Mapping the Dynamic Complexity of Sexual and Gender Minority Healthcare Disparities: A Systems Thinking Approach.

Sexual and gender minority (SGM) populations experience extensive health disparities compared to their straight and cisgender counterparts. The importance of addressing these disparities is paramount, as SGM groups often encounter significant barriers to accessing comprehensive healthcare, including societal stigma, provider bias, and financial constraints. This study utilizes a community-based system dynamics approach to understand and visualize the barriers to and facilitators of healthcare engagement for SGM groups across their life course. It aims to identify core constructs, relationships, and dynamic feedback mechanisms related to the experiences of connection/disconnection with physical, mental, and dental healthcare of SGM individuals. Barriers to access, such as discriminatory practices and the limited availability of SGM-informed healthcare professionals, exacerbate these disparities, underscoring the urgency of developing targeted interventions. System dynamics, a complex systems science (CSS) methodology, was used for this research. Group model building sessions were conducted with diverse SGM groups, including youth, older adults, and trans and gender-expansive community members. Causal loop diagrams were developed according to an iterative process, and a meta-model of their collective experiences was created. The study revealed extensive, dynamic, and shifting structural barriers for SGM community members accessing healthcare. Societal and structural stigma, provider bias, and pathologization were identified as significant barriers throughout their life course. Community-led interventions and SGM-focused holistic healthcare were identified as critical facilitators of SGM healthcare connection. The findings highlight the need for SGM-affirming and culturally responsive healthcare settings. This paper calls for a concerted effort from SGM health researchers to use CSS in developing interventions to reduce SGM health disparities.

Eliminating health care inequities through strengthening access to care.

OBJECTIVE: To provide a research agenda and recommendations to address inequities in access to health care. DATA SOURCES AND STUDY SETTING: The Agency for Healthcare Research and Quality (AHRQ) organized a Health Equity Summit in July 2022 to evaluate what equity in access to health care means in the context of AHRQ's mission and health care delivery implementation portfolio. The findings are a result of this Summit, and subsequent convenings of experts on access and equity from academia, industry, and the government. STUDY DESIGN: Multi-stakeholder input from AHRQ's Health Equity Summit, author consensus on a framework and key knowledge gaps, and summary of evidence from the supporting literature in the context of the framework ensure comprehensive recommendations. DATA COLLECTION/EXTRACTION METHODS: Through a stakeholder-engaged process, themes were developed to conceptualize access with a lens toward health equity. A working group researched the most appropriate framework for access to care to classify limitations identified during the Summit and develop recommendations supported by research in the context of the framework. This strategy was intentional, as the literature on inequities in access to care may itself be biased. PRINCIPAL FINDINGS: The Levesque et al. framework, which incorporates multiple dimensions of access (approachability, acceptability, availability, accommodation, affordability, and appropriateness), is the backdrop for framing research priorities for AHRQ. However, addressing inequities in access cannot be done without considering the roles of racism and intersectionality. Recommendations include funding research that not only measures racism within health care but also tests burgeoning anti-racist practices (e.g., co-production, provider training, holistic review, discrimination reporting, etc.), acting as a convener and thought leader in synthesizing best practices to mitigate racism, and forging the path forward for research on equity and access. CONCLUSIONS: AHRQ is well-positioned to develop an action plan, strategically fund it, and convene stakeholders across the health care spectrum to employ these recommendations.

All Shades of Anxiety: A Review of Therapeutic and Psychotropic Considerations for Child and Adolescent Youth of Color.

The literature on anxiety in Black, Indigenous, and other persons of color youth is a developing area. This article highlights distinct areas for the clinician to consider in working with these populations. We highlight prevalence and incidence, race-related stress, social media, substance use, spirituality, the impact of social determinants of health (including COVID-19 and the Syndemic), as well as treatment considerations. Our aim is to contribute to the readers' developing cultural humility.

Beyond Binge Eating: The Impact of Implicit Biases in Healthcare on Youth with Disordered Eating and Obesity.

(1) Background: Obesity and eating disorders (ED) can coexist resulting in worse health outcomes. Youth with ED are more likely to have obesity relative to peers with a healthy weight. Pediatric providers deliver first-line care to children and youth of all sizes and body shapes from infancy to adolescents. As healthcare providers (HCPs), we bring biases into our practice. Learning to recognize and address these biases is needed to provide the best care for youth with obesity. (2) Purpose: This paper aims to summarize the literature regarding the prevalence of ED beyond binge eating in youth with obesity and discuss how the intersection of weight, gender, and racial biases impact the assessment, diagnosis, and treatment of ED. We provide recommendations for practice and considerations for research and policy. (3) Conclusions: The assessment and treatment of ED and disordered eating behaviors (DEBs) in youth with obesity is complex and requires a holistic approach. This approach begins with identifying and understanding how one's implicit biases impact care. Providing care from a patient-centers lens, which considers how the intersection of multiple stigmatized identities increases the risk for DEBs in youth with obesity may improve long-term health outcomes.

Black women's distress matters: Examining gendered racial disparities in psycho-oncology referral rates.

OBJECTIVE: Presently, there is a lack of research examining gendered racial disparities in psycho-oncology referral rates for Black women with cancer. Informed by intersectionality, gendered racism, and the Strong Black Woman framework, this study sought to examine the possibility that Black women are adversely affected by such phenomena as evidenced by lower probability of being referred to psycho-oncology services compared to Black men, White women and White men. METHODS: Data for this study consisted of 1598 cancer patients who received psychosocial distress screening at a comprehensive cancer center in a large Midwest teaching hospital. Multilevel logistic modeling was used to examine the probability of referral to psycho-oncology services for Black women, Black men, White women, and White men while controlling for patient-reported emotional and practical problems and psychosocial distress. RESULTS: Results indicated that Black women had the lowest probability of being referred to psycho-oncology services (2%). In comparison, the probability of being referred to psycho-oncology were 10% for White women, 9% for Black men, and 5% for White men. Additionally, as nurses' patient caseload decreased, the probability of being referred to psycho-oncology increased for Black men, White men, and White women. In contrast, nurses' patient caseload had little effect on the probability of being referred to psycho-oncology for Black women. CONCLUSIONS: These findings suggest unique factors influence psycho-oncology referral rates for Black women. Findings are discussed with particular focus on how to enhance equitable care for Black women with cancer.

"It's Still in the Test Tube and Finding out How the Experiment Ends ". A Qualitative Study on Health and Aging in Older Gay Males Living with HIV in England.

This paper highlights experiences and perceptions of older gay males living with Human Immunodeficiency Virus (HIV) in relation to age, sexual orientation, HIV status and how they perceive health. Participants were gay males aged 50 and over living in England, diagnosed with HIV for longer than 2 years. In total, 19 interviews were conducted between March 2020 and March 2021. Data were analysed using thematic analysis. Three major themes were generated: 1.) Health as holistic and as a balance; 2.) The impact of HIV on people's lives; 3.) The Intersectionality of stigma: a lifetime of discrimination. Participants highlighted the changing nature of the concept of health through their lifespan while the intersectionality of stigma in different contexts is examined considering the personal journey of living with HIV. The implications of health as a complex concept and intersectional stigma on the planning and delivering of care in this population are discussed.

Taking up the challenge of trans and non-binary inclusion in midwifery education: Reflections from educators in Aotearoa and Ontario Canada.

Perinatal services are being challenged to acknowledge that not all pregnant and birthing people are women and to ensure the design and delivery of services that are inclusive of, and deliver equitable outcomes for, trans, non-binary, and other gender diverse people. This is posing unique challenges for midwifery with its women-centred philosophy and professional frameworks. This paper presents the critical reflections of midwifery educators located in two midwifery programmes in Aotearoa1 and Ontario Canada, who are engaged in taking up the challenge of trans and non-binary inclusion in their local contexts. The need to progress trans and non-binary inclusion in midwifery education to secure the human rights of gender diverse people to safe midwifery care and equitable perinatal outcomes is affirmed. We respond to an existing lack of research or guidance on how to progress trans and non-binary inclusion in midwifery education. We offer our insights and reflections organised as four themes located within the frameworks of cultural humility and safety. These themes address midwifery leadership for inclusion, inclusive language, a broader holistic approach, and the importance of positioning this work intersectionally. We conclude by affirming the critical role of midwifery education/educators in taking up the challenge of trans and non-binary inclusion to ensure a future midwifery workforce skilled and supported in the provision of care to the growing gender diverse population.

It's not just in my head: An intersectional, social and systems-based framework in gender and sexuality diversity.

BACKGROUND: The mental health and well-being of gender and sexuality diverse (GSD) people needs to be understood within a socio-political and cultural context. AIMS: In this paper, an intersectional, social and system-based framework for understanding the mental health and well-being of GSD people is presented, for practitioners within this field to consider GSD mental health experiences and challenges within context. MATERIALS AND METHODS: Starting with a consideration of the current landscape of understanding, pivotal theories and understandings within the field are outlined. The need for a framework that centralises intersectionality and broader systemic considerations is presented. RESULTS: The framework provided has an explicit focus on four key features: (1) intersectionality, (2) institutions, policies and laws, (3) people and groups and (4) social stories. DISCUSSION: Consideration of each of these 'circles of influence' can help practitioners to understand the multi-layered and intersectional experience of GSD folk and allows for an understanding of potential intervention at both an individual and systemic and societal level. CONCLUSION: Use of such a framework in practice goes above and beyond what is currently available by centralising the role and impact of such wider systemic variables through an intersectional lens. The framework can be applicable worldwide given its flexibility to consider and apply pertinent policies, laws, people, groups and social stories within a particular country or culture.

Integrated Care Pathways for Black Persons With Traumatic Brain Injury: A Critical Transdisciplinary Scoping Review of the Clinical Care Journey.

Objectives: This novel critical transdisciplinary scoping review examined the literature on integrated care pathways that consider Black people living with traumatic brain injury (TBI). The objectives were to (a) summarize the extent, nature, and range of literature on care pathways that consider Black populations, (b) summarize how Blackness, race, and racism are conceptualized in the literature, (c) determine how Black people come to access care pathways, and (d) identify how care pathways in research consider the mechanism of injury and implications for human occupation. Methods: Six databases were searched systematically identifying 178 articles after removing duplicates. In total, 43 articles on integrated care within the context of Black persons with TBI were included. Narrative synthesis was conducted to analyze the data and was presented as descriptive statistics and as a narrative to tell a story. Findings: All studies were based in the United States where 81% reported racial and ethnic disparities across the care continuum primarily using race as a biological construct. Sex, gender, and race are used as demographic variables where statistical data were stratified in only 9% of studies. Black patients are primarily denied access to care, experience lower rates of protocol treatments, poor quality of care, and lack access to rehabilitation. Racial health disparities are disconnected from racism and are displayed as symptoms of a problem that remains unnamed. Conclusion: The findings illustrate how racism becomes institutionalized in research on TBI care pathways, demonstrating the need to incorporate the voices of Black people, transcend disciplinary boundaries, and adopt an anti-racist lens to research.

Considerations of Intersectionality for Older Adults with Palliative Care Needs in the Emergency Department: An Integrative Review.

Purpose of Review: We sought to identify current interventions, research, or non-research evidence that has direct or indirect consideration of intersectionality in the care of older adults in the emergency department (ED). An integrative review informed by Crenshaw's Theory of Intersectionality was conducted in accordance with Whittemore and Knafl's five-stage methodology. A rigorous review process determined appropriateness for inclusion, and articles were analyzed for areas related to direct or indirect relationship to intersectionality. Recent Findings: Older adults aged 60 and above in the United States (US) account for more than 20% of ED visits annually, and half of older adults will visit the ED in their last year of life. There has been a growing focus on adapting the ED to meet the palliative care needs of older adults, but relatively little consideration has been given to older adults' intersectional identities. Summary: Six articles were identified that provided indirect insights into the status of intersectionality in ED-based palliative care for older adults. Two areas of interest were identified: (1) intersectional elements or reference to such elements embedded within the studies; and (2) the challenges of adapting quantitative methodologies to incorporate variables and approaches that would allow for intersectional analysis. This review highlights areas for future research along with recommendations for adopting an intersectional framing into commonly used methodologies.

Use and attitudes toward complementary and alternative medicine among university students: The role of gender and race.

Purpose: This study assessed gender, race, use of complementary and alternative medicine (CAM), attitudes toward CAM, and disclosure of CAM use to health providers using an online survey of 506 students at a regional public university. Methods: Ordinary least squares regression models were used to examine relationships of interest, including use, attitudes, and disclosure of CAM by self-identified gender and race. Results: The most common therapy reported included vitamins and mineral supplements, and participants of all racial and gender identities expressed generally positive attitudes toward CAM. Women reported using CAM significantly more often than men, and Whites more often than non-Whites. Conclusions: White respondents were more likely to disclose the use of CAM to healthcare providers compared to African American respondents, and women reported disclosure more often than men. A significant interaction between gender and race was noted for attitudes toward CAM for Whites and African Americans, with White women most positive toward CAM.

[Intersectionality to better understand women's health issues]. / L'intersectionnalité pour mieux comprendre la problématique de la santé des femmes.

Intersectionality, a theory for understanding women's health issue. Intersectionality offers the possibility of holistic analyzes to understand and act on women's health issue. It facilitates the exploration of the different dimensions of social inequalities in health, which are both at the level of institutions and of the individual experiences of people who live at the intersection of multiple dimensions of domination and power.

Educating the educators: Implementing cultural safety in the nursing and midwifery curriculum.

BACKGROUND: The Australian Nursing and Midwifery Accreditation Council mandates the teaching of cultural safety in Bachelor of Nursing and Midwifery programs in Australia. However nursing and midwifery academics may lack the awareness and knowledge required to share and develop cultural safety practices with their students. Specific cultural safety professional development for academics may be needed. OBJECTIVES: This research explores how nursing and midwifery academics at an Australian university understand cultural safety and whether they are equipped to embed it in the curriculum. It also examines whether professional development workshops can support academics to prepare for cultural safety. METHODS: An intervention involving three cultural safety professional development workshops was offered to nursing academics at an Australian university. The authors used qualitative surveys to consider whether the workshops deepened participants' understanding of cultural safety and developed the self-reflection required to embed cultural safety in teaching. RESULTS: The workshops contributed to participants' improved understandings of culture, colonisation, white privilege and the need for self-reflection, but not all participants developed a working knowledge of cultural safety practice. CONCLUSION: Professional development workshops can assist nursing and midwifery academics to develop their knowledge of cultural safety, but detailed, contextual understanding is likely to need more than three sessions. Academics' motivations to include cultural safety in their teaching may be linked to their desire for patient-driven and equitable services and a desire to meet accreditation requirements.

Integrating Youth Perspectives: Adopting a Human Rights and Public Health Approach to Climate Action.

Climate change is a multidimensional issue that affects all aspects of society, including public health and human rights. Climate change is already severely impacting people's health and threatening people's guaranteed fundamental rights, including those to life, health, self-determination, and education, among others. Across geographical regions, population groups and communities who are already marginalized due to age, gender, ethnicity, income, and other socioeconomic factors, are those who are disproportionately affected by climate impacts despite having contributed the least to global emissions. Although scholars have been calling for a human rights-based approach and a health perspective to climate action, the literature looking at this multidisciplinary intersection is still nascent, and governments have yet to implement such intersectoral policies. This commentary begins to reflect on the relationship between climate change, human rights, and public health from the perspective of young people engaged in climate action and discourse at the national and international levels. It presents a way forward on what we, as youth climate advocates and researchers, believe is a priority to bring intersectoral integration of human rights and public health approaches to climate change to fruition. First, scholars and practitioners should examine and support youth-led climate interventions that tackle human rights and public health violations incurred by the climate crisis. Second, participatory approaches to climate change must be designed by working synergistically with climate-vulnerable groups, including children and young people, practitioners and scholars in public health and human rights sectors to holistically address the social, health, and environmental impacts of the climate crisis and root causes of injustice. Finally, we recommend more holistic data collection to better inform evidence-based climate policies that operationalize human rights and public health co-benefits.

Humanizing racialization: Social psychology in a time of unexpected transformational conjunctions.

The unexpected transformations produced by the conjunction of COVID-19, the murder of George Floyd and the resurgence of Black Lives Matter highlight the importance of social psychological understandings and the need for a step change in theorization of the social. This paper focuses on racialization. It considers issues that social psychology needs to address in order to reduce inequalities and promote social justice. It draws on theoretical resources of intersectionality and hauntology to illuminate the ways in which social psychological research frequently makes black people visible in ways that exclude them from normative constructions. The final main part of the paper presents an analysis of an interview with the racing driver Lewis Hamilton to illustrate possible ways of humanizing racialization by giving recognition to the multiplicity and historical location of racialized positioning. The paper argues that, while social psychology has made vital contributions to the understanding of group processes and of racisms, there remains a need to humanize racialization by conducting holistic analyses of black people's (and others') intersectional identities.

The experiences of children and adolescents undergoing forced separation from their parents during migration: A systematic review.

Globally, the migration of unaccompanied minors is increasing, however, the experiences of these children have not been examined. We systematically synthesised the existing qualitative literature to examine the experiences of children undergoing forced separation from their parents during migration. The review was structured based on the PRISMA statement. A systematic search of Ovid MEDLINE, EMBASE, PsychINFO and Scopus databases from inception to November 23, 2020 was conducted to retrieve eligible studies. Only qualitative studies of children aged ≤18 years were reviewed. The data analysis and synthesis were informed by the intersectionality framework. The search yielded 10,956 studies of which eight were included in this review. Thematic analysis identified the following themes: unaccompanied minors experience a deep sense of loss; anxiety over the uncertainty of the migration process; difficulty adjusting to their new life in the host country and adverse health effects. These experiences were heightened by children's exposure to violence during migration. The intersectionality framework suggests that unaccompanied minors experience separation from their parents during migration in ways that marginalise them and widen inequalities. Migration processes need to be streamlined to provide integrated health, emotional, legal and educational supports for unaccompanied children with particular attention given to treating the trauma of past violence. More research is needed to explore how to facilitate the integration of unaccompanied children into host communities in ways that are healing and empowering.

Feminist approach to geriatric care: comprehensive geriatric assessment, diversity and intersectionality.

Despite being a collection of holistic assessment tools, the comprehensive geriatric assessment primarily focuses on the social category of age during the assessment and disregards for example gender. This article critically reviews the standardized testing process of the comprehensive geriatric assessment in regard to diversity-sensitivity. I show that the focus on age as social category during the assessment process might potentially hinder positive outcomes for people with diverse backgrounds of older patients in relation to other social categories, such as race, gender or socio-economic background and their influence on the health of the patient as well as the assessment and its outcomes. I suggest that the feminist perspective of intersectionality with its multicategorical approach can enhance the diversity-sensitivity of the comprehensive geriatric assessment, and thus improve the treatment of older patients and their quality of life. By suggesting an intersectional-based approach, this article contributes to debates about justice and diversity in medical philosophy and advocates for the normative value of diversity in geriatric medicine.

Do Spirituality, Rurality, and LGBTQ Support Increase Outness and Quality of Health in Gay and Bisexual Men?

Although the existing research suggests that spirituality may positively affect health outcomes for gay and bisexual men, it is unclear to what extent it improves the quality of health over and above sociodemographic factors. Furthermore, there remains conflicting evidence regarding the role of residential location on levels of outness for gay and bisexual men. To that end, the present study used hierarchical linear regression analyses to examine the role of spirituality, rurality, and LGBTQ connectedness in outness and quality of health. The sample comprised 2,202 self-identified gay and bisexual men aged 18 and older who responded to the Social Justice Sexuality Project survey; participants represented all 50 states and Puerto Rico. The results indicate that whereas spirituality was positively associated with a greater quality of life, there was no significant difference in outness between rural versus nonrural participants. Moreover, bisexual men endorsed significantly lower levels of outness compared to their gay counterparts. Implications for future research regarding the role of spirituality and rurality in sexual minority health are discussed.

Feminicídio Brasil-México: experiências das colonizações violentas dos corpos de mulheres negras e indígenas / Brazil-Mexico feminicide: experiences of violent colonization of the bodies of black and indigenous women

O feminicídio é um crime de gênero que pode ocorrer tanto no âmbito privado como no público, em diversos contextos societários, e a motivação se dá pelo desprezo à mulher, ou seja, é um crime misógino. Os autores do crime, em sua maioria, são do gênero masculino e possuem algum tipo de laço afetivo, consanguíneo ou não com a vítima. Tanto no Brasil como no México, há uma tendência de morrerem/serem assassinadas um tipo específico de raça/etnia/cor de pele por feminicídio. No Brasil, conforme o Atlas da Violência de 2020, 68% das que são assassinadas por feminicídio são mulheres negras e, no México, 59% das mulheres que sofrem de feminicídio são indígenas (INEGI, 2015). Nesse sentido, o artigo trata da falta de atenção do Estado em ambos os países para essas mulheres que padecem mais, pois as instituições públicas são omissas em protegê-las, ou seja, há a ausência de políticas públicas específicas, configurando-se como uma ação necropolítica em que o Estado autoriza quais corpos podem ser assassinados: os corpos das mulheres negras e das mulheres indígenas. Deste modo, o método utilizado é o materialismo-histórico dialético a partir de uma revisão bibliográfica para fazer as leituras da conformação sócio-histórica dos países e através da perspectiva de colonialidade, neocolonialidade, decolonialidade, associando-as a outros elementos fundantes, como a interseccionalidade, a fim de correlacionar a incidência de feminicídio de mulheres negras e a sua negligência no Brasil, e, no México, em relação às mulheres indígenas, buscando as causas de tal ausência de políticas públicas na formação histórica de cada país, bem como tratando aqui daquelas que não se encontram nos dados estatísticos em ambos os países, em que, neste trabalho, tal situação foi chamada de ponto cego

Femicide is a gender crime that can occur both in the private and public spheres, in different societal contexts, and the motivation is given by contempt for women, that is, it is a misogynistic crime. The perpetrators of the crime, for the most part, are male and have some kind of affective bond, consanguineous or not. In both Brazil and Mexico, there is a tendency for a specific type of race/ethnicity/skin color to be killed/murdered by femicide. In Brazil, according to the 2020 Atlas of Violence, 68% of those killed by femicide are black women, and in Mexico, 59% of women who suffer femicide are indigenous (INEGI, 2015). In this sense, the article deals with the lack of State attention in both countries for these women who suffer the most, as they fail to protect them, that is, there is a lack of specific public policies, configuring itself as a necropolitical action in that the State authorizes which bodies can be murdered: the bodies of black women and indigenous women. In this sense, the method used is the dialectical historical-materialism from a bibliographic review to make the readings of the socio-historical conformation of the countries and through the perspective of coloniality, neocoloniality, decoloniality, associating them with other founding elements such as intersectionality in order to correlate the incidence of femicide of black women and its negligence in Brazil, and, in Mexico, in relation to indigenous women, seeking the causes of such absence of public policies in the historical formation of each country, as well as dealing here with those that do not are found in the statistical data in both countries, where, in this work, this situation was called a "blind spot"

Utilizing the Four Tenets of Osteopathic Medicine as an intersectional framework for approaching sexual orientation and gender identity disclosure as a provider.

The Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and other (LGBTQI+) community continues to experience health inequity and unmet needs. This manuscript examines the application of the Four Tenets of Osteopathic Medicine (FTOM) during a patient's self-disclosure of their sexual orientation and/or gender identity to the provider, also known as coming out. Tenet One discusses the interplay between intersectionality and coming out. Tenet Two elucidates how coming out moves toward a balance of homeostasis and self-healing. Tenet Three examines how structure and function can be understood on a personal level and how society influences coming out. Tenet Four explains the resources available to facilitate the previously forementioned changes. By applying the Four Tenets, the provider may more readily understand what "coming out" means on personal and social levels and what implications they may have on their patients' health.