Limitations and Future Directions in Sex, Sexuality, and Gender Diverse Research in Neurology.

Sex, sexuality, and gender diversity is understudied and underserved in neurology. Neurology research inclusive of LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual) people is limited. Existing research struggles with a paucity of neurology studies collecting sex, sexuality, and gender diverse (SSGD) data, conflation of sex and gender, lack of precision in measures, neglect of younger and older populations, nebulous benefit to community, and absent intersectionality. Future directions in SSGD neurology research include precise and community-based measurements, respect for LGBTQIA+ colleagues, and the application of minority stress models. All patients stand to benefit from research that elucidates how SSGD variables influence neurological health. ANN NEUROL 2024;95:421-431.

Spinal epidural arteriovenous fistula with nerve root enhancement mimicking myeloradiculitis: a case report.

BACKGROUND: Gadolinium enhancement of spinal nerve roots on magnetic resonance imaging (MRI) has rarely been reported in spinal dural arteriovenous fistula (SDAVF). Nerve root enhancement and cerebrospinal fluid (CSF) pleocytosis can be deceptive and lead to a misdiagnosis of myeloradiculitis. We report a patient who was initially diagnosed with neurosarcoid myeloradiculitis due to spinal nerve root enhancement, mildly inflammatory cerebrospinal fluid, and pulmonary granulomas, who ultimately was found to have an extensive symptomatic SDAVF. CASE PRESENTATION: A 52-year-old woman presented with a longitudinally extensive spinal cord lesion with associated gadolinium enhancement of the cord and cauda equina nerve roots, and mild lymphocytic pleocytosis. Pulmonary lymph node biopsy revealed non-caseating granulomas and neurosarcoid myeloradiculitis was suspected. She had rapid and profound clinical deterioration after a single dose of steroids. Further work-up with spinal angiography revealed a thoracic SDAVF, which was surgically ligated leading to clinical improvement. CONCLUSIONS: This case highlights an unexpected presentation of SDAVF with nerve root enhancement and concurrent pulmonary non-caseating granulomas, leading to an initial misdiagnosis with neurosarcoidosis. Nerve root enhancement has only rarely been described in cases of SDAVF; however, as this case highlights, it is an important consideration in the differential diagnosis of non-inflammatory causes of longitudinally extensive myeloradiculopathy with nerve root enhancement. This point is highly salient due to the importance of avoiding misdiagnosis of SDAVF, as interventions such as steroids or epidural injections used to treat inflammatory or infiltrative mimics may worsen symptoms in SDAVF. We review the presentation, diagnosis, and management of SDAVF as well as a proposed diagnostic approach to differentiating SDAVF from inflammatory myeloradiculitis.

Sex and Gender Considerations in Episodic Migraine.

PURPOSE OF REVIEW: We seek to update readers on recent advances in our understanding of sex and gender in episodic migraine with a two part series. In part 1, we examine migraine epidemiology in the context of sex and gender, differences in symptomatology, and the influence of sex hormones on migraine pathophysiology (including CGRP). In part 2, we focus on practical clinical considerations for sex and gender in episodic migraine by addressing menstrual migraine and the controversial topic of hormone-containing therapies. We make note of data applicable to gender minority populations, when available, and summarize knowledge on gender affirming hormone therapy and migraine management in transgender individuals. Finally, we briefly address health disparities, socioeconomic considerations, and research bias. RECENT FINDINGS: Migraine is known to be more prevalent, frequent, and disabling in women. There are also differences in migraine co-morbidities and symptomatology. For instance, women are likely to experience more migraine associated symptoms such as nausea, photophobia, and phonophobia. Migraine pathophysiology is influenced by sex hormones, e.g., estrogen withdrawal as a known trigger for migraine. Other hormones such as progesterone and testosterone are less well studied. Relationships between CGRP (the target of new acute and preventive migraine treatments) and sex hormones have been established with both animal and human model studies. The natural course of migraine throughout the lifetime suggests a contribution from hormonal changes, from puberty to pregnancy to menopause/post-menopause. Treatment of menstrual migraine and the use of hormone-containing therapies remains controversial. Re-evaluation of the data reveals that stroke risk is an estrogen dose- and aura frequency-dependent phenomenon. There are limited data on episodic migraine in gender minorities. Gender affirming hormone therapy may be associated with a change in migraine and unique risks (including ischemic stroke with high dose estrogen). There are key differences in migraine epidemiology and symptomatology, thought to be driven at least in part by sex hormones which influence migraine pathophysiology and the natural course of migraine throughout the lifetime. More effective and specific treatments for menstrual migraine are needed. A careful examination of the data on estrogen and stroke risk suggests a nuanced approach to the issue of estrogen-containing contraception and hormone replacement therapy is warranted. Our understanding of sex and gender is evolving, with limited but growing research on the relationship between gender affirming therapy and migraine, and treatment considerations for transgender people with migraine.

Discrimination is associated with C-reactive protein among young sexual minority men.

This report examines associations between everyday discrimination, microaggressions, and CRP to gain insight on potential mechanisms that may underlie increased CVD risk among sexual minority male young adults. The sample consisted of 60 participants taken from the P18 cohort between the ages of 24 and 28 years. Multinomial logistic regression models were used to examine the association between perceived everyday discrimination and LGBQ microaggressions with C-reactive protein cardiovascular risk categories of low-, average-, and high-risk, as defined by the American Heart Association and Centers for Disease Control. Adjustments were made for BMI. Individuals who experienced more everyday discrimination had a higher risk of being classified in the high-risk CRP group compared to the low-risk CRP group (RRR = 3.35, p = 0.02). Interpersonal LGBQ microaggressions were not associated with CRP risk category. Everyday discrimination, but not specific microaggressions based on sexual orientation, were associated with elevated levels of CRP among young sexual minority men (YSMM). Thus, to implement culturally and age-appropriate interventions, further researcher is needed to critically examine the specific types of discrimination and the resultant impact on YSMM's health.

Assessing and Addressing Cardiovascular Health in LGBTQ Adults: A Scientific Statement From the American Heart Association.

There is mounting evidence that lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) adults experience disparities across several cardiovascular risk factors compared with their cisgender heterosexual peers. These disparities are posited to be driven primarily by exposure to psychosocial stressors across the life span. This American Heart Association scientific statement reviews the extant literature on the cardiovascular health of LGBTQ adults. Informed by the minority stress and social ecological models, the objectives of this statement were (1) to present a conceptual model to elucidate potential mechanisms underlying cardiovascular health disparities in LGBTQ adults, (2) to identify research gaps, and (3) to provide suggestions for improving cardiovascular research and care of LGBTQ people. Despite the identified methodological limitations, there is evidence that LGBTQ adults (particularly lesbian, bisexual, and transgender women) experience disparities across several cardiovascular health metrics. These disparities vary by race, sex, sexual orientation, and gender identity. Future research in this area should incorporate longitudinal designs, elucidate physiological mechanisms, assess social and clinical determinants of cardiovascular health, and identify potential targets for behavioral interventions. There is a need to develop and test interventions that address multilevel stressors that affect the cardiovascular health of LGBTQ adults. Content on LGBTQ health should be integrated into health professions curricula and continuing education for practicing clinicians. Advancing the cardiovascular health of LGBTQ adults requires a multifaceted approach that includes stakeholders from multiple sectors to integrate best practices into health promotion and cardiovascular care of this population.

Neurological care for LGBT+ people.

Sexual and gender minority (LGBT+) people face unique health disparities that must be considered by health-care providers to ensure equitable and inclusive care. Although traditionally LGBT+ health has not been integrated into neurology training, sexual orientation and gender identity have direct relevance to neurological health, driven by both systemic and interpersonal factors. In this Review, we summarize the evidence for associations between sexual orientation and gender identity with the prevalence and outcomes of various neurological conditions, including neurodegenerative diseases, epilepsy, stroke and neurodevelopmental disorders, among others. We describe important clinical considerations pertaining to LGBT+ people and recommend language and practices to promote inclusive care, as well as highlight gaps in need of further research and possible strategies to minimize these, including systematic collection of sexual orientation and gender identity and use of inclusive language.

Differences in Cardiovascular Health at the Intersection of Race, Ethnicity, and Sexual Identity.

Importance: An understanding of the intersectional effect of sexual identity, race, and ethnicity on disparities in cardiovascular health (CVH) has been limited. Objective: To evaluate differences in CVH at the intersection of race, ethnicity, and sexual identity using the American Heart Association's Life's Essential 8 measure. Design, Setting, and Participants: This cross-sectional study was conducted from July 27 to September 6, 2023, using National Health and Nutrition Examination Survey data from 2007 to 2016. Participants were noninstitutionalized, nonpregnant adults (aged 18-59 years) without cardiovascular disease or stroke. Exposures: Self-reported sexual identity, categorized as heterosexual or sexual minority (SM; lesbian, gay, bisexual, or "something else"), and self-reported race and ethnicity, categorized as non-Hispanic Black (hereafter, Black), Hispanic, non-Hispanic White (hereafter, White), and other (Asian, multiracial, or any other race and ethnicity). Main Outcome and Measures: The primary outcome was overall CVH score, which is the unweighted mean of 8 CVH metrics, assessed from questionnaire, dietary, and physical examination data. Regression models stratified by sex, race, and ethnicity were developed for the overall CVH score and individual CVH metrics, adjusting for age, survey year, and socioeconomic status (SES) factors. Results: The sample included 12 180 adults (mean [SD] age, 39.6 [11.7] years; 6147 [50.5%] male, 2464 [20.2%] Black, 3288 [27.0%] Hispanic, 5122 [42.1%] White, and 1306 [10.7%] other race and ethnicity). After adjusting for age, survey year, and SES, Black (ß, -3.2; 95% CI, -5.8 to -0.6), Hispanic (ß, -5.9; 95% CI, -10.3 to -1.5), and White (ß, -3.3; 95% CI, -6.2 to -0.4) SM female adults had lower overall CVH scores compared with their heterosexual counterparts. There were no statistically significant differences for female adults of other race and ethnicity (ß, -2.8; 95% CI, -9.3 to 3.7) and for SM male adults of any race and ethnicity compared with their heterosexual counterparts (Black: ß, 2.2 [95% CI, -1.2 to 5.7]; Hispanic: ß, -0.9 [95% CI, -6.3 to 4.6]; White: ß, 1.5 [95% CI, -2.2 to 5.2]; other race and ethnicity: ß, -2.2 [95% CI, -8.2 to 3.8]). Conclusions and Relevance: In this cross-sectional study, CVH differed across race and ethnicity categories in SM females, suggesting that different communities within the larger SM population require tailored interventions to improve CVH. Longitudinal studies are needed to identify the causes of CVH disparities, particularly in Black and Hispanic SM females and inclusive of other racial and ethnic identities.

Addressing Disparities in Acute Stroke Management and Prognosis.

There are now abundant data demonstrating disparities in acute stroke management and prognosis; however, interventions to reduce these disparities remain limited. This special report aims to provide a critical review of the current landscape of disparities in acute stroke care and highlight opportunities to use implementation science to reduce disparities throughout the early care continuum. In the prehospital setting, stroke symptom recognition campaigns that have been successful in reducing prehospital delays used a multilevel approach to education, including mass media, culturally tailored community education, and professional education. The mobile stroke unit is an organizational intervention that has the potential to provide more equitable access to timely thrombolysis and thrombectomy treatments. In the hospital setting, interventions to address implicit biases among health care providers in acute stroke care decision-making are urgently needed as part of a multifaceted approach to advance stroke equity. Implementing stroke systems of care interventions, such as evidence-based stroke care protocols at designated stroke centers, can have a broader public health impact and may help reduce geographic, racial, and ethnic disparities in stroke care, although further research is needed. The long-term impact of disparities in acute stroke care cannot be underestimated. The consistent trend of longer time to treatment for Black and Hispanic people experiencing stroke has direct implications on long-term disability and independence after stroke. A learning health system model may help expedite the translation of evidence-based interventions into clinical practice to reduce disparities in stroke care.

Neurologic Care for Transgender and Gender-Diverse People: A Review of Current Evidence and Clinical Implications.

Purpose of Review: To summarize the literature on neurologic care for transgender and gender-diverse (TGD) people and provide implications for clinical practice. Recent Findings: There are limited data on the frequency and management of neurologic conditions among TGD people. TGD people have a higher prevalence of various neurologic conditions compared with cisgender or general population cohorts, including migraine, subjective cognitive decline, sleep disturbances, functional disorders, and cerebrovascular disease. Gender-affirming hormone therapy interacts with commonly prescribed neurologic medications and increases stroke risk among transfeminine people. Sex hormones and sex chromosomes may play a role in neurodegeneration and disability progression in neuroimmunologic diseases. Clitoral reduction surgeries on intersex children can cause neurologic disability and sexual dysfunction in adulthood. Socioeconomic disparities among TGD people contribute to health care barriers. Summary: Neurologists should consider the unique experiences and health care needs of TGD people in their clinical practice and research protocols.

Exploring Stroke Risk Factors and Outcomes in Sexual and Gender Minority People.

Background and Objectives: Cerebrovascular disease in sexual and gender minority (SGM) people remains poorly understood. Our primary objective was to describe the epidemiology and outcomes in a sample of SGM people with stroke. As a secondary objective, we compared this group with non-SGM people with stroke to assess for significant differences in risk factors or outcomes. Methods: This was a retrospective chart review study of SGM people admitted to an urban stroke center with primary diagnosis of stroke (ischemic or hemorrhagic). We evaluated stroke epidemiology and outcomes, summarizing with descriptive statistics. We then matched 1 SGM person to 3 non-SGM people by year of birth and year of diagnosis to compare demographics, risk factors, inpatient stroke metrics, and outcomes. Results: A total of 26 SGM people were included in the analysis: 20 (77%) had ischemic strokes, 5 (19%) intracerebral hemorrhages, and 1 (4%) subarachnoid hemorrhage. Compared with non-SGM people (n = 78), stroke subtypes showed a similar distribution (64 (82%) ischemic strokes, 12 (15%) intracerebral hemorrhages, 1 (1%) subarachnoid hemorrhage, and 1 nontraumatic subdural hematoma, p > 0.05) but suspected ischemic stroke mechanisms had a different distribution (χ2 = 17.56, p = 0.01). Traditional stroke risk factors were similar between the 2 groups. The SGM group seemed to have higher rates of nontraditional stroke factors, including HIV (31% vs 0%, p < 0.01), syphilis (19% vs 0%, p < 0.01), and hepatitis C (15% vs 5%, p < 0.01) but were more likely to be tested for these risk factors (χ2 = 15.80, p < 0.01; χ2 = 11.65, p < 0.01; χ2 = 7.83, p < 0.01, respectively). SGM people were more likely to have recurrent strokes (χ2 = 4.39, p < 0.04) despite similar follow-up rates. Discussion: SGM people may have different risk factors, different mechanisms of stroke, and higher risk of recurrent stroke compared with non-SGM people. Standardized collection of sexual orientation and gender identity would enable larger studies to further understand disparities, leading to secondary prevention strategies.

Functional Neurological Disorder Among Sexual and Gender Minority People.

Sexual and gender minority (SGM) people can face unique stressors and structural discrimination that result in higher rates of neuropsychiatric symptoms, such as depression, anxiety, and suicidality. Although more rigorous studies are needed, emerging data suggest a possible higher prevalence of functional neurological disorder and other brain-mind-body conditions in SGM people. Representation and iterative feedback from affected community members is critical to the process of developing affirming environments. More research is needed to explore the relevance of functional neurologic disorder in SGM people within a biopsychosocial framework.

Differences in Ideal Cardiovascular Health Between Sexual Minority and Heterosexual Adults.

Importance: Research on the cardiovascular health (CVH) of sexual minority adults has primarily examined differences in the prevalence of individual CVH metrics rather than comprehensive measures, which has limited development of behavioral interventions. Objective: To investigate sexual identity differences in CVH, measured using the American Heart Association's revised measure of ideal CVH, among adults in the US. Design, Setting, and Participants: This cross-sectional study analyzed population-based data from the National Health and Nutrition Examination Survey (NHANES; 2007-2016) in June 2022. Participants included noninstitutional adults aged 18 to 59 years. We excluded individuals who were pregnant at the time of their interview and those with a history of atherosclerotic cardiovascular disease or heart failure. Exposures: Self-identified sexual identity categorized as heterosexual, gay/lesbian, bisexual, or something else. Main Outcomes and Measures: The main outcome was ideal CVH (assessed using questionnaire, dietary, and physical examination data). Participants received a score from 0 to 100 for each CVH metric, with higher scores indicating a more favorable CVH profile. An unweighted average was calculated to determine cumulative CVH (range, 0-100), which was recoded as low, moderate, or high. Sex-stratified regression models were performed to examine sexual identity differences in CVH metrics, disease awareness, and medication use. Results: The sample included 12 180 participants (mean [SD] age, 39.6 [11.7] years; 6147 male individuals [50.5%]). Lesbian (B = -17.21; 95% CI, -31.98 to -2.44) and bisexual (B = -13.76; 95% CI, -20.54 to -6.99) female individuals had less favorable nicotine scores than heterosexual female individuals. Bisexual female individuals had less favorable body mass index scores (B = -7.47; 95% CI, -12.89 to -1.97) and lower cumulative ideal CVH scores (B = -2.59; 95% CI, -4.84 to -0.33) than heterosexual female individuals. Compared with heterosexual male individuals, gay male individuals had less favorable nicotine scores (B = -11.43; 95% CI, -21.87 to -0.99) but more favorable diet (B = 9.65; 95% CI, 2.38-16.92), body mass index (B = 9.75; 95% CI, 1.25-18.25), and glycemic status scores (B = 5.28; 95% CI, 0.59-9.97). Bisexual male individuals were twice as likely as heterosexual male individuals to report a diagnosis of hypertension (adjusted odds ratio [aOR], 1.98; 95% CI, 1.10-3.56) and use of antihypertensive medication (aOR, 2.20; 95% CI, 1.12-4.32). No differences in CVH were found between participants who reported their sexual identity as something else and heterosexual participants. Conclusion and Relevance: Results of this cross-sectional study suggest that bisexual female individuals had worse cumulative CVH scores than heterosexual female individuals, whereas gay male individuals generally had better CVH than heterosexual male individuals. There is a need for tailored interventions to improve the CVH of sexual minority adults, particularly bisexual female individuals. Future longitudinal research is needed to examine factors that might contribute to CVH disparities among bisexual female individuals.

Functional neurological disorder and functional somatic syndromes among sexual and gender minority people: A scoping review.

OBJECTIVE: To describe the current literature on functional neurological disorder and functional somatic syndromes among sexual and gender minority people (SGM). METHODS: A search string with descriptors of SGM identity and functional disorders was entered into PubMed, Embase, Web of Science, PsycInfo, and CINAHL for articles published before May 24, 2022, yielding 3121 items entered into Covidence, where 835 duplicates were removed. A neurologist and neuropsychiatrist screened titles and abstracts based on predefined criteria, followed by full-text review. A third neurologist adjudicated discrepancies. Eligible publications underwent systematic data extraction and statistical description. RESULTS: Our search identified 26 articles on functional disorders among SGM people. Most articles were case (13/26, 46%) or cross-sectional (4/26, 15%) studies. Gender minority people were represented in 50% of studies. Reported diagnoses included fibromyalgia (n = 8), functional neurological disorder (n = 8), somatic symptom disorder (n = 5), chronic fatigue syndrome (n = 3), irritable bowel syndrome (n = 2), and other functional conditions (n = 3). Three cohort studies of fibromyalgia or somatic symptom disorder reported an overrepresentation of gender minority people compared to cisgender cohorts or general population measures. Approximately half of case studies reported pediatric or adolescent onset (7/13, 54%), functional neurological disorder diagnosis (7/13, 54%), and symptom improvement coinciding with identity-affirming therapeutic interventions (7/13, 58%). CONCLUSION: Despite a methodologically rigorous literature search, there are limited data on functional neurological disorder and functional somatic syndromes among SGM people. Several studies reported increased prevalence of select conditions among transgender people. More observational studies are needed regarding the epidemiology and clinical course of functional disorders among SGM people.

Measuring Ambulatory Racial and Ethnic Neurologic Disparities With the Axon Registry.

Background and Objectives: The primary objective is to examine potential racial and ethnic (R/E) disparities in ambulatory neurology quality measures within the American Academy of Neurology Axon Registry. R/E disparities in neurologic US morbidity and mortality have been clearly documented. Despite these findings, there have been no nationwide examinations of how ambulatory neurologic care affects these negative health outcomes. Methods: This was a retrospective nonrandomized cohort study of patients in the AAN Axon Registry. The Axon Registry is a neurology-specific outpatient quality registry that collects, reports, and analyzes real-world deidentified electronic health record (EHR) data. Patients were included in the study if they contributed toward one of the selected quality measures for multiple sclerosis, epilepsy, Parkinson disease, or headache during the study period of January 1, 2019-December 31, 2019. Descriptive analyses of patient demographics were performed and then stratified by race and ethnicity. Results: There were a total of 633,672 patients included in these analyses. Separate analyses were performed for race (64% White, 8% Black, 1% Asian, and 27% unknown) and ethnicity (52% not Hispanic, 5% Hispanic, and 43% unknown). The mean age ranged from 18 to 55 years, with 61% female and 39% male. Quality measures were chosen based on completeness of R/E data and were either process or outcomes focused. Statistically significant differences were noted after controlling for multiple comparisons. Discussion: The large proportion of missing or unknown R/E data and low overall rate of performance on these quality measures made the relevance of small differences difficult to determine. This analysis demonstrates the feasibility of using the Axon Registry to assess neurologic disparities in outpatient care. More education and training are required on the accurate capture of R/E data in the EHR.

Social Determinants of Health in Neurology.

Neurologic health disparities are created and perpetuated by structural and social determinants of health. These factors include, but are not limited to, interpersonal bias, institutional factors that lead to disparate access to care, and neighborhood-level factors, such as socioeconomic status, segregation, and access to healthy food. Effects of these determinants of health can be seen throughout neurology, including in stroke, epilepsy, headache, amyotrophic lateral sclerosis, multiple sclerosis, and dementia. Interventions to improve neurologic health equity require multilayered approaches to address these interdependent factors that create and perpetuate disparate neurologic health access and outcomes.

Migraine, Migraine Disability, Trauma, and Discrimination in Sexual and Gender Minority Individuals.

OBJECTIVE: This study sought to describe migrainous headache frequency and severity and to examine the relationship between trauma, discrimination, and migraine-associated disability in a sample of sexual and/or gender minority (SGM) adults. METHODS: We performed a cross-sectional study of SGM people in The Population Research in Identity and Disparities for Equality (PRIDE) Study from August-October 2018. The primary exposure was any trauma or discrimination, regardless of attribution. The primary outcome was moderate-severe migraine disability, as defined by a Migraine Disability Assessment (MIDAS) Questionnaire score ≥11. We performed descriptive analysis comparing respondents with any migrainous headache to those without. Multivariable logistic regression examined the association between trauma/discrimination and migraine disability, controlling first for sociodemographic and clinical factors and then for psychiatric comorbidities. RESULTS: Of the 3,325 total respondents, 1,126 (33.9%) screened positive for migrainous headache by ID-Migraine criteria. Most people with migraine self-reported moderate (n=768, 68.2%) or severe (n=253, 22.5%) intensity. The median MIDAS score was 11 (interquartile range [IQR] 5-25). Most respondents with migraine (n=1055, 93.7%) reported a history of trauma or discrimination. In unadjusted analysis, exposure to both trauma and discrimination was associated with higher odds of moderate-severe disability (OR 1.76, 95% CI 1.34-2.32). After adjustment for self-reported psychiatric comorbidities of anxiety, depression, and post-traumatic stress disorder, this association lost statistical significance. CONCLUSION: Migrainous headache is common among our sample of SGM adults, and prior experiences with trauma and discrimination is associated with increased migraine disability. Our findings suggest that psychiatric comorbidities play a significant role in this relationship, identifying a potentially modifiable risk factor for disability in SGM people with migraine.

Expanding sexual and gender minority research in movement disorders: More than awareness and acceptance.

Culturally competent and inclusive care is slowly becoming the standard throughout healthcare institutions. Awareness, acceptance, and inclusion of the sexual and gender minority (SGM) groups in medicine and neurology are progressing. Research in SGM health, although increasing, remains remarkably scant in parkinsonism and other movement disorders, a community whose patient population is on the rise. Most SGM health research in movement disorders only focuses on the symptoms associated with infection by the human immunodeficiency virus and the acquired immunodeficiency syndrome. Multiple clinical and epidemiological research questions remain unaddressed when considering the intersection of movement disorders and SGM health. In this article, we highlight gaps in the care of SGM individuals with movement disorders. First, the prevalence and phenomenology of movement disorders could be different, considering the different rates of risk factors and the use of gender-affirming hormones. Also, the effect of creating a safe environment in healthcare institutions to disclose sexual orientation and gender identity on seeking care, access to resources, and quality of services remains unknown. Moreover, many individuals with movement disorders would require services from multidisciplinary teams or long-term care facilities, which might not consider the needs of SGM patients in their models of care. Last, the effect of social isolation and self-perception (or misperceptions) in the SGM populations on the non-motor and motor symptoms of movement disorders and the treatment plans is not understood.

Lessons Learned From an Integrated Neurology Diversity, Equity, and Inclusion Curriculum.

The University of California San Francisco Neurology Department incorporated a formal diversity, equity, and inclusion curriculum into the residency education in 2015. During that time, we have learned a number of lessons that can be useful to other institutions planning similar initiatives including the following: (1) training should be led by a multidisciplinary team with experienced educators, (2) sustainability of the curriculum requires broad departmental buy-in from leadership to junior faculty to the residents themselves, (3) the curriculum needs to balance training on fundamental topics with flexibility to change in response to current events and the needs of the community, and (4) the sessions need to be practical.

Sexual and Gender Minority Health in Neurology: A Scoping Review.

Importance: Little is known about the neurologic health needs of sexual and gender minority (SGM) individuals, and existing research indicates health care disparities for this group. Objective: To describe the current state of science in SGM neurology and highlight areas of knowledge and gaps to guide future research. Evidence Review: All articles published before April 12, 2020, in PubMed, Embase, Web of Science, PsycInfo, CINAHL, and BIOSIS Previews were searched using a search string encompassing SGM descriptors and neurologic disorders. A total of 8359 items were found and entered into EndNote, and 2921 duplicates were removed. A blind title and abstract review was performed followed by full-text review in duplicate, with conflicts settled through consensus, to identify 348 articles eligible for data abstraction. Articles presenting primary data about an identified adult SGM population addressing a clinical neurology topic were included. Descriptive statistics were used for abstracted variables. Findings: Of 348 studies, 205 (58.9%) were case reports or series, 252 (72.4%) included sexual minority cisgender men, and 247 (70.9%) focused on HIV. An association was found between autism spectrum disorder and gender dysphoria in 9 of 16 studies (56.3%), and a higher risk of ischemic stroke in transgender women was shown in other studies. Literature in neuroinfectious disease, the most common topic, largely focused on HIV (173 of 200 studies [86.5%]). Findings in other neurologic topics were limited by lack of data. Conclusions and Relevance: In this rigorous compendium of SGM neurology literature, several deficiencies were found: most studies focused on a limited breadth of neurologic pathology, included only a portion of the overall SGM community, and did not assess other aspects of sociodemographic diversity that may contribute to disparities in health care access and outcomes among SGM individuals. Expanding neurologic research to include broader representation of SGM individuals and incorporating sociodemographic factors, like race/ethnicity and socioeconomic status, are essential steps toward providing equitable neurologic care for this community.