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Sexual orientation disclosure in healthcare: systematic review
Abstract and Figures
Background
Significant health disparities between sexual minority individuals (i.e. lesbian, gay, bisexual or transgender (LGBT)) and heterosexual individuals have been demonstrated.
Aim
To understand the barriers and facilitators to sexual orientation (SO) disclosure experienced by lesbian, gay, bisexual and transgender (LGBT) adults in healthcare settings.
Design and setting
Mixed methods systematic review, including qualitative, quantitative and mixed methods papers following PRISMA guidelines.
Method
Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT) and then underwent a qualitative synthesis. Studies were included if their participants were ≥18 years who either identified as LGBT, had a same-sex sexual relationship or were attracted to a member of the same-sex.
Results
The review included 31 studies representing 2442 participants. Four overarching themes were identified as barriers or facilitators to SO disclosure, the moment of disclosure, the expected outcome of disclosure, the HCP, and the environment or setting of disclosure. The most prominent themes were the perceived relevance of SO to care, the communication skills and language used by HCPs and the fear of poor treatment or reaction to disclosure.
Conclusion
The facilitators and barriers to SO disclosure by LGBT individuals are widespread but most were modifiable and could therefore be targeted to improve HCP awareness of their patient’s SO. HCPs should be aware of the broad range of factors that influence SO disclosure and the potential disadvantageous effects of non-disclosure on care. The environment in which patients are seen should be welcoming of different SOs as well as ensuring HCP communication skills, both verbal and non-verbal, are accepting and inclusive.
Keywords: General practice; sexual orientation (SO); disclosure; LGBT; review
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... Participants may have been reticent to disclose their sexual orientations on large, impersonal interviews such as the ESS (Ferlatte et al., 2017;Meyer & Wilson, 2009) or even consider their sexual minority status as a salient identity within that context. The ESS uses in-person interviews for data collection, which can yield lower rates of disclosing a target of stigma than paper and pencil or electronic methods (Brooks et al., 2018;Underhill et al., 2015). Furthermore, sexual minorities reticent to disclose will be more likely to do so when they may omit the information, as in the case of the ESS, as opposed to explicitly concealing when asked (Meidlinger & Hope, 2014;Underhill et al., 2015). ...
... Notably, the current studies examine disclosure patterns within the context of self-reporting during data collection. Such behaviors have consequential parallels, such as in the reporting of homophobic hate crimes (Dunlap, 2016), same-sex intimate partner violence (Calton et al., 2016), health-related sexual behaviors (Brooks et al., 2018), or responding to census surveys (Meyer et al., 2020). However, they are also impacted by self-perception. ...
Disclosure rates of sexual minority status shift based on the levels of structural stigma in sexual minority individuals’ environments. However, most measures of structural stigma combine multiple aspects of sexual minority individuals’ environments together, leaving open questions of whether different aspects of structural stigma are each associated with disclosure. Here, two studies indicate that societal attitudes and government policy toward sexual minorities are uniquely and specifically associated with disclosure. Study 1 found in a representative population-wide sample (number of countries = 28; N = 114,098) that tolerant societal attitudes and supportive governmental policies were both positively associated with greater levels of disclosure behavior, above and beyond other nonspecific factors (e.g., political conservatism). Study 2 replicated these findings on an individual level (number of countries = 23; N = 81,744) and found that attitudes and policies were associated with disclosure via perceptions of stigma. These findings suggest that sexual minorities assess their societal contexts, perceive signals related to their minoritized status, and manage their public identities accordingly.
... Mistrust of healthcare providers emerges as a common theme contributing to non-disclosure, in addition to anticipation and fear of negative experiences, especially a breach in confidentiality, homophobic and transphobic attitudes, and negative comments [31]. That could explain why most of our participants sought STI testing at NGOs rather than other facilities since such organizations are branded as queer-friendly spaces. ...
Background
This study aims to assess the physical health of individuals belonging to the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community, considering health system challenges like access to care and patient experiences and community-specific attributes like health literacy and self-acceptance.
Methods
This cross-sectional study was conducted in January-June 2022 using non-probabilistic sampling. The survey collected sociodemographic characteristics, information on access to care and patient experiences, prevalence of chronic conditions, sexually transmitted infections (STIs), and health literacy levels. The inclusion criteria required participants to be of Lebanese nationality, at least 18 years old, and to identify as part of the LGBTQ community. Descriptive statistics summarized the data. Two sample t-tests and chi-square tests were used to examine associations between variables.
Results
A total of 496 participants took the survey, with a majority identifying as bisexual (38.5%) or gay (35.1%). Around 41.1% reported at least one chronic condition. Difficulty accessing healthcare was experienced by 37.7%, with 11.1% reporting a negative patient experience. Participants who reported experiencing discrimination were significantly more likely to delay seeking health services (p < 0.001), with transgender-identifying participants experiencing significantly more discrimination that non-transgender-identifying participants. Regarding sexual health, 15.7%, of those who tested, reported at least one STI. Their preferred testing sites were Non-Governmental Organizations (59.3%). Adequate health literacy level was significantly associated with STI testing (t = 3.34, p < 0.01) and chronic disease (t = 3.76, p < 0.01).
Conclusion
Our findings underscore the importance of inclusive healthcare policies that address discriminatory experiences in healthcare settings and the need for targeted evidence-based interventions to improve health outcomes among LGBTQ individuals.
... For example, in the context of sexual health, stigma, discrimination and prejudice have a substantial impact on the awareness and knowledge of sexually transmitted infections (STIs), sexual health screening and subsequent access to relevant healthcare services (e.g., HIV pre-exposure prophylaxis) [11][12][13]. Owing to embarrassment or shame, ethnic minorities are less likely to disclose sexual health-related information such as sexual orientation to healthcare professionals [14]. Consequently, they might not be offered STI/HIV testing, resulting in a missed opportunity for diagnosis, treatment and infection control. ...
Background
The digitalisation of healthcare has provided new ways to address disparities in sexual health outcomes that particularly affect ethnic and sexual minorities. Conversational artificial intelligence (AI) chatbots can provide personalised health education and refer users for appropriate medical consultations. We aimed to explore design principles of a chatbot-assisted culturally sensitive self-assessment intervention based on the disclosure of health-related information.
Methods
In 2022, an online survey was conducted among an ethnically diverse UK sample (N = 1,287) to identify the level and type of health-related information disclosure to sexual health chatbots, and reactions to chatbots’ risk appraisal. Follow-up interviews (N = 41) further explored perceptions of chatbot-led health assessment to identify aspects related to acceptability and utilisation. Datasets were analysed using one-way ANOVAs, linear regression, and thematic analysis.
Results
Participants had neutral-to-positive attitudes towards chatbots and were comfortable disclosing demographic and sensitive health information. Chatbot awareness, previous experience and positive attitudes towards chatbots predicted information disclosure. Qualitatively, four main themes were identified: “Chatbot as an artificial health advisor”, “Disclosing information to a chatbot”, “Ways to facilitate trust and disclosure”, and “Acting on self-assessment”.
Conclusion
Chatbots were acceptable for health self-assessment among this sample of ethnically diverse individuals. Most users reported being comfortable disclosing sensitive and personal information, but user anonymity is key to engagement with chatbots. As this technology becomes more advanced and widely available, chatbots could potentially become supplementary tools for health education and screening eligibility assessment. Future research is needed to establish their impact on screening uptake and access to health services among minoritised communities.
As the number of transgender and gender-diverse (TGD) individuals seeking gender-affirming care continues to increase, it is crucial for healthcare providers to acknowledge the distinct challenges that this community faces and to offer personalized care. This article proposes a comprehensive review aimed at synthesizing current knowledge on the psycho-oncological challenges faced by TGD individuals. By exploring existing literature, it seeks to identify research gaps and provide a framework for addressing the intersection of gender identity, body image, and cancer-related healthcare needs. We aim to explore the complex relationship between being transgender and an oncologic patient, focusing primarily on the effects of gender-affirming hormone therapy (GAHT) and the implications of anatomical structures that remain after gender-affirming surgeries. The complex interplay between GAHT and cancer risks is highlighted, emphasizing the need for ongoing monitoring and tailored healthcare strategies. Psychological aspects of body image and self-identity among transgender individuals, particularly in the context of cancer treatment, are explored, as these treatments may involve significant bodily changes. For TGD individuals, these changes are intricately linked to their sense of identity and self-worth, leading to heightened distress and impaired quality of life. The disruption of sexual function due to cancer treatments can profoundly impact sexual identity and relationships, areas already vulnerable in the TGD population due to societal stigma. The role of social factors in shaping the experiences of TGD individuals in healthcare settings is also discussed, noting how these stressors can influence both the accessibility and quality of care. Research and clinical practice currently face gaps, and more comprehensive studies and guidelines that address the specific healthcare needs of TGD patients are warranted. The importance of an interdisciplinary approach, combining oncological care with gender-affirming practices, is underscored as essential for improving the overall health outcomes and quality of life for TGD individuals facing cancer.
Studies that have investigated client-provider interactions in HIV service delivery have focused mainly on the views of sexual and gender minorities. This study explored the views of both Healthcare Providers (HCPs) and Sexual Minority Men (SMM) in Zambia about factors that influence client-provider interactions and how this could affect HIV service delivery. We conducted in-depth interviews with 20 HCPs (>25 years old) and 20 SMM (20-34 years old) purposively recruited from Lusaka with help from local partners in 2021. Interviews lasted 30-80 min, were conducted in English, and were audio-recorded. Verbatim transcripts of audio files were iteratively coded using Nvivo. Thematic analysis was performed using the inductive approach. Study findings suggest that a lack of trust in HCPs among SMM and the religious and cultural persuasions of some HCPs negatively impact communication between SMM and HCPs. The above factors will likely make establishing a good working relationship between HCPs and SMM difficult and could negatively influence HIV service delivery. Therefore, promoting an SMM-friendly environment at health facilities and promoting HCPs' understanding of the health needs of SMM are critical to ensure the delivery of quality HIV services to SMM in Zambia.
Background Despite growing recognition of the importance of collecting sexual orientation and gender identity (SOGI) data to improve healthcare access and equity for LGBTQA+ populations, uncertainty remains around how these data are collected, their perceived importance and individuals’ willingness to disclose such information in healthcare settings. The aim of this study was to understand perceptions of the collection of data on sexual orientation and gender identity in healthcare settings across Australia, and individuals’ willingness to provide this data. Methods A cross-sectional online survey of 657 Australian residents was conducted to assess participants’ attitudes towards SOGI data in healthcare settings, along with preferences for methods to collect these data. Statistical analyses included ANCOVA, Chi-squared tests and Wilcoxon signed-rank tests. Results Participants generally recognised the importance of the collection of basic demographic data to support the provision of health services. Willingness to share SOGI data varied, with significant differences noted across gender, sexual orientation and cultural backgrounds. LGBTQA+ participants expressed greater willingness to provide SOGI data, but only in contextually appropriate situations, and preferred more inclusive data collection methods. Conclusions The study shows a context-dependent willingness to provide SOGI data in health care, underscoring the need for sensitive data collection methods. Insights into SOGI data collection attitudes are vital for developing inclusive and respectful healthcare practices. Improved SOGI data collection can enrich healthcare outcomes for diverse groups, informing public health policies and practices tailored to LGBTQA+ needs.
Indian studies have highlighted medical students’ negative attitudes towards LGBTQIA+ individuals and a lack of LGBTQIA+-informed training. However, no study has assessed the LGBTQIA+-cultural competency of Indian psychiatrists. This cross-sectional study assessed the cultural competency of psychiatrists in Kerala, an Indian state, and explored its association with relevant sociodemographic and experiential variables. LGBTQIA+ cultural competency was measured using the LGBT Development of Clinical Skills Scale (LGBT-DOCSS). Data were collected through stratified convenience sampling, in-person at psychiatry meetings and online through WhatsApp. Participants (N=166) had a moderate overall LGBT-DOCSS score (mean±SD: 5.03±0.80). Subscales showed moderate knowledge (median: 5.50, IQR: 2), high attitudinal awareness (median: 6.14, IQR: 1), and low clinical preparedness (3.88±1.43). LGB (5.16±0.83) and transgender (5.02±0.85) cultural competencies were moderate. Most participants (n=160, 96.4%) treated <5 LGBTQIA+ patients per month, and only 16 (9.6%) had received LGBTQIA+-informed training. Age (ρ =-0.18, p=0.018) and religiosity (ρ=-0.23, p=0.002) were significantly negatively correlated with cultural competency. Psychiatrists who treated <5 LGBTQIA+ patients per month demonstrated significantly lesser cultural competency than those who treated 5-10 (t=-2.78, p=0.033). Psychiatrists in Kerala have moderate LGBTQIA+ cultural competency, with high attitudinal awareness, moderate knowledge, and low clinical preparedness. This study highlights the need for comprehensive cultural competency training.
Purpose:
Sexual orientation affects individuals' health histories and is fundamental to providers' understanding of patients as a whole. Gay, bisexual, and other men who have sex with men (GB-MSM) are vulnerable to certain health conditions, including HIV. The aim of this exploratory analysis was to examine factors associated with sexual orientation disclosure and communication with providers about GB-MSM health issues and to discuss implications.
Methods:
We conducted a cross-sectional internet survey of GB-MSM (n = 202) in London-Middlesex, Ontario, Canada; analyses were limited to those with a regular primary provider (n = 173). Blockwise regression models explored demographic, psychosocial, and healthcare-related factors associated with sexual orientation disclosure and physician-patient communication about GB-MSM-related health.
Results:
Just over 71.1% of participants reported that their primary care provider (PCP) knew their sexual orientation, and 44.5% had talked to them about GB-MSM health. Overt negative comments or being refused care based on sexual orientation occurred infrequently, although 26.6% reported their provider had assumed they were heterosexual. Being married to or living common-law with another man, more frequent experiences of homosexual prejudice, and higher quality assessment of provider's communication skills were associated with the PCP knowing respondents' sexual orientation. Greater internalized homonegativity was associated with not talking to a PCP about GB-MSM-related health issues. More frequent experiences of homosexual prejudice, higher assessment of provider communication, and having prior negative experiences with a PCP were significantly associated with talking to a PCP about GB-MSM health.
Conclusion:
The majority of our sample disclosed their sexual orientation; however, not all patients voluntarily disclose. Medical training and education in Canada, where specific rights protections exist for sexual orientation minority populations, should emphasize awareness of essential patient health information. Training should include information about GB-MSM health and building a foundation on how to speak with GB-MSM patients nonjudgmentally.
Background:
Lesbian women have higher rates of physical and psychiatric disorders associated with experiences of discrimination, homophobia and difficulties with coming out. Therefore, easy access to specialized healthcare in an open atmosphere is needed. We aimed to describe women's access to and experiences with healthcare in Germany, and to assess the responsibility of the general practitioner (GP) compared to other specialities providing primary health care.
Methods:
A questionnaire study was conducted via internet and paper-based sampling. Using current literature, we designed a questionnaire consisting of sociodemographic data, sexual orientation, access to care and reasons for encounter, disclosure of sexual orientation, experience with the German health system (discrimination, homophobia), and psychological burden. Depression was assessed using the depression screening from the Patient Health Questionnaire (PHQ-2).
Results:
We obtained responses from 766 lesbian women. Although 89% had a primary care physician, only 40% had revealed their sexual orientation to their doctor. The main medical contacts were GPs (66%), gynaecologists (10%) or psychiatrists (6%). Twenty-three percent claimed they were unable to find a primary care physician. Another 12.4% had experienced discrimination. Younger lesbian women with higher education levels and who were less likely to be out to other physicians were more likely to disclose their sexual orientation to their primary care physician. GPs play an important role in healthcare for lesbian women, even in a non-gatekeeping healthcare system like Germany. Study participants suggested improvements regarding gender neutral language, flyers on homosexuality in waiting areas, involvement of partners, training of physicians, directories of homosexual physicians and labelling as a lesbian-friendly practice.
Conclusions:
GPs should create an open atmosphere and acquire the respective knowledge to provide adequate treatment. Caring for marginal groups should be incorporated in medical training and further education. Ideally, physicians address patients' sexual orientation pro-actively in order to address individual needs accordingly.
RÉSUMÉ
Cette étude qualitative décrit les attentes, les préoccupations et les besoins en matière de services de soins de longue durée et de soins à domicile de 12 couples de lesbiennes et de gais plus âgés qui habitent au Canada. Nos résultats reflètent quatre grands thèmes: la discrimination, l’identité, les dépenses d’énergie, et les soins nuancés. Discrimination a été caractérisée par des préoccupations concernant une discrimination déguisée; perte d’amortisseurs sociaux lorsque l’on vieillit; diminution de la capacité de plaider pour soi-même et l’autre conjoint. Les questions d’identité ont inclus le risque prévu sur la divulgation de son identité sexuelle; l’importance centrale d’être identifié comme un partenaire dans une relation couplée; et l’importance d’avoir accès à des groupes de référence constitués d’autres aînés gais. Nous concluons que les partenaires sont accablés par le travail émotionnel de dépenser de l’énergie à cacher une partie de leur identité, l’évaluation de leurs environnements de discrimination et d’apaiser autres. Les participants suggèrent que les soins nuancéssont nécessaires, ce qui implique sentir à l’aise avec les fournisseurs de soins de santé; ayant fournisseurs sentir à l’aise avec eux; et une dualité de nécessité entre vouloir être considéré comme le même, tout en même temps également reconnu comme unique. Ces thèmes informent ententes de services de soins et de soins à domicile à long terme pour les couples lesbiens et gais plus âgés.
This is an evidence review of the nature of inequality and relative disadvantage experienced by lesbian, gay, bisexual and transgender (LGB&T) people in the UK. It critically assesses the nature, robustness and strength of evidence in order to highlight differences among and between LGB&T groups, as well as other relevant comparators.
The review takes a systematic approach, scoping and critically reviewing published and unpublished literature from 2008 onwards. It covers empirical research for the UK and its constituent parts, and focuses on nine areas. These are:
education;
safety, including hate crime and domestic violence;
health and access to healthcare;
access to and experience of services;
employment;
LGB&T families, adoption and fostering;
homelessness and access to housing provision;
participation in civic society; and
16-19 year olds not in education, employment or training (NEETs).
Introduction
Systematic mixed studies reviews are a type of systematic review that combine qualitative, quantitative and mixed methods studies. They are gaining in popularity due to their potential for providing in-depth answers to complex clinical problems and practical concerns. However, several challenges are encountered in systematic mixed studies reviews because of the heterogeneity of included study designs. One of these challenges is related to the quality appraisal of included studies. To address this challenge, a critical appraisal tool for assessing the quality of quantitative, qualitative and mixed methods studies was developed in 2007: the Mixed Methods Appraisal Tool (MMAT). The aim of this project was to strengthen the content validity of the MMAT.
Methods
A new version of the MMAT was developed using the results from a literature review on critical appraisal tools and a modified e-Delphi study with methodological experts (n = 73) to identify the core relevant criteria to include in the MMAT.
Results
The results of this project and the new version of the MMAT will be presented. The MMAT has three main characteristics. First, it can be used for different study designs since it includes criteria for qualitative, quantitative and mixed methods studies. Second, the MMAT focuses on the core relevant methodological criteria and has five criteria per category of study. Third, it includes specific criteria for assessing mixed methods studies.
Conclusions
Currently, there exists over 500 critical appraisal tools, making the task of selecting the proper tools for use in systematic mixed studies reviews more difficult. The MMAT offers an alternative solution by proposing a unique tool that can appraise the quality of different study designs. Also, by limiting to core criteria, the MMAT can provide a more time efficient assessment.
This study examines lesbian, gay, and bisexual patients’ disclosure patterns of sexual orientation to
health care providers. Using a semistructured interview format, researchers conducted interviews with
24 lesbian, gay, bisexual, and queer (LGBQ) adults about sexual orientation disclosure strategies. All
interviews were transcribed and independently coded using thematic analysis. Results suggest that
patient sexual orientation disclosure may be patient initiated and may occur to clarify or correct provider
misinformation. Participants disclosed their orientation early in the medical visit during introductions,
during small talk with the provider, and during the history-taking phase of the visit. Participants
characterized sexual orientation disclosures as presented with minimal information, casually, and
often indirectly. Practical and theoretical implications are discussed.
Aims and objectives:
To develop insight into the experiences of lesbian and bisexual women accessing sexual health services and an understanding of their needs within the New Zealand context.
Background:
Lesbian and bisexual women are typically invisible in healthcare settings due to heteronormative assumptions. As lesbian and bisexual women are reluctant to come out to clinicians, opportunities for targeted opportunistic health education are often missed. Lesbian and bisexual women have different needs from both heterosexual women and gay men when seeking healthcare. There has been little exploration of the experiences of lesbian and bisexual women accessing healthcare in the New Zealand context.
Design:
Qualitative descriptive design.
Methods:
Participants (n = 6) were recruited via advertisements and snowball sampling. Those recruited lived in a provincial city in New Zealand; self-identified as lesbian or bisexual; and met the inclusion criteria. Semi-structured, face-to-face interviews were used to obtain narrative data about participants being recipients of healthcare.
Results:
Five themes were identified within the data set: Heteronormativity; The conundrum of safer sex; Implied and overt homophobia; Engagement with health promotion; and Resilience.
Conclusion:
This study highlighted the difficulties that lesbian and bisexual women face when seeking sexual healthcare, primarily due to clinicians' heteronormative assumptions. Lesbian and bisexual women have found ways of navigating the health system that make them feel safe(r) despite experiencing many adversities such as homophobia.
Relevance to clinical practice:
This study's findings can be used to guide further research to identify ways to optimise clinicians' engagement with lesbian and bisexual women. Recognition of diversity and skilful communication are essential to rectify inequities and effectively target health information.
Health inequities for sexual minorities are well documented, but there is a gap in nursing research addressing the specific experiences faced by lesbian and bisexual women with reproductive cancers. This critical feminist study explored interactions between sexual minority women with reproductive cancers and their health care providers and how these interactions enable and create barriers to meaningful support. Purposeful convenience sampling was used to recruit lesbian and bisexual reproductive cancer survivors from Ontario, Canada and providers who have cared for this population. Five lesbian and one bisexual woman who were reproductive cancer survivors participated, as well as one registered nurse who was not a survivor but who has cared for sexual minority women with reproductive cancers. Face-to-face interviews were conducted and conventional content analysis was used to analyze the data. The authors report on findings related to meaningful support, interactions with providers and organisational environments. Narratives showed that an understanding of gender norms influenced women’s perceptions of supportive and inclusive care, such as the acknowledgment of social supports and barriers to supportive care that included disclosure of sexual orientation. There are implications for nursing education and policy change to enhance inclusive interactions and environments for diverse sexual minority women with reproductive cancers.