Assessing Patient Goals for Gender-Affirming Hormone Therapy: A Standardized Patient Case for Medical Students.

Introduction: Inadequate coverage of transgender and gender-diverse (TGD) health in the UME curriculum contributes to the scarcity of competent physicians to care for TGD patients. Increasing TGD health skills-based curricula in UME can help address TGD health disparities. We developed a standardized patient (SP) case to assess TGD health skills-based competencies and attitudes among medical students. Methods: An interdisciplinary team, including individuals with lived TGD experience, developed the SP case that was completed by second-year medical students at the University of Pittsburgh School of Medicine in January 2020. After the TGD SP session, students and faculty completed a postsession survey to assess the degree to which the case met the learning objectives. Students were assessed via self-reports, faculty reports, and SP video evaluations. Results: Seventy second-year medical students, 30 faculty facilitators, and eight SPs participated in 2020. Students reported being significantly more prepared to care for TGD patients (Z = -5.68, p < .001) and to obtain a gender history (Z = -5.82, p < .001). Both faculty and students felt that skills for caring for TGD patients were important in medical education and agreed the case should remain in the curriculum. Discussion: The case effectively honed and assessed students' ability to collect a gender history and discuss goals for hormone therapy with TGD patients. It should complement ongoing curricula to effectively train medical students in TGD health care. Developing these skills in students directly addresses the barriers that many TGD patients experience in health care settings.

Stress proliferation in ethnoracial disparities of mental health among U.S. sexual minority adults.

OBJECTIVE: Non-White sexual minorities experience disproportionate adverse childhood experiences (ACEs) and adulthood discrimination, as compared to their White or heterosexual counterparts. These stressors lead to increased psychological distress and worsened clinical outcomes, including suicidality. Minority stress theory posits that systemic marginalization, as experienced by minoritized individuals, leads to distress. Intersectionality theory suggests that marginalization compounds over time for individuals with intersectional minority identities. Yet, the mechanisms underlying the stress proliferation process for individuals with intersectional minority identities remain largely unexamined. METHOD: The present study used nationally representative data of sexual minority individuals (n = 1,518, Mage = 31 years, ethnoracial minority = 38.7%, female and gender minority = 50.6%) to investigate the relations among ethnoracial minoritization, ACEs, discrimination, distress, and self-injurious/suicidal outcomes. We proposed a novel integration of minority stress, intersectionality, and stress proliferation theories. Via longitudinal mediation, we tested models of stress persistence, stress accumulation, and stress sensitization. RESULTS: Our results confirmed disparities between White versus non-White sexual minorities on ACEs, discrimination experiences, and psychological distress. We found support for the stress persistence and the stress accumulation models, but not the stress sensitization model. Moreover, we found distress and discrimination were associated with future nonsuicidal self-injurious behaviors and suicidal outcomes, highlighting the deleterious consequences of intersectional minority stress proliferation. CONCLUSION: Our results support our proposed theory of intersectional minority stress proliferation where ethnoracial and sexual minoritization intersect and beget disproportionate ACEs, which in turn contribute to accumulation and persistence of psychological distress and discrimination experiences in adulthood. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

An Ethics and Social-Justice Approach to Collecting and Using Demographic Data for Psychological Researchers.

The collection and use of demographic data in psychological sciences has the potential to aid in transforming inequities brought about by unjust social conditions toward equity. However, many current methods surrounding demographic data do not achieve this goal. Some methods function to reduce, but not eliminate, inequities, whereas others may perpetuate harmful stereotypes, invalidate minoritized identities, and exclude key groups from research participation or access to disseminated findings. In this article, we aim to (a) review key ethical and social-justice dilemmas inherent to working with demographic data in psychological research and (b) introduce a framework positioned in ethics and social justice to help psychologists and researchers in social-science fields make thoughtful decisions about the collection and use of demographic data. Although demographic data methods vary across subdisciplines and research topics, we assert that these core issues-and solutions-are relevant to all research within the psychological sciences, including basic and applied research. Our overarching aim is to support key stakeholders in psychology (e.g., researchers, funding agencies, journal editors, peer reviewers) in making ethical and socially-just decisions about the collection, analysis, reporting, interpretation, and dissemination of demographic data.

Knowledge Retention and Clinical Skills Acquisition in Sexual and Gender Minority Health Curricula: A Systematic Review.

PURPOSE: To identify exemplary medical education curricula, operationalized as curricula evaluating knowledge retention and/or clinical skills acquisition, for health care for sexual and gender minoritized (SGM) individuals and individuals born with a difference in sex development (DSD). METHOD: The authors conducted a systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed in PubMed/MEDLINE, The Cochrane Library, Web of Science, ERIC, Embase, PsycINFO, and the gray literature to identify studies that (1) pertained to undergraduate and/or graduate medical education, (2) addressed education on health care of SGM/DSD individuals, and (3) assessed knowledge retention and/or clinical skills acquisition in medical trainees. The final searches were run in March 2019 and rerun before final analyses in June and October 2020. RESULTS: Of 670 full-text articles reviewed, 7 met the inclusion criteria. Five of the 7 studies assessed trainee knowledge retention alone, 1 evaluated clinical skills acquisition alone, and 1 evaluated both outcomes. Studies covered education relevant to transgender health, endocrinology for patients born with DSDs, and HIV primary care. Only 1 study fully mapped to the Association of American Medical Colleges (AAMC) SGM/DSD competency recommendations. Six studies reported institutional funding and development support. No studies described teaching SGM/DSD health care for individuals with multiply minoritized identities or engaging the broader SGM/DSD community in medical education curriculum development and implementation. CONCLUSIONS: Curriculum development in SGM/DSD health care should target knowledge retention and clinical skills acquisition in line with AAMC competency recommendations. Knowledge and skill sets for responsible and equitable care are those that account for structures of power and oppression and cocreate curricula with people who are SGM and/or born with DSDs.

Developing Standards for Cultural Competency Training for Health Care Providers to Care for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual Persons: Consensus Recommendations from a National Panel.

Purpose: Lesbian, gay, bisexual, transgender, queer, intersex, and/or asexual and other sexual and gender diverse persons (LGBTQIA+ or SGD persons) experience barriers to equitable health care. The purpose of this article is to describe a collaborative process that resulted in core cultural competency recommendations addressing training for those who provide health care and/or social services to LGBTQIA+ patients. Methods: In 2018 and 2019, Whitman-Walker Health, a Federally Qualified Community Health Center in Washington, DC, and the National LGBT Cancer Network purposively selected leaders of community clinics and community-based organizations, cultural competency trainers, and clinicians and researchers with expertise in SGD health with diverse lived experiences to develop consensus-based cultural competency recommendations. Recommendations were developed through a synthesis of peer-reviewed studies, publicly accessible curricula, and evaluations of SGD cultural competency trainings; two in-person convenings; and iterative feedback from diverse stakeholders. Results: Five anchoring recommendations emerged: (1) know your audience; (2) develop and fine-tune the curriculum; (3) employ both adult and transformational learning theories; (4) choose multiple effective trainers; and (5) evaluate impact of training. These recommendations promote an ongoing process of individual and organizational improvement and a stance of humility rather than competence to be mastered. Conclusion: By setting core cultural competency standards for all persons involved in health care and social services, these recommendations complement existing clinical competency recommendations to advance SGD health equity.

Assessing readiness factors for implementation of LGBTQ+ affirmative primary care initiatives: Practice implications from a mixed-method study.

Introduction: Access and utilization barriers in primary care clinics contribute to health disparities that disproportionately affect lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people. Implementing inclusive practice guidelines in these settings may decrease disparities. The purpose of this exploratory/developmental study is to identify key issues affecting the readiness of primary care clinics to implement such guidelines. Methods: Using a concurrent mixed-method research design, we conducted surveys, interviews, and focus groups with 36 primary care personnel in clinics in New Mexico, USA, to examine readiness to implement LGBTQ+ inclusive guidelines, analyzing factors affecting motivation, general organizational capacity, and innovation-specific capacity. We supplemented these data by documenting LGBTQ+ inclusive policies and practices at each clinic. We undertook descriptive analyses and between-subscale comparisons controlling for within-rater agreement of the survey data and iterative coding and thematic analysis of the qualitative data. Results: Quantitatively, participants reported significantly more openness toward adopting guidelines and attitudinal awareness for developing LGBTQ+ clinical skills than clinical preparedness, basic knowledge, and resources to facilitate implementation. Six themes derived from the qualitative findings corroborate and expand on these results: (1) treating all patients the same; (2) addressing diversity in and across LGBTQ+ populations; (3) clinic climates; (4) patient access concerns; (5) insufficient implementation support; and (6) leadership considerations. Conclusion: This study demonstrates that personnel in primary care clinics support initiatives to enhance service environments, policies, and practices for LGBTQ+ patients. However, drawing on Iris Young's theory of structural injustice, we found that neutralizing discourses that construct all patients as the same and time/resource constraints may diminish motivation and capacity in busy, understaffed clinics serving a diverse clientele and reinforce inequities in primary care for LGBTQ+ people. Efforts are needed to build general and innovation-specific capacities for LGBTQ+ initiatives. Such efforts should leverage implementation teams, organizational assessments, education, leadership support, community engagement, and top-down incentives.

Gender Nonconformity and Minority Stress Among Lesbian, Gay, and Bisexual Individuals: A Meta-Analytic Review.

Lesbian, gay, and bisexual (LGB) individuals are less healthy than heterosexual individuals, and minority stress endured by LGB individuals contributes to these health disparities. However, within-groups differences in minority stress experiences among LGB individuals remain underexplored. Individuals are more likely to be categorized as LGB if they exhibit gender nonconformity, so gender nonconformity could influence concealability of sexual orientation among LGB individuals, carrying important implications for the visibility of their stigmatized sexual orientation identity and for how they experience and cope with minority stress. Through a meta-analytic review, we examined how gender nonconformity was associated with minority stress experiences among LGB individuals. Thirty-seven eligible studies were identified and included in analyses. Results indicate gender nonconformity is associated with experiencing more prejudice events, less concealment of sexual orientation, lower internalized homonegativity, and higher expectations of rejection related to sexual orientation among LGB individuals. Gender nonconformity is more strongly associated with experiencing prejudice events among gay and bisexual men than among lesbian and bisexual women. Gender nonconformity is systematically associated with minority stress experiences among LGB individuals, and future research must measure and examine gender nonconformity when investigating the role of minority stress in degraded health outcomes among LGB populations.

Enhancing primary care services for diverse sexual and gender minority populations: a developmental study protocol.

INTRODUCTION: Compared with heterosexual, cisgender populations, sexual and gender minority (SGM) people are more likely to suffer from serious health conditions and insufficient access to health services. Primary care is at the frontlines of healthcare delivery; yet, few clinics have resources or mechanisms in place to meet SGM patient needs. This developmental study protocol focuses on reducing health disparities among SGM patients by identifying, adapting and developing SGM practice guidelines/recommendations and implementation strategies for primary care clinics in urban and rural New Mexico. Using input from patients, healthcare advocates and providers, and researchers, the study will pilot a practice parameter and implementation toolkit to promote SGM-specific cultural competence at multiple service delivery levels. METHODS AND ANALYSIS: We will recruit providers/staff from four Federally Qualified Health Centers (FQHCs) serving ethnically and geographically diverse communities. Incorporating the Implementation of Change Model and an intersectionality perspective, data collection includes a systematic review of SGM-specific practice guidelines/recommendations, focus groups and semistructured interviews, quantitative surveys and the Nominal Group Technique (NGT) with providers/staff. We will categorise guidelines/recommendations identified through the review by shared elements, use iterative processes of open and focused coding to analyse qualitative data from focus groups, interviews and the NGT, and apply descriptive statistics to assess survey data. Findings will provide the foundation for the toolkit. Focus groups with SGM patients will yield supplemental information for toolkit refinement. To investigate changes in primary care contexts following the toolkit's pilot, we will undertake systematic walkthroughs and document review at the FQHCs, analysing these data qualitatively to examine SGM inclusiveness. The structured data-informed Plan-Do-Study-Act method will enable further revision of the toolkit. Finally, focus groups, interviews and quantitative surveys with providers/staff will highlight changes made in the FQHCs to address SGM patient needs, barriers to sustainment of changes, satisfaction, acceptability, usability and feasibility of the toolkit. ETHICS AND DISSEMINATION: The study has been reviewed and approved by the Pacific Institute for Research and Evaluation Institutional Review Board. Informed consent will be obtained from all participants before their involvement in research activities begins. Study results will be actively disseminated through peer-reviewed journals, conference presentations, social media and the internet, and community/stakeholder engagement activities.

Comprehensive Curriculum for Internal Medicine Residents on Primary Care of Patients Identifying as Lesbian, Gay, Bisexual, or Transgender.

Introduction: Significant gaps remain in the training of health professionals regarding the care of individuals who identify as lesbian, gay, bisexual, and transgender (LGBT). Although curricula have been developed at the undergraduate medical education level, few materials address the education of graduate medical trainees. The purpose of this curriculum was to develop case-based modules targeting internal medicine residents to address LGBT primary health care. Methods: We designed and implemented a four-module, case-based, interactive curriculum at one university's internal medicine residency program. The modules contained facilitator and learner guides and addressed four main content areas: understanding gender and sexuality; performing a sensitive history and physical examination; health promotion and disease prevention; and mental health, violence, and reproductive health. Knowledge, perceived importance, and confidence were assessed before and after each module to assess curricular effectiveness and acceptability. General medicine faculty delivered these modules. Results: Perceived importance of LGBT topics was high at baseline and remained high after the curricular intervention. Confidence significantly increased in many areas, including being able to provide resources to patients and to institute gender-affirming practices (p < .05). Knowledge improved significantly on almost all topics (p < .0001). Faculty felt the materials gave enough preparation to teach, and residents perceived that the faculty were knowledgeable. Discussion: This resource provides an effective curriculum for training internal medicine residents to better understand and feel confident addressing LGBT primary health care needs. Despite limitations, this is an easily transferable curriculum that can be adapted in a variety of curricular settings.

A Model for Improving Health Care Quality for Transgender and Gender Nonconforming Patients.

PROBLEM DEFINITION: Transgender and gender nonconforming (TGNC) populations are disproportionately affected by limited health care access and poor health outcomes and commonly report discrimination and mistreatment in health care settings. Despite these disparities, comprehensive approaches to improve the quality of health care of TGNC patient populations are currently lacking. INITIAL APPROACH: The Vanderbilt Program for LGBTQ Health has developed a multifaceted, community-engaged approach to improve the quality of health care of TGNC patients, which includes the creation of a transgender patient advocacy program, a community advisory board, and a transgender health clinic. To support the continuous quality improvement of transgender health care, the program is currently piloting a novel multilevel monitoring and evaluation (M&E) system to collect information at the individual patient visit and health systems levels. NEXT STEPS: The next steps for Vanderbilt's community-engaged M&E system are to identify the clinics and health services most used by TGNC patients and assess the level of patient satisfaction in each area. This process will support the identification of high- and low-performing clinics and health services and allow for targeted delivery of trainings to improve the quality of culturally competent health care TGNC patients receive systemwide. CONCLUSION: In collaboration with TGNC patient populations and community stakeholders, Vanderbilt has created a model to improve the quality of both transition- and non-transition-related health care at the systems level that can be adopted by other health care systems nationally.

Social and Non-social Reward Processing and Depressive Symptoms Among Sexual Minority Adolescents.

Sexual minority adolescents (SMA) are more likely to suffer from depression, putatively through experiences of social stress and victimization interfering with processing of social reward. Alterations in neural reward networks, which develop during adolescence, confer risk for the development of depression. Employing both social and monetary reward fMRI tasks, this is the first neuroimaging study to examine function in reward circuitry as a potential mechanism of mental health disparities between SMA and heterosexual adolescents. Eight SMA and 38 heterosexual typically developing adolescents completed self-report measures of depression and victimization, and underwent fMRI during monetary and peer social reward tasks in which they received positive monetary or social feedback, respectively. Compared with heterosexual adolescents, SMA had greater interpersonal depressive symptoms and exhibited blunted neural responses to social, but not monetary, reward in socioaffective processing regions that are associated with depressive symptoms. Specifically, compared with heterosexual adolescents, SMA exhibited decreased activation in the right medial prefrontal cortex, left anterior insula (AI), and right temporoparietal junction (TPJ) in response to being liked. Lower response in the right TPJ was associated with greater interpersonal depressive symptoms. These results suggest that interpersonal difficulties and the underlying substrates of response to social reward (perhaps more so than response to monetary reward) may confer risk for development of depressive symptoms in SMA.

Mental Health, Drug, and Violence Interventions for Sexual/Gender Minorities: A Systematic Review.

CONTEXT: Compared with cisgender (nontransgender), heterosexual youth, sexual and gender minority youth (SGMY) experience great inequities in substance use, mental health problems, and violence victimization, thereby making them a priority population for interventions. OBJECTIVE: To systematically review interventions and their effectiveness in preventing or reducing substance use, mental health problems, and violence victimization among SGMY. DATA SOURCES: PubMed, PsycINFO, and Education Resources Information Center. STUDY SELECTION: Selected studies were published from January 2000 to 2019, included randomized and nonrandomized designs with pretest and posttest data, and assessed substance use, mental health problems, or violence victimization outcomes among SGMY. DATA EXTRACTION: Data extracted were intervention descriptions, sample details, measurements, results, and methodologic rigor. RESULTS: With this review, we identified 9 interventions for mental health, 2 for substance use, and 1 for violence victimization. One SGMY-inclusive intervention examined coordinated mental health services. Five sexual minority-specific interventions included multiple state-level policy interventions, a therapist-administered family-based intervention, a computer-based intervention, and an online intervention. Three gender minority-specific interventions included transition-related gender-affirming care interventions. All interventions improved mental health outcomes, 2 reduced substance use, and 1 reduced bullying victimization. One study had strong methodologic quality, but the remaining studies' results must be interpreted cautiously because of suboptimal methodologic quality. LIMITATIONS: There exists a small collection of diverse interventions for reducing substance use, mental health problems, and violence victimization among SGMY. CONCLUSIONS: The dearth of interventions identified in this review is likely insufficient to mitigate the substantial inequities in substance use, mental health problems, and violence among SGMY.

Applying Organizational Change to Promote Lesbian, Gay, Bisexual, and Transgender Inclusion and Reduce Health Disparities.

Lesbian, gay, bisexual, and transgender (LGBT) populations face numerous barriers when accessing and receiving healthcare, which amplify specific LGBT health disparities. An effective strategic approach is necessary for academic health centers to meet the growing needs of LGBT populations. Although effective organizational change models have been proposed for other minority populations, the authors are not aware of any organizational change models that specifically promote LGBT inclusion and mitigate access barriers to reduce LGBT health disparities. With decades of combined experience, we identify elements and processes necessary to accelerate LGBT organizational change and reduce LGBT health disparities. This framework may assist health organizations in initiating and sustaining meaningful organizational change to improve the health and healthcare of the LGBT communities.

Affirmative and Responsible Health Care for People with Nonconforming Gender Identities and Expressions.

Although recent changes in health care delivery have improved routine and gender-affirming care for transgender people, common approaches to care are still often based on a binary (i.e., male/female) gender framework that can make patients with gender-nonconforming (GNC) identities and expressions feel marginalized. Binary representation perpetuates invisibility, discrimination, and victimization-and subsequent poorer health-among GNC patients. In response, clinicians and health care systems should extend their efforts to provide gender-affirming and responsible care to GNC people. This article reviews terminology related to gender, the limited research-and necessary directions for future research-on GNC communities, and provides strategies for health care professionals and systems to ensure provision of gender-affirming and responsible care to GNC patients.

The Priority of Intersectionality in Academic Medicine.

Recent societal events highlight inequities experienced by underrepresented and marginalized communities. These inequities are the impetus for ongoing efforts in academic medicine to create inclusive educational and patient care environments for diverse stakeholders. Frequently, approaches focus on singular populations or broad macroscopic concepts and do not always elucidate the complexities that arise at the intersection between multiple identities and life experiences. Intersectionality acknowledges multidimensional aspects of identity inclusive of historical, structural, and cultural factors. Understanding how multiple identity experiences impact different individuals, from patients to trainees to providers, is critical for improving health care education and delivery. Building on existing work within academic medicine, this Commentary outlines six key recommendations to advance intersectionality in academic medicine: embrace personal and collective loci of responsibility; examine and rectify unbalanced power dynamics; celebrate visibility and intersectional innovation; engage all stakeholders in the process of change; select and analyze meaningful metrics; and sustain the commitment to achieving health equity over time. Members of the academic medical community committed to advancing health equity can use these recommendations to promote and maintain meaningful changes that recognize and respond to the multidimensional voices and expressed needs of all individuals engaged in providing and receiving health care.

Opportunities and Gaps in Primary Care Preventative Health Services for Transgender Patients: A Systemic Review.

Purpose: Transgender people face barriers to accessing healthcare, resulting in population-level disparities in health outcomes. Little research is available to better understand the receipt of primary healthcare among transgender patients or how the rate of receipt of preventive care may differ among transgender populations. Methods: The medical literature regarding U.S. adult transgender primary healthcare was reviewed using a keyword search strategy: transgender OR transsexual OR transvestite OR gender nonconforming for articles published between January 1, 2001 and June 15, 2015. Studies addressing the following topics as assessed by the Behavioral Risk Factor Surveillance System were extracted for qualitative review: colorectal cancer screenings, mammography or chest/breast tissue examinations, cholesterol and blood pressure screenings, tobacco use and smoking cessation, cervical cancer or human papillomavirus (HPV) screenings, human immunodeficiency virus (HIV), annual flu shot, and insurance coverage. Results: The search identified 1304 eligible records, of which 41 discussed transgender primary or preventive care. The majority of studies discussed HIV rates or risk behaviors, while fewer articles addressed pelvic examinations, tobacco use, insurance coverage, and cholesterol screenings. No studies addressed mammography or chest/breast tissue examinations, colorectal screenings, or flu shots. Conclusions: Findings from articles addressing five topics are discussed: HIV, cholesterol screenings, tobacco use, pelvic health, and insurance coverage. Gaps in the extant literature, including the lack of studies of nonbinary people, transgender men of color, and transgender people living outside of large coastal urban centers, are discussed. This review, coincident with other health disparity findings, suggests an urgent need for research that addresses the primary care needs of all transgender and gender nonconforming people.