing longitudinal study, we examined the types of barriers and self-reported out-of-pocket costs associated with gender-affirming surgery most commonly endorsed by transmasculine chest (top) and genital (bottom) surgery patients at their initial surgical consultation. METHODS: A brief survey was administered to a clinical sample of transmasculine patients (n = 160; age ≥15 years) seeking a gender-affirming surgery at the Center for Gender Surgery in Boston, Mass. from April 2018 to February 2020. RESULTS: The barriers most commonly endorsed by top surgery patients were insurance coverage and age. For bottom surgery patients, the most commonly endorsed barriers were getting mental health letters and readiness for surgery. Bottom surgery patients were also more likely to report barriers of readiness for surgery and cost of/access to hair removal, than top surgery patients (Ps < 0.05). Bottom surgery patients were more likely to report out-of-pocket costs related to hair removal, surgical consultation, and surgery (Ps < 0.05), whereas top surgery patients were more likely to report hormone treatment costs (P = 0.01). Average out-of-pocket costs were high (mean = 2148.31) and significantly higher for bottom surgery patients (b = 4140.30; ß = 0.64; 95% confidence interval, 3064.6-5216.0). CONCLUSIONS: Transmasculine patients experience a variety of barriers when seeking gender-affirming surgery. Presurgical requirements, insurance access, and high out-of-pocket costs may hinder access to care for many transmasculine people seeking bottom surgery.

Sexual Orientation Identity Disparities in Mammography Among White, Black, and Latina U.S. Women.

Purpose: Our goal was to examine sexual orientation identity disparities in mammography in relationship to race/ethnicity among U.S. women. Methods: Using nationally representative 2013-2017 National Health Interview Survey data, we used multivariable logistic regression to estimate the odds of receiving a mammogram in the past year in relationship to sexual orientation identity among White, Black, and Latina U.S. women 40-75 years of age (N = 45,031) separately, adjusting for demographic factors. We also assessed whether socioeconomic and health care factors attenuated sexual orientation identity disparities in mammography across racial/ethnic groups. Results: Among White women, bisexual women had significantly lower adjusted odds of mammography compared to heterosexual women (odds ratio = 0.70, 95% confidence interval: 0.50-0.99). Among Black women, the adjusted odds of mammography were significantly higher among bisexual women relative to heterosexual women (2.53, 1.08-5.92). Black lesbian women appeared to have lower adjusted odds of mammography compared to their heterosexual counterparts; however, this difference was not statistically significant (0.80, 0.46-1.38). Similarly, among Latina women, lesbian women also seemed to have lower adjusted odds of mammography relative to heterosexual women, but this disparity was also not statistically significant (0.64, 0.37-1.13). Adding socioeconomic factors completely attenuated the disparity between White bisexual and heterosexual women (0.76, 0.52-1.10). Conclusions: Sexual orientation identity disparities in receiving a mammogram in the past year differed in relationship to race/ethnicity among White, Black, and Latina U.S. women. Additional research with larger samples of Black and Latina lesbian and bisexual women is needed to more accurately estimate and explain observed differences.

Behavioral Health Concerns and Eligibility Factors Among Adolescents and Young Adults Seeking Gender-Affirming Masculinizing Top Surgery.

Purpose: We evaluated behavioral health histories and eligibility factors for patients seeking chest reconstruction. Methods: One hundred and fifty-eight consecutive transgender patients were seen for initial masculinizing top surgery consults between May 2017 and July 2019. Chart review was used to assess behavioral health and demographic factors, and eligibility factors related to the World Professional Association for Transgender Health (WPATH) Standards of Care. Univariate and age-adjusted regression models were used to examine the relationship between demographic and behavioral health factors and WPATH criteria. Results: The average age of patients at the time of their first consult was 18 (standard deviation = 3.3, range = 14-33). Eighty-five percent had at least one behavioral health diagnosis; 27% had three or more. Sixty-four percent endorsed a history of self-harm or suicidal ideation, 13% within the last 6 months. Thirty-two percent reported a history of marijuana use and 19% a history of nicotine use. For those prescribed testosterone, additional months on testosterone were significantly associated with male (vs. nonbinary) gender (ß = 4.64, 95% confidence interval [CI] 0.37-8.90, p = 0.033), age (ß = 0.87, 95% CI 0.41-1.34, p < 0.001), living as one's affirmed gender for over 1 year (ß = 6.37, 95% CI 1.37-11.37, p = 0.013), history of marijuana use (ß = 4.54, 95% CI 1.10-7.98, p = 0.010), and history of nicotine use (ß = 6.23, 95% CI 2.22-10.26, p = 0.003). Conclusion: Patients seeking gender-affirming masculinizing top surgery are behaviorally complex, in ways not necessarily associated with surgical eligibility. Involving a behavioral health provider in perioperative assessment can help identify and address potential risks to recovery and outcomes.

Mediation Models of Perceived Medical Heterosexism, Provider-Patient Relationship Quality, and Cervical Cancer Screening in a Community Sample of Sexual Minority Women and Gender Nonbinary Adults.

PURPOSE: Sexual minority women (SMW) are vulnerable to cervical cancer, yet there is a dearth of research on potential mediators of cervical cancer disparities. Medical heterosexism, which involves sexual orientation-based discrimination in medical contexts, and provider-patient communication quality and trust in providers may be important factors influencing the cancer prevention decisions of SMW. The purpose of this study was to examine how provider-patient communication quality, trust in providers, and perceived medical heterosexism are associated with cervical cancer screening among SMW. METHODS: A dual-mode, one-time cross-sectional survey was administered to a community sample of SMW (N = 150), ages 21-53, in Richmond, Virginia, from December 2017 to February 2018. RESULTS: It was hypothesized that provider-patient communication quality and trust in providers would mediate the relationship between perceived medical heterosexism and cervical cancer screening outcomes. The hypothesis was supported; trust in providers (b = 0.05, p = 0.001, 95% confidence interval [CI] 0.02-0.08) and provider-patient communication quality (b = 0.06, p = 0.003, 95% CI 0.02-0.10) were positively associated with future screening intention, and their total indirect effect mediated the relationship between perceived medical heterosexism and intention (b = -0.03, 95% CI -0.05 to -0.02, ß = -0.25, 95% CI -0.39 to -0.15). Similarly, the total indirect effect of provider-patient communication quality mediated the relationship between perceived medical heterosexism and odds of routine screening (b = -0.03, 95% CI -0.06 to -0.01). CONCLUSION: These findings point to the need for cancer prevention and control strategies for SMW to target provider education and policy interventions that improve SMW's relationships with their providers and improve cervical cancer screening rates.

Gender Identity Disparities in Cancer Screening Behaviors.

INTRODUCTION: Transgender (trans) and gender-nonconforming adults have reported reduced access to health care because of discrimination and lack of knowledgeable care. This study aimed to contribute to the nascent cancer prevention literature among trans and gender-nonconforming individuals by ascertaining rates of breast, cervical, prostate, and colorectal cancer screening behaviors by gender identity. METHODS: Publicly available de-identified data from the 2014-2016 Behavioral Risk Factor Surveillance System surveys were utilized to evaluate rates of cancer screenings by gender identity, while controlling for healthcare access, sociodemographics, and survey year. Analyses were conducted in 2017. RESULTS: Weighted chi-square tests identified significant differences in the proportion of cancer screening behaviors by gender identity among lifetime colorectal cancer screenings, Pap tests, prostate-specific antigen tests, discussing prostate-specific antigen test advantages/disadvantages with their healthcare provider, and up-to-date colorectal cancer screenings and Pap tests (p<0.036). Weighted logistic regressions found that although some differences based on gender identity were fully explained by covariates, trans women had reduced odds of having up-to-date colorectal cancer screenings compared to cisgender (cis) men (AOR=0.20) and cis women (AOR=0.24), whereas trans men were more likely to ever receive a sigmoidoscopy/colonoscopy as compared to cis men (AOR=2.76) and cis women (AOR=2.65). Trans women were more likely than cis men to have up-to-date prostate-specific antigen tests (AOR=3.19). Finally, trans men and gender-nonconforming individuals had reduced odds of lifetime Pap tests versus cis women (AOR=0.14 and 0.08, respectively), and gender-nonconforming individuals had lower odds of discussing prostate-specific antigen tests than cis men (AOR=0.09; all p<0.05). CONCLUSIONS: The findings indicate that gender identity disparities in cancer screenings persist beyond known sociodemographic and healthcare factors. It is critical that gender identity questions are included in cancer and other health-related surveillance systems to create knowledge to better inform healthcare practitioners and policymakers of appropriate screenings for trans and gender-nonconforming individuals.