Educational guidelines on sexual orientation, gender identity and expression, and sex characteristics biases in medical education.

A commitment to diversity, equity, inclusion, and belonging in medical education requires addressing both explicit and implicit biases based on sexual orientation, gender identity and expression, and sex characteristics and the intersectionality with other identities. Heterosexism and heteronormative attitudes contribute to health and healthcare disparities for lesbian, gay, bisexual, transgender and queer or questioning, intersex, asexual individuals. Student, trainee, and faculty competencies in medical education curricula regarding the care of lesbian, gay, bisexual, transgender and queer or questioning, intersex, asexual patients and those who are gender nonconforming or born with differences of sex development allow for better understanding and belonging within the clinical learning environment of lesbian, gay, bisexual, transgender and queer/questioning, intersex, asexual learners and educators. The Association of Professors of Gynecology and Obstetrics issued a call to action to achieve a future free from racism and bias through inclusivity in obstetrics and gynecology education and healthcare, which led to the creation of the Association of Professors of Gynecology and Obstetrics Diversity, Equity, and Inclusion Guidelines Task Force. The task force initially addressed racism, racial- and ethnicity-based bias, and discrimination in medical education and additionally identified other groups that are subject to bias and discrimination, including sexual orientation, gender identity and expression, and sex characteristic identities, persons with disabilities, and individuals with various religious and spiritual practices. In this scholarly perspective, the authors expand on previously developed guidelines to address sexual orientation, gender identity and expression, and sex characteristics bias, heterosexism, and heteronormative attitudes in obstetrics and gynecology educational products, materials, and clinical learning environments to improve access and equitable care to vulnerable individuals of the lesbian, gay, bisexual, transgender and queer or questioning, intersex, asexual community.

Racial disparities in endometrial cancer: Where are we after 26 years?

INTRODUCTION: Endometrial cancer is the most commonly diagnosed female genital tract malignancy in the United States of America. Racial disparities surrounding this particular disease have been extensively investigated for over 26-years. We sought to determine if research in this area has led to any significant improvements in this disparity. METHODS: We performed a rapid systematic review of English language publications on racial disparities in endometrial cancer among African American (AAW) and white American women (WAW), from 1997 to 2023. We looked at trends in incidence and survival; impact of known poor prognostic factors (stage at diagnosis, histological subtypes, grade); co-morbidities; differences in treatment (surgery, radiation and chemotherapy); socioeconomic factors; differences in biological and genetic markers; and policies/declarations. RESULTS: During the period under review (1997-2023), there was a notable increase in both disease incidence (39%) and mortality (26%) rates for AAW, in comparison to WAW among whom the incidence rates increased by 2% and mortality rates rose, but 9% less than for AAW. It should be noted that the current incidence rate of 29.4% in AAW represent a reversal of what is was 26-years ago, when the incidence rate was 17.8%. In comparison to WAW, AAW had a higher prevalence of poor prognostic variables, more co-morbidities, lower income levels, less insurance coverage, and were more frequently under treated with surgery, chemotherapy and radiation. To date no actionable molecular/genetic markers have been identified. We were unable to locate any published recommendations or active programs of implementation strategies/policies designed to effectively mitigate the documented racial disparity. CONCLUSION: Racial disparities in disease incidence and mortality in endometrial cancer rates between WAW and AAW have widened during a 26-year period of robust research, suggesting that current research alone is not enough to eliminate this disparity. Based on this rapid systematic review we have identified and analyzed the impact of causation variables on this disparity. Additionally, we have made strong and pertinent recommendations for the benefit of mitigating this escalating racial disparity.

Promoting Anti-Racism in Clinical Practice: Lessons Learned in the Process of Removing the Race Coefficient from the Estimated Glomerular Filtration Rate Algorithm.

Background: Promoting anti-racism in medicine entails naming racism as a contributor to health inequities and being intentional about changing race-based practices in health care. Unscientific assumptions about race have led to the proliferation of race-based coefficients in clinical algorithms. Identifying and eliminating this practice is a critical step to promoting anti-racism in health care. The New York City Department of Health and Mental Hygiene (NYC-DOHMH) formed the Coalition to End Racism in Clinical Algorithms (CERCA), a health system consortium charged with eliminating clinical practices and policies that perpetuate racism. Objective: This article describes the process by which an academic medical center guided by the NYC-DOHMH tackled race-based clinical algorithms. Methods: Multiple key interested parties representing department chairs, hospital leaders, researchers, legal experts, and clinical pathologists were convened. A series of steps ensued, including selecting a specific clinical algorithm to address, conducting key informant interviews, reviewing relevant literature, reviewing clinical data, and identifying alternative and valid algorithms. Key Outcomes: Given the disproportionately higher rates of chronic kidney disease risk factors, estimated glomerular filtration rate (eGFR) was prioritized for change. Key informant interviews revealed concerns about the clinical impact that removing race from the equation would have on patients, potential legal implications, challenges of integrating revised algorithms in practice, and aligning this change in clinical practice with medical education. This collaborative process enabled us to tackle these concerns and successfully eliminate race as a coefficient in the eGFR algorithm. Conclusions: CERCA serves as a model for developing academic and public health department partnerships that advance health equity and promote anti-racism in practice. Lessons learned can be adapted to identify, review, and remove the use of race as a coefficient from other clinical guidelines.

Divisions of health equity in departments of obstetrics and gynecology.

Disparities in maternal morbidity and mortality remain vivid reminders of the role of racism in obstetrics and gynecology. If a serious attempt is to be made to purge medicine of its ongoing role in unequal care, then departments must commit the same intellectual and material resources as they would to the other health challenges in their remit. A division that understands the unique needs and complexities of the specialty, including translating theory into practice, is uniquely positioned to keep health equity as a focus of clinical care, education, research, and community engagement. To achieve reproductive justice, an approach addressing the intersectionality of race, ethnicity and gender identity is critical. In this article, we detailed the ways in which divisions of health equity within departments of obstetrics and gynecology can dismantle impediments to progress and can move our discipline closer to optimal and equitable care for all. We described the unique educational, clinical, research, and innovative community-based activities of these divisions.

Race-based Versus Race-conscious Medicine in Obstetrics and Gynecology.

Race is a social and power construct whose meaning has shifted over time. Racist beliefs in medicine fostered the continuation of these notions. In this commentary, we review race-based medicine versus race-conscious medicine. Race-conscious medicine emphasizes racism as a key determinant of illness and health. Racism in obstetrics and gynecology has deep roots in its history. The use of race in clinical decision-making tools, such as those that predict successful vaginal birth after cesarean delivery, should be eliminated. Research that explores the complexities of health disparities and their effects on clinical outcomes are pivotal to race-conscious approaches in medicine.

Educational guidelines for diversity and inclusion: addressing racism and eliminating biases in medical education.

Racism and bias contribute to healthcare disparities at a patient and population health level and also contribute to the stagnation or even regression of progress toward equitable representation in the workforce and in healthcare leadership. Medical education and healthcare systems have expended tremendous efforts over the past several years to address these inequities. However, systemic racism continues to impact health outcomes and the future physician workforce. The Association of Professors of Gynecology and Obstetrics called for action to achieve a future free from racism in obstetrics and gynecology education and healthcare. As a result of this call to action, the Diversity, Equity, and Inclusion Guidelines Task Force was created. The mission of the Task Force was to support educators in their efforts to identify and create educational materials that augment antiracist educational goals and prepare, recruit, and retain a talented and diverse workforce. In this Special Report, the authors share these guidelines that describe best practices and set new standards to increase diversity, foster inclusivity, address systemic racism, and eliminate bias in obstetrics and gynecology educational products, materials, and environments.

Contraception Utilization in Black Women via a Reproductive Justice Lens.

Background: Over 100 million women make decisions about beginning or resuming contraception after childbirth annually. The burden of an unplanned pregnancy is not equally distributed among racial and ethnic groups in the United States based on the rates of unplanned pregnancies. Objective: This article discusses the disparity in the utilization of contraception among Black women through a reproductive justice lens. Results: The reasons for these differences include a lack of access to care, and differences in contraceptive failure rates among racial and ethnic groups, as well as less of an inclination to have an abortion. Barriers to contraception for breastfeeding persons include patient medical conditions and concerns, and resistance by other health care providers due to language and cultural differences, and knowledge asymmetry. Institutionalized racism, transphobia, and homophobia may compromise patient access to the full spectrum of contraceptive options available. Conclusions: Given the individual and public health benefits of breastfeeding and the impact those benefits can have in helping Black birthing persons and children achieve health equity, it is important for obstetric and pediatric health care providers to play their part in encouraging and supporting breastfeeding.

Inadequacy and underreporting of study subjects' race and ethnicity in federally funded pelvic floor research.

BACKGROUND: The inclusion of participants who are Black, Indigenous people of color, and participants of various ethnicities is a priority of federally sponsored research. OBJECTIVE: This study aimed to describe the reporting of race and ethnicity in federally funded research published by the Eunice Kennedy Shriver National Institute of Child Health and Human Development-funded Pelvic Floor Disorders Network. STUDY DESIGN: Pelvic Floor Disorders Network publications were reviewed to determine whether race or ethnicity was reported. The number of participants included in each manuscript who were identified as White, Black, Asian, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and "other," and the number of participants who identified as having Hispanic ethnicity were recorded. Data were analyzed by publication and by the pelvic floor disorder investigated, including urinary incontinence, pelvic organ prolapse, fecal incontinence, pregnancy-related pelvic floor disorders, and multiple pelvic floor disorders. Many publications reported on overlapping patient populations, which included primary trials and secondary analyses and studies. Data were analyzed both by counting participants every time they were reported in all papers and by counting the unique number of participants in only the original trials (primary paper published). RESULTS: A total of 132 Pelvic Floor Disorders Network publications were published between 2003 and 2020. Of these, 21 were excluded because they were methods papers or described research without participants. Of the 111 remaining articles, 90 (81%) included descriptions of race and 55 (50%) included descriptions of ethnicity. All 13 primary trials described race and 10 of 13 (76.9%) described ethnicity. Of those publications that described race, 50 of 90 (56%) included only the categories of "White," "Black," and "Other," and 14 of 90 (16%) only described the percentage of White patients. Of the 49,218 subjects, there were 43,058 (87%) with reported race and 27,468 (56%) with reported ethnicity. Among subjects with race and ethnicity reported, 79% were reported as White, 9.9% as Black, 0.4% as Asian, 0.1% as American Indian or Alaska Native, and 4% as "other," whereas 13% were reported to be of Hispanic ethnicity. The racial and ethnic diversity varied based on the pelvic floor disorder studied (P<.01), which was driven by pregnancy-related and fecal incontinence studies because these had lower proportions of White patients than studies of other pelvic floor disorders. CONCLUSION: Federally funded Pelvic Floor Disorders Network research does not consistently report the race and ethnicity of participants. Even in the publications that report these characteristics, Black, Indigenous people of color, and people of Hispanic ethnicity are underrepresented. Consistent reporting and recruitment of a diverse population of women is necessary to address this systemic inequity.

Telehealth and the digital divide as a social determinant of health during the COVID-19 pandemic.

Telehealth has been shown to have comparable health outcomes in terms of patient-physician communication, and patient satisfaction and engagement. Nevertheless, the digital divide has exacerbated the social and economic factors that create barriers to health and well-being. It, therefore, maybe a social determinant of health (SDOH). Such issues as decreased internet connectivity and a lack of Wi-Fi and video chat/webcam in both urban and rural areas can hinder the effectiveness of telehealth to its full capability, especially among communities of color, the poor, and medically underserved. The social aspects of the provision of health care by physicians and health care workers are utilized to combat mistrust and strengthen the physician-patient therapeutic relationship. Addressing policy changes to address the digital divide as a SDOH may strengthen existing health care and public health systems to allow for patient and community-centered approaches to expressing lived narratives, including in a digital format.

An Introduction to Structural Competency for Haitian-Identified Patients: History, Culture, and Access to Care.

INTRODUCTION: The Haitian population within the US represents the largest diaspora outside of Haiti, with most Haitians residing in major urban communities. Despite clear differences in health outcomes specific to Haitians, the community has traditionally been aggregated into the general Black population. To address specific health disparities, this workshop was designed to distinguish and elaborate on the health care problems affecting Haitians. METHODS: We created an interactive 60-minute workshop including a PowerPoint presentation, two case presentations, and a 5-minute informational video to bring awareness of the historical perspectives impacting Haitian/Haitian American health, access to care, and health care disparities to providers. Knowledge was assessed by pre- and postworkshop evaluation forms. The module was aimed at health care professional learners. RESULTS: Seventy-four people with diverse ethnoracial identities, including medical students, residents, academic faculty, physicians, nonmedical graduate students, and health care staff and administrators, attended three workshops. All learning objectives were met, with pre- and postworkshop data indicating a statistically significant increase in participants' reported confidence. Workshop attendees commented positively on the group discussion component, the workshop's interactive nature, the opportunity to apply taught knowledge to case presentations, and the historical context provided. DISCUSSION: As the number of Haitian immigrants continues to rise throughout US urban communities, providers must increase their culture competency in training and delivery to improve care for a major population. This module can help better prepare health care providers and trainees to offer competent care to Haitian/Haitian American patients.

Addressing Disparities in Prenatal Care via Telehealth During COVID-19: Prenatal Satisfaction Survey in East Harlem.

OBJECTIVE: In the setting of an inner city, safety net hospital, patient satisfaction with prenatal care conducted via telehealth was compared with in-person visits at the height of the novel coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: Through this cross-sectional study, patients were identified who received at least one televisit and one in-person visit during the COVID-19 pandemic. The Short Assessment of Patient Satisfaction (SAPS) survey was used to measure patient satisfaction. Surveys pertaining to in-person and televisits were conducted at the end of a telephone encounter, and overall satisfaction scores were documented. Patients were excluded if they received in-person or virtual care only and not both. The SAPS score correlated with the degree of patient satisfaction. RESULTS: A total of 140 patients were identified who received both virtual and in-person prenatal care from March 1, 2020 to May 1, 2020. One hundred and four patients (74%) agreed to be surveyed: 77 (74%) self-identified as Hispanic and 56 (54%) stated that their primary language was Spanish. The overall median satisfaction score for televisits and in-person visits was 20 (interquartile range [IQR]: 20, 25) and 24 (IQR: 22, 26) (p = 0.008, Z score = 2.651). In patients who self-identified as Hispanic or identified their primary language as Spanish, there was no statistically significant difference in their satisfaction scores. CONCLUSION: While there were lower scores in patient satisfaction for televisits in every category, there were no clinically significant differences since all medians were in the "satisfied" range. By lowering patient exposure to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), especially for those at risk for reduced access to care and higher COVID-19 cases by zip code, telehealth allowed for appropriate continuation of satisfactory prenatal care with no impact on patient perceived satisfaction of care. KEY POINTS: · Telehealth allowed for continuation of satisfactory prenatal care in Hispanic patients.. · Hispanic patients are at risk for reduced access to care.. · Telehealth was a useful tool for achieving patient-perceived satisfactory care..

Black women health inequity: The origin of perinatal health disparity.

Black enslaved women endured sexual exploitation and reproductive manipulation to produce a labor workforce on the southern plantations during the Antebellum Period. Health care inequity has continued from slavery and into the 21th century primarily due of racial segregation, poverty, access, poor quality of care, eugenics and the assault of forced sterilizations. Racial disparity in maternal and infant mortality is an outcome rooted in racial injustice, social and economic determinants as well as the stresses during pregnancy throughout the generations of Black births. Affordable, available, quality and equitable care and narrowing the economic gap for Black women and families is the most significant barrier in combating racial disparity in perinatal health outcomes and health inequity.

Correction to: Communicating with African-American Women Who Have Had a Preterm Birth about Risks for Future Preterm Births.

The article [Communicating with African-American Women Who Have Had a Preterm Birth About Risks for Future Preterm Births], written by [Allison S. Bryant, Laura E. Riley, Donna Neale, Washington Hill, Theodore B. Jones, Noelene K. Jeffers, Patricia O. Loftman, Camille A. Clare, and Jennifer Gudeman], was originally published electronically on the publisher's internet portal on January 16, 2020 without open access.

Postpartum depression in special populations: a review.

UNLABELLED: This review article aims to define and characterize postpartum depression; to discuss the social, financial, regulatory and legal implications of the disorder; and to elucidate its impact on special groups, namely adolescents, immigrants, fathers, and those of different racial and ethnic groups. A MEDLINE review of the current literature was run on postpartum depression, using the key words postpartum depression, depression, pregnancy, peripartum, or postpartum, from the years 2000 to 2011. Postpartum depressive syndromes place women and their children at risk of suicide and infanticide if not appropriately diagnosed and treated. Screening should occur within 4 to 6 weeks postpartum. Women with a history of depression before or during pregnancy, adolescents, those with low incomes and poor social support, or with a history of substance abuse, are especially at high risk. Treatments include antidepressants and psychotherapy. The unique populations of adolescents, fathers, immigrants, and certain racial and ethnic groups require special consideration in terms of diagnosis, screening modalities, and treatment. Collaboration between obstetrical providers and behavioral health professionals can ensure improved outcomes. It was found that postpartum depression is a challenging diagnosis and may be difficult to treat. A multidisciplinary approach is warranted to prevent life-threatening consequences in mothers and their children. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After participating in this activity, physicians should be better able to diagnose postpartum depression and to analyze the social, financial, regulatory and legal implications of the disorder; and to evaluate its impact on special groups, namely adolescents, immigrants, fathers, and those of different racial and ethnic groups.