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JAMA Network Open Apr 2023Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of...
IMPORTANCE
Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy.
OBJECTIVE
To identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation.
EVIDENCE REVIEW
In this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080).
FINDINGS
In total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate.
CONCLUSIONS AND RELEVANCE
In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs.
Topics: Humans; Patient Reported Outcome Measures; Transgender Persons; Transsexualism; Quality of Life
PubMed: 37010869
DOI: 10.1001/jamanetworkopen.2023.6425 -
Current HIV/AIDS Reports Aug 2023Sexual and gender minority (SGM) individuals are diagnosed with HIV at disproportionate rates, and hazardous alcohol use can increase their HIV risk. This review... (Review)
Review
PURPOSE OF REVIEW
Sexual and gender minority (SGM) individuals are diagnosed with HIV at disproportionate rates, and hazardous alcohol use can increase their HIV risk. This review assessed the state of the literature examining interventions for addressing alcohol use and sexual HIV risk behaviors among SGM individuals.
RECENT FINDINGS
Fourteen manuscripts from 2012 to 2022 tested interventions that address both alcohol use and HIV risk behaviors among SGM populations, with only 7 randomized controlled trials (RCTs). Virtually all the interventions targeted men who have sex with men, with none focused on transgender populations or cisgender women. While they demonstrated some evidence of effectiveness in reducing alcohol use and/or sexual risk, the outcomes varied widely between studies. More research is needed that tests interventions in this area, particularly for transgender individuals. The use of larger-scale RCTs with diverse populations and standardized outcome measures are needed to strengthen the evidence base.
Topics: Male; Female; Humans; HIV Infections; Sexual and Gender Minorities; Sexual Behavior; Alcohol Drinking; Transgender Persons; Gender Identity
PubMed: 37225923
DOI: 10.1007/s11904-023-00660-2 -
AIDS Patient Care and STDs Jun 2022HIV pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV; however, PrEP use among transgender individuals remains low. We conducted a systematic review...
HIV pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV; however, PrEP use among transgender individuals remains low. We conducted a systematic review to identify barriers and facilitators to PrEP uptake, adherence, and persistence among transgender individuals in the United States. We conducted a literature search in PubMed and CINAHL databases in March 2021 and followed PRISMA guidelines. Studies were eligible if they were published in a peer-reviewed journal and reported interest, uptake, adherence, and/or persistence of PrEP use among transgender individuals. Articles that did not disaggregate results for transgender participants were excluded. Data from included articles were coded using content analysis and narratively synthesized using a framework matrix. We screened 254 unique articles published after US Food and Drug Administration approval of PrEP, and 33 articles were included in the review. Five themes were identified in the literature, including (1) PrEP concentrations were lower among individuals taking feminizing hormones, but the difference did not appear clinically significant; (2) concerns regarding interactions between gender-affirming hormone therapy and PrEP remain a large barrier; (3) PrEP initiation may facilitate increased self-advocacy and self-acceptance; (4) lack of trust in medical institutions impacts PrEP uptake; and (5) social networks have a significant influence on PrEP knowledge, interest, and adherence. Additional research is needed involving transgender men and nonbinary persons, and efforts to improve PrEP persistence among the transgender community are needed. Training health care providers to provide inclusive and affirming care is perhaps one of the strongest areas for intervention to increase PrEP uptake and persistence.
Topics: Anti-HIV Agents; HIV Infections; Homosexuality, Male; Humans; Male; Pre-Exposure Prophylaxis; Transgender Persons; Transsexualism; United States
PubMed: 35687813
DOI: 10.1089/apc.2021.0236 -
BMC Public Health Dec 2023Evidence from many parts of the world shows that sexual and gender minority (SGM) people have poorer health than their cisgender heterosexual counterparts. Minority... (Review)
Review
Health disparities in one of the world's most progressive countries: a scoping review of mental health and substance use among sexual and gender minority people in the Netherlands.
BACKGROUND
Evidence from many parts of the world shows that sexual and gender minority (SGM) people have poorer health than their cisgender heterosexual counterparts. Minority stressors, particularly stigma and discrimination, have been identified as major contributors to sexual orientation- and gender identity-related health disparities, particularly negative mental health and behavioral health outcomes. To better understand factors that contribute to these disparities, we conducted a scoping review of SGM mental health and substance use research in the Netherlands-a country with a long-standing reputation as a pioneer in SGM equality.
METHODS
Using Joanna Briggs Institute guidelines and the PRISMA-ScR protocol, we searched seven databases to identify studies published between 2010 and 2022 that focused on substance use and/or mental health of SGM youth and adults in the Netherlands.
RESULTS
Although there was some evidence that SGM people in the Netherlands report fewer substance use and mental health concerns than those in less progressive countries, with very few exceptions studies found poorer outcomes among SGM participants than cisgender, heterosexual participants. However, this observation must be considered cautiously given major gaps in the literature. For example, only one study focused exclusively on adult sexual minority women, two focused on older SGM adults, and very little attention was given to nonbinary individuals. Most studies used non-probability samples that were quite homogenous. Many studies, especially those with youth, assessed sexual orientation based on sexual attraction; some studies of adults operationalized SGM status as having a same-sex partner. Importantly, we found no studies that directly assessed associations between structural-level stigma and health outcomes. Studies were mostly focused at the individual level and on health problems; very little attention was given to strengths or resilience.
CONCLUSIONS
Findings of persistent health disparities-despite the relatively long history of SGM supportive policies in the Netherlands-highlight the need for more research and greater attention to population groups that have been underrepresented. Such research would not only provide guidance on strategies to improve the health of SGM people in the Netherlands, but also in other countries that are seeking to reduce health inequities. Addressing SGM health disparities in the Netherlands and elsewhere is complex and requires a multifaceted approach that addresses individual, interpersonal and structural factors.
Topics: Adult; Adolescent; Humans; Female; Male; Gender Identity; Mental Health; Netherlands; Sexual Behavior; Sexual and Gender Minorities; Substance-Related Disorders
PubMed: 38110908
DOI: 10.1186/s12889-023-17466-x -
Journal of Hypertension Feb 2021Gender-affirming hormone therapy (GHT) is utilized by people who are transgender to align their secondary sex characteristics with their gender identity. Data relating...
OBJECTIVES
Gender-affirming hormone therapy (GHT) is utilized by people who are transgender to align their secondary sex characteristics with their gender identity. Data relating to cardiovascular outcomes in this population are limited. We aimed to review the impact of GHT on the blood pressure (BP) of transgender individuals.
METHODS
We searched PubMed/MEDLINE, SCOPUS and Cochrane Library databases for articles published relating to the BP of transgender adults commencing GHT. Methodological quality was assessed via the 'Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group'.
RESULTS
Six hundred articles were screened, of which 14 studies were included in this systematic review encompassing 1309 individuals (∼50% transgender men and women) treated with GHT between 1989 and 2019. These articles were all pre-post observational studies without control groups. Mean ages ranged between 23.0-36.7 years (transgender men) and 25.2-34.8 years (transgender women). Interventions were diverse and included oral, transdermal and injectable hormonal preparations with 4 months to 5 years follow-up. Most studies in transgender men did not demonstrate a change in BP, whereas transgender women on GHT demonstrated both increases and decreases in SBP. These studies were heterogenous with significant methodological limitations and only two were determined to have a good quality rating.
CONCLUSION
There is currently insufficient data to advise the impact of GHT on BP in transgender individuals. Better quality research is essential to elucidate whether exogenous sex hormones modulate BP in transgender people and whether this putative alteration infers poorer cardiovascular outcomes.
Topics: Adult; Blood Pressure; Blood Pressure Monitoring, Ambulatory; Cohort Studies; Female; Gender Identity; Hormones; Humans; Male; Middle Aged; Prospective Studies; Transgender Persons; Young Adult
PubMed: 32809982
DOI: 10.1097/HJH.0000000000002632 -
Frontiers in Public Health 2023The representativeness of participants is crucial to ensure external validity of clinical trials. We focused on the randomized clinical trials which assessed COVID-19...
OBJECTIVE
The representativeness of participants is crucial to ensure external validity of clinical trials. We focused on the randomized clinical trials which assessed COVID-19 vaccines to assess the reporting of age, sex, gender identity, race, ethnicity, obesity, sexual orientation, and socioeconomic status in the results (description of the participants' characteristics, loss of follow-up, stratification of efficacy and safety results).
METHODS
We searched the following databases for randomized clinical trials published before 1st February 2022: PubMed, Scopus, Web of Science, and Excerpta Medica. We included peer-reviewed articles written in English or Spanish. Four researchers used the Rayyan platform to filter citations, first reading the title and abstract, and then accessing the full text. Articles were excluded if both reviewers agreed, or if a third reviewer decided to discard them.
RESULTS
Sixty three articles were included, which assessed 20 different vaccines, mainly in phase 2 or 3. When describing the participants' characteristics, all the studies reported sex or gender, 73.0% race, ethnicity, 68.9% age groups, and 22.2% obesity. Only one article described the age of participants lost to follow-up. Efficacy results were stratified by age in 61.9%, sex or gender in 26.9%, race and/or, ethnicity in 9.5%, and obesity in 4.8% of the articles. Safety results were stratified by age in 41.0%, and by sex or gender in 7.9% of the analysis. Reporting of gender identity, sexual orientation or socioeconomic status of participants was rare. Parity was reached in 49.2% of the studies, and sex-specific outcomes were mentioned in 22.9% of the analysis, most of the latter were related to females' health.
CONCLUSIONS
Axes of social inequity other than age and sex were hardly reported in randomized clinical trials that assessed COVID-19 vaccines. This undermines their representativeness and external validity and sustains health inequities.
Topics: Female; Humans; Male; COVID-19; COVID-19 Vaccines; Ethnicity; Gender Identity; Clinical Trials as Topic; Diversity, Equity, Inclusion
PubMed: 36891333
DOI: 10.3389/fpubh.2023.1069357 -
Archives of Sexual Behavior Oct 2023Sexual and dating violence (SDV) by male youth (≤ 25 years)-including sexual harassment, emotional partner violence, and rape-is a worldwide problem. The goal of...
Sexual and dating violence (SDV) by male youth (≤ 25 years)-including sexual harassment, emotional partner violence, and rape-is a worldwide problem. The goal of this preregistered (PROSPERO, ID: CRD42022281220) systematic review was to map existing SDV prevention programs aimed at male youth, including their characteristics (e.g., content, intensity), intended psychosexual outcomes, and empirically demonstrated effectiveness, guided by the principles of the theory of planned behavior (TPB). We conducted searches in six online databases for published, peer-reviewed quantitative effectiveness studies on multi-session, group focused, and interaction based SDV prevention programs for male youth ending March 2022. After screening of 21,156 hits using PRISMA guidelines, 15 studies on 13 different programs, from four continents were included. Narrative analysis showed, first, broad ranges in program intensity (2-48 h total), and few program curricula included explicit discussion of relevant aspects of the TPB. Second, programs' main intended psychosexual outcomes were to change SDV experiences, or related attitudes, or norms. Third, significant effects were found mostly on longer term behaviors and short-term attitudes. Other theoretical proxies of SDV experiences, such as social norms and perceived behavioral control, were sparsely investigated; thus, program effectiveness on these outcomes remains largely unknown. Assessed with the Cochrane Risk of Bias Tool, moderate to serious risk of bias arose in all studies. We present concrete suggestions for program content, such as explicit attention to victimization and masculinity and discuss best practices for evaluation research, including assessments of program integrity, and examining relevant theoretical proxies of SDV.
Topics: Humans; Male; Adolescent; Intimate Partner Violence; Rape; Sex Offenses; Violence; Sexual Harassment
PubMed: 37226034
DOI: 10.1007/s10508-023-02596-5 -
Drug and Alcohol Dependence Jun 2021Substance use-related stigma is a significant barrier to care among persons who use drugs (PWUD). Less is known regarding how intersectional identities, like gender,... (Review)
Review
BACKGROUND
Substance use-related stigma is a significant barrier to care among persons who use drugs (PWUD). Less is known regarding how intersectional identities, like gender, shape experiences of substance use-related stigma. We sought to answer the following question: Do men or women PWUD experience more drug use stigma?
METHODS
Data were drawn from a systematic review of the global, peer-reviewed scientific literature on substance use-related stigma conducted through 2017 and guided by the Stigma and Substance Use Process Model and PRISMA guidelines. Articles were included in the present analysis if they either qualitatively illustrated themes related to the gendered nature of drug use-related stigma, or quantitatively tested the moderating effect of gender on drug use-related stigma.
RESULTS
Of the 75 studies included, 40 (53 %) were quantitative and 35 (47 %) were qualitative. Of the quantitative articles, 22 (55 %) found no association between gender and drug use-related stigma, 4 (10 %) identified women who use drugs (WWUD) were more stigmatized, and 2 (5 %) determined men who use drugs (MWUD) were more stigmatized. In contrast, nearly all (34; 97 %) of the qualitative articles demonstrated WWUD experienced greater levels of drug use-related stigma.
CONCLUSION
The quantitative literature is equivocal regarding the influence of gender on drug use-related stigma, but the qualitative literature more clearly demonstrates WWUD experience greater levels of stigma. The use of validated drug use-related stigma measures and the tailoring of stigma scales to WWUD are needed to understand the role of stigma in heightening the disproportionate harms experienced by WWUD.
Topics: Female; Gender Identity; Humans; Male; Pharmaceutical Preparations; Social Stigma; Substance-Related Disorders
PubMed: 33901753
DOI: 10.1016/j.drugalcdep.2021.108706 -
International Journal of Health Policy... Aug 2022Human resources are at the heart of health systems, playing a central role in their functionality globally. It is estimated that up to 70% of the health workforce are...
BACKGROUND
Human resources are at the heart of health systems, playing a central role in their functionality globally. It is estimated that up to 70% of the health workforce are women, however, this pattern is not reflected in the leadership of health systems where women are under-represented.
METHODS
This systematized review explored the existing literature around women's progress towards leadership in the health sector in low- and middle-income countries (LMICs) which has used intersectional analysis.
RESULTS
While there are studies that have looked at the inequities and barriers women face in progressing towards leadership positions in health systems within LMICs, none explicitly used an intersectionality framework in their approach. These studies did nevertheless show recurring barriers to health systems leadership created at the intersection of gender and social identities such as professional cadre, race/ethnicity, financial status, and culture. These barriers limit women's access to resources that improve career development, including mentorship and sponsorship opportunities, reduce value, recognition and respect at work for women, and increase the likelihood of women to take on dual burdens of professional work and childcare and domestic work, and, create biased views about effectiveness of men and women's leadership styles. An intersectional lens helps to better understand how gender intersects with other social identities which results in upholding these persisting barriers to career progression and leadership.
CONCLUSION
As efforts to reduce gender inequity in health systems are gaining momentum, it is important to look beyond gender and take into account other intersecting social identities that create unique positionalities of privilege and/or disadvantage. This approach should be adopted across a diverse range of health systems programs and policies in an effort to strengthen gender equity in health and specifically human resources for health (HRH), and improve health system governance, functioning and outcomes.
Topics: Female; Humans; Developing Countries; Gender Identity; Health Workforce; Intersectional Framework; Leadership
PubMed: 33619934
DOI: 10.34172/ijhpm.2021.06 -
Nursing Outlook 2023In the US, sexual and gender minority (SGM) individuals continue to experience health inequities, and nursing curricula content and nursing faculty with SGM health...
A systematic review of U.S. nursing faculty's knowledge, awareness, inclusion, and perceived importance of sexual and gender minority-related content in nursing curricula.
BACKGROUND
In the US, sexual and gender minority (SGM) individuals continue to experience health inequities, and nursing curricula content and nursing faculty with SGM health expertise in the US remain limited. Addressing health disparities begins with the preparation of future nurses-US nursing faculty must be supported to meet these growing needs.
PURPOSE
To describe, appraise, and synthesize research from 2000-2020 on US nursing faculty knowledge, awareness, inclusion, and perceived importance of SGM health content.
METHODS
Following PRISMA 2020 guidelines, we registered a systematic review and appraisal protocol in PROSPERO, and then executed the protocol and synthesized the literature.
DISCUSSION
We found an empirical evidence base surrounding US nursing faculty and SGM health much more limited than expected. Only four cross-sectional, descriptive empirical articles fit the a priori inclusion criteria. The studies were of moderate quality at best and often relied on unvalidated or older measures. In general, the studies focused on examining characteristics of nursing programs, faculty comfort with content, faculty perceptions of content importance, and hours dedicated to content.
CONCLUSION
Since the close of the review, new commentaries and editorials expanding the call for change in the US were published-the time for commentary has passed. It remains unclear whether US nursing faculty are adequately prepared to educate future nurses about SGM health issues-and an unprepared healthcare workforce is yet another barrier to SGM health equity. The evidence base supporting US nursing faculty development desperately needs more studies using rigorous methodologies.
Topics: Humans; Faculty, Nursing; Cross-Sectional Studies; Gender Identity; Sexual and Gender Minorities; Curriculum
PubMed: 36924597
DOI: 10.1016/j.outlook.2023.101950