Transgender and Gender-Nonconforming Patients in the Emergency Department: What Physicians Know, Think, and Do.

STUDY OBJECTIVE: We explore self-reported knowledge, attitudes, and behaviors of emergency physicians in regard to the care of transgender and gender-nonconforming patients to identify opportunities to improve care of this population. METHODS: From July to August 2016, we electronically surveyed the American College of Emergency Physicians' Emergency Medicine Practice-Based Research Network of 654 active emergency physician participants. We performed frequency tabulations to analyze the closed-ended response items. RESULTS: Of the 399 respondents (61% response rate), 88.0% reported caring for transgender and gender-nonconforming patients in the emergency department (ED), although 82.5% had no formal training about this population. The majority of physicians (86.0%) were comfortable asking about personal pronouns. Only 26.1% of respondents knew the most common gender-affirming surgery for female-to-male patients; 9.8% knew the most common nonhormone gender-affirming medication that male-to-female patients use. Almost no respondents (<3%) were aware of emergency medicine practitioners' performing inappropriate examinations on transgender and gender-nonconforming patients. CONCLUSION: Although transgender and gender-nonconforming people represent a minority of ED patients nationwide, the majority of respondents reported personally providing care to members of this population. Most respondents lacked basic clinical knowledge about transgender and gender-nonconforming care.

Positive Trends in School-Based Practices to Support LGBTQ Youth in the United States Between 2010 and 2018.

PURPOSE: The present study tests the hypothesis that there has been a significant increase in the implementation of six LGBTQ-supportive school practices in US states between 2010 and 2018. METHODS: Data were drawn from the publicly available School Health Profiles reports published by the Centers for Disease Control and Prevention, Division of Adolescent and School Health. We conducted unadjusted linear regression models separately for each practice to examine state-specific linear trends in the percentage of secondary schools reportedly engaging in six LGBTQ-supportive practices across all 50 states. In addition, we conducted an unadjusted linear regression on the trend to estimate changes in the median percentage of schools across all states engaging in each of the six practices through time. RESULTS: In 2010, 5.7% of schools reported implementing all six practices, which increased to 15.3% in 2018. In the period from 2010 to 2018, the implementation of four of six key practices increased significantly in more than half of US states. Most states experienced a mix of either increases in practices or no change in practice prevalence, with no state experiencing a significant decrease. DISCUSSION: There have been significant gains in the percentage of schools implementing LGBTQ-supportive practices. Yet, despite increases in the examined practices, the median percentage of schools in the United States that implement all six remains low. There is considerable room to improve on the use of these practices in schools across the United States, including increased attention to the quality of implementation and the barriers and facilitators to their instantiation.

Amplification of school-based strategies resulting from the application of the dynamic adaptation process to reduce sexual and gender minority youth suicide.

BACKGROUND: Evidence-informed practices (EIPs) are imperative to increase school safety for lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) students and their peers. Recently, the Expert Recommendations for Implementing Change (ERIC), a taxonomy of discrete implementation strategies used in health care settings, was adapted for schools. The School Implementation Strategies, Translating the ERIC Resources (SISTER) resulted in 75 discrete implementation strategies. In this article, we examine which SISTER strategies were used to implement six EIPs to reduce suicidality among LGBTQ high school students. We applied the dynamic adaptation process (DAP), a phased, data-driven implementation planning process, that accounts for adaptation while encouraging fidelity to the core elements of EIPs. METHODS: Qualitative data derived from 36 semi-structured interviews and 16 focus groups conducted with school professionals during the first of a 3-year effort to implement EIPs in 19 high schools. We undertook iterative comparative analysis of these data, mapping codes to the relevant domains in the SISTER. We then synthesized the findings by creating a descriptive matrix of the SISTER implementation strategies employed by schools. RESULTS: We found that 20 SISTER strategies were encouraged under the DAP, nine of which were amplified by school personnel. Nine additional SISTER strategies not specifically built into the DAP were implemented independently by school personnel, given the freedom the DAP provided, resulting in a total of 29 SISTER strategies. CONCLUSION: This study offers insight into how schools select and elaborate implementation strategies. The DAP fosters freedom to expand beyond study-supported strategies. Qualitative data illuminate motives for strategy diversification, such as improving EIP fit. Qualitative methods allow for an in-depth illustration of the strategies that school personnel enacted in their efforts to implement the EIPs. We discuss the utility of the DAP in supporting EIP implementation to reduce disparities for LGBTQ students. PLAIN LANGUAGE ABSTRACT: Implementation science is, in part, concerned with implementation strategies, which are actions made to bridge implementation gaps between evidence-informed practices and the contexts in which practices are to be used. Implementation experts compiled a list of strategies for promoting the use of new practices in school settings. The authors of this article examine which implementation strategies in this list were promoted by the research team and which were employed independently by school personnel. Our results illustrate how school personnel applied strategies based on the conditions and needs of their individual schools. These results will contribute to knowledge about implementation strategies and improve readiness by building in strategies implementation teams will use. The authors conducted interviews and focus groups with school personnel involved in implementing six evidence-informed practices for reducing suicidality and other negative outcomes for lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) high school students. Findings are from the end of the first year of implementation and provide a glimpse into how and why certain implementation strategies were employed by school personnel to facilitate adoption of the practices. Findings describe how they applied these strategies in communities where LGBTQ people were marginalized and where anti-LGBTQ stigma influenced policies and resulted in barriers to implementation. This article contributes to efforts to identify and tailor implementation strategies that can encourage the use of evidence-informed practices to improve the well-being of LGBTQ youth and other health disparity populations.

Applying a Structural-Competency Framework to the Implementation of Strategies to Reduce Disparities for Sexual and Gender Minority Youth.

BACKGROUND: Sexual and gender minority youth (SGMY) are at high risk for adverse health outcomes. Safer schools decrease this risk. The US Centers for Disease Control and Prevention has identified 6 practices that can make schools safer for SGMY, yet few US schools implement them all. We apply a structural competency framework to elucidate factors contributing to this implementation gap. METHODS: We conducted 75 interviews and 32 focus groups with school professionals in 18 New Mexico high schools to assess factors impacting implementation of the practices over 2 years. We analyzed data using iterative coding, thematic identification techniques, and the sensitizing concept of structural competency. RESULTS: Themes included: rendering an invisible population visible; critical thinking about LGBTQ inequalities; building school personnel capacity; intersecting cultural, religious, and political conflicts; and tackling community-based sources of stigma and discrimination. CONCLUSIONS: Underlying cultural and structural forces render SGMY invisible and constrain what schools can accomplish. Professional development encouraging critical thinking about structural inequities is foundational, but efforts to close the implementation gap must attend to structural forces producing disparities for SGMY. Structural competency can strengthen the ability of the Whole School, Whole Community, and Whole Child model's cross-sector coordination of policy and process to meet the needs of every student.