Structural Racism in Newborn Drug Testing: Perspectives of Health Care and Child Protective Services Professionals.

PURPOSE: Black birthing parents and their newborns disproportionately experience newborn drug testing for prenatal substance exposure by health care professionals (HCPs), which contributes to Child Protective Services (CPS) reporting, family separation, and termination of parental rights. This qualitative study aims to interrogate dominant power structures by exploring knowledge, attitudes, and experiences of HCPs and CPS professionals regarding the influence of structural racism on inequities in newborn drug testing practices. METHODS: We conducted semistructured interviews with 30 physicians, midwives, nurses, social workers, and CPS professionals guided by an explanatory framework, and conducted inductive, reflexive thematic analysis. RESULTS: We identified 3 primary themes: (1) levels of racism beyond the hospital structure contributed to higher rates of drug testing for Black newborns; (2) inconsistent hospital policies led to racialized application of state law and downstream CPS reporting; and (3) health care professionals knowledge of the benefits and disproportionate harms of CPS reporting on Black families influenced their decision making. CONCLUSION: Health care professionals recognized structural racism as a driver of disproportionate newborn drug testing. Lack of knowledge and skill limitations of HCPs were barriers to dismantling power structures, thus impeding systems-level change. Institutional changes should shift focus from biologic testing and reporting to supporting the mutual needs of birthing parent and child through family-centered substance use treatment. State and federal policy changes are needed to ensure health equity for Black families and eliminate reporting to CPS for prenatal substance exposure when no concern for child abuse and neglect exists.

Required Mental Health Evaluation Before Initiating Gender-Affirming Hormones: Trans and Nonbinary Perspectives.

Purpose: Gender-affirming hormones (hormones)-the use of sex hormones to induce desired secondary sex characteristics in transgender and nonbinary (TGNB) individuals-are vital health care for many TGNB people. Some hormone providers require a letter from a mental health provider before hormone initiation. We explore the perspectives of TGNB individuals regarding the impact of the letter requirement on their experience of care. Methods: We conducted semistructured interviews with 21 TGNB individuals who have sought or are receiving hormones. We purposively sampled respondents who were (n=12) and were not (n=8) required to provide a letter. An Advisory Board of transgender individuals guided the methodology. Interviews were transcribed verbatim and coded both inductively and deductively. Results: We identified three themes related to the letter requirement: (1) Mental health: While participants appreciated the importance of therapy, the letter requirement did not serve this purpose; (2) Trans identity: The process of obtaining a letter created doubt in participants' own transness, along with a resistance to the pathologization and conflation of mental illness with transness; and (3) Care relationships: The letter requirement negatively impacted the patient-provider relationship. Participants felt the need to self-censor or to perform a version of transness they thought the provider expected; this process decreased their trust in care professionals. Conclusion: A letter requirement did not improve mental health and had several negative consequences. Removal of this requirement will improve access to hormones and may paradoxically improve mental health.