A patient-centered model of mental health care for trauma and minority stress in transgender and gender diverse people: A bottom-up network analysis.

Transgender and gender diverse (TGD) individuals are disproportionately exposed to traumatic and high-impact minority stressors which can produce an array of transdiagnostic symptoms. Some clinical presentations align well with established evidence-based treatments, but others may require patient-centered modifications or combined approaches to address treatment needs. In this study, we employed a novel, bottom-up approach to derive insights into preferred intervention strategies for a broad range of trauma- and TGD-minority stress-related expressions of clinical distress. Participants (18 TGD individuals, 16 providers) completed a q-sort task by first sorting cards featuring traumatic experiences and/or minority stressors and transdiagnostic psychiatric symptoms into groups based on perceived similarity. Next, participants sorted interventions they believed to be most relevant for addressing these concerns/symptoms. We overlayed networks of stressors and symptoms with intervention networks to evaluate preferred intervention strategies. TGD networks revealed transdiagnostic clustering of intervention strategies and uniquely positioned the expectancy of future harm as a traumatic stressor. Provider networks were more granular in structure; both groups surprisingly emphasized the role of self-defense as intervention. While both networks had high overlap, their discrepancies highlight patient perspectives that practical, material, and structural changes should occur alongside traditional clinical interventions.

Clinical Guidelines for Working with Clients Involved in Kink.

People involved in kink (BDSM or fetish) subcultures often encounter stigma and bias in healthcare settings or when seeking psychotherapy. Such individuals typically encounter well-meaning clinicians who are not prepared to provide culturally competent care or who have not recognized their own biases. Over a two-year period, a team of 20 experienced clinicians and researchers created clinical practice guidelines for working with people involved with kink, incorporating an extensive literature review and documentation of clinical expertise. This article summarizes the guidelines and discusses relevant issues facing clinicians and their clients, as well as implications for clinical practice, research and training.

A bottom-up approach to developing a unified trauma-minority stress model for transgender and gender diverse people.

OBJECTIVE: Transgender and gender diverse (TGD) people are at heightened risk of both Criterion A trauma exposure and other bias-related minority stressors (e.g., discrimination, rejection). In the absence of a unified trauma-minority stress theory, it remains unclear how to best conceptualize psychopathology for people who experience both trauma and minority stress. METHOD: Using a participant-driven q-sort methodology and network analytic approach, we analyzed card sort data from 18 TGD people and 16 providers with expertise in TGD care to derive thematic networks of trauma and minority stress experiences, as they connected to transdiagnostic symptoms (e.g., hyperarousal, avoidance). RESULTS: The TGD participants' resulting network illustrates conceptualizations of identity- and nonidentity-based Criterion A traumas as similar and only related to psychiatric symptoms via the shared connection through other minority stressors. The provider network was more granular, although the general pattern was consistent with TGD participants, demonstrating similar perceptions of how these experiences are associated. CONCLUSIONS: Evidence of inextricable links between trauma and psychiatric symptoms through the conduit of minority stressors lays the groundwork for novel, integrated models of trauma, minority stress, and their transdiagnostic symptom sequelae. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Real-time associations between discrimination, cannabis use, and mood among sexual and gender minority individuals.

OBJECTIVE: Sexual and gender minority (SGM) individuals experience high rates of discrimination, which is associated with increased cannabis use. Studies have also linked daily SGM discrimination to event-based mood states, but none have examined the degree to which cannabis buffers or potentially exacerbates mood in response to discrimination in real time. METHOD: Fifty SGM individuals participated in a 2-week ecological momentary assessment study. Participants completed a baseline assessment and then received six daily prompts assessing SGM discrimination, cannabis use, and current mood. We investigated the immediate associations between SGM discrimination and mood, and how cannabis use differentially moderated these associations. RESULTS: SGM discrimination was associated with increased negative mood and decreased positive mood. Among those who experienced discrimination, individuals who used cannabis reported feeling less anxious and depressed, and happier and more relaxed, in the 2 hr following an SGM discrimination experience compared to those that did not use cannabis. CONCLUSIONS: These findings uncover some of the acute within-day effects of both daily SGM discrimination and cannabis use on mood. These findings build on the current understanding of minority stress, in real time, and suggest avenues for prevention, and intervention efforts to offset risk for psychological distress and cannabis use among SGM individuals who experience minority stress. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Hazardous Substance Use Among Sexual and Gender Minority Adults: A Deeper Look into Distal Minority Stressors.

Discrimination and victimization drive health disparities among sexual and gender minority (SGM) individuals, yet little is known about the relative impacts of specific experience types on hazardous substance use. Using data from 704 SGM adults, we examined SGM-related discrimination vs. victimization and specific experiences as predictors of hazardous substance use. SGM-related victimization, not discrimination, predicted hazardous substance use, and SGM-related sexual assault and harassment predicted hazardous alcohol use, although only sexual assault predicted hazardous drug use. These findings implicate lifetime SGM-related victimization, and SGM-related sexual assault and harassment specifically, as key correlates of recent hazardous substance use among SGM adults.

The meaning of scientific objectivity and subjectivity: From the perspective of methodologists.

Given the challenges to the notion of objectivity posed by social psychological research on investigator effects, constructivist and critical epistemological perspectives, and the introduction of qualitative research methods in psychology, the investigators examined how leading methodologists understand the function of objectivity and subjectivity in psychological science. The aim of the study was to learn how contemporary methodologists view these issues so as to communicate converging perspectives to the field and inform methods education. A brief historical review of the concept of objectivity in psychology is presented to contexualize this examination. Eleven accomplished methodologists with expertise in a range of methods and epistemological perspectives were interviewed. Findings from a grounded theory analysis demonstrated that all the participants expressed concern about the belief that science is unaffected by scientists' perspectives, believing researchers and educators should problematize this perspective. Recommendations from participants included that science be viewed as a value-laden endeavor in which scientists systematically conduct research from multiple epistemological perspectives, and/or utilize diverse methods tailored to address their questions. Scientific procedures were detailed that could curtail dangers of either unchecked subjectivity or a false sense of objectivity. A functional analysis of these constructs, objectivity and subjectivity, suggested they both serve a similar scientific and an ethical purpose-to prevent the premature foreclosure of possible understanding because of the expectations of researchers. The mainstreaming of disclosures about the perspectives and positions of investigators, as well as their management, and the implementation of epistemological and methodological pluralism are encouraged to support this ethic. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Understanding Associations Between Exposure to Violent Pornography and Teen Dating Violence Among Female Sexual Minority High School Students.

Previous research indicates that teen dating violence (TDV) is more common among sexual minority than heterosexual adolescents, with approximately half of female sexual minority adolescents (SMA) endorsing TDV victimization in the last year. In samples of adolescents without regard to sexual orientation, exposure to violent pornography is associated with TDV, but this relationship has not been assessed in female SMA. The current study sample consisted of 10th-grade high school students aged 14-17 who identified as cisgender females (N = 1,276). Data were collected from a baseline survey prior to the delivery of a sexual assault prevention intervention. Female SMA had 2.54 times the odds (95%CI [1.75, 3.69]) of being exposed to violent pornography and 2.53 times the odds (95%CI [1.72, 3.70)]) of TDV exposure compared to heterosexual girls. Exposure to violent pornography was not associated with involvement in TDV among female SMA, controlling for episodic heavy drinking (aOR = 2.25, 95%CI [0.88,6.22]).Given the relatively higher rates of violent pornography and TDV exposure among female SMA compared to heterosexual girls, it is critical that sex education curricula address these experiences and meet the needs of adolescents of all sexual orientations. Future research can assess how these TDV interventions might be tailored for female SMA. Although we did not find that exposure to violent pornography was associated with TDV among female SMA, these investigations should be replicated with larger data sets, given that the association between exposure to violent pornography and engagement in TDV was in the expected direction.

The Impact of Pre-Exposure Prophylaxis on Sexual Communication and Sexual Behavior of Urban Gay and Bisexual Men.

Pre-exposure prophylaxis (PrEP) has altered the public health landscape for gay, bisexual, and other men who have sex with men (GBM) by significantly increasing protection against HIV infection. Early epidemiologic data showed GBM generally used PrEP as prescribed, i.e., as an additional protective tool over and above barrier protection, although subsequent reports have been equivocal. Irrespective of population-level trends, some GBM appear to have reevaluated their HIV risk tolerance and changed their interactions with sex partners. Scant published data have focused on factors that influence PrEP-using GBM's decisions about sexual behavior-including condom use as well as sex with HIV-positive partners-and sexual communication practices. Thus, in this study, we investigated those research concerns qualitatively via content analysis of individual interviews conducted with 103 GBM in New York City (M age 32.5 years, 50% White, 64% on PrEP > 6 months). Emergent themes reflect (1) participants' strong HIV knowledge; (2) changing GBM community norms about condom use on PrEP; (3) increased focus on risk tolerance with individual differences in post-PrEP condom use; (4) appreciation for routine sexually transmitted infection (STI) screening in PrEP care concomitant with some STI knowledge deficits; (5) decreased stigma concerning, and greater comfort with, HIV-positive sex partners; and (6) increased confidence discussing HIV status and condom use preferences with partners. Findings have implications for future research as well as for clinical practice, such as enhanced STI education and provider-initiated discussions about risk compensation, serosorting, and sexual communication skills.

IUD knowledge and experience among family medicine residents.

BACKGROUND AND OBJECTIVES: The intrauterine device (IUD) is a highly effective contraceptive method with few contraindications; however, clinician lack of training in insertion and misconceptions about IUD risks are barriers to utilization. Previous research has shown gaps in IUD training in family medicine residency programs. METHODS: An online survey addressing experience with IUD insertion, knowledge of patient eligibility and IUD risks, and intent to insert IUDs in practice was circulated to residents at 15 US family medicine residency programs. Programs were eligible to participate if they were receiving funding to enhance training in family planning and abortion care and interested in additional support to enhance IUD training. RESULTS: The overall response rate for the surveys was 76.1% (332/436). Experience with the levonorgestrel intrauterine system was more common than with the copper IUD. Residents performed well on knowledge questions, but many would not insert in common patient scenarios in which insertion was not contraindicated, including a history of sexually transmitted infection in the past 6 months (48.2% would not insert), a history of ectopic pregnancy (37.0%), no pap smear in the past year (30.7%), or if the patient was not in a monogamous relationship (29.2%). The vast majority of residents (88.7%) reported that they were likely or very likely to provide IUDs in their future family medicine practice. CONCLUSIONS: Although residents overwhelmingly expressed interest in providing IUDs after residency, our results suggest that additional clinical and didactic training is needed, particularly interventions targeted at dispelling misconceptions about patient eligibility for IUDs.

Management of early pregnancy failure and induced abortion by family medicine educators.

BACKGROUND: Reproductive health care, including treatment of early pregnancy failure (EPF) and induced abortion, is an integral part of patient-centered care provided by family physicians, but data suggest that comprehensive training is not widely available to family medicine residents. The purpose of this study was to assess EPF and induced abortion management practices and attitudes of family medicine physician educators throughout the United States and Canada. METHODS: These data were collected as part of a cross-sectional survey conducted by the Council of Academic Family Medicine Educational Research Alliance that was distributed via E-mail to 3152 practicing physician members of Council of Academic Family Medicine organizations. RESULTS: The vast majority of respondents (88.2%) had treated EPF, whereas few respondents (15.3%) had provided induced medication or aspiration abortions. Of those who had treated EPF, most had offered medication management (72.7%), whereas a minority had provided aspiration management (16.4%). Almost all respondents (95%) agreed that EPF management is within the scope of family medicine, and nearly three-quarters (73.2%) agreed that early induced abortion is within the scope of family medicine. CONCLUSION: Our findings suggest that family physician educators are more experienced with EPF management than elective abortion. Given the overlap of skills needed for provision of these services, there is the potential to increase the number of family physician faculty members providing induced abortions.

Barriers and enablers to becoming abortion providers: the reproductive health program.

BACKGROUND AND OBJECTIVES: Despite abortion being one of the most common procedures undergone by women of reproductive age in the United States, the number of abortion providers has been declining for the last 20 years. We sought to assess the long-term impact of the Reproductive Health Program (RHP), a national elective abortion training program for primary care abortion providers that operated from 1999-2005. METHODS: We conducted a mixed-methods cross-sectional study of 220 former RHP trainees. Participants were interviewed over the phone and asked a series of questions about their training at RHP, their current practice, abortion provision since RHP, and enablers and barriers to abortion provision. RESULTS: More than half of respondents (58.8%) have provided any abortions since RHP; more have provided medical abortions (56.5%) than surgical abortions (47.1%). Of respondents who have provided abortions, most have performed more than 50 surgical (87.5%) or medical (77.1%) abortions since RHP and had provided an abortion in the last 3 months (67.5%, 70.8%). More than 90% of abortion providers reported having liability insurance that covers abortion, colleague support, ease of obtaining medications and/or equipment, reimbursement, and administrative and/or staff support at the site where they provide abortions. Relative to providers, the greatest barriers reported by non-providers were lack of skills, concerns about liability, and difficulty obtaining supplies. CONCLUSIONS: Our findings suggest that the RHP model of elective training can yield a substantial percentage of abortion providers. We also describe enablers and barriers to provision once trainees are in practice, highlighting the importance of continued support after training is completed.

Family planning training in US family medicine residencies.

BACKGROUND AND OBJECTIVES: Family planning is among the most common services family physicians provide. Evidence that family doctors are not offering the broadest range of these services prompted this study of family planning training in family medicine residency programs. METHODS: This study was a cross-sectional survey of program directors and chief residents at US family medicine residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME). The survey was adapted from the instrument used by Steinauer et al in 1995. RESULTS: Didactic and clinical training in most contraception methods is common, but large gaps remain, especially with regard to implant, diaphragm, tubal ligation, and vasectomy. Didactic or clinical training in pregnancy options counseling is available in most programs; however, it should be universal to comply with ACGME requirements. Despite an even split in attitudes toward abortion within family medicine, training remains uncommon. CONCLUSIONS: Family medicine residency programs are not offering training in the broadest range of family planning methods, and abortion training is uncommon. To address these gaps, family medicine educators need to work to increase training in all methods of contraception, including newer and procedural methods, and consider strategies for offering abortion training to interested residents.

Students as patients and teachers: evaluation of an experiential emergency contraception project.

BACKGROUND AND OBJECTIVES: Students on a required family medicine clerkship participated in an experiential project designed to teach them about emergency contraception (EC). This study describes students' changes in knowledge and attitudes about barriers to care after assuming the patient role and presenting their findings to peers and after hearing a presentation about EC from their peers. METHODS: This mixed-methods study used quantitative measures of knowledge and attitudes about EC before and after the students' family medicine clerkship. Qualitative in-depth interviews were conducted with all students who self-selected the EC Project and assumed the role of a patient and then taught their peers. RESULTS: All student groups showed improvement in knowledge and attitude scores, though gains were not statistically significant. Students who participated in the EC Project reported multiple benefits related to (1) assuming the role of the patient, (2) engaging in an experiential learning process, (3) teaching their peers, and (4) considering their future role as clinicians. CONCLUSIONS: Our findings demonstrate that playing the role of a patient and teaching their peers are valuable learning experiences, and students can learn well during peer-taught sessions. Students increased their medical knowledge and sensitivity to the barriers that patients face and began to consider their role in improving systems of health care.

Abortion training at multiple sites: an unexpected curriculum for teaching systems-based practice.

BACKGROUND: In 1999, the Accreditation Council for Graduate Medical Education endorsed systems-based practice as one of six general competencies. PURPOSE: The objective is to explore the paradigm of teaching residents systems-based practice during a women's health rotation that included abortion training in multiple settings. METHODS: During a routine women's health rotation, residents from two urban family medicine residency programs received early abortion training at a high-volume abortion clinic and their continuity clinic. Thirty-min semistructured interviews were conducted with all 26 residents who rotated between July 2005 and August 2006. Transcripts were analyzed using thematic codes. RESULTS: Through exposure to different healthcare delivery systems, residents learned about systems-based practice, including understanding the failure of the larger system to meet patients' reproductive healthcare needs, differences between two systems, and potential systems barriers they might face as providers. CONCLUSIONS: Abortion training in multiple settings may serve as a paradigm for teaching systems-based practice during other rotations that include training in multiple sites.

Being in the room: reflections on pregnancy options counseling during abortion training.

BACKGROUND AND OBJECTIVES: The Residency Review Committee requires that family medicine residents learn options counseling for women with unintended pregnancies. This qualitative study identifies important domains for future formal evaluations of pregnancy options counseling by exploring the relevant benefits reported by residents who underwent routine abortion training. To our knowledge, this is the first study of abortion training in family medicine to include an in-depth examination of its benefits in areas that may be important for pregnancy options counseling. METHODS: Residents from two urban family medicine residency programs received training in first-trimester aspiration abortion at a high-volume abortion clinic during a routine women's health rotation. Thirty-minute semi-structured interviews were conducted with all 28 residents who rotated between July 2005 and November 2006. A coding scheme was developed and applied to transcripts for analysis. RESULTS: Through exposure to routine abortion training, residents reported improved knowledge, attitudes, and skills that are likely to be important for providing open and informed pregnancy options counseling. These include an understanding of the context of women's lives when they seek abortion care, familiarity with the procedure, and improved self-reported pregnancy options counseling skills. CONCLUSIONS: Our findings suggest that exposure to abortion training benefits residents in areas that may be important for providing effective pregnancy options counseling. In addition, residents' reflections on their involvement with patients during the abortion process highlight key domains for future formal evaluations of accurate and nonjudgmental options counseling for unintended pregnancy.