Suicidal Ideation Disparities Among Transgender and Gender Diverse Compared to Cisgender Community Health Patients.

BACKGROUND: Transgender and gender diverse (TGD) individuals experience more severe psychological distress and may be at higher risk for suicide compared to cisgender individuals. The existing literature largely consists of small-sample studies that do not assess subgroup differences. OBJECTIVE: To examine rates of self-reported suicidal ideation among four TGD groups compared to cisgender individuals. DESIGN: Data were extracted from the electronic health records of patients receiving primary care at a community health center specializing in sexual and gender minority health. A logistic regression was used to examine the relationship between sociodemographic variables and the presence of current suicidal ideation. PARTICIPANTS: 29,988 patients receiving care at a community health center in Northeastern US between 2015 and 2018. MAIN MEASURES: Demographic questionnaire, 9-item Patient Health Questionnaire KEY RESULTS: Younger age, sexual and gender minority identity, and public/grants-based insurance were associated with significantly higher odds of suicidal ideation. Relative to cisgender men, transgender men (OR=2.08; 95% CI=1.29-3.36; p=.003), transgender women (OR=3.08; 95% CI=2.05-4.63; p<.001), nonbinary (NB) individuals assigned male at birth (AMAB; OR=3.55; 95% CI=1.86-6.77; p<001), and NB individuals assigned female at birth (AFAB; OR=2.49; 95% CI=1.52-4.07; p<001) all endorsed significantly higher odds of current suicidal ideation, controlling for age, race, ethnicity, sexual orientation, and insurance status. Larger proportions of transgender women (23.6%) and NB AMAB individuals (26.7%) reported suicidal ideation not only compared to cisgender men (6.1%) and women (6.6%), but also compared to transgender men (17.4%; χ2[5, n=25,959]=906.454, p<0.001). CONCLUSIONS: TGD patients were at significantly increased risk of suicidal ideation, even after accounting for age, race, ethnicity, sexual orientation, and insurance status. Findings suggest distinct risk profiles by assigned sex at birth. Consistent assessment of and intervention for suicidal ideation should be prioritized in settings that serve TGD patients.

Decreased Anogenital Gonorrhea and Chlamydia in Transgender and Gender Diverse Primary Care Patients Receiving Gender-Affirming Hormone Therapy.

BACKGROUND: Transgender and gender diverse (TGD) adults in the U.S. experience health disparities, including in anogenital sexually transmitted infections (STI). Gender-affirming hormone therapy (GAHT) is known to be medically necessary and improve health. Few studies have assessed the effect of GAHT on STI diagnoses. OBJECTIVE: To evaluate the effect of GAHT delivered in primary care as an intervention to improve STI outcomes for TGD adults. DESIGN: LEGACY is a longitudinal, multisite cohort study of adult TGD primary care patients from two federally qualified community health centers in Boston, MA, and New York, NY. PARTICIPANTS: Electronic health record data for eligible adult TGD patients contributed to the LEGACY research data warehouse (RDW). A total of 6330 LEGACY RDW patients were followed from 2016 to 2019, with 2555 patients providing STI testing data. MAIN MEASURES: GAHT exposure was being prescribed hormones, and the clinical outcome was anogenital gonorrhea or chlamydia diagnoses. Log-Poisson generalized estimating equations assessed the effect of prescription GAHT on primary outcomes, adjusting for age, race, ethnicity, gender identity, poverty level, health insurance, clinical site, and cohort years. KEY RESULTS: The median age was 28 years (IQR = 13); the racial breakdown was 20.4% Black, 8.1% Multiracial, 6.9% Asian/Pacific Islander, 1.8% Other; 62.8% White; 21.3% Hispanic/Latinx; 47.0% were assigned female at birth, and 16.0% identified as nonbinary. 86.3% were prescribed hormones. Among those tested, the percentage of patients with a positive anogenital STI diagnosis ranged annually from 10.0 to 12.5% between 2016 and 2019. GAHT prescription was associated with a significant reduction in the risk of anogenital STI diagnosis (aRR = 0.75; 95% CI = 0.59-0.96) over follow-up. CONCLUSIONS: GAHT delivered in primary care was associated with less STI morbidity in this TGD cohort over follow-up. Patients may benefit from individualized and tailored clinical care alongside GAHT to optimize STI outcomes.

Sexual Orientation and Gender Identity Data Completeness at US Federally Qualified Health Centers, 2020 and 2021.

Objectives. To assess the performance of US federally qualified health centers (FQHCs) after 6 years of required sexual orientation and gender identity (SOGI) data reporting and update estimated proportions of sexual and gender minorities cared for at FQHCs. Methods. We conducted secondary analyses of data reported to the 2020 and 2021 Uniform Data System from 1297 FQHCs caring for nearly 30 000 000 patients annually. We used multivariable logistic regression to explore FQHC-level and patient-level factors associated with SOGI data completeness. Results. SOGI data were missing for 29.1% and 24.0% of patients, respectively. Among patients with reported SOGI data, 3.5% identified as sexual minorities and 1.5% identified as gender minorities. Southern FQHCs and those caring for more low-income and Black patients were more likely to have above-average SOGI data completeness. Larger FQHCs were more likely to have below-average SOGI data completeness. Conclusions. Substantial increases in SOGI data completeness at FQHCs over 6 years reflect the success of reporting mandates. Future research is needed to identify other patient-level and FQHC-level factors contributing to residual levels of SOGI data missingness. (Am J Public Health. 2023;113(8):883-892. https://doi.org/10.2105/AJPH.2023.307323).

Clinical and Behavioral Outcomes for Transgender Women Engaged in HIV Care: Comparisons to Cisgender Men and Women in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) Cohort.

Describe health of transgender women (TW) with HIV vs. cisgender men and women (CM, CW) in a U.S. HIV care cohort. Data were from Centers for AIDS Research Network of Integrated Clinical Systems (CNICS), 2005-2022. TW were identified using clinical data/identity measures. PWH (n = 1285) were included in analyses (275 TW, 547 CM, 463 CW). Cross-sectional multivariable analyses compared HIV outcomes/co-morbidities between TW/CM and TW/CW, and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were estimated. TW had poorer adherence (> 90% adherent; aOR 0.57; 95%CI 0.38, 0.87) and were more likely to miss ≥ 3 visits in the past year than CM (aOR 1.50, 95%CI 1.06, 2.10); indicated more anxiety compared to both CM and CW (p ≤ 0.001, p = 0.02); hepatitis C infection (p = 0.03) and past-year/lifetime substance treatment (p = 0.004/p = 0.001) compared to CM; and substance use relative to CW. TW with HIV differed in HIV clinical outcomes and co-morbidities from CM and CW.

Patterns of E-Cigarette Use Among Primary Care Patients at an Urban Community Center.

Tobacco use remains the leading cause of preventable disease and death in the US. The number of tobacco products has grown over the past decade. E-cigarette use has increased rapidly in recent years, but patterns and correlates of use have not been thoroughly assessed. We examined relationships among demographic factors, e-cigarette and conventional cigarette use in a large sample (N = 12,409) of adult patients at a community health center in the Northeastern US. Overall, 13% (N = 1675) of the sample reported ever using e-cigarettes. In logistic regression models, ever having used e-cigarettes was associated with younger age (ages 18-25; OR = 3.5, p < 0.001). Being transgender (OR = 1.8, p < 0.001), bisexual (OR = 1.5, p < 0.001), un-partnered (OR = 1.5, p < 0.001), having a lower income (OR = 1.6, p < 0.001) or a high BMI (OR = 1.4, p = 0.009) were associated with increased odds of use, whereas being a woman (OR = 0.7, p < 0.001) or Black/African American (OR = 0.7, p = 0.007) were associated with lower odds of use. Of the participants who reported e-cigarette use, a majority also endorsed current or former use of conventional cigarettes. Individuals who formerly used conventional cigarettes were nearly three times more likely to report daily e-cigarette use than current users. Among primary care patients at a community health center, e-cigarette use was reported by a sizeable portion of the sample. Overall, odds of use were higher in certain patient populations, and individuals who formally used cigarettes were more likely to report e-cigarette use than individuals who currently smoke, suggesting that e-cigarettes may be functioning as a cessation aid or a strategy to reduce conventional cigarette use.

Different functional traits among closely related algal symbionts dictate stress endurance for vital Indo-Pacific reef-building corals.

Reef-building corals in the genus Porites are one of the most important constituents of Indo-Pacific reefs. Many species within this genus tolerate abnormally warm water and exhibit high specificity for particular kinds of endosymbiotic dinoflagellates that cope with thermal stress better than those living in other corals. Still, during extreme ocean heating, some Porites exhibit differences in their stress tolerance. While corals have different physiological qualities, it remains unknown whether the stability and performance of these mutualisms is influenced by the physiology and genetic relatedness of their symbionts. We investigated two ubiquitous Pacific reef corals, Porites rus and Porites cylindrica, from warmer inshore and cooler offshore reef systems in Palau. While these corals harbored a similar kind of symbiont in the genus Cladocopium (within the ITS2 C15 subclade), rapidly evolving genetic markers revealed evolutionarily diverged lineages corresponding to each Porites species living in each reef habitat. Furthermore, these closely related Cladocopium lineages were differentiated by their densities in host tissues, cell volume, chlorophyll concentration, gross photosynthesis, and photoprotective pathways. When assessed using several physiological proxies, these previously undifferentiated symbionts contrasted in their tolerance to thermal stress. Symbionts within P. cylindrica were relatively unaffected by exposure to 32℃ for 14 days, whereas P. rus colonies lost substantial numbers of photochemically compromised symbionts. Heating reduced the ability of the offshore symbiont associated with P. rus to translocate carbon to the coral. By contrast, high temperatures enhanced symbiont carbon assimilation and delivery to the coral skeleton of inshore P. cylindrica. This study indicates that large physiological differences exist even among closely related symbionts, with significant implications for thermal susceptibility among reef-building Porites.

Sexual Orientation and Gender Identity Data Collection at US Health Centers: Impact of City-Level Structural Stigma in 2018.

Objectives. To examine the relationship between city-level structural stigma pertaining to sexual orientation and gender identity (SOGI) and completeness of patient SOGI data collection at US federally qualified health centers (FQHCs). Methods. We used the Human Rights Campaign's Municipal Equality Index to quantify city-level structural stigma against sexual and gender minority people in 506 US cities across 49 states. We ascertained the completeness of SOGI data collection at FQHCs from the 2018 Uniform Data System, which describes FQHC patient demographics and service utilization. We included FQHCs in cities captured by the structural stigma index in multinomial generalized linear mixed models to examine the relationship between city-level structural stigma and SOGI data completeness. Results. FQHCs in cities with more protective sexual orientation nondiscrimination policies reported more complete patient sexual orientation data (adjusted odds ratio [AOR] = 1.6; 95% confidence interval [CI] = 1.2, 2.1). This association was also found for gender identity nondiscrimination policies and gender identity data collection (AOR = 1.7; 95% CI = 1.3, 2.2). Conclusions. Municipal sexual and gender minority nondiscrimination laws are associated with social and municipal environments that facilitate patient SOGI data collection.(Am J Public Health. 2021;111(11):2059-2063. https://doi.org/10.2105/AJPH.2021.306414).

Capturing Relevant Patient Data in Clinical Encounters Through Integration of an Electronic Patient-Reported Outcome System Into Routine Primary Care in a Boston Community Health Center: Development and Implementation Study.

BACKGROUND: Electronic patient-reported outcome (ePRO) systems can improve health outcomes by detecting health issues or risk behaviors that may be missed when relying on provider elicitation. OBJECTIVE: This study aimed to implement an ePRO system that administers key health questionnaires in an urban community health center in Boston, Massachusetts. METHODS: An ePRO system that administers key health questionnaires was implemented in an urban community health center in Boston, Massachusetts. The system was integrated with the electronic health record so that medical providers could review and adjudicate patient responses in real-time during the course of the patient visit. This implementation project was accomplished through careful examination of clinical workflows and a graduated rollout process that was mindful of patient and clinical staff time and burden. Patients responded to questionnaires using a tablet at the beginning of their visit. RESULTS: Our program demonstrates that implementation of an ePRO system in a primary care setting is feasible, allowing for facilitation of patient-provider communication and care. Other community health centers can learn from our model in terms of applying technological innovation to streamline clinical processes and improve patient care. CONCLUSIONS: Our program demonstrates that implementation of an ePRO system in a primary care setting is feasible, allowing for facilitation of patient-provider communication and care. Other community health centers can learn from our model for application of technological innovation to streamline clinical processes and improve patient care.

Evaluation of 4 Algorithms to Identify Incident Syphilis Among HIV-Positive Men Who Have Sex With Men Engaged in Primary Care.

We developed 4 algorithms for syphilis among HIV-positive men who have sex with men who engaged in primary care in 2016 to 2017. Clinician-based diagnosis from chart reviews was the gold standard. Sensitivities ranged from 74.2% to 93.9%. Specificities were greater than 99% with positive and negative predictive values of greater than 95%. Algorithms that incorporated treatment data performed best.

Increasing Syphilis Detection Among Patients Assigned Male at Birth Screened at a Boston Community Health Center Specializing in Sexual and Gender Minority Health, 2005-2015.

BACKGROUND: United States syphilis rates have increased to levels last seen in the 1990s. We examined syphilis epidemiology of patients attending a Boston community health center specializing in sexual and gender minority health. METHODS: We performed a retrospective cohort study of all patients assigned male at birth screened with rapid plasma reagin from 2005 through 2015. We developed an algorithm to identify new infections and used repeat cross-sectional analysis to assess temporal trends in syphilis diagnoses. We also performed longitudinal analysis to calculate syphilis incidence using a Cox proportional hazards model that accounts for multiple infections over time. RESULTS: Eighteen thousand two hundred eighty-two patients had a total of 57,080 rapid plasma reagins, 1170 (2.0%) tests met criteria for syphilis. Adjusted syphilis diagnoses increased from 1.2% to 1.9%, recurrent syphilis diagnoses increased from 0.04% to 0.3% during the study period. Black and Hispanic/Latinx patients, patients aged 35 to 44 years, gay/bisexual patients, cisgender men, and human immunodeficiency virus (HIV)-infected patients and those who became HIV-infected during the study period were more likely to test positive for syphilitic infection in repeat cross-sectional analysis. Among 6199 patients screened more than 1 time over 21,745 person-years, there were 661 new syphilis cases (3.0% annual incidence; 95% confidence interval [CI], 2.8% to 3.2%). Compared with those aged 14 to 24 years, patients 45 years or older were less likely to experience syphilis. New HIV infection was associated with increased risk of incident syphilis (adjusted hazard ratio, 2.87; 95% CI, 1.61-5.13). Virally suppressed HIV-infected patients were less likely to experience incident syphilis (adjusted hazard ratio, 0.69; 95% CI, 0.55-0.87). CONCLUSIONS: The high incidence of syphilis among patients assigned male at birth disproportionately affected young patients, black and Hispanic/Latinx patients, gay/bisexual patients, cisgender men, and those with new or chronic HIV infection. Syphilitic reinfection rates increased over time.

Required Sexual Orientation and Gender Identity Reporting by US Health Centers: First-Year Data.

Objectives. To assess the performance of US health centers during the first year of required sexual orientation and gender identity (SOGI) data reporting and to estimate the baseline proportion of lesbian, gay, bisexual, and transgender patients accessing health centers. Methods. We conducted a secondary analysis of SOGI data from 2016. These data were reported by 1367 US health centers caring for 25 860 296 patients in the United States and territories. Results. SOGI data were missing for 77.1% and 62.8% of patients, respectively. Among patients with data, 3.7% identified as lesbian, gay, bisexual, or something else; 0.4% identified as transgender male or female; 27.5% did not disclose their sexual orientation; and 9.3% did not disclose their gender identity. Conclusions. Although health centers had a high percentage of missing SOGI data in the first year of reporting, among those with data, the percentages of lesbian, gay, bisexual, and transgender people were similar to national estimates, and disclosure was more than 70%. Future data collection efforts would benefit from increased training for health centers and improved messaging on the clinical benefits of SOGI data collection and reporting.

HIV Preexposure Prophylaxis as a Gateway to Primary Care.

OBJECTIVES: To determine whether HIV preexposure prophylaxis (PrEP) use is associated with use of non-HIV-related health care. METHODS: We conducted a cross-sectional study of potential PrEP candidates at a Boston, Massachusetts, community health clinic during 2012 to 2016, comparing the proportion of PrEP users and non-PrEP users receiving primary care. RESULTS: Of 5857 PrEP candidates, 2047 (35%) were prescribed PrEP. After adjustment for demographics and number of visits, more PrEP users received influenza vaccination (prevalence ratio [PR] = 1.28; 95% confidence interval [CI] = 1.20, 1.37), tobacco screening (PR = 1.06; 95% CI = 1.02, 1.09), and depression screening (PR = 1.07; 95% CI = 1.04, 1.11) compared with non-PrEP users. After additional adjustment for diabetes, hypertension, and overweight or obesity, more PrEP users received glucose testing (PR = 1.64; 95% CI = 1.56, 1.72) but fewer received hemoglobin A1c testing (PR = 0.81; 95% CI = 0.71, 0.93) compared with non-PrEP users. CONCLUSIONS: PrEP use was associated with receipt of influenza vaccination, tobacco and depression screening, and glucose but not hemoglobin A1c testing. Among PrEP users receiving routine care, the benefits of PrEP may extend to behavioral health, mental health, and prevention and treatment of other infectious and chronic diseases.

Treatment Outcomes Associated with Quitting Cigarettes Among Sexual Minority Men Living with HIV: Antiretroviral Adherence, Engagement in Care, and Sustained HIV RNA Suppression.

Cigarette smoking is particularly harmful for sexual minority men living with HIV. This study aimed to find benefits of quitting by examining relationships between smoking and sustained HIV RNA suppression, recent CD4 count, ART medication adherence, and engagement in HIV medical care. Sexual minority men (n = 346), former or current smokers, received HIV care at a community health center. Survey responses were combined with electronic health record data in adjusted regression models. Most patients were Caucasian (87%) and 148 (46%) had incomes below the poverty level and 80% had sustained HIV RNA suppression. Compared to current smokers, former smokers had increased odds of sustaining HIV RNA suppression (OR 1.89; 95% CI 1.02-3.48) of reporting > 90% adherence (OR 2.25; 95% CI 1.21-4.17), and were less likely to miss appointments (OR 0.37; 95% CI 0.17-0.82). Heavier smokers (OR 0.36; 95% CI 0.17-0.77) and patients who smoked the longest (OR 0.31; 95% CI 0.14-0.68) had reduced odds of sustaining HIV RNA suppression. Smoking assessment, treatment, and referral could augment HIV outcomes for sexual minority men with HIV.

Co-occurring psychosocial problems predict HIV status and increased health care costs and utilization among sexual minority men.

Sexual orientation related health disparities are well documented. Sexual minority men appear to be at risk for mental health problems due to the stress they experience in establishing and maintaining a minority sexual identity. These mental health issues may combine synergistically and lead to higher medical costs to society. We examine whether sexual minority specific syndemic indicators were associated with higher health care costs, health care utilization, or the risk of being HIV-infected. Health care consumers at a community health center (N = 1211) completed a brief screening questionnaire collected over 12 months. Self-reported data were linked with participants' clinical billing records. Adjusted logistic regression models identified that four syndemic indicators (suicidality, substance use, childhood sexual abuse, and intimate partner violence) were each significantly related to each other. Multiple syndemics significantly predicted higher medical care utilization and cost, and were associated with 2.5 times the risk of being HIV-infected (OR 2.49, 95% CI 1.45-4.25). Syndemic indicators did not significantly predict the number of mental health visits or costs per patient. These results confirm and extend earlier findings by relating syndemics to health services use and costs for sexual minority men.

The Association of Health Seeking Behaviors With Human Papillomavirus Vaccination Status Among High-Risk Urban Youth.

BACKGROUND: Vaccination is the primary strategy to reduce the burden of human papillomavirus (HPV) related diseases in the United States. Unvaccinated youth are at risk for HPV infection and associated diseases, and limited research has explored factors associated with HPV vaccination among those who are disadvantaged and at high risk, including lesbian, gay, bisexual, transgender and queer and/or homeless. METHODS: A retrospective electronic medical record review was conducted at an urban, homeless, and lesbian, gay, bisexual, transgender and queer focused health center in northeastern US logistic regression models examined the associations between HPV vaccination and demographic/social characteristics and health behaviors. RESULTS: A total of 1211 men and 1326 women (gender at birth) records were reviewed from patients (ages 13-26 years) who presented for care between January 2010 and June 2013. The sample was diverse, and about half identified as heterosexual and reported stable/secure housing. Approximately 8% of men and 29% of women had obtained ≥ 1 HPV vaccine dose. The strongest predictors of vaccine initiation were health-related behaviors: having an annual examination, obtaining a non-HPV vaccine, and engaging in oral sex. Additionally, for women only, having had a Pap test or a sexually transmitted infection visit were also associated with an increase in odds, whereas identifying as transmale decreased the odds of vaccination. Having private insurance was the only predictor of 3-dose completion (women only). CONCLUSIONS: Among a high-risk adolescent sample, primarily health-seeking behaviors increased the odds of HPV vaccination, reinforcing the importance of providers using various routine preventative visits as opportunities/cues to vaccine.

The Predictive Syndemic Effect of Multiple Psychosocial Problems on Health Care Costs and Utilization among Sexual Minority Women.

Previous studies documenting sexual minority women's disproportionate risk for a range of medical, mental health, and substance use disorders have not provided a predictive framework for understanding their interrelations and outcomes. The present study aimed to address this gap by testing the syndemic effect of co-occurring psychosocial problems on 7-year health care costs and utilization among sexual minority women. The sample was comprised of sexual minority women (N = 341) who were seen at an urban LGBT-affirmative community health center. Medical and mental health care utilization and cost data were extracted from electronic medical records. Demographically adjusted regression models revealed that co-occurring psychosocial problems (i.e., childhood sexual abuse, partner violence, substance use, and mental health distress [history of suicide attempt]) were all strongly interrelated. The presence of these indicators had a syndemic (additive) effect on medical costs and utilization and mental health utilization over 7-year follow-up, but no effect on 7-year mental health costs. These results suggest that the presence and additive effect of these syndemic conditions may, in part, explain increased medical costs and utilization (and higher medical morbidity) among sexual minority women.

Comprehensive transgender healthcare: the gender affirming clinical and public health model of Fenway Health.

This report describes the evolution of a Boston community health center's multidisciplinary model of transgender healthcare, research, education, and dissemination of best practices. This process began with the development of a community-based approach to care that has been refined over almost 20 years where transgender patients have received tailored services through the Transgender Health Program. The program began as a response to unmet clinical needs and has grown through recognition that our local culturally responsive approach that links clinical care with biobehavioral and health services research, education, training, and advocacy promotes social justice and health equity for transgender people. Fenway Health's holistic public health efforts recognize the key role of gender affirmation in the care and well-being of transgender people worldwide.

Body mass index, depression, and condom use among HIV-infected men who have sex with men: a longitudinal moderation analysis.

Findings have been inconsistent regarding the association of obesity and sexual risk behaviors. The purpose of the current study was to assess the prospective nature of body mass index (BMI), depression, and their interaction in predicting condom use during anal intercourse among HIV-infected men who have sex with men (MSM). The sample (N = 490) was obtained from a large, HIV clinical cohort from four sites across the U.S. The following inclusion criteria were employed: identification as MSM and had completed at least one wave of patient-reported measures (e.g., depression, as measured by the PHQ-9) in the clinical cohort study. Longitudinal linear mixed-effects modeling revealed a significant BMI by depression interaction. Depressive symptoms were predictive of less frequent condom use for obese but not overweight men. Analogous results were found in regard to comparisons between normal weight and overweight men. Obesity, in the context of depression, is a risk factor for unprotected anal intercourse among HIV-infected MSM. Cognitive behavioral interventions to reduce HIV transmission risk behaviors among HIV-infected MSM should adopt an integrated perspective, combining sexual risk reduction with treatment for depression and body-related concerns.